Acne Vulgaris

Acne vulgaris is an inflammatory disease of the skin which appears as plugged pores (blackheads and whiteheads), pimples, and deep inflamed lumps (cysts). Acne can occur on the face, neck, back, chest, shoulders, and arms. The disease is very common in teenagers. In fact, most of teenagers have some acne. Usually acne diminishes over time, and tends to disappear by the early twenties. However, adults in their 20’s, 30’s, 40’s or older can still suffer from acne.

How does acne form?

The secretion of androgens (male hormones found in both boys and girls) increases during teenage years. Androgens make oil glands (or sebaceous glands) of the skin grow larger and produce more oil. To moisturize the skin, oil needs to reach the skin surface through a narrow channel connected to a hair follicle. The channel opens onto the skin surface and is lined by skin cells. In acne patients, these cells do not shed normally. They stick together and plug the pore.

Now large amount of oil produced in the skin cannot come out onto the skin surface. Bacteria (Propionebacterium acnes) grow in the oil glands and make chemicals that stimulate inflammation. Redness, swelling, and pus appear, resulting in pimples and cysts. The severity of acne depends on your genetic make up. In other words, some people have mostly plugged pores and few pimples. Other patients have plugged pores, lots of pussy pimples, and deep cysts.

Now large amount of oil produced in the skin cannot come out onto the skin surface. Bacteria (Propionebacterium acnes) grow in the oil glands and make chemicals that stimulate inflammation. Redness, swelling, and pus appear, resulting in pimples and cysts. The severity of acne depends on your genetic make up. In other words, some people have mostly plugged pores and few pimples. Other patients have plugged pores, lots of pussy pimples, and deep cysts.

Acne myths.

Acne is not caused by the foods you eat (greasy foods, chocolate, etc). It is also not caused by poor hygiene or lack of washing the skin. Masturbation or sex does not have anything to do with acne. And sun tan will certainly not clear your acne.

Treatment of acne.

Many times simple over-the-counter (OTC) acne treatments are enough to clear the disease. If OTC products do not work, your doctor may choose your medicines based on severity of your acne. When you start your regimen, you should not expect results overnight.
First improvement usually appears at about 4 weeks of treatment. A final result of a particular therapy is expected at about 3 months of using your medicine. It is important not to give up the treatment if you still have pimples several weeks after the start of your skin care regimen.

As time goes by, many patients forget to apply their medicines or skip taking their pills. Remember, the only way you can get a clear skin is to follow your regimen daily. Most of acne treatments are preventive. If you use them every day, new pimples and bumps stop appearing. You cannot reverse a pimple after it shows up. It will take time to resolve on its own. Therefore, you have to use your medicines every day to get results.

As time goes by, many patients forget to apply their medicines or skip taking their pills. Remember, the only way you can get a clear skin is to follow your regimen daily. Most of acne treatments are preventive. If you use them every day, new pimples and bumps stop appearing. You cannot reverse a pimple after it shows up. It will take time to resolve on its own. Therefore, you have to use your medicines every day to get results.

Mild cases (plugged pores or comedones, and few pimples) can be easily managed with topical regimens (creams, gels, lotions, foams, and cleansers). Most of acne topical medicines are “leave on” products. They do not need to be washed off after application. Cleansers or washes present exception to this rule. They are washed off from the skin right after the application.

Moderate acne (plugged pores, pimples, and small bumps or papules) is usually treated with oral antibiotics in addition to topical products. In women, oral contraceptives and hormonal agents (spironolactone, and cyproterone acetate) also can be used. Severe acne (deep bumps or cysts, and scarring) is treated with isotretinoin (Accutane).

TOPICAL TREATMENTS

Topical retinoids(tretinoin, adapalene, tazarotene) are effective agents which act to unblock the pores and normalize oil secretion. They can be used for mild and moderate acne. In some patients these drugs can cause skin irritation. That results in dryness, scaling, and redness. It is very important to use a very small amount of retinoid cream, gel, or lotion. If irritation appears, topical moisturizing creams can be used together with a retinoid.

