Mild acne usually responds to topical retinoids or benzoyl peroxide, particularly if the patient is counselled the side effects of these topical preparations.
Alternative possible preparations include (1,2,3):
anticomedomal preparations - appropriate where patient has blackheads and whiteheads but few inflamed lesions:
topical retinoid preparations eg tretinoin 0.1-0.25% once daily, isotretinoin 0.05% once or twice daily, adapalene 0.1% once daily
comedolytic effects
treatment of choice for comedonal acne; they have an anti-inflammatory effect as well as decreasing inflammatory lesions indirectly by preventing comedone formation
patients should be advised apply a thin ‘pea-sized’ amount to any area affected by acne and continue until lesions clear
application should be at bedtime - this because retinoids are inactivated by light
side effects include erythema, desquamation, occasional hypo- or hyper- pigmentation, and sensitisation of the skin to sunlight. Topical retinoids should be avoided during pregnancy
women should be warned of the potential risk of teratogenicity and should not use topical retinoids if attempting to conceive
the majority of patients develop a mild dermatitis, with redness and scaling of the face after a few days - however this may be controlled by reducing the amount used or the frequency of application
adapalene is less irritating than other agents and also has anti-inflammatory properties (2)
azelaic acid is an allternative anticomedonal preparations to topical retinoids
azelaic acid may also improve postinflammatory hyperpigmentation (2)
salicyclic acid is another alternative to topical retinoids for comedomal acne
preparations targetting Propionibacterium acnes (P. acnes) and inflammation - where the patient has papulopustular acne (comedomes and some pustules and papules):
benzoyl peroxide 2.5-10% once daily - a potent oxidising agent with antibacterial and keratolytic properties e.g. benzamycin (R) gel. Main adverse effects are bleaching of clothes, transient skin irritation, and occasional allergic contact dermatitis. This drug may be used long term in conjunction with oral antibiotics for moderate acne vulgaris
the use of benzoyl peroxide does not induce P. acnes resistance
azaleic acid 20% twice daily - also an alternative to benzyl peroxide but is reputed to cause less irritation
azelaic acid has antimicrobial as well as anticomedonal properties
topical antibiotics e.g. clindamycin 1% twice daily, erythromycin 2% and 4% with zinc acetate 1.2% twice daily - useful in mild to moderate acne and acne which is resistant to benzoyl peroxide
most useful when inflammatory lesions predominate
topical antibiotics are useful for mild to moderate acne when used with topical retinoids (2) - this is because the use of topical antibiotics as single agents should be avoided because of the risk of development of antimicrobial resistance, which can cause treatment failure
Notes:
topical salicylic acid and abrasive agents may be used during pregnancy
if papulopustular acne then consider the use of a topical retinoid (or alternatively azelaic acid) at night for treatment of comedomes - in addition to specific therapy for papulopustular acne
Moderate
Topical treatment combined with oral medication
if papulopustular acne then topical retinoids should be used at night in combination with an oral antibiotic
also benzoyl peroxide may also be applied in the morning
Oral antibiotics remain the mainstay of treatment.
