Acne is a common disorder seen during adolescence. Acne appears as noticeable pimples that occur on the skin. Dr. Bornstein will discuss practical insights into understanding the symptoms, causes, and treatments.

DEFINITION OF ACNE: 

Acne is a common disorder of adolescence, which includes the appearance of some or all of the following:

  • Microcomedones
  • Blackheads
  • Whiteheads
  • Papules
  • Pustules
  • Cysts
  • Nodules most commonly found on the face, chest, and back

SYMPTOMS: 

  • Noticeable and sometimes painful pimples that can occur on any skin surface.

CAUSES: 

The causes of acne are multifactorial.

  • Follicular hyperkeratinization means that the hair follicles get clogged with skin cells. This is usually due to an increase in the hormone androgen, which is present from birth to 6 months of age and again after 8 years of age.
  • Increased androgen.
  • Increased sebum. Sebum is a substance containing oily lipids and is produced by the sebaceous glands. This is also due to the increase in androgen.
  • The appearance of a bacterium called Propionibacterium acnes. P. acnes can cause inflammation leading to the formation of comedones or pimples. The more P. acnes a person has, the more likely acne will develop.
  • Genetics seem to play a role as well.
  • Diet plays no factor.

TREATMENT:

Education is very important. Treatment usually takes weeks before there is any noticeable difference. At times, the acne may look worse before improving. To treat acne, you must focus on the different causes.

Although both oral and topical treatments are available, topical treatments are the preferred treatment. You should only consider oral medication after there is no resolution using topical. The oral treatments may have side effects.

The over-the-counter topical treatments usually contain glycolic acid, salicylic acid, or benzoyl peroxide.

  • Glycolic acid is supposed to decrease the follicular hyperkeratinization. Studies do not show much benefit.
  • Salicylic acid is supposed to dry and peel the skin. There are no good studies showing that this works well, either.
  • Benzoyl peroxide is the most widely used topical agent. It can reduce the amount of P. acnes and prevent hyperkeratinization. It comes as 2.5% to 10% gels, creams, lotions, and washes. It has been shown to be beneficial. The prescription-strength benzoyl peroxide preparations include Benzac, Benzac-AC, Benzac W, Benzagel, Benzaclin (with clindamicin), Benzamycin (with erythromycin), Benzashave, Brevoxyl, Desquam-E, Desquam-X, Panoxyl, Panoxyl AQ, Sulfoxyl (with sulfur), Sulfoxyl strong (with sulfur), Triaz, and Vanoxide-HC.

Topical retinoids are also a topical class of acne agents that studies have shown to be useful. These can inhibit P. acnes, normalize the production of keratin, and promote drainage of current acne lesions. The retinoids include tretinoin (Retin-A, Avita) tazarotene (Tazorac), and adapalene (Differin). Topical retinoids can cause a burning sensation and sensitivity to the sun. Therefore, it is best to apply a thin layer on the affected area at night. It is always best to start with the lowest strength and increase if necessary.

Topical antibiotics reduce the amount of P. acnes on the skin. They can also decrease inflammation on the skin. The most common topical antibiotics are clindamycin, erythromycin, and the sulfonamides. Since these medicines only eradicate P. acnes and do not have any anti-comedone effect, it is best if they are used in combination with benzoyl peroxide or a topical retinoid. Topical antibiotics include: Akne-mycin (erythromycin), A/T/S (erythromycin), Benzaclin (benzoyl peroxide plus clindamicin), Benzamycin (benzoyl peroxide plus erythromycin), Cleocin T (clindamycin), Emgel (erythromycin), Erycette (erythromycin), Klaron (sulfacetamide), Novacet (sulfacetamide), Sulfacet-R (sulfacetamide), Theramycin Z (erythromycin), and T-Stat (erythromycin). Azelaic acid—which is available as Azelex 20%—is produced by the fungus Pityrosporum ovale and by some P. acnes antimicrobial activity.

Oral medicines are also an option, but you must exercise caution when using these medicines.

  • The first group consists of antibiotics. The most commonly used are tetracycline, minocycline, doxycycline, erythromycin, trimethoprim-sulfamethoxazole (Bactrim, Septra), and cephalexin (Keflex). Since P. acnes as well as other bacteria can become resistant to these antibiotics, they should only be used short-term, if at all.
  • Another oral medication is isotretinoic acid (Accutane). This is meant for severe cystic and scarring acne. You must closely monitor liver function tests during the course of this medication due to its potential liver toxicity. Many physicians agree that this medicine should only be prescribed under the advice and consultation of a dermatologist familiar with this medication.
  • Antiandrogenic agents—such as spironolactoine, flutamide, cyproterone acetate, gonadotrophin-releasing hormone antagonists, and 5 alpha reductase inhibitors—can regulate androgen production and alleviate acne in females. These are more experimental and should only be used under the advice of an endocrinologist or gynecologist familiar with hormonal therapy.
  • Oral contraceptives—such as triphasic norgestimate (Ortho Tri-Cyclen)—can be used in female patients to help regulate androgens.

OUTCOME:

With consistent treatment, patience, and good follow-up, acne can be controlled until the hormonal changes are such that it lessens naturally. Cystic acne is harder to treat, but with the help of a dermatologist, Accutane can even control this more severe type. The vast majority of teenagers get acne. It is best to seek treatment early so this sometimes-embarrassing skin condition is alleviated.

ONE DOCTOR’S OPINION ABOUT ACNE:

The hardest thing with acne is to get a teenager to ask for treatment. They are frequently embarrassed and will usually try over-the-counter preparations instead of seeking medical attention. It has been shown that children with acne suffer from more depression and may even avoid social participation. Therefore, it is best to be open and address this condition. The next hardest thing is to get a teenager to stick with the program. Acne is not immediately curable. Most of the medicines take weeks to start helping and with some, things may even appear worse before they get better.

Once a person does seek help, it is best to start with the medicines that cause the least amount of side effects and increase the strength, if necessary. I like to start with combination therapy first. I will usually use a benzoyl peroxide in combination with a topical antibiotic. If that doesn’t work, I will go to the topical retinoids. If that doesn’t work, I will add in a short course of oral antibiotics. After that, for females over 15 years of age, I will try an oral contraceptive. If the acne is persistent and nothing seems to be helping, then I will suggest Accutane, but I prefer to get a dermatologist involved at that point. The type of soap or cleanser they are using doesn’t seem to make a difference so I don’t use any special soaps or scrubs. I have found that with this regimen, we will eventually find the best combination for each individual and get this common—but sometimes embarrassing—skin condition under control.

This blog was written by Dr. Michael Bornstein, who has 30 years of experience as a pediatrician. 

Disclaimer: The contents of this article, including text and images, are for informational purposes only and do not constitute a medical service. Please note that all images belong to their original owners. Always seek the advice of a physician or other qualified health professional for medical advice, diagnosis, and treatment.