Blemishes, zits, pimples.
These are all common names for the skin disease called acne. Acne is so common during childhood and teenage years that it is considered a normal right of passage. However, when the acne becomes so severe that there is either ridicule from friends or actual disfigurement of the face, then medical treatment becomes necessary. First, let us describe all of the different types of skin lesions that may be found in acne. The pearly lesion of acne is the open comedo or blackhead. An open comedo is a hair follicle opening that is blocked by accumulated skin cells. The dark color is caused by oxidation of the protein on exposure to hair. A closed comedo, also called a whitehead, is the skin lesion which has a thin layer of normal skin overlying it and is not exposed to the air. Both of these lesions may rupture or break open and expose their contents to the surrounding inflammatory cells in the skin. When this happens, the next skin lesion that will be observed is a red raised bump which dermatologists call inflammatory papules and patients call a pimple or a zit. Sometimes the inflammatory papules develop a collection of pus or white blood cells on the surface and would then be called a pustule. A deeper and more serious type of inflammation may develop below the surface of the skin and this would become a cyst which is usually very painful to the patient as well as being disfiguring. All of the inflammatory types of acne lesions including papules, pustules, and cysts may heal with scarring, especially if they are squeezed or otherwise manipulated by the patient. That is why mothers and dermatologists frequently recommend that patients not “squeeze their pimples.”
What are the causes of Acne?
There are several contributory factors to acne, but it is known that it is necessary to have the four following factors in order for acne to develop:
Because acne can be such an emotionally charged issue as well as a devastating skin condition, there are many questions and myths surrounding acne that can be dealt with simply at this time.
Acne Treatment
The earliest and simplest cases of acne probably began in pre-pubescent children around 10-12 years of age. They can be treated with the few over-the-counter agents that are effective for acne. We recommend the cleansers that contain 2% Salicylic acid (Neutrogena oil-free acne cleanser and store brand), astringent or dry agents that contain rubbing alcohol or acetone, and the Benzoyl peroxide products which are available as cleansers and gels in 5 and 10 percent concentration. These medications are effective for mild cases with oily skin, but if inflammatory papules and pustules persist, then a consultation with a dermatologist is recommended for prescription medications which are much more effective. Medications for acne may be prescribed by the topical or local application route or by the systemic or internal dosing route such as by tablets or capsules. First we will cover topicals by medication category.
TOPICALS
Retinoids: Synthetic medicines derived from Vitamin A which causes normalization of skin cell growth within hair follicles allowing for the reduction of the obstruction to the opening to the skin surface, thereby preventing blockage, bacterial overgrowth, and rupture.
Tretinoin: Tretinoin is Vitamin A acid. It was first developed as Retin-A and is available in various concentrations of creams and gels. It is very effective for treatment of all forms of acne except for the deep cystic nodules.
Adapalene: Originally called Differin is also available in cream and gel form and may be slightly less effective than Tretinoin but also is less irritating to the skin.
Tazarotene: Available in different concentration of creams and gels is a synthetic aromatic form of Vitamin A that is slightly more irritating than Tretinoin but probably more effective at normalizing the cell growth within the hair follicles. This drug is also approved for the treatment of psoriasis which is definitely a disease of abnormal skin cell growth recognized by thick red raised scaling plaques on elbows and knees.
ANTIBIOTICS
Benzoyl Peroxide Products: These are available as creams, gels, and cleansers, both by prescription and over-the-counter in varying concentrations from 2.5%- 10%. Drying of the skin and irritation increases with the concentration of the drug. Benzoyl peroxide is a mild antibiotic for the skin. Some of the benefits may result from the exfoliation of the skin caused by the drying effect.
Erythromycin: This is one of the first antibiotics available in topical form for the treatment of acne. Antibiotics are used for both their antibacterial effect and anti-inflammatory effect on acne. Because Erythromycin has been around so long for the treatment of acne, many of the bacteria have become resistant to it, and therefore may not be as effective as Clindamycin.
Clindamycin: Clindamycin is available in liquid solution, and gel form. It is very effective at helping to clear mild to moderate superficial inflammatory acne lesions.
