HOW TO TREAT ACNE

Welcome to The Acne File: How To Treat Acne.

You looked into the mirror this morning and found a blemish. Could it be the start of a pimple?  Oh! no! This is just what you don't need!   Now what are you going to do?  Well, you could pick at it, or squeeze it to get the gunk out and hopefully it won't be so noticeable (actually that could make it worse). You could put a bandage over it, maybe no one will notice. Or,

cover the blemish with makeup and clog up your follicle pores and risk additional acne breakouts.

 

I used to cry in front of the mirror and wish the acne would just suddenly vanish. I tried a lot of home remedies and cures for acne hoping that one of them might work and rid me of acne once and for all. When all the cures had failed, I felt that I was caught in a nightmare from which there is no escape. Though my family was kind and supportive, that just didn't seem like enough. No matter how kind my parents’ were they could not make people stop staring at me in the street. It got so bad that I lost interest in school and sunk into depression.  I felt I was doomed to be the “girl with a bad case of acne” for the rest of my life.

 

Some Basic Acne Information

What is Acne?
Acne, aka Acne Vulgaris or "common" acne, is a skin disease that affects 60% to 70% of Americans at some point in their lives but is most prevalent among adolescents and young adults.  Acne may occur on the face, chest, back and sometimes more extensively on the body. Usually, but not always, acne sufferers have oily skin.

Acne Vulgaris is a disease of the pilosebaceous unit (PSU) found just under the skin.

Numerous on the face, upper back, and chest the PSU contain glands called "sebaceous glands" that connect to hair follicles and produce an oily substance called "sebum" that normally flows up the hair follicle and out onto the skin, through the hair follicle pore, to moisturized the skin and hair.

Acne Vulgaris is characterized by noninflammatory, open or closed comedones and by inflammatory papules, pustules, and nodules.

A mulitfactorial skin disease, researchers and scientists list several factors for the cause of and aggravation of acne:

• Genetics. If both parents had acne then it is expected that 3 of 4 children will develop acne. If one parent had acne then the expectation is 1 out of 4 children will also have acne.  Of course, similar to other genetic conditions, not every generation will exhibit the condition and show no signs of acne. According to researchers the inherited factor is what is the hyper proliferation of follicular epidermal cells which increases the chances of plugged follicle pores.
• Sex Hormones. Androgens (male sex hormones) increase in both boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum.  More boys than girls have acne during adolescence and more adult woman than men develop acne vulgaris. 
• Excess Sebum Production.  Sebum, the oil that is produced by the Sebaceous gland, is regulated in production and excretion by a couple of different hormones and biological mediators. Androgens, growth hormones, and insulin like growth factor can increase the production of Sebum. The more Sebum produced, the more likely a follicle pore will be plugged.
• Propionibacterium acnes.  Propionibacterium acne (P. acne)is an anaerobic bacterium that is present on most people's skin and lives on the fatty acids in Sebum. When the follicular pore is blocked P. acne will grow and release a chemical that breaks down the follicular pore wall. This can introduce Staphylococcus into the skin and create inflamed acne lesions.  A hypersensitivity to P. acne can result in inflammatory acne for some acne suffers and not others.
• Cosmetics.  Certain cosmetics and hair products may worsen existing acne. Cosmetics that have noncomedogenic or non-acnegenic claims on labels are the best to use for acne prone skin.
• Medications.   Some medicines can cause or aggravate acne, however the reason is unclear. These medications include, steroids, antidepressants (lithium, amoxapine), some anti epileptics, iodides, bromides, chlorides and  B vitamins.
• Environmental irritants.  Pollution and high humidity can account for some acne aggravation as can certain Fungicides, Insecticides, Herbicides and Wood preservatives that come in contact with the skin.
• Mechanical occlusion.  Pressure from sports equipment, tight uniforms, headbands, hat bands, under-wire bras, backpacks, tight collars and other similar items.
• Excessive sunlight.  Excessive sunlight will either improve acne since it is anti-inflammatory, or cause the acne to flare. Regardless, the ultraviolet exposure ages the skin and lead to skin cancer.  

 
Acne occurs when sebum is blocked from exiting the hair follicle pore and creates what is called an Acne lesion on the skin.  As mentioned, common acne (acne vulgaris) is the resulting disease of the skin when the pore is blocked by sebum and dead cells. The area around the hair follicle will swell since sebum can no longer drain onto the skin.

The affected follicle are called comedones which is the plural form for comedo. Comedo is Latin for glutton and back in early, early medicine it was believed that the contents of a comedo were the remains of gluttonous worms.  

The forms of noninfalmmatory comedo are, Microcomedo which is the smallest and start of an acne lesion, the closed comedo or "whitehead" that has an obstructed opening to the skin and, opened comedo or "blackhead" has a wide opening to the skin that is capped with a blackened mass of skin debris and dried sebum.  

It can take up to two (2) months for a closed comedo (whitehead) or open comedo (blackhead) to develop on the skin. This means that you have had acne longer than you realized by the time a "whitehead" or "blackhead" appears.

Mouse over each image for actual acne picture.
  

          Whitehead               Blackhead

     

If it took a couple of months for the noninflammatory acne leisons to show up, imagine how long it took for that first inflammed pimple to show up.  

Better known as papules, pustules and the nasty, larger, deeper nodules, the inflammatory acne lesions are just as it sounds, inflammed, red, swollen, larger and usually painful.  These inflammed lesions are all closed comedo with the pustule being the most recognizable as the "zit" as it swells and begins to rupture on the skin. Forming a pustular (puss) heads of various size.

 

Usually when you "pop" a pimple you're rupturing a pustule and causing damage to the skin.  So instead of a "pimple" or "zit", you now have a cutaneous open wound that can become infected and cause skin damage and scarring.  That's why your told not to pop that "zit".

   

The papules become large, red, swollen and inflammed above the skin surface but without the "puss" factor.  The papule is deeper in the pore follicle with a thicker layer of keratinized skin and does not develop the puss head like the pustule.

   

Nodules, sometimes called "acne cysts", are large, hard and painful swellings below the skin surface.  As the nodule develops it becomes extremely inflammed and will rupture through the pore follicle causing pain. Because the nodule is deep in the pore structure scarring usually results in the skin when the nodule ruptures.

 

Nodules usually will require medical treatment beyond that of over the counter topical acne care.

Mouse over each image for an actual picture of acne.

Pustule

Papule

      

          
                       

Nodule

Additional information regarding different forms of acne and severe acne can be researched  at the National Library of Medicine (active link).

Acne Treatment Options

There are numerous ways to treat acne; allopathic, homeopathic, naturopathic, holistic, homemade, diet based, faith based, etc, the list goes on.  But you need to know that what ever treatment or method someone uses to clear and control their acne problem, that works, is the best treatment option for that person.

When you choose a treatment plan it is imperative that ,if possible, you stick with it. It can take from 2 to 8 weeks, sometimes longer, for the treatment to work. And, usually the symptoms will worsen before the acne begins to clear because most all treatments involve removing and replacing the damaged skin cells.

Applying any topical lotion, cream, ointment, oil, foam, even vinegar can cause skin irritation and redding, so don't expect anything less of a medicated product to treat acne.

In short, your acne probably will get worse in the beginning with any treatment but that is to be expected.  So don't stop the treatment because it's part of the process.

Let's start with the treatment for the most severe treatment resistant acne.

Intralesional Corticosteroid Injections.

Intralesional Corticosteroid Injections are used when nodulocystic acne is severely inflamed and oral or topical medications are not effective and deep scarring is possible.

A type of acne surgery, the physician injects a diluted solution of corticosteroid into the cyst.  As a strong anti-inflammatory drug, cortisone quickly reduces the cysts inflammation and enhances the healing process.

This type of treatment can show skin improvement in 3 to 5 days.  Other drugs such as bleomycin, stibogluconate, interferons and 5-flurouracil are used.
 

Isotretinoin.

Isotretinoin AKA- Accutane(no longer manufactured and distributed in the USA), Roaccutane, Amnesteem,  Claravis, Sotret, Accure isotrentinoin is a retinoid class of drug used orally to treat severe nodular or cystic acne that has not improved with use of other treatments.

Developed by La Roche Pharmaceuticals in 1982, and called Accutane,

A retinoid is a derivative of vitamin A, which means that it is synthetic or natural compound related in structure to vitamin A, used to treat various diseases of the skin including acne and certain cancers.

Used orally Isotretinoin functions to reduce the production of sebum by causing cell death in the sebaceous gland which shrinks the gland, disrupts keratinization (hardening) of the cell, allowing the cell to slough off easier and reduces the growth of bacteria. Isotretinoin also has an antimicrobial property that kills Propionibacterium acnes.

Oral Isotretinoin treatment is very effective in completely clearing acne for the majority of patients. The treatment is extremely successful in preventing acne scarring that is associated with severe forms of acne.  

Treatment with oral isotretinoin can last from 4 to 7 months. If the first treatment does not help, a second series of treatment can began in about 2 months.

Oral Isotretinoin can be the best treatment protocol for individuals with severe nodular cystic acne, in fact studies have shown that 80% of those acne sufferers that are treated with oral Isotretinoin are cleared of acne and decrease scarring.

This form of treatment also has some negative attributes. Some of these negatives are:

• Possible liver damage - hepatotoxicity
• Possible bone loss - hypercalcemia
• Could trigger pancreatitis - increased levels of triglycerides
• Could cause birth defects - known teratogenic
• Could cause depression - no studies available to confirm this
• Very common to cause dry eyes, lips,mouth, nose, or skin
• Results in nosebleeds; muscle aches; sensitivity to the sun
• Causes itching and poor night vision

Because of these side effects, especially teratogenicity (birth defects), the use of oral Isotretinoin has to met certain requirements imposed by the FDA.

Since April 2002, a system has been in place to eliminate birth defects by preventing pregnant women from being prescribed Isotretinoin. The system called SMART (System to Manage Accutane Related Teratogenicity) was eventually classified a failure and in March 2006 a new program call IPLEDGE was instituted to restrict and control the dispensing of Isotretinoin in the USA.

Isotretinoin has restrictive use in other countries including; the United Kingdom, Australia, New Zealand, Mexico, Colombia, and Brazil.

As a side note, as of June, 2009 Accutane is no longer available in the United States because La Roche Pharmaceuticals discontinued the manufacture and distribution of the drug.  Other Isotretinoin products are still available.

Oral Antibiotics.

Oral Antibiotics are the most widely used treatment for acne and are a very effective treatment for severe inflammatory acne when topical treatments have been ineffective.

It is necessary for the antibiotic to have contact with the offending bacteria to be effective and if the follicle pore is plugged a topical antibiotic won't reach the infected area of the sebaceous gland.

Oral antibiotics rely upon the the bodys system to gravitate to the infected site and reduce the bacteria numbers and inflammation caused by the infection.

Some of the oral antibiotics used in the treatment of acne include:

•  Erythromycin


•  Minocycline


•  Doxycycline


•  Lymecycline


•  Trimethoprim


•  Tetracycline      

Treatment duration can vary, from 3 weeks to show some improvement to 6 months for maximum benefit with 3 months treatment as a minimum.  There have been few, if any, detailed studies to provide a good guideline.

As with any treatment modality there are risks of side effects. Erythromycin can cause GI upset, doxycycline can make you hypersensitive to the sun, minocycline can create a feeling of dizziness and tetracyclines should not be given to pregnant or lactating women or to children under age 9 due to potential development of bone and teeth abnormalities.

Using Tetracycline(s) while on high doses of vitamin A may increase the risk of a condition called intercranial hypertension which is a rise in the pressure of the brain fluid.  Inform your physician if your self treating with vitamin A before taking tetracycline(s); tretacycline, minocycline and demeclocycline.

Because tetracyclines are broad-spectrum antibiotics good and bad bacterium are effected and onset of bacterial resistance can limit the effectiveness the treatment.

Oral antibiotic treatment will take time to show results. As mentioned above anywhere form 3 weeks to 3 months for recognizable improvement to 6 months for maximum benefit.  Any adjustment to the plan of treatment will probably extend the treatment time so be prepared to spend the time.

Oral treatment is usually companioned by topical antimicrobials including benzoyl peroxide,azelaic acid, antibiotics, retinoid or a combination of these products. 

Topical  Antimicrobials.

Topical Antimicrobials have the ability to inhibit the growth of or outright kill certain microorganisms.  The primary function of topical antimicrobials is to reduce the numbers of Propionibacterium acnes (P .Acne) ,the bacteria responsible for inflammation and the development of severe forms of acne.

Some antimicrobails are broad spectrum non-prescription antiseptics that can be used at home on a daily bases and contain chemicals such as alcohol, peroxide, benzoic acid, carbolic acid and specifically benzoyl peroxide.

Some are prescription prescription only, non-antibiotic, antimicrobials such as azelaic acid 15%-20% gel or cream, while others are broad spectrum prescription antibiotics including erythromycin, clindamycin, tetracycline and sodium sulfacetamide.

Although non-antibiotic antimicrobials and antibiotic antimicrobials reduce the numbers of P.Acne and ultimately reduce the associated inflammation, the manner which antimicrobials use to attack the P.Acne is important for treatment success.

Antibiotic antimicrobials are naturally occurring or semi-synthetic bacteria that are bacteriostatic and usually work by interfering with developmental aspects of bacterium. An example is tetracycline, this antibiotic inhibit the bacterium cell growth by interfering with binding function of an amino acid to the ribosome of the cell. Without this amino acid the bacterium cannot grow, multiply and increase infection growth and inflammation.   

Because bacterium, in this case P.Acne, are evolving living cells certain cell have developed defense mechanisms to resist antibiotic actions. As a result, the bacterium become resistant to antibiotics and continue to flourish. This is particularly true for tetracycline.

Antiseptic antimicrobials on the other hand are bactericidal, and their action is to destroy the bacterium.   The bacterium, P.Acne, is unable to develop a resistance to the antiseptic action.

Benzoyl peroxide and Azelaic acid are are the two most common antiseptic antimicrobials used to treat P.Acne and are used as part of the topical antibiotic treatment regime.

Azelaic acid,a natural dicarboxylic acid found in wheat, barley and rye, has the ability to resolve the abnormal keratinization (hardening) of skin cells (epithelium) on the epidermis and those affected skin cell lining the follicle wall when applies as a cream at 20% active formulation. This allows the skin to soften and slough off properly on the surface and unblock the follicle enabling sebum to flow to the surface. The ability to penetrate the upper layer of the dermis provides azelaic acid the opportunity to treat follicle kertinized skin cells as well as surface cells.
 
Azelaic acid as an antimicrobial agent interferes with protein synthesis in the bacteria P.Acne which reduces the growth of P.Acne in the follicle and on the skin surface. The reduction of P.Acne and ultimate reduction of the waste fatty acids help in reducing inflammation associated with acne.

Clinical studies have shown Azelic acid to be as efficacious as Benzoyl peroxide in reducing surface bacterium count in controlled situations.   

Side effects of the medication include:

• Site irritation
• Itching
• Dryness
• Burning
• Redness
• Skin peeling
• Skin discoloration

Approved in 1995 as a prescription only product in the U.S., Azelaic acid for acne is sold as a cream, AZELEX® 20%.

In Europe it is sold as Skinoren Cream 20%. 

Although the patent on the drug has expired in the U.S.A., there are no approved generic equivalent on the market. So it's not advisable to buy a "generic" from an online pharmacy.

Azelaic acid is also available for Rosacea in the U.S. as a gel sold under the name Finacea gel 15%.


Benzoyl Peroxide has been a mainstay of the acne treatment in the U.S. since 1934.  As a monotherapy Benzoyl Peroxide usually is one of the first over the counter (OTC) treatments acne sufferers will use.

