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Abstract
The conventional, allopathic treatment of acne vulgaris happens through
drugs
that are used locally and orally. Given the increasing resistance of
acne
producing bacteria, it is recommended to minimize prolonged use of
antibiotics
topically or orally in the treatment of acne. In the presence of many
comedones, topical application of a retinoid is usually the first
choice. In
the presence of numerous papules and pustules, benzoyl peroxide is
effective in
mild to moderate dosage and does not cause resistance. In more severe
forms,
oral antibiotics may be indicated. To minimize resistance problems, it
is
recommended not to prescribe antibiotics alone - rather a
combination with
benzoyl peroxide or a retinoid is better. Oral contraceptives are a
treatment
option if the woman wants contraception.
In
severe acne,
systemic treatment with isotretinoin should often be considered with
all the
precautions that includes among others,
contraception.dermatological
condition most frequently encountered in adolescents and young adults.
It is an
inflammatory dermatosis that is partly explained by the proliferation
of acne
causing bacteria, a multiplication and abnormal differentiation of
keratinocytes
(with formation of comedones) and an increase of seborrhea (oil
secretion)
under the influence of androgens.
For
many years, antibiotics have occupied a central place
in the management of acne, but the significant increase in the
resistance of
acne causing bacteria in recent years needs reviewing of the
recommendations in acne treatment. This article discusses the role of
different
drugs in the treatment of this condition and proposes some guidelines
based on
clinical presentation and severity of acne.
Topical
retinoids
Topical
retinoids are tretinoin,
adapalene and tazarotene. These derivatives of vitamin A prevent the
formation
of comedones by normalizing desquamation of follicular epithelium. They
are
used in forms of acne with a predominance of comedones, as well as to
enhance
the effectiveness of antibiotic treatment or to consolidate the results
obtained after systemic therapy. The main side effects of topical
retinoids are
pruritus, erythema, rashes, skin bleaching and phototoxicity - a
worsening of
acne can be observed during the first few weeks of treatment. Retinoids
are
contra-indicated in women who are pregnant or planning a pregnancy.
[Editor's
note: The speciality based tazarotene (0.05% and 0.1%) available in
Belgium
(Zorac®) is registered for the treatment of mild to moderate psoriasis,
but not
acne].
Topical
antibacterials
The
clindamycin and erythromycin antibiotics are conventionally used
topically in the treatment of acne vulgaris. They are antibacterial and
anti-inflammatory and reduce the number of inflammatory lesions, but
they have no effect on comedones. Adverse effects of topical
antibiotics are erythema, desquamation, dry skin and burning sensation.
Their use is limited by the increasing bacterial resistance [ie,
erythromycin is no longer recommended as many germs become resistant
Gram-positive bacteria]. According to a recent consensus, it is
recommended not to prescribe antibiotic monotherapy locally but to
associate benzoyl peroxide or a topical retinoid, in order to increase
the effectiveness of treatment and reduce the risk of bacterial
resistance. It is also advisable not to use topical
antibiotics and oral antibiotics concomitantly in the treatment of acne.
Benzoyl
peroxide (5 or 10%) is a potent antibacterial that also has an
anti-inflammatory effect. Its effectiveness is comparable to topical
antibiotics, but unlike them, it does not appear to cause bacterial
resistance. Benzoyl peroxide is the first choice anti-bacterial in mild
to moderate acne. Adverse effects consist of skin irritation and
rarely, contact dermatitis and discoloration of hair, clothing and
linens.
Azelaic
acid is republished here with antibacterial agents as it has
antibacterial activity against acne causing bacteria, in addition to
its comedolytic effect. It is less effective and takes longer than
retinoids, but it causes less skin irritation. Like benzoyl peroxide,
azelaic acid also leads to bacterial resistance.
Oral
antibiotics
The main
antibiotics used orally in
acne are tetracycline (300-600 mg), doxycycline and minocycline
(100-200 mg).