an adequate dose of antibiotic should be given for at least three months before deciding that a patient has failed to respond
after three months therapy then a reduction of acne lesions by 30-50 per cent should have occurred
if there has been good response to oral antibiotic therapy then antibiotic therapy should be continued for a further three months and then the patient maintained on an appropriate topical regimen
if there has been poor response to oral antibiotic therapy then an alternative antibiotic may be substituted (see notes)
First line antibiotic therapy:
tetracycline 500mg twice daily for 3 months and then reduced to 250mg twice daily for a further 3 months - in order to ensure adequate absorption tetracycline should be taken before food. Patients should also avoid concomitant ingestion of milk and iron supplements. An alternative first-line antibiotic is oxytetracyline 500mg twice daily
Alternative antibiotic treatments include:
erythromycin 500 mg bd for 3 months then 250 mg bd for 3 months
less useful because increased levels of Propionobacterium acnes (P. acnes) resistance to erythromycin among acne patients
only licensed oral therapy for acne that is safe in pregnancy (1)
doxycycline 100mg once daily
minocycline 100mg (slow release) once daily or 50mg twice daily - little difference between efficacy of tetracycline and minocycline - however its unusual propensity for causing immunologically mediated reactions (e.g. systemic lupus erythematosus, chronic active hepatitis) "may make it less safe than other tetracyclines" (BMJ editorial)
should be avoided in patients with a family history of lupus erythematosus and patients receiving long-term minocycline should be monitored for the development of antinuclear antibody (1)
Oral antiandrogen:
cyproterone acetate 2mg with ethinyloestradiol 35 mu g once daily is an alternative in adolescent girls who also require contraception
licensed only for women with severe acne that has not responded to antibacterials and for treatment of acne in women with moderately severe hirsutism
risk of venous thromboembolism is higher in women taking co-cyprindiol than a low-dose COC
therefore in a patient with uncomplicated mild to moderate acne (without hirsutism or obesity) who requires oral contraception, conventional low-dose second- or third-generation COCs are more appropriate (1)
in moderate acne then may be treated using an oral antiandrogen in combination with a topical antimicrobial and topical retinoid or azelaic acid (1)
Notes:
trimethoprim is highly effective in the treatment of acne and is increasingly used by dermatologists - however it may cause an allergic rash in 5 per cent of patients
if a patient with moderate acne and nodular lesions fails to respond to two courses of antimicrobial therapy (each for three months) in combination with a topical retinoid and benzoyl peroxide then s/he should be referred for consideration for oral isotretinoin therapy (1)
The respective summary of product characteristics must be consulted before prescribing any of the drugs mentioned above.
Severe
treatment of severe acne is with isotretinoin by a dermatologist
reasons for referral to a dermatologist regarding acne treatment include: nodulocystic acne, scarring, pigmentation, poor treatment response, unpleasant side effects from current treatment regime, late onset acne (1)
Examples of other treatments that may be initiated by a specialist
alternative antibiotics
trimethoprim
highly effective in the treatment of acne
may cause an allergic rash in 5 per cent of patients
occasionally prescribe may use other antibiotics, such as clindamycin and clarithromycin
also dermatologist may use anti-inflammatory agents such as dapsone
Psoriasis
The treatment regime is determined by the precise clinical pattern of an individual's psoriasis. As a general rule, all treatment should be accompanied by reassurance and explanation about the non-contagious and benign nature of the complaint. The wide range of treatments should be emphasised as well as the usual life long nature of the condition.
A simple regimen for the initial topical treatment of chronic plaque psoriasis can be outlined as follows (1):
General measures:
use of a soap substitute, e.g. aqueous cream, and a bath additive e.g. Polytar emollient or Balneum with Tar, and apply a moisturiser after having a bath
For localised plaque psoriasis e.g. on the elbows or knees, the following topical preparations (listed in no particular order) can be tried. The exact choice will depend on the feelings of the doctor and patient about the different treatments, e.g. side-effects:
a tar-based cream (e.g. Alphosyl or Carbo-Dome), or a tar/steroid mixture (e.g. Alphosyl HC or Tarcortin)
a mild-to-moderate potency topical steroid (e.g. 1% hydrocortisone, or betamethasone valerate 0.025%)
a vitamin D analogue (i.e. calcipotriol or tacalcitol)
a dithranol preparation (e.g. Dithrocream), usually used as a short contact treatment
For more widespread plaque psoriasis e.g. on the trunk or the limbs, the same treatments may be appropriate, with the proviso that dithranol may be impractical to apply to several small lesions
For scalp psoriasis
a tar-based shampoo (e.g. Polytar or T-gel) is usually tried first
followed by either a 2% salicylic acid preparation (e.g. made up in Unguentum Merck), a coconut oil/tar combination ointment (e.g. Cocois Ointment), a potent topical steroid preparation (e.g. 0.1% betamethasone valerate), or calcipotriol scalp application.
