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Friday, May 08, 2009

Phác đồ điều trị mụn trứng cá

Sau đây là các phác đồ điều trị mụn trứng cá. Các bác sĩ da liễu có thể tham khảo. Còn việc vân dụng cụ thể như thế nào là nghệ thuật của từng bác sĩ. Vì "Medicine is an Art", phải không quí đồng nghiệp?



Grading of acne severity and treatment

Mild acne

Moderate acne

Severe acne


Open and closed comedones (whiteheads and blackheads), a few papules and pustules

Comedones, more frequent papules and pustules, but minimal scarring; can be subdivided into mainly comedonal or mainly inflammatory acne

Comedones, more pustules, and pustules plus nodular abscesses with more extensive scarring

First line treatments

• Topical retinoid
• Benzoyl peroxide (BP)
• BP + topical antibiotic

• BP + topical retinoid
• BP + topical antibiotic

As for moderate acne, plus referral to a dermatologist for oral isotretinoin

Second line treatments

• Azelaic acid

• Oral antibiotic + BP ± topical retinoid
• Azelaic acid
• Consider combined oral contraceptive pill for female patients

As for moderate acne, plus referral to a dermatologist for oral isotretinoin

First line treatments

  • Topical retinoids, the first line treatment for mild acne, have comedolytic, anti-comedogenic, and anti-inflammatory effects and are good in early and established acne and as maintenance therapy. The most common side effects are dryness and irritation, which can be avoided by application on alternate days initially. In theory retinoids are teratogenic, so women should be advised about this.
  • An alternative to topical retinoids is benzoyl peroxide. It is highly effective at reducing antibiotic sensitive and resistant propionibacterium acnes so is good for inflammatory acne and is more effective than topical antibiotics. It has mild comedolytic activity but no anti-comedogenic action. It can cause dryness and irritation, so start with a low strength cream formulation and titrate up. Advise that it can bleach clothes.
  • Topical antibiotics are also helpful in mild to moderate inflammatory acne but should be used as combination formulations with benzoyl peroxide to help reduce the risk of bacterial resistance.

Second line treatments

  • Topical azelaic acid 20% works in a similar way to benzoyl peroxide and retinoids but is less irritating. It is likely to be much less effective than retinoids and benzoyl peroxide but is helpful in patients with post-inflammatory pigmentation.
  • For moderate acne a generic tetracycline (but not minocycline, because of the risk of skin pigmentation and other more serious adverse effects) is recommended for at least six weeks, in combination with topical treatment. Combining an oral antibiotic with benzoyl peroxide helps to reduce the risk of bacterial resistance. Advise female patients that tetracyclines are contraindicated in pregnancy and that they should take adequate measures to avoid conceiving. Tetracyclines should not be prescribed to children aged under 12 years, because of potential staining of teeth enamel.
  • Hormonal treatment may improve acne in some women. There is little evidence that any is better than the others. Given the potential for adverse effects, particularly venous thromboembolism (VTE), you should consider the risk-benefit ratio when prescribing hormonal treatment. Any hormonal treatment is contraindicated in women with focal migraine or a higher than normal risk of VTE. Co-cyprindiol has a product licence for severe acne and can improve acne in up to 90% of female patients. Because of concerns about the risk of VTE, the advice is that this be given for 3-4 cycles after the acne is completely resolved then withdrawn (repeat courses may be given for recurrence). However, a recent paper by S Franks and colleagues (see Further Reading) has shown that this is not necessary, as there is no good evidence to confirm an increased VTE risk, and there are moves to change this recommendation.
  • Consider referral if the above described treatments do not result in the desired outcomes (see box).

Guidance on referral to a specialist (based on NICE guidance, May 2001)
Consider referral if the patient has:

  • Severe acne or painful nodulo-cystic acne, with potential or actual scarring. Such acne is likely to benefit from isotretinoin, an oral retinoid that is very effective but can have serious side effects, ranging from dry skin, lips, and eyes to teratogenicity and possible mood changes. It can be prescribed only by a dermatologist
  • Severe social or psychological problems as a result of the acne
  • Moderate acne after six months of trying treatment in primary care, or
  • A suspected underlying endocrine cause, such as polycystic ovarian syndrome.