Macrolides are no longer first choice. Antibiotics exert both an
antibacterial
effect against acne causing bacteria as well as have an
anti-inflammatory
effect. Minocycline and doxycycline have similar efficacy in this
indication
and appear more effective than tetracycline. With minocycline, it
should take
into account the risk of side effects such as liver damage, possibly
severe
lupus with arthralgia and reactions during prolonged treatment, as well
as its
high cost. Doxycycline is associated with a greater risk of
phototoxicity.
Tetracyclines are contra-indicated during pregnancy. The efficacy of
antibiotic
therapy should be evaluated after 3 months and in case of an
improvement,
antibiotics may be extended up to 6 months in general, but always in
combination with local treatment with benzoyl peroxide or retinoids. In
the
absence of results after 3 months, the antibiotic should be
discontinued and an
alternative treatment (eg isotretinoin) should be considered. As
mentioned
above, it is recommended to administer concomitant antibiotics
topically and
orally.
Hormonal
treatment
For women
in whom contraception is
desired or indicated for another reason (eg. Irregular cycles), the
prescription of oral contraceptives alone or in combination with other
acne
treatments may be useful . Although it does not seem to be of much
difference
in efficacy between oral contraceptives, preference is often given to
contraceptives containing a progestin with the least androgenic
properties (eg.
Desogestrel, gestodene or norgestimate ). In case of insufficient
efficacy, an oral contraceptive containing 2 mg cyproterone
acetate and
0.035 mg ethinyl estradiol is opted for. Hormonal treatment should be
continued
for at least 2-4 months.
In severe
cases, cyproterone acetate
at 10 mg per day for the first 15 days of the cycle, may be offered for
women
in combination with an oral contraceptive. [Editor's note: In Belgium,
cyproterone acetate is the only anti-androgen used.]
Isotretinoin
Isotretinoin
is a derivative of
vitamin A, which inhibits the secretion of sebum (the body oils) and
prevents
the formation of comedones by normalizing desquamation of follicular
epithelium. Isotretinoin is indicated in severe nodulocystic acne and
other
forms of acne rebellious to conventional treatment. The recommended
dose is 0.5
mg / kg / day, which may possibly be increased after one month up to 1
mg / kg
/ day. The optimal treatment regimen consists of a cumulative
dose of
120-150 mg / kg and for a cure, a treatment period of several months is
usually
necessary. [Editor's note: Due to variations in individual efficacy and
side
effects, the treatment is usually started with lower daily doses (0.3
to 0.5 mg
/ kg), and then the dose is individually adjusted.] In case of a
relapse after
discontinuation of treatment, it is recommended to wait two months
before
starting a new treatment. Side effects of isotretinoin are numerous:
dry lips,
skin and eyes, alopecia, decreased night vision, headache, neck pain,
musculoskeletal pain, hyper-calcemia, central nervous system disorders
and
psychiatric disorders. Rare cases of benign intracranial hypertension
have been
reported, some with the concomitant use of tetracyclines. Isotretinoin
can also
cause elevated liver enzymes and triglycerides - blood tests are
therefore
recommended before initiation of treatment, after one month, then every
2 to 3
months and the concomitant use of vitamin A is to be avoided.
Isotretinoin
is teratogenic and effective contraception is required throughout the
duration
of treatment and for one month after stopping it. Caution is also
advised
during blood donations.
Practical recommendations
Mild to
moderate acne, especially
with comedones
Adapalene
or tretinoin, at the rate
of one application per day is the treatment of choice. Effect occurs
within 12
weeks. Adapalene 0.1% causes less skin irritation than
tretinoin 0.05% and
its cost is also lower. Azelaic acid (2 applications per day) is less
effective
but may be offered in case of contra-indication of retinoids. Oral
contraceptives may be offered if the woman wants contraception.
Mild
to moderate papular
and pustular acne
This form
of acne is usually treated
locally by benzoyl peroxide (1 to 2 applications per day), an
antibiotic (2
applications per day) or retinoid (1 application per day). Benzoyl
peroxide is
the first choice here as it is effective, costs less and there is only
a low
risk of resistance development. As mentioned above, it is inadvisable
to
prescribe a topical antibiotic alone and it should be prescribed
preferably in
combination with benzoyl peroxide or a topical retinoid. Antibacterial
treatment is usually continued for at least two to three months - in
the
absence of effects after this period, it is necessary to review the
treatment.