Those patients with extensive disease, who need systemic treatment, will normally be under the supervision of a consultant dermatologist, because of the potential toxicity of these drugs. The dermatologist will also be involved in the care of difficult cases where the site, or unresponsiveness of the rash, are important factors.
Systemic agents should be given under the supervision of a dermatologist. They include:
methotrexate - given as a single dose each week (max. 0.5 mg/kg); complications include myelosuppression; hepatic fibrosis; and teratogenesis
indicated for recalcitrant disease unresponsive to topical or phototherapy and is particularly useful if the patient has an associated arthropathy
long-term use of methotrexate is associated with liver toxicity so regular liver function tests are required
incidence of cirrhosis is related to cumulative dose, and if this is below 1.5g the risk is low (1) - if this level has been reached then liver biopsy is required to check for signs of toxicity
if serial propeptide of type III procollagen levels remain normal repeat liver biopsies can be avoided (1)
retinoids
useful agent for pustular and erythrodermic psoriasis but are less effective in chronic plaque psoriasis (1)
if used as combination therapy with PUVA or UVB then this allows dose reduction and decreases the incidence of adverse effects
cyclosporin - 2.5 mg/kg/day; complications include hypertension; renal impairment; hypertrichosis; and increased risk of skin malignancy and lymphoma
Indications for systemic therapy (2) include:
failure of adequate trial of topical therapy
repeated hospital admissions for topical therapy
rxtensive chronic plaque psoriasis in the elderly or infirm
reneralised pustular or erythrodermic psoriasis
revere psoriatic arthropathy
Note that etretinate, methotrexate are specifically contraindicated for use in pregnancy.
Reference:
Typical regieme
in most cases of chronic plaque psoriasis:
it is appropriate to begin with a mild tar preparation
if this fails then change to calcipotriol - can be supplemented with a 2-3 week course of topical steroids if clearance is not satisfactory. Dithranol may be used as an alternative for calcipotriol.
failure to respond to treatment at this stage warrants referral for dermatological advice.
erythrodermic psoriasis - initial therapy is with systemic treatments such as methotrexate.
guttate psoriasis - tends to settle after a month or two; a mild topical steroid might be the first choice treatment
ECZEMA
Treatment options include:
emollients - combat dry skin
soap substitutes
soap is drying as it removes natural oils from the skin. A soap substitute (e.g. aqueous cream) should be used to wash with instead
bath/shower emollients
topical emollients These should be applied to all areas at least twice a day
topical corticosteroids - used to control inflammation (see linked item)
work by suppressing the inflammatory response in eczematous skin
should be used in addition to emollients where there is active inflammation
the least potent steroid required to suppress the inflammation should be used, although in practice it is common to use a more potent steroid to start with and then 'drop down' to a milder preparation once the acute inflammation is improving
antibiotics - control of staphylococcal overgrowth e.g. a seven-day course of flucloxacillin or erythromycin is first line if signs of moderate to severe infection (1). The same MeReC bulletin states that there is no evidence that topical antibiotic/corticosteroid preparations are superior to corticosteroids alone and topical antibiotics should be avoided or reserved for single small lesions only. Also there is no evidence that bath oils containing antimicrobials are any more effective than standard bath oils and their routine use cannot be recommended (1)
antivirals - eczema herpeticum should be suspected in atopic patients with a sudden, severely painful exacerbation with vesicular or ulcerated lesions
in severe cases then prompt admission may be required
treatment is with oral aciclovir
topical corticosteroids should not be used in the presence of herpes infection (2)
antihistamines - sedative antihistamines combat itching
pimecrolimus - moderately effective in atopic eczema, but is place in therapy is unclear (1)
Other treatment options that may be used in management of eczema include:
cotten bandages and dressings:
wet wrapping is a technique popular with paediatric patients, particularly at night-time
large amounts of emollient and sometimes a mild topical steroid are applied under a damp layer of bandage (e.g. Tubifast); a second dry layer is then applied on top. As the bandage dries the skin cools, therefore reducing pruritus
the occlusion results in increased absorption of the topical steroid and therefore care is required
the technique needs to be demonstrated to the patient's parents
is contraindicated in the presence of secondary infection.
