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Oral isotretinoin (13-cis-retinoic acid [Accutane]) is the only available agent with the potential both to cure acne. Most patients are started at 0.5-1 mg/kg qd or bid, typically for 15-20 weeks. Isotretinoin may be considered for unresponsive moderate-to-severe inflammatory acne. Virtually all patients will see an 80%-90% reduction in acne lesions within 2-4 months of isotretinoin initiation. Adverse reactions to isotretinoin include cheilitis, nose bleeds, dry skin and mucous membranes, and photosensitivity. Less common are arthralgias myalgias, headache, nyctalopia, and, in rare cases, pseudotumor cerebri. Isotretinoin can induce abnormalities in liver, hematologic, and lipid functions such as hypertriglyceridemia and hypercholesterolemia. Isotretinoin is a teratogen associated with major fetal malformations. Contraception must be ensured both during use and for at least 1 month after discontinuation.
Comedone extraction is an office procedure used to disimpact obstructive acne lesions. The obstructing plug can usually be expressed after enlarging the pore with a 25-gauge needle.
Intralesional corticosteroid injection can rapidly (within 48-72 hours) resolve large or recalcitrant inflammatory acne lesions and reduce the risk for scarring. A 30-gauge needle is used to inject 0.05-0.3 mL of a solution containing triamcinolone acetonide through the pore of the lesion. The corticosteroid solution is usually diluted with normal saline or lidocaine to a concentration of 0.63-2.5.
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