By Gary M. White, MD
Cheilitis (lip inflammation) from isotretinoin.
For acne resistant to standard therapy, isotretinoin is the treatment of choice. For acne that has relapsed after a first course of isotretinoin, a second course may be given. For women whose acne has relapsed after a second course, check DHEAS and testosterone and then consider spironolactone plus oral contraceptives (e.g. Ortho Tricyclen) along with a topical retinoid and a topical antimicrobial (e.g. benzoyl peroxide), see hormonal therapy. For men who relapse after a second course of isotretinoin, low dose, intermittent isotretinoin may be considered. For acne resistant to standard therapy who cannot take isotretinoin (e.g. developed acne fulminans or pseudotumor ceribri), one may consider the following: One may always consider the third line oral antibiotics for acne such as trimethoprim/sulfamethoxazole (e.g. Bactrim or Septra DS twice daily) or amoxicillin/ampicillin e.g. 500 mg twice a day. With the sulfa drugs, caution the patient about the increased risk of allergy (4% woman and 2% men) and sun sensitivity and the potential for a decreased white blood cell count. With the penicillins, check of course for penicillin sensitivity.
Also, azithromycin has been reported effective in acne. The dose used was a 5-day pulse started on the 1st and 15th of each month and dosed at 500 mg on day 1 and 250 mg on days 2-5.
Dapsone was used extensively for severe acne prior to the advent of isotretinoin. It may be tried with the usual precautions.
Oral clindamycin 150 mg twice a day may be effective but great care must be taken in regard to pseudomembranous colitis which if untreated and severe can be deadly. Among other things, the patient must stop the medication and seek medical attention immediately if diarrhea occurs.
Colchicine 1 mg/day was given to 22 patients with severe acne with reportedly good results [Acta Derm Venereol vol 78; page 388].