ACNE PART II: Treatment (b)

Dr. SchleicherACNE PART II: Treatment (b)

Contraceptives

         Although some oral contraceptives may actually aggravate acne, others may reduce oil production and promote acne clearing. Women with persistent acne who do not respond to more traditional therapies may be candidates for such hormonal manipulation. Certain birth control pills (Ortho Tri-Cyclen, Estrostep, Yasmin, and Yaz) have even been approved as a treatment for acne. The drug spironolactone helps counteract the male hormone and may also prove useful for women with moderately severe breakouts.

 Isotretinoin

         In 1982 a powerful medication for the treatment of severe acne was released in the United States. Called isotretinoin, this “miracle” drug will actually “cure” selected cases of acne. Trade names include Amnesteem, Claravis, and Sotret. The flagship product, Accutane, was voluntarily withdrawn from the market in July, 2009. The manufacturer cited business reasons with no relation to safety and efficacy.

        Isotretinoin is a derivative of vitamin A and is available in capsule form. The medicine is taken for a five- to six-month period. Within three weeks of commencing the medication, varying degrees of skin dryness invariably occur and may be accompanied by dry eyes, cracked lips, and nosebleeds. These annoying side effects may last for the duration of therapy. Isotretinoin may also raise the level of circulating fats, and for this reason periodic blood tests are mandatory.

        For those with cystic acne, the results of isotretinoin therapy are well worth any transient aggravation. The disfiguring cysts resolve, and for the majority of people undergoing the treatment, new cysts rarely appear. Some 80 percent of such patients achieve long-lasting remission. By preventing deep cysts, isotretinoin abruptly halts the dreaded sequelae (scarring) of acne. Some individuals with chronic, less severe, forms of acne may benefit as well.

        Controversy exists regarding the association of isotretinoin with mood changes, depression and colitis; direct links, if they do occur, are certainly rare. This drug must never be taken by pregnant women because of the high incidence of birth defects. Women of childbearing age must practice strict birth control. Isotretinoin should only be administered under a dermatologist’s care. Indeed, persons taking this drug must be registered in a central government-mandated database called I-Pledge.

Other Treatments

         What about the physical methods used to treat acne? Again, please remember not to pop pimples or further manipulate acne lesions unless properly instructed by a dermatologist. Extraction of open comedones (blackheads) can be accomplished under proper supervision by use of a comedone extractor. This instrument features an open loop that is placed over the blackened pore, allowing the contents to be expressed when firm pressure is applied. Comedone expression has minimal influence on the course of acne. The widened pore will reaccumulate its blackened contents within a month’s time; however, many persons obtain cosmetic and psychological benefit from this procedure and welcome the removal of these unsightly black dots.

        Most recently, lasers, IPL (intense pulsed light), blue and red light sources, and even a topically applied solution activated by light have been employed as acne therapies. Such interventions, of varying costs, may lessen the need for oral antibiotics. The verdict is still out as to the overall effectiveness of these physical modalities, which are somewhat expensive and generally not covered by health insurance.

        Persons who develop large, disfiguring cysts benefit from the injection of a steroid solution (Kenalog) directly into each cyst. This medicine often dramatically reduces the size of a lesion within twenty-four hours and may prevent subsequent scarring.

Scarring

           What can be done for those already scarred by acne? Dermatologists and plastic surgeons possess several tools for the correction of scarring, including dermal filler implants (such as Cosmoderm, Juvederm, Radiesse, Zyderm), dermabrasion (mechanical sanding), and lasers. Which procedure(s) to use depends on a number of factors, including the extent and depth of scarring. Shallow, concave, pliable scars respond immediately to dermal filler injection. More superficial scars may respond to multiple laser sessions. Good results are being reported with fractional laser photothermolysis. Consult with a dermatologist who is knowledgeable in all facets of scar correction. Keep in mind that although 100 percent correction is unlikely, some degree of improvement may be achieved. Often the changes are dramatic.

           In summary, the immediate goal of acne therapy is to clear up existing pimples and blemishes and prevent new ones from appearing. You may have such mild acne that daily washing coupled with an over-the-counter benzoyl peroxide or salicylic acid preparation is all that will be needed to control the disorder. However, if these measures fail, an appointment with the dermatologist would be prudent. The skin care specialist has at his disposal a variety of beneficial treatments for acne. Two or more different medications are commonly employed at the same time. One must bear in mind that such regimens rarely produce instant results; acne does not clear up overnight. Be patient! You should always give a new regimen a minimum of three to four weeks for visible results to occur.

          Those with cystic acne that is unresponsive to antibiotics should experience considerable improvement following a several-month-long course of isotretinoin. Certain scars may improve with injectable fillers or laser therapy.

