Acne Information
Acne is the most common skin disease affecting
adolescents. Some eighty-five percent of high school students will
have some form of acne. Ten percent of those with adolescent acne
will continue to suffer from acne into their mid twenties and early
thirties. Adolescent females experience the worst skin conditions
between the ages of 14 and 17 while male acne is usually more severe
the acne peaks between the ages of 16 and 19. Acne continues to
affect some 6-8 percent of individuals into late adulthood.
Acne is believed to be secondary to the obstruction
of specialized follicles which are located mainly on the back, chest
and face. Excessive amounts of a substance called sebum (white thick
oily substance) are produced by the sebaceous (oil) glands. These
follicles slough off an excessive number of cells, the sloughed
cells often obstruct the opening of the follicle. This can cause
an inflamed lesion known as a comedo. Comedos are later infected
with a local bacteria, Propioni bacterium Acnes. The lesion subsequently
produces the the classic signs of redness and swelling of the infected
area.
Acne is classified into several types including
the following:
Acne Vulgaris (most common acne) - condition
of the sebaceous glands of the skin. Sebaceous glands surround each
hair follicle and produce sebum, (white thick oily substance), produced
to lubricate the hair. Acne Vulgaris usually appears one to two
years prior to puberty and is prompted by stimulation of the facial
sebaceous glands the male hormones, androgens.. Women also produce
small quantities of these male hormones contributing to their acne.
Recent studies have suggested that those individuals with acne have
an increased sensitivity to the androgens rather than increased
levels of the hormones.
Comedonal Acne - refers to the pattern
of acne in which most lesions are comedones or blackheads that are
located on the chin and/or forehead of the patient. Open comedones
are blackheads secondary to the presence of surface pigment (melanin)
as compared whiteheads that are closed comedones that contains particle
such as dirt. The cells lining the sebaceous duct proliferate excessively
in this form of acne blocking the sebaceous duct forming a comedone.
Infantile Acne - effects newborn babies
that often get mild acne primarily on their faces. Infantile acne
generally affects the cheeks, chin and forehead. As with other forms
of acne infantile acne is more common amongst male and usually only
lasts a few months. However, infants with severe infantile acne
are more prone to develop acne vulgaris near puberty.
Acne Conglobata - is a severe form of
acne affecting the face, chest and back. Acne conglobata is a severe
form of acne vulgaris. Acne conglobata is characterised by multiple
inflamed and un-inflamed nodules and scars. The acne may be associated
with Hidradenitis suppurativa, a condition in which similar boil-like
lesions occur in the armpits, groins and under the breasts.
Acne fulminans - is a rare and very severe
form of acne conglobata associated with systemic symptoms. The acne
almost always affects males.nearly always affects males. Often the
acne is precipitated by the use of Testosterone.
Acne Fulminans is usually charaterized by
the following:
Acne excorié - is a term used to describe
individuals that excessively pick at their lesions removing the
active lesions and comedones resulting in only scratch marks, sores
and scares.. Most individuals are guilty of picking or squeezing
their lesions. However, physicians do not approve of this method
of treatment because this can result in infection and excessive
scarring. Acne excorié is more common in females than males, and
is often an indication of stress or depression.
Acne Scarring - affects some 30 percent
of those individuals with moderate to severe acne vulgaris. Scarring
is particularly common in acne conglobata and acne fulminans. Scarring
results from a fibrous process in which new collagen is laid down
to heal the injured cells. The new collagen subsequently results
in excessive "scare tissue". Individuals should seek treatment
early to help reduce future scarring.
Myths Concerning Acne
The following is a list of common myths concerning
the causes of acne:
- Acne is a result of certain foods
we consume. Acne was often thought to be caused by the consumption
of certain foods i.e. chocolates, dairy foods, soft drinks, citrus
and various other foods and beverages. Clinical studies have shown
that individuals who change their diet did not have significant
changes in the their acne. All adolescents should follow a healthy
diet, however, eating, on occasion the common fast foods and deserts
will not have a significant effect on the their acne.
- Acne is an infectious disease. Although
one of the treatment options for acne is antibiotics acne is not
an infectious disease. Acne is not contagious and cannot be spread
to other people.
- Acne somehow is an allergy. Acne
is not an allergic disease.
- Acne is secondary to poor personal
hygiene. Acne is not caused by poor personal hygiene. In fact
excessive scrubbing or cleaning often will make the acne worse.
- Sunlight is beneficial for acne.
