DERMAdoctor articles frequently mirror my own life experiences and this acne article is no exception. Our earliest readers may recall my trials and tribulations regarding my toddler's chickenpox. Unbelievably like a blink of the eye time has flown. Just the other day I was surprised to witness my son's (who is now 9) first outbreak of acne! So much in the way of acne treatment has changed with an ever-expanding list of options that I thought the timing perfect to revisit this topic.
It's rare to escape the acne experience. Approximately 45 million young adults between the age of 12 and 24 have acne. And this does not include the millions of acne patients in their 20's and 30's who are more likely to develop acne than their teen counterparts.
A strong genetic predisposition is the source of most acne, exacerbated by hormonal changes (most women already know this!); stress associated with school, jobs and starting families and occasionally, poor skin care habits.
How Does Acne Form?
Acne is not due to a single event but the result of multiple steps going "wrong". Acne is a disorder of keratinization, meaning the development of cells lining the sebaceous gland is faulty.
These cell walls are sticky, binding together, plugging the gland rather than easily exfoliating themselves onto the surface.
Despite the presence of this plug, the sebaceous glands, triggered by DHT, the active form of testosterone, continue to secrete sebum.
Proprionobacterium acnes (P. acnes), the bacteria that live upon the skin, thrive in this environment. Lack of air and lots of sebum nourish the bacteria, allowing them to flourish. Too many P. acnes contribute to the inflammation within the gland.
Ultimately, a combination of persistent plugging, excessive oil build-up (envision an expanding water balloon) and inflammation produced by bacterial over growth cause the gland to rupture. On the surface, this manifests itself as an inflamed acne papule or cyst.
Intervening at several points along this pathway maximizes acne therapy.
Acne & Food
Was mom right? Until recently, contrary to what your mother may have told you, dermatologists have been taught that it's not what you're eating (with the possible exception of nuts) that leads to acne.
Yet a study out of Colorado State University suggests otherwise. Kitivan Islanders of Papua New Guinea who eat traditional low carbohydrate diets are acne free. In contrast, those living in Western Europe and North America, 79 to 95 percent of teens struggle with acne and 40 to 54 percent of adults 25 and older still break out. Is diet the difference?
The theory behind the study rests upon known physiology. A diet with a high glycemic value (high in sugar) sends insulin levels skyrocketing triggering sebum production and indirectly acne. Epithelial cells form more quickly and as they become trapped within the sebaceous gland, the P. acnes feast upon the excess oils. The result - blemishes.
So perhaps those potato chips, chocolate and other junk food mom warned about has some kernel of scientific truth. Not because they're oily but because they're loaded with carbs. Should you shun all the goodies? From a realistic standpoint, it's unlikely to happen. I certainly don't have that level of permanent willpower. Go for the healthy, well-rounded approach.
NOT ALL ACNE IS CREATED EQUAL
There are different types of acne lesions as well as grades of acne severity. Treatment is based upon the possible permutations.
Types of acneiform lesions
- Open Comedone (aka the blackhead)
- Inflamed Papule
- Pustule (aka the whitehead)
- Painful Nodular Cysts
Dermatologists perform acne grading essentially guesstimating the number of blemishes. This factors into how aggressive to make therapy as well as track improvement or lack thereof. Grade 1 is the mildest, with very few lesions. This graduates to a high of grade 4.
Treatment
Too many acne sufferers go untreated far too long. We have so many effective therapies that weren't available in the 70's when I was growing up. Acne can have a real impact on an individual's self esteem. I can't emphasize enough that NO ONE needs to suffer from acne.
When a patient presents in my office, I quickly evaluate the overall severity of the acne (the grade) and the types of lesions present. Every dermatologist has their favorite combinations of treatments that have been successful for their patients.
I allow 6-8 weeks for any therapy regimen to show considerable improvement (notice I didn't say miraculous) improvement. If a patient does not display this, I will often change their medications. Anyone finding themselves on the same medicines for a year and continuing to break out don't hesitate to broach a change with your doctor!
How do you or your dermatologist decide what needs to be done? Here are the issues that are targeted by treatment:
- Kill the bacteria
- Reduce unnecessary oils
- Unplug the pores
- Reduce inflammation
Many acne treatments conveniently provide more than one benefit, helping simplify the process.
Prescription Therapy For Acne Currently On The U.S. Market
Pills
Systemic therapy (pills) is best for inflammatory acne and practically mandatory for acne cysts.
