ACNE: TREATMENT TECHNIQUES

By Kathryn Khadija Leverette

Acne Homecare and Lifestyle Changes
A daily system of antibacterial and exfoliating homecare is needed to acne. True control means no physical sign of the disease shows in its active stage. Since acne is a treatable disease with no cure, the adult acne sufferer will be tied to an acne-fighting regimen for life, whether or not they get clinical facials or peels on a regular basis. It is “skin care suicide” for an acne client to achieve total clearing, and then abruptly abandon home treatment and the positive lifestyle changes that affect acne. Retention hyperkeratosis (the process of dead skin cells building up and sticking together in the pore) is an ongoing, chronic condition that runs in families. If the acne prone client doesn’t adhere to a diligent day-to-day system to interfere with retention hyperkeratosis, and make permanent lifestyle changes (less stress, enough sleep, reduced iodides in the diet, etc.), visible signs will begin to reappear almost immediately.

Clinical Acne Treatments
Professional skin care treatments, including light peels and clinical facials provide a variety of therapeutic and preventative benefits:
They exfoliate dead skin cells.
They gradually help fade dark spots left by residual acne and razor bumps.
They help even out skin tone and fade dark patches.
They lighten beard “shadowing” caused by bumping up, ingrowns and shaving powders.
They help exfoliate dead skin build-up that buries ingrown hairs.
They help soften and reduce the thickness of scar tissue.
They help remove and control excess oil.
They reduce flakiness and tightness.
They make extraction of pimples and blackheads easier.
They help smooth rough-textured skin.
They help clean out clogged pores.
They help deliver active ingredients deeper into the pores for better results.
They help reduce the depth of fine lines and wrinkles.

Antibiotics
To those reluctant to abandon the “old school” tetracycline, Minocin™ and erythromycin, consider this point: "If tetracycline can arrest venereal disease within 10 days, why are you still broken out after several years? Or: "If erythromycin can stop an ear infection in 10 days, why are you still covered with acne?"

If you request a medical definition of acne, it would be read something like this: Acne is a genetic disease evolving from retention hyperkeratosis of the follicular epithelium. So, if we are dealing with a disorder of the follicle (pore), why flood your body with antibiotics so that some of it ends up in the pore killing only a fraction of the bacteria? Then, there is the issue of the side effects which include severe sun sensitivity (leading to hyperpigmentation), birth defects, yeast infections and digestive disorders to name a few. Topical antibiotics including clindamycin, erythromycin and tetracycline can kill bacteria in the surface lesions, but don’t penetrate the pore on their own to kill bacteria where it starts, or interfere with the process that actually causes acne.

AHAs, Salicylic and Azelaic Acid
Fruit acids (AHAs), especially glycolic and lactic acid, are effective for several reasons. There are fewer adverse side effects, i.e. excessive flaking, redness, dark blotches, irritation and sun sensitivity than with retinoids, like Retin A®. They help reduce dead cell build-up in the pore, help fade dark spots and soften scars, have a lower price tag, and are widely available without a prescription. AHA peels are highly effective office procedures that are safe for all skin types and tones. Home care products are available in gels, lotions and creams in strengths ranging from 5%-20%. Oil-free gels are more appropriate for acne and should be introduced gradually. OVER>

Skin brighteners (hydroquinone, kojic acid diplamitate, l-arbutin, azelaic acid, bearberry, mulberry and licorice extracts) and salicylic acid (also known as BHA, an anti-bacterial acne ingredient that also increases cell turnover) work better when formulated with glycolic and lactic acid, which carry them deeper into the follicle to the target tissues. Gel formulations can be worn under benzoyl peroxide (BPO) at night. Azelaic acid, a known skin brightener, is marketed as a stand-alone acne treatment, but is not very effective when used alone. Azelaic acid and salicylic acid work better when used in formulations containing pore-penetrating, active ingredients (like glycolic and lactic acid) for a deeper, synergistic effect.

Benzoyl Peroxide
Benzoyl peroxide is a topical acne medication available over-the-counter, by prescription and from clinical estheticians. Benzoyl peroxide (BPO) penetrates the pore, releases oxygen and kills p. acnes, a bacteria that lives without oxygen below the skin's surface. It also causes peeling deep in the follicle, similar to Retin-A® and the AHAs, which loosens and softens acne impactions. A strong BPO worn on the skin for a long enough period of time each day, will continue to exfoliate dead cell build-up deep in the follicles. This action below the skin line prevents bacteria overgrowth to help new impactions from forming.

The good new and bad news about BPO: The good news is that BPO, in the right formulation, is unsurpassed in treating all grades of acne. Unlike Accutane®, oral antibiotics and retinoids like Retin A®, BPO is safe for pregnant women. The bad news is BPO products are not all created equal. First, we must examine the base with which the BPO is formulated. Is the BPO mixed with true oil, synthetic oil, glycerin, sulfur or water? Your BPO might be 10%, but its oily or fatty-acid base may seal off the skin, preventing adequate penetration of the BPO itself. Also, the shelf life of over-the-counter products may not be monitored closely; older BPO products lose their potency.

