How is acne vulgaris diagnosed

Acne vulgaris is the most prevalent chronic skin disease in the United States, affecting nearly 50 million people per year, mostly adolescents and young adults. Potential sequelae of acne, such as scarring, dyspigmentation, and low self-esteem, may result in significant morbidity. Typical acne lesions involve the pilosebaceous follicles and the interrelated processes of sebum production, Cutibacterium acnes (previously called Propionibacterium acnes) colonization, and inflammation. Acne may be classified as mild, moderate, or severe based on the number and type of skin lesions. Multiple treatment agents and formulations are available, with each agent targeting a specific area within acne pathogenesis. Treatment selection is based on disease severity, patient preference, and tolerability. Topical retinoids are indicated for acne of any severity and for maintenance therapy. Systemic and topical antibiotics should be used only in combination with benzoyl peroxide and retinoids and for a maximum of 12 weeks. Isotretinoin is used for severe, recalcitrant acne. Because of the risk of teratogenicity, patients, pharmacists, and prescribers must register with the U.S. Food and Drug Administration–mandated risk management program, iPledge, before implementing isotretinoin therapy. There is limited evidence for physical modalities (e.g., laser therapy, light therapy, chemical peels) and complementary therapies (e.g., purified bee venom, low-glycemic-load diet, tea tree oil); therefore, further study is required.

Acne vulgaris is the most prevalent chronic skin disease in the United States, affecting nearly 50 million people.1 Acne is most common in adolescents and young adults but may persist into the 30s and 40s at a cost of $3 billion. Sequelae of acne include scarring, dyspigmentation, depression, anxiety, and low self-esteem. Specific estimates of prevalence for psychiatric comorbidities vary, and further study is needed.2,3

Pathogenesis

Acne vulgaris is a chronic disease originating within the pilosebaceous follicles. Four interrelated processes are involved: sebum overproduction, abnormal shedding of follicular epithelium, follicular colonization by Cutibacterium acnes (previously called Propionibacterium acnes), and inflammation.4–6

Sebum overproduction is the result of excessive androgen hormones or a heightened sebaceous gland sensitivity to normal levels of androgen hormones.7 Inflammatory pathway activation is evident at all stages of acne progression.7 There may also be a genetic component to acne.8 Certain foods and drinks, particularly those with a high glycemic index (e.g., sugary drinks, starchy foods, highly processed foods) and skim milk, seem to affect acne severity.9,10 Other factors that may be involved in the development or progression of acne include psychological stress, tobacco smoke, and damaged or unhealthy skin.9–13

Classification

Acne lesions typically occur on the face, chest, or upper back. The lesions may be noninflammatory closed comedones (i.e., papules formed by the accumulation of sebum/keratin within the hair follicle; also called whiteheads); open comedones (i.e., distension of the hair follicle with keratin leads to opening of the follicle, oxidation of lipids, and deposition of melanin; also called blackheads); or inflammatory papules, nodules, pustules, and cysts. Inflammatory lesions result from follicle rupture triggering an inflammatory response. Based on the extent and types of lesions, acne severity may be classified as mild, moderate, or severe (Figure 1,Figure 2, and Figure 3). However, there is currently no universally accepted grading system for acne.1,2  Several skin conditions should be considered in the differential diagnosis of acne (Table 1).2

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FIGURE 1.

Inflammatory acne with pustules and scarring.


FIGURE 1.

Inflammatory acne with pustules and scarring.

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FIGURE 2.

Mild acne with closed comedones and pustules.


FIGURE 2.

Mild acne with closed comedones and pustules.

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FIGURE 3.

Severe inflammatory acne with open comedones, cysts, and nodules.


FIGURE 3.

Severe inflammatory acne with open comedones, cysts, and nodules.

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TABLE 1.

Differential Diagnosis of Acne Vulgaris

DiagnosisDistinguishing characteristics

Acne cosmetica

Associated with use of heavy oil-based hair products and cosmetics and resolves with discontinuation of these products

Drug-induced acne

Monomorphic lesions and history of medication use (glucocorticoids, lithium, oral contraceptives, phenytoin [Dilantin], isoniazid, androgens)

Folliculitis

Monomorphic lesions, abrupt onset and variable distribution with absence of comedones, spreads with scratching or shaving

Hidradenitis suppurativa

Double-headed comedones (two pustules), inflamed nodules with abscesses, predilection for intertriginous areas, sinus tracts

Miliaria

Nonfollicular papules, pustules, and vesicles; occurs in response to heat or exertion

Perioral dermatitis

Papules, pustules, and erythema confined to the chin and nasolabial folds with sparing of the area directly adjacent to the vermilion border

Pseudofolliculitis barbae

Occurs in bearded areas with short, curly hair that is shaved closely

Rosacea

Erythema and telangiectasia, absence of comedones

Seborrheic dermatitis

Greasy scales with yellow-red, coalescing macules and papules

TABLE 1.

Differential Diagnosis of Acne Vulgaris

DiagnosisDistinguishing characteristics

Acne cosmetica

Associated with use of heavy oil-based hair products and cosmetics and resolves with discontinuation of these products

Drug-induced acne

Monomorphic lesions and history of medication use (glucocorticoids, lithium, oral contraceptives, phenytoin [Dilantin], isoniazid, androgens)

Folliculitis

Monomorphic lesions, abrupt onset and variable distribution with absence of comedones, spreads with scratching or shaving

Hidradenitis suppurativa

Double-headed comedones (two pustules), inflamed nodules with abscesses, predilection for intertriginous areas, sinus tracts

Miliaria

Nonfollicular papules, pustules, and vesicles; occurs in response to heat or exertion

Perioral dermatitis

Papules, pustules, and erythema confined to the chin and nasolabial folds with sparing of the area directly adjacent to the vermilion border

Pseudofolliculitis barbae

Occurs in bearded areas with short, curly hair that is shaved closely

Rosacea

Erythema and telangiectasia, absence of comedones

Seborrheic dermatitis

Greasy scales with yellow-red, coalescing macules and papules

Treatment

TOPICAL AGENTS

Acne treatment is based on severity and location on the skin (Figure 4).2  Effective topical therapies are available over the counter and by prescription and come in multiple formulations (e.g., washes, creams, pads) and strengths, permitting individualized treatment. Table 2, Table 3, and Table 4 summarize the topical agents used in the treatment of acne.1,2,14

Benzoyl Peroxide. Benzoyl peroxide is comedolytic, anti-inflammatory, and bactericidal against C. acnes.15 Benzoyl peroxide is available over the counter and by prescription in multiple strengths and formulations, and can be used alone or in combination with topical antibiotics or retinoids. A reduction in acne lesion count may occur within days of initiating treatment with benzoyl peroxide.15 Use of benzoyl peroxide itself does not induce bacterial resistance.1,15,16 Benzoyl peroxide is safe to use during pregnancy. Adverse effects of benzoyl peroxide include burning, dryness, stinging, erythema, peeling, hypersensitivity, and bleaching of hair or clothing.

Topical Antibiotics. Topical antibiotics, including clindamycin 1% and erythromycin 2%, are commonly used for the treatment of mild to moderate acne in combination with benzoyl peroxide. Topical antibiotics possess anti-inflammatory and, depending on the formulation, bacteriostatic or bactericidal properties.16,17 Clindamycin is favored over erythromycin because of the declining effectiveness of erythromycin, which is likely associated with emerging resistance of C. acnes.16–19 To reduce the risk of resistance, use of topical antibiotics as monotherapy or maintenance therapy is not recommended, and the duration of therapy should be limited to 12 weeks.16–19

Erythromycin and clindamycin are available in combination with benzoyl peroxide, and clindamycin is available in combination with retinoids. Use of combination agents is recommended to reduce the risk of resistance (benzoyl peroxide) and to enhance effectiveness (retinoids, benzoyl peroxide).1 Topical antibiotics may have mild adverse effects, including burning, erythema, and pruritus, mainly when used in combination with benzoyl peroxide and retinoids. A rare serious adverse effect is Clostridium difficile colitis (clindamycin and erythromycin).1

Retinoids. Retinoids are vitamin A derivatives recommended as a component in the primary treatment of noninflammatory acne and most inflammatory acne, regardless of severity. Retinoids are effective against microcomedo and comedo formation and have anti-inflammatory effects.1,20–22Retinoids are indicated as monotherapy for mild comedonal acne, in combination with other topical or oral agents for the treatment of moderate to severe acne, and as maintenance therapy once treatment goals are achieved and oral agents are discontinued.1,14,17,20–23

