effects of acne
both
physiological: in the form of scarring
AND
psychological: the presence of acne has been shown to be associated with lower self-esteem with a possible impact on quality-of-life
factors that influence the formation of acne
Genetics Androgenic hormonal triggers Excessive sebum production Alteration in the keratinization process Proliferation of P. acnes Resulting inflammatory processes
Development of clinical acne lesions is determined by the level of immune response, which is genetically determined
Exclusions for Self-Treatment
Moderate-to-severe acne
Exacerbating factors (drugs, mechanical irritation)
Possible rosacea
Non-Pharmacologic Treatment:
- Eliminating possible exacerbating factors
- Cleansing the skin with a mild soap or nonsoap cleanser twice a day
- Good hydration
- Changing dietary habits by eliminating or decreasing consumption on high-glycemic load foods (high sugars/carbohydates)
NOTE:
dehydration can increase inflammatory chemicals in the cells
abrasive products and/or excessive cleansing may worsen acne
OTC acne products
Benzoyl Peroxide- Bactericidal, slight keratinolytic
(wash, liquid, lotion, cream, gel)
causes bleached hair and clothes, drying, photosensitivity
Salcylic Acid-Keratinolytic, Comedolytic (lyses comedones)
(pads, cream, gel)
potent keratolytic at high concentration, drying, photosensitivity
Sulfur-Bactericidal, Keratinolytic, Comedolytic
(cream, lotion)
Causes color, malodorous, drying
All 3 are pregnancy category C
Gels and solutions:
Gels most effective because they are astringents and remain on skin longest. They have a drying effect which can cause contact dermatitis but this effect may be beneficial in patients with oily skin
Creams and lotions
Less irritating to skin and those with low fata content are intended to counteract drying and peeling. Alternatives to gel formulations and are recommended for dry or sensitive skin and for dry winter weather.
Ointments
Not used because they are occlusive and worsen acne
Bars and liquids
Medicated cleansing products are of little value since they leave inadequate active ingredient residue on the skin. – use non-medicated cleansers
Exacerbating factors in acne
- Local irritation or friction from occlusive clothing, headbands, helmets, or other friction-producing device
- Excessive contact between face and hands (resting the chin/cheek on hand)
- Occlusion by oil-based cosmetics, moisturizers, pomades, or other health/beauty products
- Exposure to dirt, vaporized cooking oils, certain industrial chemicals (coal tar, petroleum derivatives)
- Medications (PIMPLES): Phenytoin, Isoniazid, Moisturizers, Phenobarbital, Lithium, Ethionamide, Steroids. Others: azathioprine, rifampin, quinine
- Stress and emotional extremes
- High-humidity environments and prolonged sweating
- Hormonal alterations (pregnancy, medical conditions, medications)
- Genetics
General Approach to Acne Treatment
Identifying and limiting exposure to exacerbating factors
use the least aggressive treatment regimen that is effective while also avoiding treatments that encourage the development of bacterial resistance
Acne Treatment Goals
alleviate discomfort, control the lesions, prevent pitting or scarring, preventing new lesions from developing and minimizing adverse drug reactions using the least aggressive treatment regimen that is effective while also avoiding treatments that encourage the development of bacterial resistance
address as many age-appropriate pathogenic factors for acne development. This includes reducing sebum production, prevention of microcomedone formation, suppressing P. acnes and reducing the inflammatory process to prevent scarring.
There is only one single acne treatment, isotretinoin, which addresses all pathogenic factors, though most treatments will target more than one mechanism
Patient Acne Education
- It may take up to 8 weeks to see visible benefits of treatment
- Acne is a condition which will get worse before it gets better; peeling of the skin upon initial topical use may occur
- Hormonal therapy is an excellent treatment option of moderate to severe acne if also needed for gynecologic reasons
- Oral isotretinoin is contraindicated in pregnancy and requires extensive monitoring; visit www.iPledge.com
- If using tetracycline, separate from dairy products by 1-2 hours and use sunscreen to avoid photosensitivity
Comedonal treatment
Benzoyl Peroxide alone AND/OR topical retinoids alone
OR
BP/clinda OR
BP/adapalene OR (if those fail)
Clinda/tretinoin
If inadequate
add oral contraceptives (women only)
Still inadequate
Send to dermatologist
evaluate every 2-3 months once adequate treatment is found to determine need for maintenance or escalation
Mild Papulopustular Treatment
Benzoyl Peroxide alone AND/OR topical retinoids alone
OR BP/clinda OR BP/adapalene OR (if those fail) Clinda/tretinoin !!AND!! oral contraceptives (women only) OR systemic antibiotics
IF inadequate
Send to dermatologist
evaluate every 2-3 months once adequate treatment is found to determine need for maintenance or escalation
low strength recommendation: blue light and oral zinc
Moderate Papulopustular Treatment
oral contraceptives OR
systemic antibiotics
IF inadequate
Send to dermatologist
oral contraceptives (women only)OR systemic antibiotics
IF inadequate
Send to dermatologist
evaluate every 2-3 months once adequate treatment is found to determine need for maintenance or escalation
low strength recommendation: blue light and oral zinc
Severe Papulopustular/Nodular Treatment
Oral Isotretinoin
IF unwilling or can’t tolerate
Systemic antibiotics AND
topical BP +/- topical retinoid
OR
Systemic antibiotics AND oral contraceptives (women only)
If inadequate
See dermatologist
oral contraceptives (women only) OR systemic antibiotics
IF inadequate
Send to dermatologist
evaluate every 2-3 months once adequate treatment is found to determine need for maintenance or escalation
Or evaluate MONTHLY for isotretinoin
