ACNE TREATMENT… IN ITS PRIME
Acne is an inflammation of the pilosebaceous units and the areas particularly affected are the ones rich in sebaceous glands such as the face, chest, back and buttocks. It occurs mainly in adolescence but it may appear at any age, and it manifests with comedones, papules, pustules, or nodules and cysts. Atrophic of hypertrophic scar formation may be caused by all types of acne, especially nodular and cystic acne. Acne is most commonly linked to the beginning of puberty, but women with hyperandrogenism can also be affected. Treatments that reduce the sebum production (retinoids, estrogens, anti-androgens) are quite effective in combating acne.
Acne is the result of four factors in people with a suitable genetic background.
(A) Overproduction or excessive production of sebum: The areas particularly affected are the ones where the sebaceous glands tend to be more active, such as the face, chest, back and buttocks. It is related to seborrhea and it shows at the beginning of puberty, when the glands are mature enough. When their operation is suspended, acne can be controlled.
(B) Blocking of the pilosebaceous pore due to a disorder of keratinization of hair follicles: The keratinous material is denser, blocking the secretion of sebum. The dilated follicular lumen contains concentrated keratin and lipid residues (closed comedo). When the follicle has an opening to the skin surface and the semi-solid mass is projected, a bump is developed (open comedo). This disorder, in combination with a complex interaction of hormones (androgens) and bacteria (propionibacterium acnes) in pilosebaceous units, leads to acne lesions. Androgens (being normal in quality and quantity) stimulate the sebaceous glands to produce larger amounts of sebum.
(C) Microbial agents: Staphylococcus, pityrosporum yeast and propionic bacteria are always present in hair follicles, be it a healthy or an acne-affected person. Bacteria contain lipases that convert lipids into free fatty acids that are comedogenic.
(D) Inflammation: The dilated follicular walls may rupture and the contents (sebum, lipids, fatty acids, keratin, etc.) can leak into the dermis, causing foreign body reaction (papules, pustule, nodule). This rupture and the subsequent intense inflammation leads to scarring.
Comedones, open (blackheads) or closed (whiteheads).
Inflamed papules and pustules (red) or with no inflammation present.
Nodules or cysts, 1-4 cm in diameter.
Fistulas, usually in nodular acne.
Scars, atrophic or hypertrophic.
Seborrhea of the face and scalp.
(A) Comedonal acne, where only open and closed comedones are present.
(B) Papulopustular acne, where papules, pustules or papulopustules are present.
(C) Nodular or cystic acne, unhealthy complexion with nodules, cysts, pustules and scars present.
SPECIAL ACNE TYPES
Adult Female Acne: Persistent acne in a hirsute (hairy) woman with or without menstrual irregularities.
Acne conglobata: Severe form of acne which inflammatory lesions on the torso. It is rarely related to XYY genotype or to polycystic ovary syndrome.
Acne fulminans: Documented in young men (13-17 years). Acute onset of severe cystic acne with suppurative lesions and ulceration. It may present with pain, fatigue, fever, arthralgia (joint pain), leukocytosis and increased ESR [Erythrocyte Sedimentation Rate].
Persistent acne: It may be related to congenital adrenal hyperplasia (11-6- or 21-6-hydroxylase deficiency).
Acne Mallorca or Summer Acne: After sun exposure in women of 20-30 years of age.
Other types: Acne Tropicalis or Tropical Acne, Pre-menopausal Acne, Acne Cosmetica, Chloracne, Acne Mechanica, Keloid Acne and Gram-negative Folliculitis.
LAB TESTS / IMAGING
- Pelvic (ovary) ultrasound.
-Free testosterone, FSH, LH, DHEA-S, 17-OH progesterone.
