Severe acne is almost always managed by a dermatologist. This type of acne is very complex and requires a great deal of experience and knowledge of the available treatments. The acne is very prone to failure and success rates of treatment are variable and many a times, disappointing.
Presently, medical therapy is first choice for the treatment of severe acne and a combination of drugs is frequently used. The medical drugs used to treat severe acne include:
Steroids: Topical steroids of varying strength have been used to treat severe acne. But despite using the high concentrations, these drugs appear to lack effectiveness when applied on the skin.
Interlesional Corticosteroid Injection: In the severe cases of inflamed acne, the steroid may be injected directly in to the lesion. When intralesional steroid is injected it prevents the inflammation and rupture of the cysts, thus lessening the chance of a scar. Once injected, the steroids decrease the reddening inflammation in a few days. Repeat injections may be required in future.
Oral corticosteroids: In the rare cases of very resistant acne, oral corticosteroids in high doses are administered for 1-2 weeks. Because of their side effects the drugs are rapidly tapered of. The steroids do work in some individuals but many fail to respond. The failure to respond remains a puzzle.
Retinoids: The Retinoids have become the major drugs to fight off severe acne. These vitamin A derived drugs are potent and frequently used to treat all types of acne. Retinoids such as Isotretinoin have to be taken once a day for at least 3-4 months in severe cases of acne.
Retinoids work for all type of severe acne. They decrease the oil production and limit the bacterial growth on the skin. Once Isotretinoin works, the condition may remain dormant for month to years. Most patients require just one session of treatment. However, there are a few cases, where there is no response.
While the drug is very effective it also has a number of side effects. The most worrisome complication is that of fetus malformations. All women who take this drug have to be seriously counseled before taking the drug. The drug is strictly monitored by the FDA and there is a registry of all female users. There have been a number of litigations against the company because of the fetal defects.
Oral Antibiotics: Oral antibiotics have been used to treat severe acne for decades. Most topical antibiotics appear to have no effect at all for this type of acne. The dosages of oral antibiotics are usually maximal and require long term treatment. The results of antibiotics are not immediate and can take months. A major problem with the use of antibiotics for long term is the onset of drug resistance. Doxycycline or any of the other tetracyclines has had some response but overall most individuals fail to show any significant improvement.
Oral Contraceptives: Because it is strongly believed that acne may be due to the excess of the male sex hormone, testosterone, oral contraceptives have often been used to counter the male sex hormone. The oral contraceptives are only for use in women. These medications do work but they also have some side effects like formation of blood clots and worsening of migraines.
Spironolactone: This anti hypertensive drug has anti androgenic activities and can be used by both males and females to treat severe acne. It has some mild side effects but for the males the most concerning is the development of breasts (the females love this side effect). This breast growth disappears once the medication is stopped. The medication is administered for a few months before any significant effect is seen. Some individuals show a good response to severe acne.
In most cases of severe acne, a combination of drugs is used for the best response. Current treatment trends indicate that 30-50% of individuals with severe acne will benefit from medical therapy.