Three categories of oral medication:
- Antibiotics (used to help kill bacteria and reduce inflammation)
- Hormonal therapy (used to reduce the hormone DHT from triggering acne)
- Accutane (considered the closest thing to an acne "cure")
Antibiotics*
- Tetracycline
- Minocycline
- Doxycyline
- Erythromycin
- Sulfa
*This list is not meant to be fully comprehensive.
Bacteria drive acne formation. P. acnes thrive upon excess sebum and an environment low on oxygen. Blackheads and cellular debris plug the neck of the sebaceous gland, preventing contact with air. The result of bacterial growth is the formation of free fatty acids highly inflammatory, causing whiteheads, red bumps and painful cysts. A stray monthly pimple doesn't warrant a long-term commitment to antibiotic therapy. Yet the patient plagued by these types of blemishes, whether numerous or resistant to topical therapy, may qualify.
Antibiotics are used not only to kill P. acnes but also to reduce the inflammatory process. IN acne therapy, the tetracycline family is the most effective group of antibiotics.
Tetracycline (aka Sumycin) is most commonly prescribed in doses of 500mg twice daily. Minocin (aka minocycline) is a more aggressive member of this antibiotic family and given in a dosage of 50mg once or twice a day. It also is much more expensive. I reserve Minocycline for patients unresponsive to tetracycline, or patients with primarily cystic acne. Doxycycline is similar to minocycline; however, I have not had nearly the response rate to this medication as I have to Minocin so I tend to avoid its use.
The tetracycline family may cause increased sun sensitivity and are not to be used if pregnant or nursing nor is it appropriate for patients younger than 13 years of age due to potential dental enamel discoloration.
Erythromycin is not as effective for treating acne and tends to cause significant stomach upset. I save this for patients unable to take tetracycline or its family members. Erythromycin should be taken on a full stomach to reduce nausea.
Sulfa is infrequently prescribed for acne therapy but is highly effective. Sulfa allergies are very common, hence the hesitancy for use.
Hormonal/Anti DHT Therapy
- Birth Control Pills (Ortho Tricyclen)
- Spironolactone (aka Aldactone)
Blame it on the hormonesfor the acne, that is. Hormonal imbalance may lead to chronic acne or that once-a-month flare-up. But one woman's hormonal flare is another woman's means to a quick fix.
What is it about hormones that create such havoc with the skin? Androgen and estrogen balance creates harmony for the skin, sort of a biochemical Yin and Yang. Upset this delicate balancing act can lead to blemishes, galore.
All women produce androgens and these hormones are there for a reason. It is when androgens outweigh estrogen either through total amounts or genetic hypersensitivity to the mere presence of androgen that a problem may arise.
Women can either make too much testosterone (such as in polycystic ovary syndrome/PCOS); make too little estrogen to mask the testosterone or have a genetic predilection towards highly sensitive skin and hair follicle cells to "normal" levels of androgens. By far the most common cause of androgenic acne is this natural ultra sensitivity to androgens.
Contrary to popular belief, testosterone is not the bad actor; it's DHT, the undesirable testosterone metabolite that's responsible for triggering an increase in sebum production, enlargement of the sebaceous glands and generally flares acne, creates rosacea complications and exacerbates oily skin. Control the DHT and you control the acne.
Birth Control Pills
Why do BCPs help control acne? In order to treat acne hormonally, one of the following must occur to stop hormones from wreaking havoc with the skin. The treatment must either:
- Block the androgens from reaching the receptors.
- Reduce the level of circulating androgens in the bloodstream.
- Prevent the formation of the androgens in the first place.
Conveniently, oral contraceptives are capable of all three of these actions. All oral contraceptives are anti-androgenic. OCs increase sex hormone binding globulin (SHBG), which binds to androgens and literally prevent them from going anywhere. Sort of a sponge-action approach.
At the same time, the progestin component (the synthetic form of progesterone) of an oral contraceptive competes to bind to the androgen receptors.
All birth control pills decrease the levels of circulating total and free testosterone.
Oral contraceptives help prevent the formation of active androgens.
The enzyme 5 alpha reductase is vital for converting testosterone into the active metabolite dihydrotestosterone (DHT). Birth control pills interfere with enzyme function. No enzyme, no DHT, no acne.
The FDA has only given its approval for Ortho-Tricyclen to carry the indication for treating acne. This particular medication went through the rigorous testing and studies required to prove to the FDA that it indeed was beneficial for acne as well as its ability to be a quality oral contraceptive.
Spironolactone
Many women are turning to non-contraceptive anti-androgen options in the treatment of their acne. Spironolactone (brand name Aldactone) is a water pill (diuretic) used to help reduce water retention in addition to helping control high blood pressure.
