Before anti-androgens and  isotretinoin were available, the treatment of patients with 'difficult' acne was, by definition, not easy. Clofazimine has been reported (in noncontrolled studies) to help. A controlled study of dapsone  against isotretinoin showed  dapsone to be virtually without effect.

 

   Oral steroids should never be recommended on  a longterm basis but  are  the  drug of  choice in acne fulminans. Such patients, who develop an immune  complex  reaction to P. acnes,  present with severe acne (especially on the trunk), fever, polyarthralgia and bone pain. The recommended dosage of prednisolone is 40mg/day for one week,  reducing the dose gradually  to zero  over six  weeks.  Tetracycline  or erythromycin 1 g is given in addition to the prednisolone but they are of virtually no benefit by themselves.

 

   Nonsteroidal anti-inflammatory  drugs  have been advocated but control studies are few. It is likely that they  are most beneficial  in  combination  with  oral antibiotics. A dramatic effect was reported with benoxaprofen before it was taken off the market in the UK because of associated renal problems. The mechanism of action of such drugs could be via their effect on the arachidonic acid pathways but there is no evidence as to whether such mediators are involved in acne inflammation.

 

   Occasionally the patient is unquestionably depressed because of his condition. Although the use of anxiolytic drugs is rarely indicated in acne, relevant therapy may be appropriate for  a few weeks.

 

Isotretinoin and Diane or Dianette (plus  lOOmg cyproterone acetate) are the most effective in reducing sebum excretion.  Isotretinoin,  although  having no direct effect on P. acnes nevertheless directly reduces the number of surface P. acnes, with benzoyl peroxide being the next most effective. Isotretinoin and  topical retinoic acid are the therapies with the greatest effect in reducing the  numbers of comedones.