Health Care Industry
Industry: Email Alert RSS FeedDrug update: systemic acne treatments for women
OB/GYN News, August 1, 2002 by Mitchel L. Zoler, Heidi Splete
Drug Daily Dosage Cost/Day *
norgestimate and ethinyl 180-250 [micro]g $1.11
estradiol norgestimate and 35
(Ortho Tri-Cyclen) [micro]g ethinyl
estradiol
norethindrone acetate 1 mg norethindrone $1.18
and ethinyl estradiol acetate and 20-35
(Estrostep) [micro]g ethinyl
estradiol
levonorgestrel and 100 [micro]g $1.13
ethinyl estradiol levonorgestrel and
(Alesse) 20 [micro]g ethinyl
estradiol
Drug Comment **
norgestimate and ethinyl First birth control pill with FDA
estradiol approval for acne. Contains 35 [micro]g
(Ortho Tri-Cyclen) of estrogen. Generally well tolerated.
norethindrone acetate Approved by the FDA for treating
and ethinyl estradiol moderate acne. Formulated so that
(Estrostep) ethinyl estradiol dose rise as pills
are used during a cycle, starting at 20
[micro]g/day early in cylce and
increasing to 30 [micro]g/day and then
to 35 [micro]g/day. May be better
tolerated in some women than
alternative formulations. Currently
the lowest estrogen does with FDA
approval for acne.
levonorgestrel and Application for acne indication
ethinyl estradiol submitted to FDA in January 2001;
(Alesse) approval expected this year. Delivers
20 [micro]g of ehtinyl estradiol daily
throughout cycle, making it the
lowest-estrogen formulation. May be
better tolerated in women with
bloating or nausea on higher-dose
formulations.
OTHER SYSTEMIC AGENTS
Drug Daily Dosage Cost/Day *
tetracycline 1 g $0.22
doxycycline 150 mg $0.87
(doxycycline
hyclate);
$3.72
(doxycycline
monohydrate)
minocycline 75-100 mg $4.66
(100 mg b.i.d.)
isotretinoin 1-2 mg/kg 419.50
(Accutane) (40 mg b.i.d.)
Drug Comment **
tetracycline Effective for moderate inflammatory
acne, but an oral contraceptive may be
a better choice if acne seems to have
a hormonal influence. Tetracycline
resolves moderate acne, precluding need
for isotretinoin, which has more side
effects. Some patients have success
using tetracycline plus birth control
pills. May disrupt effectiveness of
birth control pills, so additional
conctraception should be used.
Tetracycline dosage varies widely.
Patients whose acne is mostly under
control can get by on 250 mg/day. Avoid
in women who are pregnant or breast-
feeding and in women taking
isotretinoin; not recommended for women
over 40 with vascular problems. Can't
be taken immediately before or after
eating, which makes compliance
challenging. May cause
photosensitivity, so patients on
tetracycline must use sun protection.
doxycycline Tetracycline-related antibiotic that's
more convenient for some patients since
it can be taken with food and milk.
Taking at breakfast and dinner
increases compliance, although taking
at bedtime can cause indigestion.
Downside is more pronounced
phototoxicity than tetracycline and
higher cost. Can't be prescribed to
patients taking isotretinoin. May
disrupt effectiveness of birth control
pills, so additional contraception
should be used. Two forms of
doxycycline exist: the hyclate salt
and the monohydrate salt. Safety and
efficacy are similar, but there is a
substantial price difference and the
monohydrate causes fewer
gastrointestinal side effects.
minocycline Most recent drug available in
tetracycline class. More effective
than other drugs in class, but also
more expensive. Reports of liver
toxicity and photosentivity with use.
Usually reserved for acne that does
not respond to other antibiotics.
May disrupt effectiveness of birth
control pills, so additional
contraception should be used.
isotretinoin Very effective for treating nodular
(Accutane) cystic acne but has most severe side
effects of any systemic acne
treatment. Discuss potential adverse
effects thoroughly with patients
before prescribing. Because of
teratogenic risk, women of child-
bearing age taking isotretinoin should
use two forms of contraception to
prevent pregnancy. If patient isn't
already using an oral contracetive,
physician may want to suggest a
formulation approved for acne
treatment. To curb the number of women
who become pregnant while on
isotretinoin, the manufacturer launched
an intensive education and control
program early this year aimed at
physicians and pharmacists. Dosage is
divided and taken twice a day; course
of treatment is about 5 months. If side
effects appear, lower the daily dosage
and extend the treatment period to
deliver the full regimen. Patients
on isotretinoin must avoid
tetracycline, doxycycline, and
minocycline, which raise the risk of
pseudotumor cerebri.
* Cost/day is based on the average wholesale price in the 2001 Red Book
for a 100-unit container or closest available size of the generic
formulation, unless otherwise specified.
** Comments reflect the opinions and expertise of the following sources:
Dr. Diane Berson, director of dermatology, Iris Cantor Women's Health
Center, and assistant professor of dermatology, Cornell University, New
York.
Dr. Julia R. Nunley, associate professor of dermatology, Virginia
commonwealth University, Richmond.
Dr. Alan R. Shalita, chairman and distinguished teaching professor,
department of dermatology, State University of New York Downstate
Medical Center, Brooklyn.
Dr. James C. Shaw, associate professor, division of dermatology,
University of Toronto.
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