Acne Treatments

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What is a Acne?

Acne (also called acne vulgaris) is a common skin disease characterized by clogged pores and pimples, blackheads, or red, swollen bumps. Acne lesions are most common on the face, but they can also occur on the neck, chest, back, shoulders, scalp, and upper arms. Acne lesions are commonly referred to as pimples, spots, or zits.

Severe acne is inflammatory, but acne can also manifest in noninflammatory forms.

More than four out of five people between the ages of 12 and 24 have acne at least once. But while the disorder is often associated with teenagers, it can affect people of all ages.

Acne is rarely a serious medical condition, but it often causes emotional distress and can lead to scarring of the skin.

Acne seems to affect the sexes somewhat differently. Before children reach puberty, acne is more commonly seen in girls. During puberty, acne affects boys and girls almost equally, but boys generally have more severe cases. In adulthood, it tends to be seen more often in women.
Types of Acne

Acne lesions range in severity from comedones (blackheads and whiteheads) to nodules and cysts.

* Blackheads occur in partially blocked pores. Dead skin cells, bacteria, and sebum drain to the surface of the skin. The pigments are exposed to air, which causes the black color.
* Whiteheads are slightly raised, skin-colored bumps, develop from a blockage deeper in a pore. Lacking a drainage path, the oil accumulates in the skin, causing small flesh-colored or white-colored bumps. Unlike blackheads, whiteheads are more likely to lead to the inflammation known as pimples or zits.
* Papules are inflamed lesions that usually appear as small, pink bumps on the skin and can be tender to the touch.
* Pustules are closed comedos, which become inflamed and begin to rupture into the skin forming pustular heads of various sizes.
* Nodules represent large, tender, swollen acne lesions, which have become intensely inflamed and rupture under the skin. If untreated, these can produce deep scarring.
* Cysts are deep, painful, pus-filled lesions that can cause scarring.

Acne causes

Acne occurs when the hair follicles become plugged with oil and dead skin cells. However, the exact cause why some people get acne and some do not is unknown.

Several factors are known to be linked to acne:

* Hormones likely play a role in the development of acne, making the condition most common in teenagers. Some adult women experience mild to moderate acne due to hormonal changes associated with pregnancy and their menstrual cycles. Higher levels of sex hormones (like testosterone and androsterone) stimulate oil production by the glands surrounding hair follicles. This excess oil clogs these follicles or pores, thus causing a pimple.
* Heredity (genetics). Researchers believe that the tendency to develop acne can be inherited from parents.
* Medications. Certain drugs, including androgens and lithium, are known to cause acne. Greasy cosmetics may alter the cells of the follicles and make them stick together, producing a plug.

Acne Treatment

How long is treatment needed?
Whatever treatment is used, it is normal to take up to four weeks to see any noticeable improvement in the skin. There is often a good response to treatment by six weeks. However, it can take up to four months (sometimes longer) for maximum response to a treatment, and for the skin to be generally free of spots. The most common reason for a treatment failure is because some people think that treatment is not working after a couple of weeks or so, and give up.

Will acne return after treatment?
Once the spots have cleared, acne commonly flares up again if you stop treatment. Therefore, after the spots have gone or are much reduced, it is common to carry on with a 'maintenance' treatment to prevent acne from flaring up again. It is common to need maintenance treatment for 4-5 years to keep acne away. This is typically until the late teens or early 20s. In a small number of cases, acne persists into the 30's, or even later. For these people it is possible to continue to treat the skin to keep it under control. Maintenance treatment is usually with a topical treatment - either benzoyl peroxide or a topical retinoid. The dose used to prevent spots from returning is often lower than that used to treat acne.

Antibiotics (oral)
Antibiotics are effective in treating most inflammatory acne (papules and pustules). They work by killing the acne causing skin bacteria - Propionibacterium acnes. Antibiotics also work by decreasing the redness and swelling seen in the inflammatory forms of acne. However, they have little effect on unplugging blocked pores, that is blackheads and whiteheads.

Treatment with oral antibiotics usually begins with a higher dosage, which is reduced as acne resolves. Generally, antibiotics are prescribed for six months or less. Over time, the P. acnes bacteria can become resistant to the antibiotic being used to treat it. When resistance occurs, acne is no longer controlled. Another antibiotic or alternative treatment can be prescribed.

Antibiotics taken by mouth can be associated with more side effects than if applied to the skin.

Tetracyclines
Tetracycline based antibiotics are the most commonly used antibiotics to treat acne. Tetracyclines reduce the papules and pustules of acne. These medications should not be taken by children younger than 8 years of age because they can affect growth and stain teeth. They should also not be taken by a woman who is pregnant or breast feeding.

Tetracycline is the most widely prescribed antibiotic for acne. The usual starting dose is 500 mg twice a day continued until a significant decrease in acne lesions is seen. The dose can then be decreased to 250 mg twice a day or discontinued. The main drawback for this antibiotic is that it must be taken on an empty stomach to be the most effective. For a teenage boy who eats frequently, this can be very difficult.

Doxycycline proves especially effective in treating inflammatory acne. This antibiotic is better tolerated than tetracycline. Doxycycline is started at 50 to 100 mg twice a day. It should be taken with food; otherwise it can cause significant nausea. Doxycycline is more likely than tetracycline to increase sensitivity to the sun, or cause sunburns.

Minocycline has a long history of use to treat acne. It is often effective in treating acne that has not responded to other oral antibiotics. Minocycline is especially useful for pustular type acne. Minocycline also seems to produce fewer incidents of antibiotic resistance. While the absorption of minocycline is decreased with food, it is not as significant as the decrease seen with tetracycline. The usual starting dose is 50 to 100 mg twice a day.
Topical Antibiotics

Antibiotics may be taken orally or applied to the skin in the form of gels and lotions. Giving an antibiotic by mouth is often needed for acne that is more extensive, red, and tender.

