ACNE: the nightmare of adolescence

Acne is a common skin disease occurring mostly in young adults. It develops as a result of blockage of hair follicles. Sebaceous glands in  skin enlarges & starts to produce more sebum(an oily substance secreted from our skin) under hormonal(androgen) influence at the onset of adolescence. These are commonly called pimples.   Most pimples form on the face, neck, back, chest and shoulders. In these pimples bacteria  (Propionibacterium acnes) start to grow & develop producing inflammation & the simple pimple is then converted into papules, infected pustules, or nodulesThese may produce mild to severe scarring of face . . Some others are cystic called nodulocystic acne. They produce severe scarring. Acne also affect psychology specially decreased self-esteem & depression. Severe form of acne is more common in male.

No one knows exactly what causes acne. But some probable reasons are

                1.familial predisposition- A family history of acne is associated with  occurrence of acne. Previous history of acne in the family and more specifically in the father or mother increases the risk of acne in children.

                2.hormonal effects- During puberty, an increase in male sex hormones called androgens cause the follicular glands to get larger and make more sebum. During menstruation some hormonal changes takes place & causes exacerbation of acne.

3. Oily skin- this is because of increased sebum production. People having oily skin are more affected by acne. Sebum production is under control of androgen.

4. Early Onset of Acne Lesions- Acne lesions beginning before puberty increases the risk of severe acne.

5. Cigarette Smoking-acne is more frequent in smokers.

6. Drugs: (aggravating or inducing acne )

      Steroids: first, it masks the condition then aggravates it. 

      Anabolic  steroid.

      Oral contraceptive pills ( norgesterone ) à androgen stimulants.

Thiazides

      Rifampicin and lithium 

1. The patient should know that it is long standing disease and self limited and require few years or at least 4 – 6 months to relieve ( as comedones need 4 months to appear )

2. Aim of treatment is healing with healthy skin without scar formation.

3. Treatment should include acne prone areas.

4. No use from excessive use of soap or excessive face washing.

5. Patient should not play with the lesions.

6. 5 % of patients may suffer from aggravation of the condition at first due to hydration of the skin by the vehicle if the drug.

7. Medical soap is ineffective as 1- the superficial bacteria has no role in the pathogenesis. 2 – the follicular bacteria can not be reached by this soap.

Non Inflammatory condition:

1. Tretinone

§ Best topical medication.

§ Conc. ( 0.01, 0.025, 0.05, 0.1 % )

§ 0.05 % is the most irritating conc.

§ Present in three forms : cream ( least irritating ), lotion and jell (most irritating )

§ Before use, a sensitivity test by application of the drug on dry skin at the night every other day for 3 times ( 6 days ) à if prove do be safe , continue treatment for 4 months.

§ You should start treatment by the lowest available conc. And the least possible irritating vehicle.

§ If no response, á irritation by changing the vehicle or á conc. Till reach the most suitable drug.

§ Application of the drug on exposure to UV rays or fluorescent lamp at 120 cm or less is unsafe. So, preferred to be applied at night or away from fluorescent lamp.

2. Azalenic Acid 20 % :

 Slowly acting à gives best results after 8 weeks.

 Used once daily at the first week à twice / day in the second week à till 8 weeks.

 SE: pricking sensation

 It should be applied on dry skin.

3. Irritant medications :

 Tazarotene 0.1 ( ;ow irritant )

 Iso trtinone 0.05 ( low irritant )

4. Non irritant medications : Adapalene 0.1

Inflammatory condition :

1. Benzoyl peroxidase :

§ Conc. : 2.5 % , 5%, 10 %

§ New conc. à 4% irritancy and 10 % efficacy.

§ New conc. à 8 % irritancy and 20 % efficacy.

§ Should be applied on skin for three days at night :

- If no response à give twice daily at night for 4 months

- If no sensitivity à give once daily at night for 4 months.

§ Disadvantages:

- Photo-pigmentation in fair skin.

- Dehydration à so , require more emollient.

2. Local Antibiotics:

i. Clindamycin 1 %

- Twice daily for 2 weeks.

- Effective but expensive.

ii. Erythromycin 2% or (4% +zinc):

- Twice daily with 8 – 10 hours interval.

- For 12 weeks then stop the drug for one week to prevent the development of resistance.

iii. Topical combined preparations:

- Benzoyl peroxidase 5% erythromycin 3%

- Erythromycin 3% + tretinone 0.03%

- Isotretinone 5% + clindamycin 1%

Systemic Preparations:

i.Macrolides:

- Tetracycline 1 / day

- Erythromycin 1g/ day

- Minocycline – doxyciline 100 mg / day

- The patient should e examined after 2 weeks.

- If good response à continue for 3 weeks.

- If not effective à double the dose for another 2 weeks.

- If no response à stop the drug and shift to another one.

- NB: never to mix topical and systemic antibiotics together

ii.Anti-androgens :

- Only for females > 35 years with other androgen dependent problems (hirsutism)

iii.Systemic retinoids:

- Only in severe nodulocystic acne, not responding to all other modalities.

- SE: hyperlipidemia , hepatotoxicity, GIT bleeding and teratogencity.

1. Peeling:

- Never to be done with active acne as it is mutagenic and stimulates IL-1α.

- Pre-peeling preparations (tretinone for 6 weeks and glycolic acid ) are done firstà

Then one session / week .

- Never to exceed 5 sessions.

- Topical retinoids has the same effect and cheaper.

2. Blue light laser.

3. Photodynamic therapy

4. Intra-cystic steroids ( intra-regional) à mask the condition but not cure it