Topical Antibiotics
(erythromycin and clindamycin) are effective and well-tolerated medicines. Both erythromycin and clindamycin can be safely used in pregnancy. The downside of these agents is antibiotic resistance. If erythromycin and clindamycin are used for more than 3 months, in many patients P. acne bacteria of the skin will become resistant. That means that acne will no longer be controlled by the medicine.

To prevent the problem of bacterial resistance, topical antibiotics are most commonly used in combination with other medicines, such as benzoyl peroxide and retinoids.

Benzoyl Peroxide
(BPO) is an effective medicine which kills bacteria. Bacterial resistance is not a problem with BPO. It is known to produce irritation and dryness in some patients. Therefore, it is important to use only a small amount of BPO when applying to the face. Application of moisturizers is also helpful in relieving the dryness. Bleaching of clothing or hair may occur.


Combinations

Combination topical gels and creams containing retinoids or benzoyl peroxide with erythromycin or clindamycin are more effective than either agent used alone. Their use decreases bacterial resistance and enhances efficacy. There are currently several combination gels and creams commercially available.

Other topical products

Salicylic acid is a major ingredient of multiple OTC products. It is less effective than retinoids, but also less irritating. It is best used in patients with mild acne when topical retinoids cause too much irritation. Azelaic acid has a mild effect in stopping acne, but with low irritancy. It is safe with pregnancy. Sulfur, resorcinol, and sodium sulfacetamide may also be used for acne treatment.

ORAL ANTIBIOTICS

The choice of oral antibiotics is guided by the following parameters: efficacy, bacterial resistance, patient acceptability, benefit-risk ratio, and cost-effectiveness.

Erythromycin
is an effective low-cost antibiotic which is safe for pregnant women. A lot of acne-causing bacteria develop resistance to erythromycin, which makes it useless in patients with resistant bacteria. This drug is capable of causing gastrointestinal adverse effects (diarrhea, bloating, etc). Additionally, erythromycin increases levels of carbamazepine, theophylline warfarin, cyclosporine. This can cause toxicity in patients taking these drugs.
Given the above, erythromycin is used primarily in pregnant women, children, and patients with allergies to other antibiotics.

Azithromycin is very similar to erythromycin. It has longer duration of action, and therefore may be taken less frequently. Tetracycline’s advantages include effficacy, safety, and low cost. Its absorption is affected by food and milk. Tetracycline is best taken on an empty stomach, which makes its use inconvenient. It can cause gastrointestinal adverse effects. Tetracycline can cause permanent brown discoloration of the teeth in children, and is therefore not used routinely for children under the age of 8.

Tetracycline
is mostly used in patients without insurance when cost is a factor, and in patients who experience side effects with minocycline or doxycycline.

Doxycycline is an effective and safe antibiotic. Its absorption is not affected by food. Just like other tetracyclines, doxycycline may cause gastrointestinal side effects. It can rarely cause photosensitivity (severe sunburns) and inflammation of the esophagus (esophagitis). The chances of latter complication can be minimized by taking doxycycline with a full glass of water and not lying down after taking the drug. Doxycycline is the drug of choice of many dermatologists when treating acne.

Minocycline is an effective antibiotic known to cause rapid improvement in acne. Just like doxycycline, it can be taken with or without food. It has a higher cost than other tetracyclines. Rare serious side effects (lupus, hepatitis, pneumonitis) can occur with minocycline. Serious side effects are thought to occur in 6 patients per 10,000 prescriptions, a very small risk. Yet, patients who do not wish to take even a risk that small should not take minocycline. Vertigo, dizziness, and dark pigmentation of scars, shins, and forearms can infrequently be also observed with minocycline use. Minocycline is a very commonly used drug for the treatment of acne.

