Department of Internal Medicine, New York Presbyterian-Weill Cornell Medical Center, New York, USA.
Am J Clin Dermatol. 2011 Feb 1;12(1):7-14. doi: 10.2165/11532280-000000000-00000.
Severe nodular acne, defined as grade 4 or 5 acne on the Investigator's Static Global Assessment scale, is a skin condition characterized by intense erythema, inflammation, nodules, cysts, and scarring. Both the well known risk of physical scarring and the more recent recognition that acne can be a chronic, psychologically distressing disease with significant adverse effects on a patient's quality of life, have prompted earlier, more aggressive treatment with more effective medications, in the hope of preventing progression to more severe, nodular forms of the disease. Oral antibacterials, primarily tetracyclines, have long been the first-line therapy for severe nodular acne, which frequently remained refractory to therapy. However, concerns of antibacterial adverse effects, patient adherence, and antimicrobial resistance prompted the search for alternate therapies and combinations thereof in order to target the multifactorial pathogenesis of the disease. Isotretinoin, an oral retinoid introduced in 1982, has since become the gold standard therapy in severe acne and has revolutionized its treatment. Several adjunctive agents exist. Oral antibacterials are indicated as an alternative for patients with severe acne who cannot tolerate oral retinoids, or for whom a contraindication exists. In order to prevent bacterial resistance, antibacterials should always be used in combination with benzoyl peroxide, a nonantibiotic antimicrobial agent with anti-inflammatory activity. Topical retinoids are often added to this regimen. In women, hormonal agents, which include oral contraceptives, spironolactone, and oral corticosteroids, and, in Europe, cyproterone acetate, may be used as monotherapy or concomitantly with isotretinoin. For rapid treatment of inflammatory nodules, intralesional corticosteroids are effective. These treatment modalities have been studied, refined, and combined in novel ways in order to target the multifactorial pathogenesis of the disease, and in this article we review each of their roles.
重度结节性痤疮，定义为研究者静态总体评估量表上的 4 级或 5 级痤疮，是一种以强烈红斑、炎症、结节、囊肿和瘢痕为特征的皮肤疾病。已知的身体瘢痕形成风险以及最近认识到痤疮可能是一种慢性、心理困扰的疾病，对患者的生活质量有重大负面影响，这促使人们更早地、更积极地采用更有效的药物进行治疗，希望能预防疾病向更严重的结节性形式发展。口服抗菌药物，主要是四环素，长期以来一直是重度结节性痤疮的一线治疗药物，但这种治疗方法常常仍然无效。然而，人们对抗菌药物的不良反应、患者的依从性和抗菌药物耐药性的担忧，促使人们寻找替代疗法及其组合，以针对该疾病的多因素发病机制。异维 A 酸，一种于 1982 年推出的口服维 A 酸，自此成为重度痤疮的金标准治疗方法，并彻底改变了其治疗方法。目前已有多种辅助药物。对于不能耐受口服维 A 酸或存在禁忌证的重度痤疮患者，口服抗菌药物是一种替代治疗方法。为了防止细菌耐药，抗菌药物应始终与过氧化苯甲酰联合使用，后者是一种具有抗炎活性的非抗生素类抗菌药物。局部用维 A 酸通常也会添加到该方案中。在女性中，激素药物，包括口服避孕药、螺内酯和口服皮质类固醇，以及在欧洲，醋酸环丙孕酮，可作为单一疗法或与异维 A 酸联合使用。为了快速治疗炎症性结节，皮损内皮质类固醇是有效的。这些治疗方法已经经过研究、改进，并以新的方式联合使用，以针对该疾病的多因素发病机制，在本文中我们将回顾它们各自的作用。
