Acne

Definition

Acne vulgaris is a disease of the skin that results from the interplay of follicular hyperkeratinization, the presence of Propionibacterium acnes bacteria in the follicular canal and sebum production. It commonly occurs on the face, neck, back and chest.

Description

Technically called acne vulgaris, this skin disease affects millions of Americans annually. It can vary from quite mild to extremely severe.

Acne usually develops when the sebaceous glands and the lining of the skin duct begin to work overtime, as they do in adolescence. Normally, the lining of the duct sheds cells that are carried to the surface of the skin by the sebum. When the duct is blocked, cells and sebum accumulate, forming a plug (comedo).

If the plug stays below the surface of the skin, it is called a "closed" comedo or whitehead. If the plug enlarges and pops out of the duct, it is called an "open" comedo or blackhead because the top is dark. This is not dirt and will not wash away. The discoloration is due to a buildup of melanin, the dark pigment in the skin.

Causes and Risk Factors

About 80 percent of all teenagers develop acne, but this disease can also begin as late as the ages 25 or 30, particularly for women. No one is certain as to what exactly causes acne or why it usually begins in adolescence. But a number of factors, most importantly heredity, play a role. If one of your parents had acne, there's a good chance you will, too.

Symptoms

There are two main types of acne: non-inflammatory and inflammatory.

In non-inflammatory acne, there are usually just a few whiteheads and blackheads on the face. A relatively mild type of acne, it can be treated effectively with nonprescription medicines, or as in the case of blackheads, with the prescription drug called Retin-A. The majority of people with acne have this type of acne.

With inflammatory acne, the whiteheads become inflamed, and pimples and pustules develop. In its most severe form, inflammatory acne can cause disfiguring cysts and deep, pitting scars of the face, neck, back, chest and groin. Prescription drugs and sometimes surgery are needed to treat inflammatory acne.

Treatment

Doctors suggest the following to clear up mild acne:

• Get a nonprescription acne medicine and apply regularly. Over-the-counter drugs containing sulfur, resorcinol, salicylic acid, and benzoyl peroxide, are all effective for treating mild acne.

• Use ordinary hygiene on affected areas, washing your face once or twice daily with your usual soap or cleanser. Deodorant soaps may be used, but they are of no particular value for acne.

If these measures don't work, see a dermatologist. While it might be tempting to pick at pimples and squeeze blackheads, this can injure the skin and underlying tissues. Doctors advise patients not to pick pimples. Medical instruments, called comedo extractors, are used to remove blackheads. Some doctors may suggest that their patients use such an instrument themselves. Other doctors would rather remove the blackheads in the doctor's office or clinic because of the risk of scarring.

Topical Formulations

Topical tretinoin is a highly effective comedolytic agent that limits abnormal follicular keratinization and reduces the number of comedones. General guidelines for choosing a topical formulation call for:

• Gel for oily or combination skin (patches of oily and dry skin)

• Cream for dry, sensitive skin

• Liquid for patients who fail to respond to a gel or cream

• Some experts recommend using the cream in winter and the gel in summer

Many patients cannot tolerate the liquid, which is the most irritating form of this drug. Start tretinoin therapy cautiously: redness, peeling and itching often occur before the patient's skin adjusts to the medication.

The patient should be told that about in a third of all cases, acne worsens during the first three to four weeks of therapy, with transient outbreaks of pustules, but treatment should continue. The outbreak is self-limited in most patients, and therapeutic benefits become visible in approximately two months.

Because tretinoin causes photosensitivity, patients are advised to avoid direct sun exposure during the middle of the day, if possible. As a precaution, a noncomedogenic sun block of SPF 15 or higher, as well as wearing a hat during unavoidable exposure to the sun, is recommended.

If the clinical response is unsatisfactory or the patient has papules or pustules in addition to comedones, benzoyl peroxide is sometimes used as a supplement to tretinoin. Benzoyl peroxide is a potent antibacterial agent; daily application produces significant reduction in the follicular population of Propionibacterium acnes.

Accutane

For very severe, disfiguring acne which is unresponsive to the treatments mentioned, the doctor may prescribe isotretinoin, commonly known as Accutane. Also a vitamin A derivative, Accutane is taken orally in capsule form. It is highly effective for treating severe cystic acne and preventing the deep pits and scars that result. Scientists do not know exactly how Accutane works, but evidence suggests that it reduces the size of the sebaceous gland and the amount of sebum secreted. In any case, it completely clears up the disease in many people.