Retinoids approved by the U.S. Food and Drug Administration (FDA) include adapalene (Differin), tazarotene (Tazorac), and tretinoin (Retin-A). Tazarotene is more effective than tretinoin or adapalene, although adapalene is less irritating than tazarotene. There are multiple formulations and strengths of tretinoin, and a gradual increase in strength minimizes skin irritation.20–22 Although more costly, the topical combination agents clindamycin phosphate 1.2%/tretinoin 0.025% (Veltin, Ziana) and adapalene 0.1% or 0.3%/benzoyl peroxide 2.5% (Epiduo) may enhance compliance. Oxidation, a chemical reaction, occurs with tretinoin (except with the microsphere formulation) when used in combination with benzoyl peroxide. Because oxidation causes degradation of tretinoin, reducing its effectiveness, simultaneous application of benzoyl peroxide and tretinoin should be avoided.

Adverse effects of retinoids include erythema, dryness, pruritus, stinging, and photosensitivity (use of sunscreens is recommended).1 Tretinoin and tazarotene are not indicated during pregnancy.1 Several agents that contain retinoids are FDA approved for use in adolescents. Adapalene 0.1%/benzoyl peroxide 2.5% is approved for patients nine years and older, and tretinoin 0.05% micronized gel is approved for patients 10 years and older. All other retinoids are approved for patients 12 years and older.1,14

Azelaic Acid. Azelaic acid 20% (Azelex) is FDA approved as an alternative treatment for acne, alone or in combination with other agents. It has mildly comedolytic, antibacterial, and anti-inflammatory properties.1 Advantages of azelaic acid 20% include the potential for safe use in pregnancy and its effectiveness in the treatment of postinflammatory dyspigmentation. Although usually well tolerated, azelaic acid 20% may cause burning, stinging, and hypopigmentation in individuals with dark skin.1,24

Dapsone. Dapsone 5% or 7.5% gel (Aczone) has anti-inflammatory and antibacterial properties and is effective as an adjunct therapy in the treatment of acne. A meta-analysis of multiple randomized controlled, double-blind trials showed that topical dapsone is more effective in adult women compared with men or adolescent females.25 Dapsone may cause mild to moderate local irritation. Testing for glucose-6-phosphate dehydrogenase deficiency is unnecessary.1,25

Other Topical Agents. There is insufficient evidence to support the use of over-the-counter therapies containing salicylic acid, niacinamide (nicotinamide), sulfacetamide, sulfur, zinc, or resorcinol. There are only two studies of aluminum chloride, with conflicting outcomes.1

SYSTEMIC ANTIBIOTICS

Tetracyclines, macrolides, trimethoprim/sulfamethoxazole, trimethoprim, penicillins, and cephalosporins have been used effectively in the treatment of inflammatory acne.1,23,26Systemic antibiotics (Table 51,2,14) are indicated in the management of moderate to severe inflammatory acne and should be used in combination with nonantibiotic topical agents to prevent resistance and enhance effectiveness.1,23

A recent systematic review found that no antibiotic class, individual antibiotic, or dosage is superior.23 However, the American Academy of Dermatology (AAD) recommends doxycycline and minocycline (Minocin) as first-line therapies based on studies indicating superiority over tetracycline and azithromycin (Zithromax).1,26


FIGURE 4.

Severity-based approach to treating acne vulgaris.

Adapted with permission from Titus S, Hodge J. Diagnosis and treatment of acne. Am Fam Physician. 2012;86(8):736. Accessed July 11, 2019. https://www.aafp.org/afp/2012/1015/p734.html

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TABLE 2.

