Acne vulgaris is an extraordinarily common disease throughout the world. Some people see the disorder as merely cosmetic, but few skin diseases cause as much physical and psychological misery as this scourge of adolescence.1
Between 17 million and 28 million Americans have acne, about 7 million of whom have moderately intense activity and 750,000 of whom have more severe inflammation.2 Acne is one of the most common complaints in clinical practice, whether it is the chief complaint, a secondary complaint or simply
noticed by clinicians during routine inspection. Acne is not difficult to recognize, but strangely, it is sometimes difficult to understand. With an increase in the percentage of acne patients being treated by their primary care providers,3 we must realize the importance of our thorough understanding of the skin so that we can chose appropriate and effective treatments.
Patients with acne have a disfigurement at an age when its effects are felt most acutely. Depression and anxiety are clearly linked to severe acne.4 It's sometimes helpful to create a systematic approach that's flexible enough to allow for the great variety of presentations of acne and acne-like disorders. For the recalcitrant and scarred patients, we must know about the resources available to help improve the appearance of their skin.
Acne: Where It All Begins
All acne lesions begin as microcomedones. Prevent microcomedones and you'll prevent acne. The plugging of follicles, whether in the form of an open or closed comedo, is necessary to some extent in the formation of acne lesions. This superficial obstruction is the hallmark of acne and separates it from the similar folliculitis, perioral dermatitis and rosacea.
The acne cyst is an infection within the sebaceous hair follicle. It originates above the point where the sebaceous gland empties into the hair follicle. This is why acne is referred to as a pilosebaceous disease--and incorrectly referred to as a sebaceous disease. Acne has no true etiology and is not caused by any single factor. Lesions typically occur on the face, chest and back, where there are plenty of sebaceous glands. The face has about 800 sebaceous glands per square inch, and the back has an average of 50 sebaceous glands per square inch.1
Within the sebaceous hair follicle, sebum mixes with the sloughing epidermal lining (squamous epithelium from the shaft of the sebaceous follicle) to "clog" the follicle. When the follicle becomes engorged, it is visible as the common closed comedo, commonly referred to as a whitehead. If the comedo is exposed to oxygen, the material in the plug oxidizes and darkens and becomes an open comedo, or blackhead. The material in the comedo becomes a medium for Propionibacterium acnes. These factors act together to produce irritating free fatty acids, which are thought to attract inflammatory elements.5
Understanding Skin
Normal skin is simultaneously growing and sloughing at a constant rate. I compare the skin to a brick wall that grows from the bottom. The bricks at the top are dried and have already done their job to protect the body. The "glue" (desmosomes) that holds the dried skin cells together is still healthy, which allows the skin to become thicker on the surface. This is how I describe the purpose of keratolytic products to patients--this outer layer needs help in sloughing off, but without physical scrubbing.
Sometimes, we're too late because the patient has delayed medical care during many attempts to rid himself or herself of this nuisance. Often, we see a patient with acne who has tried every over-the-counter product available to no avail. It's crucial to review good skin care with patients and reinforce healthy skin habits.
Patients should cleanse their skin once or twice a day with a gentle or soapless cleanser such as Aquanil, Cetaphil, Neutrogena Oil-Free Acne Wash, Lever 2000, Dove, Basis, Purpose or Oilatum. Cleansing should be a gentle process and not scrubbing or "buff-puffing" the skin aggressively. I tell patients that every time they squeeze or rub the skin hard, the contents spill out onto surrounding healthy skin, adding further trauma to the already infected skin.
I often add that when I was diagnosed personally with acne in high school, like many young men, I didn't use my medicine as often as I should have. If I could go back to those days, I'd work hard to avoid the problems I created by picking and scratching my acne. I believe this would have been more beneficial than never missing a dose or application of medication. I use this example to show patients the importance of letting the skin heal itself and not causing further damage and possibly scarring the skin.
Why Now, Why Me?
Puberty is acne's typical age of onset, but it is not confined to adolescence.6 One of the effects of hormones on the body during puberty is the maturation of the sebaceous gland, which can include a 15-fold increase in the size of the gland. Sebum production is increased to a lifetime high, and acne may begin to occur. This hormonal effect also occurs when some women begin taking oral contraceptives. Yet at the same time, Ortho Tri-Cyclen (ethinyl estradiol and norgestimate), which has recently been cleared by the U.S. Food and Drug Administration acne treatment, is a fantastic therapeutic adjunct for acne. Adult women with no acne history sometimes have their first occurrence along with other significant hormonal changes such as pregnancy or menopause.
Clearly, acne has a hormonal component, but with these wildly varying effects from the same or similar factors, acne cannot be thought of in a neatly linear pattern. Some women get the best skin of their life during pregnancy, while other pregnant women suffer from horrible acne.
Numerous studies have documented specifically the trauma that disfiguring diseases have on patients. These psychological studies include patients who either had a body-image disorder or acne. Facial scarring may be a risk factor for suicide, especially for men.7 This makes a clear case that we should always try to know our patients a little bit better and take acne seriously as a treatable disease.
Severe and Common Forms
It's sometimes difficult to narrow the many treatment options considering the varieties of acne. The best approach to acne is to divide it into two major types: more severe, scarring and recalcitrant acne, and common acne (acne vulgaris). Common acne typically presents itself as comedonal or noncomedonal.
Comedonal acne must be approached differently than the more severe pustular or nodular acne. When choosing acne treatments, I use some commonsense guidelines and adjust them according to the reaction with the patient. If they have tried every OTC product under the sun, they might have made their acne worse with too many irritants.
With mild nonerythematous acne, I recommend the following: Discontinue all other "acne" products. Emphasize a mild cleanser. Initiate Retin-A Micro, beginning two to three times per week and increasing in frequency based on the dryness and irritation. I find this topical tretinoin less irritating and very beneficial for the primarily comedonal variety of acne.
For many patients, Retin-A Micro is too irritating, even when applied every other night. For these patients, I recommend adapalene gel (Differin) with the same instructions regarding increase in frequency as the Retin-A Micro. When even these therapies are too irritating, Retin-A 0.025% cream or moisturizers containing alphahydroxy acids are very mild options (NeoStrata has some excellent sensitive moisturizers and other skin products available for this purpose). Patients who cannot tolerate topical products can use an occasional chemical peel to help rid and prevent comedones. This can be repeated every 2 to 6 weeks, depending on the sensitivity of the patient and strength of the peel.
Erythematous papules (with or without comedones) lead me to prescribe topical antibiotic creams. I still like the effect of the benzoyl peroxide gels, so I usually begin with Benzamycin (benzoyl peroxide and erythromycin). I use this in the morning, alternating with Retin-A at night, or else Benzamycin b.i.d. with Differin at night. (Retin-A and benzoyl peroxide are thought to cancel each other chemically, but many dermatologists use them together very successfully).
With two effective active ingredients, Benzamycin gel has an excellent history in many nonbiased studies for quickly reducing overall comedones and inflammatory papules.8 With increasing resistance to topical and oral antibiotic therapy in acne patients, quickly reducing the total use of all forms of antibiotics is an exceptionally desirable goal. When transitioning off antibiotics, do it gradually, from b.i.d. to q.d. to q.o.d., with 1- to 4-week intervals. I also like to continue benzoyl peroxides or superficial acids. These products (azelaic acids such as Azelex; benzoyl peroxides such as Benzac and Triaz) provide a hostile environment for acne but little or no discomfort for the patient.
Recalcitrant Acne
Any significant pustules with nodular acne result in the prescription of an oral antibiotic. I usually begin with doxycycline in the winter and switch to cephalexin or enteric-coated erythromycin for the summer months. Tetracycline is still the drug of choice, but I find the food restrictions too much for the already hard-to-make-compliant patient.
When patients have acne that is recalcitrant to multiple treatment attempts, I will consider prescribing isotretinoin (Accutane). In addition, patients with severe scarring nodular or cystic acne, acne conglobata or acne fulminans are likely candidates for Accutane. Isotretinoin (13-cis retinoic acid) is a vitamin A analog that inhibits sebaceous glands and reduces sebum production. It also normalizes intrafollicular keratinization. When I begin a patient on Accutane, it typically means that they have failed oral antibiotic therapy. I expect they have attempted no fewer than two or three different families of antibiotics over a 4- to 6-month period. When Accutane is used for acne, the standard therapeutic regimen is 0.5 to 1 mg/kg/day for 20 weeks.
