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Acne vulgaris, the common form of Acne, affects large numbers of people (and virtually most (up to 85%) of adolescents. Acne sometimes causes distressing psychosocial effects. This may lead to low self-esteem, shame, and even to depression when acne is very severe or disfiguring.
We can help YOU with in depth evaluation for causes of acne and a wide range of treatments that exist for acne, each of which combats particular aspects of the underlying process that results in acne. These treatments work best when used in a carefully constructed treatment plan we will develop together.
EVALUATION AND TREATMENT MAY INCLUDE…
- Hormone evaluation to obtain hormone balance
- Stool testing to evaluate bacterial health that influences skin bacterial health
Topical Treatment – applied to or performed on the skin
- Physician Only Skin Care Products
- Benzoyl Peroxide
- Microdermabrasion – exfoliates and opens plugged comedomes
- Skin Peels – exfoliates and opens plugged comedomes
Systemic Treatment – taken orally (by mouth)
- Rarely oral antibiotics
Energy Based Treatment
- Blue Light Treatment – Kills p. acnes.
- Red Light Treatment – reduces inflammation and redness.
- Laser – Shrinks sebaceous glands and decreases sebum production.
To understand how these treatments work, you need to know how the mechanisms that produce acne interact.
MEDICAL ATTITUDES ABOUT ACNE VULGARIS
The attitude of physicians to acne varies tremendously. Some take the attitude that it is a ‘normal physiological process’ and that the sufferer just has to wait to ‘grow out of it’. This can lead to disfiguring scarring of the skin and emotional scarring!
I take a more pro-active stance and am keen to aggressively treat this inflammatory condition!
STRUCTURE AND FUNCTION OF NORMAL SKIN
The skin is the largest body organ system. It has a huge surface area of about 2 square meters in an adult. The skin has many important functions, including:
- Regulation of body temperature (via sweating and blood flow control)
- Detoxification (directly and via oil and sweat glands)
- Synthesis of vitamin D (important in calcium metabolism)
- Your skin ranges in thickness from 0.5 mm to 4 mm and consists of two layers:
Epidermis – the thinner outer layer, which is made up of different layers.
Dermis – the thicker inner layer containing nerve endings, glands, blood vessels, hair follicles and other structures.
Beneath the dermis is the fatty subcutaneous layer, which attaches to underlying tissues and organs.
The epidermis contains four main types of cell arranged in a layered structure known as stratified squamous epithelium.
• Keratinocytes compose about 90% of the epidermis. These cells produce keratin, a protein that helps waterproof and protect the skin, and that forms hair and nails.
• Melanocytes, which produce the pigment melanin
• Langerhans cells, which are involved in immune defense
• Merkel cells, which are thought to be involved in the sensation of touch.
The keratinocytes are arranged in four, or in some locations (such as the palms of the hands and soles of the feet, which contain the extra layer of the stratum lucidum) five layers. The deepest layer is called the stratum basale, which contains the stem cells that produce keratinocytes. The young keratinocytes push upwards through the stratum spinosum, to the stratum granulosum and stratum corneum in a process known as keratinisation.
Keratin is incorporated into the keratinocytes in the stratum granulosum and, as their nuclei degenerate, the keratinocytes die. When they reach the stratum corneum, the keratinocytes have flattened and are completely filled with keratin. Eventually they are sloughed off, to be replaced by the next row of keratinocytes.
The whole process of keratinisation takes approximately 2-4 weeks.
The dermis is composed of connective tissue containing blood vessels, collagen and elastin fibers with a few fat cells, macrophages and fibroblasts interspersed. It also contains specialized nerve endings that are sensitive to touch (Meissner’s corpuscles), pressure (Pacinian corpuscles), heat and cold. Sweat glands, sebaceous glands and hair follicles are embedded in the dermis and extend through the epidermis to open onto the surface of the skin. A pilosebaceous follicle is a unit consisting of one hair and an associated sebaceous gland.
Sebaceous glands are present in the skin throughout the body. They produce sebum, an oily substance consisting of a mixture of fats, cholesterol, proteins and salts. Sebum spreads from the sebaceous follicle onto the hair and skin. It prevents hair from drying out and keeps skin supple. It also inhibits the growth of certain bacteria.
There are three kinds of pilosebaceous follicle in the dermis:
• vellus follicles, comprising a tiny hair and a much larger sebaceous gland.