For women who want contraception, oral contraceptives may be useful.
Moderate
to severe papular
and pustular acne
Treatment
is usually based on the
administration of oral antibiotics (eg. Doxycycline or minocycline
100-200 mg
per day), in combination with topical benzoyl peroxide or a retinoid.
The
administration of antibiotics alone is not recommended. Treatment is
often
required for several months, but in case of lack of results after 3
months, the treatment should be reviewed. In case of failure,
isotretinoin
may be considered. For women who want contraception, the administration
of oral
contraceptive cyproterone acetate may be considered.
Severe
nodulocystic acne
The
severe nodulocystic acne and
other severe forms of acne like acne fulminans, pyoderma, facial acne
conglobata and acne recalcitrant to treatment require systemic
treatment
(oral antibiotics, isotretinoin, hormonal treatment) .
Should
we stop treating
acne during the summer?
This
question has been asked by several
experts in dermatology and their responses can be summarized as
follows. Almost
all acne medications are photosensitizing (either phototoxic or
photoallergic)
and should be used with caution in sunny periods. The decision to treat
or not
treat acne during the summer depends on several factors: initiation or
continuation of treatment, amount of sunshine, severity of acne and so
on.
As
regards local treatment, it may
be preferable to enforce it only in the evening and possibly use a
preparation
or product under less irritating doses (e.g. Adapalene instead of
tretinoin).
With
regard to oral treatments, it
is recommended not to initiate treatment phototoxicity (eg.
Tetracycline or
isotretinoin) when sun exposure is anticipated, for example, before
going on vacation.
When treatment is already underway, it may possibly be pursued by
reducing the
dose, as phototoxicity is dose-dependent. In all cases, it is
recommended to
use a sun protection during the day and avoid prolonged exposure to
sunlight.
Please E-mail dr_ramanand@
rediffmail.com for any questions/treatment
Let
us take the big question head-on. Does homeopathic
treatment give permanent relief from those recurrent pimples? The
answer is a
big yes, but the treatment is quite different from the conventional
ones.
Homeopaths realise the truth in skin disorders. All forms of pimples
(acne) are
due to an internal disorder - thus the usage of external application
does not
yield permanent results. Internal homeopathic medication is
often the best
natural option to stop the recurrence of acne and that too without
side-effects. Medically speaking too, acne results out of an internal
disorder.
It is a disorder resulting from the action of hormones on the skin's
oil glands
(sebaceous glands), which leads to plugged pores and the outbreak of
lesions
commonly called pimples or acne. They usually occur on the face, neck,
back,
chest, and shoulders. An important causative factor is an increase in
hormones
called androgens (male sex hormones). These increase in both boys and
girls
during puberty and cause the sebaceous glands to enlarge and make more
sebum
(oil). Hormonal changes related to pregnancy or starting or stopping
birth
control pills can also cause acne - another factor is heredity or
genetics.
Researchers believe that the tendency to develop acne can be inherited
from
parents. For example, studies have shown that many school-age boys with
acne
have a family history of the disorder. Certain drugs, including
androgens and
lithium, are known to cause acne. Greasy cosmetics may alter the cells
of the
follicles and make them stick together, producing a plug. The following
factors
also influence the growth of acne: Changing hormone levels in
adolescent girls
and adult women two to seven days before their menstrual period starts;
friction caused by leaning on or rubbing the skin pressure from
backpacks, or
tight collars; environmental irritants such as pollution and high
humidity;
squeezing or picking at blemishes, hard scrubbing of the skin, etc.
Medicines for
acne:Belladonna: It is very useful in an
acute flare-up where pus formation hasn't started and acne is red and fiery looking. 30c
potency of Belladonna taken internally 3-4 times a day can be used to treat this
acute stage.Pulsatilla: It is often the most indicated medicine in the
treatment of acne in girls. Acne associated with menstrual abnormalities are often
best treated with Pulsatilla. It is strongly indicated in a mild, yielding
and sensitive personality with a weeping disposition.Sulphur: No other
medicine is more effective than Sulphur, which covers nearly all kinds of acne.
