Sir, acne vulgaris I not a disease but an alteration or aberration in the lipid of sebaceous glands with proliferation of P acnes. Symptoms and signs of acne arises as a result of subsequent block of fine tubules, which secretes lipid out o the glands.
Acne has different modalities of treatment based on cause, severity and underlying conditions.
Under normal conditions the first line would be the use of anti biotic cream, like clindamycin, and or systemic antibiotics, and benzyl peroxide.
The use of chemical peels has accentuated or accelerated the response rate of acne.
retinoids use has also benefitted the client suffering from acne which is given as both systemic and local forms.
IPL has also been giving good results when used judiciously.(Intense Pulsed Light).
So the term resistance may be limited to a few cases where therapy is limited.
Thank you for this information, actually my patient received all medicine mentioned but still had sever acne,
Hi..thatsnot my field of practice but a long course of tetracycline with retinoic acid LA works really well...
Please consider whether it is drug induced, whether she is on chemo, or steroid, or any herpes, or malazezia infection.
kindly try a short dose of ketoconazole,
Dr Ankush, true that's what we follow for many cases, but avoiding a long course of tetracycline is best to protect the gut
Propionibacterium acnes is close UV light sensitive. It is possible to decrease its population using 410-390 nm UV light. It is clear than it is not the way to prevent the problem however it is able to help pharmacotherapy.
Not my area of expertise but topical application of essential oils can reduce scarring. http://www.organicauthority.com/5-clear-skin-tricks-with-acne-fighting-essential-oils
Dear Ghaly I see you are asking about poor or non responsive in treatment of Acne Vulgaris that's mean refractory or recalcitrant case so usual modalities either topical or systemic in such a case Isotretinoin (Vitamine A acid derivatives) 0.5-0.75 mg/kg body weight/day for 16-52 weeks preferable at grafe 3-4 after doing Liver Function Test and absolutely condemned in pregnancy of absolute teratogenicity.
I disegree with Lavon's idea. Essential oils are irritating agents. Even in the cited text is written: "Don’t do this if you have extremely sensitive skin" (Tea Tree part), however there is no explanation why. Jojoba oil is irritant also (http://www.acne.org/jojoba-oil.html ) and it can induce some skin problems just after manual massage. Additionaly lipophylic oils can form rather good environment for development of propionibacterium acnes. In my opinion it is not propper way to solve the problem.
5% Dapsone gel may be tried.
The use of Daposone in treatment of Acne vulgaris was suggested as early as 1961 by Dr. C M Ross.
Dapsone has bacteostatic action on selected bacteria.
It has complex actions on functions of neutrophils, antigen-antobody reaction etc.
Has the patient tried Oral dose of Doxycyline 100 MG ?Daily W/Food? And the use of clyindomycine phosphate externally However, the patient must be informed of the extreme sensitivity to light most students udnrg during their iniial period on te medication.
dg wiol e
Dear Ghaly I see still we are taking about the usual modalities in treatment of Acne Vulgaris although the question is about refractory or recalcitrant case I.e poorly or non responding!?
The usual treatments for acne vulgaris would be topical bezoyl peroxide alone or in combination with clindomycine or topical retinoids.
There is a number of casuses for unresponsiveness:
1. The diagnosis may be different (rosacea, acne excorie, perioral dermatitis, POEM syndrome etc).
2. The patient may be non-compliant. - A big problem.
3. Look for the skin care products and procedures, since some of them may aggravate acne.
4. If problems 1-3 have been resolved, the next step of treatment would be a short course of internal tetracyclines and/ or medical peeling with salicylic acid peel.
I would be not so enthusiastic with dapsone, since in individual paptients long standing cytopenias may be induced and evidence based medicine does not provide a good enough scientific background.
The most common cause of 'resistance' is **remarkably** common and grossly under-recognized. I see 3-4 cases a week of this. The topical and oral antibiotics used in acne vulgaris are very effective in killing bacteria and moderately effective in calming inflammation, **even when that inflammation is actually caused by Malassezia**.
