Acne Treatment- Dermatology, Pediatrics

Acne, or otherwise known as Acne vulgaris, is a chronic inflammatory skin condition that affects the pilosebaceous unit, which comprises the hair follicle, hair shaft, and sebaceous gland. Acne is often seen in adolescents and young adults (ages 12-25) with a prevalence of 85%, however, it can also affect older adults. Acne is caused by several factors: (1) increased sebum or oil production by the sebaceous glands, (2) the presence and activity of bacteria (C. acnes), (3) follicular epidermal hyperproliferation, and (4) inflammation. This means that treatments should be able to target all of these factors in order to have a more successful result.

Skin findings in Acne

The face, back, chest, and shoulders are the most common sites of acne. Acne is characterized by several lesion types:

• Comedones
  • Open comedones (blackheads)
  • Closed comedones (whiteheads)
• Inflammatory lesions
  • Red papules, pustules (with pus), or nodules
• Oily skin
• Scarring
  • There are different types of acne scars: ice-pick, rolling, boxcar, atrophic, and hypertrophic scars. A patient with acne can have a combination of these types of scars.

Complications of Acne

Aside from potential scarring, acne lesions can leave red marks (post-inflammatory erythema) or dark marks (post-inflammatory hyperpigmentation) on the skin. These scars and marks can be a cause for having low self-esteem, and can be a source of anxiety, depression, or other psychological issues, especially in young people. Numerous studies have demonstrated that those affected by acne rate their quality of life as low.

Treatments for Acne

There is a wide variety of treatments available for acne with the following treatment goals:

• To decrease the activity of sebaceous glands
• To decrease proliferation of C. acnes
• To normalize skin cell shedding
• To reduce inflammation

A visit to your dermatologist can help decide which treatments best suit your needs. The usual treatment regimen consists of a combination of different kinds of treatment modalities. Your dermatologist will evaluate what kinds of acne lesions you have, as well as look for any dark or red marks and scarring, in order to provide the most suitable treatment for you.

1. Gentle skin care and cleansing

The value of gentle skin care and cleansing cannot be underestimated for any kind of skin condition, and this includes acne vulgaris. It’s best to use a gentle cleanser twice daily to clean the skin, followed by the acne regimen prescribed by your doctor. The use of sunscreens for sun protection and hypoallergenic, non-comedogenic moisturizers are also recommended.

2. Topical and oral retinoids

Retinoids aim to normalize the abnormal follicular epithelial differentiation that occurs in acne. This means that they aid in the exfoliation of dead skin cells, preventing them from building up in the hair follicles. Retinoids can be given in topical or oral formulation. Some examples of topical retinoids are tretinoin and adapalene, while the most commonly used oral retinoid for acne is isotretinoin.

3. Topical and oral antibiotics

Topical and oral antibiotics address the bacteria on the skin that can infect hair follicles. Some examples of topical antibiotics include benzoyl peroxide, erythromycin, and clindamycin. Benzoyl peroxide is one of the most commonly prescribed topical medications for acne because numerous studies show that bacteria are unable to build resistance against it. Oral antibiotics are also used especially if there are many inflamed lesions. Some examples that may be prescribed by your doctor are doxycycline, lymecycline, and minocycline.

4. Salicylic acid

Salicylic acid is a keratolytic agent – it helps in the exfoliation of dead skin cells in the surface of the skin.

5. Azelaic acid

Azelaic acid is used to treat mild to moderate acne. It has antimicrobial properties, and it also aids in the treatment of post-inflammatory erythema and post-inflammatory hyperpigmentation. It helps reduce the redness brought about by inflammation, and also targets dark acne marks. Azelaic acid is also used to treat acne in pregnant patients.

6. Hormonal therapy

Hormonal therapies are most often used to help women with hormonal problems such as Polycystic Ovary Syndrome. They target excess sebum production caused by the effect of androgens on the sebaceous glands.

Procedural Treatment for Acne

1. Acne surgery

Acne surgery makes use of an instrument called a comedone extractor. The purpose of this procedure is to remove comedones and pustules so that these individual acne lesions can involute.

2. Subcision

Subcision is a procedure best used for rolling acne scars. A hypodermic needle is inserted into the edge of a scar to the underlying area of the scar tissue. The needle is guided to move under the scar to loosen the fibrotic adhesions. This will result in collagen formation as the wound heals, helping the scar to become level with the rest of the surface of the skin.

