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🔴 Comprehensive Treatment of Acne — All Types

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Part I: Understanding Acne — Types & Classification

1. Follicular hyperkeratinization → comedone formation
2. Sebaceous gland hyperactivity → excess sebum (androgen-driven)
3. Cutibacterium acnes (formerly P. acnes) colonization → inflammation
4. Inflammatory cascade → papules, pustules, nodules, cysts

Lesion Types

Clinical Subtypes

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Part II: Severity-Based Treatment Algorithm

🟡 MILD ACNE

Comedonal Mild Acne

• Topical retinoid (tretinoin, adapalene, or tazarotene) ± physical comedo extraction

• Alternate retinoid; benzoyl peroxide (BPO); salicylic acid; azelaic acid

Papulopustular Mild Acne

• BPO or topical antimicrobial + topical retinoid
• BPO wash for mild truncal lesions

• Alternate antimicrobial + alternate retinoid; azelaic acid; sodium sulfacetamide-sulfur

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🟠 MODERATE ACNE

• Topical retinoid + BPO ± topical antibiotic
• Oral antibiotic (doxycycline or minocycline) + topical retinoid + BPO
• In women: Spironolactone and/or oral contraceptive + topical retinoid ± BPO

• Change oral antibiotic; alternate topical retinoid
• If moderately severe or scars form → oral isotretinoin

Oral antibiotics should be limited to 3–4 months and never used as monotherapy. They must always be paired with BPO to prevent resistance.

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🔴 SEVERE ACNE (Nodular/Cystic)

• Oral isotretinoin (drug of choice)
• Oral antibiotic + topical retinoid + BPO ± topical antibiotic
• In women: Spironolactone + OCP + topical retinoid ± topical/oral antibiotics ± BPO

• Intralesional triamcinolone acetonide (2.5–5 mg/mL) — especially for nodular and cystic lesions; rapid reduction of inflammation

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Part III: Individual Drug Classes — Detailed

1. 🧴 TOPICAL RETINOIDS

• Apply to entire acne-prone area (not spot treatment)
• Start every other night → titrate to nightly as tolerated
• Use daily SPF sunscreen
• Avoid in pregnancy (all retinoids)
• Retinoids are the preferred maintenance agents after initial control

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2. 🫧 BENZOYL PEROXIDE (BPO)

• Apply once daily (usually morning) or twice daily
• Washes effective for truncal acne; leave in contact ≥2 minutes
• Use concurrently with antibiotics (topical or oral) to prevent resistance
• Warning: Bleaches hair, clothing, towels, and sheets
• Water-based, lowest-strength formulations are least irritating without compromising efficacy

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3. 🦠 TOPICAL ANTIBIOTICS

• Never use as monotherapy — must be combined with BPO to minimize antibiotic resistance
• Concurrently use topical retinoid to hasten response and allow earlier antibiotic discontinuation
• Well-tolerated; category B in pregnancy
• Topical dapsone 5–7.5% gel: Alternative; apply twice daily; note skin discoloration if BPO applied afterward; hemolytic anemia risk (check G6PD in at-risk patients)
• Topical minocycline 4% foam: Newer option under review

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4. 💊 ORAL ANTIBIOTICS

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5. ☀️ ISOTRETINOIN (Oral Retinoid)

• Severe nodular/cystic acne
• Moderate acne with scarring
• Moderate acne that relapses quickly off oral antibiotics
• Psychological distress despite adequate topical/systemic therapy
• Acne conglobata and acne fulminans

• Standard: 0.5–1 mg/kg/day; total cumulative dose 120–150 mg/kg (for long-lasting remission)
• Duration: typically 4–6 months
• Split into two daily doses with food (fat enhances absorption)

• Monthly pregnancy tests in all females of childbearing potential (teratogen — Category X, absolute contraindication)
• Monthly LFTs, fasting lipids (triglyceride elevation common)
• Baseline and periodic CBC

• Mucocutaneous: Cheilitis (nearly universal), dry skin/eyes/nose, epistaxis
• Teratogenicity: Two forms of contraception mandatory in females
• Dyslipidemia: Hypertriglyceridemia; reduce dose or add fibrate if severe
• Musculoskeletal: Myalgia, arthralgia
• Psychiatric: Screen for depression/suicidal ideation (debated causal link)
• Night blindness (rare)
• Pseudotumor cerebri — avoid with tetracyclines simultaneously