Dirty unhealthy skin and abuse of cosmetics are leading indication for its
use. It is very useful in stopping the recurrence of pimples. Sulphur is a very
deep acting medicine and should be used only in consultation with an
experienced homoeopath.Hepar sulph: Hepar sulph. is very appropriate for treating
acne that has an easy tendency to develop into pustules (filled with pus),
as well as where acne is very painful to touch. Silicea (also called Silica):
It is often indicated in cases of long-standing acne along with general low
resistance and is often used for its scar-dissolving properties.
Developing a natural resistance towards acne: Once the acute flare-ups have been
attended to, one would like a natural resistance towards acne. A thorough
constitutional treatment by an experienced homoeopath would do the needful.
Typically,
acne or pimples appear on
the face, neck, chest, back, shoulders and the areas of the skin with
the
largest number of functional oil glands. Frequently, people with acne
or
pimples have a variety of lesions. The comedo (plural: comedones) - the
basic
acne lesion, is simply a plugged, enlarged sebaceous (oil producing)
follicle.
Acne or pimples can take the following forms :
- BLACKHEADS
: Blackheads, also known as open comedones, are follicles that have a
wider than normal opening. They are filled with plugs of sebum and
sloughed-off cells and have undergone a chemical reaction resulting in
the oxidation of melanin. This gives the material in the follicle the
typical black colour.
- WHITEHEADS
: Whiteheads, also known as closed comedones, are follicles that are
filled with the same material, but have only a microscopic opening to
the skin surface. Since the air cannot reach the follicle, the material
is not oxidized, and remains white.
Both whiteheads & blackheads may stay on the skin for a long
time.
Other troublesome acne and pimple lesions may develop, which include
the following :-
- PAPULES :
A papule is defined as a small (5 millimeters or less), solid lesion
slightly elevated above the surface of the skin. A group of very small
papules and microcomedones may be almost invisible but have a
"sandpaper" feel to the touch. A papule is caused by localized cellular
reaction to the process of acne.
- MACULES :
A macule is the temporary red spot left by a healed acne lesion. It is
flat, usually red or pink, with a well-defined border. A macule may
persist for days to weeks before disappearing. When a number of macules
are present at one time, they can contribute to the "inflamed face"
appearance of acne, which shows a "red faced" appearance.
- PUSTULES
: A pustule is a dome-shaped, fragile lesion containing pus that
typically consists of a mixture of white blood cells, dead skin cells,
and bacteria. A pustule that forms over a sebaceous follicle usually
has a hair in the center. Acne pustules that heal without progressing
to cystic form usually leave no scars.
- NODULES :
Like a papule, a nodule is a solid, dome-shaped or irregularly-shaped
lesion. Unlike a papule, a nodule is characterized by inflammation,
extends into deeper layers of the skin and may cause tissue destruction
that results in scarring. A nodule may be very painful. Nodular acne is
a severe form of acne that may not respond to conventional (allopathic)
treatment.
- CYSTS : A
cyst is a sac-like lesion containing liquid or semi-liquid material
consisting of white blood cells, dead cells, and bacteria. It is larger
than a pustule, may be severely inflamed, extends into deeper layers of
the skin, may be very painful and can result in scarring. Cysts and
nodules often occur together in a severe form of acne called
nodulocystic. Systemic therapy with homeopathy is sometimes the only
effective treatment for nodulocystic acne. Some acne investigators
believe that true cysts rarely occur in acne, and that (1) the lesions
called cysts are usually severely inflamed nodules, and (2) the term
nodulocystic should be abandoned. Regardless of terminology, this is a
severe form of acne that is often resistant to conventional
(allopathic) treatment and likely to leave scars after healing.
There
can be prominent
unsightly scars after resolution of acne or pimple lesions - these can
also be
set right with the proper homeopathic treatment.
The
following are the
commonly recognized types of acne :
- Acne
vulgaris
- Acne
rosacea
- Acne
cosmetica
- Acne
conglobata
- Acne
fulminans
- Acne
keloidales nuchae.
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