The treatment is to give oral ketoconazole in a very low dose schedule. Topical therapy does not work because the yeasts are too deep in the pores and recurrence is common because there is a reservoir in the scalp hair follicles.
For patients 50 kg or less, give one 200 mg tablet of ketoconazole taken with a mouthful of water and followed with a tablespoon of peanut butter (or other fatty load such as bacon and eggs for breakfast). For over 50 kg, use two of the tablets. Wait one hour before other food. This is repeated once weekly for eight weeks and then the dose is gradually reduced to every 2 or 3 or 4 weeks. Bill Cunliffe et al recognized the organism in acne papules in 1988 PMID: 2964856 but somebody misspelled his name. Jan Faergemann recognized the effectiveness of this dose in a 1993 paper on pityriasis versicolor PMID: 8312142 but never tried it in acne.
Want to hear more? Come to AAD Annual Meeting in San Francisco Forum F090: Superficial Mycotic Infections: An Update 03/22/2015, 1:00 PM - 3:00 PM
I am un-sponsored. Or, perhaps better, self-sponsored.
Is Ketaconazol response in Acne Vulgaris due to acne pathogenesis mechanism or to erradication of Malassesia folliculitis associated.
I believe, but cannot prove, that the low dose of ketoconazole cited above is too low to impact androgen metabolism. An alternative theory is that this drug, which is exceptionally lipophilic, concentrates in the Folliculopilosebaceous unit and is a very good anti-inflammatory. Nevertheless, I think it is much more likely that this is an anti-Malassezia effect. See PMID 8245236
anti bacterial effect of ketoconazole against p acnes which are resistant to macrolides. need some more light on this
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oral Isotretinoin for some month with appropriate contraceptive measures
I agree with Dr Honigsmann as that is the alternative treatment for refractory or recalcitrant cases of Acne Vulgaris with the precautions in such treatment.
What about the serious idiosynacratic side effect of Ketoconazole
Dr. Venkata is correct in citing the antibacterial effect of ketoconazole. What we do not know is the effective dose. More study needed.
Dr. Al-Dhalimi's concern reflects a widespread indeed worldwide belief fostered by the known effects of the full dose regimen used for deep fungal infections, and the Package Insert here in the USA perpetuates the problem. I have never seen transaminitis or any other sign of hepatitis, when using keto in the low dose regimen - indeed for over 20 years this has been my 'safe way' to use it. Serial serum AST levels after ingestion show no rise in the few patients I have studied. There is no report of idiosyncratic reaction at the low dose in the over 1200 adverse reaction reports FDA provided me. I hesitate to label this a myth but I have seen no evidence (at this low dose) of side effects other than the GI upset associated with the use of grapefruit juice. That is why I now use peanut butter.
The drug certainly inhibits CYT P450 when used in full dose and thus interferes with elimination of other drugs taken concurrently, they accumulate to excess and produce toxic effects. Care is needed in patients on coumadin, but even with this drug the effect is minimal. There is occasionally a feeling of lethargy for 18-24 hours, an occasional headache, an occasional GI upset (diarrhea). The greatest side effect is the acid reflux occasioned in the prescriber by telephone discussions with pharmacists, pharmacy benefit managers and in-office interactions with "internet-educated" patients. I suggest you pre-empt or counter this ignorance with the attached. Thank you for stimulating me to update it :-)
I get best result by combining RF micr-needle fractional at one month interval.
No side effects and best result in acne and even scaring.
I have found that use of "peeling" with TCA in low doses (5.0% and 2.5%) in a cream has had good effects in controlling the infection and then I use topical vitamin A to change the sebaceous gland activity. Its not really a peel but can be used on alternate days even to control infection. A study (to be published) showed that a TCA cream such as I have described (available through Environ Skin Care) is more effective against more bacteria than any antibiotic. I prefer to use this regime before resorting to cis-retinoic acid therapy.
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