Trimethoprim/sulfamethoxazole is an effective, low cost antibiotic. It is rarely used for acne, therefore bacterial resistance is not an issue. The use of trimethoprim/sulfamethoxazole is limited because of rare life-threatening side effects (Stevens-Johnson syndrome, toxic epidermal necrolysis). It also has very common gastrointestinal side effects (3%), and rashes (3%). Trimethoprim/sulfamethoxazole interacts with warfarin and methotrexate. Most dermatologists use trimethoprim/sulfamethoxazole if other antibiotics fail.

Isotretionoin
Isotretionoin (Accutane, Sotret, Amnesteem, Claravis) is the “atom bomb” for acne. It is the most potent anti-acne medicine. The absolute majority of patients treated with isotretinoin are completely clear at the end of the course. Up to three quarters of patients treated with this drug never have acne again.
Isotretinoin is a derivative of vitamin A. It reduces oil (sebum) production by reducing sebaceous gland size, reducing the plugging of hair follicles, and reducing P. acne on the skin.

Multiple side effects limit the use of isotretinoin. Almost all patients experience dry lips and dry skin. Less common side effects include hair thinning, blurry vision, skin infection, abdominal pain, bone and joint pain, headache, bone spurs, mood swings, and depression. The list of side effects is very long. Yet, most of the serious side effects are very rare. Patients treated with isotretinion should be on the lookout for anything unusual (headaches lasting for many days, depressed mood, abdominal pain, etc). If something out of the ordinary happens, the drug should be stopped. Most side effects are temporary and reversible.
Isotretinoin causes severe birth defects in babies born to women who were on the drug during pregnancy. All women of child-bearing age are required to either be abstinent during isotretinoin treatment, or use two forms of contraception (for example, birth control pills and a condom).

The course of isotretinoin usually lasts five months. Blood work is required during treatment. Monthly pregnancy tests for women are also required. Isotretinoin is not a toxic drug. It does not damage the liver, kidneys, or other internal organs. The most clinically important test on a blood panel during isotretinoin treatment is the level of triglycerides (blood fats). Occasionally triglycerides increase to very high levels which may be dangerous.
Because of multiple side effects, isotretinoin use is reserved for severe cystic acne, or lesser degrees of acne that are treatment-resistant. Acne with scarring, or acne causing psychological distress may also be treated with isotretinoin.

Hormonal Therapies

Hormonal therapies may be an important component of acne treatment in women. A patient whose acne fails to respond to conventional therapy, whose acne flares up every month with her period, is a good candidate for such treatment. Most of these women have normal hormone levels; however, they may still benefit from hormonally-based therapies.

Oral contraceptives are most commonly used. Ortho-Tri-Cyclen and Estrostep are currently FDA-approved for the management of acne.

Spironolactone is an anti-androgen (blocking male hormones from exerting their effects). Side effects include menstrual irregularities, breast tenderness, and intestinal symptoms. It can occasionally cause an increase in potassium levels in the blood.

References:

Strauss JS. Krowchuk DP. Leyden JJ. Lucky AW. Shalita AR. Siegfried EC. Thiboutot DM. Van Voorhees AS. Beutner KA. Sieck CK. Bhushan R. American Academy of Dermatology/American Academy of Dermatology Association. Guidelines of care for acne vulgaris management. Journal of the American Academy of Dermatology. 56(4):651-63, 2007 Apr

Alexander Doctoroff, D.O., F.A.O.C.D.

Assistant Chief of Dermatology, Veterans Administration Medical Center
East Orange, New Jersey
Assistant Clinical Professor of Medicine,
University of Medicine and Dentistry of New Jersey.
www.metropolitanderm.com

Stephen M. Purcell, D.O., F.A.O.C.D.

Professor and Chairman of the Department of Dermatology
Philadelphia College of Osteopathic Medicine
Philadelphia, Pennsylvannia
www.adaltd.com