Common acne – causes, symptoms, treatment

Acne vulgaris is a chronic inflammatory disease of the sebaceous glands and the hair follicle. It is characterized by the occurrence of non-inflammatory eruptions (e.g. closed and open comedones) and inflammatory eruptions (e.g. pustules, cysts, papules). In 90% of acne vulgaris lesions are located on the face.

Who has acne vulgaris?

Common acne is the most common skin disease in adolescence. It affects 80-100% of people between 11 and 30 years of age, of which 85% is mild, while 15% of patients have severe inflammatory forms, often leaving scars and discoloration.

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The onset of the disease before the age of 12 is observed only in 7% of cases, new cases after the age of 16. that’s almost 40% of the time. The peak intensity of clinical symptoms in 30-66% of patients is on the 14-17th day. year in women and 16-19. year in men. There is an increase in the average age of people visiting a doctor due to acne from 20,5 to 26,5 years. Over 25 years of age acne on the face occurs in 54% of women and 40% of men. In 5% of women and 1% of men in 40 years of age changes of clinical significance are still observed in the face.

WARNING! Acne vulgaris is not only a disease of young people who are in their teens, but more and more often it is becoming a problem of mature people.

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Common acne – causes

The ailments etiology is multifactorial:

1. genetic conditions – individual tendency to excessive production of sebum and keratinization of the hair follicles. Mode of inheritance – autosomal dominant with different penetrance of the gene. More frequent incidence of the disease in children whose parents suffered from acne, as well as in both siblings among pairs of monozygotic twins compared to dizygotic couples. There is a genetic predisposition to the development of certain forms of acne, mainly severe (acne conglobata, acne nodulocystica);
2. hormonal changes in puberty – increased activity of androgen hormones during this period (stimulation of sebum production, enlargement of the sebaceous glands);
3. overgrowth of the sebaceous glands and excessive production of sebum;
4. excessive keratinization of the mouths of the sebaceous ducts (hyperkeratinization);
5. the process of comedogenesis – the main pathogenetic factor in the development of acne. As a result of the increased keratinization of the hair follicles, they are blocked by dense masses of corneocytes. As a consequence, it leads to a hindered excretion of sebum from the follicular sebaceous glands and a slow expansion of the exit ducts. In the process of comedogenesis, initially clinically invisible, precursor changes occur, which over time develop into microcomedones;
6. infectious agents – anaerobic bacteria (Propionibacterium acnes, less frequently P. granulosum and avidum), aerobic bacteria (Staphylococcus epidermidis) and yeast-like fungi (Pityrosporum ovale) are isolated from the surface of the skin and the drainage ducts of sebaceous glands. Staphylococcus epidermidis and Pityrosporum ovale, although occurring within acne lesions, are not pathogenetic factors. Their presence on the skin can also be found in healthy people. Pityrosporum ovale can induce folliculitis changes in the skin of the back. The most important pro-inflammatory factor is Propionibacterium acnes; development of inflammation and immune response – P. acnes initiates a cascade of inflammatory reactions, both immune and non-immune;
7. drugs, cosmetics – steroids, isoniazid, iodine, vitamins B6, B12, phenytoin, barbiturates, lithium, tar, mineral oils.

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Symptoms of acne vulgaris

The lesions are located in the following areas: face (seborrheic gutter) – 99%, back (interscapular area) – 90% and chest (sternum area) – 70%.

Clinical symptoms include:

1. intensification of seborrhea;
2. non-inflammatory changes – micro-blackheads transform into closed comedones, so-called whitehead (blackheads with a characteristic yellowish translucent sebaceous masses) and open blackheads, the so-called blackhead, which are formed as the hair follicle openings continue to expand and the keratin plug on the surface of the skin oxidizes;
3. inflammatory changes – papules, pustules, inflammatory infiltrates, nodules, cysts. The formation of comedones ends the period of non-inflammatory acne, usually followed by the transition to the inflammatory phase, in which the most important role is played by infectious agents – anaerobic bacteria, in particular Propionibacterium acnes;
4. post-inflammatory changes – discoloration, atrophic scars, hypertrophic scars, keloids. Due to the nature of morphological changes, the following are distinguished:
5. pimple
6. purulent acne
7. nodular cystic acne
8. acne is focused
9. scar acne
10. fulminant acne
11. mild acne
12. moderate acne
13. severe acne
14. caused acne
15. the so-called self-damaging acne

