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Adolescents and Young Adults
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–Use topical therapies as initial treatment as monotherapy (except topical antibiotics—do not use as monotherapy) or in combination with other topical or oral therapies.
Topical retinoids (tretinoin, adapalene, tazarotene, trifarotene).
Benzoyl peroxide.
Topical antibiotics (erythromycin, clindamycin, minocycline, dapsone).
–Consider clascoterone (topical antiandrogen), salicylic acid, and azelaic acid.
–Use oral antibiotics (doxycycline has the strongest data) as an adjunct to benzoyl peroxide and other topicals, not as monotherapy. Limit to shortest duration possible, typically <4 mo.
–Consider combined oral contraceptives and/or spironolactone in female patients without contraindications.
–Consider intralesional corticosteroids for patients with larger papules or nodules who are at risk for scarring.
–Insufficient evidence to recommend for/against oral steroids, metformin for acne.
–Consider oral isotretinoin for severe recalcitrant nodular acne. Monitor LFTs and lipid panel during therapy. Pregnancy prevention is mandatory, and patients must enroll in FDA-mandated iPLEDGE program.
–Insufficient data for comedone extraction, chemical peels, laser devices, microneedle radiofrequency device, or photodynamic therapy.
–Insufficient data for low-glycemic-load diet, low dairy diet, low whey diet, omega 3 fatty acids, or chocolate.
–Skin care advice: (NICE)
Use skin pH neutral or slightly acidic wash twice daily.
Do not use oil-based or comedogenic skin care products, sunscreens, and makeup.
No picking or scratching lesions.
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Practice Pearls
Benzoyl peroxide helps prevent bacterial resistance. Improvement may be seen within days. It causes burning, dryness, stinging, erythema, peeling, hypersensitivity, and bleaching of hair and clothing.
Tretinoin comes in a range of strengths; increasing the potency gradually will minimize skin irritation. Retinoids can cause photosensitivity, erythema, dryness, pruritus, and stinging.
Clindamycin is the favored topical antibiotic. Limit duration to 12 wk.
Do not use topical antibiotics as monotherapy because of the risk of bacterial resistance.
Topical adapalene, tretinoin, and BP are safely used in preadolescent children.
Use systemic antibiotics for shortest duration and do not use as monotherapy without topicals.
Remember that contraceptives have several medical contraindications.
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ACTINIC KERATOSIS (AK)
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