Nonantibiotic Topical Agents for the Treatment of Acne Vulgaris

Medication*Adverse effectsPregnancy/children†Cost‡

Azelaic acid (Azelex, Finacea)§

Burning, dryness, stinging, erythema, pruritus, hypersensitivity reaction, asthma exacerbation, hypopigmentation in individuals with dark skin

May use during pregnancy; no human data available, although risk of fetal harm is not expected based on minimal systemic absorptionSafety and effectiveness not established in children younger than 12 years

20% cream: — ($680) for a 50-g tube15% gel: $120 ($345) for a 50-g tube

Benzoyl peroxide

Burning, dryness, stinging, erythema, peeling, hypersensitivity, bleaching of hair or clothing

May use during pregnancy; inadequate human data available, although risk of fetal harm is not expected based on minimal systemic absorptionSafety and effectiveness not established in children younger than 12 years

Variable cost based on over-the-counter vs. prescription, brand vs. generic, formulation (many available), and size

Dapsone (Aczone)

Burning, dryness, erythema, pruritus, orange staining of skin

May use during pregnancy; no human data available, although risk of fetal harm is not expected based on minimal systemic absorptionSafety and effectiveness not established in children younger than 12 years

5% gel: $250 ($665) for a 60-g tube7.5% gel: — ($665) for a 60-g tube

TABLE 2.

Nonantibiotic Topical Agents for the Treatment of Acne Vulgaris

Medication*Adverse effectsPregnancy/children†Cost‡

Azelaic acid (Azelex, Finacea)§

Burning, dryness, stinging, erythema, pruritus, hypersensitivity reaction, asthma exacerbation, hypopigmentation in individuals with dark skin

May use during pregnancy; no human data available, although risk of fetal harm is not expected based on minimal systemic absorptionSafety and effectiveness not established in children younger than 12 years

20% cream: — ($680) for a 50-g tube15% gel: $120 ($345) for a 50-g tube

Benzoyl peroxide

Burning, dryness, stinging, erythema, peeling, hypersensitivity, bleaching of hair or clothing

May use during pregnancy; inadequate human data available, although risk of fetal harm is not expected based on minimal systemic absorptionSafety and effectiveness not established in children younger than 12 years

Variable cost based on over-the-counter vs. prescription, brand vs. generic, formulation (many available), and size

Dapsone (Aczone)

Burning, dryness, erythema, pruritus, orange staining of skin

May use during pregnancy; no human data available, although risk of fetal harm is not expected based on minimal systemic absorptionSafety and effectiveness not established in children younger than 12 years

5% gel: $250 ($665) for a 60-g tube7.5% gel: — ($665) for a 60-g tube

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TABLE 3.

Topical Antibiotics for the Treatment of Acne Vulgaris

Medication*Adverse effectsPregnancy/children†Cost‡

Clindamycin 1% (Cleocin, Evoclin)

Pruritus, erythema, dryness, peeling, Clostridium difficile colitis, folliculitis, photosensitivity

May use during pregnancy; no human data available, although risk of fetal harm is not expected based on minimal systemic absorptionSafety and effectiveness not established in children younger than 12 years

Gel: $70 ($285) for a 60-g tubeLotion: $50 ($220) for 60-mL bottleSolution: $30 ($150) for a 60-mL bottleFoam: $190 ($500) for a 50-g can

Clindamycin 1%/benzoyl peroxide 5% (Benzaclin)

Pruritus, erythema, dryness, peeling, C. difficile colitis, anaphylaxis

May use during pregnancy; no human data available, although risk of fetal harm is not expected based on expected limited systemic absorptionSafety and effectiveness not established in children younger than 12 years

Gel: $70 ($190) for a 25-g jar

Erythromycin 2% (Erygel, Ery)

Dryness, irritation, C. difficile colitis

May use during pregnancy; no human data available, although risk of fetal harm not expected based on minimal systemic absorptionSafety and effectiveness not established in children younger than 12 years

Gel: $70 ($12§) for a 60-g tubeSolution: $25 (—) for a 60-mL bottlePads: $40 ($40) for 60 pledgets

Erythromycin 3%/benzoyl peroxide 5% (Benzamycin)

Pruritus, erythema, dryness, peeling, burning, urticaria, C. difficile colitis

May use during pregnancy; no human data available, although risk of fetal harm is not expected based on minimal systemic absorptionSafety and effectiveness not established in children younger than 12 years

Gel: $130 ($85) for a 46.6-g jar

TABLE 3.