Most dermatologists agree that sunlight and ultraviolet light
has no beneficial effect in the treatment of acne. Excessive sunlight
and ultraviolet light may cause premature ageing and skin cancer.
Summary of treatment options for
acne
Individuals with severe acne or acne that is
not responding to therapy are often referred to a dermatologist.
The type and extent of the acne, as well as, other underlying factors
should be considered prior to treatment. Remember a number of medications
may actually cause acne or make it worse. The use of certain oil
based cosmetics can also precipitate acne.
Blackheads can often take up to 2-3 months to
develop. Therefore, although there is some initial improvement in
the first few weeks of treatment it can often take up to 2-3 months
of compliant medication use before you can assess the full benefit
of any acne medication.
Many preparations used to treat acne can aggravate the skin resulting
in dry skin, peeling, or possibly increased sensitivity to sunlight.
Individuals should address the current skin care products they are
currently using prior to beginning treatment with any prescription
medication. Individuals should avoid and products that are strongly
fragranced or alcohol based. Search for products that are described
as "oil free" or "non-comedogenic" on the label.
Skin care products should include a mild cleanser
and application of a non-comedogenic sunscreen for those areas exposed
to excessive sunlight. If irritation, peeling and/or dryness occurs
following the use of these products, an individual may apply an
oil free moisturizer to the treatment plan. Please note: Most individuals
with chronic acne do not need to use a moisturizer on a regular
basis.
The following is a list of general principles
concerning acne:
Topical Treatments Options
Topical treatments for acne include a wide variety of creams, lotions,
gels or solutions. These products use a combination of benzoyl peroxide,
alphahydroxy acids, antibiotics, salicyclic acid, or retinoids (vitamin
A derivatives) such as tretinoin, isotretinoin and adapalene.
A popular over the counter treatment for acne
is benzoyl peroxide, which has proven to be extremely effective
in many individuals with mild acne. Individuals with acne should
continue to follow a regular treatment regimine. Remember, acne
can take up to several months to develop, therefore, it is important
to continue treatment even thought there are no any active lesions
present.
If the over the counter treatment options do
not provide relief from the acne individuals may need to consult
with their physician to use prescription topical preparations. Most
prescription topical preparations contain a vitamin A derivative
such as tretinoin, isotretinoin.
There is often some confusion between the different
forms of Retin-A on the market. Currently, you will see literature
on Retin-A, Retin-A Micro and Renova. All three of these brand name
medications contain the same active ingredient Tretinoin. The difference
in the three products is the vehicle by which the Tretinoin is delivered
topically to the skin.
Retin-A - There are three different forms
of Retin-A., cream, gel and liquid. They are available in different
strengths that are available from your physician. Retin-A (tretinoin)
is indicated for topical application in the treatment of acne vulgaris.
Although the exact mechanism of action is unknown, Retinis thought
to loosen and expel existing acne plugs in the skin and prevent
new lesions from forming. It directly attacks the primary cause
of acne, the plug.
Retin-A Micro (tretinoin gel) microsphere,
0.1% - was approved by the U.S. Food and Drug Administration
on February 7, 1997, for the treatment of acne vulgaris.This is
the first prescription medication utilizing the Microsponge® systems
technology. Where as conventional formulations of topical medications
are intended to work on the outer layers of the skin; releasing
their active ingredients upon application, producing a highly concentrated
layer of active ingredient that is rapidly absorbed. The Microsponge®
systems can prevent excessive accumulation of medication within
surface layer of the skin. Thus, significantly reducing the irritation
of effective medication without reducing their efficacy.
Less than one-thousandth of an inch in diameter,
each Microsponge system can serve as a reservoir or a closed container
to protect certain substances from degradation or absorption, and
as an absorbent receptacle to collect undesirable substances. Microsponge
technology of entrapment of undesirable substances is believed to
contribute to the decrease in reported side effects in the Retin-A
Micro system as compared to more traditional methods of delivering
Tretinoin the active ingredient in Retin-A.
The novel acne treatment entraps Tretinoin in
Microsponge systems and formulates them into a gel. The microspheres
hold the medication in reserve, allowing the skin to absorb small
amounts of tretinoin over time. Dermatologists who conducted the
pivotal clinical studies believe this may be why most Retin-A Micro
patients experience little or no irritation. The microspheres themselves
remain on top of the skin and are easily washed off when patients
shower or wash their face. Retin-A Micro also reduces the appearance
of facial shine (oiliness) on the skin's surface.
In clinical studies, the overwhelming majority
of Retin-A Micro patients experienced little or no cutaneous irritation
in four categories — erythema, peeling, burning/stinging, and itching
- at two weeks, the typical peak irritation period for tretinoin.
