DR. FATIMA NAZIR

• MRCGP (INT) – Royal College of General Practitioners
• MBBS –University of China

• Acne vulgaris is an inflammatory disorder of the pilosebaceous unit, which runs a chronic course and it is self-limiting. Acne vulgaris is triggered by Cutibacterium acnes in adolescence, under the influence of normal circulating dehydroepiandrosterone (DHEA). It is a very common skin disorder which can present with inflammatory and non-inflammatory lesions chiefly on the face but can also occur on the upper arms, trunk, and back.

Fast facts on acne

Causes

Acne vulgaris is caused by a combination of hormones, oil, and bacteria. During puberty, a hormone called androgen increases and the sebaceous glands produce more of the oily substance sebum. Typically, sebum and dead skin cells come up through the hair follicles and out through the pores in the skin. When sebum, skins cells, and bacteria clog the follicles, the sebum can’t escape through the pores, which causes acne.

As you enter early adulthood, those hormones may decrease enough that acne will start to disappear. For about 40% of women, acne may continue into their 40s because of hormonal changes and other causes, including:

• Hormonal changes in pregnancy or from the menstrual cycle
• Some medications
• Certain cosmetics and lotions
• High humidity and sweating
• Polycystic ovary syndrome (PCOS)

Who gets acne vulgaris?

Nearly all of us have acne at some time or another. It mainly affects adolescents (and can start as young as 8 years old), but acne may persist, begin or become more severe in adulthood.

Symptoms

Acne signs vary depending on the severity of your condition:

• Whiteheads (closed plugged pores)
• Blackheads (open plugged pores)
• Small red, tender bumps (papules)
• Pimples (pustules), which are papules with pus at their tips
• Large, solid, painful lumps under the skin (nodules)
• Painful, pus-filled lumps under the skin (cystic lesions)

Acne usually appears on the face, forehead, chest, upper back and shoulders.

Secondary lesions

• Excoriations (picked or scratched spots)
• Erythematous macules (red marks from recently healed spots, best seen in in fair skin)
• Pigmented macules (dark marks from old spots, mostly affecting those with dark skin)
• Scars or various types

Individual acne lesions usually last less than 2 weeks but the deeper papules and nodules may persist for months. Many acne patients also have oily skin (seborrhoea).

Treatment:

• Home remedies:

There are many suggested home remedies for acne, but not all of them are supported by research.

Diet: It is unclear what role diet plays in worsening acne. Scientists have found that people who consume a diet that offers a good supply of vitamins A and E and of zinc may have a lower risk of severe acne. One review describes the link between acne and diet as “controversial,” but suggests that a diet with a low glycemic load may help.

Tea-tree oil: Results of a study of 60 patients published in the Indian Journal of Dermatology, Venereology, and Leprology suggested that 5-percent tea-tree oil may help treat mild to moderate acne.

If you want to buy tea-tree oil, then there is an excellent selection online with thousands of customer reviews.

Tea: There is some evidence that polyphenols from tea, including green tea, applied in a topical preparation, may be beneficial in reducing sebum production and treating acne. However, the compounds in this case were extracted from tea, rather than using tea directly.

Moisturizers: These can soothe the skin, especially in people who are using acne treatment such as isotretinoin, say researchers. Moisturizers containing aloe vera at a concentration of at least 10 percent or witch hazel can have a soothing and possibly anti-inflammatory effect.

Topical Therapy

• Topical retinoids like retinoic acid, adapalene, and tretinoin are used alone or with other topical antibiotics or benzoyl peroxide. Retinoic acid is the best comedolytic agent, available as 0.025%, 0.05%, 0.1% cream, and gel.
• Topical clindamycin 1% to 2%, nadifloxacin 1%, and azithromycin 1% gel and lotion are available. Estrogen is used for Grade 2 to Grade 4 acne.
• Topical benzoyl peroxide is now available in combination with adapalene, which serves as comedolytic as well as antibiotic preparation. It is used as 2.5%, 4%,and 5% concentration in gel base.
• Azelaic acid is antimicrobial and comedolytic available 15% or 20% gel. It can also be used in postinflammatory pigmentation of acne.
• Beta hydroxy acids like salicylic acid are used as topical gel 2% or chemical peel from 10% to 20% for seborrhoea and comedonal acne, as well as, pigmentation after healing of acne.
• Topical dapsone is used for both comedonal and papular acne, though there are some concerns with G6PD deficient individuals.

Systemic Therapy

• Doxycycline 100 mg twice a day as an antibiotic and anti-inflammatory drug as it affects free fatty acids secretion and thus controls inflammation.
• Minocycline 50 mg and 100 mg capsules are used as once a day dose.
• Other antibiotics such as amoxicillin, erythromycin, and trimethoprim/sulfamethoxazole are sometimes used, and if bacterial overgrowth or infection is masquerading as acne, other antibiotics such as ciprofloxacin may be used in pseudomonas related ‘acne.’ 
• Isotretinoin is used as 0.5 mg/kg to 1 mg/kg body weight in daily or weekly pulse regimen. It controls sebum production, regulates pilosebaceous epidermal hyperproliferation, and reduces inflammation by controlling P. acnes. It may give rise to dryness, hairless, and cheilitis.
• An oral contraceptive containing low dose estrogen 20 mcg along with cyproterone acetate as anti-androgens are used for severe recurrent acne.
• Spironolactone (25 mg per day) can also be used in males. It decreases the production of androgens and blocks the actions of testosterone. If given to females, then pregnancy should be avoided because the drug can cause feminization of the fetus.
• Scars are treated with submission, trichloroacetic acid, derma roller, microneedling, or fractional CO2 laser.