Topical Antibiotics for the Treatment of Acne Vulgaris

Medication*Adverse effectsPregnancy/children†Cost‡

Clindamycin 1% (Cleocin, Evoclin)

Pruritus, erythema, dryness, peeling, Clostridium difficile colitis, folliculitis, photosensitivity

May use during pregnancy; no human data available, although risk of fetal harm is not expected based on minimal systemic absorptionSafety and effectiveness not established in children younger than 12 years

Gel: $70 ($285) for a 60-g tubeLotion: $50 ($220) for 60-mL bottleSolution: $30 ($150) for a 60-mL bottleFoam: $190 ($500) for a 50-g can

Clindamycin 1%/benzoyl peroxide 5% (Benzaclin)

Pruritus, erythema, dryness, peeling, C. difficile colitis, anaphylaxis

May use during pregnancy; no human data available, although risk of fetal harm is not expected based on expected limited systemic absorptionSafety and effectiveness not established in children younger than 12 years

Gel: $70 ($190) for a 25-g jar

Erythromycin 2% (Erygel, Ery)

Dryness, irritation, C. difficile colitis

May use during pregnancy; no human data available, although risk of fetal harm not expected based on minimal systemic absorptionSafety and effectiveness not established in children younger than 12 years

Gel: $70 ($12§) for a 60-g tubeSolution: $25 (—) for a 60-mL bottlePads: $40 ($40) for 60 pledgets

Erythromycin 3%/benzoyl peroxide 5% (Benzamycin)

Pruritus, erythema, dryness, peeling, burning, urticaria, C. difficile colitis

May use during pregnancy; no human data available, although risk of fetal harm is not expected based on minimal systemic absorptionSafety and effectiveness not established in children younger than 12 years

Gel: $130 ($85) for a 46.6-g jar

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TABLE 4.

Topical Retinoids for the Treatment of Acne Vulgaris

Medication*Adverse effectsPregnancy/children†Cost‡

Adapalene (Differin)

Burning, peeling, stinging, pruritus, erythema, dryness, photosensitivity

May use during pregnancy; risk of fetal harm not expected based on limited human data and insignificant systemic absorptionApproved for use in children 12 years and older

Cream: $100 ($380) for a 45-g tube0.1% gel: $70 ($600) for a 45-g tube0.3% gel: $100 ($360) for a 45-g tubeLotion: $300 ($350) for a 59-mL bottle

Adapalene/benzoyl peroxide (Epiduo)

Burning, peeling, stinging, pruritus, erythema, dryness, photosensitivity

May use during pregnancy; risk of fetal harm not expected based on limited human data and insignificant systemic absorptionApproved for use in children nine years and older

0.1%/2.5% gel: $80 ($360) for a 45-g pump0.3%/2.5% gel: — ($480) for a 45-g pump

Clindamycin phosphate/tretinoin (Veltin, Ziana)

Burning, peeling, stinging, pruritus, erythema, dryness, photosensitivity, colitis

Consider avoiding use during pregnancy, especially in the first trimester Approved for use in children 12 years and older

1.2%/0.025% gel: $300 ($740) for a 60-g tube

Tazarotene (Tazorac)

Burning, peeling, stinging, pruritus, erythema, dryness, photosensitivity

Use alternative during pregnancyApproved for use in children 12 years and older

0.05% cream: — ($830) for a 60-g tube0.1% cream: $250 ($875) for a 60-g tube0.05% gel: — ($415) for a 30-g tube0.01% gel: — ($440) for a 30-g tube

Tretinoin (Retin-A, Atralin)

Burning, peeling, stinging, pruritus, erythema, dryness, photosensitivity

Consider avoiding use during pregnancy, especially in the first trimesterApproved for use in children 10 years and older

Cream (for a 45-g tube): 0.025%: $85 ($100) 0.05%: $100 ($100) 0.1%: $150 ($100)

Gel (for a 45-g tube): 0.01%: $90 ($100) 0.025%: $60 ($100) 0.05%: $200 ($600)

Microsphere (for a 45-g tube): 0.04%: $200 ($800) 0.1%: $200 ($800)

TABLE 4.

