Acne Information

Acne Treatments

Learn about acne, causes, misconceptions and treatments defined.

Available treatments
There are many products sold for the treatment of acne, many of them without any scientifically-proven effects. However, a combination of treatments can greatly reduce the amount and severity of acne in many cases. Those treatments that are most effective tend to have greater potential for side effects and need a greater degree of monitoring, so a step-wise approach is often taken. Many people consult with doctors when deciding which to use, especially when considering using any of treatments in combination. There are a number of treatments that have been proven effective:

Exfoliating the skin
This can be done either mechanically, using an abrasive cloth or a liquid scrub, or chemically. Common chemical exfoliating agents include salicylic acid and glycolic acid, which encourage the peeling of the top layer of skin to prevent a build-up of dead skin cells which combine with skin oil to block pores. It also helps to unblock already clogged pores. Note that the word "peeling" is not meant in the visible sense of shedding, but rather as the destruction of the top layer of skin cells at the microscopic level. Depending on the type of exfoliation used, some visible flaking is possible. Moisturizers and anti-acne topicals containing chemical exfoliating agents are commonly available over-the-counter.

Topical Bactericidals
Widely available OTC bactericidal products containing Benzoyl peroxide may be used in mild to moderate acne. The gel or cream containing benzoyl peroxide is rubbed, twice daily, into the pores over the affected region and primarily prevents new lesions by killing P.Acnes. Unlike antibiotics, Benzoyl peroxide has the advantage of being a strong oxidiser (essentially a mild bleach) and thus does not appear to generate resistance. However, it routinely causes dryness, local irritation and redness. A sensible regimen may include the use of suitable non-comedogenic moisturisers to help avoid overdrying the skin.

Other antibacterials that have been used include triclosan, or chlorhexidine gluconate but these are often less effective.

Topical antibiotics
Externally applied antibiotics such as erythromycin, clindamycin or tetracycline aim to kill the bacteria that are harbored in the blocked follicles. Whilst topical use of antibiotics is equally as effective as oral, this method avoids possible side effects of stomach upset or drug interactions (e.g. it will not affect the oral contraceptive pill), but may prove awkward to apply over larger areas than just the face alone.

Oral antibiotics
Oral antibiotics used to treat acne include erythromycin or one of the tetracycline antibiotics (tetracycline, the better absorbed oxytetracycline, or one of the once daily doxycycline, minocycline or lymecycline). Trimethoprim is also sometimes used (off-label use in UK). However, reducing the P. acnes bacteria will not, in itself, do anything to reduce the oil secretion and abnormal cell behaviour that is the initial cause of the blocked follicles. Additionally the antibiotics are becoming less and less useful as resistant P. acnes is becoming common. Acne will generally reappear quite soon after the end of treatment—days later in the case of topical applications, and weeks later in the case of oral antibiotics.

Hormonal treatments
In females, acne can be improved with hormonal treatments. The normal combined oestrogen/progestogen contraceptive pills have some effect, but the anti-testosterone Cyproterone in combination with an oestrogen (Diane 35) is particularly effective at reducing androgenic hormone levels. Diane-35 is not available in the USA, but a newer oral contraceptive containing the progestin drospirenone is now available with fewer side effects than Diane 35 / Dianette. Both can be used where blood tests show abnormally high levels of androgens, but are effective even when this is not the case.

External retinoids
Normalizing the follicle cell lifecycle. A group of medications for this are topical retinoids such as tretinoin (brand name Retin-A), adapalene (brand name Differin) and tazarotene (brand name Tazorac). Like isotretinoin, they are related to vitamin A, but they are administered as topicals and generally have much milder side effects. They can, however, cause significant irritation of the skin. The retinoids appear to influence the cell creation and death lifecycle of cells in the follicle lining. This helps prevent the hyperkeratinization of these cells that can create a blockage. Retinol, a form of vitamin A, has similar but milder effects and is used in many over-the-counter moisturizers and other topical products. Effective topical retinoids have been in use over 30 years but are available only on prescription so are not as widely used as the other topical treatments.

Oral retinoids
Reducing the secretion of oils from the glands. This is done by a daily oral intake of vitamin A derivatives like isotretinoin (marketed as Accutane, Sotret) over a period of 4-6 months. It is believed that isotretinoin works primarily by reducing the secretion of oils from the glands, however some studies suggest that it affect other acne-related factors as well. Isotretinoin has been shown to be very effective in treating severe acne and can either improve or clear well over 80% of patients. The drug has a much longer effect than anti-bacterial treatments and will often cure acne for good. The treatment requires close medical supervision by a dermatologist because the drug has many known side effects (which can be severe). About 25% of patients may relapse after one treatment. In those cases, a second treatment for another 4-6 months may be indicated to obtain desired results. It is often recommended that one lets a few months pass between the two treatments, because the condition can actually improve somewhat in the time after stopping the treatment and waiting a few months also give the body a chance to recover. Occasionally a third or even a fouth course is used, but the benefits are often less substantial. The most common side effects are dry skin and occasional nosebleeds (secondary to dry nasal mucosa). There are reports that the drug has damaged the liver of patients. For this reason, it is recommended that patients have blood samples taken and examined before and during treatment. In some cases, treatment is terminated due to changes in various levels of chemicals in the blood, which might be related to liver damage. Others claim that the reports of permanent damage to the liver are unsubstantiated, and routine testing is considered unnecessary by some dermatologists. Blood triglycerides also need to be monitored. However, routine testing are part of the official guidelines for the use of the drug in many countries. Some press reports suggest that isotretinoin may cause depression but as of September 2005 there is no agreement in the medical literature as to the risk. The drug also causes birth defects if women become pregnant while taking it or take it while pregnant. For this reason, female patients are required to use two separate forms of birth control or vow abstinence while on the drug. Because of this, the drug is supposed to be given as a last resort after milder treatments have proven insufficient. Very restrictive rules (IPledge Program) for use will be in force in the USA beginning in 2006.