Women should use Accutane with extreme caution because it can cause miscarriage and birth defects. If pregnant while taking the drug, there is a great possibility that the baby will be born deformed. Therefore, Accutane's use is tightly regulated by the FDA. Doctors may only prescribe it for a woman who has had a negative pregnancy test, does not intend to become pregnant while taking it, and who has signed a consent form that she has been duly informed of the side effects.

In addition to the danger of fetal malformation and miscarriage, there are a number of minor side effects associated with Accutane. Ninety percent of those who take the drug experience inflammation of the lips (and less frequently of the eyes), and 80 percent experience drying of the skin, nose or mouth.

Antibiotics

Oral antibiotics are suggested for patients with:

• Acne that does not respond well to topical therapy

• No tolerance for topical medication

• Extrafacial acne - on the back, shoulders and chest, for example

• Places where topical medications are less effective

Whenever feasible, the patient taking an oral antibiotic should use topical therapy concurrently. This may reduce the amount of oral antibiotic required and possibly, all need for it.

In addition, some experts recommend that patients with extrafacial acne scrub apply it to affected areas of the body with poyidone/iodine (Betadine) each evening in the shower, using a long-handled brush. Applying benzoyl peroxide to trouble spots expedites healing of lesions.

Tetracycline is the antibiotic of choice because of its safety, efficacy and low cost. Begin therapy with 500-mg bid, either one hour before or two hours after meals, to maximize absorption. Continue this dosage for one to two months.

If treatment is effective, gradually reduce the daily dosage by 250 mg every six weeks, with the expectation that the acne might be managed with topical therapy alone.

Patients should be cautioned to avoid excessive exposure to sunlight while on tetracycline or to use a sunblock of SPF 15 or higher when outdoors.

If the patient does not respond to tetracycline therapy after an eight-week trial or cannot tolerate the drug, or when tetracycline is contraindicated, oral erythromycin is prescribed. An advantage of erythromycin is that it can be taken with meals, which most patients find more convenient.

Minocycline (Minocin) is an excellent alternative for those who fail to respond satisfactorily to either tetracycline or erythromycin. This antibiotic achieves a high intrafollicular concentration and has a more prolonged effect than does tetracycline. A 200-mg dose of minocycline given daily is equivalent to about 1,500 mg of tetracycline.

Minocycline is widely used, and serious reactions are rare. However, its unusual propensity for causing immunologically mediated reactions may make it less safe than other tetracyclines, and this should be taken into account when treating essentially benign conditions such as acne. It is also very expensive.

Scarring

Proper prevention and treatment of acne can reduce long-term scarring. While moderate acne can leave some scars, most red or brown discolorations eventually diminish without treatment in a few months to several years. However, scarring from more severe acne is usually permanent. In most cases, treatment can only reduce scars; it cannot eradicate them.

The most common approach to superficial skin damage is collagen injection, which raises shallow scars to the level of the surrounding skin; and chemical peels, in which glycolic acid removes the top layer of skin to reduce pitting.

Deeper scars may require a type of plastic surgery called dermabrasion, in which the patient is sedated and the affected skin is frozen with a refrigerant spray. The skin is then planed with a hand-held device consisting of rotating wire brushes or stainless steel wheels to which industrial diamonds are bonded.

If scars are very deep, the surgeon may need to remove the fibrous tissue and fill the depressions with skin taken from behind the ear. Once these skin grafts have healed, dermabrasion can be used to smooth the surface.

Azelaic acid cream (Azelex) for mild to moderate acne may be as effective as other forms of acne treatment, while causing fewer side effects. Azelaic acid, sold as a 20 percent cream, has both antibacterial and antikeratinizing properties. Azelaic cream produced similar results compared to benzoyl peroxide, tretinoin, or erythromycin. At least 60 percent of all patients with mild to moderate acne responded well to azelaic acid.

Severe acne, however, seems to require oral isotretinoin in order to lower sebaceous gland secretion. Burning and itching episodes are apparently rare during the use of azelaic acid. Dark complexions may experience changes in pigmentation, according to the manufacturer.

Questions to Ask Your Doctor

What type of treatment will you be recommending?

Will you be prescribing any medications? What are the side effects?

How long will I need to take medication?

How long should it take for the medication or treatment to start working?

Should a dermatologist be seen?