List Of Acne Medications

Acne vulgaris is one of the most common dermatologic conditions that affects nearly everyone at some point in their lifetime. Once thought as a condition only affecting teenagers, prevalence in adulthood has been increasing, especially in women 25 years of age and older.

Almost 90% of all teenagers will report acne, and many will experience persistent acne into adulthood; by 40 years of age 1% of men and 5% of women will still have lesions.

Despite the prevalence being higher in adolescents, the mean age for presentation to a physician is 24 years with 10% of office visits being made by patients between the ages of 35 and 44 years.

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Although not life-threatening, acne may result in permanent scarring and long-lasting psycho-social effects, including low self-esteem, social anxiety, and depression. The avoidance of such consequences motivates patients to seek treatment; over $1 billion is spent on prescription medications annually, and the OTC market is estimated to be anywhere from 2 to 4 times this amount.

Many patients will frequently seek OTC options prior to being evaluated by a physician for many reasons, including lower out-of-pocket costs, ease of accessibility, less irritation compared with prescription products, and perceived safety.

There are many products available without a prescription for the treatment of acne, and pharmacists are in an ideal position to aid patients in the appropriate selection of a therapeutic regimen and provide education on the appropriate use.

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Acne is a multifactorial inflammatory disease of the pilosebaceous duct, resulting in bacterial over-growth and inflammation. Four pathophysiologic processes have been identified in contributing to the formation of lesions

: 1) abnormal keratinocyte proliferation and desquamation; 2) androgen-driven increase in sebum production; 3) proliferation of Propionibacterium acnes; and 4) inflammatory mediators.

The pilosebaceous unit consists of a hair follicle and surrounding sebaceous glands. These units can be found all over the dermis except for the palms and soles; the highest concentrations can be found on the face, upper back, and chest area.

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An increased production of androgen, usually coinciding with the onset of puberty, causes abnormal epithelial desquamation and hyperkeratin-ization, along with an increase in sebum secretion by the sebaceous glands. The accumulation of sebum, epithelial cells, and keratin within the follicle eventually obstructs the follicle, leading to the formation of a keratin plug and follicle swelling.

This results in the formation of a microcomedone, the primary precursor lesion of acne that is not visible to the naked eye.

With the continued swelling of the follicle and enlargement of the keratin plug, a visible comedone will eventually form. Two types of comedones can emerge: a comedone with a widely dilated opening (open comedone or blackhead) or a comedone with a microscopic opening (closed comedone or whitehead).

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Increased sebum production can result in the proliferation of P acnes, a gram-positive anaerobe that is part of the normal skin flora. This leads to release of chemical mediators that promote inflammation.

The formation of more severe acne lesions such as papules, pustules, nodules, or cysts develop when comedones rupture and contents of the pilosebaceous unit spill out into the surrounding area.

Acne appears earlier in girls, but more boys are affected during the adolescence years; the average age for the onset of acne is 11 years in girls, affecting up to 82%, and 12 years in boys, affecting up to 95%. Recently, there has been a rise in the appearance of acne in those as young as 8 or 9 years of age. This increase at such a young age has been attributed to the decreasing age of puberty onset.

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Ethnicity and genetics may influence acne prevalence and severity. A positive family history of acne can greatly increase someone’s risk. Scarring and hyperpigmentation occur more commonly in those with darker pigmented skin. Several modifiable factors have also been associated with increasing acne risk. These include cigarette smoking, a diet high in dairy and glycemic carbohydrate intake, hot and humid conditions, local irritation or friction (occlusive clothing or repeated scrubbing), use of oil-based skin and hair products, prolonged sweating, and emotional stress.

A patient’s medication history should also be taken into consideration when evaluating risk factors for acne. Drugs that can increase an individual’s risk include anti-epileptics, corticosteroids, hormones, calcineurin blockers, phenytoin, carbamazepine, lithium, aripiprazole, trazodone, and haloperidol.

Acne is characterized by the presence of lesions most commonly on the face, neck, chest, or back. These lesions include noninflammatory open or closed comedones and inflammatory lesions characterized as papules, pustules, nodules, and cysts. Currently, there is no single accepted universal grading system. In general, acne can be classified as mild, moderate, or severe (TABLE 1).

