Acne

May 12, 2021

Acne

Acne or acne vulgaris is an inflammatory skin condition characterized by pimples on certain body parts. Generally, it affects the face, chest, forehead, chin, shoulder, neck, and upper back. In Acne, the hair follicle gets clogged with oil, hair, bacteria, and dead skin cells that result in whiteheads, blackheads, cysts, and other types of pimples.

Studies report that Acne can occur at any age but highly prevalent among adolescents or young adults and teenagers. It significantly impacts the lifestyle of individuals, causing discomfort, distress, permanent skin scarring, low self-esteem, disfigurement, anxiety, and embarrassment. These negative effects highly contribute to poor social and mental wellbeing. [1, 3]

Cause of the Acne 

Around 80% of acne cases are related to genetic factors. However, medical studies reported that the majority of acne cases are highly connected with the following factors. [3, 4]

  • Due to certain medications use, including steroids, androgens, anticonvulsants, and lithium.
  • Due to occlusive wear such as headbands, back pads, shoulder pads, or underwire brassieres.
  • Excessive exposure to sunlight. 
  • Due to pore-clogging cosmetics.
  • Certain endocrine dysfunctions or hormonal changes during pregnancy.
  • Genetic factors that are affecting the branched fatty acids percentage in sebum.  

Moreover, other factors such as poor diet, stress, excessive oil secretion, and smoking also increase the risk of Acne development. [1, 3]

Signs and symptoms of Acne

Signs and symptoms of Acne include the appearance of whiteheads comedones, blackheads comedones, micro-comedones, nodules, papules, pimples, cysts, and pustules. Acne can also involve skin scarring and pigmentation. [1, 3, 5, 6]

  • Comedones: A small skin-colored acne papules 
  • Pimples: A small pustule or papule.
  • Papules: A raised skin area of less than 1 cm.
  • Nodules: Small bump beneath the skin.
  • Micro-comedones: Smallest and invisible acne skin blemishes.
  • Acne Cysts: Sac filled with fluid that appears deep under the skin. 
  • Pustules: Small bumps with fluid or pus on the skin.

Types of Acne

Acne is divided into four groups or grades based on the severity of symptoms. [2]

  1. Grade I or Mild Acne: Characterized by an open and closed comedones with few inflammatory papules and pustules.
  2. Grade II or Moderate Acne: Characterized by papules and pustules mainly on face. 
  3. Grade III or Moderately severe Acne: Characterized by numerous papules and pustules, and occasional nodules, also on chest and back.
  4. Grade IV or Severe Acne: Characterized by many large, painful nodules and pustules.

Acne Treatment

Acne treatment involves managing existing lesions and other symptoms, reducing skin scarring, arresting further progression, and decreasing the risk of other acne-associated complications. The application of treatment interventions depends on the acne severity, the patient’s current medical condition, the patient’s endocrine history, and the nature of lesions. Both topical and systemic therapeutic options are available for the treatment of acne. Moreover, along with pharmaceutical drugs, natural herbs and other treatment modalities also help manage acne symptoms. It is important to know that the application of multiple treatment modalities of acne significantly performs better than single therapy. [2, 6]

Topical Acne Treatment

Topical treatment involves the application of topical products containing anti-acne agents intended for mild to moderated acne symptoms. The patient usually prefers topical route for maximum exposure of clogged pores or symptoms to the therapeutic agent, and it also excludes the systemic absorption factor. Topical anti-acne agents are formulated in gels, creams, solutions, washers, and lotions for optimal drug delivery.  [2, 6]

Topical products contain the following anti-acne therapeutic agents.

Topical Retinoids: Retinoids such as Isotretinoin, tazarotene, tretinoin, motretinide, adapalene, and retinoyl-β-glucuronide control the formation of comedones and lesions. Plus, they help existing lesions, reduce sebum production and improve epithelium integrity. Studies reported that retinoids show anti-inflammatory action and suppress the formation of both microcomedones and comedones. Further, they support the therapeutic action of other anti-acne agents, decrease pigmentation, and repair skin scarring. The common side effect of retinoids includes the flare-up of acne during the first week of applications. [2, 6]

