Acne is the most common dermatological problem and acne treatment is the most common treatment dermatologists are asked to provide.
Acne may appear on the face, chest, back and buttocks. Every area identified with acne requires special treatment.
Topical acne treatment is ideal for mild, common, puberty acne and pregnancy acne. It is also administered as adjuvant to systemic treatment. Facial acne responds better to treatment than acne that is situated on the torso. The topical agents used to treat acne are mostly antimicrobial or keratolytic, and limit keratinization of the pilosebaceous pore.
Acne treatment with benzoyl peroxide
Benzoyl peroxide is an effective antimicrobial and comedolytic agent for treating acne. It is available in strengths of 5% and 10%. It may cause skin irritation, so treatment must be initiated using low concentrations of benzoyl peroxide and applied every other night, to enhance patient’s tolerability. Acne pimples gradually subside within a few weeks.
Retinoic acid is used in acne treatment as a keratolytic agent, because it accelerates cell mitosis on the basal stratum, epithelial alternation and the breaking down of comedones. It causes inflammation, which is not acceptable to some patients. It is recommended for non inflamed acne pimples, such as blackheads.
Sulfur, salicylic acid and resorcinol
Resorcinol, which is often used in acne treatment in combination with salycilic acid and sulfur, is believed to act as a keratolytic agent with beneficial effects on facial acne pimples.
Benzoyl peroxide is one of the most widely used topical antibiotics in acne treatment, together with clindamycin, erythromycin and tetracyline. The last two, however, are not as effective as clindamycine. In the past, neomycine and chloramphenicol were also used in acne treatment in combination with preparations that contained sulfur and a less potent corticosteroid. However, their use was questioned due to possible side effects they could cause.
Sometimes, preparations that contain drug combinations, also contain less potent corticosteroids. Although steroids should not be used as a monotherapy for the treatment of acne, it is true that they do limit the inflammatory reactions of the keratolytics, and thus their use is allowed. Topical antibiotics are recommended for inflamed acne pimples.
Azelaic acid has a predominant position in acne treatment. It inhibits cell proliferation in the corneal (horny) layer of the epidermis and normalizes the skin differentiation processes that have been impaired by acne. Moreover, azelaic acid significantly reduces the growth and activity of the bacterium Propionibacterium acnes, as well as the free fatty acid fraction of the epidermal lipids. It reduces facial acne without causing irritation.
Many patients have observed that their acne improves during the summer months. Adequate doses of UV B light are used to treat acne by inducing mild erythema that leads to skin exfoliation.
If acne does not subside with topical treatment, it might require systemic therapy.
Systemic administration of antibiotics
Antibiotics are the cornerstones in acne treatment, as they cause reduction of free fatty acid concentration in the sebum via the inhibition of bacterial lipases. Moreover, they reduce acne inflammation as they inhibit the neutrophil chemotactic activity.
Systemic acne treatment is usually initiated with a tetracyline, such as oxytetracyline. Patients with acne who are unresponsive to tetracycline can use minocyline. Other alternative medications include erythromycin and trimethoprim. Systemic antibiotics for acne treatment should be administered for at least three months, or more, because acne is a chronic disease that antibiotics manage to control until the acne pimples on face, chest, and back subside.
Hormonal acne treatment
Hormonal acne treatment primarily involves high-dose estrogen treatment, namely contraceptive pills containing 50 mg ethinylestradiol, which have a beneficial effect on adult women acne with marked acne flares before menstruation.
On the contrary, progesterone contraceptives may induce a flare up on this type of acne pimples and should thus be avoided. Moreover, a combination of antiandrogens and estrogens is often used to treat acne. Low doses of cyproterone acetate are usually used to limit the conversion of testosterone to a very potent androgen, dihydrotestosterone, which, in combination with ethinylestradiol, limits sebum production.
This acne treatment is ideal for women who already use oral contraceptives.
