For far too long, consumers and many times, doctors, have taken a very one-dimensional approach to acne therapy. However, acne is not due to a single event but the result of multiple steps going "wrong". A more innovative therapeutic approach targets multiple points in the development of a blemish, providing faster results and clearer skin.

At its essence, acne is a problem involving the sebaceous (oil) glands. The oil glands lie deep within the dermis and possess a low oxygen environment. An oil gland is a long test tube-shaped organ. Envision it resembling the letter "U".

At the base of the "U", is where oil is produced. The arms of the "U", lined by skin cells called keratinocytes, extend up through the dermis and epidermis and open onto the skin's surface. A pore is essentially the opening of a sebaceous gland.

KERATINIZATION

A normal sebaceous gland's daily activities would include the production of acceptable levels of sebum (oil) meant to lubricate and protect the skin. A small number of keratinocytes are shed along with the oil into the center of the gland and secreted onto the surface of the skin. This is a natural process and typically goes unnoticed.

What's actually going on as a blemish forms? Acne is considered a disorder of the keratinization process. As the cells which line the sebaceous gland are produced (the keratinization process), their surface membranes are abnormally sticky. The keratinocytes which are supposed to be shed unfortunately stick together and are unable to be eliminated through the pore.

Treatments typically used to normalize the keratinization process:

Retinoids

• Rx Topical tretinoin (Retin A), adapalene (Differin), tazarotene (Tazorac), Oral Accutane and high levels of Vitamin A (Aquasol A)
• OTC retinol is thought by most dermatologists to also help, although not "blessed" by the FDA for this claim. Consider product DERMAdoctor Poetry In Lotion intensive retinol 1.0, Afirm 3X or MD Formulations Vit-A-Plus Clearing Complex.

EXFOLIATION

Over time, more newly shed keratinocytes continue to cling to each other, forming a cluster that extends up toward the surface of the skin. Lacking the body's natural exfoliation process, the debris reaches the opening of the pore and comes in contact with air. Oxidation occurs, creating what we call a blackhead.

Treatments typically used to aid exfoliation:

• Rx Topical tretinoin (Retin A), adapalene (Differin), tazarotene (Tazorac) and the topical OTC retinols listed above.
• OTC salicylic acid and sulfur are the only agents approved by the FDA for this use to help clear and prevent acne. Salicylic acid levels range from 0.5, 1.0, 1.5, 2.0%, although in my personal experience, 2% is the only level effective in non-prescription OTC acne therapy. Consider DERMAdoctor Ain't Misbehavin' Medicated Acne Control Serum and DERMAdoctor Ain't Misbehavin' Medicated AHA/BHA Acne Cleanser.
• Other ingredients that can help aid in exfoliation but do not carry FDA approval to be labeled as acne therapy: glycolic acid, retinol, retinyl palmitate and lactic acid. Consider Peter Thomas Roth AHA/BHA Acne Clearing Gel and DERMAdoctor Picture Porefect Pore Minimizing Solution.
• Physical exfoliation through the use of scrubs, microdermabrasion creams and washrags can also expedite exfoliation. Be careful not to over scrub as this action could break the sebaceous gland and lead to an acne flare-up. Consider the use of :DERMAdoctor Physical Chemistry facial microdermabrasion + multiacid chemical peel or Clarisonic CLASSIC Skincare Brush - White Sonic Cleanser System.

HORMONES

A bevy of hormones can cause acne to form. Hormones responsible for acne include testosterone (an androgen), anabolic steroids, gonadotropins, corticosteroids and ACTH. Stress increases circulating glucocorticosteroids and should be factored into the hormone driven flare-up.

In most acne patients, it is DHT, the active metabolite of the hormone testosterone that triggers acne. It's not only men who form DHT. The ovaries produce both estrogen and testosterone. In women, estrogen levels should be in much higher concentrations, masking the androgenic or "male" effects of testosterone. It is when androgens outweigh estrogen either through total amounts or genetic hypersensitivity to the mere presence of androgen that a problem may arise.

The hormone progesterone also factors into acne formation as it is a precursor of testosterone. Surges in progesterone during the last 2 weeks of the menstrual cycle are responsible for premenstrual acne flare-ups. An interesting multicenter study (JAAD 2001;45:957-60) showed that almost half of all women do experience a premenstrual flare of acne. But it's women ages 33 and up who are most often affected.

The cause of hormonal flare-ups is due to DHT stimulating the sebaceous glands to produce oil at higher levels. Excessive oil serves as a source of nourishment to the P. acnes bacteria, aiding in their overgrowth.

Hormonal intervention for acne has traditionally revolved around the use of birth control pills. Why do BCPs help control acne? This type of treatment relies upon the ability of the product to affect DHT levels that are focused upon sebaceous glands and hair follicles.

Birth control pills that are estrogen dominant (higher levels) and/or contain progesterone derivatives which are less likely to produce androgenic effects are one way to help control unsightly blemishes. Spironolactone, a diuretic, is structurally competitive with DHT, able to block its actions and reduce acne outbreaks.

Prescription oral medications used in the treatment of acne:

• Ortho tricyclen
• Yaz a birth control pill structurally related to spironolactone and recently approved by the FDA for the indication to treat acne. Yaz contains the progestin Drospirenone that is very similar structurally to Spironolactone. Because of its resemblance to Spironolactone, Yaz can help avoid those extra few pounds of weight gain and may be beneficial in addressing androgenic acne.
• Spironolactone is a water pill (diuretic) that also goes by the name Aldactone.