          Acne is a cosmetically disfiguring problem. If left untreated, the condition may lead to immense physical and emotional scarring. Today acne is certainly controllable, and select cases may even be cured.

DermDOX Centers for Dermatology
EM:  sschleicher@dermdox.org
PH:  570-459-0029
Website:  http://www.dermdox.org

ACNE PART II: Treatment (a)

Dr. Schleicher

ACNE

 PART II: Treatment (a)

        For most, acne merely represents a temporary embarrassment, while for some the condition constitutes a disfiguring disease. Regardless of the extent of involvement, virtually all cases should significantly improve with proper therapy.

        Certain general principles are best followed when dealing with acne. As mentioned, it is advisable to wash the affected areas two or three times daily to remove excess sebum and bacteria from the skin’s surface. (It should be noted that excessive washing only leads to excessive dryness and irritation.) Acne cleansers and soaps often contain surfactants that facilitate oil removal. Cleansers containing benzoyl peroxide and salicylic acid are very effective. Defatting solutions known as astringents may aid in the temporary removal of surface film. Abrasive cleansers contain fine granules that are rubbed against the skin to produce a mild “sandpaper” effect. Such preparations will help reduce excess oil but can cause increased peeling and may prove too harsh for some persons; dermatologists discourage their use in the inflammatory types of acne. Nonirritating, noncomedogenic soaps are recommended for those with sensitive skin.

         Persons with acne must strenuously avoid picking, scratching, squeezing, or otherwise manipulating their pimple-plagued skin. Unless properly instructed, leave all mechanical manipulations to a skin care specialist. The temptation is certainly great to force out pus-bumps and to pop zits. But such facial trauma, besides coating the bathroom mirror, may transform an ordinary pimple into a permanent scar.

         Overzealous use of certain cosmetics may exacerbate acne. Many adolescent and adult women are heavy makeup users. Their day begins with the application of moisturizers, foundation creams, and coloring agents and ends with the smearing on of a night cream. Frequently one witnesses a vicious cycle. A woman with a few scattered pimples may try to camouflage their presence with makeup. This in turn leads to a flare-up of acne and to the subsequent use of an even greater quantity of cover-up. The cycle is broken when the woman is advised to stop using all cosmetics, although actual clearing may be delayed for many months. Fortunately most cosmetics now on the market are noncomedogenic, meaning “non-pore-plugging,” when used in moderation.

         Sunlight often plays a beneficial role in acne treatment. Many people experience a considerable improvement in their complexion during the summer months. Of course, one must weigh this benefit against any harmful, long-term effects of ultraviolet radiation. And, as you will soon learn, some acne therapies do not mix with sunlight.

         Persons with acne usually try over-the-counter acne preparations as first-line treatment. Active ingredients may include sulfur, resorcinol, benzoyl peroxide, salicylic acid, or alcohol. All promote drying and peeling and help limit bacterial growth.

         Those who do not respond to the above measures should consider medical consultation. Dermatologists possess considerable knowledge concerning the nature and course of acne and have at their disposal a number of powerful therapeutic modalities to improve one’s appearance and—of equal importance—to prevent scars. Indeed, a good percentage of persons with acne require medical specialist treatment to prevent physical or psychological scarring.

    Benzoyl Peroxide

         One of the mainstays of acne therapy is application of benzoyl peroxide. Preparations containing this substance promote facial drying and are antibacterial leading to rapid reduction of inflammatory lesions.

         Benzoyl peroxide is formulated in a number of concentrations ranging from 2.5 percent to 10 percent. In general, one should start therapy with the lowest concentration. The major side effects encountered with this product are excessive dryness, irritation, and allergic reactions. As these untoward reactions increase with higher concentrations and several studies have failed to demonstrate significantly improved efficacy with higher dosing, most individuals are best maintained on lower strengths. Individuals with sensitive skin may not be able to tolerate this compound, and it should be noted that benzoyl peroxide will stain clothing.

         Certain benzoyl peroxide preparations are advertised as cosmetics and may be purchased over the counter. Other preparations are marketed strictly as drugs and must be obtained by prescription only (examples include Benzac, Brevoxyl, Cleanse & Treat and Triaz). The rationale for this somewhat nonsensical dichotomy rests with the FDA.

         Benzoyl peroxide is a potent oxidizing agent that kills germs on contact. Unlike with antibiotics, bacteria do not develop resistance to this agent.