Renova (tretinoin cream) 0.05% - approved
by FDA in 1995, is clinically proven to reduce fine facial wrinkles,
fade brown spots and smooth surface roughness. Clinical trial data
suggest that the emollient (an agent that softens and soothes the
surface to which it is applied) system used in Renova is significantly
better than Retin-A's vehicle at minimizing irritancy, the main
limiting factor when treating photodamaged skin with retinoids.
All three medications contain the active ingredient
Tretinoin, the difference is the delivery system to the different
layers of the skin. Retinol, should not be confused with Retin-A,
Retin-A Micro or Renova. Retinol is the technical name for (preformed)
vitamin A (vitamin A is created in the body from beta-carotene).
Cosmetics companies from Estee Lauder to Neutrogena, Avon, and others
all have their assortment of products containing retinol or retinyl
palmitate, and their claims mirror those made for Retin-A and Renova.
Retinol must become all-trans retinoic acid to work like tretinoin,
and that process requires a series of steps and changes. The notion
that the skin can perform this action with retinol is unproven and
considered by many to be unlikely and has not been approved by the
FDA for decreasing the signs of aging.
Oral Medication Treatment Options
Acne that is more severe or resistant to topical
treatment can be treated with oral medications. Oral antibiotics
are effective in treating acne, however like topical preparations,
they do not cure acne, and may need to be taken for a prolonged
period of time.
Oral antibiotics i.e. tetracycline, minocycline,
doxycycline or erythromycin remain the mainstay of oral treatment
for acne that is resistant to topical treatment. Maximum benefit
may take several months, and the dose should be adjusted to achieve
and maintain satisfactory control of acne. In addition, caution
should be used when using antibiotic treatment such as tetracycline
secondary to increased sensitivity to the sun.
Oral hormonal therapy is often used effectively
in females with acne. Women who benefit most from
hormonal treatment are typically in their 20s or 30s, and have a
history of failed treatment, or an intolerance to standard acne
therapies (both topical and systemic). In addition, many have a
history of menstrual irregularities, premenstrual acne flare-up,
and facial oiliness. Hormonal treatment is generally not used in
the most severe forms of acne, nodular/cystic acne. While certain
popular oral contraceptive pills can result in an increase in acne
while other oral contraceptives can help improve acne. The
progesterone component of the pill largely determines whether a
brand of pill will exacerbate or improve acne.
When a woman in her late thirties or early forties
develops acne increased androgen production is suspected. In almost
all adult female patients with this condition, supplemental progesterone
clears the skin. One hypothesis is that ovarian follicle depletion
leading to progesterone deficiency results in increased adrenal
production of androgens. When progesterone is re-supplied, androgen
production goes down and the skin clears.
Other non-contraceptive hormonal therapies including
spironolactone are also used to treat acne.
In females, oestrogens and antiandrogens such as Diane 35 or spironolactone.
Spironolactone is a medication used
primarily for the treatment of high blood pressure. Recently it
has been used to treat acne and excess hair growth in women. Spironolactone
and flutamide act by blocking the effects of testosterone (androgen)
on the oil glands and hair follicle. It is the male hormone testosterone
which triggers the acne. The result is a reduction in oil production
and facial hair growth, and the improvement of acne and excessive
hair growth.
Some patients also benefit from the use of nonsteroidal
anti-inflammatory agents such as ibuprofen or naproxen.
Oral isotretinoin, a vitamin A derivative, is
also used in more severe cases of acne. Oral isotretinoin, is commonly
used to treat severe cystic acne, and can be very effective in these
severe and potentially scaring cases of acne. Oral Isotretinoin
is usually given for a 4-6 month course which will improve a large
number of individuals' acne. However, many individuals will experience
some recurrence of their acne, which is often much less severe,
but may require additional oral isotretinoin treatment. Oral isotretinoin
treatment is usually limited to those individuals with severe acne
secondary to the severe side effects associated with the medication.
Common side effects associated with oral isotretinoin include: dry
skin often resulting in dermatitis, cracked dry lips, irritation
to the nose and eyes.
Oral isotretinoin is strictly controlled secondary
to its potential effect on an unborn fetus if taken during pregnancy.
It is essential that all females of potential child bearing age
are counseled prior to treatment and that these women be on a suitable
contraceptive routine. Isotretinion has no adverse effects on male
fertility.
Physical treatments for acne
The following is a brief list of physical treatment
options:
