The Treatment of Acne

The Treatment of Acne

Acne is a skin condition that can present as small lumps, nodules, redness, or cysts. It affects most teenagers but can affect adults too. Some cases can result in permanent scarring. Lesions can occur on the face, neck, chest, back, and arms.

Acne is a disease of the sebaceous gland. These are glands in the skin that produce an oily substance called sebum. They are connected to hair follicles. When these glands become plugged, they become growing collections of sebum, dead cells, hairs, and bacteria.

Acne can present in several ways, as comedones, nodules, and cysts. A comedo is a plugged sebaceous follicle. When the opening to the plugged follicle is wide, it is called a blackhead because the follicular plug appears black. A white head is seen when the opening to the follicle is narrow and looks like a skin colored bump on the skin.

Comedones

A papule is a small (<5mm) solid lump that protrudes above the skin's surface.

Papules

A pustule is a rounded lump in the skin containing pus, a mixture of white blood cells, dead skin cells, and bacteria. If they heal without progressing to cystic forms, they usually do not result in scarring.

Pustules, papules, comedones

A macule is a temporary red spot left where an acne lesion has healed. It is red and flat, and may persist for days to weeks. These lesions, when numerous, can coalesce and give a red inflamed face appearance.

Reddish appearance of macules

A nodule is a solid lump that goes deeper into the skin and can lead to scarring. Nodules can become painful. Nodular acne is a severe form of acne that may be resistant to most treatments.

A cyst is a sac containing pus but it is larger than a pustule. It can be very inflamed, go deeper into the skin and cause scarring. Cysts and nodules occurring together is a severe form of acne called nodulocystic disease.

Nodulocystic disease

Acne occurs in almost all people between the ages of 12-17. Up to 40% of mid teenagers have acne severe enough to merit treatment by a doctor. Acne usually starts by the age of 10 or 13 and lasts for 5-10 years. It usually resolves in the twenties but can persist into adulthood. Some people can get acne for the first time as adults. It affects men and women equally, but men tend to have more severe forms. Women may have intermittent acne related to menstral cycles and acne caused by cosmetics.

Acne scarring

The inflammation that occurs around a plugged sebaceous gland can heal leaving scars. Some people are more prone to scarring than others. Scarring occurs frequently from nodulocystic acne, but may occur with less severe forms as well.

Scars from nodulocystic disease

It is difficult to predict precisely who will get scarring, how bad scars will get, or how long they will last. But scarring may be prevented by treating acne as early as possible and as long as necessary. The better the control of inflammation the less likely scarring will result.

There are two kinds of scarring, scars with overgrowth of tissue and scars with loss of tissue. Tissue overgrowth results in hypertrophic scars or keloids. An excess amount of scar tissue or collagen is built up to form raised irregularly shaped masses. They can be 1-2 mm in diameter or over 1 cm wide and can persist for years. They may run in families.

Hypertrophic scarring or keloids

Scars associated with tissue loss are similar to scars from chicken pox and are more common. They can be ice pick type scars or wide deep depressions. They can be skin colored or whitish.

Scarring can be treated and improved. Collagen like substances like Restylane or Juvederm can be injected under the scars to fill in depressed scars. It does not work for ice pick or keloid scars. The benefits may last for 6 months. Laser therapies can be used to shave down raised scars or pare down the edges of depressed scars to make them shallower and promote healing over of depressed scars. Narrow scars like ice pick scars can be “punch” excised. Keloids sometimes can be removed, injected with steroids, or retinoic acid applied to the skin.

Acne can have significant social impact as well. It has been associated with social withdrawal, decreased self esteem, poor body image, and depression.

Treatment of Acne

Mild Acne

Mild acne presents as blackheads, whiteheads, or pustules. It can be controlled with gentle washing of the areas with warm water and mild soap two times a day to remove excess oil and dead skin. Over the counter acne creams like benzoyl peroxide or salicylic acid are used. Acne lesions should not be popped, picked, or squeezed. This can result in spread of inflammation or super infection with other bacteria making inflammation worse. Acne can lead to more irritation and make acne worse. The cosmetic or toiletries used should be labeled as noncomedogenic, does not clog pores. One can avoid aggravating acne by keeping oily hair off the face and washing it daily. Avoiding oily hair care products, and wearing cotton or moleskin under sports equipment to keep them off the skin can help. Tanning may mask acne but does not clear acne. It does increase risk of skin cancer and may react with some skin ointments like Retin A making skin more prone to light injury.

Home treatment requires 4-8 weeks to see improvement. And once acne clears, treatment must continue to keep new lesions from forming. Combination therapy with topical (ointments or creams) antibiotics and topical retinoids are commonly used.

Heavy foundation make up should not be used. Powder blushes and eye shadow is preferred over creams. Green undercover cosmetics help mask red acne lesions. Studies have not proven that stress or diet promote acne, but many people feel chocolate, colas, peanuts, shellfish, and fatty foods worsen acne.