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6. 🩺 HORMONAL THERAPY (Females Only)

Combined Oral Contraceptive Pills (COCPs)

• Mechanism: Suppress ovarian + adrenal androgen production via estrogen + progestin
• Preferred progestins (anti-androgenic): Norgestimate, desogestrel, drospirenone (avoid androgenic progestins like levonorgestrel)
• FDA-approved for acne: Ortho Tri-Cyclen (norgestimate/EE), Yaz (drospirenone/EE), Estrostep (norethindrone/EE)
• Meta-analysis: COCPs equivalent to oral antibiotics in reducing acne lesions at 6 months
• Takes 3–6 menstrual cycles for full effect

Spironolactone

• Mechanism: Androgen receptor blocker + inhibits 5α-reductase; reduces sebum
• Dose: 50–200 mg/day (start 50–100 mg, titrate)
• Particularly effective for adult female hormonal acne (jawline pattern)
• Side effects: Menstrual irregularity (co-prescribe with OCP), breast tenderness, hyperkalemia, hypotension
• Monitor: K⁺, BP; avoid in renal failure or those on ACE inhibitors/ARBs
• Pregnancy category X — contraception required

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7. 🔬 OTHER TOPICAL AGENTS

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Part IV: Special Acne Variants — Specific Treatments

🔴 Acne Conglobata

• Oral isotretinoin is first-line (standard dosing protocol)
• Oral antibiotic + topical retinoid + BPO as alternative
• Intralesional triamcinolone for individual nodules
• Surgery: incision and drainage of fluctuant abscesses
• Biological agents (dapsone, colchicine) used in refractory cases

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🔥 Acne Fulminans

1. Oral corticosteroids first (prednisolone 0.5–1 mg/kg/day) to suppress explosive inflammation — start 2–4 weeks BEFORE adding isotretinoin
2. Then introduce isotretinoin at low dose (10–20 mg/day initially) while tapering steroids
3. Gradually increase isotretinoin to standard dose
4. Topical BPO + topical retinoid as adjuncts
5. NSAIDs for arthralgia

⚠️ Do not start high-dose isotretinoin acutely in fulminans — it can worsen the flare.

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👶 Neonatal & Infantile Acne

• Usually Malassezia-related (neonatal cephalic pustulosis)
• Mostly self-resolving
• If treatment needed: topical ketoconazole 2% cream

• True comedonal and inflammatory acne; can be severe
• First-line: Topical retinoid + topical BPO
• Moderate–severe: Low-dose oral erythromycin (safest antibiotic in infants)
• Check for underlying androgen excess (precocious puberty, CAH, androgen-secreting tumor)

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💊 Drug-Induced Acne

• Discontinue or substitute the offending drug whenever possible
• Topical BPO + topical retinoid for mild/moderate lesions
• Corticosteroid-induced acne: typically monomorphic pustular — responds to topical BPO; tetracyclines if widespread

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👩 Hormonal/Adult Female Acne

• Perimenstrual flares, jawline/lower face distribution, resistant to standard topicals
• Spironolactone 50–200 mg/day ± COCP (first-line in adult women)
• Low-dose isotretinoin as alternative
• Rule out PCOS, CAH, androgen-secreting tumor (free testosterone, DHEAS, LH/FSH if clinical suspicion)

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🏋️ Acne Mechanica

• Due to friction, pressure, occlusion (helmets, chin straps, tight clothing)
• Treatment: Remove/modify mechanical factor; topical BPO; topical retinoid; use moisture-wicking clothing

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Part V: Procedural & Physical Treatments

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Part VI: Pregnancy-Safe Acne Treatment

⚠️ Isotretinoin, tetracyclines, and tazarotene are absolutely contraindicated in pregnancy.

