The spectrum of systemic therapy and procedural approaches in the management of moderate to severe acne vulgaris: A review

Systemic therapy is usually required in patients with moderate to severe acne, especially when scarring potential is present. The most common approaches to systemic treatment include the choice of various antibiotics, isotretinoin and hormones. Oral antibiotics are indicated for moderate to severe inflammatory acne, preferably in combination with topical agents that reduce follicular plugging. Tetracyclines (tetracycline, minocycline, doxycycline, lymecycline) and macrolides (erythromycin, azithromycin, roxithromycin) are the antibiotics of choice. Antibiotic systemic therapy should last no longer than the time to achieve control of acne in order to minimize the chance of drug resistance. Oral isotretinoin is recommended as the treatment of choice in severe nodulocystic/conglobate acne. It may be used in patients who failed conventional treatment, who have scarring or chronic relapsing acne, and in patients with severe psychological distress from acne. According to recent European agency findings, isotretinoin is restricted to use as a second-line treatment in severe forms of acne that are resistant to adequate courses of conventional therapy. Hormonal therapy includes anti-androgens, estrogens and agents that block ovarian and adrenal androgen production. It represents an alternative therapeutic approach in women with elevated or normal serum androgens. It may also be warranted for females with severe seborrhea, clinically apparent androgenic alopecia, seborrhea/acne/hirsutism/alopecia syndrome, late-onset acne. Alternative systemic therapy includes dapsone. Procedural treatment approaches include comedone extraction, skin resurfacing, phototherapy and photodynamic therapy, thermotherapy, cryotherapy and cryoslush therapy, intralesional injections of corticosteroids, and herbal therapy.