By Dr Zohra Zaidi, Dr Zarnaz Wahid & Dr Jawed Usman
Acne is a common disorder. It occurs at the time when young adults are conscious of their looks and appearance. Acne at this age can be a cause of great psychological stress. The acne patient is often found depressed, has low self-esteem, there is frustration, anger and embarrassment. The acne patient can become anti-social and may at times have suicidal tendencies.
In developed countries scientist are speaking of gene therapy, targeting disease with monoclonal antibodies. We in our part of the world are still struggling in treating disorders which can easily be prevented and cured. Acne is one such disorder, which, if properly treated, will result in a clear skin without scars and pigmentation. Scars are a stigma for life. A simple awareness of acne can prevent these complications.
Acne is a chronic inflammation of the pilosebaceous units characterised by the formation of comedones, papules, pustules, at times nodules and cysts, and in some cases by scar formation. It occurs in those parts of the body where sebaceous glands are most numerous as the face, chest and back. The disease generally resolves by the mid-twenties. In some cases it persists, this may be due to other causes as cosmetic, occupation, drugs etc., or due to persistence of the etiological factors mentioned below.
Pathophysiology of acne
The sebaceous glands produce excessive amounts of sebum under the influence of androgens at the time of puberty. This along with other factors results in abnormal keratinization of the epitheliums of the pilosebaceous duct; this presents clinically as the white and black comedones (non-inflammatory lesions of acne). Comedones are temporary structures; they undergo cyclical growth. Extracted blackheads regrow in 2-6 weeks. Some comedones are blocked by hydration; this explains the development of premenstrual and tropical acne. Corynebacterium (C) acne is normally present in the pilosebaceous duct; their growth is influenced by various factors: as oxygen tension, PH, and nutrient supply. They grow well when subjected to low oxygen tension as seen in acne. The increased proliferation of C acne is followed by inflammation and the formation of papules and pustules. These changes are brought about by the leukotrienes, prostaglandins enzymes liberated by C acne and ductal corneocytes.
To summarise, the following changes occur in acne:
• Increased sebum production
• Ductal hypercornification
• Bacterial proliferation
• Mediation of inflammation
Assessment of acne
For proper management of acne its assessment is necessary. There are a number of ways of assessing acne. The two common methods used are the lesion count and grading of acne. The lesion count is helpful for clinical trials and the grading of acne in routine clinical practice. We treat acne according to the type and severity of acne. Acne is graded as follows:
• 0-Normal skin, with no evidence of acne vulgaris
• 1-Few non-inflammatory and few inflammatory lesions present
• 2-Multiple non-inflammatory and inflammatory lesions, non-inflammatory lesions predominate
• 3-Multiple non-inflammatory and inflammatory lesions, inflammatory lesions predominate. Few nodules/cysts may be found
• 4-Severe acne with nodules and cysts
(Note: Always palpate the skin while examining acne patients as sometimes papules and nodules can only be felt and not seen because they are deep in the skin. A wrong grading will result in wrong treatment.)
Management of acne
Acne is treated according to the severity of acne, type of lesions present: non-inflammatory (comedones) or inflammatory (pustules, cysts and nodules). Acne treatment is aimed at targeting the abnormal pathology present:
• Reduce abnormal sebum production
• Reduce the number of C acne
• Normalise the abnormal keratin
The other factors to be taken into consideration when treating acne is the duration of acne, the previous treatments, the psychological impact of acne on the patient, the socio-economic status of the patient and the compliance of the patient.
There are numerous anti-acne drugs available in the market, some acting against the non-inflammatory (comedones) and some against the inflammatory lesions, some act on both of them. We have to prescribe the medication after assessing the patient on the factors described above. Mild acne can be treated by local medications.
A systemic treatment is required in the following cases:
• Severe acne
• Acne not responding to local treatment
• Prolonged history
• Acne excoriee
• Patients with gram negative folliculitis
• Active acne, causing post inflammatory hyper pigmentation and scarring
Total treatment
The non-inflammatory lesions respond to keratolytic agents and the inflammatory lesions to antibiotics. There are a number of topical preparations available in the market; most of them act on both lesions.
• Those that are mainly comedogenic are: the vitamin A derivatives, azeliac acid, salicylic acid, benzoyl peroxide
• Those that are predominantly antimicrobial are: clindamycin, erythromycin, tetracycline, benzoyl peroxide, azeliac acid
• The predominantly anti-inflammatory drugs are: antibiotics, adapalene (third generation retinoid)
The keratolytic agents often irritate the skin and can cause dryness. This side effect should be explained to the patient before initiation of therapy; the use of moistruisers and adjusting the application schedule can minimise this side effect. Patients often avoid to use anti-keratolytics; this is a cause of therapeutic failure.
