Acne
Bill V. Way, D.O.
Dermatology Residency
Program Director
What is Acne? Acne is a skin disorder resulting from
the action of hormones on the skin’s oil glands (sebaceous glands) which leads to plugged pores and outbreaks of the lesions of papules, pustules, comedones, inflammatory cysts commonly called pimples or zits.
Acne
Over 17 million people in the US have acne today. It is the most common skin disease.
Not a serious health threat, but severe acne can lead to disfiguring, permanent scarring, low self esteem.
Acne
The disease of the pilosebaceous units of the skin.
Most commonly on the face, neck, chest, back and shoulders were more of the pilosebaceous units are located.
Acne
The basic acne lesion is called the comedo (KOM-e-do), simply an enlarged and plugged hair follicle.
If it remains below the surface it is called a closed comedo and produces a whitish bump called a whitehead, this is not a milium.
Acne: Comedo
If the comedo reaches the surface, it is called an open comedo or blackhead
The black color is not dirt, but is from the oil oxidizing when it reaches the surface of the skin
Acne: Papule
Inflammed lesions that usually appear as small pink bumps on the skin and may be tender to the touch
Acne: Pustule
Inflammed papules with a pustule on the top that may be red at the base and usually tender. (Pimple)
Acne: Nodules
Large, painful, solid lesions that are lodged deep within the skin
Acne: Cysts
Deep,painful, pus-filled lesions that can cause scarring
What causes Acne?
Exact cause of acne is unknown. Several factors may play a role.
One important factor is an increase in androgens (male hormones). These increase in both boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum.
What causes Acne?
Other factors: heredity or genetics; medications, androgens, lithium; greasy cosmetics; occlusive clothing
Hormone changes related to pregnancy or starting and stopping birth control pills can also be a cause of acne.
What causes Acne?
Propionibacterium acnes (P.acnes) are the anaerobic bacteria responsible for causing acne.
Other factors: heredity or genetics; medications, androgens, lithium; greasy cosmetics; occlusive clothing
Hormone changes related to pregnancy or starting or stopping birth control pills can also be a cause of acne.
Propionibacterium acnes
Anaerobic bacteria in hair follicle. These bacteria use the sebum as food and
break the sebum down into irritating substances, which cause inflammation.
The abnormal flaking of the cells inside the hair follicle and the irritating substances lead to a plug formation and the to follicle swelling and then rupturing and developing into the papule then to the pustule.
What can make Acne worse?
Changing hormone levels in adolescent girls and adult women 2-7 days before their menstrual period starts
Friction by leaning or rubbing skin Pressure from helmets, backpacks Environment: pollution and high humidity Squeezing or picking at pimples Hard scrubbing of the skin
Myths about causes of Acne
Foods; chocolate, greasy or fried foods. No foods cause acne.
Dirt. Acne is not the result of uncleanliness or infrequent washing.
Stress. Just the opposite, Acne may cause the patient more stress.
Sunlight or tanning clears acne. No tanning will lead to sundamaged skin, wrinkles and skin cancers.
Skin must be scrubbed. No, too much scrubbing may actually make acne worse.
Who gets Acne?
People of all races and ages. Most common in adolescents and
young adults 85% between ages 12-25 Resolves with time around age 25-30 Few patients may have persistent acne
into their 40’s and 50’s
Who should be treating Acne?
Family Practice Pediatrics Internal Medicine Dermatology
What are the goals in treating Acne? Heal existing lesions Stop new lesions from forming Prevent scarring Minimize the psychological stress and
embarrassment, thus improving self-esteem and self-confidence and avoiding depression
Teach the patient what acne is, how to treat their acne and what to expect from treatment
Acne Treatment
Medical treatment is aimed at reducing several problems that play a role in causing acne; abnormal clumping of cells in the follicles, increased oil production, bacteria and inflammation.