Topical Retinoids for the Treatment of Acne Vulgaris

Medication*Adverse effectsPregnancy/children†Cost‡

Adapalene (Differin)

Burning, peeling, stinging, pruritus, erythema, dryness, photosensitivity

May use during pregnancy; risk of fetal harm not expected based on limited human data and insignificant systemic absorptionApproved for use in children 12 years and older

Cream: $100 ($380) for a 45-g tube0.1% gel: $70 ($600) for a 45-g tube0.3% gel: $100 ($360) for a 45-g tubeLotion: $300 ($350) for a 59-mL bottle

Adapalene/benzoyl peroxide (Epiduo)

Burning, peeling, stinging, pruritus, erythema, dryness, photosensitivity

May use during pregnancy; risk of fetal harm not expected based on limited human data and insignificant systemic absorptionApproved for use in children nine years and older

0.1%/2.5% gel: $80 ($360) for a 45-g pump0.3%/2.5% gel: — ($480) for a 45-g pump

Clindamycin phosphate/tretinoin (Veltin, Ziana)

Burning, peeling, stinging, pruritus, erythema, dryness, photosensitivity, colitis

Consider avoiding use during pregnancy, especially in the first trimester Approved for use in children 12 years and older

1.2%/0.025% gel: $300 ($740) for a 60-g tube

Tazarotene (Tazorac)

Burning, peeling, stinging, pruritus, erythema, dryness, photosensitivity

Use alternative during pregnancyApproved for use in children 12 years and older

0.05% cream: — ($830) for a 60-g tube0.1% cream: $250 ($875) for a 60-g tube0.05% gel: — ($415) for a 30-g tube0.01% gel: — ($440) for a 30-g tube

Tretinoin (Retin-A, Atralin)

Burning, peeling, stinging, pruritus, erythema, dryness, photosensitivity

Consider avoiding use during pregnancy, especially in the first trimesterApproved for use in children 10 years and older

Cream (for a 45-g tube): 0.025%: $85 ($100) 0.05%: $100 ($100) 0.1%: $150 ($100)

Gel (for a 45-g tube): 0.01%: $90 ($100) 0.025%: $60 ($100) 0.05%: $200 ($600)

Microsphere (for a 45-g tube): 0.04%: $200 ($800) 0.1%: $200 ($800)

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TABLE 5.

Systemic Antibiotics for the Treatment of Moderate to Severe Inflammatory Acne Vulgaris

MedicationDosageAdverse effectsPregnancy/children*Cost†

Doxycycline (Vibramycin, Acticlate)

Children: 2 mg per kg per dose every 12 hours on day 1, then 2 mg per kg once per day thereafter (maximum dose is 100 mg)Adults: 50 to 100 mg once or twice per day

Nausea, diarrhea, dyspepsia, esophagitis, headache, vaginal candidiasis, photosensitivity, tooth/bone discoloration, pseudotumor cerebri, hepatotoxicity, Clostridium difficile colitis

Avoid use during pregnancySafety and effectiveness not established in children younger than eight years

$15 ($380) for 30 100-mg capsules$300 ($1,100) for 30 150-mg tablets

Erythromycin‡

Children and adults: 250 to 500 mg two to four times per day

Nausea, vomiting, drug interactions, arrhythmias

May use during pregnancy; possible risk of fetal harm based on conflicting human dataSafe for use in children

$480 (—) for 60 250-mg tablets

Minocycline (Minocin)

Children: 1 mg per kg once per dayAdults: 50 mg one to three times per day

Nausea, vomiting, diarrhea, vestibular dysfunction, photosensitivity, hyperpigmentation, pseudotumor cerebri, lupus-like reaction, drug reaction with eosinophilia and systemic symptoms, hepatotoxicity, Stevens-Johnson syndrome

Avoid use during pregnancyNot indicated in children younger than eight years

$15 ($850) for 30 50-mg capsules$40 (—) for 30 50-mg tablets

Sarecycline (Seysara)

Children and adults 33 to 54 kg (73 to 119 lb): 60 mg per day 55 to 84 kg (121 to 185 lb): 100 mg per day 85 to 136 kg (187 to 300 lb): 150 mg per dayTreat for 12 weeks then reassess

Nausea, lightheadedness, dizziness, vertigo, headache, vaginal candidiasis, photosensitivity, tooth/bone discoloration, pseudotumor cerebri, hepatotoxicity, C. difficile colitis

