At times, acne may indicate a serious systemic disorder. Excess androgen production may be associated with acne in women. Benign hypersecretory states such as congenital adrenal hyperplasia should be considered, though polycystic ovaries are far more common. Severe, scarring, or unresponsive Isotretinoin administeredunder close guidance of a dermatologist Two topical retinoids, tretinoin and adapalene, are the most widely used comedolytic agents. These medications decrease follicular plugging, break up microcomedones, and normalize differentiation of the epidermal cells that synthesize keratin.
Salicylic acid is also comedolytic.
When inflammatory acne does not respond to topical medication, oral antibiotics are needed to reduce the concentration of the bacteria Propionibacterium acnes . This agent decreases sebum production, normalizes formation of keratin, prevents comedo formation, and decreases inflammation. Isotretinoin is a strong teratogen and is absolutely contraindicated during pregnancy. Because estrogen decreases sebum production, oral contraceptives are helpful for some women with severe acne. Although not first-line therapy, oral contraceptives can be used in conjunction with topical and systemic agents when inflammatory acne persists.