Pedoman Tatalaksana Akne Vulgaris Terkini: Update 2023

Kolegium DVE Indonesia merilis Pedoman Tatalaksana Akne Vulgaris Terkini 2023 sebagai panduan komprehensif berbasis bukti ilmiah terkini untuk manajemen akne vulgaris di Indonesia.

Pendahuluan

Akne vulgaris merupakan salah satu kondisi dermatologi paling sering dijumpai dalam praktik sehari-hari. Pedoman ini disusun berdasarkan evidence-based medicine terkini dan disesuaikan dengan kondisi populasi Indonesia.

Epidemiologi di Indonesia

• Prevalensi: 80-90% remaja, 20-30% dewasa
• Peak age: 14-17 tahun (perempuan), 16-19 tahun (laki-laki)
• Adult acne: Meningkat 25% dalam 10 tahun terakhir
• Impact: Psikologis, sosial, ekonomi signifikan

Tujuan Pedoman

1. Standardisasi diagnosis dan grading
2. Evidence-based treatment recommendations
3. Algoritma terapi yang praktis
4. Guideline untuk kasus khusus
5. Patient education standardization

Patofisiologi Update

4 Faktor Utama

1. Hiperproliferasi Keratinosit

• Abnormal keratinization
• Microcomedo formation
• Follicular obstruction

2. Hipersebore

• Androgen-stimulated sebum production
• Altered sebum composition
• Pro-inflammatory lipids

3. Kolonisasi C. acnes

• Biofilm formation
• Pro-inflammatory factors
• Immune activation

4. Inflamasi

• Innate immune response
• Cytokine release
• Inflammatory cascade

Faktor Kontribusi Tambahan

Internal factors:

• Genetics (familial tendency)
• Hormonal (PCOS, hyperandrogenism)
• Stress (cortisol elevation)
• Dietary (high glycemic index, dairy)

External factors:

• Kosmestik komedogenik
• Occlusivemedications
• Environmental (pollution, humidity)
• Mechanical (friction, pressure)

Klasifikasi & Grading

Sistem Grading Kolegium DVE

Grade 1: Mild Non-inflammatory

• Lesi: Predominantly comedones
• Count: <20 lesions
• Inflamasi: Minimal/absent
• Jaringan parut: None

Grade 2: Mild Inflammatory

• Lesi: Comedones + papules/pustules
• Count: 20-50 lesions
• Inflamasi: Mild
• Jaringan parut: Minimal risk

Grade 3: Moderate

• Lesi: Papules, pustules, few nodules
• Count: 50-100 lesions
• Inflamasi: Moderate
• Jaringan parut: Moderate risk

Grade 4: Severe

• Lesi: Numerous papules, pustules, nodules
• Count: >100 lesions
• Inflamasi: Marked
• Jaringan parut: High risk

Grade 5: Very Severe

• Lesi: Extensive nodules, cysts, sinus tracts
• Distribusi: Face + body
• Inflamasi: Severe, conglobata
• Jaringan parut: Almost inevitable

Special Forms

• Acne fulminans: Sudden severe, systemic symptoms
• Acne conglobata: Interconnected comedones, nodules
• Gram-negative folliculitis: Post-antibiotic
• PCOS-related acne: Hormonal pattern
• Adult female acne: Jawline distribution

Algoritma Terapi

Grade 1: Mild Non-Inflammatory

First Line

Topical retinoids (pilihan utama):

• Tretinoin 0.025-0.05% cream/gel
• Adapalene 0.1% gel
• Tazarotene 0.05-0.1% cream

Alternative:

• Azelaic acid 20% cream
• Salicylic acid 2% gel
• Benzoyl peroxide 2.5-5% gel

Duration & Monitoring

• Initial response: 4-6 minggu
• Optimal result: 12 minggu
• Maintenance: 6-12 bulan
• Follow-up: Monthly (first 3 months)

Grade 2: Mild Inflammatory

First Line

Combination therapy:

• Topical retinoid + BPO
• Topical retinoid + topical antibiotic

Recommended combinations:

• Adapalene 0.1% + BPO 2.5%
• Tretinoin 0.025% + clindamycin 1%
• Adapalene 0.1% + clindamycin 1% + BPO 2.5%

Second Line (if inadequate response at 12 weeks)

• Add oral antibiotics (short-term)
• Increase topical strength
• Consider hormonal therapy (females)

Grade 3: Moderate

First Line

Topical combination + oral antibiotics:

• Adapalene + BPO + doxycycline 100 mg/day
• Tretinoin + clindamycin + minocycline 100 mg/day

Duration oral antibiotics: 6-12 minggu maximum

Second Line

Hormonal therapy (females):

• COC (Ethinyl estradiol 20-35 μg + progestin)
• Spironolactone 50-100 mg/day
• Cyproterone acetate 2 mg + EE 35 μg

Other options:

• Oral isotretinoin (consider early)
• Intralesional corticosteroid
• Chemical peels

Grade 4-5: Severe to Very Severe

First Line: Oral Isotretinoin

Dosing:

• Initial: 0.5 mg/kg/day
• Maintenance: 0.5-1 mg/kg/day
• Cumulative dose: 120-150 mg/kg

Duration: 4-6 bulan (individualized)

Monitoring:

• Baseline: Liver function, lipid profile, pregnancy test
• Monthly: Blood tests, pregnancy test
• Side effects surveillance

Adjunctive Therapy

• Intralesional steroid: For acute nodules/cysts
• Incision & drainage: For large cysts
• Systemic corticosteroids: For acne fulminans
• Topical therapy: Maintenance post-isotretinoin

Panduan Terapi Spesifik

Topical Retinoids

Mekanisme Kerja

• Normalize follicular keratinization
• Anti-inflammatory effects
• Comedolytic & anti-comedogenic
• Enhance penetration of other agents

Penggunaan Optimal

Application:

• Evening application (photosensitivity)
• Pea-sized amount untuk entire face
• Avoid eyes, mouth, mucosa

Tolerability:

• Start low concentration
• Gradual increase frequency
• Short contact therapy (initial)
• Combination dengan moisturizer

Side effects management:

• Dryness, erythema, peeling (common)
• Retinoid dermatitis (transient)
• Photosensitivity (use sunscreen)
• Pregnancy category (teratogenic)

Benzoyl Peroxide

Mekanisme

• Antimicrobial (bakterisidal)
• Keratolytic
• Anti-inflammatory
• No bacterial resistance

Guidelines

Concentration:

• Start: 2.5%
• Maintenance: 2.5-5%
• Severe: Up to 10%

Formulation:

• Gel (paling efektif)
• Lotion (dry skin)
• Wash (large areas)

Tips:

• Apply after cleansing
• Avoid simultaneous dengan tretinoin (inactivation)
• Dapat bleach fabric (warning)
• Combine dengan antibiotics (synergistic)

Oral Antibiotics

First Choice

Doxycycline 100 mg/day:

• Anti-inflammatory properties
• Good tolerability
• Subantimicrobial dose (40 mg) option

Minocycline 100 mg/day:

• More lipophilic (better penetration)
• Effective untuk resistant cases
• Monitor for rare adverse effects

Duration Limits

• Maximum: 3-4 bulan
• Rationale: Antibiotic resistance prevention
• Maintenance: Switch to topical
• Combination: Always dengan BPO

Monitoring

• Clinical response setiap 4-6 minggu
• GI symptoms
• Photosensitivity
• Vestibular symptoms (minocycline)
• Drug interactions

Hormonal Therapy (Females)

Indications

• PCOS atau hormonal acne
• Late-onset acne
• Premenstrual flares
• Jawline distribution
• Failed conventional therapy

Options

A. Combined Oral Contraceptives

B. Anti-androgens

• Spironolactone: 50-100 mg/day (off-label)
• Cyproterone acetate: 50-100 mg/day (Day 5-15)

Contraindications

• Pregnancy/breastfeeding
• Thromboembolism history
• Breast cancer
• Liver disease
• Smoking (age >35)

Oral Isotretinoin

Indications (Absolute)

• Severe nodulocystic acne
• Acne fulminans
• Scarring acne
• Psychological impact

Indications (Relative)

• Moderate acne resistant to conventional therapy
• High relapse rate
• Acne with dysmorphia

Dosing Protocols

Standard protocol:

• 0.5-1 mg/kg/day
• Duration: 4-6 bulan
• Cumulative: 120-150 mg/kg

Low-dose protocol:

• 0.25-0.5 mg/kg/day
• Duration: Longer
• Better tolerability
• Lower relapse? (controversial)

Side Effects Management

Laboratory Monitoring

Baseline:

• CBC, liver function (ALT, AST)
• Lipid profile (triglycerides, cholesterol)
• Pregnancy test (females)

Monthly:

• Pregnancy test (females)
• Liver function, lipids (1st & 2nd month, then as needed)

Abnormal results:

• Triglycerides >500: Dose reduction/discontinuation
• ALT >2x ULN: Dose reduction/discontinuation
• Monitor for pancreatitis symptoms

Terapi Adjuvan

Chemical Peels

Indications

• Comedonal acne
• Mild-moderate inflammatory acne
• Post-inflammatory hyperpigmentation
• Combination dengan topical therapy

Types

Superficial peels:

• Salicylic acid 20-30%
• Glycolic acid 30-50%
• Jessner's solution
• Frequency: Every 2-4 weeks

Medium peels:

• TCA 20-35%
• Combination peels
• Frequency: Every 4-6 weeks

Laser & Light Therapy

PDT (Photodynamic Therapy)

