Drug treatment for acne vulgaris

Acne vulgaris can occur in people of all ages, with the highest incidence in adolescents. Acne vulgaris, also known as "acne," is a chronic inflammatory skin disease that affects the hair follicles and sebaceous glands. It often occurs on the face, chest, and back. Clinically, it mainly manifests as acne, papules, pustules, cysts, or nodules, often accompanied by enlarged pores and sebum secretion.

The goal of acne vulgaris treatment is to eliminate skin lesions, prevent recurrence, improve the patient's quality of life, and prevent sensitive skin, post-inflammatory erythema, pigmentation, and permanent scarring . Clinically, a personalized treatment plan can be developed based on the severity of the patient's condition, age, and gender.

Acne vulgaris grading/grading

The "Guidelines for Primary Diagnosis and Treatment of Acne Vulgaris (2023)" points out that the grading/grading of acne vulgaris is an important basis for the selection of acne treatment plans and the evaluation of efficacy . The guidelines mainly divide acne vulgaris into 4 grades (Grade I, Grade II, Grade III, Grade IV) and 3 degrees (mild, moderate and severe) based on the nature of the skin lesions, namely:

Grade Ⅰ (mild): only acne;

Grade II (moderate): There are inflammatory papules;

Grade III (moderate): Pustules appear;

Grade IV (severe): There are cysts and nodules.

Medication is the first choice for acne treatment

The main drugs for treating acne include retinoic acid drugs, benzoyl peroxide, antibiotics, antiandrogens and glucocorticoids, as well as a variety of physical and chemical treatments.

1. Topical retinoic acid drugs - the first choice for maintenance treatment of acne

1. Mechanism of action: Improves keratinization of hair follicle sebaceous gland ducts, dissolves micro-acne and acne, anti-inflammatory, prevents and improves post-inflammatory pigmentation and acne scars of acne.

2. Representative drugs: retinoic acid, tazarotene, adapalene

3. Scope of application:

(1) As the sole first-line medication for mild acne.

(2) Combination medication for moderate acne.

Adverse reactions : Mild skin irritation may occur locally, such as erythema, desquamation, accompanied by tightness and burning sensation, which can be gradually tolerated over time. It is recommended to stop the drug if the irritation is severe.

Retinoic acid drugs will undergo photodecomposition, which will increase the skin's sensitivity to ultraviolet rays. Therefore, you should avoid sunlight or apply sunscreen.

Note: Pregnant women should use topical retinoic acid cream and adapalene gel with caution, and pregnant women should not use tazarotene.

2. Oral retinoic acid drugs

1. Mechanism of action: It inhibits sebaceous gland lipid secretion, regulates abnormal keratinization of sebaceous gland ducts, improves the anaerobic environment of hair follicles to reduce the reproduction of Propionibacterium acnes, fights inflammation and prevents scar formation. It is currently the only oral drug that targets the four key pathological and physiological links of acne.

2. Representative drugs: Isotretinoin, Vitretinoin

3. Scope of application:

(1) First-line treatment for severe nodulocystic acne.

(2) Alternative treatment for moderate or moderately severe acne that is ineffective with other treatments.

(3) Acne patients with scars or a tendency to scarring should use it as early as possible.

(4) Frequent recurrence of acne that is not responsive to other treatments.

(5) Patients with acne and severe seborrhea.

(6) Patients with mild to moderate acne who require rapid therapeutic effects.

(7) Acne variants such as acne fulminans and conglobate can be used after using antibiotics and corticosteroids to control the inflammatory response.

4. Precautions for use : These drugs must be taken with a fat meal to increase their oral bioavailability. The course of treatment is usually no less than 16 weeks, and generally takes effect in 3 to 4 weeks.

5. Adverse reactions : Common adverse reactions include dryness of the skin and mucous membranes. It is recommended to use it with skin barrier repair agents.

Retinoic acid drugs are teratogenic. Female patients of childbearing age must strictly observe contraception one month before treatment, during treatment, and within three months after treatment.

Long-term use before puberty may cause premature epiphyseal closure, bone hyperplasia, osteoporosis, etc., so it should be avoided in children under 12 years old .

3. Antioxidant (Benzoyl Peroxide)

1. Mechanism of action : Benzoyl peroxide can slowly release new ecological oxygen and benzoic acid, which can kill Propionibacterium acnes and have anti-inflammatory effects.

2. Indications and drug selection : It can be used as the first choice topical drug for grade II and grade III acne vulgaris. Currently, Propionibacterium acnes has no resistance to this drug. It can be used alone or in combination with topical antibacterial drugs. The concentration range is 2.5%~10%, and it is available in emulsion, gel and other dosage forms.

3. Usage and precautions : Apply topically to the affected area; skin irritation may occur during use, so it is recommended to try it on a small area with a low concentration, and use functional skin care products that soothe and repair the skin barrier on the entire face; use with caution in patients with acne and sensitive skin.

This drug has an oxidative bleaching effect on clothing or hair, so contact should be avoided as much as possible; at the same time, the oxygen free radicals released by benzoyl peroxide can inactivate all-trans retinoic acid, so the two should be used externally in combination at different times.

4. Topical Antimicrobial Drugs

1. Mechanism of action : anti-Propionibacterium acnes, anti-inflammatory.

2. Representative drugs : erythromycin, lincomycin, clindamycin, chloramphenicol, metronidazole, and fusidic acid.

3. Scope of application : superficial inflammatory acne such as papules and pustules.

4. Precautions for use : It is recommended to use it in combination with benzoyl peroxide, topical retinoic acid or other drugs; it is not recommended to use it alone or for a long time.

5. Adverse reactions: Irritation reactions rarely occur. Common skin irritation symptoms include erythema, dryness, burning, pain, etc. Systemic adverse reactions such as diarrhea or pseudomembranous colitis are relatively rare.

5. Oral Antimicrobial Drugs

1. Mechanism of action : Anti-Propionibacterium acnes, anti-inflammatory. Tetracyclines such as doxycycline and minocycline are preferred. For patients who cannot tolerate or have contraindications, consider using macrolides such as erythromycin, roxithromycin, azithromycin, etc.

2. Representative drugs : doxycycline, minocycline, erythromycin, roxithromycin, and azithromycin.

3. Scope of application :

(1) It is the first choice for patients with moderate to severe acne and an alternative treatment for patients with moderate acne who are ineffective with topical treatments.

(2) Patients with severe acne with severe inflammatory reactions can first use oral antibiotics in the early stages, and then use oral retinoids sequentially. Or, if oral retinoids are not effective, oral antibiotics can be used instead.

(3) Early treatment of acne variants such as acne fulminans or acne conglobata.

4. Precautions for use : Oral antibacterial drugs must be used for a sufficient course of treatment and avoid intermittent use, but it is recommended not to exceed 8 weeks; combined use of topical retinoic acid or benzoyl peroxide can effectively improve the efficacy and reduce the development of drug resistance in Propionibacterium acnes.

5. Adverse reactions : Tetracycline drugs have many types of adverse reactions, but they are relatively rare, such as vaginal candidiasis in susceptible women, gastrointestinal discomfort, photosensitivity reactions, pigment deposition and benign intracranial hypertension.

Combination with oral retinoic acid drugs may induce or aggravate benign intracranial hypertension. Tetracycline drugs should not be used in pregnant women, lactating women and children under 8 years old, and macrolide drugs may be considered instead.

Minocycline may cause vestibular involvement (such as dizziness, vertigo), rare lupus-like syndrome and benign intracranial hypertension (such as headache, etc.), and the drug should be discontinued immediately if it occurs.

6. Anti-androgen drugs

1. Mechanism of action : Anti-androgen drugs reduce or antagonize the activity of androgens by inhibiting the production of androgen precursors or acting on androgen metabolic enzymes and receptors in the skin, thereby reducing the secretion of sebum by sebaceous glands and achieving the purpose of improving common acne.

2. Indications : Female acne patients with hyperandrogenism.

3. Drug selection : birth control pills, spironolactone, and tanshinone.

4. Treatment course :

(1) Contraceptive pills: The most commonly used pill is ethinyl estradiol cyproterone acetate, which contains estrogen and progestin. It takes 2 to 3 months for the pill to take effect, and the recommended course of treatment is more than 6 months.

(2) Spironolactone: The course of treatment is 3 to 6 months.

(3) Tanshinone: The course of treatment is generally 6 weeks, and it is recommended to be used in combination with antibacterial drugs.

5. Note : Contraceptive pills and spironolactone are prohibited for pregnant and lactating women.

7. Glucocorticoids

1. Mechanism of action : Small doses inhibit renal androgen secretion, while larger doses have anti-inflammatory and immunosuppressive effects.

2. Scope of application : Early treatment of severe inflammatory acne.

3. Precautions for use : It is mainly used for acne fulminans, conglobate acne, and severe acne with heavier inflammatory reactions. The course of treatment should not exceed 4 weeks, usually combined with oral isotretinoin treatment.

8. Chinese patent medicine

The selection of Chinese patent medicine should be based on the severity of skin lesions and different syndrome types.

If it is a syndrome of wind-heat in the lung meridian, the treatment should be to soothe the wind and promote lung function, clear away heat and resolve nodules. Such Chinese patent medicines include Gardenia and Golden Flower Pills.

If it is a syndrome of damp-heat in the spleen and stomach, the treatment should be to clear away heat and dampness, such as Yiqing Capsules. Those with constipation can choose Fangfeng Tongsheng Pills, and those with loose stools can choose Shenling Baizhu Pills.

If it is a syndrome of phlegm and blood stasis, the treatment should be to promote blood circulation and remove blood stasis, resolve phlegm and disperse nodules, such as Danshen Capsules and Danggui Kushen Pills.

If it is a syndrome of Chong and Ren disharmony, the treatment should be to harmonize Chong and Ren, regulate Qi and activate blood circulation, such as Xiaoyao Pills, Zhibai Dihuang Pills, etc.

Summarize

The "Guidelines for Primary Diagnosis and Treatment of Acne Vulgaris (2023)" summarizes the recommended treatment options for acne as follows:

It is worth noting that acne is a chronic process. Patients need to have regular follow-up visits during treatment and adjust their treatment and skin care plans in a timely manner based on the treatment response to reduce the occurrence of sequelae.

References:

1. Chinese Medical Association, Chinese Medical Association Journal, Chinese Society of Dermatology and Venereology, etc. Primary diagnosis and treatment guidelines for acne vulgaris (2023). Chinese Journal of General Practitioners, 2023, 22(02):138-145. DOI:10.3760/cma.j.cn114798-20221121-01095

2. Chinese Acne Treatment Guidelines (2019 Revised Edition)