It is important that while applying the topical therapy it should be applied to the whole area prone to acne and not just to the acne spots. The reason being that the apparent normal skin adjacent to the acne lesion is likely to have microscopic lesions not seen by the naked eye. In most cases it is appropriate to use an anti-inflammatory agent in the morning and a comedolytic in the evening.
Acne is a common disorder; so are the myths associated with it
Systemic treatment
Oral medications for acne include the antibiotics, hormones and the retinoids. Other drugs, which may be used, are dapsone, trimethoprin, clofazamine, zinc sulphate and clindamycin. The oral medication has to be used for a minimum of six months. Only 20 per cent improvement is to be expected at the end of two months, 60 per cent improvement by the end of four months and about 80 per cent at six months. Most of the patients expect a dramatic improvement as soon as the treatment begins and often complain of the failure of treatment at this time. They then run from doctor to doctor, not only spending time but also spending a large sum of money. It is important to warn the patient of the duration of treatment on the first visit. Some patients do not want to take the antibiotic for such a length of time; they think it will harm the body system. No such side effects occur by acne treatment; acne is treated all over the world with this standard therapy.
Oral antibiotics are widely used throughout the world. The tetracyclines are the treatment of choice. These include tetracycline, oxytetracycline, minocycline and doxycycline. The tetracyclines and erythromycin should be given in a dose of 1gm a day. The tetracyclines should be given 1/2 hour before meals and should be taken with water not milk, which interferes with its absorption due to chelation with calcium containing foods. Minocycline and doxycycline are given in a dose of 100mg/day.
Hormonal therapy should be used when antibiotics fail. The hormones commonly used are the oestrogens and the anti-androgens. Cyproterone is often used in combination with oestrogen. This treatment is given to selected female patients. A standard screening work-up of androgens should be done before prescribing hormonal therapy. The risk of hormonal therapy requires regular beats and pelvis examination to guard against the risk of certain types of cancer. Topical cyproterone is not very effective, but trials are going on to find a suitable vehicle for this anti-androgen. Oral cyproterone is not used in men as it decreases libido, produces gynaecomastia and azoospermia.
The retinoids have revolutionised the treatment of acne, isotretinoin (roaccutane); it is the drug of choice in difficult cases of acne. It acts on all the areas of pathogenesis. i.e. reduces sebum production, reduces the number of C acne and inflammation and corrects the abnormal keratinization. The drug has to be monitored very carefully due to side effects; it is also teratogenic. Roaccutane should not be given in pregnancy and pregnancy should be excluded before starting treatment. A dermatologist should only prescribe retinoids.
Other modalities
Intralesional steroids are used for large inflamed cysts; if injected deeply skin atrophy may occur, so one has to be very careful while injecting the steroids. It should be in the right dilution and at the correct site in the skin.
Dermabrasion and collagen injection may be used for some cases of superficial scarring. Deep scars do not respond to dermabration. Persistent non-inflamed cysts can be excised. Blue light reduces the number of C acne.
For resistant comedones, superficial peeling and electrodessication are effective. Peeling can lead to numerous side effects; expert hands should only use it.
Regardless of the treatment, the patient should observe the following guidelines:
• Do not squeeze the pimples
• Use non-comedogenic cosmetics
• Gently wash the face 2-3 times a day, depending upon the greasiness of the skin; too much washing may worsen acne air borne grease, clothing or sporting equipment
• Avoid things that grease acne, as blocking of the pilosebaceous ducts by oil
• Avoid drugs that aggravate acne oral contraceptives that contain progestogens, halogens, phenobarbitone, isoniazid, androgens and lithium
• Avoid hot and humid climate
Acne is so common a disorder; so are the myths associated with it. Much folklore exists regarding diet and acne. There is very little scientific proof to implicate that diet plays a significant role in acne, but studies are going on. Do not lay too much importance regarding food until there is some scientific evidence.
Conclusion
Acne is a very common disorder but it is unfortunate that there is no awareness of the disease in Pakistan. Acne, if properly treated in its early stages, should not give rise to nodules, cysts and scar formation. Scars are permanent and cause disfigurement for life. Instead of running from doctor to doctor and spending large amounts of money, the patients of acne should know that the disease can be kept under control.
Acne is a common disorder. It occurs at the time when young adults are conscious of their looks and appearance. Acne at this age can be a cause of great psychological stress. The acne patient is often found depressed, has low self-esteem, there is frustration, anger and embarrassment. The acne patient can become anti-social and may at times have suicidal tendencies.
Other modalities
