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Table 12-1

TreatmentComedonesInflammatory papules/pustulesMixed pictureNodulocystic
First line

Topical retinoid

Azelaic acid

Salicylic acid

Benzoyl peroxide

Topical retinoid ± topical antibiotic ± benzoyl peroxide

Combination of all three

Oral antibiotic + topical retinoid
Second linePhysical comedone extraction

Oral antibiotic

Oral contraceptive pill (high oestrogen, low androgen, e.g. Yasmin®)

Azelaic acid + benzoyl peroxide ± topical antibiotic

Oral isotretinoin

A short course of systemic steroids may be given initially with the isotretinoin

Third line

Anti-androgens e.g. co-cypindiol (Dianette®)

Different oral antibiotic

Hormone therapy

Spironolactone

Oral antibiotic

Oral isotretinoin

Triamcinolone injections to unresponsive lesions