Almost all adolescents will get some acne. About 15% will seek medical
care. Acne tends to begin during or right before puberty. This is because
puberty is characterized by an increase in sex hormones. These hormones
cause development of secondary sex characteristics in both males and
females. Persons who get severe acne do not necessarily have an over
production of hormones, but rather a hyper-response to the hormones.
Mild inflammatory acne is usually the next stage. It also tends to develop in women in their twenties. Usually there is some component of bacterial infection. Mild cases will respond quite nicely to topical antibiotics or benzyol peroxide. Benzyol peroxide is available over the counter. Occasionally, several different topical antibiotics will need to be tried to find out which one works best.
Inflammatory acne is more severe. This type of acne causes more scaring
and will cause deep, inflammatory nodules. Another name for this condition
is cystic acne. Usually topical tretinoin is applied once daily with
an oral antibiotic. Again, it may take four to eight weeks to reduce
the bacteria and curtail the formation of new inflammatory lesions.
Large lesions may be injected with steroids. Widespread cystic acne
will usually require isotretinoin(Accutane) therapy. A four-to five-month
course is usually required. Birth control pills may be effective in
treating females with moderately severe acne.
As mentioned above, there are three different factors that contribute to the development of acne:
1. Overproduction of sebum from the sebaceous glands,
2. Abnormal sloughing of the cells that form the inside of the glands, and
3. Growth of bacteria called Propionibacterium Acnes.
Treatment is aimed at modifying or reducing one or more of these three factors.
1. Reduce the production of sebum. This can only be accomplished by oral medication. Estrogens(such as birth control pills) are sometimes quite effective in the treatment of acne. This can only be used in females. A water pill called spironolactone can also be effective. Isotretinoin(Accutane) is extremely effective and is used quite extensively for severe acne.
2. Abnormal and excessive sloughing of the cells that form the inner lining of the gland. Isotretinoin also decreases the sloughing of cells and can be quite effective. Oral antibiotics also have an indirect effect on improving this problem. Topical medication is quite effective in decreasing the sloughing of cells. Topical medicines that are helpful are tretinoin(Retin-A), salicylic acid, adapalene(Differin gel) and tazarotene.
3. Proliferation of bacteria called Propionibacterium Acnes. This results
in an inflammatory reaction and makes the acne appear very red and sometimes
swollen. Oral medications for this include tetracycline, erythromycin,
minocycline, doxycycline, Bactrim, clindamycin and isotretinoin. Topical
medications to reduce the bacteria include erythromycin, clindamycin,
benzyol peroxide and azelaic acid. A combination of benzyol peroxide
and erythromycin is extremely effective and goes by the brand name of
Benzamycin. Benzyol peroxide is also combined with glycolic acid. Using
oral steroids as well as isotretinoin can also reduce inflammation.
Inflammation can be reduced by topical metronidazole (MetroGel). Injecting
the acne lesions with steroids can also be effective.
Wiedermann BL, et al. Acne. Griffith' 5 Minute Clinical Consult. 2004, Electronic version 4.0.139.
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