What Skin Care Routines and Treatments Are Effective for Adolescent Acne?

Theodore D. Scott, RN, MSN, FNP-C

Disclosures

February 15, 2008

Question

There are many prescription and OTC products for treating adolescent acne, including combination products. Do you have a protocol that you follow in your practice?

Response from Theodore D. Scott, RN, MSN, FNP-C

 

Theodore D. Scott, RN, MSN, FNP-C
Clinical Preceptor, University of San Diego, San Diego, California; Nurse Practitioner, Southern California Permanente Medical Group, San Marcos, California


I use a protocol that emphasizes good basic skin care and a stepwise approach to prescribing medications for the treatment of acne. When seeing new patients with acne, I usually start by reviewing the over-the-counter (OTC) products that they use, and making these skin care suggestions:

  • Use a gentle cleanser with an alpha- or beta-hydroxy acid to soften and dissolve the keratin plugs at the end of the pilosebaceous units. Neutrogena Oil-Free Acne Wash, which contains 2% salicylic acid, is effective; several other excellent OTC brands are available, including Clean & Clear Continuous Control Acne Wash, Oil Free and pHisoderm Anti-Blemish Body Wash. I am frequently asked about the Proactiv Acne System and similar products, such as Klear Action Acne Treatment System and Neutrogena Advanced Solutions Complete Acne Therapy System. These products are comparable but expensive, and I believe that the same basic skin care can be achieved with less costly products.

  • Wash the face gently, only twice a day. Acne isn't caused by dirt or oil on the surface of the skin, but by clogged sebaceous glands.

  • Throw out astringents (which are mostly alcohol), exfoliants, microdermabrasion devices, or any product that says "scrub" on the label. These products only aggravate the oil glands.

  • After washing, apply a benzoyl peroxide aqueous gel (no creams or lotions). Benzoyl peroxide kills Propionibacterium acnes, the microorganisms that multiply in clogged follicles. Benzoyl peroxide works by increasing the concentration of free oxygen radicals in the pores.

It is best to get to the root of the patient's acne early in the course of treatment. Acne can be viewed as a consequence of "angry" oil glands. The usual source of this anger is testosterone, an androgen produced by both sexes. Redness, inflammation, open or closed comedones, and cysts are caused by mechanical blockage of the pilosebaceous units or by secondary infection with P acnes. The only treatment that will calm the angry oil gland is a retinoid. Topical retinoids, in order of weakest to strongest, include adapalene (Differin), tretinoin (either Avita or Retin-A), or tazarotene (Tazorac). The patient should apply the topical retinoid to a dry face at bedtime, waiting at least 30 minutes after washing in order to minimize irritation. Retinoid products should be used every night at bedtime, but I recommend starting with an every-other-night regimen for the first 2 weeks to allow the skin to get used to the medication.

The combination of an OTC cleanser and a prescription topical retinoid will treat most of the mild-to-moderate cases of acne that present in your practice. If there are signs of secondary infection, such as pustules, replace the benzoyl peroxide gel with clindamycin or erythromycin topical gels or solutions. If signs of deep infections (cysts or nodules) are present, prescribe an oral tetracycline (tetracycline 500 mg twice daily, doxycycline 100 mg twice daily, or minocycline 100 mg twice daily) or erythromycin 500 mg twice daily if the patient can't tolerate tetracyclines. We have had some success with sulfamethoxazole/trimethoprim in patients who cannot tolerate routine antimicrobials.

Each time a new product or medication is begun, you must counsel the patient that any change in the regimen will take at least 6 weeks to show a difference. Female patients should also be counseled that if they become pregnant or are attempting pregnancy, they should discontinue all tetracyclines and retinoids.

If your female patient with acne has no medical contraindications or moral or religious objections, you may wish to consider the use of an oral contraceptive to suppress androgen production. This adjunct therapy works well for some women who experience flare-ups of acne associated with their menstrual cycles. The best oral contraceptives to prescribe for acne are those with low-androgen activity. A drospirenone-containing pill (Yasmin or Yaz) actively blocks testosterone-binding sites in a matter that is similar to spironolactone.

If these suggestions fail to result in improvement, refer your patient to a dermatologist for consideration of oral retinoid treatment (Accutane, Sotret). This class of medication is effective when used correctly with the appropriate support and monitoring. Oral retinoids are teratogenic and can cause severe birth defects. These drugs cannot be taken during any stage of pregnancy. A federally mandated monitoring program (iPledge) is in place, and the prescribing provider, the patient, and the dispensing pharmacy must all register online for oral retinoids to be used.

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