Combination: After years of use of Erythromycin and Clindamycin topically in the treatment of acne, it became apparent that these medicines were losing some of their effectiveness because the bacteria were becoming resistant to the antibiotic effect of these drugs. They were able to maintain their anti-inflammatory effects, however. With the addition of Benzoyl peroxide to the treatment regimen, antibiotic resistance has been delayed. Therefore, pharmaceutical companies have developed active combinations of two anti-acne drugs in one cream or gel. For example, Clindamycin has been combined with Benzoyl peroxide, Erythromycin has been combined with Benzoyl peroxide and Benzoyl peroxide has been combined with Adapalene.
Anti-Inflammatory: A new topical drug for acne has been approved called Aczone which is 5% Dapsone gel. It is a new class of acne treatment which has been available as an oral drug for many years but considered to be too toxic for the treatment of acne. The topical formulation is safe and without significant side effects, however, it is only mildly effective for acne. It may be useful in combination with some of the other medications in this list to substitute for other medications that have either been too irritating or cause allergies.
ORAL AGENTS
ANTIBIOTICS
The Tetracycline class of antibiotics was the first oral and topical antibiotic that came into general use. The topical formulation was dropped because it made the skin glow in ultraviolet light, not a pretty sight in the discotheques of the 1980’s. These medicines are very effective as antibiotic and anti-inflammatory drugs because they are concentrated in the oily or lipid layers of the skin including concentrating in the sebum where the P.acnes bacteria grow. Tetracycline is very safe and inexpensive. Occasionally people may suffer from mild gastrointestinal side effects and women may develop vaginal yeast infections as with any other broad spectrum antibiotic. There are some minor disadvantages: 1) Tetracycline is best taken on an empty stomach which means one hour before or two hours after a meal. This may be difficult for some of our busy teenage patients that find themselves eating snacks throughout the day. 2) Tetracycline may not be taken with dairy products at the same time as swallowing the capsule because the calcium in milk or cheese prevents the antibiotic from being absorbed well into the bloodstream. So it is best to take the capsule on an empty stomach with a full glass of water. 3) Tetracycline is slightly sun sensitizing. That means that you may be more likely to get a sunburn even after a shorter exposure to the sun than usual. This can be more of a problem to patients who live in southern or tropical climates where it is sunny even during the winter.
To overcome some of the shortcomings of Tetracycline, different but related chemical derivatives of Tetracycline were developed. One of these is Doxycycline. It may be taken with food or dairy products. It has slightly more gastrointestinal side effects than Tetracycline and is definitely more sun sensitizing than Tetracycline. The patient must be willing not to get excessive sun exposure while taking the medication and to diligently use sunscreens which are broad spectrum, that is, blocking both UVB and UVA. Minocycline is also very effective for all forms of acne including cystic acne. It concentrates in the lipid fractions of skin very well. It is less likely to cause gastrointestinal side effects than Doxycycline and is much less sun sensitizing than Doxycycline. One disadvantage that occasionally occurs is darkening of the skin either generalized after sun exposure or in healing inflammatory lesions or bruises.
None of the Tetracycline antibiotics should be given during pregnancy because the medication accumulates in the forming teeth and bones of the developing fetus. For the same reason, Tetracycline should not be given to children until after puberty when their bones stop growing at about age 16.
While it is uncommon, some patients develop rashes or hives when taking Tetracycline antibiotics. If that happens, the antibiotic must be stopped and usually cannot be substituted with another antibiotic in the same category.
Erythromycin
Erythromycin is also one of the first medications that was used for acne in both topical and oral form. Most of the bacteria have developed resistance to Erythromycin, and it is considered not to be as effective as the other alternatives listed here. However, because it is cheap and relatively safe, it can be tried as a second line therapy for a patient who cannot tolerate the Tetracycline antibiotics.
