Most adolescents get acne, some more badly than others. These days there are a variety of ways doctors can treat the condition, so that the discomfort and embarrassment can largely be avoided......

Introduction

Between 85% and 100% of Americans will get acne sometime before they reach 24. Depending on its severity, acne can be a mild nuisance (the occasional 'zit') or a distressing, embarrassing condition affecting many aspects of the sufferer's life. In the last 20 years or so, new treatments have been introduced that allow physicians to offer a good likelihood of relief. However, using them to best advantage -- balancing effectiveness against possible side effects -- requires the doctor to know about them in some depth. Dr Susan Bershad of the Mount Sinai School of Medicine in New York has recently reviewed the various treatment choices available.

Acne -- what it is

Acne begins when skin pores, which are really openings or ducts leading to oil glands, become blocked by dead skin cells and natural oil, called sebum. The outward appearance at this stage is referred to as a comedo (pleural: comedones). Depending on the level of the blockage, comedones are called 'blackheads,' which are at the skin surface, or 'whiteheads,' located just beneath the surface. If a comedo becomes colonized with skin bacteria called Propionibacterium acnes , inflamed papules or pustules may form. These might eventually heal on their own, or they may enlarge, causing the ducts to rupture and form nodules, sometimes called acne cysts.

The most common sites for acne are the face and upper body. Acne is slightly more common and often worse in males, but it's more likely to persist into adulthood in females.

Although good hygiene and nutrition are important at all ages, contrary to popular wisdom they aren't very involved in causing acne. Rather, a surge in the production of male hormones (androgens) during adolescence and a hereditary tendency are the main culprits.

Management of acne

In the early stages, when whiteheads and blackheads are the main features, there is a great temptation for the sufferer to squeeze out the comedo. This should not be done -- it's likely to lead to infection, or excessive force causing scarring. A physician has a suitable tool -- a comedo expresser -- that allows the manually extraction of the comedones. This can be done every 3 to 6 weeks.

If necessary, medicated creams or lotions will be prescribed. Those that prevent the formation of one of the duct blocker substances -- keratin -- are useful. These agents are called 'comedolytics' because they dissolve comedones and prevent new ones. The most effective comedolytic medications are compounds related to vitamin A, termed retinoids. The original retinoid, tretinoin, has been in use for over 30 years. Usually retinoids are applied topically, but one called isotretinoin is given by mouth for severe acne.

Retinoids applied to the skin can cause irritation, and they also increase sun sensitivity. One of the newer retinoid gels contains tretinoin in microspheres (microscopic sponges), which are designed to release the medication slowly over time and cause less skin irritation. The two most recent retinoids, adapalene and tazarotene, can be more effective than tretinoin in some patients. Adapalene is less irritating than tretinoin, but tazarotene is about the same as tretinoin in causing skin dryness, peeling, and discomfort. Dr Bershad has found that tazarotene applied once or twice a day for only 2-5 minutes per application can produce a 50% reduction in comedones within 12 weeks. This method is much less irritating than the standard technique of leaving the retinoid on the skin overnight.

Inflammatory acne

When inflammation is present, meaning when red papules and pustules are seen, antibacterial medications are given, either in a topical gel, cream or lotion, or by mouth. Often an antibiotic preparation is applied in the morning and a comedolytic compound at bedtime. If necessary, the antibiotic can be applied twice during the day and the comedolytic agent at bedtime.

Benzoyl peroxide is a powerful anti-bacterial agent, which is available in prescription and over-the-counter gels, lotions, and cleansers. It reduces comedones as well as improving inflammatory acne. However, it may cause dry skin and have a bleaching effect on clothing. Occasionally, it causes allergic dermatitis.

Two other antibacterial drugs, clindamycin and erythromycin, are also commonly used in topical preparations for acne. A 1% clindamycin solution has been shown to be just as effective in treating inflammatory acne as a tetracycline capsule given orally twice a day. Benzoyl peroxide is sometimes combined with clindamycin or erythromycin, increasing their effectiveness.

Sulfur compounds and azelaic acid, found in other acne products, provide milder anti-inflammatory and comedolytic effects.

Oral antibiotics used for acne treatment include tetracycline, minocycline, doxycycline, erythromycin, azithromycin, and trimethaprim with or without sulfamethoxazole. Many physicians prescribe long-term oral antibiotic therapy for acne, but Dr. Bershad prefers full dosage for 2-3 weeks, and repeated if there is a flare-up. Possible side effects of oral antibiotic treatment are stomach upset, skin rash, yeast infection, dizziness, and an increased tendency to sunburn (phototoxicity).