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Acne vulgaris diagnosis

Histopathological examination is not performed, except for scientific examinations. Blackheads – dilated cystic hair follicles filled with keratin deposits. With the development of inflammatory changes, the walls of the hair follicles may be destroyed and a foreign body-type granulomatous reaction may develop. When diagnosing common acne, it should be differentiated from:

1. rosacea,
2. perioral dermatitis (dermatitis perioralis),
3. inflammation of the hair follicles (folliculitis),
4. pseudofolliculitis,
5. disseminated facial lupoid (lupoid miliaris disseminatus faciei),
6. seeps (milia),
7. Favre-Racouchot disease.

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How to treat acne vulgaris?

Due to the long-lasting process of acne vulgaris treatment, the patient should be informed about the necessity of several months or even several years of treatment.

Topical treatment of acne vulgaris

Topical medications, used alone or in combination, have proven effective in most mild forms of acne vulgaris. More than 50% of patients can only be successfully treated with topical preparations. Topical treatment remains an important complementary component to general treatment in more severe clinical forms.

1. As an auxiliary in treatment, it is worth using cosmetics intended for acne-prone skin, such as Bioherba Cleansing Gel for oily and acne skin with activated carbon or Bioherba Moisturizing Milk for oily and acne skin.

Preparations used in the treatment of acne vulgaris:

1. Side effects
2. Azelaic acid: has an antibacterial, bacteriostatic effect against P. acnes, comedolytic, anti-comedogenic, reducing sebogenesis, discoloration by inhibiting melanogenesis (treatment of discoloration). Like benzoyl peroxide, it does not cause antibiotic resistance. Preparations – Skinoren and Hascoderm (each contains 20% azelaic acid)
3. Side effects
4. Corticosteroids: For large acne cysts, steroids can be used as intralesional injection (0,1 ml triamcinolone acetonide at a concentration of 2,5 mg / ml once a week for multiple injections).
5. Other topical preparations: Sulfur, which has been used for over 40 years, is less and less recommended because of its unpleasant odor and because of the arrival of many newer preparations. Sulfur is comedolytic, but it can also be comedogenic.
6. Ichthyol (Ammonium sulfobituminicum): shows anti-inflammatory, disinfecting, reducing, keratoplastic, anti-exudative and analgesic properties.
7. The keratolytic effect of salicylic acid (Acidum salicylicum) is exploited when it is used in concentrations of 1-5% together with sulfur in combined preparations in the form of pastes and slurries. Preparations – Acnosan, Oxy.
8. Resorcinol (resorcinum, m-dihydroxybenzene) – has a disinfecting, exfoliating, keratoplastic and reducing effect. It can stain skin, hair, nails and clothing. Used in the form of 1-3% aqueous solutions or 10-40% ointments and pastes. Both sulfur, resorcinol, ichthyol and salicylic acid are components of many prescription preparations.
9. Side effects

For the treatment of lighter varieties of acne vulgaris Alpha-hydroxy acids (AHA) – organic compounds derived from natural sources (e.g. fruit), which can also be obtained by chemical methods, have also found application (mainly with a large number of comedones) and scars after its severe forms. The mechanism of their peeling effect on the skin depends on:

1. type of acid (lactic, citric, oxalic, butyric),
2. its concentration (5-70%),
3. substrates (places of application),
4. exposure time (3-5 minutes).

Chemical peeling with hydroxy acids causes the relaxation of the cells of the stratum corneum and normalization of the keratinization of the hair follicles.

Another method of treating acne vulgaris are vaccine – specific vaccines containing two types of P. acne and one type of P. granulosum did not meet the expectations placed on them (Acnevac, Pseudovac). They are effective only in 30% of patients with slightly severe maculopapular acne. The use of a vaccine may even exacerbate the lesions. Autovaccines are contraindicated.

As an adjuvant in the treatment of acne, it is worth using Lavender Water – a mist for the face and body that perfectly cleanses the skin and soothes inflammation. For the daily care of acne-prone skin, eczema or psoriasis, we recommend the Sulfur Olive-Laurel Sulfur Cleansing Soap Surgras Aleppo Soap Co. by Tadé.