• sebaceous follicles, comprising a tiny hair and an exceptionally large multiacinar sebaceous gland.
• terminal hair follicles, comprising a long, stiff, thick hair and a proportionately sized sebaceous gland.
The sebaceous follicles are the only ones involved in acne, although the other types contribute to the amount of oil on the surface of the skin. Sebaceous follicles are found only on the face, upper arms, chest and upper back.
Acne only occurs in these areas.
BACTERIAL FLORA OF THE SKIN
The skin comes into contact with a large number of organisms, and as such is our first best defense against the environment in which we live. Fortunately most of these organisms find the skin a hostile environment and do not survive. As a normal part of this defense mechanism everyone has a range of bacteria living on their skin.
One of the normal bacteria found on the skin surface is Propionibacterium acnes, which unfortunately also has an important role in the development of acne. Other micro-organisms that might be involved in the mechanism of acne are Pityrosporum ovale and Staphylococcus epidermidis.
DEVELOPMENT OF ACNE VULGARIS
Acne is a disorder of the sebaceous follicles of the face, neck, upper back and upper chest and involves four stages:
• Oversecretion of sebum
• Abnormal keratinisation and comedone formation
• Bacterial proliferation
HORMONAL IMBALANCE and OVERSECRETION OF SEBUM
The activity of the sebaceous glands is controlled by the male sex hormones known as androgens. Androgen levels increase at puberty (in both males and females) and this increase results in the enlargement and proliferation of the sebaceous glands. In turn, this results in an increase in the production of sebum, which causes the seborrhea that is associated with acne. Although the higher androgen levels that are reached during puberty continue into adulthood, many people stop suffering from acne when they leave their adolescence as hormone levels stabilize. An additional explanation is that there is over-activity of sebaceous gland androgen receptors during puberty, in which there is increased local conversion of testosterone (an androgen) to the more potent dihydrotestosterone by the enzyme 5-alpha-reductase. As this overactivity resolves, so does the acne.
ABNORMAL KERATINIZATION AND COMEDONE FORMATION
A malfunction of the keratinization process in the epidermis lining the sebaceous duct can result in a thickening of the epidermis. In combination with sebum and bacteria, the thickened epidermis can block the sebaceous duct with a plug of keratinocytes. Sebum and keratinous debris accumulate behind the blockage and eventually, distension of the sebaceous unit produces readily visible comedones of which there are two types:
In open comedones, the keratinous plug is relatively large and visible and has a dark surface, hence the name “blackhead”. The black coloration is due to the accumulation of the pigment melanin; it is not dirt. Open comedones never evolve into acne (as long as they are not squeezed by the patient), probably because the plug is easily overcome by the increased levels of sebum secreted by the follicle. There is, therefore, no invasion of the dermis, and thus no inflammatory changes.
In closed comedones, the keratinous plug is small but blocks the sebaceous duct completely. The distension of the sebaceous gland produces a raised white papule – the “whitehead”.
Blockage of the sebaceous duct and accumulation of sebum creates the anaerobic conditions in which the bacterium P. acnes starts to grow and accumulate in number.
The proliferating P. acnes produces various enzymes. These enzymes split sebum into free fatty acids which induce inflammation in the pilosebaceous unit. As these inflammation producing free fatty acids diffuse through the walls of the pilosebaceous gland into the dermis they attract infection fighting white blood cells (neutrophils) to kill and clean up the growing number of bacteria. The neutrophils enter the pilosebaceous gland where they do their assigned job, but unfortunately during this process as they release enzymes which attack and disrupt the walls of the bacteria, these enzymes also weaken the walls of the sebaceous gland causing it to rupture. This allows the contents of the unit, including free fatty acids and bacteria, to spread into the dermis where they produce an inflammatory response.
The inflammation produces redness, swelling and pain. The severity of the resulting lesion depends on the extent of the damage and the healing capabilities of the person’s skin and immune system. This ranges from a small pustule in some to a large nodule or cyst. Healing of the lesions, particularly the more severe lesions, may produce pigment changes of the skin, especially in darker skinned individuals (post inflammatory hyperpigmentation – PIH) and worse, the typical pitted scarring. Occasionally, the scar becomes thickened and raised due to excess production of collagen – known as keloid scars.
OTHER CONTRIBUTORY FACTORS
Genetic factors have an important influence on the severity, duration and clinical pattern of your acne. If your parents had bad acne, chances are you will struggle with it also!
