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Moderate to severe acne vulgaris in adolescents and adults: Selection of systemic therapy

Moderate to severe acne vulgaris in adolescents and adults: Selection of systemic therapy
  • Although definitions vary, we consider the presence of 1 or more of the following features indicative of moderate to severe acne:
    • Visually prominent acne consisting of many comedones, inflamed papules, or pustules
    • Presence of large papules or nodules (>5 mm diameter)
    • Involvement of multiple body areas
    • Associated scarring
  • Systemic therapy is not mandatory but is commonly utilized for moderate to severe acne vulgaris to optimize and simplify treatment. With the exception of oral isotretinoin, systemic therapy is typically combined with topical therapy (eg, topical retinoids, benzoyl peroxide, azelaic acid). Patients who prefer to avoid or cannot receive systemic therapies can be treated with topical and/or procedural therapies alone. Refer to UpToDate topics on the overview of the management of acne vulgaris for details.
  • The systemic therapies described here are not appropriate for use during pregnancy. Refer to UpToDate topics on the overview of the management of acne vulgaris for guidance on the treatment of acne vulgaris in pregnancy.
  • The treatment of acne fulminans, a severe variant of acne vulgaris characterized by the acute development of large nodules, friable plaques, erosions, ulcers, and hemorrhagic crusts, is discussed elsewhere in UpToDate.

* Patients with extensive, nodular acne vulgaris (eg, acne conglobata) are at risk for severe acne flares at the start of isotretinoin. Low initial doses of isotretinoin (<0.5 mg/kg per day) given in conjunction with oral glucocorticoids is advised. Refer to UpToDate topics on oral isotretinoin therapy for acne vulgaris for details.

¶ Selection of an appropriate systemic therapy involves consideration of patient characteristics (eg, sex, pregnancy status, risk factors for adverse effects) and patient preference. Refer to UpToDate topics on the management of moderate to severe acne vulgaris for details.

Δ Oral antibiotics should always be used in conjunction with topical benzoyl peroxide to reduce risk for the development of antibiotic resistance. Treatment courses should be limited to 3 to 4 months whenever feasible.

◊ At least a partial response to these therapies is expected within 3 months.
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