"Though we travel the world over to find the beautiful, we must carry it with us or we find it not." ~ Ralph Waldo Emerson
Acne
Acne is a skin condition, in which the pores become blocked, causing pimples to develop. Acne is the most common skin disorder in North America; it affects 85% of adolescents in varying degrees.
Effective acne treatments are available to treat existing pimples and prevent new ones from developing. In addition, cosmetic treatments can help to minimize scarring and changes in skin color caused by acne.
Although acne is not physically disabling, its psychological impact can be striking, contributing to lower self-esteem, depression, and anxiety. As a result, there is a significant demand for effective acne therapies. In 2001, the global market for prescription acne products was estimated to be two billion dollars; the non-prescription market was estimated at two to four times that size.
A variety of medications are available for the treatment of acne. The lack of standardization for grading acne severity and measuring treatment outcomes has made systematic interpretation of the literature difficult. However, quality evidence-based literature in the field of acne is growing
How Does Acne Develop
There are four basic steps involved in the development of an acne lesion.
- Hair follicles become blocked with an overabundance of normal skin cells). These cells combine with sebum (an oily substance that lubricates the hair and skin), creating a plug in the follicle.
- The glands that produce sebum, known as sebaceous glands, enlarge during adolescence and sebum production increases. Numerous sebaceous glands are found on the face, neck, chest, upper back, and upper arms.
- The increase in sebum production allows for the overgrowth of bacteria that normally lives on the skin.
- Bacterial overgrowth causes local inflammation, which causes rupture of the follicle. This can lead to the formation of a pimple.
Patient Assessment
The treatment of acne includes a number of topical and systemic therapies and is guided by several clinical features. Deciding on the appropriate course of treatment for an individual patient requires a comprehensive assessment that includes:
- Clinical type of acne (eg, comedonal, inflammatory, nodular)
- Severity of acne
- Skin type (dry, oily)
- Presence of acne scarring or postinflammatory hyperpigmentation
- Menstrual history and history of signs of hyperandrogenism in women
- History of prior successful and failed treatments
- History of acne-promoting medications
The presence or absence of acne scarring should be assessed. Patients with acne who are experiencing scarring may warrant more aggressive initial therapy. In addition, acne-related postinflammatory hyperpigmentation can be distressing for patients. Patients with postinflammatory hyperpigmentation can benefit from the use of medications or procedures that accelerate resolution.
Acne Causes
Hormonal changes
Hormonal changes during adolescence cause the sebaceous glands to become enlarged and sebum production increases. In most people with acne, hormone levels are normal, but the sebaceous glands are highly sensitive to the hormones.
Less often, women's hormone levels are affected by an underlying medical problem known as polycystic ovary syndrome (PCOS). This syndrome is found in young women who have skipped menses, excess hair growth (lots of waxing), and acne, as well as many ovarian follicles on pelvic sonogram. [See “PCOS” section of this website.]
Androgens in Acne
Androgens play an important role in the pathogenesis of acne. For some women with moderate to severe acne that does not respond to other therapies, hormonal therapies can be effective. The most common medications that are prescribed are oral contraceptives and spironolactone.
Androgen production rises during the prepubertal period, leading to androgen-stimulated increased sebum production by sebaceous glands. The accumulation of sebum and keratinous material within pilosebaceous follicles contributes to the formation of microcomedones, which are precursor lesions of acne vulgaris. As sebum and keratin continue to accumulate, larger open or closed comedones are formed. Sebum also provides a growth medium for P. acnes, a bacterium that resides in pilosebaceous follicles. Proliferation of this bacterium contributes to the inflammatory response seen in acne vulgaris.
Indications for Hormone Therapy
Androgen levels are normal in the majority of women with acne. Even in the absence of a hyperandrogenic state, hormonal therapies are useful for the treatment of acne. Adult women may present with inflammatory acne involving the lower face and neck associated with premenstrual flares. These women, in particular, seem to benefit from hormonal therapies, although other women may benefit as well.