 Sulfur

         Sulfur-containing compounds have been used to treat acne since the 1800s. Sulfur has anti-inflammatory activity, and many formulations have a distinctive odor. As with benzoyl peroxide, some sulfur-based products are available over the counter (for example, Rezamid), while others require a prescription (Avar, Klaron, Plexion, Rosanil, Rosula, and Sulfacet-R. Nuox gel is a prescription medication that combines benzoyl peroxide and sulfur).

Retinoids

         Another modality commonly used to treat acne consists of the topical application of vitamin A derivatives called retinoids (examples include Atralin, Avita, Differin, Retin-A, Tazorac, and Tretin-X). These substances possess comedolytic properties; they dislodge dried sebum and help keep the pores open. There is increasing evidence that retinoids may also exert a direct anti-inflammatory effect upon the follicle. The major downside of such therapy is undue irritation.

         Most vitamin A derivatives utilized as acne therapy require a doctor’s prescription. Undesirable side effects include facial redness, peeling, and burning. These reactions frequently diminish with repeated use.

         Skin treated with retinoids may become very sensitive to sunlight and easily sunburned. For this reason, excess sun exposure should be minimized. In fact, at least in the summer months, prescription retinoids are best applied only at night and thoroughly washed off in the morning.

 Antibiotics

         Topical antibiotics are commonly used to treat acne. Clindamycin and erythromycin are formulated in solution, gel, and pledget formulations (including Cleocin-T, Clindets, Evoclin, Erygel, and Erycette). Azelaic acid (Azelex, Finacea) is an antibacterial cream derived from wheat. Newly released is topical dapsone gel (Aczone); interestingly, the oral form is used to treat leprosy.

          An antibiotic may be combined with benzoyl peroxide in a gel form (Benzamycin, Benzaclin, and Duac). Combination therapy is thought to decrease the potential for bacterial resistance. Recently a combined form of retinoic acid and clindamycin has been released (Ziana) as well as a combination featuring adapalene and benzoyl peroxide (Epiduo).

         Oral antibiotics are the mainstay of therapy for moderate to severe acne. As a general rule, antibiotic treatment for this condition begins with tetracycline or a tetracycline derivative. Oral tetracycline has been used to treat acne for decades. The drug is remarkably safe; people have been on tetracycline for years without any serious long-term effects. As far back as 1975, the American Academy of Dermatology reported on the safety and efficacy of chronic antibiotic therapy for acne. After studying thousands of patients, the Academy concluded that tetracycline is effective in the control of this disorder and that usage over long periods of time is indeed safe. Today the conclusions of their report are still widely accepted by the medical community. A 2004 study published in the Journal of the American Medical Association suggested a link between chronic antibiotic use and breast cancer. Another similar study published one year later found no such link. Still, the lowest dose of an antibiotic necessary to control acne is the wisest course of action, with discontinuation recommended once adequate control is achieved.

           Tetracycline should not be taken with meals, milk, or vitamin-mineral combinations because these substances bind the drug in the stomach and lessen its acne-fighting abilities. For this reason tetracycline is best taken on an empty stomach no sooner than thirty minutes before or one hour after a meal. Tetracycline may lead to mild stomach upset and heartburn. Some women on this medication may acquire vaginal yeast infections. Tetracycline must never be taken by pregnant women for the drug can enter the womb and stain the child’s teeth yellow, nor should it be given to nursing women and children under the age of eight.

        Erythromycin may also be used as a first-line acne therapy as it possesses antibacterial and anti-inflammatory activity. Manufactured in liquid, tablet and capsule form, the antibiotic is moderately priced. Occasionally erythromycin may produce gastric upset, but as with tetracycline, long-term usage has proved extraordinarily safe.

         A drawback to using tetracycline and erythromycin has been the emergence of resistant strains of the germs that cause acne. This, coupled with an inconvenient dosing regimen, has led to the popularity of tetracycline derivatives as first-line therapies. Although more expensive than tetracycline, these compounds have better efficacy and can be taken with meals. Like tetracycline, these agents are quite safe but should be avoided by pregnant women. Doxycycline (Adoxa, Doryx, Monodox, Oracea) and minocycline (Minocin, Solodyn) are widely prescribed. Minocycline in high doses may produce nausea and dizziness and has recently been linked to transient blood chemistry abnormalities. Minocycline may rarely cause abnormal skin pigmentation, and doxycycline may uncommonly cause sun photosensitivity.

DermDOX Centers for Dermatology

EM:  sschleicher@dermdox.org

PH:  570-459-0029

Website:  http://www.dermdox.org

ACNE

Dr. Schleicher PART I: Cause

           Do zits give you fits? Chances are, yes. Acne is the most common skin problem affecting three out of every four teenagers to some degree. And an imperfect complexion is not limited to this age group; many in their twenties and thirties also suffer with this condition. The problem is an expensive one, with millions of dollars spent each year on over-the-counter preparations as well as prescription drugs. For many, acne consists of nothing more than an occasional pimple or blemish on the face, back, or chest. A few are less fortunate and develop extensive, persistent eruptions resulting in permanent pits and scars. The psychological effects may be devastating, and acne has been linked to depression and suicidal thoughts.