Grading Acne
Scale 0-4 0 – no acne, clear +1– mild acne, comedos, papules, few
pustules +2 – moderate acne, comedos, multiple
papules and pustules +3 – moderately severe, multiple comedos,
papules and pustules, mild scarring +4 – severe, multiple comedos, papules,
pustules, inflammatory cysts, nodules, scarring
Treatment for Blackheads, Whiteheads and mild inflammatory Acne OTC or Rx Benzoyl peroxide, resorcinol, salicyclic
acid and sulfur Benzoyl peroxide products kill P.acnes
and may reduce oil production Resorcinol and salicyclic acid and sulfur
help break down blackheads and whiteheads
OTC Treatment
Benzoyl peroxide washes and gel Salicyclic Acid washes Must be used twice daily regularly for 8-
12 weeks, then reevaluate
Treatment of Moderate to Severe Inflammatory Acne Prescription topical and or oral
medications alone or in combination Recheck patient every 4-8 weeks for
results and to adjust acne treatment program
Treatment of Severe Nodular or Cystic Acne Should be seen and treated by a
dermatologist Failure to respond to a variety of topical
antibiotics, topical retenoids and oral antibiotics
Consider Accutane Therapy
OTC Topical Acne Cleansers
Neutrogena Acne Wash Cetaphil Facial Cleanser Oil of Olay Facial Cleanser Various Benzoyl Peroxide Cleansers,
Clearsil, Clean and Clear, others
Acne Treatment
Clean skin gently Avoid squeezing, pinching, picking or
scratching the acne lesions. Bleeding leads to scarring Shave carefully Avoid sunburn or suntan Choose cosmetics carefully, oil-free,
water based
OTC Acne Topicals
Benzoyl peroxide cleansers Sulfur products Salicyclic acid pads
Prescription Acne CleansersBenzoyl Peroxide Brevoxyl 4%, 8% Triaz 3%, 6%, 10% Benzac 5%, 10%
Prescription Cleanser
Plexion Cleanser: Sodium Sulfacetamide 10% & Sulfur 5%
Topical Antibiotics
Clindamycin: Solution,Gel, Lotion, Pads Erythromycin:Solution,Gel,Pads,
Ointment Combination: Benzoyl peroxide and
topical antibiotic Sodium Sulfacetamide and Sulfur
Topical Antibiotics
Cleocin T Solution, Lotion, Gel, Pads Erycette Pads Benzamycin Gel BenzaClin Gel Klaron Lotion Plexion SCT
Topical Retenoids
Retin A: gel, cream, microgel Differin: gel, cream, pad Generic Tretinoin: gel, cream
Retin A Microgel
0.04% and 0.1% 20gm and 45gm Apply at hs Recommend sunscreens in am
Oral Antibiotics
Tetracycline Minocycline Doxycycline Erythromycin Azithromycin
Oral Tetracycline
Generic Tetracycline is ok Must be taken correctly, 1 hour before
meal or 2 hours after meal with glass of water
Not to taken with milk Increased change of inducing vaginal
yeast infections
Oral Minocycline
Dynacin, Minocin, Adoxa, Generic Better absorption, less GI upset May be taken with food, minimal loss of
effect 1-2 times daily Avoid 100mg bid for it may induce a
blue gray hyperpigmentation in areas of cysts, bleeding or brusing
Oral Minocycline
Increased cost Very effective May be used long term
Oral Doxycycline
Doryx, Generic Good absorption, less GI upset May be taken with food, minimal loss 1-2 times daily Occasional photosensitivity, rare Increased cost, very effective, may be
used long term
Oral Erythromycin
Eryc 250mg 1 bid Effective for short times, then bacterial
resistance starts to develop Low cost, increased GI upset May have other drug interactions
Oral Azithromycin
Recommend use only by dermatologist due cost
Accutane (Isotrenoin)
10mg, 20mg, 40mg Used by itself Patients must be enrolled into the
SMART Program and rules and regulations must be followed exactly
Recommend patient be referred to dermatologist
Accutane (Isotretinoin)
Very effective Useful to help prevent scarring 15-20 weeks of therapy SMART Program Expensive Patient must be monitored very closely No other acne treatment needed
Accutane: Disadvantages
Can cause birth defects Female patients must not get pregnant
while on Accutane Depression, Irritability Loss of appetite, hair thinning, curling Dry eyes, mouth, lips, nose and skin,
itching, nosebleeds, muscle aches, sensitivity to sun, poor night vision
Accutane: Disadvantages
Changes in blood such as increase in triglycerides and choesterol or a change in liver function
Must monitor blood prior to starting and every 4 weeks while on Accutane
CBC, CMP, Lipid Panel, UA, Urine pregnancy test
Adjunct Derm Treatment
Acne Surgery Mild Chemical Peels Microdermabrasion New ClearLight treatment Dermabrasion or Laser tx for scarring Surgical scar revision Fillers for scars, fat transfer Intralesional steroid injections
How often should the Acne Patient be seen? Initially every 4-8 weeks Then every 8-12 weeks Then every 3-4 months Acne is monitored and treated for
several years from ages 12-25
Hormonally Influenced Acne
Increased excessive androgen levels in females may present as hirsutism, premenstrual acne flares, irregular menstrual cycles, elevated blood levels of certain androgens
Birth control pills with increased androgens will increase acne
Birth control pills with increased estrogens decrease acne
Recommend OrthoTri-Cyclen or Demulen Occasionally but rare use of low dose
corticosteroid drugs, prednisone or dexamethasone may be used to suppress the androgen production by the adrenal gland
Occasional use of spironolactone to reduce excessive oil production.
Web Sites on Acne
www. aad.org www.aocd.org www.niams.nih.gov www.derm-infonet.com/acnenet