Acne therapy with an oral contraceptive or anti-androgen is considered for women with moderate to severe acne who are not trying to become pregnant. Women with milder acne who choose oral contraceptives for the purpose of pregnancy prevention can also experience the ancillary benefit of improvement in their acne.
When treating patients with moderate to severe acne, hormonal therapy should be used as part of a treatment regimen that contains a topical retinoid; concomitant therapy with topical or oral antimicrobial agent(s) may also be indicated. A minimum of three to six months of therapy is required for evaluation of the efficacy of hormonal therapies.
Although most women with acne have normal androgen levels, disorders of androgen excess, such as polycystic ovarian syndrome, congenital adrenal hyperplasia, and adrenal or ovarian tumors are potential causes of acne .
Women with menstrual irregularity and excess hair growth (waxing often) should have a gynecologic and hormonal evaluation. The results of this evaluation can help guide therapy:
- Oral contraceptives, particularly those preparations with a low androgenic progestin, are indicated for women with excessive ovarian androgen production (eg, polycystic ovarian syndrome)
- Glucocorticoids are indicated for those with excessive adrenal androgen production, such as in classical congenital adrenal hyperplasia. For those with nonclassical (late-onset) congenital adrenal hyperplasia, oral contraceptives rather than glucocorticoids are generally used. Both treatments suppress adrenal androgens, but oral contraceptives have fewer side effects and complications.
Combination oral contraceptives
Combination oral contraceptives contain progestins, many of which are known to possess intrinsic androgenic activity. Newer third generation progestins (norgestimate, desogestrel, or gestodene) are considered to be less androgenic than their precursors. However, because all low-dose combination oral contraceptives are actually estrogen-dominant (and thus, anti-androgenic), oral contraceptives containing other progestins are beneficial in acne.
Oral contraceptives and antibiotics
In some cases, patients may be treated with oral contraceptives and oral antibiotics simultaneously. There is no definitive evidence that oral antibiotics, with the exception of rifampin, reduce oral contraceptive effectiveness for pregnancy prevention. The use of antibiotics other than rifampin does not warrant an additional form of pregnancy protection.
Medications that block androgen receptors
Androgen receptor blockers act at the peripheral receptor level to decrease sebum production. Androgen receptor blockers that have been used in the treatment of acne include spironolactone. cyproterone acetate, and flutamide. Cyproterone acetate is not available in the United States, but is prescribed as a sole agent or as a component of oral contraceptives elsewhere. Flutamide can cause fatal hepatitis, and is infrequently used for acne.
Spironolactone
Spironolactone is an oral anti-androgen that blocks androgen receptors and inhibits androgen biosynthesis. It has been used to treat disorders such as acne, hirsutism, and androgenic alopecia in women. Spironolactone therapy may be considered for women whose moderate to severe acne has not responded to conventional treatments and who prefer to avoid oral isotretinoin.
Side effects of spironolactone include menstrual irregularities, breast tenderness, minor gastrointestinal symptoms, orthostatic hypotension, and central nervous system symptoms (headaches, dizziness, and fatigue). Side effects (excluding central nervous system symptoms) are less frequent at lower doses (50 to 100 mg/day). Initial doses of 25 to 50 mg/day, with subsequent dose escalation according to patient tolerance and response, will help to minimize side effects.
External factors
Oil-based cosmetics may contribute to the development of acne. Oils and greases in hair products can also worsen skin lesions. Water-based or "non-comedogenic" products are less likely to worsen acne.
People with acne often use soaps and astringents. While these treatments remove sebum from the skin surface, they do not decrease sebum production; frequent or aggressive scrubbing with these agents can actually worsen acne.
Acne tends to resolve between ages 30 to 40, although it can persist into or develop for the first time during adulthood. Post-adolescent acne predominantly affects women, in contrast to adolescent acne, which predominantly affects men. Acne can flare before a woman's menstrual period, especially in women older than 30 years.
