Treatments

• Topical:  
• Retinoids -comedolytic
• Benzoyl peroxide -comedolytic and antibacterial. Gel 2.5-10% bid. 
• Topical abx AND Benzoyl peroxide  
• Clindamycin (Cleocin T, ClindaMax) gel. Apply thin film bid 

• Systemic: For Moderate-Severe Inflammatory acne 
• Doxycycline 50-100mg bid x 12-18 week

• SEVERE NODULOCYSTIC, REFRACTORY acne:
• Isotretinoin (Accutane): 0.5-10mg/kg/day x 16-20 weeks

• Control triggers
• Control contributing conditions (URI, Rhinitis, GERD)

INTERMITTENT MILD: Albuterol (Proventil-HFA, Ventolin-HFA, ProAir-HFA) 90mcg/puff 2 puffs every 4-6h prn or 10mnts before exercise.

• PERSISTENT MILD:  Albuterol (Proventil-HFA, Ventolin-HFA, ProAir-HFA) 90mcg/puff 2 puffs every 4-6h prn or 10mnts before exercise
• Maintenance medication: Mometasone (Nasonex): ONCE-daily dosing. 2 prays (100mcg) in each nostril qd.

PERSISTENT MODERATE: Combination Inhaled Glucocorticoid/LABA = Budesonide/Formoterol HFA (Symbicort): Reliever and Controller med. 80mcg/4.5mcg 2 puffs bid.   

PERSISTENT SEVERE: Combination Inhaled Glucocorticoid/LABA = Budesonide/Formoterol HFA (Symbicort): Reliever and Controller med.  160mcg/4.5mcg 2 puffs bid.

• Treat underlying condition
• D/C Tobacco 

• LOW-Na diet 1-2g daily
• Water restriction

Loop Diuretics: Control fluid retention. Furosemide (Lasix). Initial: 20-80mg/dose, repeat if inadequate response in increments of 20-40mg/dose at intervals of 6-8h.  May be titrate up to 600mg/day.  Maintenance dose: once or twice a day. 

ACEI: Interfere with RAS. Enalapril (Vasotec) 10-20 bid. Initial: 2.5-5mg/day,   increased if needed at 1-2 week intervals.  range

BBl: If LV dysfunction. Carvedilol (Coreg) 25mg bid.  Initial: 3.125mg bid for 2 weeks, increase if tolerated to 6.25mg bid. Double dose every 2 weeks until highest dose tolerated. 

NO ASA, NSAIDS, CCBs

• Main stay drug therapy:  Bronchodilators (beta-agonists, anticholinergics), and inhaled glucocorticoids, given alone or in combination depending upon the severity of disease and response to therapy. 
• Beta Agonists (SABAs, LABAs)
• SABAs:
• Albuterol (ProAir HFA, Proventil HFA, Ventolin HFA, AccuNeb) 2 puffs every 4-6h prn with metered-dose inhaler. 

• LABAs:
• Salmeterol (Serevent Diskus)
• Formoterol (Foradil Aerolizer) 

• Anticholinergics: 
• Short-Acting Anticholinergics: Ipratropium (Atrovent HFA)
• Long Acting Anticholinergic: Tiotropium (Spiriva HandHaler)

• SABA/Short-Acting Anticholinergic:  
• Albuterol/Ipratropium (Combivent, Duoneb)

• Inhaled Corticosteroids: 
• Budesonide (Pulminort Flexhaler)
• Fluticasone (Flovent HFA)
• LABA/Long-Acting Inhaled Steroids combinations:
• Fluticanose/Salmeterol (Advair Diskus, Advair HFA)
• Formoterol/Budesonide (Symbicort) 

• MCC = S. aureus (gram +)
• Long term antibiotic use can bring on gram – strains
• Superficial infection of hair follicle in epidermis

• Antibacterial soaps
• Bleach baths
• Topical abx: Mupirocin (Bactroban) ointment applied tid. 

Systemic: 1st gen cephalosporin (has good skin penetration)

Lifestyle modifications: wt loss, avoid bedtime snacks, avoid trigger foods (chocolate, peppermint, coffee, tea, citrus fruit), decrease meal size, elevate head of bed, d/c EtOH, d/c tobacco

Omeprazole (PPI) 20mg one daily for up to 4 weeks 

• I&D: Large fluctuant cysts
• Intralesional steroids 
• Weight loss- reduce friction
• Long term antibiotics (oral/topical): Tetracycline 250-500mg bid. 
• Oral contraceptives for premenstrual flares
• Isotretinoin (Accutane)-selected cases (early, non-scarring)
• Laser hair removal may provide benefit
• Infliximab, Etanercept: Biologics-agents used to attack proinflammatory cytokines TNF
• Wide surgical excision

Lifestyle modifications: wt loss, limit EtOH, regular aerobic exercis, d/c tobacco, low-Na diet, low-fat/chol diet. 

• STAGE 1 (140-159/90-99)
• INITIAL Rx: Thiazide diuretic (Hydrochlorothiazide) or BBl
• Hydrochlorothiazide (Microzide): 12.5-50mg/day. 
• or 
• Atenolol (Tenormin): 25-50mg qd.  May increase to 100mg/day. 

STAGE 2 (>160/>100): TWO drugs required.

• Soap and water
• Warm compresses 

• Abx should cover Beta-hemolytic Strep and Strep aureus
• Topical Abx: Mupirocin (Bactrobam) ointment apply tid x 3-5, then re-evaluate. 
• Systemic Abx: Cephalexin (Keflex).  Child: 25mg/kg/day in 4 divided doses. Adult: 250-1000mg every 6 hours. Maximum 4g/day. 

• MCC = Strep pneumoniae
• Others: Mycoplasma pneumoniae, Chlamydophila pneumoniae
• Less common: Legionella pneumoniae, Haemophilus influenzae

• HEALTHY, NO use of abx in last 3 months:
• Macrolide:
• Azithromycin 500mg x 1d, 250mg x 4d
• or
• Clarithromycin 500mg bid x 7d

• IMMUNOCOMPROMISED, use of abx in last 3 months: Macrolide + Respiratory Fluoroquinolone Macrolide:
• Azithromycin 500mg x 1d, 250mg x 4d 
• or
• Clarithromycin 500mg bid x 7d
• AND
• (Resp Fluoroquinolone)  Levofloxacin 750mg po q24 x 5 days 

Avoid Triggers (EtOH, hot/spicy foods/beverages) 

• Topical Agents:  
• Metronidazole (Metrocream or Metrogel) 0.75% bid
• Noritate cream qd

• Oral Abx:
• Tetracycline 250-500 mg po BID
• Doxycycline 50-100mg BID
• Minocycline 50-100mg QD-BID

Isotretinoin (Accutane)

Rhinophyma- (surgical ablation, electrosurgery, wire-brush)