Hormonal therapy may be considered in some cases, particularly in young women with monthly acne flare-ups -- because of the role of increased androgens. Several brands of oral contraceptive pills have been proven effective for acne. Another anti-androgen drug for use in women is spironolactone, which can be combined with an oral contraceptive. These treatments are not suitable for males.

According to Dr. Bershad, the latest trends in acne therapy are phototherapy (light treatments) and lasers. The FDA has recently approved an acne-clearing machine using high-intensity visible blue light. Light treatments are given in the doctor's office twice per week for about a month. Each treatment takes approximately15 minutes. Studies show an average of 70% acne clearing after 8 to 10 phototherapy treatments. The results may last for up to 6 months or occasionally longer. Treatments are painless, and there are no known side effects. The type of light used is similar to ordinary lightbulbs and doesn't involve ultraviolet or laser exposure.

Another new treatment for acne is the diode laser, which is FDA-approved for acne on the back and also for pitted facial acne scars. A study showed that scars improve about 50% after one treatment, but the beneficial effects may take several months to appear.

The new phototherapy and laser treatments are not as readily available as medications. In addition, they are costly, and medical insurance may not provide coverage. Many doctors who perform these procedures will provide estimates of their costs over the phone.

Severe acne

When acne is severe, with formation of cysts and nodules, there may well be some response to all the treatments described so far, but it's still not enough to make the patient comfortable. In such cases, oral isotretinoin (13-cis-retinoic acid) is the treatment of choice. It suppresses both of the duct-blocking agents (sebum and keratin). A full 20-week course produces significant improvement in about 80% of patients. The effect usually lasts at least 1 to 3 years, and some patients experience permanent improvement.

Finding the right dose of isotretinoin is important. Most physicians prefer to start low and increase the dose later, if necessary. Fairly common side effects include: dry, cracked skin or lips, occasional nosebleeds, dry eyes, patchy skin rashes, joint and muscle pains, increased blood lipids (triglycerides and cholesterol), and tendency to sunburn. Very rarely there can be symptoms of depression, although a clear cause-and-effect relationship hasn't been proven. Tetracyclines should not be given with isotretinoin, as they may increase the risk of headaches and sun sensitivity.

The major problem with isotretinoin is a risk of abnormalities to an unborn fetus, if the patient is pregnant. This means that all sexually active females considered for isotretinoin treatment must use reliable birth control and have 2 negative pregnancy tests before starting treatment. In addition, they are required to have negative pregnancy tests every month during isotretinoin therapy and for one month afterward.

For patients who don't achieve full improvement after 20 weeks of isotretinoin, a second course may be given after a drug-free interval of at least 8-weeks. Recurrence of acne is seen within 3 years in two-thirds of patients given isotretinoin, but only a third of these have it badly enough to require a repeat course of the drug.

Conclusions

Despite the abundance of treatments, acne is still a very common condition for several reasons: sufferers may not seek medical help, or the treatment is not well planned, or patients don't use their medications correctly. This last can be difficult - treatment must be applied to healthy-looking skin and continued when the condition is at its best, if it's to be fully effective.

In Dr. Bershad's view, acne management is an art as well as a science -- it requires excellent doctor-patient communication and cooperation. She recommends topical therapy alone when possible. Her opinion about unproven remedies found at health-food stores and cosmetic counters: avoid them, unless approved by your physician, because they may interfere with the treatment plan.

Oral antibiotics, hormonal therapy, phototherapy, and lasers are usually reserved for moderate to severe acne that doesn't respond to topical preparations. Isotretinoin is an extremely effective drug for severe acne, but its side-effect profile requires a lot of patient monitoring. The perfect drug for acne has obviously not yet been found.

Source

Topical acne drugs: review of clinical properties, systemic exposure, and safety. A. Akhavan, S. Bershad, Am J Clin Dermatol, 2003, vol. 4, pp. 473--92

The Modern Age of Acne Therapy: A review of current treatment options. SV. Bershad, Mt Sinai J Med, 2001, vol. 68, pp. 279--286

Links

• See ACNE.ORG links page

Everything You Need to Know About Acne: A Helping Book for Teens by Jennifer Ceaser