Avoid use during pregnancy or while breastfeedingAvoid use in children younger than nine years

— ($900) for 30 tablets of any strength

Tetracycline

Children: 25 to 50 mg per kg per day in two to four divided dosesAdults: 250 to 500 mg once or twice per day

Nausea, vomiting, diarrhea, abdominal pain, photosensitivity, tooth and nail discoloration, pseudotumor cerebri, hepatotoxicity, urticaria

Avoid use during pregnancyNot indicated in children younger than eight years

$70 (—) for 30 250-mg capsules

Trimethoprim/sulfamethoxazole‡

Children and adults: 160/800 mg twice per day

Stevens-Johnson syndrome, toxic epidermal necrolysis, hepatotoxicity, bone marrow suppression, drug eruptions

Consider alternative during pregnancy; possible risk of spontaneous abortion based on limited human data; possible risk of congenital neural tube and cardiovascular defects based on conflicting human data and trimethoprim's mechanism of actionSafety and effectiveness not established in children younger than two months

$15 (—) for 60 160/800-mg tablets

TABLE 5.

Systemic Antibiotics for the Treatment of Moderate to Severe Inflammatory Acne Vulgaris

MedicationDosageAdverse effectsPregnancy/children*Cost†

Doxycycline (Vibramycin, Acticlate)

Children: 2 mg per kg per dose every 12 hours on day 1, then 2 mg per kg once per day thereafter (maximum dose is 100 mg)Adults: 50 to 100 mg once or twice per day

Nausea, diarrhea, dyspepsia, esophagitis, headache, vaginal candidiasis, photosensitivity, tooth/bone discoloration, pseudotumor cerebri, hepatotoxicity, Clostridium difficile colitis

Avoid use during pregnancySafety and effectiveness not established in children younger than eight years

$15 ($380) for 30 100-mg capsules$300 ($1,100) for 30 150-mg tablets

Erythromycin‡

Children and adults: 250 to 500 mg two to four times per day

Nausea, vomiting, drug interactions, arrhythmias

May use during pregnancy; possible risk of fetal harm based on conflicting human dataSafe for use in children

$480 (—) for 60 250-mg tablets

Minocycline (Minocin)

Children: 1 mg per kg once per dayAdults: 50 mg one to three times per day

Nausea, vomiting, diarrhea, vestibular dysfunction, photosensitivity, hyperpigmentation, pseudotumor cerebri, lupus-like reaction, drug reaction with eosinophilia and systemic symptoms, hepatotoxicity, Stevens-Johnson syndrome

Avoid use during pregnancyNot indicated in children younger than eight years

$15 ($850) for 30 50-mg capsules$40 (—) for 30 50-mg tablets

Sarecycline (Seysara)

Children and adults 33 to 54 kg (73 to 119 lb): 60 mg per day 55 to 84 kg (121 to 185 lb): 100 mg per day 85 to 136 kg (187 to 300 lb): 150 mg per dayTreat for 12 weeks then reassess

Nausea, lightheadedness, dizziness, vertigo, headache, vaginal candidiasis, photosensitivity, tooth/bone discoloration, pseudotumor cerebri, hepatotoxicity, C. difficile colitis

Avoid use during pregnancy or while breastfeedingAvoid use in children younger than nine years

— ($900) for 30 tablets of any strength

Tetracycline

Children: 25 to 50 mg per kg per day in two to four divided dosesAdults: 250 to 500 mg once or twice per day

Nausea, vomiting, diarrhea, abdominal pain, photosensitivity, tooth and nail discoloration, pseudotumor cerebri, hepatotoxicity, urticaria

Avoid use during pregnancyNot indicated in children younger than eight years

$70 (—) for 30 250-mg capsules

Trimethoprim/sulfamethoxazole‡

Children and adults: 160/800 mg twice per day

Stevens-Johnson syndrome, toxic epidermal necrolysis, hepatotoxicity, bone marrow suppression, drug eruptions

Consider alternative during pregnancy; possible risk of spontaneous abortion based on limited human data; possible risk of congenital neural tube and cardiovascular defects based on conflicting human data and trimethoprim's mechanism of actionSafety and effectiveness not established in children younger than two months

$15 (—) for 60 160/800-mg tablets