What is the treatment for acne conglobata?

Treatment of Acne Conglobata

The treatment of acne conglobata requires aggressive systemic therapy with isotretinoin (0.25-0.4 mg/kg/day) as the first-line treatment, combined with topical retinoids and benzoyl peroxide, due to its severe and potentially scarring nature. 1

First-Line Treatment Approach

Systemic Therapy

• Isotretinoin: 0.25-0.4 mg/kg/day is the cornerstone of treatment for severe acne including acne conglobata
  • Contraindicated in pregnancy and breastfeeding women 1
  • Monitor for potential isotretinoin side effects including teratogenicity, mood changes, and lipid abnormalities
  • Continue until significant improvement or complete clearance is achieved

Adjunctive Topical Therapy

• Topical retinoids: Apply daily to help normalize follicular keratinization
• Benzoyl peroxide (2.5-5%): Apply daily to reduce bacterial colonization and inflammation 1

Systemic Antibiotics

• Doxycycline: 200mg on first day, followed by 100mg daily maintenance dose
  • Effective against Cutibacterium acnes
  • Contraindicated in children under 8 years, pregnant or breastfeeding women 1

Special Considerations

For Female Patients

• Consider hormonal therapy alongside other treatments:
  • Drospirenone-containing combined oral contraceptives for women who also desire contraception 1
  • Spironolactone as an anti-androgenic option 1

For Patients with Hidradenitis Suppurativa "Conglobata Phenotype"

• Avoid isotretinoin as it may worsen the condition in these patients 2
• This is particularly important in male patients and those with BMI >25 kg/m2 2

Alternative and Advanced Treatments

For cases resistant to conventional therapy:

1. Photodynamic Therapy (PDT)

   • PDT with 5-aminolevulinic acid and red light has shown significant improvement in acne conglobata with high cure rates and reduced scar formation 3
   • Treatment protocol: Once every 10 days for a month

2. CO₂ Laser Treatment

   • Effective for opening cystic lesions and removing sinus tracts
   • Should be combined with topical tretinoin to prevent new lesions 4

3. Surgical Intervention

   • Reserved for severe, treatment-resistant cases
   • Involves wide and deep excision of affected areas 5
   • Primary or secondary wound closure depending on body region

4. External Beam Radiation

   • May be considered as a last resort for treatment-resistant cases 6
   • Modern techniques minimize long-term risks

Scar Management

• Control active acne before initiating scar treatment 1
• Scar treatment options based on severity:
  • Mild: Topical retinoids and chemical peels
  • Moderate: Fractional laser therapy, microneedling with topical growth factors
  • Severe: Laser punch-out technique, punch excision/elevation procedures 1

Lifestyle Modifications

• Reduce consumption of high-glycemic foods
• Consider limiting dairy intake
• Strict sun protection to prevent post-inflammatory hyperpigmentation 1

Treatment Monitoring

• Evaluate response every 4-6 weeks
• If no improvement after 8-12 weeks of systemic therapy, consider alternative or combination approaches
• Continue maintenance therapy with topical retinoids after achieving control 1