Topical options:

Nordihidroguiaretic acid (NDGA) - is a natural, bioactive agent typically derived from the Mexican desert plant, Larrea Divaricata. From the Journal of Biochemistry and Pharmacology (2002 Mar 15;63(6):1165-76), it states that "certain natural products contain components that are inhibitors of 5 alpha-reductase, such as the green tea catechin (-)-epigallocatechin gallate (EGCG). Other flavonoids that were potent inhibitors of the type 1 5alpha-reductase include nordihydroguaiaretic acid." Consider using DERMAdoctor Ain't Misbehavin' Medicated Acne Control Serum for traditional acne or DERMAdoctor Calm Cool & Corrected Anti-Redness Tranquility Cream for rosacea.

OILS

Sort of a corollary to the hormones is the mere presence of excessive sebum on the skin. True, reducing hormonal signals is a big help. However, make certain to reduce oils with cleansers that bust (but don't strip away) excess oils and treatments to help soak up that oil. Consider DERMAdoctor Ain't Misbehavin' Medicated AHA/BHA Acne Cleanser, and DERMAdoctor Ain't Misbehavin' Medicated Acne Control Serum.

BACTERIA

These bacteria produce a natural by product of their metabolic existence known as free fatty acids (FFAs). As these FFAs reach higher than normal levels, they stimulate white blood cells to the area. Because white blood cells fight germs, it misleads people into thinking that acne is an infectious process. In actuality, acne forms as the inflammation builds in intensity, merely due to the life cycle of P. acnes.

Did you know that most acne regimens, whether they are prescribed by your dermatologist, or purchased at your local drugstore, focus solely on killing bacteria? Think about it benzoyl peroxide, sulfur, prescription topical antibiotic cleansers, lotions, gels and pills all work to kill bacteria. While an important step in acne management, how many times can you kill a bacteria until it's dead? An acne regimen limited to antibacterial therapy is unquestionably redundant, to say the least, and certainly not the optimal way to manage acne.

Prescription antibacterial medications used to treat acne:

• Antibiotic pills, including tetracycline, minocycline and doxycycline. For children under the age of 13, pregnant women and those allergic to this family of medications, erythromycin, penicillin and cephalosporins and occasionally sulfa medications may be used as appropriate.
• Topical antibiotic gels, lotions, pads, cleansers include Cleocin T, benzoyl peroxide, BenzaClin, MetroGel/Lotion/Cream, T Stat, Erystat, Benzamycin (a blend of benzoyl peroxide and erythromycin), Plexion, Ovace (both sulfa based). Azelex is another rx option. Its function is not fully understood, however, it is thought to both kill bacteria and normalize the keratinization process. It is also used to help normalize discoloration associated with post acne healing.
• Non prescription ingredients include benzoyl peroxide and sulfur (the only 2 officially recognized by the FDA to have an antibacterial acne claim. Other ingredients frequently included that are thought to have astringent or antibacterial action include tea tree oil, triclosan and hydrogen peroxide.

Consider using DERMAdoctor Ain't Misbehavin' Medicated Acne Control Serum, Peter Thomas Roth Sulfur Cooling Masque, B. Kamins Blemish Gel 10% and Cortaid Advanced Maximum Strength Cream. DERMAdoctor Ain't Misbehavin' Medicated Acne Control Serum doesn't kill bacteria, per se, but heats the oil gland which then reduces the oils produced which in turn prevent the bacteria from flourishing. Other options include ClearLight blue light treatments and lasers such as SmoothBeam.

INFLAMMATION

The results of the inflammatory process are what we really see on the skin's surface. The gland is plugged, the oils continue to form, bacteria flourish and inflammation is taking place. Early on, the plugged pore and/or blackhead have small collections of white blood cells forming, visible as a white head.

As the blemish is expanding beneath the skin's surface (imagine a water balloon being filled), the inflammation becomes more intense and the blemish appears as a red, raised bump. Ultimately, the blemish ruptures and the inflammation is at its zenith. That's how an acne cyst is formed.

Controlling the inflammatory process is an important key to controlling acne. Obviously, addressing the other points in the pathway, from preventing or removing the plug in the first place, reducing oil production and killing the bacteria means that inflammation is greatly reduced. But it doesn't mean one can ignore this very important factor.

Treatments typically used to help control inflammation in acne:

• Oral antibiotics frequently also help inadvertantly interfere with some of the inflammatory process by killing the bacteria and reducing the levels of FFAs produced. Much of the time, however, antiinflammatory therapy is limited to the use of injectable cortisone shots into out-of-control acne cysts.
• Topical antibiotics, as discussed above, also work to reduce FFA production, however they are not technically antiinflammatory. For some of my patients when appropriate, I will recommend they take (on a very limited basis) an NSAID or Tylenol to reduce inflammation on an emergent basis (such as several painful cysts).
• The rare application of a topical steroid to a cyst (like Cortaid Advanced Maximum Strength Cream for a day or two may help in a pinch. Do not, however, rely upon topical steroids or one can get steroid acne in its place!
• The medical literature has long recognized the calming effects that green and white tea extracts, high in EGCG have. Also, oleanolic acid is a leukotriene inhibitor, with further calming abilities. Consider using DERMAdoctor Ain't Misbehavin' Medicated Acne Control Serum or DERMAdoctor Calm Cool & Corrected Anti-Redness Tranquility Cream to gain these benefits.

Multifunctional therapy rules over monotherapy when it comes to keeping skin clear of acne. If you are acne prone, be certain to evaluate your therapy regimen and target as many of these important trigger points as possible.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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