Overview of the treatment of acne vulgaris
Section snippets
Epidemiology
Acne is a disorder of the pilosebaceous unit, characterized by skin lesions on the face, chest, and back. In the United States, about 40-50 million people are affected by acne annually. Eighty-five percent of those between the ages of 12 and 24 years have acne. Although it is primarily a disease of adolescence, 12% of women and 3% of men battle it into their fifth decade of life.1 All races are affected, but Caucasians tend to have more severe forms of acne than African Americans.2
Pathogenesis
The cause of acne is multifactorial, including genetics, hormones, and bacteria. It is known that the number of sebaceous glands that one has is an inherited trait, and that it is unlikely for 1 twin to develop acne of different severity than the other twin.1 This points to a genetic component. Hormones (such as androgen and testosterone) have a great effect on sebum production by sebaceous glands. Conditions such as polycystic ovarian syndrome, hirsutism, and high levels of serum testosterone
Clinical features
Clinical features can vary significantly from mild comedones to fulminant systemic disease. The lesions of acne are divided into inflammatory and noninflammatory types. Noninflammatory lesions include comedones. If open to the air, the lipids in the sebum become oxidized and turn black (blackheads or open comedones) (Figure 1). If covered, they are closed comedones (whiteheads). Inflammatory lesions include papules, pustules, and nodules or cysts. Being able to quickly differentiate between the
Differential diagnosis
There are several “mimickers” of acne vulgaris. These include acne rosacea (important differentiation is that there are no comedones present in rosacea), seborrheic dermatitis (positive KOH and flaking at scalp, eyebrows, and hairline), demodex folliculitis, perioral dermatitis (erythema near mouth and unresponsive to acne treatments), and keratosis pilaris (resemble closed comedones on erythematous cheeks, more likely present on upper arms) (Table 2).2
Treatment
There are several factors to consider when choosing medications to treat an individual patient with acne. These include clinical type of acne (inflammatory, comedonal, and pustulocystic), severity (number and size of lesions, and amount of inflammation), oily vs dry skin, menstrual history and signs of hyperandrogenism in women, attempted or failed past treatments, history of acne-promoting medications, and the presence of scarring. Ultimately, the clinical type of acne is most important in
Choosing a treatment-delivery system
The choice of delivery system for topical acne medications depends on the patient's skin type (oily vs dry). Gels may cause some dryness and may be of value for patients with oily skin. Creams and lotions tend to be moisturizing. Solutions are drying but they cover large areas more easily than other preparations (such as acne on the upper back), and, together with foams they are easy to apply to hair-bearing areas.3
Mild acne consisting of open and closed comedones with only a few inflammatory
Topical retinoids
Retinoids are a class of medications derived from vitamin A, also known as comedolytics. Tretinoin (Atralin and Retin-A) is the prodrug of this class. Their efficacy lies in their ability to normalize follicular keratinization. They increase follicular cell turnover; causing epithelial cells to shed faster, comedones to be extruded, and the formation of new comedones to be inhibited. In addition, retinoids are known to have some antiinflammatory properties, making them useful for both comedonal
Systemic antibiotics
Antibiotics are a mainstay in the treatment of inflammatory acne. They work through several mechanisms to reduce the inflammatory response both directly and indirectly. Most importantly, they reduce the number of bacteria (P. acnes) in and around the follicle. They also reduce the inflammatory chemicals produced by white blood cells, and the free fatty acid concentration in the sebum, both of which reduce inflammation.
The prototypical antibiotic used in the treatment of acne is tetracycline.
Comedone extraction
At times, it may be necessary to facilitate the healing of comedonal lesions, manually extracting the contents. This is a simple, effective way to reduce the amount of bacteria and pressure in the comedone, thereby reducing inflammation. The process is simple. A comedone extractor is an instrument with a small loop on one or both ends, resembling one curved end of a paper clip. For open comedones (blackheads), the extractor is placed over the comedone with direct pressure perpendicular to the
Conclusions
There are several things to remember when developing a treatment regimen for an individual acne patient. As in all of medicine, treatment is to be based on appropriate diagnosis. This includes acne type (inflammatory or noninflammatory), lesion type (comedone, papule or pustule, and cyst or nodule), skin type (oily or dry or pigmented), and demographic (child or adult or pregnant or breastfeeding). Based on these factors, an appropriate regimen of medications can be chosen. It is always best to
Disclosures
Dr Sammons is a paid speaker for Solodyn (Medicis Pharmaceutical Corp).
Dr Benner has no disclosures to make.
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