Spironolactone has a curious molecular structure lending itself to mimic androgens. This unique architecture allows it to bind to the androgen receptor and block the true androgen from binding and triggering those undesirable "male" skin and hair traits.
The downside to Spironolactone use includes symptomatic low blood pressure, irregular menstrual cycles, spotting and higher levels of potassium in the bloodstream. Avoiding excessive binging on high potassium-containing foods like bananas is important.
For women who crave the benefits of an anti-androgen but want to be on oral contraceptives, or for those who want to be on a BCP but hate those extra few pounds of water retention that tend to go hand in hand, a new generation pill, Yasmin, may be a solution.
Yasmin contains the progestin Drospirenone that is very similar structurally to Spironolactone. Because of its resemblance to Spironolactone, Yasmin can help avoid those extra few pounds of weight gain and may be beneficial in addressing androgenic acne.
Accutane
Many patients with the most severe form of acne, grade 4 cystic acne fail more traditional "aggressive" therapy.
Accutane has been a blessing for these patients.
A Vitamin A derivative in capsule form, this is the closest medication to acne "cure." Accutane helps normalize what's really wrong within the sebaceous gland that contributes to the formation of acne in the first place the keratinization process.
Therapy is limited to 5 months unlike chronic antibiotic acne therapy. The success rate is high and the results impressive. Rarely, patients with significant acne unresponsive to other aggressive treatment might also be placed on Accutane.
Accutane is a drug to be taken seriously.
It can have serious possible side effects. Similar to what occurs with excessive systemic Vitamin A, problems include dryness of skin, eyes and mucosal membranes; chapped, cracked lips; increased blood fats called triglycerides; low blood counts; liver enzyme abnormalities; hair loss; pressure behind the eyes; headaches; nausea, concerns about depression and most importantly birth defects.
Pregnancy must be avoided while on Accutane and 1 month after discontinuing treatment. Two methods of birth control should be used. Birth defects affect the developing fetus exposed to the medication. It is important to understand that the medication does NOT affect ovaries, eggs, sperm or future pregnancies.
While on Accutane, blood work is done for screening, every 2 weeks for the first month of use and monthly for the final 4 months of use. This monitors early changes in blood counts, liver and kidney function and triglyceride levels that can skyrocket during Accutane use.
DIETARY SUPPLEMENTS
VitaMedica Healthy Skin Formula is a nutritional supplement that provides internal skin care by enhancing the body's natural systems for repairing, cleansing and healing. The supplement is intended as an adjunctive therapy to the topical products and/or treatments that skin care professionals recommend for acne patients.
Many topical treatments for the care of acne and inflammatory disorders of the skin are currently available. While effective, these regimens contain products that produce an action primarily on the outer layer of the skin. Although the topical approach represents the foundation of good skin care, it also makes sense to address what is going on internally. That's because what you put inside your body may be just as important as what you apply externally.
VitaMedica Healthy Skin Formula is indicated for patients with mild to moderate acne. The product is suitable for patients 12 years or older. This nutraceutical is ideal for individuals who do not eat a well-balanced diet on a consistent basis. Certain individuals should seek the advice of their doctor before beginning the program particularly diabetics, pregnant or lactating women. Healthy Skin Formula contains Vitamin A. If you are presently taking Accutane (isotretinoin) for the treatment of acne, please refrain from taking HEALTHY SKIN FORMULA until the end of the treatment cycle.
Murad Pure Skin Clarifying Dietary Supplement is a patented formula which aids in supporting elimination of breakouts.:
- Vitamin A supports normal cell production to help prevent clogged pores
- Yellow Dock and Burdock support the body's ability to remove blemish-producing toxins
- Zinc helps reduce the appearance of skin irritation
Injectable Steroids
The stray cyst can rapidly be resolved with a small shot of steroid solution known as Kenalog (triamcinolone). The up side is the rapid resolution for those "little emergency" situations like weddings, prom, etc. The downside - this is simply not the way to treat widespread recurrent acne. Nor is it pleasant should you experience the atypical "sink" spot where fat atrophy has taken place as a side effect from the shot. Fortunately this is unusual and spontaneously fills in over several months.
If you don't have an established relationship with a dermatologist, getting in for an injection can be a challenge. Consider having DERMAdoctor Ain't Misbehavin' Medicated Emergency Acne Spot Treatment on-hand to help treat those little surprise blemishes. It works Better than a cortisone shot with a combination of Chinese, Ayurvedic and Western Medicinal ingredients.
See Acne Part - Topical Therapies, Skin Care, SciFi Procedures that Work and Therapy Down the Pike.
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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