A holistic approach is important to keep acne at bay for long term. Initial intensive therapy to halt the progression of acne should be followed with maintenance treatment so that lesions do not recur. A thorough evaluation is required before starting any kind of therapy keeping in mind the requirements of the patient in terms of skin type, severity and compliance.
- Topical therapy: Retinoids, benzoyl peroxide, antibiotics and mild keratolytics.
- Oral treatment: Broad spectrum antibiotics, retinoids and hormonal therapy
- Adjuvant therapy: Chemical peeling, zinc supplements and cryoslush.
- Lights and lasers: Blue light, red light, photodynamic therapy, intense pulsed light and Lasers.
- Life style modifications
Strategy for acne treatment:
- Treat early
- Treat at the stages of comedones before they become cysts and comedones
- Start antibiotics and retinoids after assessing severity
- Give topical for maintenance
- Treat aggressively to reduce the chances of scar
- Lifestyle changes to keep acne at bay
- Inculcate healthy skin habits
Resistant or recalcitrant acne
There are types of acne where conventional therapies do not work. When there is less than 50% improvement in acne with conventional therapy in the form of antibiotics and creams. In such instances there is requirement for initiation of retinoid therapy.
Role of skin care
- Poor hygiene and cleansers: Cleansing with a mild cleanser twice daily is adequate. There is no requirement for frequent washing and scrubbing. Both cause more harm than good.
- Cosmetics: Girls tend to camouflage their acbe with heavy makeup such as concealers and foundation base for coverage. These compounds have fragrances and photosensitizers which aggravate acne. These compounds also block the skin pores. It is best to avoid any form of cosmetics in case of active lesions. Light water based oil-free cosmetics should be used when absolutely necessary.
- Moisturizers: There is popular belief that acne prone skin does not require moisturizer and need to be kept dry. Excessive drying of skin is also not good. Water based light weight moisturizers can be used.
- Sunscreen: It is best to use a water based gel form of sunscreen.
Role of Isotretinoin in acne:
Isotretinoin is a very effective therapy in acne and is a precious tool for acne control. It should be taken for a few months for
Mode of action
- Reduces binding capacity of androgen receptor in skin
- Stabilizes ductal epithelium ie normalises hypercornification.
- Reduce size of sebaceous glands
- Reduce sebum production
- Promote maturation of keratinocytes (skin cells)
- Alteration of skin surface lipids > decrease in wax esters, reduction in squalene
Dosage: Dose ranges from 0.5 to 1mg/kg. It is given as a single daily dose taken after the heaviest meal in the day (fat increases absorption). It should be taken for 6-8 months to achieve remission in cases of severe acne. Low dose isotretinoin at 0.25mg per kg is also found to be effective. Hence, dosage depends upon the severity of condition.
There can be dryness of lips: Frequent use of Vaseline jelly or lip balms will reduce the problem.
Dryness of eyes: it can occur. Artificial tear drops can be used.
Role of cleansers in Acne
Acne occurs as a result of increased oil production by sebaceous glands and also blockage of the duct. There is popular belief that excessive cleaning will clean the skin and reduce acne. This forces people to use neem based face washes and harsh scrubs. These lead to more skin irritation and dryness which in turn aggravates acne. Also, the drugs prescribed by doctors for acne already cause little dryness. Hence, one should not self prescribe any cleansers on their own.
Acne in pregnancy
- Acne can start or be aggravated during pregnancy due to hormonal imbalances.
- Certain antibiotics (macrolides) are considered safe in pregnancy and can be taken
- For topical therapy, benzoyl peroxide (2.5-5%) can be used.
Lights and lasers in acne
- They are known to be effective in inflammatory acne. They have an antibacterial effect on P. acnes and a thermal effect on oil forming (sebaceous) glands. Near and mid infrared lasers at long wavelength cause damage to sebaceous glands.
- Blue-light: most effective visible wave-length for photoactivation of P. acnes endogenous porphyrin components because the 407–420 nm band has the strongest porphyrin photoexcitation coefficient.
- Redlight (660 nm): less effective at activating porphyrins, but it penetrates deeper into the tissue but have anti-inflammatory properties by influencing cytokine release from macrophages that stimulate fibroblast proliferation and the production of growth factors, and by influencing the process of inflammation, healing, and wound repair.
- Photodynamic therapy (PDT): PDT is more effective than lights alone. They create an oxidative stress and damage the pilosebaceous glands.The light sources can be: red- light from a diode laser (635 nm, 25 mW/cm2), pulse excimer dye laser (634 nm, 5 J/cm2), or a broadband halogen source (600–700 nm, 13 J/cm2).
- ALA-PDT offers a unique way of improving acne by selectively damaging the pilosebaceous units and killing P. acnes. There is little damage to the surrounding skin, and it produces prompt and sustained improvement even in nodular and cystic acne.
- Lasers that have been tried in acne include: 532-nm KTP, 585-nm and 595-nm pulse dye (PDL), 810-nm and 980-nm Diode. These also aim at reducing the activity of the pilosebaceous unit.