Any BPO that you can tolerate overnight the first week or two is not going to be strong enough to control acne in the long run, because the skin rapidly gets used to it, and it stops working. In turn, any BPO product strong enough to clear your acne and keep it that way, is definitely too strong to be tolerated overnight for the first 2-3 weeks of therapy. The side effects from incorrect usage, including, redness and excessive scaling, is why many clients abandon BPO. Urban Skin Solutions prefers to gradually wean clients onto a strong, water-based BPO gel that contains no oils, fatty acids or moisturizers to impede its action. Some BPO medications are so glutted with acne-aggravating ingredients that they can actually cause clogged pores and breakouts.

Sulfur
Sulfur has been around for centuries, and was used by the ancient Greeks as an anti-inflammatory and drying agent. Available in topical acne medications, and often formulated with resorcinol or benzoyl peroxide, and in masks that can smooth and exfoliate the skin dramatically. Sulfur is generally safe and effective, unless one is allergic to it or suffers from eczema. Sulfur works best in conjunction with other acne methods

Retin-A® and Retinoids

Retin-A® and its generic counterparts (known as vitamin A acid, tretinoin or retinoic acid) are topical treatments available in .01% and .02 1/2% alcohol-base gels, .05% liquid and .025%, .05% and .1% creams. The gel (Retin-A® and Differin®) and liquid varieties are helpful in the treatment of non-inflammatory acne including blackheads, closed comedones, clogged pores and rough texture. The emollient cream versions (which include Renova®, Retin A Micro® and others) are loaded with isopropyl myristate and stearic acid and other emollients, and can be acne aggravators. These creams are better anti-aging treatments for the non-acne-prone person with photo-damaged skin. The problem with retinoids is that while they cause a desirable peeling effect deep in the follicle and help loosen and dislodge comedones, they don’t kill bacteria like BPO. Though often prescribes to lighten hyperpigmented skin, they are slow-acting (unless formulated with a melanin-inhibiting lightener) and cause sun sensitivity that can lead to severe darkening. Retinoids, in the right formulation (used along with benzoyl peroxide and full-spectrum sun care and sun avoidance) are excellent “texturizer” that can help refine the pores and rejuvenate and brighten the skin.

Accutane
Accutane® is an extremely potent systemic retinoid, a vitamin A derivative, used in the treatment of severe cystic acne which is treatment-resistant. It works by shutting down the sebaceous activity in the entire body. Side effects can include severe birth defects, diabetes, kidney malfunction, severe dry and peeling skin, conjunctivitis, chapped lips, gum inflammation and bleeding, severe sun sensitivity, sometimes permanent hair loss, aching joints, nausea and vomiting, bone changes, headaches, blurred vision, rectal bleeding and digestive disturbances. Pregnancy testing, using two foolproof birth control methods, and blood tests for liver and kidney function and glucose levels are mandatory.

Unfortunately, many patients with lesser grades of acne are being prescribed Accutane® quite casually. Not only is Accutane® potentially dangerous, it simply doesn't work for most types of acne. There are thousands of disillusioned post-Accutane® failure cases who were promised permanent results and put at risk when Accutane® was clearly not indicated for them. Some cystic acne will clear up after one or more cycles of Accutane® only to have the condition return within months of stopping the drug. Or, when the dosage is adjusted higher, the cystic acne is gone for good, but an oily, non-inflamed or pustular acne often returns in its wake, usually within a year. Recently, taking Accutane® has been linked to depression, and more importantly, to suicide. Also, because Accutane® interferes with the skin enzyme collagenase, there is increased risk of severe scarring if procedures like dermabrasion, deep chemical peels, laser resurfacing and other facial surgery are performed after taking Accutane®.

Other Methods

Spironolactone is an anti-androgen diuretic that can decrease testosterone production. This is not a popular treatment for those not diagnosed with a severe androgenic hormonal imbalance. Side effects include nausea, fatigue, irregular menses, sun sensitivity and headache. Spironolactone interrupts the masculinization of a male fetus, so using two foolproof methods of birth control is a must. When severe acne, obesity and hirsutism are treated because of polycystic ovarian syndrome (PCOS), spironolactone is sometimes used with success, especially when combined with estrogen and metformin (a drug used to treat insulin resistance and adult-onset diabetes). Estrogen and spironolactone are sometimes given to male-to-female transgenders as part of their therapy. However, acne and hirsutism can be genetic and cultural, i.e. run in certain families of certain ethnicities, and are not necessarily be caused by a severe hormonal imbalance.

Estrogen dominant birth control pills are less popular these days as a way to control acne when other hormonal factors, like irregular periods, are not involved. Ortho Tricyclen® is advertised as a contraceptive that also helps clear acne, though this has been disputed. It should be noted that oral contraceptives can cause severe sun sensitivity and melasma (hormonal hyperpigmentation characterized by dark patches on the face), in addition to other serious risk factors, especially in women over 35 or those who smoke.