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Part VII: Step-up Algorithm & Key Principles

COMEDONAL          →  Topical retinoid ± salicylic acid
       ↓
MILD INFLAMMATORY  →  Add BPO + topical antibiotic (short-term)
       ↓
MODERATE           →  Add oral tetracycline (≤3 months) + topical retinoid + BPO
                       In females: Consider spironolactone / COCP
       ↓
SEVERE / NODULAR   →  Oral isotretinoin (120–150 mg/kg cumulative)
                       Intralesional triamcinolone for nodules
       ↓
ACNE FULMINANS     →  Oral corticosteroids FIRST → then isotretinoin (low dose → titrate)
       ↓
MAINTENANCE        →  Topical retinoid ± BPO (long-term)

General Management Principles

• Treat the entire acne-prone area, not spot treat
• Allow 6–8 weeks before judging efficacy; full effect at 3–4 months
• Avoid antibiotic monotherapy — always combine with BPO
• Limit antibiotics to 3–4 months maximum
• Topical retinoids are the backbone of maintenance therapy
• Address post-inflammatory hyperpigmentation (PIH) — azelaic acid and retinoids help
• Advise non-comedogenic moisturizers, sunscreens, and cosmetics
• Do not pick or manipulate lesions
• Educate about dietary factors (high glycemic index diet may worsen acne)
• Screen all patients on isotretinoin for depression

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Summary Reference Table

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💊 Comprehensive Acne Treatment Guide — With Full Drug Doses & Prescriptions

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Part I: Understanding Acne — Types & Classification

1. Follicular hyperkeratinization → comedone formation
2. Sebaceous gland hyperactivity (androgen-driven excess sebum)
3. Cutibacterium acnes colonization → inflammatory cascade
4. Release of proinflammatory cytokines → papules, pustules, nodules, cysts

Lesion Types

Clinical Subtypes

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Part II: Severity-Based Treatment Algorithm With Doses

🟡 MILD ACNE

Comedonal

Tretinoin 0.025% cream — apply a pea-sized amount to entire face at night; start every other night × 2 weeks → titrate to nightly as tolerated

Adapalene 0.1% gel — apply nightly; may apply morning or evening (light-stable); available OTC

Salicylic acid 0.5–2% wash or gel — apply once or twice daily (OTC) Azelaic acid 15% gel — apply twice daily to affected area

Papulopustular Mild

Benzoyl peroxide (BPO) 2.5–5% gel/wash — apply once daily (morning), leave on ≥2 min if wash + Clindamycin 1% gel or lotion — apply twice daily (morning + night) to affected area + Tretinoin 0.025% cream or Adapalene 0.1% gel — apply nightly

• Clindamycin 1.2% / BPO 2.5% gel (Duac/Benzaclin) — once daily
• Adapalene 0.1% / BPO 2.5% gel (Epiduo) — once daily
• Tretinoin 0.1% / Clindamycin 1.2% gel (Ziana) — once nightly

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🟠 MODERATE ACNE

Adapalene 0.3% gel or Tretinoin 0.05% cream — nightly to entire face + BPO 5% gel — once daily (morning) + Doxycycline 100 mg — orally twice daily with food and large glass of water × max 3 months

Spironolactone 50–100 mg/day — orally once daily; titrate to 100–200 mg/day as tolerated + Combined OCP (e.g., Drospirenone 3 mg / Ethinyl estradiol 0.02 mg [Yaz]) — one tablet daily × 21 days, 7 days off

Minocycline 50–100 mg — orally twice daily × max 3 months (use if doxycycline not tolerated) Or Sarecycline 1.5 mg/kg/day (weight-based) — once daily orally

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🔴 SEVERE ACNE (Nodular/Cystic)

Isotretinoin 0.5–1 mg/kg/day — orally in 2 divided doses with fatty meal Target cumulative dose: 120–150 mg/kg (reduces relapse risk) Duration: typically 4–6 months (16–20 weeks)

Oral antibiotic (Doxycycline 100 mg twice daily) + Tretinoin 0.05–0.1% cream + BPO 5% gel

Intralesional Triamcinolone acetonide 2.5–5 mg/mL — injected directly into nodule/cyst (Dilute triamcinolone 40 mg/mL to desired concentration with normal saline; inject 0.05–0.1 mL per lesion)

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Part III: Drug-by-Drug Prescribing Reference

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🧴 A. TOPICAL RETINOIDS — Full Formulary

All retinoids: Apply pea-sized amount to entire acne-prone region. Start every-other-night × 2 weeks → daily. Use SPF sunscreen daily. Avoid eyes and nasolabial folds.