Sulfa containing antibiotics such as Bactrim and Septra which are most often used for urinary tract and other infections, are also very effective for certain forms of acne, especially in older females who have tried many of the other treatments. Naturally, if the patient is known to be allergic to Sulfa containing antibiotics, they cannot be used. There is also a fairly high incidence of developing rashes from taking Sulfa antibiotics. Again, if this happens, then the medication must be stopped immediately. There is also a slight amount of sun sensitivity associated with Sulfa-containing antibiotics, and the patient must be aware of their tendency to sunburn more easily and to avoid tanning salons and therapeutic ultraviolet light.
Clindamycin
Clindamycin is very effective for acne and other acne-like diseases. The main side effect is that it can cause diarrhea which may lead to a more serious condition called colitis. This side effect was once considered to be more common than it is today, so the drug may have been under utilized. Clindamycin has been making a comeback of sorts, again especially for patients who are either resistant or intolerant to the other antibiotics on this list.
RETINOIDS
The only retinoid or Vitamin A derivative that is approved for the treatment of acne in the U.S. is Isotretinoin, which is better known by its original brand name Accutane. This medication is remarkably effective at healing the most severe and resistant forms of acne which are usually cystic and scarring and involve the face as well as the back and chest. It has many minor side effects which relate mostly to dryness of the skin and mucous membranes, but it is notorious for its more serious side effects which include teratogenicity (the ability to cause birth defects in women who are pregnant at the time of taking the medication), causing mood changes that may result in depression and suicidal thoughts, and diarrhea which may lead to inflammatory bowel diseases (ulcerative colitis and Crohn’s disease). Because most of our acne patients are young and therefore of childbearing potential, the Federal Drug Administration and the American Academy of Dermatology have implemented very strict control on the prescribing of this medication by a program called “ iPledge.” This program requires that the patients return for a follow up appointment for every refill of a prescription including a pregnancy test for females and blood tests for males and females.
The medication is dosed by the weight of the patient, and the treatment is continued until an effective cumulative dose is reached or the patient’s skin is completely clear. About 80 percent of treated patients will enjoy a nearly complete remission or “cure” of their acne which may only recur as mild superficial lesions that can be treated topically. Of the remaining 20 percent some will require a second or a third treatment course of Accutane in order to obtain a satisfactory response. A minority of patients may still require oral medication after discontinuing the Accutane. A course of Accutane is typically between 3 and 6 months.
HORMONES
Because we know that the male hormone is necessary for the appearance and sustaining of acne, it is reasonable to expect that the female hormone counteracts the effect of the male hormone. Therefore, females may benefit from the addition of estrogen to their hormone balance. Certain oral contraceptive pills have been developed which contain a small amount of estrogen and have been shown to be beneficial for the treatment of acne as well as for providing contraception. Examples of brands are Ortho-tricyclen and Yaz. Some dermatologists are comfortable prescribing birth control pills for their patients for the treatment of acne, but others prefer that these drugs be provided by their current gynecologists so that a more thorough evaluation of their female reproductive health may be undertaken to include pap smears, breast exams, and management of the menstrual cycle.
COMBINATIONS
In order to get the best response in any given patient, it is common to prescribe a combination of a topical medication and an oral medication. A typical example of a patient with moderate acne would be treated with topical Clindamycin solution in the morning, Tretinoin cream at bedtime and oral Tetracycline or Minocycline during the day. There are also some combinations to be avoided. For example, the Tetracycline antibiotic should not be given at the same time to patients who are also taking Accutane. A rare side effect of swelling of the brain has been reported with the latter combination. On the other hand, for the young females who are taking Accutane, it would it be beneficial for them to take one of the oral contraceptive agents that improve acne and also prevent pregnancy while taking Accutane which could result in a birth defect. Most dermatologists would also not prescribe a topical Retinoid such as Tretinoin, Adapalene, or Tazarotene while the patient was also taking Accutane because of the extreme dryness and exfoliation that this combination of two Retinoids might cause.
ROSACEA
Rosacea, also known as Acne Rosacea or “adult acne,” is a skin disease that appears very similar to common teenage acne except is really thought to be a different disease with a different cause. For example, it usually affects adults of middle age, around 40’s and 50’s. There is a genetic tendency for this disease, so that you are more likely to acquire it if one or both of your parents had it. There is also a tendency for certain ethic groups to get Rosacea, notably Celtic- English- Welsh and Northern European populations and Americans with this ancestry .