• Indications: Moderate-severe acne
• Protocol: ALA + red/blue light
• Sessions: 4-6 sessions
• Efficacy: 60-80% improvement

Laser

• 1450-nm diode laser: Sebaceous gland target
• 1550-nm fractional: Scarring prevention
• IPL: Anti-inflammatory, reduce P. acnes

Intralesional Corticosteroid

Indications

• Acute inflamed nodules/cysts
• Hypertrophic scars prevention
• Rapid improvement needed

Technique

• Agent: Triamcinolone acetonide 2.5-5 mg/mL
• Volume: 0.05-0.1 mL per lesion
• Frequency: Can repeat setelah 2-4 minggu
• Risk: Atrophy (temporary)

Manajemen Akne Scar

Prevention

• Early aggressive treatment
• Avoid self-manipulation
• Control inflammation quickly
• Consider isotretinoin earlier

Classification

Atrophic scars (95%):

• Ice pick: Deep, narrow (kurang dari 2 mm)
• Rolling: Wide, shallow
• Boxcar: Wide, sharp edges

Hypertrophic/keloid scars (5%):

• Elevated, firm
• More common pada truncal acne

Treatment Options

Patient Education

Skincare Regimen

Morning Routine

1. Gentle cleanser
2. Topical medication (if prescribed AM)
3. Moisturizer (oil-free, non-comedogenic)
4. Sunscreen SPF 30+ (broad spectrum)

Evening Routine

1. Double cleanse (makeup remover + cleanser)
2. Topical medication
3. Moisturizer

Myths vs Facts

Lifestyle Modifications

Diet:

• Reduce high glycemic index foods
• Limit dairy products
• Increase vegetables, fruits
• Adequate hydration

Stress management:

• Regular exercise
• Adequate sleep (7-8 hours)
• Relaxation techniques
• Avoid excess caffeine

Hygiene:

• Tidak squeeze lesions
• Clean phone screen regularly
• Change pillowcase frequently
• Avoid touching face

Follow-Up & Monitoring

Follow-Up Schedule

Assessment Parameters

Objective:

• Lesion count (total, type)
• Inflammatory score
• Scarring assessment
• Photography (standardized)

Subjective:

• Patient satisfaction
• Quality of life score
• Side effects
• Compliance

Treatment Adjustment

Inadequate response at 12 weeks:

• Review compliance
• Assess severity grade
• Step up therapy
• Consider referral

Relapse:

• Reinitiate effective regimen
• Long-term maintenance
• Address contributing factors
• Consider isotretinoin

Special Populations

Pediatric Acne

• Age <7: Workup untuk hyperandrogenism
• Age 7-11: Usually mild, topical therapy
• Adolescent: Follow standard guidelines

Pregnant Women

• Safe: Azelaic acid, topical erythromycin, BPO (limited)
• Avoid: Retinoids (topical & oral), tetracyclines, hormonal therapy
• Consider: Glycolic acid peels, LED therapy

Breastfeeding

• Generally safe: Topical therapies (avoid nipple area)
• Caution: Oral antibiotics, hormonal therapy
• Contraindicated: Isotretinoin

Kesimpulan

Tatalaksana akne vulgaris memerlukan pendekatan komprehensif dan individualized. Pedoman ini memberikan framework berbasis bukti yang dapat diadaptasi sesuai kondisi masing-masing pasien.

Key Principles

✅ Early intervention prevents scarring
✅ Combination therapy superior vs monotherapy
✅ Maintenance therapy prevents relapse
✅ Patient education improves compliance
✅ Regular monitoring ensures optimal outcome

Future Directions

• Novel antimicrobial agents
• Sebum modulation therapy
• Microbiome-based treatment
• Personalized medicine approach
• Digital health integration

Referensi

1. Kolegium DVE Indonesia. Pedoman Tatalaksana Akne Vulgaris 2023.
2. American Academy of Dermatology. Guidelines of care for acne vulgaris management. J Am Acad Dermatol. 2016.
3. European Academy of Dermatology and Venereology. European evidence-based guidelines for acne treatment. J Eur Acad Dermatol Venereol. 2021.
4. Zaenglein AL, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74(5):945-973.

Download Pedoman Lengkap

Pedoman lengkap dengan algoritma detail, tabel dosis, dan formulir assessment available untuk download:

• Format PDF: www.kolegiumdve.id/pedoman-akne-2023
• Pocket guide: Tersedia dalam bentuk cetak (melalui sekretariat)
• Mobile app: PPK AI (integrated guidelines)

Kontak

Untuk pertanyaan mengenai pedoman:

• Email: pedoman@kolegiumdve.id
• Konsultasi kasus: Via PPK AI platform
• Workshop: Check www.kolegiumdve.id/events

Pedoman ini telah melalui review oleh panel ahli Kolegium DVE Indonesia dan disetuji dalam Rapat Pleno bulan September 2023.