Rx: Tretinoin 0.025% cream
Disp: 20 g tube
Sig: Apply a pea-sized amount to entire face at bedtime.
     Start every other night × 2 weeks, then nightly.
     Avoid eyes and corners of nose.
     Use SPF 30+ sunscreen daily.
Refills: 5

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🫧 B. BENZOYL PEROXIDE — Full Formulary

No bacterial resistance develops. Always co-prescribe with antibiotics.

• Wash (2.5–5%): Apply to affected area, lather, leave 2 minutes, rinse. Once daily (morning).
• Leave-on gel/cream (2.5–5%): Apply thin layer once or twice daily.
• Start at 2.5% to minimize irritation; increase to 5–10% as tolerated.

Rx: Benzoyl Peroxide 5% gel (or wash)
Disp: 60 g tube
Sig: Apply once daily (morning) to affected areas.
     If wash: leave in contact ≥2 minutes before rinsing.
     Warning: Bleaches clothing, towels, bedding.
Refills: 3

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🦠 C. TOPICAL ANTIBIOTICS — Full Formulary

Never monotherapy — always combine with BPO to prevent resistance.

Rx: Clindamycin phosphate 1% gel
Disp: 30 g tube
Sig: Apply a thin layer to affected areas twice daily (AM + PM).
     Use with benzoyl peroxide wash in the morning.
Refills: 2

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💊 D. ORAL ANTIBIOTICS — Full Prescribing Details

Rule: Always combine with BPO ± topical retinoid. Limit to 3 months maximum.

1. Doxycycline (First-line, preferred)

Rx: Doxycycline hyclate 100 mg tablets
Disp: 60 tablets (#60)
Sig: Take 1 tablet by mouth twice daily with food and
     a full glass of water. Remain upright ≥1 hour.
     Avoid prolonged sun exposure; use SPF 30+.
     Duration: 3 months (do not use longer without review).
Refills: 0

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2. Minocycline

⚠️ More serious adverse events than doxycycline — many guidelines now prefer doxycycline as first-line.

Rx: Minocycline extended-release 90 mg tablets
Disp: 90 tablets
Sig: Take 1 tablet orally once daily with or without food.
     Duration: 3 months maximum.
     Warn: dizziness on first few doses; pigmentation changes.
Refills: 0

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3. Sarecycline (Narrow-spectrum tetracycline, ≥9 years)

Rx: Sarecycline 100 mg tablet
Disp: 90 tablets
Sig: Take 1 tablet orally once daily with or without food.
     Duration: 3 months.
Refills: 0

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4. Erythromycin (Pregnancy/age <8 years)

⚠️ High resistance rates worldwide — reserve for pregnancy or pediatric cases.

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5. Azithromycin (Pregnancy/tetracycline intolerance)

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6. Trimethoprim-Sulfamethoxazole (TMP-SMX)

• Dose: TMP 160 mg / SMX 800 mg (double-strength) — 1 tablet twice daily
• Use only for antibiotic-resistant cases or failed tetracyclines/macrolides
• Risk of severe adverse reactions (SJS, agranulocytosis) limits routine use

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☀️ E. ORAL ISOTRETINOIN — Complete Prescribing Guide

Indicated for: Severe nodular/cystic acne, acne with scarring, relapsing moderate acne, acne conglobata, acne fulminans (after steroids), severe acne resistant to antibiotics.

Dosing Protocol

Starting: 35 mg/day (0.5 mg/kg) × 4 weeks
Titrate:  70 mg/day (1 mg/kg) × remaining course
Target cumulative: 70 × 120 = 8,400 mg total

Pre-treatment Workup (Before Starting)

Side Effect Management

Rx: Isotretinoin (Accutane/generic) 20 mg soft gelatin capsules
Disp: 60 capsules
Sig: Take 1 capsule (20 mg) twice daily with meals
     (start 0.5 mg/kg/day; titrate to 1 mg/kg/day).
     Target total dose: 120–150 mg/kg.
     Enrolled in iPLEDGE program.
     No pregnancy — two forms contraception required.
     Labs at weeks 4 and 8 (lipids, LFTs, CBC).
Refills: Per iPLEDGE (monthly Rx only)