Rosacea, as one might expect from the name, begins as a flushing or blushing tendency which usually affects the face, neck, and upper chest associated with emotion or stressful situations. This is considered to be the first and mildest stage of Rosacea and suggests that the disease is based on a sensitivity of the blood vessels to either emotional or thermal stimuli.
After the flushing stage which may result in permanent dilation of small blood vessels on the face called capillaries, the next stages of Rosacea include the development of red papules and pustules, usually localized to the central face. This would include the nose and cheeks. Sometimes there is swelling of the face including the eyelids associated with flare ups of Rosacea. There are also forms of Rosacea where the pimples and pustules may be seen either on the skin around the mouth or the skin around the eyes which would be called perioral or periocular dermatitis, respectively. The fourth and most serious stage of Rosacea is usually only seen in men and involves the nose with an enlargement of the oil glands in the skin. This condition is known as Rhinophyma and describes an enlarged, lumpy-bumpy, and misshapened nose. The patient may also have the inflammatory papules and pustules and dilated capillaries called telangiectases on the nose or on the facial skin around the nose. The Rhinophyma has been associated with alcoholism because of the alleged behavior of the famous comedian WC Fields, but certainly not all patients who have Rosacea or Rhinophyma are alcoholics.
We know that there are many triggers for the development or cause of Rosacea. The most commons ones are sun exposure, hot environment, and vigorous exercise which all have the same effect of increasing the dilation of the blood vessels on the skin leading to redness but also the development of inflammatory papules and pustules. Other less common but important aggravating factors for Rosacea include emotional stress, drinking alcohol, especially red wine, and eating spicy foods. Finishing up the list of triggers includes drinking extremely hot or cold liquids. Contrary to popular belief, caffeinated drinks are not the problem but rather the temperature of the drink itself. Therefore, more tepid or lukewarm water would help prevent the Rosacea flare up for people who like to drink caffeinated teas and coffee. Skin affected by Rosacea tends to be very sensitive, and certain skin care products may not react well with it. This might include any of your everyday cosmetics and cleansers. For this reason, the treatment of Rosacea is different from the treatment for common acne in some respects: the exfoliating or drying treatment used in acne patients who generally have oily skin often cannot be tolerated on the already reddened and sensitive skin of Rosacea patients. A small subset of patients with Rosacea of the skin will also develop a form of Rosacea that affects the eyes, especially the membranes inside the eyelid and the outside white membrane of the eye globe. The most severe form of Rosacea may even affect the cornea. The patient who complains of dry eyes or a gritty sensation in their eyes who also has Rosacea of the skin should be referred to an eye doctor along with the dermatologist.
In most cases, the diagnosis of Rosacea can be made by the dermatologist after taking a history of aggravating factors and an examination of the skin. Occasionally, because of the sun sensitivity, other diagnoses may have to be entertained such as Lupus of the skin. Therefore, additional blood testing or skin biopsies may be performed in such cases.
TREATMENT OF ROSACEA
The treatment of Rosacea should always include informing the patient about all of the aggravating factors that may be relevant to their lifestyle and asking them to reduce or eliminate those triggers. In addition, the two most effective medications for Rosacea are oral Tetracycline and topical Metronidazole cream or gel. The former can be used in low doses or for a short period of time followed by the use of the latter for chronic maintenance. The patient should be informed that Rosacea is a chronic disease and if they discontinue the medications which are helping them, then the condition is more likely to recur. An alternative to Metronidazole cream is Azelaic acid gel. A cleanser containing 5 percent precipitated Sulfur and 10 percent Sulfacetamide is also very helpful for Rosacea patients when used 1-2 times daily. Unfortunately, these medications do not really help an established Rhinophyma , and those patients may require some form of cosmetic treatment of their noses to reduce the enlargement and smooth out the irregularities. The dilated capillary spots called telangiectasias can be treated by certain types of lasers that are specific for blood vessels.
