[Treatment with low-dose isotretinoin is effective for patients with moderate inflammatory acne]. / Isotretinoin i lågdos effektivt vid akne efter antibiotikakurer.

The recommended isotretinon dose for severe (nodulocystic) acne has for almost 40 years been 0,5-1,0 mg/kg/day reaching a cumulative dose of 120-150 mg/kg.  Moderately severe acne has been treated with long-term systemic antibiotics, which carries a risk for microbial resistance in skin och intestinal flora. The Swedish Medical Products Agency approved in 2014 that patients with acne recurring after oral antibiotics given for at most two 3-month periods can be considered for isotretinoin treatment, but the dose regimen was not changed. These patients have moderate inflammatory acne (papulopustular) and studies over the recent years have shown that treatment with low-dose isotretinoin, 0,2-0,4 mg/kg/day, until acne recovery and independent of cumulative dose is effective. There are less frequent and less severe mucocutaneous side-effects, reduced risk of acne flares and it is considerably less expensive than traditional dosing. The duration of treatment is however prolonged, and the pregnancy prevention program must be followed.

[Time to limit the use of antibiotics in rosacea!] / Dags att minska användningen av antibiotika vid rosacea - Isotretinoin bör övervägas vid frekventa recidiv ­ lokalbehandling fortfarande förstahandsterapi.

Rosacea is a chronic inflammatory disease with facial erythema and papulopustules. It is common in middle-aged/elderly persons and often affects self-perception and social well-being. It is generally classified into four subtypes. Improved understanding of pathophysiology has resulted in novel treatment approaches, but routine management in health care usually follows old trails. Most patients are managed in primary care. Greater attention to the reduced skin barrier, avoidance of exacerbating factors, better topicals and encouragement to topical maintenance treatment should reduce the use of oral tetracyclines. Low-dose isotretinoin is reserved for treatment-resistant patients, but relapses are frequent unlike its use in acne. In order to reduce antibiotic use, we propose that patients should be referred to a dermatologist for optimization of therapy including consideration of isotretinoin following tetracycline treatment of a maximum of 4-6 months.

An expert view on the treatment of acne with systemic antibiotics and/or oral isotretinoin in the light of the new European recommendations.

In 2003 the European Agency for the Evaluation of Medicinal Products amended the summary product characteristics for oral isotretinoin to standardise information provided from the different countries of the European Community. The Committee for Proprietary Medicinal Products recommended that among others, exclusively severe forms of acne (such as nodular or conglobate acne or acne at risk of permanent scarring) resistant to "adequate courses" of standard therapy with systemic antibacterials and local therapy should benefit from oral isotretinoin. However, no indication was provided on what were considered adequate courses or the possibility given to use oral isotretinoin as first line treatment. The aims of the present report were: 1) to provide a specialist view on when it is appropriate to introduce oral isotretinoin as a second line therapy for acne, taking into consideration optimum dosage and duration of systemic antibiotics prior to the start of the oral isotretinoin, and 2) to support the use of oral isotretinoin as first line therapy in specific cases for acne in clinical practice. The recommendations are based on an exhaustive literature review as well as on the personal experience of the members of an European panel of acne specialists. The EEP agreed with the decision made by the CPMP that oral isotretinoin should be administered as 2nd line therapy in those cases of severe acne, which were resistant to or which did not respond successfully to an initial combination regimen with systemic antibiotics and topical treatments (topical retinoids +/- benzoyl peroxide). However, the members emphasized that a number of prognostic factors, as well as psychosocial morbidity should be taken into account when choosing the regimen and that these factors may influence the use of oral isotretinoin as first line therapy.

European recommendations on the use of oral antibiotics for acne.

Non-rational prescribing of oral antibiotics in acne is common, and there is currently an unmet need for up-to-date guidelines that specifically address these issues. Presented here is a set of recommendations on the use of oral antibiotics in acne, developed by a group of European acne specialists, designed to be considered by dermatologists and general practitioners in their daily practice throughout Europe. Recommendations cover optimal choice of antibiotic, drug doses, duration of treatment, combination treatment, and maintenance therapy.