BNF for Children 2011-2012

578 13.6.2 Oral preparations for acne BNFC 2011–2012Acnisal c (Alliance) UTopical solution, salicylic acid 2% in a detergent andemollient basis, net price 177 mL = £3.39.Excipients include benzyl alcoholNote may be difficult to obtainDoseApply up to 3 times daily13.6.2 Oral preparations for acneVenous thromboembolism occurs more frequentlyin women taking co-cyprindiol than those taking alow-dose combined oral contraceptive. Co-cyprindiolis licensed for use in women with severe acnethat has not responded to oral antibacterials and formoderately severe hirsutism; it should not be usedsolely for contraception. It is contra-indicated inthose with a personal or close family history ofvenous thromboembolism. Women with severeacne or hirsutism may have an inherently increasedrisk of cardiovascular disease.13 SkinOral antibacterials for acneOral antibacterials may be used in moderate to severeinflammatory acne when topical treatment is not adequatelyeffective or is inappropriate. Concomitant anticomedonaltreatment with topical benzoyl peroxide orazelaic acid may also be required (section 13.6.1).Tetracyclines should not be given to children under 12years. In children over 12 years, either oxytetracyclineor tetracycline (section 5.1.3) is usually given for acnein a dose of 500 mg twice daily. If there is no improvementafter the first 3 months another oral antibacterialshould be used. Maximum improvement usually occursafter 4 to 6 months but in more severe cases treatmentmay need to be continued for 2 years or longer.Doxycycline and lymecycline (section 5.1.3) are alternativesto tetracycline in children over 12 years. Doxycyclinecan be used in a dose of 100 mg daily.Lymecycline is given in a dose of 408 mg daily.Although minocycline is as effective as other tetracyclinesfor acne, it is associated with a greater risk oflupus erythematosus-like syndrome. Minocycline sometimescauses irreversible pigmentation; it is given in adose of 100 mg once daily or 50 mg twice daily.Erythromycin (section 5.1.5) in a dose of 500 mg twicedaily for children over 12 years is an alternative for themanagement of moderate to severe acne with inflamedlesions, but propionibacteria strains resistant to erythromycinare becoming widespread and this may explainpoor response. Infants with acne requiring oral treatmentwith erythromycin should be given 250 mg oncedaily or 125 mg twice daily; in cases of erythromycinresistantP. acnes in infants, oral isotretinoin may beused on the advice of a consultant dermatologist.Concomitant use of different topical and systemic antibacterialsis undesirable owing to the increased likelihoodof the development of bacterial resistance.Hormone treatment for acneCo-cyprindiol (cyproterone acetate with ethinylestradiol)contains an anti-androgen. It is no more effectivethan an oral broad-spectrum antibacterial but is usefulin females of childbearing age who also wish to receiveoral contraception.Improvement of acne with co-cyprindiol probablyoccurs because of decreased sebum secretion which isunder androgen control. Some females with moderatelysevere hirsutism may also benefit because hair growth isalso androgen-dependent. Contra-indications of cocyprindiolinclude pregnancy and a predisposition tothrombosis.CO-CYPRINDIOLA mixture of cyproterone acetate and ethinylestradiol in themass proportions 2000 parts to 35 parts, respectivelyCautions see under Combined Hormonal Contraceptives,section 7.3.1Contra-indications see under Combined HormonalContraceptives, section 7.3.1Hepatic impairment see under Combined HormonalContraceptives, section 7.3.1Pregnancy avoid—risk of feminisation of male fetuswith cyproteroneBreast-feeding manufacturer advises avoid; possibilityof anti-androgen effects in neonate with cyproteroneSide-effects see under Combined Hormonal Contraceptives,section 7.3.1Licensed use licensed for use in females of childbearingageIndication and doseSevere acne in females of childbearing agerefractory to prolonged oral antibacterial therapy(but see notes above), moderately severehirsutism. By mouth1 tablet daily for 21 days starting on day 1 ofmenstrual cycle and repeated after a 7-day interval,usually for several months; withdraw 3–4months after acne or hirsutism completelyresolved (repeat courses may be given if recurrence);long-term treatment may be necessary forsevere symptomsCo-cyprindiol (Non-proprietary) ATablets, co-cyprindiol 2000/35 (cyproterone acetate2 mg, ethinylestradiol 35 micrograms), net price 63-tab pack = £4.70Brands include Acnocin c , Cicafem c , Clairette cDianette c (Bayer Schering) ATablets, beige, s/c, co-cyprindiol 2000/35 (cyproteroneacetate 2 mg, ethinylestradiol 35 micrograms),net price 63-tab pack = £7.71Oral retinoid for acneThe retinoid isotretinoin reduces sebum secretion. It isused for the systemic treatment of nodulo-cystic andconglobate acne, severe acne, acne with scarring, or foracne which has not responded to an adequate course ofa systemic antibacterial. Isotretinoin is used for thetreatment of severe infantile acne resistant to erythromycin.Isotretinoin is a toxic drug that should be prescribedonly by, or under the supervision of, a consultant