Treatment of Acne

What is acne?

Acne vulgaris: a chronic condition linked to the onset of puberty

Not a physical threat;However, acne may have a significant

negative psychological effect: low self esteem, social phobia and depression;

Epidemiology of Acne

Universal incidence;85% of those between 15-24 years;Males: 12-18 and females: 15-17Papular lesions: mid-teens, nodular

lesions: late teens;Males: clears by mid 20s. In females: 3rd or

4th decades and may worsen during menopause

Pilosebaceous Unit: most commonly on face, chest and back

Anatomy and Physiology of skinPilosebaceous unit=hair follicle + sebaceous gland

Etiology of Acne

1. Abnormal keratinization of the epithelial cells in the infindibulum;

2. An increase in sebum production;

3. An accelerated growth of Propiobacterium acnes;

4. The occurrence of inflammation;

Exacerbating Factors for Acne

Several factors are known to exacerbate existing acne or cause periodic flare-ups of acne in some patients;

Some may have control over, while others not (e.g. heredity);

Factors: environmental and physical factors, cosmetic use, hormonal factors and medication use

Environmental & Physical

1. Hydration: decreases size of duct orifice and prevents loosening of comedone. e.g. high humidity environment or prolonged sweating and occlusive clothing

2. Irritation and friction (acne mechanica): may increase symptoms of acne. E.g. occlusive clothing, headbands, helmets, resting chin or cheek on hand etc

3. Occupational acne: exposure to dirt, vaporized cooking oils, or certain industrial chemicals

Cosmetic Use

Acne cosmetical mild form of acne on the face, cheek and chin;

Typically: closed, non-inflammatory comedones; Occurs as a result of using oil-based products

on the skin that causes occlusion of the pilosebaceous unit;

Oil-based cosmetics may exacerbate acne or even induce it;

Moisturizers or tanning oils may contain comedogenic oils (e.g. lanolin, mineral oil, cocoa butter)

Pomade acne Comedo extractor

pustulePustules (purulent nodules)

Rosacea

Emotional FactorsSevere or prolonged periods of stress may

exacerbate acne; however they do not induce acne!

Mechanism is not known

Hormonal FactorsMany women with acne experience a premenstrual

flare-up of symptoms (i.e. ovulation, pregnancy). OCP with high androgenic progestin are implicated

in the production of acne

Medication Use

P

I

M

P

L

E

S

Isoniazid

Phenobarbital

Lithium

Ethionamide

Steroids

Phenytoin

Moisturizers

Unsubstantiated Etiologic Factors

Little evidence supports link between: diet and acne;

A rule of thumb: people should be advised to avoid any particular food that seems to exacerbate their acne;

Excessive scrubbing in attempt to open blocked pores may exacerbate rather than improve acne

Pathophysiology of Acne

Abnormal keratinization of the cells in the infundibulum results in obstruction of the follicle with impacted cells and sebum to form a plug;

This plug will distend the follicle and form a microcomedone

Microcomedone is the initial pathologic lesion of acne

Microcomedone

Pathophysiology of Acne

As more sebum accumulate, the microcomedone enlarges and becomes visible as a closed comedo, or white head

The whitehead: is a small pale nodule just beneath the skin surface that may form a precursor for other acne lesions

An open comedo (blackhead) occurs: when the desquamated epithelial cells and sebum accumulate behind the plug and the orifice of the follicular canal becomes distended, allowing the plug to protrude

The tip of the plug may darken because of melanin NOT dirt;

Closed comedone (whitehead)

Open comedo (blackhead)

Pathophysiology of Acne Increase in the level of circulating androgens

stimulates production of sebum, which is prevented from reaching the skin surface by the obstructing plug;

At same time; P. acnes colonizes the pilosebaceous duct;

Bacterial colony counts are higher in patients with acne than in those without acne

P. acnes: major contributor to causing inflammatory acne lesions lipase: breakdown of sebum to highly irritating free fatty acids

