Learning Outcomes
By the end of this section, you should be able to:
- 40.2.1 Identify the characteristics of drugs used to treat acne.
- 40.2.2 Explain the indications, actions, adverse reactions, and interactions of drugs used to treat acne.
- 40.2.3 Describe nursing implications of drugs used to treat acne.
- 40.2.4 Explain the client education related to drugs used to treat acne.
Acne vulgaris (acne) is a skin condition in which sebum—dead skin cells—and bacteria accumulate in a skin pore. The pore becomes clogged and allows bacterial growth, which causes the surrounding skin to erupt in skin lesions or vesicles. Although acne is typically considered a condition of adolescents and young adults, occasionally it may continue into adulthood, especially in female clients. Oily skin, hormonal changes, family history, and some medications may cause or exacerbate acne. Acne presents as multiple pustules, papules, or nodules on the skin, particularly on the face but also on the back, upper arms, and trunk (Sutaria et al., 2023). Figure 40.3 shows the development of acne within a pore.
Effective treatment of acne begins with proper skin hygiene. In addition to cleansing and exfoliating the skin, treatment also focuses on reducing inflammation and decreasing bacteria on the skin. Both systemic and topical medications are used to manage acne to achieve these goals.
Systemic Acne Drugs
Systemic medications for the treatment of acne consist mainly of oral anti-infectives used to reduce bacterial colonization in skin pores. This reduces inflammation and infection, allowing pustules and lesions to heal while also preventing further development of acne. These anti-infectives include tetracyclines such as tetracycline hydrochloride, minocycline hydrochloride, and doxycycline. Clindamycin, a lincosamide antibiotic, may also be used. Drugs such as these specifically treat organisms affecting the skin, including streptococcal and staphylococcal bacteria.
Table 40.1 lists common systemic acne drugs and typical routes and dosing for adult and pediatric clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Tetracycline hydrochloride
(Sumycin, Panmycin, Acnecycline) |
Oral Adults: 1000 mg/day in divided doses for acute acne; maintenance for acne prevention: 125–500 mg daily. Children ≥8 years: 25–50 mg/kg daily, divided into 4 equal doses. Children <8 years: Do not administer. Topical 3% ointment: Apply twice daily in a thin layer over the entire affected area. |
| Minocycline hydrochloride (Minocin, Ximino, Zilxi) |
Oral Adults: Initial dose: 200 mg orally, then 100 mg orally twice daily. Children ≥8 years: Initial dose: 4 mg/kg orally, then 2 mg/kg orally every 12 hours. Children <8 years: Do not administer. Topical 4% foam: Apply small (cherry-sized) amount to affected areas. Repeat as needed until symptoms resolve. Apply at the same time each day at least 1 hour before bedtime or before bathing, showering, or swimming. |
| Clindamycin (Cleocin) |
Oral Adults: 150–450 mg orally every 6 hours. Children: 8–20 mg/kg daily orally, divided into 3–4 doses. Topical 1% topical solution: Apply thin film to affected areas twice daily. |
| Doxycycline hyclate (Vibramycin, Doxycin) |
Adults and children ≥45 kg: Initial dose: 200 mg orally, then 100 mg every 12 hours. Children <45 kg: 4.4 mg/kg divided into 2 doses on the first day of treatment followed by maintenance dose of 2.2 mg/kg orally as a single dose or divided dose every 12 hours. |
Adverse Effects and Contraindications
Common adverse effects associated with these treatments include hypersensitivity reactions, yeast infections, and gastrointestinal intolerance. Tetracyclines are also associated with skin rashes, tooth damage and discoloration, and altered bone growth and development. Tetracycline hydrochloride has more specific precautions and contraindications (see Table 40.2) (DailyMed, Tetracycline Hydrochloride, 2023).
Table 40.2 is a drug prototype table for systemic acne drugs featuring tetracycline hydrochloride. It lists drug class, mechanism of action, adult and pediatric dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Antibiotic (gram-negative and gram-positive) Mechanism of Action Bacteriostatic action to reduce bacterial colonization Inhibits protein synthesis |
Drug Dosage Oral Adults: 1000 mg daily in divided doses for acute acne; maintenance for acne prevention: 125–500 mg daily. Children ≥8 years: 25–50 mg/kg daily, divided into 4 equal doses. Children <8 years: Do not administer. Topical 3% ointment: Apply twice daily in a thin layer over the entire affected area. |
| Indications Acne and other skin infections Sexually transmitted infections (syphilis, chlamydia, gonorrhea) Therapeutic Effects Reduces pustules that form in acne by eliminating the bacteria that cause lesions |
Drug Interactions Antacids Iron Sodium bicarbonate Zinc penicillin Anticoagulants Food Interactions Dairy products |
| Adverse Reactions Gastrointestinal upset Esophageal irritation Enterocolitis Black hairy tongue Yeast infections Tooth discoloration and dental caries Skin rashes that may progress to exfoliative dermatitis Renal and liver toxicities Anemia Thrombocytopenia Neutropenia Severe photosensitivity Anaphylaxis |
Contraindications Hypersensitivity Children younger than 8 years Pregnancy and lactation Caution: Decreases effectiveness of hormonal contraceptives—barrier contraceptives may be needed |
Topical Acne Drugs
Topical acne medications are often used in combination with systemic acne medications to provide better management of acne. Topical therapy is applied directly to the skin that is affected by the presence of acne lesions. Azelaic acid 15% and benzoyl peroxide 2.5% are used in both acne and rosacea to eliminate bacteria and decrease inflammation as well as to reduce oil on the skin. Salicylic acid, another topical treatment, assists in acne treatment by exfoliating dead skin cells to reduce pore blockages, reducing inflammation, and decreasing sebum secretion. Adapalene 1% topical ointment, when applied to the areas affected by acne, helps to differentiate skin cells and reduces the accumulation of cells in skin pores. Tazarotene, another topical treatment for acne, is thought to assist with reducing fine lines and discolorations in the skin. It is thought that this medication may also play a role in the reduction of scarring from acne lesions. Tretinoin 0.025% ointment, a retinoid, benefits clients undergoing treatment for severe acne. The actions of topical retinoids are not fully understood but are thought to increase cell mitosis and decrease cell cohesion to prevent clogging of skin pores (DailyMed, Tretinoin, 2019).