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Patients should avoid any contributing factors that may increase their risk of developing acne. In addition, basic facial care with twice-daily washings using a mild noncomedogenic soap is recommended. Patients should also avoid oily skin products, touching their face, and manipulating or picking at the lesions.

Acne is usually a self-limiting dis-ease, but many agents are available to help minimize symptoms and reduce scarring, which can lead to improvements in quality of life. Management of acne can be divided into two phases: the initial treatment phase, which aims at reducing the severity in a relatively short period of time, and the maintenance phase, which aims to prevent recurrence.

Acne treatment may be required for a few months to several years. Initial symptom improvement may take up to 8 weeks. It is important to educate patients about the importance of continual use and that symptoms may actually appear to worsen during the first few weeks of treatment.

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There is an array of therapies available OTC for the management of acne. They include topical products, mechanical treatments, essential oils, and vitamins (TABLE 2).

There are many topical nonprescription products available for the management of acne. Topical agents are only active where and when they are applied. Topical therapy can be used as monotherapy or in combination with other topical therapies and/or oral agents for both initial control and maintenance of acne.

Benzoyl Peroxide: Benzoyl peroxide has been used in the management of acne since the late 1970s. It has bactericidal activity against P acnes and is most commonly used as a first-line treatment.

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It is available in a variety of dosage forms, including creams, lotions, gels, foams, and washes and in concentrations ranging from 2.5% to 10%. It can be used as a leave-on or wash-off agent; however, reduction of P acnes is more effective with leave-on products.

Recommend a lower concentration, water-based, wash-off product to patients with sensitive skin. Newer products are often combined with a moisturizer to decrease skin redness and irritation. Patients should be counseled on the importance of avoiding excessive sun exposure and use of sunscreen and protective clothing. In addition, patients should be warned about the possibility of staining and bleaching of fabric and hair.

Hydroxy Acids: Hydroxy acids are classified into two categories: alpha-hydroxy acids (AHAs) and beta-hydroxy acids (BHAs). The two types of AHAs found in OTC products are glycolic acid from sugar cane and lactic acid from milk. They are available in concentrations up to 10% and can be found as washes, creams, lotions, and peel kits. Glycolic acid used in the form of a chemical peel may be useful in the treatment of mild scarring and mild improvement in noninflammatory lesions.

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Salicylic acid is the only BHA used in dermatologic practice. It is a comedolytic agent but is considered less potent than benzoyl peroxide; it should be considered for use in patients who cannot tolerate benzoyl peroxide or in combination with other more effective medications.

It is available in many OTC acne products in concentrations ranging from 0.5% to 2%. When used in concentrations >2%, it has been associated with local skin peeling.

Two studies have demonstrated tea tree oil’s efficacy in treating acne, although when compared to benzoyl peroxide, it had a slower onset of action.

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Nicotinamide is a derivative of niacin that is used both orally and topically in the treatment of acne. Topical nicotinamide 4% has been shown to be as effective as clindamycin gel 1%, but further studies are needed to assess nicotinamide’s role in the treatment of acne. Retinol is naturally occurring vitamin A. It is transformed into several metabolites, including retinoic acid. Theoretically, topical retinol should be beneficial in the treatment of acne, but no studies have been performed demonstrating this effect. Zinc is bacteriostatic against P acnes and may be effective in the treatment of severe and inflammatory acne.

Adapalene Gel: In July 2016, the FDA approved Differin Gel 0.1% (adapalene) for OTC use in those 12 years of age and older.

This approval made Differin the first prescription acne medication to go OTC since the 1980s. Patients will now have access to a new, safe, and effective OTC option, which is important since acne is so frequently occurring. Differin is also available as a 0.3% gel; however, this strength still requires a prescription.

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Differin is a type of retinoid, a class of medications commonly used to treat acne. Differin attaches to skin-cell DNA and modifies the production of enzymes needed for creation of new skin cells. In addition, it counteracts the processes of hyperkeratinization and excessive growth in pore linings, and