Diet
The role of diet in acne is controversial. Some studies have found associations between cow's milk and an increased risk of acne, perhaps because of hormones that occur naturally in milk.
However, there is no strong evidence that high-fat foods or chocolate increase the risk of acne.
Stress
Psychological stress can probably worsen acne. In several studies of students, acne severity appeared to worsen during times of increased stress.
Acne Treatment
There is no single best treatment for acne, and combinations of treatments are sometimes recommended. Since acne lesions take at least eight weeks to mature, you should use a treatment for a minimum of two to three months before deciding if the treatment is effective.
Acne skin care
Skin care is an important aspect of acne treatment.
Wash your face no more than twice daily using a gentle non-soap facial skin cleanser (eg, Cetaphil®, Oil of Olay® bar or foaming face wash, or Dove® bar) and warm (not hot) water. Some providers recommend avoiding use of a washcloth or loofah, and instead using the hands to wash the face. Vigorous washing or scrubbing can worsen acne and damage the skin's surface.
Do not pick or squeeze pimples because this may worsen acne and cause skin swelling and scarring. It can also cause lesions to become infected.
Moisturizers
Use of a moisturizer minimizes dryness and skin peeling, which are common side effects of some acne treatments. People with dry skin often benefit from a cream or lotion while people with oily skin may prefer a gel-based moisturizer. Moisturizers that are labeled as "non-comedogenic" (will not block skin pores) and without fragrances or dyes are less likely to cause irritation.
Sun protection
Some acne treatments increase the skin's sensitivity to sunlight (eg, retinoids, doxycycline). To minimize skin damage from the sun, avoid excessive sun exposure and use a sunscreen with SPF 15 or higher every day.
Noninflammatory acne
Noninflammatory acne causes whiteheads or blackheads without redness or skin swelling.
Can I treat my own acne?
If you have mild acne, you can try to treat yourself with non-prescription products initially. Non-prescription acne treatments may include salicylic acid, benzoyl peroxide, sulfur, alpha hydroxy acids, or tea tree oil, all of which are available in non- prescription strengths. A combination of these treatments may be more effective than using one single product alone.
If you do not improve after three months of using non-prescription products or you have moderate or severe acne, consult a healthcare provider for advice on the most effective treatments.
Retinoids
Topical retinoid medications are often recommended for noninflammatory acne, including tretinoin (Retin-A®, Avita), adapalene (Differin®) and tazarotene (Tazorac®).
Retinoids are usually applied once per day, although people who develop skin irritation can reduce this to every other day or less, then increase as tolerated over time. Most people become more tolerant of retinoids over time.
Most retinoids are available in a gel or cream. People with oily skin may prefer gels because they have a drying effect, while people with dry skin may prefer a cream.
Retinoids can cause skin irritation. While using topical retinoids, you should wear a sunscreen with SPF 15 or greater during the day.
Other acne products
People who cannot tolerate retinoids may try other topical medications, such as salicylic acid, glycolic acid, or azelaic acid (Azelex®, Finacea®). All of these treatments can be helpful in reducing noninflammatory acne, and azelaic acid may reduce acne-related darkening of skin.
Mild to moderate inflammatory acne
Mild to moderate acne with some inflammation is usually treated with topical retinoids. A combination of two medications, usually benzoyl peroxide with a topical antibiotic or retinoid (eg, tretinoin), is more effective than treatment with one agent alone.
Benzoyl peroxide
Benzoyl peroxide is usually applied twice per day. It may be combined with a topical retinoid, in which case the benzoyl peroxide is applied in the morning and the retinoid is applied at night. Benzoyl peroxide can irritate the skin, sometimes causing redness and skin flaking, and it can bleach clothing, towels, bedding, and hair.
Topical antibiotics
Topical antibiotics (creams or liquids) control the growth of acne bacteria and reduce inflammation.