Stress can cause an increase in acne and has a number of other negative effects on the body. Try to get an adequate amount of sleep and limit your amount of stress by learning how to reduce it (Self Hypnosis is an excellent way to do this!).
There are certain Medications that can cause or worsen acne. These include progestin-dominant birth control pills, injectable Depo-Provera®, androgens, Lithium, ACTH, INH, bromides, iodine, barbiturates, steroids and Dilantin.
DO NOT stop taking your medication on your own and risk a serious medical problem – talk with your physician if you have concerns that a medication may be worsening your acne so you may formulate an alternate treatment regimen.
Diagnosis of Acne Vulgaris
The diagnosis of acne is usually straightforward, being based on the presence of comedones with or without papules, pustules, nodules, cysts and scarring occurring in a typical distribution. Comedones are the most important diagnostic feature. Investigations are not usually required to confirm the diagnosis. Occasionally, fluid from acne lesions is cultured to exclude other forms of skin infection.
GRADING OF ACNE VULGARIS
Grading acne vulgaris is a means of assessing the severity of this highly variable condition. The techniques used can provide useful information to monitor the variation of the condition over time and the effect of treatment in individuals. Importantly, grading techniques can also facilitate the conduct of clinical trials and comparisons between completed trials. However, there is no standard acne grading system.
Several grading systems have been developed. The simplest of these is a system that classifies the condition as being mild, moderate or severe:
Mild – open and closed comedones, some papules and pustules.
Moderate – comedones with more frequent papules and pustules with mild scarring.
Severe– comedones, papules, pustules, nodular abscesses and scarring (sometimes keloidal).
The Cook system involves evaluating the overall severity of the acne on a 0 to 8 scale anchored to photographic standards that illustrate grades 0, 2, 4, 6 and 8.
COOK GRADING SCALE
|Severity of Acne||Grade Description|
|0||Need not be perfect; 3 small comedones and/or papules are permitted, if they are scattered|
|2||Very few pustules, up to 3 dozen papules and/or comedones; no big or prominent lesions; lesions are hardly visible from 2.5m away|
|4||Between grades 2 and 6. Red lesions and inflammation are present to a significant degree. Worthy of treatment|
|6||Numerous comedones, but no inflammation or inflammatory lesions, numerous pustules, lesions easily recognised at 2.5m, some pustules may be quite large (1-2 cm)|
|8||Conglobata, sinus or cystic type acne or Highly inflammatory acne covering most of the face; yellow pustules extend to neck and chin.|
Management and Treatment of Acne Vulgaris
This section outlines the principles of the management of acne vulgaris and explains the mode of action, advantages and disadvantages of the range of treatments used.
AIMS OF TREATMENT
Limit disease duration.
Washing twice daily to remove surface sebum is generally advised to improve appearance. However, it has no impact on existing or future acne lesions. In addition, washing may dry-out the skin if too frequent (for example, more than twice a day) and may actually cause the skin to react by forming more sebum! You need to moisturize with a non-comedogenic product to prevent this – use our Physician Grade Bellederm Clear Acne Kit to provide an ideal regimen!
Patients are also advised to:
- avoid oil based make-up, as it may block the follicle outlet.
- remove make-up thoroughly at night.
- avoid squeezing lesions (this forces sebum and its inflammatory products deep into the skin – this causes more severe inflammation followed by scarring).
Large blackheads can be removed using a special implement called a comedone extractor. Education about acne is vital in enhancing compliance with treatments and to counter misconceptions about the condition.
ENERGY BASED TREATMENTS
Red Light / Blue Light – 8 treatment sessions twice a week for ALL Acne.
- The Blue light – actually kills P. Acnes in the skin and sebaceous glands!
- The red light – really calms down the redness of inflammation of lesions already present and thereby speeds healing.
- Combine with chemical peels to open pores, microdermabrasion to exfoliate and remove plugs from comedones.
This treatment package markedly improves the appearance of the acne – this will also continue to improve for weeks after the last treatment!!
Laser Treatment – several treatments at two week intervals for Moderate to Severe Acne.
- Reduces Gland Size – shrinks comedones.
- Less sebum and hence less inflammation.
- Skin appearance less oily.
- Combine with chemical peels to open pores, microdermabrasion to exfoliate and remove plugs from comedones.