Phototherapy
It has long been known that short term improvement can be achieved with sunlight. However studies have shown that sunlight worsens acne long-term, presumably due to UV damage. More recently, visible light has been successfully employed to treat acne (Phototherapy) - in particular intense blue light generated by purpose-built fluorescent lighting, dichroic bulbs, LEDs or lasers. Used twice weekly, this has been shown to reduce the number of acne lesions by about 64%; and is even more effective when applied daily. The mechanism appears to be that porphyrins produced within P. acnes generate free radicals when irradiated by blue light. Particularly when applied over several days, these free radicals ultimately kill the bacteria[12]. Since porphyrins are not otherwise present in skin, and no UV light is employed, it appears to be safe, and has been licensed by the U.S. FDA. The treatment apparently works even better if used with red visible light (660 nanometer) resulting in a 76% reduction of lesions after 3 months of daily treatment); and overall clearance was similar or better than benzoyl peroxide. Unlike most of the other treatments few if any negative side effects are typically experienced, and the development of bacterial resistance to the treatment seems very unlikely. After treatment, clearance can be longer lived than is typical with topical or oral antibiotic treatments, several months is not uncommon. However, the equipment or treatment is expensive, although portable home use equipment costs can be very much comparable to Benzoyl Peroxide/moisturiser/cleanser costs over a few years.

In addition, basic science and clinical work by dermatologists Yoram Harth and Alan Shalita and others have shown that intense blue/violet light (405-425 nanometer) can decrease the number of inflamatory acne lesion by 60-70% in 4 weeks of therapy, particularly when the P.Acnes is pretreated with delta-aminolevulinic acid (ALA), which increases the production of porphyrins.

Less widely used treatments
Azelaic acid (brand names Azelex, Finevin, Skinoren) is suitable for mild, comedonal acne.
Zinc. Orally administered zinc gluconate has been shown to be effective in the treatment of inflammatory acne, although less so than tetracyclines.

Insulin treatment - insulin treatment has been reported to work, although no big studies have been performed
Chromium - Chromium supplementation appeared to work in a small study.

Future treatments
Laser surgery have been in use for some time to reduce the scars left behind by acne, but research is now being done on lasers for prevention of acne formation itself. The laser is used to produce one of the following effects:

• to burn away the follicle sac from which the hair grows
• to burn away the sebaceous gland which produces the oil
• to induce formation of oxygen in the bacteria, killing them

Since lasers and intense pulsed light sources cause thermal damage to the skin there are concerns that laser or intense pulsed light treatments for acne will induce hyperpigmented macules (spots) or cause long term dryness of the skin. As of 2005, this is still mostly at the stage of medical research rather than established treatment.

Because acne appears to have a significant hereditary link, there is some expectation that cheap whole-genome DNA sequencing may help isolate the body mechanisms involved in acne more precisely, possibly leading to a more satisfactory treatment. (Crudely put, take the DNA of large samples of people with significant acne and of people without, and let a computer search for statistically strong differences in genes between the two groups). However, as of 2005 DNA sequencing is not yet cheap and all this may still be decades off. It is also possible that gene therapy could be used to alter the skin's DNA.

Preferred treatments by types of acne vulgaris
Comedonal (non-inflammatory) acne: local treatment with azelaic acid, salicylic acid, topical retinoids, benzoyl peroxide.
Mild papulo-pustular (inflammatory) acne: benzoyl peroxide or topical retinoids, topical antibiotics (such as erythromycin).
Moderate inflammatory acne: benzoyl peroxide or topical retinoids combined with oral antibiotics (tetracyclines). Isotretinoin is an option.

Severe inflammatory acne, nodular acne, acne resistant to the above treatments: isotretinoin, or contraceptive pills with cyproterone for females with virilization or drospirenone.

Also:
• About Acne
• adult acne
• Causes of Acne
• Acne Treatments
• Acne Scars
• Actinic keratosis
• Microdermabrasion

• Dermatology
• List of Dermatological Diseases
• Dermasurgery

This article is licensed under the GNU Free Documentation License.
It uses material from the Wikipedia article "Acne vulgaris".