Acne

COURSE

Acne usually ends by itself when a person is in their mid-20s or it may continue over the age of 40. Acne flare-ups during the premenstrual and menstrual period or in the winter are quite common. The only physical consequence is scarring, which can be avoided by appropriate treatment, mainly by administering isotretinoin in the early stages of the disease.

TREATMENT

The psychological effects of acne should be individually assessed in each patient and treatment should be adjusted accordingly. The aim of the treatment is to reduce seborrhea, prevent further comedo formation, reduce propionibacterium acnes colonization, and clear inflammation with the appropriate topical and/or systemic treatment.

General hygiene measures

Cleaning of the affected areas twice a day (in the morning and in the evening)

Topical Acne Treatment

Topical agents used in topical treatment are mostly antimicrobial or keratolytic, which suffice to treat mild acne conditions.

Among the most commonly used types of medications to treat inflammation are:

(a) Benzoyl Peroxide: It works by reducing the amount of acne-causing bacteria. It is applied to the areas of your skin affected by acne at night, and it is rinsed with water in the morning.

(b)Topical antibiotics: Tetracycline, erythromycin, clindamycin. They have antimicrobial properties and they work by inhibiting the growth of Propionibacterium acnes colonization.

Retinoic acid and azelaic acid are used in keratolytic treatment. (a) Retinoic acid dissolves comedones, corrects keratinization disorders in the follicle and slows down the increased production of keratinocytes. It is applied in the evening and is removed with water in the morning. Due to some irritation side effects such as erythema, dryness and skin peeling, some patients have to stop treatment. (b) Azelaic acid has anti-inflammatory and keratolytic properties. It is applied on the affected areas twice a day, every morning and evening.

Systemic Acne Treatment

In cases of moderate and severe acne, topical agents alone may be insufficient to treat acne, so a combination of both topical and systemic treatments might prove much more efficient. Systemic agents include oral antibiotics, isotretinoin, and hormones.

Among systemic antibiotics, tetracycline remains the first choice, followed by erythromycin. They are both administered for 6-8 months. Tetracycline is not to be administered to women during pregnancy, as it inhibits the skeletal formation of the fetus. It should also be avoided in children, particularly younger ones, during the period of tooth development to avoid permanent yellow teeth discoloration. Antibiotics act directly on the lesions, and they have few side effects such as nausea, diarrhea and vaginitis in women.

Isotretinoin is indicated for the treatment of severe cystic acne or for acne unresponsive to antibiotics. Treatment with isotretinoin is associated with impressive results. The treatment lasts 4-7 months or more, depending on the dosing schedule. If lesions are cleared earlier than that, the treatment stops; nevertheless, the effects appear to persist even after its discontinuation. Laboratory monitoring pertaining to blood lipids, triglycerides and liver function is performed before and during the course of treatment. Retinoids are potent teratogenic, so women are required to take strict contraceptive measures during the treatment. There are also several adverse effects such as cheilitis (lip chapping), dry skin, itching, nosebleed, inflammation of the whites of the eyes (conjunctivitis), cracking or peeling skin on palms and soles, photosensitivity, headaches, etc. Despite the undesirable effects, isotretinoin is an effective medicine. However, patients must always be monitored closely.

Hormonal Treatment

The use of estrogens in women in the form of oral contraceptives (birth control pills) block the effect of androgens on the sebaceous glands, thus suppressing sebum production. They are administered for a long period of time (6-12 months). Recently, spironolactone and glucocorticoids have also been administered to patients.

Great care must be taken when using oral contraceptives. The treating physician should always consider the contraindications carefully when prescribing these medications. These include pregnancy, smoking, age over 35, coagulation disorders, migraine, hypercholesterolemia (high cholesterol), diabetes, prolonged immobilization following surgery and many others.

There are plenty of hormonal treatments for acne. Such a treatment is useful for women with acne who show clinical or laboratory signs of hyperandrogenism. Working with an endocrinologist or a gynecologist is always helpful. Effective treatment always depends on proper co-operation between the doctor and the patient.