Topical Antibiotics: Antibiotics such as clindamycin and erythromycin are intended for topical application to manage the severity of mild to moderate inflammatory acne. They inhibit the growth of bacteria and decrease their colonization on the skin surface and within hair follicles. Thus, there agents are highly effective against P. acnes bacteria responsible for inflammation of the lesions. Note that topical antibiotics are preferred for a short period of up to 3 months due to the high risk of resistance. Medical research studies recommend using topical antibiotics combined with benzoyl peroxide, zinc, or retinoids to minimize the risk of bacterial resistance. Remember that don’t use both topical and systemic antibiotics simultaneously for the treatment of acne. [2, 6]

Other diverse topical treatment options

Other topical options for acne treatment also involve chemical peels, dapsone, corticosteroids, niacinamide, sulfur, triclosan, salicylic acid, and sodium sulfacetamide. [2, 6]

  • Salicylic Acid: It helps skin integrity and provides the anti-inflammatory, antifungal, and antibacterial activity. 
  • Chemical Peeling with Hydroxy Acids: Chemical peeling agents relieve hyperpigmentation, reduce skin scarring and improve acne symptoms.
  • Benzoyl Peroxide: It provides antibacterial properties, prevents pores clogging, and decreases the comedones formation. Benzoyl peroxide helps mild to moderate acne and can be applied for 6-8 weeks as a monotherapy for acne management. Remember that don’t apply it in combination with topical retinoids (except adapalene). Side effects of topical benzoyl peroxide include dryness, erythema, stinging, and burning.
  • Azelaic Acid: It helps inhibit P. acnes species and provides antioxidant, anti-inflammatory, antibacterial, and anti-keratinizing that help acne management. 
  • Sulfur: It provides mild keratolytic and bacteriostatic properties that aid acne treatment. 
  • Hydrogen Peroxide: Studies showed that hydrogen peroxide manages mild-to-moderate Acne.
  • Niacinamide: It controls sebocyte secretions that reduce skin oiliness and also provide anti-inflammatory properties. Thus, niacinamide topical formulation significantly improves acne symptoms.
  • Topical Corticosteroids: They help inflammatory acne conditions. 
  • Dapsone, Sodium Sulfacetamide, and Triclosan: They show antibacterial and anti-inflammatory activities that help the treatment of acne. Note that they are not recommended as first-line agents for acne management. 

Systemic Therapeutic agents

When the topical product fails, then oral systemic agents are prescribed for the treatment of acne. The oral-systemic options significantly improve the nodules, lesions, and scarring. The commonly recommended systemic therapeutic interventions include oral retinoids, antibiotics, and hormonal agents. [2, 6]

Oral Retinoids: Retinoids such as Isotretinoin is a first-line agent for acne associated with severe nodular or inflammatory lesions. It significantly benefits mild to moderate acne and acne resistance to topical agents. Isotretinoin relieves the symptoms of severe acne on the trunk and face. Note that the course of Isotretinoin therapy ranges from 16 weeks to 24 weeks. It decreases sebum production and reduces the risk of bacterial colonization that help the management of acne condition. [2, 6]

Oral Antibiotics: Antibiotics such as erythromycin, levofloxacin, minocycline, lymecycline azithromycin, roxithromycin, doxycycline, and co-trimoxazole are indicated for the treatment of moderate to a severe acne condition. They inhibit the growth of acne-causing bacteria and also provide an anti-inflammatory activity that manages the acne symptoms. Remember that the use of antibiotics increases the risk of bacterial resistance. So, they are always preferred combined with topical benzoyl peroxide or retinoids to minimize the risk of resistance. Also, don’t use antibiotics for more than 12 weeks. [2, 6]

Hormonal agents: Hormonal agents antagonize the effect of androgen on the sebaceous gland and control sebum production. Most oral contraceptives, especially progestins, are used for this therapeutic approach. They halt the action of androgen and increase the sex hormone-binding globulin level in the body. Moreover, the hormonal agents work better in combination with other options such as antibiotics, retinoids, and spironolactone in the treatment of acne. [2, 6]

Other oral treatment options:

Along with the previously discussed option, other oral therapeutic agents including zinc sulfate, corticosteroids, ibuprofen, and clofazimine also provide an anti-inflammatory activity that helps manage acne symptoms. Systemic corticosteroids like oral prednisolone help treat the severe form of inflammatory Acne vulgaris, Acne fulminans and Pyoderma faciale.