coal tar and ichthammol :
coal tar and the less irritating shale derivative ichthammol are both used in a variety of preparations to treat eczema
most suitable for chronic lichenified eczema and may be applied as crude coal tar, tar-containing creams, eg Clinitar, or in combination with zinc paste either as a cream or a bandage, eg Ichthopaste
side-effects comprise of skin irritation, folliculitis and staining of skin and clothes
not suitable for facial use
salicylic acid - a keratolytic- may be used in combination preparations. Makes the upper layers of the skin more easy to peel off
potassium permanganate - 1:8000 - mild antiseptic and a drying agent
Notes (3):
oral antihistamines should not be used routinely in the management of atopic eczema in children
healthcare professionals should offer a 1-month trial of a non-sedating antihistamine to children with severe atopic eczema or children with mild or moderate atopic eczema where there is severe itching or urticaria. Treatment can be continued, if successful, while symptoms persist, and should be reviewed every 3 months
healthcare professionals should offer a 7-14 day trial of an age-appropriate sedating antihistamine to children aged 6 months or over during an acute flare of atopic eczema if sleep disturbance has a significant impact on the child or parents or carers. This treatment can be repeated during subsequent flares if successful
use of topical antibiotics in children with atopic eczema, including those combined with topical corticosteroids, should be reserved for cases of clinical infection in localised areas and used for no longer than 2 weeks
eczmea herpeticum in a child
if eczema herpeticum (widespread herpes simplex virus) is suspected in a child with atopic eczema, treatment with systemic aciclovir should be started immediately and the child should be referred for same-day specialist dermatological advice. If secondary bacterial infection is also suspected, treatment with appropriate systemic antibiotics should also be started
if eczema herpeticum involves the skin around the eyes, the child should be treated with systemic aciclovir and should be referred for same-day ophthalmological and dermatological advice
Reference:
(1) MeReC Bulletin 2003; 14(1): 1-4.
(2) Prescriber 2001; 12 (12).
(3) NICE (December 2007).Atopic eczema in children Management of atopic eczema in children from birth up to the age of 12 years.
Severe cases may require hospital admission and systemic treatment:
These second-line therapies require specialist advice:
phototherapy - UV or PUVA
UV radiation has profound effects on skin and systemic immune responses. Both narrow-band UVB and PUVA (psoralen + UVA) therapies are used for atopic eczema
psoralens work by photosensitising the skin
there are possible short-term and long-term side effects to phototherapy:
UVB light can cause burning; PUVA increases the incidence of skin cancers (1) – this is a dose-related effect relating to the total amount of PUVA received
narrow-band UVB is thought to be safer and therefore can be used in children
psoralen tablets can cause nausea; also the photosensitisation requires sunglasses to be wore for a period of time after treatments to help prevent formation of cataracts.
immunosuppressants
oral corticosteroids, e.g. prednisolone 30mg daily for one week (2)
other immunosuppressive drugs e.g. azathioprine, ciclosporin - should only be used in the secondary care setting
gamolenic acid may reduce symptoms in a small number of patients with atopic eczema - however a double-blind, placebo-controlled trial showed no benefit (3)
tacrolimus is a topically active immunosuppressant - a Drugs and Therapeutic Bulletin review (4) concluded that it is an effective topical treatment, appropriate for use under the guidance of a specialist
Reference:
Prescriber (2001); 12(12).
Update (1999); 59 (3): 189-200.
Hederos CA, Berg A. Epogam evening primrose oil treatment in atopic dermatitis and asthma. Arch Dis Child 1996;75:494-7.
Drugs and Therapeutics Bulletin (2002); 40:73-5.
