Islamabad Clinic Address:
House 25A, Street 52, Sector F6/4,
Super Market, Islamabad, Pakistan
Tel : 92 51 8733552
92 51 8733553

 

Acne

Acne is one of the world’s most common skin conditions. It can produce lifelong physical and emotional scarring.

 

Pathophysiology

Understanding the pathophysiology of acne can help the physician tailor therapy to the individual patient. Acne lesions arise from pilosebaceous units, which consist of sebaceous glands and small hair follicles. These units are found everywhere on the body except the palms and soles. Pilosebaceous density is greatest on the face, upper neck and chest, at roughly nine times the concentration found elsewhere on the body.

 

Pilosebaceous units are present and active at birth as a reaction to maternal hormones. Thus, neonates can present with acne. The pilosebaceous units atrophy during childhood but, under the influence of androgens, reemerge during adolescence.

 

Obstruction of the pilosebaceous canal is the primary cause of acne and occurs because of a variety of factors. The first factor is sebum overproduction stimulated by hypersensitivity to androgenic steroids. Excess sebum production combined with abnormal epithelial cell turnover leads to formation of microcomedones, which can progress to open comedones, commonly termed “blackheads,” or to closed comedones, often called “whiteheads”. Normal skin bacteria colonise these pores and the body’s response causes the inflammation or reddening of the skin that we associate with acne.

 

 

 

 

 

 

FIGURE 1.

Comedonal acne.

The combination of sebum and desquamated cells provides an environment that is ripe for the growth ofPropionibacterium acnes, the principal organism in inflammatory acne lesions. Proliferation of P. acnes leads to the conversion of sebum to free fatty acids, which are irritating and stimulate the immune response, leading to the development of inflammatory lesions(Figure 2). The stages of acne are illustrated in Figure 3.
Inflammatory papule and pustule in acne
Figure-8---Inflammatory-acne-with-papules-and-pustules

 

 

 

 

 

 

 

FIGURE 2.

Inflammatory papule and pustule in acne.

 

 

 

 

 

 

 

 

FIGURE 3.

Stages of acne. (A) Normal follicle; (B) open comedo (blackhead); (C) closed comedo (whitehead); (D)papule; (E) pustule.

 

Clinical Manifestations

The physician needs to determine if the condition is noninflammatory (open and closed comedones), inflammatory (papules or pustules) or a mixture of both (the most common situation). Topical treatment is sufficient in most patients with acne, but systemic therapy is required in patients who have deep acne with nodules and cysts (Figure 4). In most situations, the physician does not need to look for an underlying cause of acne. However, medications should be reviewed because corticosteroids, anabolic steroids, lithium and some oral contraceptives can contribute to the development of this condition.

 

 

 

 

 

 

 

FIGURE 4.

Nodular cystic acne.

 

PATIENT EDUCATION

The therapeutic approach to acne should begin with patient education. It is important to dispel the many myths about this disorder.

Most of the times acne is running in the families. The patient gets genetically predisposed towards having acne and it’s a life long struggle to keep it under control and can be very easily handled.

Patients need to know that acne is not a disease of hygiene. They should not try to scrub the lesions away, and they should not use alcohol-based astringents that can dry and irritate their skin. Patients should be instructed to wash their face twice a day with a mild soap or a face wash with salicylic acid.

Hormone imbalance of any kind like polycystic ovaries, increased production of prolactin, abnormal TSH can all give rise to acne.

Patients should also be informed that acne has no relationship to diet. For example, no evidence links acne to chocolate, pizza or soda.

Acne gets worse by physical and mental stress. It is a fact and needs to be kept in mind.

Patients should be directed to use oil-free, noncomedogenic cosmetics. Oily hair products, sub standard whitening formula creams, ammonia bleaching done at salons, waxing, threading hair all exacerbate acne.

Female patients should be told that acne usually worsens during and a week before menses.

Mechanical trauma can make acne worse. Therefore, patients should be encouraged to avoid picking at lesions, because doing so may cause more inflammation.

 

Treatment of Acne

 

Topical Treatment

In the treatment of acne, the vehicle (cream, gel, lotion or solution) may be as important as the active agent. Consequently, it is important to assess the patient’s skin type.

Creams are appropriate for patients with sensitive or dry skin who require a nonirritating, nondrying formulation.

Patients who have oily skin may be more comfortable with gels, which have a drying effect. However, gels may cause a burning-type irritation in some patients.