If my patients are on oral antibiotics, I see them every 4 to 12 weeks, depending on the control. Once the acne is under control, I follow up one to four times every year and encourage patients to taper off of oral antibiotics and transition to topical medications. For patients who do not have severe enough acne to warrant (Accutane), but have not been helped with the typical oral antibiotics, here are other drugs I use successfully: Septra DS (b.i.d.); ampicillin (250 or 500 mg b.i.d.); azithromycin (z-pack after 10th day begin t.i.d. or b.i.d.).9
Scar Revision
When acne has progressed treated or untreated for years, the emotional scars are unseen and often are ignored. The visible scars are often seen, noted and described--and then ignored. We can achieve tremendous scar revision outcomes with new laser technology.10 The scars that were once notoriously difficult to treat are now significantly improved with the latest laser therapies.11 It wasn't long ago when the only alternative to having acne scars for life was freezing the skin of the face hard enough to sand down the prominent peaks. Now we can cosmetically remove deep pits and replace them with miniature skin grafts of the same size. Combined with state-of-the-art lasers, we can resurface the skin, leaving it smoother, healthier and younger looking. Chemical peels and moisturizers can improve skin tone and texture. We now have a topical vitamin C that reverses sun damage to the skin, diminishes wrinkles and stimulates collagen regrowth. These and a vast array of other possible skin-enhancing tools are relatively recent improvements that we must pass along to our patients with acne disfigurement.
Other Forms of Acne
When considering the possible scarring effects of acne, we should also consider the possibility of preventing the disease. Some forms of acne are caused, at least in part, by exogenous factors and can be prevented.
Acne mechanica is a form of acne produced by repeated physical trauma to the sebaceous skin, such as football and baseball players' foreheads--both have constant mild trauma, and sometimes acne forms that's localized to only these locations. This also occurs in students who rest their head in one hand on one side of the face, or teenagers who talk on the telephone with the mouthpiece pressed firmly to the side of the face. Treat these by reducing or removing the friction (with softer material, lubricants, etc.)
Acne cosmetica comes from products that contain chemicals that occlude the follicle and help form acne lesions. Steroid acne is a diffuse papulopustular eruption that can take place while on systemic steroids. Usually treatable topically, steroid acne dissipates when steroids are discontinued. Neonatal acne is a common acneiform presentation for infants because the mother's androgens stimulate the baby's sebaceous glands. This is self-limiting and usually requires no treatment.
Occupational acne, pomade acne and pitch acne are forms of acne in which environmental chemicals help occlude the pores and lead to acne. Acne excori_e des filles (excoriated acne or picker's acne) is a form with no active lesions. It is usually a condition of girls and young women who compulsively pick and squeeze minute ore even nonexistent facial lesions, leading to larger lesions. Healed crusted ulcers, large erythematous adherent crusts and postinflammatory hyperpigmentation are the hallmarks of this disease.
Gram-negative acne sometimes forms after long antibiotic use and a shift in acne flora. This is easily treated with a cephalosporin such as cephalexin 500 mg b.i.d. for 21 days.
Milia are small, white, dome-shaped papules that are very shallow cysts with no follicular opening. These require fine-needle drainage and sometimes expression. Keratolytics sometimes can help cases of chronic milia.12
Some diseases that frequently occur on the face are confused for acne, but are best not treated as acne. With any perioral distribution, I ensure first that the patient discontinue any steroid use at the face. I plan a 3-month course of antibiotics (0.1% metronidazole cream q.d.), and sometimes add a class V or VI steroid, sodium sulfacetamide (Klaron) or both to help in the first few weeks until the erythema subsides.
For rosacea, I use the same formula as for perioral dermatitis, expecting to use topical and possibly oral antibiotics for years. I especially prefer the newer 0.1% metronidazole cream. This seems more effective at reducing erythema quicker and is only applied once a day, but Metrogel and Metrocream are still excellent options. It is crucial to explain to rosacea patients that there are triggers that dilate (flush) the face, and if the triggers can be controlled, then the rosacea should lessen.
A Simple Approach
Many acne and acne-like disorders can be devastating to our patients. With early recognition, we can greatly reduce the risk of permanent scars. "If acne were so simple," I tell my patients, "your doctor would have already noticed your acne and prescribed for you 'the' acne pill or 'the' acne cream, and the acne would be gone by now!"
Unfortunately, acne treatment is a little more complex than that, but it is still very manageable. Ask your patients with noticeable comedones or acne lesions how they feel about their acne and whether they would want a prescription that you could quickly write for them (while asking about their basic skin care). If they simply are asked during a medical office visit, they more likely will tell you exactly what they think, and if they want help. Do not rely on their spontaneity. With some patients, we can do a great deal of good with little effort. Acne is the perfect condition to apply a simple approach and have a tremendous outcome.
I have mentioned many products by name in this article. I hope you use this as a starting point only and expand your treatment of dermatologic disorders based on your personal experiences. I have received no payments for any part of this article and use the products mentioned as a personal choice because of excellent results. *