That's not hard to understand especially since there is well over 100 + products containing some form of therapeutic level of Benzoyl Peroxide that is marketed as OTC or are prescription only topicals for acne treatment.

The FDA provides a list of 200 + product labels both OTC and Rx, but admits it's an incomplete list. The FDA does not review or approve OTC medications. As long as the OTC meets established regulations and conforms to set policies the OTC can be marketed.

Therapeutic strengths of Benzoyl Peroxide start from a low of 2.5% to a high of 10% of total carrying solution.  It's best to start with the lowest % of active ingredient as benzoyl peroxide can be uncomfortable on the skin as it degenerates.

One of the first organic compounds synthesized, Benzoyl peroxide is the product of  hydrogen peroxide and  benzoyl chloride.  Classified as a lipophilic oxidizing agent, benzoyl peroxide is attracted to  lipids (oily organics) in bacterium and in the keratinocyte (outer layer of skin cells) because the compound is easier dissolved in lipids than in water. The molecular size of benzoyl peroxide allows deep penetration in to the skin and more access to affected areas in the follicle.

As it makes contact with the skin benzoyl peroxide begins to break down into benzoic acid and oxygen. During this decomposition benzoyl peroxide acts as an oxidizing agent deteriorating keratinocyte and bacterium.

The half life of Benzoly peroxide once applied to the skin is about an hour, depending on surface temperature. It breaks down into oxygen and benzoic acid which is eliminated in the urine.

Because of the ability to penetrate the skin and kill P.Acne, benzoyl peroxide is used as a co-agent in prescription acne topicals including:   

• ACANYA GEL;  BENZOYL PEROXIDE 2.5%; CLINDAMYCIN PHOSPHATE 1.2%.
• BENZACLIN GEL;  BENZOYL PEROXIDE 5%; CLINDAMYCIN PHOSPHATE 1%.
• BENZAMYCIN GEL;  BENZOYL PEROXIDE 5%; ERYTHROMYCIN 3%.
• BENZAMYCIN PAK GEL;  BENZOYL PEROXIDE 5%; ERYTHROMYCIN 3%.
• DUAC GEL;  BENZOYL PEROXIDE 5%; CLINDAMYCIN PHOSPHATE 1%

Brand Names of Benzoyl Peroxide products.

Acne-10,Acne-5, Acne-Clear, Acnigel, Ance 10, Ben-Aqua, Benoxyl 10,
Benoxyl 5, BenzEFoam, Benzac, Benzagel, Benzagel Wash, Benzashave,
Benziq, Benziq LS, Binora, Brevoxyl, Caraderma, Clean and Clear,
Clean and Clear Advantage Breakout Erasing Cleanser, Clear By Design,
Clearasil, Clearplex,  Clearskin, Clinac, Del-Aqua,  Delos, Desquam, Ethexderm,
Face Up, Fostex, Glytone Acne 3P, Inova, Lavoclen, Loroxide, NeoBenz Micro,
NeoBenz Micro Wash, Neutrogena Acne Mask, Neutrogena On Spot Acne Treatment, Oscion, Oxy 10, Oxy 10 Balance, Oxy Balance, Oxy Daily Wash,
Oxy Vanishing Gel, Pacnex, PanOxyl, Peroderm, Peroxin A, Peroxin A 10,
Persa-Gel, Proactiv, Relovox, Repiderm, Seba-Gel, Soluclenz, Theroxide,
Triaz, Unblemish, Vanoxide, Zaclir, Zeroxin, ZoDerm 4.5, ZoDerm 5.75,
ZoDerm 6.5, Zoderm, Zoderm 8.5

Some of the possible side effects of Benzoyl Peroxide.

• Excessive dryness of the skin 

• Excessive peeling of skin

• Warm feeling of the treatment area

• Unusual tingling on the skin

• Stinging during and after application

• Can bleach hair and clothing

It takes time to adjust to using the product and will take some time to see results. So be prepared to spent a month or two before you see improvement.