There a a number of kinds of Acne, but the most frequent type is called Acne Vulgaris (from the Latin: Vulgar = common). The disease usually begins at or around puberty. Most causes are seen in the middle and late teenage years, however, particularly in women, one may see acne into the twenties and thirties.
Acne is a disease of the sebaceous glands. After puberty, glands produce fat which are acted on by the normal bacteria of the skin. Fats then become irritating to the skin and cause acne lesions.
The common acne lesions are:
- Comedones – Opened and Closed
- Papules – Red Bumps
- Pustules
- Cysts
Acne Myths:
Diet: In most cases, your diet probably plays a very small role in causing acne. If you feel that some food makes your acne worse, it is best to avoid them; but by and large soda, chips, chocolates and other “forbidden foods” do not cause acne. Occasionally a patient who eats large amounts of iodides (seaweed, kelp, vitamins with iodine) will get acne.
Sun: While a suntan may cover the acne lesions, the sun probably has no curative role in acne.
Treatment:
There are many ways to treat acne. Basically they can be divided into topical and Systematic (oral). Some cases don’t even need therapy.
Topical Therapy:
- Cleansing: The surface fat and bacteria do not cause acne. Only those fats and bacteria in hair follicles provoke acne lesions. Therefore, simple washing is not helpful in acne. Excessive washing may make the condition worse. However, washing may remove excessive surface oil and improve appearance somewhat.
- Benzoyl Peroxide (BP): This is a potent antibacterial agent. By killing the number of bacteria on the skin, it decreases the number of acne lesions found. For the first few weeks of use, it causes some redness, scaling, and itching. Therefore, usually the weak 2.5 or 5% preparation before the stronger 10%. BP comedones as a wash or a gel.
- Retinoic Acid: (Vitamin A Acid (Retin A, Differin, Azelex). Topical vitamin A preparations function primarily as irritants, peeling agents and are particularly useful when there are many white heads (closed comedones). These may exaggerate the effects of the sun. For this reason, they are best applied in the evening. Fair-skinned patients should be careful about prolonged sun exposure.
- Topical antibiotics: Erythromycin and Clindamycin are the most widely used. These are quite effective, but it is doubtful that they will replace systematic antibiotics in moderate to severe acne. These too may cause redness, scaling, and itching for a short time.
Systematic Therapy:
Antibiotics:
Tetracyclines and Erythromycin are the most common antibiotics used. If a patient is taking tetracycline, it is not absorbed in the presence of food, and must be taken on an empty stomach. Iron pills taken with the tetracycline will interfere with the absorption also. The tetracycline derivatives – doxycycline and minocycline are less dependent on an empty stomach and easier to take.
Tetracyclines result in a yeast vaginitis in around 10% of the women who take them. This is not serious and can be handled with creams and is not a reason to stop the drug. (Remember, 90% of the users do not develop this.) Tetracycline is usually prescribed before Erythromycin, because more studies have been done with it; but both are equally safe. Warning: Tetracycline should not be taken after the third month of pregnancy or by children under 12, as it will stain growing teeth. Erythromycin is similarly to be avoided during pregnancy. Tetracyclines may also interfere with the efficacy of the birth control pill.
Isotretinoin (Accutane)
Accutane was introduced for acne around 1982. It is a vitamin A derivative and is the most effective anti-acne agent we have. Originally used for only the most severe cases, it is being used now for milder cases which have failed other therapies. A five – six month course of Accutane will completely clear almost every patient. Fifty percent are cured – their acne does not come back – while the acne recurs in another 50%. Of these, most have milder acne that can be managed more simply. Around 20% of patients go on to receive a second course of Accutane. Accutane can raise the fats in the blood and causes birth defects in woman who are pregnant when they take it, therefore close monitoring is important – and all sexually active women who take Accutane must be using oral contraceptives or two alternative methods. Pregnancy testing is done monthy on these patients. Sexually active patients who are categorically against abortion should not take this drug.
Hormones:
Birth control pills (BCP) can help women with acne. In my experience these are not as effective as oral antibiotics – but some women do quite well with these. Orhto TriCyclen and Demulen are two pills which are recognized to be of value. Some BCP can actually make acne worse – so this should be discussed with a patients dermatologist of gynecologist.
Antiandrogens are quite effective for acne in women with resistant disease. The most commonly used is cyproterone acetate. However, this is not available in the United States. For more information on these agents, you can check PubMed.
Other treatments:
Acne cysts respond to weak concentrations of steroids injected into them. The improvement is rapid and the procedure is not very painful.
Acne surgery refers to the removal of acne lesions. It is most commonly applied to comedones, and may prevent their evolution into more inflammatory lesions (the papules, pustules, and cysts).
Course under Treatment:
With therapy, results are seen within 2-3 month. The response is not usually more rapid and it is unwise to change therapy radically before 2 months on a given treatment. Those patients that do not respond to tetracycline may respond to erythromycin (as well as Bactrim, Septra, amoxicillin or other antibiotics). About 60% of patients will do well with either of these two agents (or other antibiotics) and good topical care. In their early twenties, most patients will spontaneously improve, however, some patients will continue to develop lesions into their thirties or beyond and still need treatment. Acne scarring frequently improves with time, but certain patients may have significant scarring which requires definitive treatment. In the past, this was dermabrasion – but now laser techniques are used.
After you read this, if you have any questions, please do not hesitate to bring them to my attention.