A very wide range of treatments is available for acne. Some are applied to the surface of the skin (topical treatments) and some are taken orally (systemic treatments). They vary in their mode of action and side effects.
The severity of the acne is the deciding factor in choosing a particular treatment.
Topical treatments are usually used in all grades of acne from mild to severe.
Systemic treatments (with or without topical co-therapy) are usually used in the treatment of severe acne. Systemic treatments may be used in mild and moderate acne if topical treatments do not produce the desired improvement.
Co-prescription (topical and oral) occurs regularly in more severe cases of acne.
APPROACHES TO DRUG TREATMENT
The treatments used for acne vulgaris attack different aspects of the underlying pathogenesis of the condition.
Most treatments for acne vulgaris may take several weeks, if not months, to achieve maximal efficacy. Furthermore, most treatments do not alter the natural course of the disease: they suppress its manifestations until the disease resolves of its own accord. As a result, an effective treatment needs to be continued for prolonged periods.
Topical treatments are applied to the whole area affected by acne, not just to the acne lesions currently visible. The potential advantages of topical treatment over systemic antibiotics include more appropriate targeting of the affected area, higher skin concentrations of antibiotic, a theoretically lower risk of systemic side-effects and fewer interactions with other therapies. Many topical treatments contain combinations of therapeutic agents, each of which treats acne via a different mode of action. Topical antibiotics usually require a prescription.
BENZOYL PEROXIDE (e.g. Brevoxyl, Panoxyl)
Benzoyl peroxide is available as creams and gels (2.5-10%), and also soaps and washes.
Every patient that can tolerate BP should be on a minimum of 2.5%!
Benzoyl peroxide is not an antibiotic, although it does have a bactericidal (it kills acne bacteria) action and reduces the number of P. acnes in the skin. It also breaks down keratin and comedones; it may also suppress sebum production. In combination with the antibiotic erythromycin or clindamycin, benzoyl peroxide helps to prevent the development of antibiotic resistance by bacteria. The major adverse effect of benzoyl peroxide is skin irritation, including contact dermatitis, which often subsides if the frequency of application is reduced. It can also bleach hair and clothes.
TRETINOIN (e.g. Retin-A)
Topical tretinoin (also known as retinoic acid) is a derivative of vitamin A. It is available as lotions, creams and gels (0.025% and 0.1%). Tretinoin acts by stimulating the division and turnover of keratinocytes. It also reduces the cohesiveness (‘stickiness’) of the keratinocytes, promoting the disappearance of comedones by dissolving the keratin plugs and inhibiting the formation of new ones. Removal of the comedone makes the sebaceous unit more aerobic and discourages the proliferation of P. Acnes. In addition, tretinoin suppresses the activity of sebaceous glands. Tretinoin has exfoliating effects and may cause skin irritation and peeling, but this is usually a transient effect. Topical retinoids should be avoided in severe acne involving large areas of the body, and should be used with caution on sensitive areas such as the neck. In patients with inflammatory lesions as well as comedones, antibiotics or benzoyl peroxide may also be needed.
Tretinoin may cause photosensitivity. Therefore, it is usually recommended to apply tretinoin in the evening, although many preparations are licensed for twice daily application.
The topical antibiotics used most frequently for the treatment of acne are erythromycin and clindamycin, although tetracycline is also used. They are available as lotions, creams and gels (1-4%) and are useful for treating the inflammatory aspects of acne vulgaris, but in general have no comedolytic effects. Many cases of acne have a combination of comedones and inflammatory lesions, and antibiotics are sometimes combined with a comedolytic product such as tretinoin for a more rapid effect.
Antibiotics improve acne by reducing the population of P. acnes in the skin. They also have anti-inflammatory effects by suppressing the migration of white blood cells to the inflamed areas. Antibiotics may also inhibit certain enzymes, which will reduce the proportion of free fatty acids, therefore reducing the amount of inflammation.
Topical antibiotics have fewer systemic side-effects, and are found in higher therapeutic levels in the follicle than their oral counterparts, which act systemically. However, the alcohol base used in some formulations may cause burning or stinging when applied to the skin and some patients develop hypersensitivity to the antibiotic itself. A residue left by topical tetracycline may fluoresce under ultraviolet lights.