Lotions can be used with any skin type, and they spread well over hair-bearing skin. Yet lotions contain propylene glycol and thus may have burning or drying effects.

Solutions are mainly used with topical antibiotics, which are often dissolved in alcohol. Like gels, solutions work best in patients with oily skin.

 

Benzoyl Peroxide

Benzoyl peroxide, available over the counter and by prescription, has been a mainstay of acne treatment since the 1950s. This agent has bactericidal and comedolytic properties. It is the topical agent most effective against P. acnes,with bacteriostatic activity superior to that of topical antibiotics. It also functions as a mild comedolytic agent by increasing epithelial cell turnover with desquamation.

Benzoyl peroxide can be obtained in various concentrations (2.5 to 10 percent), although little evidence exists that efficacy is dependent on the dose. This agent comes in water-based or alcohol-based gels. The water-based formulations are less drying than the alcohol-based preparations. Benzoyl peroxide gels are applied once or twice daily.

Skin irritation is the most common side effect of benzoyl peroxide. This effect occurs more often at higher concentrations and tends to decrease with continued use. Contact allergy occurs in 1 to 2 percent of patients. Patients using benzoyl peroxide formulations for the first time should be instructed to test for allergic dermatitis by applying a small amount of the agent in the antecubital area before using it on the face.

Because benzoyl peroxide is an oxidizing agent, patients should be warned about potential bleaching of clothing and bed linens. This problem can be avoided by applying benzoyl peroxide to a clean, dry face in the morning and putting it on the face again at dinner time, if needed.

 

Salicylic Acid

Salicylic acid is an ingredient of various over-the-counter preparations. It is available at a concentration of 0.5 or 2 percent in a number of creams and lotions. This agent inhibits comedogenesis by promoting the desquamation of follicular epithelium. It has been shown to be as effective as benzoyl peroxide in the treatment of comedonal acne.Salicylic acid is well tolerated and should be applied once or twice daily.

 

Sulfur Preparations

Sulfur preparations have been used to treat acne since the time of Hippocrates. Sulfur is combined with various other acne medications in many over-the-counter washes and cleansing bars. This agent has been shown to be effective in the treatment of inflammatory acne lesions, most likely as a result of keratolysis.

Preparations containing sulfur can cause some skin discoloration and can have a displeasing odor. Consequently, sulfur medications are now used less often in patients with acne.

The combination of sulfacetamide and sulfur can be effective in the treatment of inflammatory skin lesions without the unpleasant side effects that occur with sulfur preparations alone. One study of sulfacetamide-sulfur lotion showed an 83 percent reduction in inflammatory lesions after 12 weeks of therapy.

 

Azelaic Acid

Azelaic acid is a decarboxylic acid that was first investigated in the 1970s as a treatment for hyperpigmentation and was coincidentally found to be an effective acne treatment. In 1996, the U.S. Food and Drug Administration (FDA) labeled azelaic acid for the treatment of mild to moderate inflammatory acne. Although its exact mechanism of action is unknown, this agent has antibacterial and antikeratinizing activity, and it appears to be as effective as benzoyl peroxide or tretinoin in the treatment of mild to moderate acne.

Azelaic acid is fairly well tolerated, with only about 5 percent of patients complaining of transient cutaneous irritation and erythema. This rate is lower than the incidence of such complaints reported for benzoyl peroxide and tretinoin. Because azelaic acid decreases pigmentation, it should be used with caution in patients with darker complexions.

 

Topical Retinoids

Retinoids, which are derivatives of vitamin A, function by slowing the desquamation process, thereby decreasing the number of comedones and microcomedones. Retinoids are the most effective comedolytic agents in use. They have been a mainstay of acne treatment for the past 25 years.

 

TRETINOIN

Until recently, tretinoin was the only available topical retinoid. This agent is effective as monotherapy in patients with noninflammatory or mild to moderate inflammatory acne.

Tretinoin is available as a cream, gel or liquid. The cream has the lowest potency, and the liquid has the highest potency. All tretinoin formulations can cause some skin irritation. The liquid is the most irritating, and the cream is the least irritating. The concentration of the agent also affects the degree of irritation.

Tretinoin should be applied in small amounts to clean, dry skin. Because the irritation associated with tretinoin is compounded by sun exposure, the formulation should be applied to affected areas once daily at bedtime. To minimize irritation, tretinoin should be started at a low concentration, which can then be titrated upward as needed. Skin irritation usually decreases with continued therapy.