Treatment with Systemic retinoids
An innovative acne treatment in the 1980’s was the 13-cis retinoic acid. While it was widely accepted that vitamin A had beneficial results in treating acne, the side effects caused by the therapeutic dosage were not acceptable. 13-cis retinoic acid (Roaccutane) is an active, but less toxic synthetic derivative of Vitamin A, that improves and eliminates acne pimples causing 90% reduction of sebum secretion within a period of one month, and limiting bacteria present in acne, especially Propionibacterium ances, both on the skin’s surface and on the pilosebaceous pore.
It reduces the obstruction of the pore’s parietal cells and limits inflammation and chemotaxis. The most impressive characteristic of 13-cis retinoic acid, from a pathological point of view, is that it reverses the sebaceous glands to their prepubertal state. This is not achieved by its hormonal effect, but with its significant effect on the growth and differentiation of the epithelium.
Today, it is the drug of choice for treating cystic acne, non responsive to treatment acne, and scarring acne. The results from the treatment with the 13-cis-retinoid acid are not immediate. Acne pimples start to subside within 6 weeks. Many patients report that it is the best acne treatment they have ever tried, especially since they continue to see improvement even after the end of treatment. A full treatment cycle usually suffices. All patients develop skin dryness, especially on the lips (cracked lips), but it is not so severe to require treatment discontinuation. Moreover, nosebleeds may be observed, but only in patients with relative susceptibility.
In some cases of acne treatment with retinoids, patients, especially adolescents, report joint pains and muscle pains. Headaches, and benign intracranial hypertension, might also occur, which is a contraindication for further use of treatment. A rare adverse reaction of acne treatment with retinoids is the diffuse interstitial skeletal hyperostosis (”DISH”). 13-cis-retinoic acid causes temporary hyperlipidaemia, and as it is metabolized in the liver, it is recommended that blood lipid tests and liver function tests be performed before the initiation of treatment.
Teratogenecity is the most significant adverse reaction caused by retinoid acne treatment, so patients must always use contraception, and continue its use for at least three months after the end of treatment. Acne pimples usually completely resolve, and do not reappear.
Other specific acne treatments
Treatment of acne with intralesional steroid injection (triamcinolone). Large and inflamed cysts are completely evacuated of cyst fluid and then injected with a small amount of triamcinolone solution.
Surgical treatment of cystic acne. Unsightly scars and persistent cysts may be excised when they are no longer inflamed.
Acne Treatment with Fractional Laser CO2. Acne pimples and unsightly scars may significantly improve with fraction laser CO2, which, by inducing minor epidermal injuries stimulates new collagen and elastin production by the fibroblasts, thus leading to significant skin rejuvenation. It is an innovative and safe treatment for acne and acne scars.
Acne treatment with chemical peels. Acne marks and unsightly scars may improve with chemical peels. This form of treatment induces a controlled chemical “burn” aiming in epidermal exfoliation, i.e., in removing its outer layer. The preferred chemical peels for active acne include salicylic acid, lipohydroxy, and azelaic acid, with very good results. Their effect in pimple reduction is immediate. For acne scars, deeper chemical peels, such as Trichloroacetic acid (TCA), are preferred.
Acne treatment with deep facial cleansing. The dermatologist can significantly reduce acne sebum and facial pimples after a thorough facial cleansing using a special tool, the comedo-extractor. Deep cleansing is not only a treating method for acne but also a preventive one.
Acne treatment with autologous – PRP and stem-cells mesotherapy. It has been found that apart from its impressive healing properties, PRP also has antimicrobial properties, reduces acne pimples and repairs tissue damage. PRP can be applied as a monotherapy or in combination with fractional laser (Total Plasmalift).
Photodynamic therapy for acne (PDT). It is an active acne treatment that uses the effect of light emitted by a Peterson lamp. Following thorough cleansing of the skin, aminolevulinate acid is applied on the active “pimples”. Then light is emitted from the special lamp, causing a photochemical reaction that leads to the regression and treatment of active acne lesions. Two to four sessions are required at an interval of 15 days.