Diffificult acne

Difficult acne may be defined as Acne that fails to respond to elected treatment approach, or acne that presents with constraints and/or challenging clinical features. Failure to respond, that is, under-responsiveness, may arise from a variety of reasons. Failure to address the pathogenesis; inappropriate selection of treatment modalities; lack of patient compliance (adherence); improper methodology; drug interactions; antibiotic resistance; overlooked concomitant pityrosporum folliculitis; and high glycemic load diet. There are clinical features which by their presence add to the difficulty in treating acne. Some of these features include: macrocomedones, cysts, sinus tracts, keloids, scarring, and hyperandrogenism.

The following clinical subtypes of acne are more difficult to treat: acne in preteens, adult acne, scarring acne, nodulocystic acne, acne corporis, acne conglobata, acne fulminans, pyoderma faciale, and SAPHO syndrome. Acne with constraints includes: acne patient attempting to conceive; acne in pregnancy; difficult personality - patient averse to taking oral medications; patient averse to topical medication; allergy/intolerance to medications; patients with cynical attitude and phobias; cost considerations/inability to afford prescribed medications; and acne treatment against a deadline! It is also difficult to manage acne in the setting of an underlying chronic systemic disease such as tuberculosis, cirrhosis, or chronic renal failure.

Successful management of difficult acne requires greater effort by the patient and the treating dermatologist. It requires climbing the therapeutic ladder. It requires mastering the use of oral retinoids and antiandrogens. It pays to employ drug combinations, and to create innovative, customized, treatment programs.