Patients should be warned that they may suffer a pustular flare during the first few weeks of tretinoin therapy. Rather than being an indication to stop or alter therapy, this pustular flare is a sign of the accelerated resolution of existing acne.

Because of the known teratogenic effects of oral vitamin A products, the use of tretinoin in pregnancy has been an issue of concern. Tretinoin is listed as a pregnancy category C drug. However, a study of 215 women exposed to tretinoin in the first trimester showed no increase in anomalies compared with control subjects. Individual physicians should decide if they are comfortable using this medication in pregnant women.

Tretinoin is now available in a new delivery system (Retin-A Micro) that may minimize its irritative effects. This delivery system works by entrapping the drug in microspheres that bring the medication more directly to the follicle and serve as reservoirs for the medication.The 0.1 percent tretinoin microsphere gel has been shown to be less irritating than 0.1 percent tretinoin cream.

 

ADAPALENE

Adapalene (Differin) is a topical retinoid that was labeled by the FDA in 1997. Its mechanism of action is similar to that of tretinoin. Adapalene comes in a 0.1 percent gel or solution for application once daily in the evening.

Studies have shown that 0.1 percent adapalene gel is at least as effective as 0.025 percent tretinoin gel and significantly less irritating.Adapalene gel has not yet been compared with the newer tretinoin delivery system. Like tretinoin, adapalene may cause skin irritation and initial exacerbation of acne lesions.

 

TAZAROTENE

Tazarotene (Tazorac) gel is a retinoid product that the FDA has labeled for use in the treatment of psoriasis and mild to moderate acne. It comes in a 0.05 or 0.1 percent gel for once-daily application. Studies comparing tazarotone with vehicle alone have shown that the medication is effective in treating noninflammatory acne lesions.

Although comparative drug trials have not been performed, tazarotene and the standard form of tretinoin appear to have similar irritation rates. The use of tazarotene in pregnant women is not recommended.

 

Topicals available in our clinic

The cream available in our clinic is scientifically proven to control acne.

 

Functions of active ingredients of this cream

Reduce Bacterial Count

  • Octadecenoic Acid
  • Salicylic Acid
  • Oleanolic Acid
  • Panthenol
  • Enantia Chlorantha Extract
  • Morinda Citrifolia Fruit Extract

 

Reduce Hyperpigmentation

  • Niacinamide
  • Octadecenoic Acid
  • Cimicifuga Racemosa Root Extract
  • Glycyrrhiza Glabra Extract

 

Reduce Sebum Production

  • Niacinamide
  • Octadecenoic Acid
  • Oleanolic Acid
  • Enantia Chlorantha Extract

 

Reduce Hyperkeratinisation of Follicle that Block the Gland

  • Octadecenoic Acid
  • Salicylic Acid

 

Reduce Inflammation

  • Niacinamide
  • Octadecenoic Acid
  • Salicylic Acid
  • Panthenol
  • Morinda Citrifolia Fruit Extract

 

Directions of use:

To be applied twice daily to a clean face. Massage into the skin until fully absorbed.

 

Caution:

Avoid contact with eyes and mucous membranes.

 

Fruit Peel Skin Exfoliation Available in our clinic

 

The cream available in our clinic is scientifically proven international award winning formulation made by a Swiss dermatologist manufactured by a renowned pharmaceutical company.

 

It will help you in getting rid of dead superficial skin giving you a baby soft skin. It has anti acne, anti aging and anti pigmentation properties. Exfoliation is important in acne treatment as acne prone skin is a sluggish skin at the top and dead skin cells donot exfoliate at a normal pace and this causes a traffic blockade for the skin cells coming from the underneath layers. By exfoliating acne breakouts can be reduced.

Use it 3 times a week. The minimum time interval between one application and the next should be 1-2 days.

Wet your face and spread a little amount of exfoliant on your face and very gently scrub with for couple of seconds. After sometime, rinse with plain water. Dab your face dry and moisturize. But never ever apply retinoids or anti bacterial topicals or toners after that.

You can use the exfoliant any time of the day and in case you are using retinoids or anti bacterial topicals at night,do not use this exfoliant at night as this is the time to apply retinoids or anti bacterials.

 

It will help you in getting rid of dead superficial skin giving you a baby soft skin. It has anti acne, anti aging and anti pigmentation properties. Use it 3 times a week. The minimum time interval between one application and the next should be 1-2 days.