Topical antibiotics work by killing the Propionibacterium acnes bacteria. This also indirectly keeps the pores open.

Clindamycin
Topical clindamycin has a long history of successfully treating acne. It works by killing P. acnes and decreasing inflammation. In topical form, clindamycin has proven to be safe and is well tolerated. Skin dryness and irritation are possible side effects. It is important to use clindamycin as directed to decrease bacterial resistance that can occur with antibiotic use.

Erythromycin
Topical erythromycin is an antimicrobial and anti-inflammatory. When topical erthyromycin is combined with benzoyl peroxide, the combination proves to be quite effective as the patient gets the effects of two antimicrobial agents. Like topical clindamycin, erythromycin may cause skin dryness and possible irritation. Erythromycin is safe for use by pregnant women.

Topical Retinoids - Tretinoin (Retin-A)

Retinoids are synthetic vitamin A derivatives. Medicines made from vitamin A are useful in treating several types of acne lesions.

Some common topical retinoids include:

* Adapalene (Differin)
* Tretinoin (Retin-A, Retin-A Micro. Avita, Renova)
* Tazarotene (Avage)
* Tazarotene (Tazorac)

Topical retinoids are prescribed to treat acne ranging from mild to moderately severe. These help to open clogged pores by creating a mild peeling effect. Topical retinoids work by increasing skin cell turnover promoting the extrusion of the plugged material in the follicle. They also prevent the formation of new comedones.

Drying of the skin can be a frequent side effect. Topical retinoids can irritate the skin and increase sun sensitivity so it is important to use sun protection and follow the dermatologist’s directions to maximize effectiveness. An added benefit in using topical retinoids is that they may help diminish the signs of aging, such as fine lines and wrinkles.

Topical retinoids are very effective. It may take 6-9 weeks to see a noticeable difference. It takes at least 6 months to see a noticeable difference in wrinkles. The best benefit is seen if medication is used for at least a year.
Oral Retinoids - Isotretinoin (Accutane)

Oral retinoids are reserved for treating the more extensive nodular type of acne or severe inflammatory acne, which has not responded to other treatments. Oral retinoids not only have a peeling effect but also decrease the production of oil.

Isotretinoin (brand name Accutane) is classified as a retinoid, made from a synthetic form of vitamin A. According to a study published in the Journal of the American Academy of Dermatology (2001, vol. 45, pgs. 187–195) 69% to 75% t of those who completed a course of isotretinoin have a significant decrease breakout production or a complete remission of acne.

Isotretinoin works by shrinking the sebaceous glands within the dermis, reducing the amount of oil produced. The exact mechanism of this is still unknown. The reduction of oil within the follicle means less clogging of the pores, leading to a reduction of overall breakouts.

The most common treatment course consists of a 16- to 20 weeks followed by a period of rest. More courses are then prescribed if sufficient clearing is not achieved. For the majority of patients, one course is all that is needed. About 20% of patients require a second course.

The most serious side effects of this drug are miscarriage and severe birth defects in babies whose mothers took the medication while pregnant. It can also cause elevated blood fats (triglycerides) and damage to the liver. Your doctor may recommend certain blood tests to check for these problems (and to make sure you are not pregnant) if you are given oral retinoids. Depression and suicidal thoughts have been reported while taking oral retinoids.
Oral Contraceptives - Birth control pills

Oral contraceptives are often prescribed for hormonal acne. While only Ortho Tri-Cyclen and Estro-Step are currently approved by the FDA for this indication, experts agree that low-dose contraceptives improve acne regardless of which formula is used.

Oral contraceptives have been shown to effectively clear acne in women by suppressing the overactive sebaceous glands and can be used as long-term acne therapy. However, oral contraceptives should not be prescribed to women who smoke, have a blood-clotting disorder, are older than 35 or have a history of migraine headaches - without the advice of a gynecologist.

It is important to know that in some cases birth control pills may make acne worse.
Other Topical Medications

Azelaic acid
Azelaic acid, naturally occurring in the skin, is used to treat mild to moderate inflammatory and non-inflammatory acne. It is believed that azelaic acid clears acne by reducing the populations of P. acnes, decreasing the abnormal shedding of skin cells and reducing inflammation. This medication has also been proven to be effective in treating the dark spots that develop in some acne patients with skin of color.

Azaleic acid is well tolerated by most people and can be safely used for years. Side effects may include skin dryness and lightening of the skin where applied.

Azelaic acid is as effective as tretinoin and may have even more beneficial effects when used with tretinoin.

Benzoyl peroxide
Benzoyl peroxide is a good choice for people with mild acne. It works by killing bacteria P. acnes. However, it does not have anti-inflammatory properties. It is available in a wide range of strengths and can be found as a gel, lotion, cleanser, cream and wash. All strengths are available without a prescription.

Many acne preparations include benzoyl peroxide because research shows that benzoyl peroxide increases the effectiveness of some medicines, such as erythromycin and clindamycin. When used in combination with antibiotics, benzoyl peroxide also reduces the likelihood of developing resistance to the antibiotic.

The most common side effects are skin irritation, the potential to bleach hair and fabrics as well as possible allergic reaction.

Salicylic Acid
Salicylic acid belongs to a group of medicines known as keratolytics. It helps slow down shedding of the cells inside the follicles, preventing clogging. Salicylic acid also helps break down blackheads and whiteheads. All strengths are available over-the-counter.