                    Acne depends on the presence of sebaceous (oil) glands found within the dermis of the skin. These specialized structures are most numerous on the face but are also present on the back, chest, and upper arms. At puberty the glands undergo rapid enlargement because of hormonal stimulation. As the glands grow in size, they become more active, manufacturing a mixture of oils that in excessive amounts gives rise to the so-called oily complexion. The gland openings (pores) may become clogged, causing the oil, or sebum, to back up and stagnate. Bacteria growing in the sebum break this substance down into a number of irritating compounds that lead to the formation of blackheads, whiteheads, and those unsightly mountains and craters affectionately called zits.

        There are several different types of acne lesions. These include comedones (whiteheads and blackheads), papules, pustules, cysts, and scars. Comedones are of two varieties: open and closed. A closed comedone, called a whitehead, arises when a pore becomes clogged with oil and the sebum creates a tiny white covering over the entrance. When the opening remains unobstructed, the oil is oxidized by the air and turns black. This open type of comedone is called a blackhead.

        A papule is a solid, elevated lesion of the skin. Papules range in hue from flesh-colored to bright red. Red papules are those pimples still undergoing inflammation.

        A pustule is a pimple filled with fluid, or pus. This substance is composed of dead cells and bacteria. When a pustule becomes larger and deeper, it is then termed a cyst. Tender, inflamed red pustules and cysts may result in scars, which is why these two types represent the most severe forms of acne.

        What then is the cause of acne? Why is it that some people escape this condition entirely, while others are plagued with blemishes, zits, and blackheads year after year?

        Acne appears to be the result of a number of factors; there is no single cause. Certainly a major factor is heredity. If one of your parents had acne, you run an increased risk of acquiring this condition.

        Another contributing factor to the development of acne is the activity of certain hormones within the body. For many, acne first becomes a problem at puberty. During this period, testosterone, the male sex hormone, is formed not only by the male sex organs, but also in small quantities by the ovaries in young women. Testosterone causes marked growth of the sebaceous glands and, in susceptible persons, may trigger or worsen acne.

        Some women develop one or two pimples each month shortly before their menstrual periods. Others may flare when placed on certain birth control pills. In both cases, the resultant acne is due to changes in the body’s hormone levels. Polycystic ovary syndrome is characterized by irregular periods, excess facial hair, and scalp hair thinning. Abnormal hormone levels in women so afflicted results in persistent acne.

        Another factor that contributes to acne is the bacteria that live within the sebaceous glands breaking the skin’s natural oils down into irritating by-products. These bacteria and the substances they produce play a key role in the inflammatory lesions of acne.

        An increasing number of American women are developing acne not at puberty or in adolescence but during their twenties. This phenomenon has been attributed in part to the prolonged use of cosmetics. Certain moisturizers, creams, and cover-ups may contribute to pore plugging and consequently lead to comedones and papules.

        Emotional upsets and stress also tend to worsen existing acne. Many high school and college students experience marked flare-ups during their exam periods.

        Certain factors once thought to play a significant role in the cause and perpetuation of acne are now considered quite unimportant. No evidence exists that lack of regular washing leads to a worsening of acne. By the same token, acne does not appear to be improved by incessant cleansing. Washing two or three times daily is all that is usually needed to remove excess oil and germs on the skin’s surface.

        Lingering controversy surrounding acne involves the role of diet. A diet high in fats and oils does not make the skin oilier; greasy skin is not caused by greasy foods. A scientific study conducted years ago was unable to demonstrate that feeding individuals with acne huge quantities of chocolate led to increased pimple formation. However, more recently, a link has been postulated between breakouts and high-glycemic-load diets that are rich in processed carbohydrates. Acne severity decreased in volunteers maintained on low-carbohydrate diets, but these diets also promoted weight loss, which alone may have triggered changes in body hormones that diminished the number of breakouts.

        Speaking of hormones, yes, the role of milk in acne causation is also controversial. Again, a recent study found a positive association between milk intake and acne. Since the majority of milk comes from pregnant cows, a tenable hypothesis holds that hormones in milk have a stimulatory effect on the oil glands of those that drink it.

DermDOX Centers for Dermatology

EM:  sschleicher@dermdox.org

PH:  570-459-0029

Website:  http://www.dermdox.org