Treating Acne Vulgaris: Systemic, Local and Combination Therapy

Laura J Savage; Alison M Layton

Disclosures

Expert Rev Clin Pharmacol. 2010;13(4):563-580. 

In This Article

Approach to Therapy

Selection of acne therapy should depend on a comprehensive assessment of the disease. This should include a thorough personal history, including details of the duration of the acne and a record of previous therapies (with subsequent response), family history and a careful physical examination.

Various photometric grading systems are available to visually assess acne, including the revised Leeds Grading Score,[1] Cook's Scale Method[2] and the Pillsbury Scale.[3] Assessment of the extent and severity of acne is paramount, not only to facilitate choice of the most appropriate therapy, but also to monitor the response to treatment and measure patient satisfaction.

The psychosocial disability that can ensue from acne and potential scarring must not be overlooked. Acne should be managed as a chronic disease with recognition of the psychological sequelae and appreciation that patient perception does not always correlate with the physician's assessment of severity. Several formal questionnaires have been developed to enable the clinician to quantify the impact of acne on mental health and their use is advocated in all patients with acne of any severity. These include generic assessments such as the Dermatology Life Quality Index (DLQI),[4] and disease-specific scoring systems such as the Leeds Assessment of Psychological and Social Effects of Acne (APSEA)[5] and the Cardiff Acne Disability Index (CADI).[6]

Predisposed individuals may experience impaired self esteem, anxiety and clinical depression as a direct consequence of acne, which can lead to social isolation, interpersonal difficulties and even suicidal ideation.[7–9] In a study of 60 adult patients with acne, Lasek et al. found that patients reported emotional effects as a consequence of their skin condition that were similar in magnitude to those reported by patients with psoriasis,[10] which is traditionally regarded as a condition causing significant psychological disability. Scarring and/or persistent hyperpigmentation are not uncommon sequelae in acne, and patients who scar have an even higher prevalence of psychological morbidity when compared with nonscarring acne sufferers and controls.[11] However, the psychological impact of acne does not necessarily correlate with disease severity; even mild/moderate acne can be associated with significant depression and suicidal ideation.[8] Limiting the duration of active disease by early and effective treatment therefore offers the possibility of minimizing both the physical and emotional scarring caused by acne.

Following thorough assessment, it is important for physicians to educate patients regarding available treatment options and their expected outcomes. Patients need to be aware that the response to treatment can be slow and patients frequently need repeated encouragement to adhere to the chosen regimen. Medical adherence can be optimized by selecting preparations that compliment the patient's lifestyle, produce minimal adverse effects and are acceptable and affordable for the patient.[12]

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