3. Intralesional steroid injections

Intralesional steroid injections are used as an anti-inflammatory agent in acne. Injecting large, nodular lesions will give relief from pain and reduce the size of the breakout.

4. Chemical peels

Chemical peels cause the skin to peel off, allowing new skin to develop. It can address problems with pigmentation as well. Some of the most common chemicals used in acne include tricholoracetic acid (TCA) and glycolic acid.

5. Phototherapy

In the treatment of acne, UV radiation is thought to possibly have anti-inflammatory benefits. A combination of blue and red light is found to improve symptoms of acne.

6. Lasers

Lasers, such as the fractional CO₂ laser, are used to improve the appearance of acne scars. Multiple sessions are needed to see some improvement.

7. Dermabrasion

For larger atrophic scars, dermabrasion is used to remove the top layer of the skin causing redness and possibly some pain for several months. As the skin heals, some improvement in the appearance of the scars may be observed.

8. Microneedling

In microneedling, fine needles are used to puncture the epidermis. These little puncture wounds stimulate the release of growth factors and aid in collagen production, helping the epidermis heal quickly and remain intact.  It is used to treat acne lesions and acne scars.

9. Fillers

Dermal fillers are injected into acne scars to stimulate collagen production and improve its appearance.

Prognosis

Acne vulgaris is a chronic condition that usually lasts for several years. Spontaneous remission is expected in most cases, as a lot of patients experience clearing of their acne lesions by their 20s or 30s. However, in some cases, lesions can persist until adulthood. Other medical conditions (e.g. hormonal problems and PCOS) as well as other factors, such as family history and diet, also have to be taken into consideration when treating acne.

Take-Home Messages

As previously discussed, there are many treatment options available for acne. A visit to your dermatologist can help pinpoint specific problems and determine which treatment modalities are most suitable for you. Good compliance to your treatment regimen coupled with gentle skin care and sun protection can yield good results.

At Mya Care you can connect with the best doctors and healthcare providers for acne treatment. Our database includes hospitals and clinics in Croatia, Greece, India, Malaysia, Singapore, Slovakia, Spain, Thailand, UAE, Turkey, UK and USA.

References:

• Kang, S. (2018). Fitzpatrick’s Dermatology, Ninth Edition, 2-Volume Set (EBOOK). McGraw Hill Professional.
• Gollnick, H. P., Bettoli, V., Lambert, J., Araviiskaia, E., Binic, I., Dessinioti, C., Galadari, I., Ganceviciene, R., Ilter, N., Kaegi, M., Kemeny, L., López-Estebaranz, J. L., Massa, A., Oprica, C., Sinclair, W., Szepietowski, J. C., & Dréno, B. (2016). A consensus-based practical and daily guide for the treatment of acne patients. Journal of the European Academy of Dermatology and Venereology, 9, 1480–1490. https://doi.org/10.1111/jdv.13675
• Hayashi, N., Akamatsu, H., Iwatsuki, K., Shimada-Omori, R., Kaminaka, C., Kurokawa, I., Kono, T., Kobayashi, M., Tanioka, M., Furukawa, F., Furumura, M., Yamasaki, O., Yamasaki, K., Yamamoto, Y., Miyachi, Y., & Kawashima, M. (2018). Japanese Dermatological Association Guidelines: Guidelines for the treatment of acne vulgaris 2017. The Journal of Dermatology, 8, 898–935. https://doi.org/10.1111/1346-8138.14355
• Iraji, F., Sadeghinia, A., Shahmoradi, Z., Siadat, A., & Jooya, A. (2007). Efficacy of topical azelaic acid gel in the treatment of mild-moderate acne vulgaris. Indian Journal of Dermatology, Venereology and Leprology, 2, 94. https://doi.org/10.4103/0378-6323.31892
• Acne: Diagnosis and treatment. (n.d.). American Academy of Dermatology. Retrieved March 22, 2022, from https://www.aad.org/public/diseases/acne/derm-treat/treat
• Acne: Who gets and causes. (n.d.). American Academy of Dermatology. Retrieved March 22, 2022, from https://www.aad.org/public/diseases/acne/causes/acne-causes
• website. (19 C.E.). Acne - Complications  - NHS. Nhs.Uk. https://www.nhs.uk/conditions/acne/complications/
• Acne scarring  | DermNet NZ. (n.d.). DermNet NZ – All about the Skin  | DermNet NZ. Retrieved March 22, 2022, from https://dermnetnz.org/topics/acne-scarring

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