General treatment

It is indicated in moderate and severe forms of acne vulgaris. It is also implemented regardless of the severity of acne lesions, in the case of depression due to the disease; in people whose acne interferes with normal life activities (e.g. difficult interpersonal relationships), or in people whose slightly severe acne eruptions disappear leaving scars, keloids and post-inflammatory discoloration. It should be used for a minimum period of 6-8 months. The main groups of drugs used in oral therapy are antibiotics, anti-androgen drugs and retinoids.

In order to support the treatment of acne, it is necessary to take care of proper skin care. Try dermocosmetics available on Medonet Market:

1. Aknea cream contains oak bark extract, thyme and tea tree. These natural ingredients accelerate skin regeneration, moisturize it properly and prevent the formation of new acne lesions,
2. Orientana tonic for combination skin with ginger and lemongrass reduces sebum production and soothes skin inflammation,
3. Sylveco soothing body lotion with anti-inflammatory properties will work well in the care of skin with acne vulgaris.

Antibiotics: tetracyclines (tetracycline, doxycycline, minocycline), erythromycin, co-trimoxazole and clindamycin. They have antibacterial and anti-inflammatory properties. They are the first-line drugs in moderately severe and severe forms of acne vulgaris, and in all milder forms where local treatment has proved ineffective. They are indicated in maculopapular forms and in acne with inflammatory and infiltrative changes.

1. Tetracycline – has a bacteriostatic effect on P. acne and is directly anti-inflammatory. Treatment is started with doses of 1,0-1,5 g / day. After a visible improvement in the local condition is achieved, the dose should be reduced to 250-500 mg / day.
2. Limecycline – used at a dose of 200 mg / day.
3. Erythromycin – recommended in patients intolerant to tetracyclines, in women planning to become pregnant and in pregnant women requiring oral treatment. We start the treatment from 1,0-1,6 g / day, gradually reducing the dose depending on the improvement to 0,6-0,2 g / day.
4. Cotrimoxazole (Biseptol – trimethoprim and sulfamethoxazole) – is a chemotherapeutic agent showing effectiveness similar to erythromycin and tetracycline. It is especially indicated for patients with gram-negative folliculits.

Of the other antibiotics, the less frequently used antibiotics are listed below.

1. Minocycline – unregistered in Poland, commonly used in Western countries in doses of 100-200 mg / day; at this dose it does not show better efficacy than 1 g / day of tetracycline. Recommended for patients who do not respond to conventional acne treatment.
2. Doxycycline – used in doses of 100-200 mg / day shows similar effectiveness to minocycline.
3. Clindamycin – rarely used due to the risk of pseudomembranous enteritis. The complication may also occur topically after long-term use of erythromycin and tetracycline.
4. Azithromycin (first week: 500 mg for 3 days, subsequent 9 weeks: 500 mg once a week). The spectrum of action of azithromycin is P. acnes.

Oral antibiotic therapy should be continued for at least 6-7 months. After 6 months, the improvement is visible in 80-90% of patients treated. In the event of any relapses, the treatment can be repeated, starting the treatment with doses analogous to those in the first round.

Side effects are temporary symptoms, mainly in the gastrointestinal tract: nausea, vomiting, diarrhea and abdominal pain; vaginal mycosis occurs in 6% of patients. In addition, there is a risk of a mild increase in intracranial pressure after minocycline (drowsiness, headache, blurred vision, concentration disorders), less often after tetracycline. After minocycline, there is a possibility of blue-black discoloration on the skin; dark gray, diffuse or generalized change in skin color (muddy skin syndrome); tooth discoloration in adults after minocycline; lowering the effectiveness of oral contraceptives; phototoxic reactions, risk of discoloration of deciduous teeth, onycholysis – after tetracycline.

A separate problem is the development of antibiotic resistance, including the possibility of cross-resistance. If not responding to antibiotic therapy, the possibility of resistance development should be considered and antiandrogen or retinoid therapy should be tried.

Acne skin should be properly cared for with the use of specialized cosmetics. Try, for example, the Daily Soothing Acne Cleanser, which is designed to regulate sebum production, soothe irritations and accelerate skin regeneration. We also recommend EPTA AC cleansing peeling for oily and acne skin, which you can buy on Medonet Market separately or in the EPTA AC Set for Cleansing and Care of Oily and Acne Skin.