Oral antibiotics
Oral antibiotics work to slow the growth of acne-producing bacteria. However, oral antibiotics can have bothersome side effects, including vaginal yeast infections in women and stomach upset.
Doxycycline and minocycline are the most commonly prescribed oral antibiotics for acne. These medications must be taken on an empty stomach. They cannot be used during pregnancy or in children less than 9 years of age.
Moderate to severe inflammatory acne
For people with moderate to severe inflammatory acne, oral antibiotics or an oral retinoid known as isotretinoin (Accutane®) may be recommended. Topical medication may be used in combination with oral treatments.
The Big Gun: Oral isotretinoin (Accutane)
Oral isotretinoin (Accutane®) is a potent retinoid medication that is extremely effective in the treatment of severe acne. It cures acne in nearly 40% of people for life, with the remaining 60% of people needing further treatment with topical or oral medications. Oral isotretinoin is effective in treating the most disfiguring effects of acne.
Oral isotretinoin is usually taken in pill form twice daily with food for 20 weeks, then stopped. In some cases, acne can initially worsen before it improves. After treatment
is stopped, improvement can continue for up to five months.
Side effects and risks
Despite its positive effects, oral isotretinoin can have serious side effects and should be used with caution.
Taking isotretinoin during pregnancy can cause miscarriage and life-threatening malformations in the baby. For these reasons, there are strict rules in the United States for healthcare providers, pharmacists, and patients regarding the use and prescription of oral isotretinoin.
Prescriptions of isotretinoin are regulated by the iPLEDGE program(www.ipledgeprogram.com), which requires the following:
- All women must have two negative pregnancy tests before receiving a prescription, and then they must have monthly pregnancy tests throughout the course of treatment.
- Women who could become pregnant must fill their prescription within seven days of receiving it; after this time, a new prescription must be written.
- Any woman who is or might become sexually active with a male partner must use two forms of birth control for at least one month before starting therapy and continue until one month after stopping isotretinoin.
- Women who cannot become pregnant and men must also participate in iPLEDGE, but do not require pregnancy testing or use of birth control.
- Non-pregnancy related side effects of isotretinoin may include:
- Dryness or peeling of skin, soreness and cracking of the lips, itching, and sensitivity to the sun.
- There is concern about the relationship between isotretinoin and depression and suicidal behavior. While there is not enough evidence to conclude that it causes depression or suicidal behavior, patients taking isotretinoin should report any sadness, depression, or anxiety to their healthcare provider.
- Isotretinoin can cause increases in triglycerides (fatty substances related to cholesterol), liver damage, pancreatitis, and changes in the blood counts.
- While many of these side effects can be managed without stopping the drug, others can be dangerous and require that you immediately stop taking it. Stay in touch with your doctor, and follow instructions for getting regular blood tests to monitor cholesterol, triglycerides, liver function, and blood counts.
The Bottom Line:
You don't have to accept acne like we did when I was a teen. Our Dermatologists have an algorithm of options to tailor to your needs. Given time and a little effort they can help you look and feel as gorgeous and empowered as you deserve to feel.
WH Dermatology Physicians
Medical, Surgical and Cosmetic Dermatology,
including Mohs Surgery, Tumescent Liposuction and Laser Surgery
- Athena Kaporis,MD
- Meredith Kosann, MD
- Ross Zeltser, MD
- Stuart Zweibel, MD, PhD
185 Kisco Avenue, Suite 3
Mount Kisco, New York
(914) 242-2020
Often I will work with the dermatologist if Accutane is prescribed, as you will be required to be using 2 forms of birth control during the 5-month course of therapy.
Even if you do not use Accutane, as noted above, pubertal acne is often related to hormonal changes, and if you are a candidate for the oral contraceptive pill, this can be used in conjunction with the dermatologist's other options.
I find my WH Dermatology colleagues extremely warm and professional, and we share many patients.
"Let the beauty you love be what you do. There are a thousand ways to kneel and kiss the earth." ~ Rumi
[edited from uptodate.com]
