A 20-year-old woman complains of skin problems and is noted to have erythematous papules on her face with blackheads (open comedones) and whiteheads (closed comedones). She has also had cystic lesions. She is prescribed topical tretinoin, but without a totally acceptable result. You are considering oral antibiotics, but the patient requests oral isotretinoin, which several of her college classmates have used with benefit. Which of the following statements is correct?
a/. Intralesional triamcinolone should be avoided due to its systemic effects.
b/. Systemically administered isotretinoin therapy cannot be considered unless concomitant contraceptive therapy is provided.
c/. Antimicrobial therapy is of no value since bacteria are not part of the pathogenesis of the process.
d/. The teratogenic effects of isotretinoin are its only clinically important side effects.
e/. The patient will not benefit from topical antibiotics since she did not respond to topical retinoids.
Answer
The answer is B
In general, the treatment of acne is based on the stage of the disease. Comedonal acne is first managed with topical retinoids. Mild to moderate disease usually requires the use of topical antibiotics, and moderate to severe acne is often managed with oral antibiotics, usually tetracycline derivatives. The more severe papulonodular forms may require the addition of isotretinoin supplemented with intralesional steroids for cystic lesions.
Isotretinoin has a high potential for teratogenicity and should not be used in women in their childbearing years unless contraception (preferably dual contraception) is being practiced. The drug also causes hypertriglyceridemia, musculoskeletal pains, and drying of mucous membranes. It should be reserved for severe or refractory acne. Intralesional triamcinolone is effective for occasional cystic lesions and does not cause systemic side effects. Antimicrobial therapy is of value, in part due to its suppressive effect on Propionibacterium acnes. The combination of topical retinoids and topical antibiotics has been shown to be better than topical retinoids alone.
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Dermatology
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