Hormonal treatment – anti-androgenic in acne vulgaris

Widely used, especially in women who do not respond to conventional therapy and for whom oral retinoids cannot be administered for various reasons. It is advisable:

1. in women with early-onset acne,
2. in acne resistant to treatment with antibiotics,
3. in acne with accompanying symptoms of hirsutism, systemic virilization features (clitoral hypertrophy, deep voice, muscle hypertrophy), alopecia, menstrual disorders and obesity.

Preparations containing progestogens devoid of androgenic activity (e.g. desogestrel, norgestimate, gestodene) are preferred. They reduce the bioavailability of biologically active free testosterone, inhibit the production of ovarian androgens, and the effect of this activity is a reduction in sebum production.

Hormone therapy should last from 6 to 12 months and be combined with local therapy. The improvement may not be seen until 4-6 weeks of treatment.

From the group of drugs, the following are used, among others spironolactone and ethinylestradiol in combination with cyproterone acetate, drospirenone, dienogest or desogestrel.

In severe and very severe acne in women, anti-androgen drugs are combined with oral isotretinoin. Such a combination provides patients with effective contraception, while increasing the effectiveness of therapy.

1. Spironolactone

One of the best known and most widely used anti-androgen drugs is cyproterone acetate with ethinyl estradiol (Diane 35). All hormonal preparations, although they differ in the composition of hormones, have a similar mechanism of action, the same indications, contraindications and side effects, which may only slightly differ in intensity. Diane 35 (ethinylestradiol – 0,035 mg + cyproterone acetate – 0,002 g) – progesterone derivative with antiandrogenic, progestagenic and antigonadotropic properties. It lowers the sebum secretion index, consequently reducing comedogenesis. The effectiveness of Diane 35 is comparable to treatment with oral tetracycline at a dose of 1 g / day.

-Yasmin (ethinyl estradiol – 0,03 mg + drospirenone – 3 mg) – a new generation drug containing drospirenone, a unique progestogen with anti-androgenic and anti-mineralocorticosteroid properties. Drospirenone is the equivalent of 25 mg spironolactone. It blocks androgen receptors, acting comparable to Diane 35.

-Cyprest (ethinyl estradiol 0,035 mg + cyproterone acetate 2 mg) – a preparation with anti-androgenic, gestagenic and antigonadotropic properties.

In addition, anti-androgenic drugs are used:

1. Regulon (etynyloestradiol 0,03 mg + dezogestrel 0,15 mg),
2. Marvelon (etynyloestradiol 0,03 mg + dezogestrel 0,15 mg),
3. Sindi 35 (ethynyloestradiol 0,035 mg + octane cyproterone 2 mg),
4. Jeanine (etynyloestradiol i dienogest).

Newer drugs containing low doses of hormones (levonorgestrel 100 µg + ethinylestradiol 20 Eg) proved to be effective in the treatment of acne, while showing less adverse complications from the cardiovascular system. The recommended precautions and contraindications are the same for all hormonal drugs.

Side effects of taking hormonal drugs:

1. headaches,
2. gastrointestinal complaints (nausea, vomiting),
3. breast tightness or swelling,
4. menstrual disorders
5. spotting,
6. weight changes and decreased libido,
7. depressive states,
8. discoloration on the face (chloasma), especially when exposed to UV radiation.

Women with leg varicose veins and smoking cigarettes should not take this medicine due to the risk of developing venous thrombosis (deep vein thrombosis, pulmonary embolism). It is not recommended to use in cases of arterial embolism in the history (stroke, myocardial infarction) and with concomitant ischemic symptoms (angina, transient cerebral ischemia). Before starting treatment, you should perform a checkup (palpation and ultrasound) and measure your blood pressure. These tests should be repeated every 6 months.

WARNING! Hormone treatment of acne vulgaris is contraindicated in women with changes in the breasts and high blood pressure. Patients with suspected or diagnosed cancer of the reproductive organ or other hormone-dependent cancer are also excluded from treatment with this preparation.

Patients using hormonal anti-androgen therapy must be aware of the increased risk of thromboembolism. Moreover, with long-term use there is an increased risk of developing cervical cancer and a slight increase in the relative risk of developing breast cancer. Therefore, such treatment should be carried out under regular medical supervision.

