Chapter 15: Acne Vulgaris & Rosacea – Pharmacologic Care

Acne vulgaris, which involves increased sebum production and abnormal keratinization often triggered by hormonal increases, is classified from comedonal to severe cystic forms. Initial treatment emphasizes nonpharmacologic skin care and topical agents, including comedolytics like retinoids (e.g., retinoic acid, adapalene, tazarotene) that promote cell turnover, and antibacterials like benzyl peroxide (BPO), which target Cutibacterium acnes and reduce inflammation. If topical therapy is inadequate for inflammatory acne, oral antibiotics such as tetracycline derivatives (doxycycline, minocycline) are introduced, often at anti-inflammatory doses, but long-term use is discouraged due to resistance. Specialized systemic treatments include spironolactone or oral contraceptives for adult women with hormonal acne, and the powerful systemic retinoid, isotretinoin, which is strictly reserved for refractory, severe nodulocystic acne and requires mandatory registration in the iPledge program due to extreme teratogenicity and the need for comprehensive lab monitoring. Rosacea, a chronic disorder presenting in midlife with central facial redness and telangiectasia, is managed initially with topical anti-inflammatory agents like metronidazole, azelaic acid, or the anti-parasitic ivermectin, alongside avoidance of common triggers such as sun exposure, stress, and spicy foods. For unresponsive papulopustular rosacea, low-dose oral antibiotics, particularly doxycycline, are typically added, or in rare, severe cases, oral isotretinoin may be considered, while counseling patients that improvement for either condition typically requires patience over four to six weeks.