The resultant inflammation: localized tissue destruction

Pathophysiology of Acne

Inflammatory acne begins with closed comedones that distend the follicle, causing the cellular lining of the walls to spread and become thin;

Primary inflammation results from disruption of the epithelial lining + lymphocyte infiltration

A severe inflammatory reaction happens if the follicle wall ruptures spontaneously or is ruptured by picking, squeezing, or attempted expression with a comedo extractor

Pathophysiology of Acne

Contents are discharged into surrounding tissue: abscesses scars or pits after healing

Pustules or purulent nodules of inflammatory acne are more likely to cause scarring than those of non-inflammatory acne

Pits

“I know you're never supposed to squeeze a zit, but I'm not about to leave the house with a major eruption on my face. Isn't there any good way to pop it?”

!!!!!

Can I pop a pimple?

Opinion differs (Some say popping a pimple can scar, others say it can't scar)

Most: lancing and gently squeezing pimples that are at the surface and white will usually not lead to scarring.

However, trying to squeeze and pop a pimple which is still below the surface may lead to major problems.

!!

Signs and Symptoms of Acne

Non-inflammatory acne is characterized by whiteheads or blackheads

Inflammatory acne is characterized by pimples (i.e. small, prominent inflamed elevations of the skin) which may rupture to form a papule

Papules are inflammatory lesions appearing as raised, reddened areas on the skin, which may enlarge to form pustules

Pustules appear as raised reddened areas filled with pus

pimple

Papule

pustuleblackheads

whiteheads

Signs and Symptoms of Acne

More extensive penetration into surrounding and underlying tissue produces necrotic purulent nodular lesions (previously designated as cysts), and may lead to pitting or scarring if untreated

Typical acne patient presents with a combination of lesions: comedones (open and closed), papules and pustules

Usually found on the face, chest and back (sometimes on neck and upper arms too)

Very severe acne, cystic acne, acne conglobata

Classification of AcneGrade of Acne

Qualitative Description

Quantitative Description

I Comedonal acne Comedones only, < 10 on face, none on trunk, no scars, noninflammatory lesions only

II Papular acne 10-25 papules on face and trunk, mild scarring, inflammatory lesions < 5 mm in diameter

III Pustular acne More than 25 pustules, moderate scarring, size similar to papules but with visible purulent core

IV Severe persistent pustulocyctis acne

Nodules or cysts, extensive scarring, inflammatory lesions > 5 mm in diameter

- Recalcitrant severe cystic acne

Extensive nodules/cysts

Treatment of Acne

Non-pharmacologic therapyCleansing of SkinMinimize Exacerbating factors

Pharmacologic Therapy

Pharmacologic Therapy

Benzoyl PeroxideSalicylic acidSulfurSulfur-Resorcinol combination

products

Benzoyl Peroxide

Available in variety of concentrations (2.5%, 5% and 10%) and dosage forms (lotions, gels, creams, cleansers, masks and soaps);

MOA: (1) irritation & desquamation-prevents closure of pilosebaceous duct. Incerase turnover rate of epithelial cells. (2) Oxidizing potential-antibacterial activity, decreasing P.acnes

Safety studies are ongoing

Benzoyl Peroxide

The most effective and widely used OTC drug for non-inflammatory acne;

Clinical response to all concentrations is similar in reducing the number of inflammatory lesions

Different formulations are not equivalent: alcohol gel is superior to lotion of the same concentration;

Washes and cleansers: have little or no comedolytic effect

New formulation: phospholipid liposomes (not commercially available) promise for papulopustular acne

Benzoyl Peroxide

Adverse Effects: excessive dryness, peeling, some skin sloughing, erythema or edema lower concentrations must be used for shorter duration

Stinging/burning: nor alarming unless persist or worsen

Precautions: (1) bleach hair, clothes, bed linens, (2)avoid excessive sun or sunlamps, (3) alcohol-based products (e.g. after shave lotion)( may exacerbate stinging/burning