It seems that resistance of P. acnes to antibiotic therapy is increasing and may be the explanation for poor response to antibiotics in some patients. However, this is not usually the case, perhaps for the following reasons:
Patients may have a mixture of resistant and non-resistant bacteria on their skins, therefore patients might improve with appropriate treatment.
Topical antibiotics do not need to eliminate all bacteria.
It is possible that topical preparations achieve concentrations in the sebaceous gland that exceed the MIC and so reduce bacterial numbers.
OTHER TOPICAL AGENTS
AZELAIC ACID is a dicarboxylic acid with antimicrobial and anticomedonal properties. It has been reported to cause alterations in the free fatty acid content of the skin, and significantly reduces bacterial colonization. Some patients prefer this agent to benzoyl peroxide. This product is also helpful in decreasing skin pigmentation caused by acne inflammation in dark skinned individuals.
NICOTINAMIDE can be used to treat inflammatory acne: side-effects include skin dryness as well as redness, burning and irritation.
SALICYLIC ACID can be used for its keratolytic effect in patients who cannot tolerate retinoids, and there are several over-the-counter preparations.
TOPICAL COMBINATION PRODUCTS
More than one topical agent maybe used in the treatment of acne, either combined in one product or as separate products used sequentially. These agents may act together to combine effects and produce enhanced results over each used separately.
SYSTEMIC (ORAL) TREATMENTS
I infrequently recommend systemic antibacterial treatment for acne due to the many possible side effects of oral antibiotics. They are helpful with unusually severe inflammatory acne where topical treatment is not adequately effective or where it is inappropriate. For example, this may be the case where the back is affected, making application of a topical treatment impractical.
In female patients oral contraceptives or spironolactone help improve acne by reducing the size of the sebaceous gland, and so reducing sebum production, as well as reducing sex hormone binding globulin.
Oral antibiotics are the most widely used systemic therapy for acne. Tetracycline and minocycline have traditionally been the most commonly used systemic antibiotics for acne; erythromycin, doxycycline and co-trimoxazole are also used. The topical antibiotic clindamycin is not used systemically because of the risk of pseudomembranous colitis.
The need for long-term treatment may increase the incidence of side effects from oral antibiotics. The oral antibiotics can cause gastrointestinal problems and should not be used during pregnancy and lactation. Furthermore:
- Tetracycline should not be used in children under 12 years because it can discolor the deciduous teeth
- Minocycline can also discolor the teeth. Further, it can cause vertigo-like symptoms and ringing of the ears. There are also concerns over its ability to produce more severe side effects, such as drug-induced hepatitis and systemic lupus erythematosus*
- Doxycycline has similar contraindications to tetracycline and can cause photosensitivity
- Bactrim (co-trimoxazole) can cause bone marrow suppression. This is an unlicensed treatment for acne, but it is used frequently when allergies to the others exist.
- Azithromycin – a longer acting erythromycin derivative that has fewer side effects and may be used in short “cycles” as it is incorporated in the pilosebaceous unit and cells and remains active for a timer period beyond which it is taken.
ORAL ISOTRETINOIN (ACCUTANE)
Isotretinoin is an oral vitamin A derivative. It is highly effective in the treatment of very severe cystic acne. It:
- Is thought to act by reducing the size of and amount of secretion from the sebaceous glands.
- Reduces keratinization.
- Has anti-inflammatory effects.
A course of treatment is usually 16-20 weeks long and it may take several weeks for an effect to become apparent. However, improvement may continue after cessation of therapy and the remission may last for months or years. Because of possible severe adverse effects, isotretinoin can only be prescribed by, or under the supervision of, a registered physician. It requires extensive informed consent, and a signed contract between the physician and female patients requiring the use of 2 forms of birth control while taking it and requires regular monthly pregnancy tests.
The side effects of isotretinoin include: dry skin and mucous membranes, cheilitis (cracking or the angles of the lips), dry eyes, nose bleeds, diminished night vision, photosensitivity, hair loss, aching joints, and headache. Because it is causes severe birth defects, isotretinoin can NOT be used in women of child-bearing age who are not using contraceptives.
Other measures used in the treatment of acne vulgaris include:
- Comedone removal
- Injection of triamcinolone or other corticosteroids into severely inflamed cysts and nodules
- Micro Dermabrasion and Chemical Peels – gradual removal of epidermis layers, including scars. The epidermis then regenerates
- Excision of scars and persistent cysts
- Injections of collagen into depressed scars to raise them to the usual skin level.