Moderate to moderately sever acne

In moderate to moderately severe acne, there are several whiteheads, blackheads, papules, and pustules covering ¼ to ¾ of the face and other areas. Treatment includes comedo extraction or laser/light therapies in addition to over the counter medications. Perscription medications are used as topical antibiotics, topical retinoids, oral antibiotics or oral contraceptives. Treatment should be early to help prevent scarring.

Severe Acne

Severe acne present with deep nodules, cysts, inflammation, tissue damage, and scarring. It requires aggressive treatment by a dermatologist. Methods include drainage of lesions, surgical incision, interlesional steroid injections, isoretinoin (Accutane), oral antibiotics, and oral contraceptives.

Acne surgery are extractions done under sterile conditions by trained professionals. Intralesional steroid injections are for severely inflamed acne cysts that will likely rupture and scar. Cysts can be injected with diluted steroids to decrease inflammation and allow healing over a period of 3-5 days. Isotretinoin is a potent synthetic drug reserved for severe cystic or resistant acne. It is a pill taken 1-2 times per day for 16-20 weeks. It works on excess oil production, clogged pores, P. acnes bacteria and inflammation. Remissions last months to years. Many patients only need one course of therapy. Isotretinoin has several serious side effects including birth defects. Women cannot get pregnant on this drug. Women are required to get 2 pregnancy tests and use 2 forms of contraception 1 month before therapy and for 1 month after therapy. They cannot breast feed during this time. Other side effects include chest or abdominal pain, trouble swallowing, headaches, joint pain, nausea, vomiting, diarrhea, bleeding, depression, dryness of skin eyes or nose, and hair thinning. Patients are monitored with monthly blood tests for chemical abnormalities. Medication must be taken as ordered even after acne clears to prevent recurrence. Reddish macules may replace acne lesions but these fade in 6-8 weeks.

Oral antibiotics reduce P. acnes bacteria and decreases inflammation. Doxycycline, erythromycin minocycline and tetracycline have been used. Resistance to antibiotics can occur.

Oral contraceptives suppress overactive sebaceous glands and can be used as long term therapy. It cannot be used in women who smoke, have blood clotting disorders, are older than 35, or have migraine headaches without the advice of a gynecologist. Spironolactone is a steroid sometimes used with oral contraceptives to decrease androgen (male hormone) production in females. Side effects include irregular periods, breast tenderness, headache and fatigue.

Over the counter medicines

Alcohol and acetone used together is a degreasing agent and antibacterial. Benzoyl peroxide reduces P. acnes and removes dead skin to prevent comedones. The main side effect is skin dryness. It can bleach hair, sheets , and clothing. It should be continued after acne clears to prevent recurrences.

Salicylic acid helps decrease abnormal shedding of skin cells and unclogs pores. It does not have any effect on sebum production or P. acnes bacteria. It must be used continuously to prevent outbreaks. It is in many over the counter preparations. It can be irritating to the skin. Other agents like sulfur and resourcinol may be in over the counter products.

Physical procedures

Chemical peels

Light chemical peels with glycolic acid can loosen blackheads and decrease papules. It peels the top layer of skin and opens plugged follicles. Comedo extractions can be done with sterile devices by professionals. Large cysts can be drained by trained medical personnel. Laser and light therapies can treat P. acnes without the bother of taking medications and can treat hard to reach areas like the back.

Prescription Medications

Topical antibiotics

Azelaic acid treats mild to moderate acne by decreasing P. acne bacteria, abnormal skin cell shedding and inflammation. It can treat dark spots that occur in acne patients of color. It can be used for years but may cause skin dryness and lightening.

Benzoyl peroxide kills P, acnes bacteria and is anti-inflammatory. It can increase effectiveness of antibiotics and used in combination can help prevent resistance.

Clindamycin is a topical antibiotic that decreases P. acnes bacteria and inflammation. It is well tolerated but can cause skin dryness and irritation. Erythromycin is a topical antibiotic active against P. acnes bacteria and is anti-inflammatory. It too can cause skin dryness and irritation. Sodium sulfacetamide is a topical antibiotic that treats P acnes bacteria and opens clogged pores in inflammatory acne. Some patients do not like the sulfur odor.

Topical Retinoids

This is a derivative of vitamin A that treats mild to moderately severe acne. They unclog pores. They may diminish wrinkles. They can irritate the skin and increase sensitivity to the sun.

Adapalene is a gel or cream that unclogs pores and is anti-inflammatory. Improvement can be seen in 8-12 weeks. Side effects include skin irritation and dryness.

Tazarotene is a gel or cream that keeps skin pores clear. It can cause birth defects and skin irritation.

Tretinoin unclogs pores and keeps them unclogged. It can be irritating causing redness, scaling, itching, dryness, and burning.

Oral antibiotics

These are for moderate to severe acne to treat P. acnes bacteria. Treatment begins with higher doses and then decreased as acne improves. Duration of therapy is 6 months or less. Erythromycin, tetracycline, doxycycline, and minocycline are used.

Laser Therapy

Blue light therapy has been approved by the FDA. It kills P. acnes bacteria in inflammatory acne resistant to other therapies. It does not contain UV light which can damage skin and is not used for acne treatment anymore. Usually 8, 15 minute sessions are done over 4 weeks. Studies demonstrate many but not all patients can see up to 55% clearance. Side effects include skin color change, swelling and dryness. It may not be useful for nodulocystic acne.

Intense pulsed light therapy destroys P. acnes bacteria and decreases sebum production by shrinking sebaceous glands. It is FDA approved to treat mild to moderate acne. Side effects may include changes in skin coloration and must be avoided or used carefully in darker skin types. For these people, laser therapy with a 1319 nm wave length can be used instead of or in combination with IPL.

ALA and light therapy

A solution of 5-aminolevulunic acid (ALA) is placed on the skin for 15-60 minutes. It concentrates in the sebaceous glands and is converted by light therapy to a chemical toxic to sebaceous glands and bacteria to reduce acne. Blue light or IPL can be used.

Other topical treatments

Ziana gel is a topical treatment for acne vulgaris in patients 12 years or older. It contains clindamycin phosphate 1.2% and tretinoin 0.025% in 2, 30, and 60 gm tubes. At bedtime, wash the face with mild soap and warm water, then a pea sized amount is squeezed onto the finger tip and dotted on the chin, cheeks, nose, and forehead, then gently rubbed over the entire face. It should be kept away from the eyes, mouth, angles of the nose and mucous membranes. A sunscreen should be applied every morning and reapplied during the day as needed. Patients should avoid exposure to sunlight, UV light and sunlamps. Ziana may cause skin redness, scaling, itching, burning, or stinging. It may lead to diarrhea or abdominal cramps from severe colitis associated with Clostridium difficile infection.

Retin A (tretinoin) cream 0.05% (0.1 – 0.04%) is a metabolite of vitamin A for the treatment of acne vulgaris where comedones, papules, and pustules predominate. It is not recommended as sole therapy for severe pustular deep nodulocystic acne. It should be applied once a day or at bedtime lightly covering the entire affected area. During early weeks of therapy, inflammatory lesions may worsen before they improve and is not a reason to stop the medicine. Results should be noticed after 2-3 weeks, but 6 weeks may be needed to see definite improvement. Once lesions respond it may be possible to decrease frequency of applications. Exposure to sunlight and sunlamps should be minimized. Sunburn patients should avoid use until the burn clears. Sunscreen of at least SPF 15 should be used. Extremes of wind or cold can be irritating. Soaps and cosmetics with strong drying effects or high alcohol content should be used with caution. It should be kept out of eyes, mouth angles of the nose and mucous membranes. Studies do not show harm to the fetus in animals. It is not known if there is excretion in breast milk so caution should be exercised. Side effects include redness, peeling, blistering, and crusting. True contact allergies are rare.

Cleocin T topical gel or lotion comes in pleget applicators that are used twice a day with 30-60 cc applicator bottles or a carton of 60 single use pledgets. The gel comes in 30 or 60 gm tubes. Side effects include burning, itching, drying, redness, peeling, and colitis. Contact to eyes, nose mouth, and broken skin should be avoided. It may take 2-6 weeks to note improvement and up to 12 weeks to see full benefit.

Accutane (isotretinoin) is a vitamin A analog approved for treating severe nodular acne resistant to other treatments. Severe nodular acne is defined by many red swollen tender lumps pea sized or larger. Nodular acne can cause permanent scarring if untreated. Women who can get pregnant follow a specific program of testing and birth control. Accutane is given twice a day with meals. For severe acne, 35-38% are cured after one course of treatment and 70% experience long term remission. Adult women have higher relapse rates than teenagers. One course of therapy lasts 4-6 months. The dose is 0.5-1 mg/kg body weight. The total dose taken should not be less than 120 mg/kg over the entire treatment period. Oily skin, giant blackheads, younger teen, acne on chest or back have higher relapse rates. Multiple courses can be taken.

Accutane affects sebaceous glands to produce normal amounts and composition of oils to prevent pores from clogging. It prevents excess keratin production decreasing comedone formation. Side effects include blurred vision, depression, stomach or chest pain, diarrhea, headache, nausea, muscle pain, increased cholesterol, and birth defects. Periodic blood tests are required.

Oral antibiotics

Oral antibiotics are for moderate to severe acne vulgaris. Moderate inflammatory acne is treated with oral antibiotics and topical reinoids with benzoyl peroxide. Mild acne is treated with topical antibiotics or benzoyl peroxide with a retinoid. The initial benefits may take 1-2 months. It is necessary to be compliant for 8-12 weeks to see if it is working. Doxycycline 100 mg bid is taken for the first few weeks then the dose is decreased to once a day for 1-3 months. The goal is to stop the antibiotic by the end of the third month. Doxycycline comes in two forms, hyclate and monohydrate. The hyclate is associated with more GI side effects. GI side effects are minimized by taking the medication 30 minutes after a meal. Photosensitivity may occur with doxycycline so avoid tanning beds. Minocycline can cause hypersensitivity reactions, lupus, dizziness, vertigo, pigmentation changes, and bluish discoloration.