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Reflection point answers and discussion.

Article Excerpt
Case 1: Ms. S. (Dr. Bikowski responds)

REFLECTION POINT 1

Answer Choice: Combination therapy with a systemic and a topical agent

I would not select this approach I hesitate to prescribe for a pregnant woman an aggressive combination regimen that includes a systemic agent Additionally, her condition is nonscarring. The urgency associated with concern for permanent cosmetic defect--a possible indication for aggressive combination therapy--is not present This approach, therefore, probably would be overly aggressive

Answer Choice: Monotherapy with a systemic agent

I would not select this treatment approach. It is best to avoid use of systemic agents at every stage of pregnancy, whenever possible.

Answer Choice: Monotherapy with a topical agent

I feel that this is the best choice Although exceptions exist, topical therapy is generally considered the safer pharmacologic option for pregnant patients Additionally, Ms S's condition is limited to the face. Systemic agents often are required in the treatment of patients who have acne affecting the chest, back. and shoulders This patient, therefore, is an ideal candidate for a single, safe, topical agent

REFLECTION POINT 2

Answer Choice: Erythromycin, oral, 250 mg 4 times daily, plus evening application of 5% BP gel

I would not choose this regimen for Ms S In addition to including a systemic agent, this particular combination is associated with additional concerns Although oral erythromycin is an FDA Pregnancy Category B agent, the drug may cause gastrointestinal upset (19)--a consideration in light of the pregnant woman's nutritional requirements Systemic antibiotics also may cause vaginal candidiasis, (19) to which pregnant women have increased susceptibility Other concerns include potential challenges to compliance because of the 4-times-daily regimen, as well as potential for bacterial resistance. The patient's acne demonstrates an inflammatory component, and erythromycin's anti-inflammatory efficacy may be inferior to other currently available antibiotics. Finally, BP is an FDA Pregnancy Category C agent. Although BP is available as an over-the-counter preparation, it is unknown whether it harms the developing fetus BP, therefore, should not be used by pregnant patients in the unlikely event that teratogenicity may occur. BP also irritates the patient's hypersensitive skin

Answer Choice: Doxycycline, 100 mg twice daily

This is not an appropriate choice for Ms S Doxycycline is an FDA Pregnancy Category D drug, which may cause alterations in tooth development. (32)

Answer Choice: AZA 15% gel, twice daily

This is the best choice for Ms. S. AZA 15% gel is a Pregnancy Category B topical preparation, and it is a naturally occurring ingredient found in many popular breakfast cereals. The agent has proven efficacy in the treatment of noninflammatory and inflammatory acne vulgaris, and it has not been associated with bacterial resistance Common adverse effects are mild and include cutaneous irritation. (21) I believe AZA 15% gel provides the best efficacy with the most desirable safety profile

You prescribe off-label application of AZA 15% gel, twice daily, and direct Ms S to continue with her daily cleansing and moisturizing regimen. At the patient's first 4-week follow-up visit, you note a dramatic improvement. marked by an approximate 75% decrease in the number of lesions...

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