Salicylic Acid

Available in wide range: 0.5%-2%A milder, less effective alternative for

teretoinMOA: acts as a surface keratolytic, mild

comedolytic agentWhen used in cleansing preparations:

adjunctive treatment

SulfurKeratolytic and antibacterial (precipitated or

colloidal) 3%-10%Generally: accepted as effctive in promoting

the resolution of existing comedones, but, on continued use, may have a comedogenic effect

Alternative forms of sulfur: Na thiosulfate, Zn sulfate, Zn sulfide NGRSE

Applied in thin film to skin 3 times dailyHave noticeable color and odor

Sulfur-Resorcinol combination3-8% sulfur with resorcinol 2% (enhances

the effect of sulfur)MOA: keratolytics, fostering cell turnover

and desquamationResorcinol produces a reversible dark

brown scale on some darker-skinned individuals

Therapeutic ComparisonBenzoyl Peroxide Salicylic Acid Sulfur

Bactericidal Yes - -

Keratolytic - Yes Yes

Comedolytic - Yes Yes

Concentration 2.5%-20% 0.5%-2% 2%-10%

Frequency of use 1-2 times daily Used mainly as cleanser, then rinsed off

1-3 times daily

Adverse effects Bleached hair and clothing

Potent keratolytic at high concentration

Color, unpleasant odor

Product Selection Guidelines

Cosmetic appearance may influence compliance

Cleansers (bars, liquids, suspensions, lotions, creams, gels, and pads/wipes) are not of much value (WHY?)

Lotions & creams with low fat content are intended to counteract drying (astringent effect) and peeling (keratolytic effect): alternative to more effective gels for dry sensitive skin or during winter weather

Patient Education:

The goal of self-treatment is to control mild acne, thus preventing more serious form from developing

Acne usually goes away on its ownSymptoms can usually be managed with

diligent and long term treatment Best approach is use cleansers and

medications to keep skin ducts and orifices open

Patient Education:

Cleanse skin thoroughly but gently at least twice daily to produce a mild drying effect that loosens comedones, using soft wash cloth, warm water and facial soap without moisturizing oils

To prevent or minimize acne flare-ups, avoid or reduce exposure to environmental factors, such as dirt, dust, petroleum products, cooking oils or chemical irritants

Patient Education:

To prevent friction or irritation that may cause acne flare-ups, do not wear tight-fitting clothes, headbands, or helmets, avoid resting the chin on the hand;

To minimise acne related to cosmetic use, do not use oil based cosmetics and shampoos

Patient Education:

To prevent excessive hydration of the skin, which can cause flare-ups, avoid areas of high humidity and do not wear tight fitting clothes that restrict air movement;

Try to maintain proper diet, although a link between diet and acne is not found;

Avoid stressful situations. Stress may play a role in acne flare-ups but it does not cause acne

Selected websites for acne information

www.aad.orgwww.acne.orgwww.derm-infonet.com/acnenetwww.facefacts.comwww.fda.govwww.nlm.nih.gov/medlinepluse/acne.htmlwww.rosacea.orgwww.Skincarephysicians.com/acnenetwww.holisticonline.com/remedies/Acne.htm

Glossary:

Comedo: A plug of keratin and sebum within the dilated orifice of a hair follicle, frequently containing the bacteria Propionibacterium acnes, Staphylococcus albus and Pityrosporon ovale, also called blackhead.

Propiobacterium acnes: a gram positive anearobic rod found on the skin

Pustule: a vesicle or an elevation of the cuticle with an inflamed base, containing pus.

Glossary:

Blemish: Any mark of deformity or injury, whether physical or moral; anything; that diminishes beauty, or renders imperfect that which is otherwise well formed

Pimple: Any small acuminated elevation of the cuticle, whether going on to suppuration or not

Papule: A small circumscribed, superficial, solid elevation of the skin