Types of Acne
Comedonal acne
Comedones are blackheads and whiteheads, which are associated with increased oil production on the nose, forehead, and chin (T-zone). This form of acne often develops in preteens and during the early teenage years. The treatment for this type of acne consists of a topical comedolytic agent. The standard choice is a retinoid such as Retin A (tretinoin cream or gel), which can unplug clogged pores. Newer topical retinoid medications include adapalene gel (Differin gel) and tazarotene gel (Tazorac gel). Retinoids exfoliate the skin to improve its texture, but can be associated with temporary side effects such as peeling, flaking, dryness, redness, and irritation. They can cause non-inflamed comedones to become inflamed. Patients should begin therapy using the lowest concentration possible and then increase as tolerated. Women who are pregnant or nursing should not use retinoids. It is also important to use a daily moisturizer with an SPF of 15 or greater when using retinoid acne medication. Tazarotene gel, which is available in two strengths, is the newest retinoid. It is helpful in very stubborn cases of comedonal acne. Users often apply it every other day, due to its frequent side effects of dryness, peeling, and irritation.
Alternative comedolytic agents include azelaic acid (Azelex cream), alpha-hydroxy acid products, and salicylic acid products, which are commonly found in over-the-counter astringents and acne cleansers/products.
Inflammatory acne
When a comedone ruptures and the body mounts an immune response against it, an inflammatory reaction occurs. Acne lesions get very red, with small pustules coming to heads in the centers of the acne bumps. This type of acne responds well to topical antibacterial solutions, gels, or lotions. Benzoyl peroxide is a very potent bacteria-killing agent. It is the gold standard of therapy for inflammatory and comedonal acne. It is available in many forms and concentrations, including cleansers, masks, gels, and pastes. Side effects include dryness, redness, peeling, irritation, and the possible staining of certain clothing.
Topical Treatments
Erythromycin and clindamycin are excellent topical antibacterial medications that are available as pads, solutions, lotions, and gels. These agents are used twice daily and help suppress the growth of a particular type of bacteria, which plays a role in the development of acne, called Propionobacterium acnes. Antibiotic resistance has been associated more frequently with erythromycin, and develops more often after prolonged use of antibiotics in low concentrations.
Additional topical antimicrobial medications to treat inflammatory acne include azelaic acid (Azelex cream) and sodium sulfacetamide/sulfur preparations. Azelaic acid was originally used to treat brown spots/hyperpigmentation. It is useful for comedonal acne as well as mild to moderate inflammatory acne. It can also help lighten blemishes and old acne marks. It shows no tendency to promote the development of bacterial resistance. It may tingle or sting when applied; this is usually transient or temporary and occurs generally during the first few weeks of treatment. It is very effective when used in conjunction with topical clindamycin (one-percent solution), and is also used twice daily.
Sodium sulfacetamide, when combined with sulfur, is found in topical medications such as Novacet and Sulfacet R. These products are useful in patients with rosacea, a type of acne in which patients have ruddy complexions and inflammatory acne. Sulfacet R is available in tinted or tint-free preparations. The tint has a color blender that helps cover up blemishes and dry up oily T-zones. These medications are not to be used in patients who are allergic to sulfonamide drugs. Klaron lotion does not contain sulfur, and is not as drying as Sulfacet R. It is helpful in patients with dry and/or more sensitive skin, and it is also an antimicrobial.
Systemic Treatment Options
In some patients, local, topical therapy is not enough for the adequate control of acne. In these cases, patients require systemic medications, usually in the form of pills, which treat the entire body as a whole. Systemic acne treatments include antibiotics (tetracycline, doxycycline, minocycline), oral retinoids (isotretinoin), and hormonal agents.
Antibiotics
Tetracycline is an oral antibiotic that has been used to treat acne for many years. It is anti-inflammatory, inexpensive, and is absorbed directly into the sebaceous glands and hair follicles, which are found below the skin where acne begins. Tetracycline can’t be prescribed to pregnant or nursing patients. Side effects may include: nausea, upset stomach, diarrhea, vaginal yeast infections, and sun sensitivity. It can stain the permanent teeth if given to a child under nine years of age. Tetracycline should not be taken with any milk products, isotretinoin (Accutane ), food, iron tablets, or antacids.
Doxycycline is similar to tetracycline, yet has superior absorption compared to tetracycline. It is associated with sun sensitivity in less than one percent of patients taking the drug. This photosensitivity can manifest itself with severe sunburn and possibly blistering. Patients taking doxycycline should try to avoid sun exposure and wear sunscreen daily.
Minocycline is also related to doxycycline and tetracycline. It is an oral antibiotic not associated with sun sensitivity. It is taken with food and is more expensive than either tetracycline or doxycycline. Side effects may include headaches, dizziness, upset stomach, nausea, vaginal yeast infections, and diarrhea. Less commonly, it can be associated with blue-black staining in the mouth or bruise-like marks on the legs and thighs. This unusual pigmentation from minocycline is usually reversible upon discontinuation of the drug. Rarely, in approximately two out of 100,000 patients, a lupus-like illness can develop with hepatitis. If patients taking minocycline don’t feel well, they should notify their physician immediately to get blood tests and a check-up.