Link to Learning
The Psychosocial Impact of Skin Disorders
Although the physical effects of acne can be devastating, the psychosocial impacts—anxiety/depression, self-esteem, stigma, body image, social support, social interaction, sexual life, social acceptance and optimism, and objective factors—also must be considered. This NursingOpen article discusses the psychologic impact of acne and other skin disorders (Zhang et al., 2021).
Table 40.3 lists common topical acne drugs and typical routes and dosing for adult and pediatric clients.
| Drug | Routes and Dosage Ranges |
|---|---|
| Azelaic acid (Azelex, Finacea, Finevin) |
Adults: Apply a thin layer topically twice daily. Children: Safety and effectiveness have not been established in pediatric clients. |
| Benzoyl peroxide (Benzac) |
Adults: Apply a thin layer to the affected area 1–3 times daily. Children: Safety and effectiveness have not been established in pediatric clients. |
| Adapalene (Differin) |
Adults and children ≥12 years: Apply a thin layer topically once daily, in the evening. Children <12 years: Safety and effectiveness have not been established. |
| Tazarotene (Tazorac) |
Adults: Apply a thin layer topically once daily, in the evening. Children: Safety and efficacy have not been established in clients under the age of 12. |
| Salicylic acid (Salex, Virasal) |
Adults: Apply a thin layer topically 1–3 times daily. Children >2 years: Follow health care provider recommendations. Not recommended for use in children under 2 years. |
| Tretinoin (Retin-A, Atralin) |
Adults and children ≥12 years: Apply a thin layer topically once daily, at night. |
Adverse Effects and Contraindications
Adverse effects for topical acne medications most often involve localized skin redness, scaling, itching, and burning. These may worsen when adapalene is used concomitantly with other substances that cause irritation or dry skin. For this reason, contraindications include the use of other non-approved substances, soaps, and cleansers that cause skin irritation. Other contraindications are sun or other ultraviolent light and the use of occlusive dressings—those that do not allow air or moisture to get in or out.
Table 40.4 is a drug prototype table for topical acne drugs featuring adapalene. It lists drug class, mechanism of action, adult and pediatric dosage, indications, therapeutic effects, drug and food interactions, adverse effects, and contraindications.
| Drug Class Retinoid, anticomedogenic Mechanism of Action Decreases inflammation and clogging of pores in acne |
Drug Dosage Adults and children ≥12 years: Apply a thin layer topically once daily, in the evening. Children <12 years: Safety and effectiveness have not been established. |
| Indications Acne and other skin infections Therapeutic Effects Decreases formation of acne lesions |
Drug Interactions Soaps, creams, and cosmetics that have a drying effect or contain alcohol or astringents Food Interactions No significant interactions |
| Adverse Reactions Skin irritation Redness Itching Flakiness |
Contraindications Hypersensitivity Dry, flaky, or open skin |
Special Considerations
Topical Acne Drugs
Adolescents using topical acne medications are at high risk of discontinuing treatment prematurely because of improved symptoms, side effects, and the need to use multiple products or treatments. Research suggests that monotherapy, treatment with oral medications, and/or anticipatory guidance on side effects can increase an adolescent client’s adherence to the prescribed therapy.
(Source: Habeshian & Cohan, 2020)
Nursing Implications
The nurse should do the following for clients who are taking acne drugs:
- Assess and thoroughly document skin condition baseline.
- Assess and monitor the client for adverse effects, drug and food interactions, and contraindications.
- Evaluate and document the client’s response to current treatment and overall improvement of skin condition.
- Assess the psychosocial impact of acne on individual clients.
- Provide client teaching regarding the drug and when to call the health care provider. See below for client teaching guidelines.
Client Teaching Guidelines
The client taking a systemic acne medication should:
- Take prescribed medications exactly as directed.
- Report side effects such as skin redness, excessive dryness, or peeling to their health care provider.
- Use birth control methods as instructed and avoid pregnancy.
- Refrain from breastfeeding.
- Follow up with appointments as instructed.
The client taking a topical acne medication should:
- Take prescribed medications exactly as directed.
- Report side effects such as skin redness, excessive dryness, or peeling to their health care provider.
- Cleanse skin thoroughly before applying medication.
- Apply only a thin layer of medications to the affected areas only.
- Avoid contact with eyes and mucous membranes.
- Wash hands well before and after application.
The client taking a topical acne medication should not:
- Cover the medication with occlusive dressings.
FDA Black Box Warning
Systemic Acne Medications
Embryo-fetal loss and malformations may occur when systemic acne drugs are administered to a pregnant client.