Skin Procedures:

Acne Regimen

Acne is a common skin disease that affects nearly 80% of adolescents and young adults aged 11 to 30 years old. It is not unusual for women, in particular, to develop acne in their mid- to late-20s, even if they have not had breakouts in years (or ever). The psychosocial impact is understandably difficult to assess, however, anecdotally we can all relate to the psychological damage when we develop a blemish or see our children fixate on its social ramifications as they try to navigate through adolescence. Acne lesions do not only affect the face; they often affect the back, chest, and other areas with a high concentration of pilosebaceous glands. Acne is a disease of the pilosebaceous unit, involving abnormalities in sebum production, follicular epithelial desquamation, bacterial proliferation, and inflammation. The goals of treatment therefore target opening up clogged pores, decreasing the function of the pilosebaceous unit, killing bacteria, and decreasing inflammation. There are very few conditions that affect over 80% of the population with such severe psychosocial costs.

The choice of therapy in my office is based principally based on the type of lesions and the severity of the acne,

but the degree of psychosocial disability relating to the disease and the presence of scarring may also influence the approach to treatment. In general, this armamentarium includes:

  • Facial cleansers which promote cleaner skin, removal of oils, and bacteria
  • Benzoyl Peroxides
  • Glycolic Acids or Salicylic Acids
  • Topical Antibiotics ( clindamycin, erythromycin )
  • Oral Antibiotics ( tetracycline, doxicycline, minocycline )
  • Combination Topical Antibiotics and Benzoyl Peroxides (eg. Ziana )
  • Topical Retinoids ( Retin-A )
  • Oral Retinoids ( Isotretinoin- otherwise known as Accutane )
  • Photofacial BBL and/or Profractional Laser Treatments

Another way to think about the treatment algorhythm is based on the principles ( as mentioned above ) of opening up clogged pores, decreasing the function of the pilosebaceous unit, killing bacteria, and decreasing inflammation.

Opening up clogged pores
  • Facial cleansers
  • Topical Retinoids
  • Glycolic Acids or Salicylic Acids
Decreasing the Function of the Pilosebaceous Units and Sebum Production
  • Topical Retinoids
  • Photofacial BBL
  • Profractional Laser Treatments
  • Oral Retnoids ( Accutane )
Killing Bacteria:
  • Facial Cleansers
  • Benzoyl Peroxides
  • Topical Antibiotics
  • Combination Antibiotics and Benzooyl Peroxides
  • Photofacial BBL
  • Profractional Laser Treatments

As mentioned above, the algorithm used in deciding how to treat a patient is usually dependent on the severity of the acne. However, one should understand the pathophysiology of what causes acne to truly understand the treatment protocols used in my office in treating a patient with acne.

What causes acne?

No one factor causes acne. Acne happens when oil (sebaceous) glands come to life around puberty, stimulated by male hormones from the adrenal glands of both boys and girls. Sebum (oil), which is produced from the sebaceous glands is a natural substance which lubricates and protects the skin, and under certain circumstances, cells that are close to the surface block the openings of sebaceous glands and cause a buildup of oil underneath. This oil stimulates bacteria (which live on everyone's skin and generally cause no problems) to multiply and cause surrounding tissues to become inflamed. Inflammation near the skin's surface produces a pustule; deeper inflammation results in a papule (pimple); deeper still and it's a cyst. If the oil breaks though to the surface, the result is a "whitehead." If the oil accumulates melanin pigment or becomes oxidized, the oil changes from white to black, and the result is a "blackhead." Blackheads are therefore not dirt, and do not reflect poor hygiene.

Based on the above knowledge, the principles of acne treatment include:
  • Unclog pores
  • Kill Bacteria
  • Minimize facial oils
Manifestations of acne
  • Congested pores ( comedones )
  • Whiteheads
  • Blackheads
  • Pustules
  • Cysts or Boils
  • Scarring
Treatment Algorhythm When a Patient Comes in To See Me
The Mainstay in The Treatment of Mild Acne is counseling on Personal Hygiene:
  • Mild Soaps ( such as Neutrogena or Cetaphil ): used to wash away dirt, irritants, and oils 2 – 3 times per day
  • Benzoyl peroxide (2.5-5%): Applied twice a day as a topical antimicrobial agent to kill bacteria. Benzoyl peroxide also works as a peeling agent, increasing skin turnover and clearing pores, thus reducing the bacterial count there as well as directly as an antimicrobial.
    • It commonly causes initial dryness and sometimes irritation, although the skin develops tolerance after a week or so. A small percentage of people are much more sensitive to it and liable to suffer burning, itching, peeling and possibly even swelling.
    • It is sensible to apply the lowest concentration and build up as appropriate. Once tolerance is achieved, increasing the quantity or concentration a second time and gaining tolerance at a higher level usually gives better subsequent acne clearance
  • Glycolic acids, Salicylic, and/or Alpha Hydroxy Acids: gently exfoliate the skin (opens pores)
  • Warm compresses can be applied to the pustules
  • Astringents / toner- can help by wiping away oils
  • Use a light skin moisturizer ( I prefer kinerase ) as most of the treatments can make your skin feel dry
Moderate to Severe Acne Generally Requires:

The treatment of moderate to severe acne begins with the addition of topical antibiotics and retinoids to the treatments already discussed above for mild acne.

Retinoids: promote cellular turn-over and exfoliation of the epidermis- thereby unclogging the pores. Apply once at night.

  • Retin- A ( tretinoin )
  • Differin ( adapalene )
  • Tazorac ( tazarotene )
  • Adapalene ( may reduce inflammation )

Today, topical retinoids are one of the cornerstones of acne therapy and are recommended as first-line therapy for all but the most severe forms of acne. Topical retinoids are used alone for mild comedonal acne. For more severe inflammatory acne, topical retinoids may be used in combination with benzoyl peroxide and antibiotics and/or hormonal therapy for females. Because of the high prevalence of antibiotic-resistant strains of Propionibacterium acnes, topical antibiotics should no longer be used as monotherapy.

Topical retinoid monotherapy is recommended for maintenance because it prevents formation of microcomedones, the precursor lesions in acne. Combination topical retinoid/antimicrobial therapy ( Such as Ziana ) has become the current recommended standard of care for the management of patients with acne.

The combination retinoid/antimicrobial medications appear to be effective and well tolerated. By reducing the number of medications and applications, fixed-combination products have the potential to improve patient adherence, thereby improving treatment outcomes.

Topical Antibiotics:

  • Clindamycin ( Benzaclin, Duac )
  • Sufacetamide ( Klaron )
  • Azelaid Acid ( Azelex )
  • Erythromycin

Oral Antibiotics: Despite many people's concerns about using oral antibiotics for several months or longer, such use does not "weaken the immune system" and make them more susceptible to infections or unable to use other antibiotics when necessary. Doctors prescribe oral antibiotic therapy for acne only when necessary and for as short a time as possible.

  • Tetracycline
  • Doxycycline
  • Minocycline
  • Amoxicillin
Treatment of Severe Acne (not responsive to Retinoids, Topical and Oral Antibiotics)

The treatment of severe acne not responsive to retinoids, benzoyl peroxide, topical, and oral antibiotics generally requires the addition of more directed treatments. These include one or all of the below options:

  • Isotretinoin ( Accutane )
  • Photofacial BBL
  • Profractional PFX Laser Treatments

Isotretinoin: (Accutane was the original brand name; there are now several generic versions in common use, including Sotret, Claravis, and Amnesteem.) Isotretinoin is an excellent treatment for severe, resistant acne and has been used on millions of patients since it was introduced in Europe in 1971 and in the U.S. in 1982. It should be used for people with severe acne, chiefly of the cystic variety, which has been unresponsive to conventional therapies like those listed above. Those with milder forms of acne often relapse shortly after finishing a course of isotretinoin, making this drug less useful in such cases. This means that isotretinoin is not a good choice for people whose acne is not that bad but who are frustrated and want "something that will knock acne out once and for all."

  • Used properly, isotretinoin is safe and produces few side effects beyond dry lips and occasional muscle aches. This drug is prescribed for five to six months. Fasting blood tests are monitored monthly to check liver function and the level of triglycerides and relatives of cholesterol which often rise a bit during treatment, but rarely to the point where treatment has to be modified or stopped.
  • Even though isotretinoin does not remain in the body after therapy is stopped, improvement is often long-lasting. It is safe to take two or three courses of the drug if unresponsive acne makes a comeback. It is, however, best to wait at least several months and to try other methods before using isotretinoin again.
  • Isotretinoin has a high risk of inducing birth defects if taken by pregnant women. Women of childbearing age who take isotretinoin need two negative pregnancy tests (blood or urine) before starting the drug, monthly tests while they take it, and another after they are done. Those who are sexually active must use two forms of contraception, one of which is usually the oral contraceptive pill. Isotretinoin leaves the body completely when treatment is done; women must be sure to avoid pregnancy for one month after therapy is stopped. There is, however, no risk to childbearing after that time.
  • Another concern, much discussed in the popular press, is the risk of depression and suicide in patients taking isotretinoin. Government oversight has resulted in a highly publicized and very burdensome national registration system for those taking the drug. This has reinforced concerns in many patients and their families have that isotretinoin is dangerous. In fact, large-scale studies so far have shown no increased risk for depression and suicide in those taking isotretinoin compared with the general population. Although it is important for those taking this drug to report mood changes (or any other symptoms) to their doctors, even patients who are being treated for depression are not barred from taking isotretinoin, whose striking success often improves the mood and outlook of patients who have suffered and been scarred by acne for years.

Photofacial BBL: It has long been known that light is helpful in acne. Teens recognize that summer sun diminishes pimples, and wise pharmaceutical companies know that a drug trial ending in sunny months will have an elevated placebo response. Recent years have brought reports of success in treating acne using lasers and similar devices. It appears that these treatments are safe and can be effective. Phototherapy is thought to open the pores, dry and shrink the pilosebaceous units, and modulate the immune system against bacteria

  • Studies have shown a 40% decrease after one treatment and 80% reduction after 4 treatments spaced 1 month apart.
  • The goal of phototherapy using the photofacial BBL is not to permanently treat bacteria; it is to temporarily give relief from severe acne while avoiding potentially systemic toxic medicines such as accutane

Profractional PFX Laser: Fractionated laser ablation devices appears to be an excellent adjust to temporarily reduce acne. Fractionated laser treatment opens pores, kills bacteria, and compromises the pilosebaceous unit.

  • Studies have shown a 50% decrease in acne after only one treatment with results lasting for up to a month.