Erythromycin is an anti-inflammatory oral antibiotic that, in certain forms, is safe to take if you are pregnant. However, if you become pregnant while taking antibiotics as acne treatment, you must notify your doctor as soon as possible. Bacterial resistance is more common with erythromycin, as is gastrointestinal upset, nausea, and diarrhea. It is available as coated tablets, which can be taken with meals to decrease the chances of an upset stomach.
Oral Retinoids
Isotretinoin (Accutane ) is a powerful anti-inflammatory systemic medication, which is usually prescribed for approximately five months. It is used in moderate to severe cases of acne and cases of cystic acne that have not responded to multiple treatments, such as topical or other oral medications. It decreases the size of oil glands and also decreases oil production. It can help prevent some future scarring and achieve a long remission of a patient’s acne. Some patients may initially get worse before they get better on isotretinoin therapy. Other patients may need a second treatment course if their treatment fails. In many patients, their complexions smooth out, their marks fade, and their acne resolves.
Side effects
There are many potential side effects of isotretinoin. First, you need to monitor certain blood tests each month because this drug can cause elevations of cholesterol, liver enzymes, and triglycerides. A physician should monitor the patient monthly to examine him or her and review any side effects he or she may have, such as dry eyes, dry facial/body skin, chapped lips, achy joints, dry nasal passages, wounds not healing properly, hair loss, headache, tendonitis, and decreased night vision, to name a few. Rarely, isotretinoin has been associated with bloody diarrhea, depression, suicide, pancreatitis, and swelling of the brain. The possibility of more extreme side effects is why it is so important to regularly see a physician while taking this medication.
Patients should not drink alcohol while taking isotretinoin and are more sensitive to the sun. Every day they should wear a sunscreen with an SPF of 15 or greater. It is also important not to take minocycline, tetracycline, or doxycycline together with isotretinoin. Women of childbearing potential must be counseled regarding the risks of birth defects and pregnancy on isotretinoin. A pre-treatment pregnancy test, as well as monthly pregnancy tests are done by your doctor. Two reliable methods of birth control are recommended to any woman who could potentially get pregnant while taking isotretinoin.
Localized Treatment
Cortisone injections
Intralesional cortisone (steroid) injections are extremely effective in reducing the pain, swelling, and redness of acne papules or cysts. The procedure involves a doctor or nurse injecting a very small amount of diluted cortisone solution into the pimple or cyst. In 24 to 48 hours, the pimple goes down significantly or goes away. The injection is painful and can sometimes result in a superficial dent if too much solution or too strong a concentration is injected. This dent usually resolves in many months, but it can be permanent.
Facials
Facials can be very helpful for deep-pore cleansing. An aesthetician should be well-trained and not leave skin marks (scars) or scabs afterward. Many blackheads and whiteheads can be extracted using acne masks, steam, and manual acne comedone removal (squeezing). Physicians and nurses can also remove whiteheads and blackheads with instruments called comedone extractors, which helps reduce the acne count significantly.
Astringents
Astringents and toners help dissolve oil residue on the oily T-zone areas and remove buildup of dead cells that clog pores. Many are available over-the-counter in pharmacies and stronger toners containing glycolic acid are sold in physicians’ offices. Acne cleansers are also helpful for exfoliating clogged blackheads and drying oily skin.
Hormonal Treatments
Many female patients have tried multiple over-the-counter and prescription acne medicines, and have seen numerous dermatologists, yet continue to break out well into their 20s and 30s. Some of these women may have androgenic acne, where their body produces higher levels of certain male hormones, which induce acne, oily skin, and even facial hair growth. Patients may also have a personal history of irregular periods, infertility, endometriosis, and excessive hair growth on the chest, abdomen, and face. Their acne tends to be more prominent over the chin, jawbone, and lower face. Premenstrual cysts are more common and tend to be painful.
Your doctor can order a hormonal panel of blood tests to see if you have any hormonal abnormalities. These hormonal abnormalities can be the cause of the acne. The treatment of women with this disorder is challenging. The first line of therapy is the birth control pill. The oral contraceptive contains estrogens, which suppress oil production, regulate menstruation, and suppress ovulation. Taking the Pill can help regulate hormonal abnormalities only while a woman is taking it. Once she stops the Pill, her hormonal problems return. Women receiving the Pill need to be counseled regarding its risks, as with any medication, and should be reminded by their gynecologists to have regular Pap smears and breast exams. OrthoTri-Cyclen is a popular birth control pill that was FDA-approved for the treatment of acne in 1996. If this treatment should fail, your dermatologist, gynecologist, or endocrinologist can prescribe other treatments that may be helpful.
Summary
Patients may suffer from various types of acne from their early teens into later adulthood. Fortunately, there are many treatment options for acne. Many times, patients have tried numerous topical medications and need to take oral medication to finally control their acne. There are several topical and systemic medications that can successfully treat acne. It is important to use your acne medicine exactly as directed in order for it to work effectively. Another critical factor to treating acne successfully is having a good rapport with your dermatologist. |