 

Topical Antibiotics

Topical antibiotics work directly by killing P. acnes. Through their bactericidal activity, they also have a mild indirect effect on comedogenesis. These agents are available in a variety of forms and are applied once or twice daily.

Topical erythromycin and clindamycin are the most commonly used agents and have similar efficacy in patients with acne. Clindamycin has been shown to be significantly more effective than topical tetracycline.

Almost all topical antibiotics are associated with some minor skin irritation. This adverse effect may be influenced by the vehicle used.

 

Combination Topical Therapy

Combination therapy is often employed when patients have a mixture of comedonal and inflammatory acne lesions. Because adequate clinical studies are lacking, it is difficult to compare various combination therapies.

The combination of benzoyl peroxide and erythromycin is a highly effective acne treatment. The mixture must be refrigerated. The benzoyl peroxide–erythromycin mixture is then applied to affected areas once or twice daily. This mixture has been shown to be superior to either product alone and to clindamycin monotherapy. Its increased efficacy may be due to the fact that fewer strains of P. acnes develop resistance to benzoyl peroxide–erythromycin than to erythromycin alone.

Other combination therapies may lack convenience but are also effective. In the patient with comedones and inflammatory lesions, a comedolytic agent such as tretinoin, adapalene or azelaic acid may be combined with benzoyl peroxide or a topical antibiotic. The combination of clindamycin and tretinoin causes less irritation than tretinoin alone. In using tretinoin and the benzoyl peroxide–erythromycin combination together, the patient should alternate the products to minimize irritation. When agents that cause irritation are used, patience is necessary, but the results may be well worth the wait.

 

Oral Treatment

Acne treatments work by reducing oil production, speeding up skin cell turnover, fighting bacterial infection, reducing the inflammation or doing all four. With most prescription acne treatments, you may not see results for four to eight weeks, and your skin may get worse before it gets better.

Your doctor or dermatologist may recommend a prescription medication you apply to your skin (topical medication) or take by mouth (oral medication). Oral prescription medications for acne should not be used during pregnancy, especially during the first trimester.

Types of acne treatments include:

  • Antibiotics. For moderate to severe acne, you may need a short course of prescription oral antibiotics to reduce bacteria and fight inflammation. Since oral antibiotics were first used to treat acne, antibiotic resistance has increased significantly in people with acne. For this reason, your doctor likely will recommend tapering off these medications as soon as your symptoms begin to improve. In most cases, you’ll use topical medications and oral antibiotics together. Studies have found that using topical benzoyl peroxide along with oral antibiotics may reduce the risk of developing antibiotic resistance. Antibiotics may cause side effects, such as an upset stomach, dizziness or skin discoloration. These drugs also increase your skin’s sun sensitivity and may reduce the effectiveness of oral contraceptives.
  • Isotretinoin. For deep cysts, antibiotics may not be enough. Isotretinoin is a powerful medication available for scarring cystic acne or acne that doesn’t respond to other treatments. This medicine is reserved for the most severe forms of acne. It’s very effective, but people who take it need close monitoring by a dermatologist because of the possibility of severe side effects. Isotretinoin is associated with severe birth defects, so it can’t be taken by pregnant women or women who may become pregnant during the course of treatment or within several weeks of concluding treatment. If a woman is on isotretinoin and wants to get pregnant, she is asked to stop taking the medicine and wait for a month till she has her menses. The drug takes almost a month to get flushed out of the system. After that she can conceive.
    Isotretinoin commonly causes side effects — such as dry eyes, mouth, lips, nose and skin, as well as itching, nosebleeds, muscle aches, sun sensitivity and poor night vision. The drug may also increase the levels of triglycerides and cholesterol in the blood and may increase liver enzyme levels.
    In addition, isotretinoin may be associated with an increased risk of depression and suicide. Although this causal relationship has not been proved, doctors remain on alert for these signs in people who are taking isotretinoin. If you feel unusually sad or unable to cope while taking this drug, tell your doctor immediately.
    Blood Tests including the Liver Function Tests and Lipid Profile are done before starting the patient on isotretinoin and monthly afterwards till the patient is off the medication.
  • Oral contraceptives. Oral contraceptives, including a combination of norgestimate and ethinyl estradiol can improve acne in women. However, oral contraceptives may cause other side effects — such as headaches, breast tenderness, nausea and depression — that you’ll want to discuss with your doctor. The most serious potential complication is a slightly increased risk of heart disease, high blood pressure and blood clots.

 

Treatment Modalities Used in Dermatologist office