ACNE PART II: Treatment (a)

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

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