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🩺 F. HORMONAL THERAPY — Full Prescribing

1. Spironolactone (Women only)

Rx: Spironolactone 100 mg tablets
Disp: 90 tablets
Sig: Take 1 tablet orally once daily.
     Monitor potassium at 1 month.
     Use reliable contraception (teratogenic).
     Avoid in pregnancy and with ACE-I/ARB.
Refills: 2

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2. Combined Oral Contraceptives (FDA-approved for acne)

Onset of acne benefit: 3–6 menstrual cycles. Meta-analysis shows equivalence to oral antibiotics at 6 months for inflammatory acne.

Rx: Drospirenone 3 mg / Ethinyl Estradiol 0.020 mg (Yaz)
Disp: 1 blister pack (28 tablets)
Sig: Take 1 tablet daily at same time; follow pack sequence
     (24 active + 4 inert tablets).
Refills: 11

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🔬 G. OTHER TOPICAL AGENTS WITH DOSES

Rx: Azelaic acid 15% gel (Finacea)
Disp: 30 g tube
Sig: Apply a thin layer to affected areas twice daily
     (morning and evening) after washing face.
     Safe in pregnancy. May sting initially.
Refills: 3

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Part IV: Special Acne Variants — Specific Doses

🔴 Acne Conglobata — Treatment

1. Oral isotretinoin 1 mg/kg/day in 2 divided doses; cumulative 150 mg/kg
2. Bridge: Doxycycline 100 mg twice daily + topical retinoid + BPO (while isotretinoin takes effect)
3. Intralesional triamcinolone 5 mg/mL into individual nodules
4. Surgical: I&D of fluctuant abscesses
5. Refractory: Oral dapsone 50–100 mg/day; adalimumab (biologic — off-label)

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🔥 Acne Fulminans — Stepwise Protocol

⚠️ Do NOT start high-dose isotretinoin acutely — risk of paradoxical worsening.

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👶 Neonatal & Infantile Acne — Dosing

Rx: Ketoconazole 2% cream
Sig: Apply to affected area twice daily × 4–6 weeks
     (if Malassezia-driven neonatal cephalic pustulosis confirmed)

• Mild: Adapalene 0.1% gel — apply every other night; BPO 2.5% wash
• Moderate: Erythromycin ethylsuccinate 30–50 mg/kg/day in 3–4 divided doses orally × 6–8 weeks
• Rule out androgen excess (measure testosterone, DHEAS, 17-OH progesterone)

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👩 Hormonal/Adult Female Acne — Prescription Summary

Rx: Spironolactone 100 mg daily + Yaz 1 tablet daily
    + Adapalene 0.3% gel nightly + BPO 5% wash AM

Rx: Spironolactone 100–200 mg daily alone
    (with reliable non-hormonal contraception)

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💊 Drug-Induced Acne

• Discontinue offending drug when possible
• Corticosteroid-induced (monomorphic pustular): BPO 5% gel once daily; Doxycycline 100 mg twice daily if widespread
• EGFR inhibitor acne: Topical clindamycin 1% + topical steroid (mild); doxycycline 100 mg twice daily (moderate–severe)

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🤰 Pregnancy-Safe Acne Treatment — Prescriptions

❌ Absolutely contraindicated in pregnancy: Isotretinoin, all tetracyclines, tazarotene, spironolactone.

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Part V: Procedural Treatments With Doses

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Part VI: Maintenance Therapy

Maintenance Rx (standard):
Adapalene 0.1% gel — apply nightly to entire face
± BPO 2.5% wash — once daily (especially if was on antibiotics)

Duration: Indefinite (months to years as needed)

Topical retinoids alone are the gold standard maintenance — they prevent new comedone formation and address subclinical microcomedones.

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Part VII: Summary Prescribing Reference by Severity

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⚠️ Clinical Disclaimer: All prescriptions should be individualized based on patient age, weight, comorbidities, contraindications, and local antibiotic resistance patterns. Isotretinoin requires enrollment in the iPLEDGE REMS program in the USA.