Natural treatment of Acne

Different natural herbs and supplements also help the management of acne symptoms. These remedies act on sebum production, bacterial growth, inflammation, and keratinization. Plus, they also provide moisturizing and soothing effects upon topical application that aid the acne treatment. [2, 6]

These natural remedies include:

  • Basil Oil: Topical application of Basel oil provide antibacterial properties and aid acne management.
  • Copaiba Oil: Topical gel formulation of copaiba oil shows anti-inflammatory and antiseptic activities that aid the healing of pustules and aid mild acne treatment. 
  • Green Tea: It provides antioxidant, anti-inflammatory, and antibacterial properties that help inflammatory acne conditions.
  • Minerals: Topical application of different minerals such as clay minerals, including palygorskite, talc, kaolinite, zinc, and smectites helps the treatment of comedones and spots that aid acne management. They provide action against sebum production and bacteria that reduce acne symptoms.
  • Resveratrol: It reduces the inflammatory response and inhibits P. acnes growth that helps manage acne symptoms.
  • Rosa Damascena: Topical application of Rosa Damascena provides antioxidant activity, anti-inflammatory properties, antimicrobial action, and inhibit lipid peroxidation that aid the treatment of Acne. 
  • Seaweed: Topical application of seaweed significantly improve mild Acne via its anti-inflammatory and antibacterial properties.
  • Taurine Bromamine (TauBr): Taurine Bromamine (TauBr) and Taurine chloramine (TauCl) show anti-inflammatory, antibacterial, and antioxidant activity that reduce acne lesions and help mild to moderate facial acne vulgaris.
  • Tea Tree Oil: Topical application of tree oil shows antimicrobial and anti-inflammatory activities that improve inflammatory acne lesions and helps acne management.
  • Probiotics: The antimicrobial properties of probiotics also may help acne symptoms.

Additionally, other medicinal plants are also gaining popularity in the treatment of acne vulgaris. [7] These include:

  • 50% Aloe Vera gel with tretinoin for mild Acne. 
  • 2% Green tea lotion for mild to moderate acne treatment. 
  • Mahonia aquifolium or Berberis aquifolium root extract for pustules.
  • Usnea barbata extract shows antibacterial activity.
  • Whole fruit extract of Vitex Agnus –cactus prevents acne. 
  • Topical application of Hamamelis virginiana tannins helps acne management. 
  • Extract from onion peels is also a better option for treating acne.

Other Interventions:

Studies reported the use of some physical procedures as adjunctive acne treatment. [2, 6] These include:

  • Extraction of the comedones.
  • Cryoslush Therapy.
  • Cryotherapy.
  • Electrocauterization for comedones eradication.
  • Intralesional Corticosteroids for the treatment of inflammatory nodules.
  • Optical Treatments involve the use of laser therapy and light sources for mild to moderate acne treatment. 


References

  1. Sutaria AH, Masood S, Schlessinger J. Acne Vulgaris. [Updated 2020 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459173/
  2. Kraft, J., & Freiman, A. (2011). Management of acne. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 183(7), E430–E435. https://doi.org/10.1503/cmaj.090374
  3. Aydemir E. H. (2014). Acne vulgaris. Turk pediatri arsivi, 49(1), 13–16. https://doi.org/10.5152/tpa.2014.1943
  4. Bataille, V., Snieder, H., MacGregor, A. J., Sasieni, P., & Spector, T. D. (2002). The influence of genetics and environmental factors in the pathogenesis of acne: a twin study of acne in women. The Journal of investigative dermatology, 119(6), 1317–1322. https://doi.org/10.1046/j.1523-1747.2002.19621.x
  5. Oon, H. H., Wong, S. N., Aw, D., Cheong, W. K., Goh, C. L., & Tan, H. H. (2019). Acne Management Guidelines by the Dermatological Society of Singapore. The Journal of clinical and aesthetic dermatology12(7), 34–50.
  6. Fox, L., Csongradi, C., Aucamp, M., du Plessis, J., & Gerber, M. (2016). Treatment Modalities for Acne. Molecules (Basel, Switzerland), 21(8), 1063. https://doi.org/10.3390/molecules21081063
  7. Nasri, H., Bahmani, M., Shahinfard, N., Moradi Nafchi, A., Saberianpour, S., & Rafieian Kopaei, M. (2015). Medicinal Plants for the Treatment of Acne Vulgaris: A Review of Recent Evidences. Jundishapur journal of microbiology, 8(11), e25580. https://doi.org/10.5812/jjm.25580

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