Acne Vulgaris is the most common skin problem encountered in most dermatologic practices throughout the world. It is an important part of our practice. We have a special academic interest in this condition with over 60 papers studying various aspects of this disease, from the use of benzoyl peroxide to the uses of lasers and light devices to treat this challenging condition.* Please feel free to visit the articles and lectures posted under the acne vulgaris and laser reference sections of our website to review our educational activities and investigations into this problem.
Causes of Acne
Acne Vulgaris is characterized by an abnormality of the hair follicle unit on the face, chest, and back and by comedones which can appear as blackheads and non-inflamed papules. These lesions arise from hormonal stimulation of the sebaceous glands associated with the hair follicle. This can cause an overgrowth of the skin cells lining the ducts. This proliferation and sebum over-production results in a plugged gland visible as a blackhead or invisible as a micro comedone. There are resident bacteria on the surface of the skin and in the follicle. The primary organism is p-acnes which is an anaerobic bacteria. In other words, this bacteria prefers to grow in the oxygen-deprived environment of the comedone. When this occurs, our body’s immune system steps into action creating an inflamed papule that is also known as a pustule or “zit”. In some instances, there is such an intense inflammation that a large cyst can form. This inflammatory aspect of acne is extremely important to control since it can lead to scarring.
Acne Treatment options
Treating acne involves the use of multiple products in combination to address the key pathophysiologic elements of sebaceous gland hyperactivity, comedone formation and inflammation elicited by p-acnes.* One of the important cornerstones of acne treatment is benzoyl peroxide also known as BPO.* This product is a highly oxidating agent which directly kills p-acnes and does not involve the use of an antibiotic where resistance can develop.* In fact, chronic use of an antibiotic as a single agent does invariably lead to resistance. However, when used in combination with BPO, resistance is prevented despite continued use of the antibiotic.* I have been active in imploring the FDA to ban the use of topical antibiotics alone since this can lead to the proliferation of bacteria like MRSA, which are a health care nightmare. We have done many clinical studies with the use of BPO and clindamycin in the treatment of acne vulgaris and find this an important part of combination therapy. Please refer to the chapter which we wrote on benzoyl peroxide if you desire more information on this product. We have also included an article on resistance in acne vulgaris.
Topical retinoids are another important pillar in the treatment of acne vulgaris.* Their primary action is to normalize skin growth in the follicular skin ducts thereby permitting the free flow of sebum or oil from the sebaceous glands through the constricted ducts to the surface of the skin.* This prevents the over proliferation of p-acnes and many of the aspects of inflammatory acne characterized by pustules or pimples.* Topical retinoids also have anti-inflammatory properties.* While we use these sometimes as single agents, they are best used in combination with benzoyl peroxide and clindamycin. We have done numerous clinical studies that have demonstrated enhanced efficacy by the use of these combined agents not only for inflammatory acne but also comedonal-acne.
There are many instances of moderate to severe acne where topical therapy is just not adequate. In those instances, we rely upon the oral tetracycline derivatives particularly minocycline and doxycycline.* These agents have a direct effect on p-acnes which is an important part of treating this type of inflammatory acne.* Recent research has also characterized anti-inflammatory properties of tetracycline-like antibiotics on the immune system. It is likely that both mechanisms are important in acne vulgaris.* It is not uncommon to use these systemic antibiotics for many months and sometimes years. While we are concerned about bacterial resistance we are hopeful that the use of benzoyl peroxide and the anti-inflammatory uses of these drugs will prevent this from being a significant problem.* Our goal is always to eventually taper off systemic and topical antibiotics. Topical retinoids are the best for long-term maintenance therapy.*
In some cases, particularly those with cystic acne, topical and systemic therapies are not adequate. However, even in cystic acne, the topical use of BPO and clindamycin with a potent topical retinoid and the systemic use of minocycline is extremely useful.* We have done a clinical study using these agents in combination and have found that with reliable use over 3 months many cases of cystic acne can be controlled.* In some cases, these agents are not enough and Isotretin also known as Accutane is an important part of treatment.* The problems with this drug are well known and include birth defects, mood changes, dryness, acne flares, and other side effects. These issues are controllable and this class of drugs remains an important part of our treatment of severe acne.* It would be important to view the i-pledge program online if you have more questions about the regulatory aspects of this drug.
Women with Adult Acne
Another important patient subset of acne vulgaris are women with adult acne. This can be seen in women who are in their 20s, 30s, 40s, and even 50s. It is often characterized by inflammatory lesions, particularly around the mouth and chin areas. There are often hormonal triggers for adult-onset acne. The drugs listed above are useful as topical agents.* However, topical retinoids are often difficult to use around the mouth due to the over absorption of topical retinoids causing a drying of the area. BPO/clindamycin and topical dapsone can typically be used effectively in this patient group.* Hormonal therapies, particularly birth control pills with despirdone, do have a place in blocking the effect of testosterone on sebaceous gland overactivity.* If a female is not considering conception spironolactone can also be used. The chronic nature of this condition can be frustrating, but the above therapies can be helpful in the treatment.
Many individuals have discussed the use of lasers, lights, and photodynamic therapy. These therapeutic modalities can be helpful, but they do not have the track record that our topical and systemic agents have demonstrated over many years of use. We have done studies using some of these devices. They are useful initially over the first number of weeks.* After a period of 2-3 months, the topical therapies and systemic agents can have a much more reliable and profound effect.* We do hope that photodynamic therapy with a deeper penetrating red light aimed at eliminating the overactive sebaceous glands will some day provide help for those with cystic acne.* However, at this time our pharmacologic agents remain the cornerstone of therapy.
If you need acne treatments please contact our office by calling 916.454.5922 or completing the contact form on the left side of this page.