ACNE HORMONE TESTS
Lab tests are conducted in the following conditions:
- menstrual irregularities
- hirsutism, persistent acne, adult acne
- acne recurring soon after systemic use of isotretinoin
- children 7-9 suffering from acne
- infants with acne and accompanying signs of hyperandrogenism
Acne usually ends by itself when a person is in their mid-20s or it may continue over the age of 40. Acne flare-ups during the premenstrual and menstrual period or in the winter are quite common. The only physical consequence is scarring, which can be avoided by appropriate treatment, mainly by administering isotretinoin in the early stages of the disease.
The psychological effects of acne should be individually assessed in each patient and treatment should be adjusted accordingly. The aim of the treatment is to reduce seborrhea, prevent further comedo formation, reduce propionibacterium acnes colonization, and clear inflammation with the appropriate topical and/or systemic treatment.
General hygiene measures
Cleaning of the affected areas twice a day (in the morning and in the evening)
Topical Acne Treatment
Topical agents used in topical treatment are mostly antimicrobial or keratolytic, which suffice to treat mild acne conditions.
Among the most commonly used types of medications to treat inflammation are:
(a) Benzoyl Peroxide: It works by reducing the amount of acne-causing bacteria. It is applied to the areas of your skin affected by acne at night, and it is rinsed with water in the morning.
(b)Topical antibiotics: Tetracycline, erythromycin, clindamycin. They have antimicrobial properties and they work by inhibiting the growth of Propionibacterium acnes colonization.
Retinoic acid and azelaic acid are used in keratolytic treatment. (a) Retinoic acid dissolves comedones, corrects keratinization disorders in the follicle and slows down the increased production of keratinocytes. It is applied in the evening and is removed with water in the morning. Due to some irritation side effects such as erythema, dryness and skin peeling, some patients have to stop treatment. (b) Azelaic acid has anti-inflammatory and keratolytic properties. It is applied on the affected areas twice a day, every morning and evening.
Systemic Acne Treatment
In cases of moderate and severe acne, topical agents alone may be insufficient to treat acne, so a combination of both topical and systemic treatments might prove much more efficient. Systemic agents include oral antibiotics, isotretinoin, and hormones.
Among systemic antibiotics, tetracycline remains the first choice, followed by erythromycin. They are both administered for 6-8 months. Tetracycline is not to be administered to women during pregnancy, as it inhibits the skeletal formation of the fetus. It should also be avoided in children, particularly younger ones, during the period of tooth development to avoid permanent yellow teeth discoloration. Antibiotics act directly on the lesions, and they have few side effects such as nausea, diarrhea and vaginitis in women.
Isotretinoin is indicated for the treatment of severe cystic acne or for acne unresponsive to antibiotics. Treatment with isotretinoin is associated with impressive results. The treatment lasts 4-7 months or more, depending on the dosing schedule. If lesions are cleared earlier than that, the treatment stops; nevertheless, the effects appear to persist even after its discontinuation. Laboratory monitoring pertaining to blood lipids, triglycerides and liver function is performed before and during the course of treatment. Retinoids are potent teratogenic, so women are required to take strict contraceptive measures during the treatment. There are also several adverse effects such as cheilitis (lip chapping), dry skin, itching, nosebleed, inflammation of the whites of the eyes (conjunctivitis), cracking or peeling skin on palms and soles, photosensitivity, headaches, etc. Despite the undesirable effects, isotretinoin is an effective medicine. However, patients must always be monitored closely.
The use of estrogens in women in the form of oral contraceptives (birth control pills) block the effect of androgens on the sebaceous glands, thus suppressing sebum production. They are administered for a long period of time (6-12 months). Recently, spironolactone and glucocorticoids have also been administered to patients.
Great care must be taken when using oral contraceptives. The treating physician should always consider the contraindications carefully when prescribing these medications. These include pregnancy, smoking, age over 35, coagulation disorders, migraine, hypercholesterolemia (high cholesterol), diabetes, prolonged immobilization following surgery and many others.
There are plenty of hormonal treatments for acne. Such a treatment is useful for women with acne who show clinical or laboratory signs of hyperandrogenism. Working with an endocrinologist or a gynecologist is always helpful. Effective treatment always depends on proper co-operation between the doctor and the patient.