Common acne and systemic retinoids

Orally administered isotretinoin (13-cis-retinoic acid, 13-cis-vitamin A) has revolutionized the treatment of severe and very severe forms of acne. It belongs to the first generation of retinoids and is a synthetic steroisomer of all-trans tretinoic acid (tretinoin). Affects all mechanisms of acne pathogenesis:

– reduces the secretion of sebum by up to 90%,

– causes the involution of the sebaceous glands,

– has antibacterial properties – reduces the number of surface and ductal P. acnes,

– works against blackheads – normalizes the processes of intraductal keratosis,

– has anti-inflammatory properties.

The indications for treatment with oral isotretinoin are:

1. severe and very severe forms of acne such as acne phlegmonosa, acne conglobata, acne nodulo-cystica and acne inversa;
2. severe and moderate forms that are unresponsive to 18 months of conventional therapy;
3. severe and moderate forms of the disease, characterized by relapses after conventional treatment;
4. forms with moderate intensity of lesions with a tendency to scarring;
5. moderately severe maculopapular acne in which no improvement of more than 50% of the baseline was achieved after 2-3 cycles of conventional antibiotic therapy for 3 months each;
6. patients with dysmorphophobia, mental disorders and suicidal tendencies resulting from the disease;
7. acne accompanied by severe seborrhea;
8. resistant to treatment Gram-negative folliculitis, acne fulminans and facial pyoderma (pyoderma faciale), especially after a one-month treatment with oral steroids.

Dosage: the optimal dose of isotretinoin is 0,5-1,0 mg / kg. for 24 hours for 4-7 or even 9 months. The total dose, i.e. the dose of the drug used during the entire treatment, is of great importance. The optimal dose of isotretinoin for maximum long-term beneficial effects is 120-150 mg / kg. If the treatment is unsuccessful, it can be repeated only after a period of 6 months. Treatment with isotretinoin does not require additional topical preparations.

Side effects resulting from taking the preparation:

1. teratogenicity – the need to use effective contraception throughout the treatment period and for 2 months after its completion,
2. the mutagenic or carcinogenic effect of retinoids has not been proven,
3. mucosa and skin side effects – excessive dryness of the mucous membranes and skin, dryness and inflammation of the mucous membranes of the nose (rhinitis sicca), blood from the nose, blepharitis and conjunctivitis, inflammation of the red lips and facial skin (facial dermatitis) and facial erythema. These symptoms are called retinoid dermatitis.
4. the possibility of exacerbation of acne lesions in the initial period of treatment with isotretinoin,
5. bone and joint pain and muscles,
6. headache, possible development of mild intracranial hypertension (impaired concentration and visual disturbances – blurred vision and blurred vision), especially in combination with tetracyclines,
7. the so-called disseminated bone hyperostosis,
8. possible depressed mood, depression, suicidal thoughts, panic attacks,
9. diarrhea and ulcerative colitis,
10. Wegener’s granuloma,
11. the development of vasculitis lesions that mimic the image of polyarteritis nodosa,
12. isolated cases of demyelinating changes in the cerebellum on MRI,
13. the occurrence of pyogenic granulomas,
14. possibility of occurrence of foot after isotretinoin,
15. hair loss and thinning,
16. both within the lesions and around the nails, there may be changes in the form of granuloma telangiectodes,
17. deviations in laboratory tests: increase in transaminase levels, increase in alkaline phosphatase, bilirubin, lipid metabolism disorders (increase in triglycerides, total cholesterol and LDL fraction with a simultaneous decrease in the HDL fraction), increase in uric acid levels, increase in ESR, decrease in the number of white blood cells. Laboratory tests should be performed before treatment and then every 1-2 months,
18. risk of hypervitaminosis A – avoiding taking vitamin A supplements.

Among the less frequently used general drugs in the treatment of acne, the following should be mentioned:

1. Corticosteroids – orally administered steroids are recommended only in severe and very severe forms of acne (acne phlegmonosa et conglobata, acne fulminans). In acne fulminans they are used in combination with systemic antibiotics.
2. -Dexamethasone 1 mg / day, prednisone 20-40 mg / day, and even 40-60 mg / day. Corticosteroids can be combined with sulfones and retinoids.
3. -Sulfones – treatment with preparations from this group may be effective in cases of acne resistant to antibiotics and with cyst-like skin lesions. Dapsone at a dose of 100 mg / day. Mainly anti-inflammatory effect.

Side effects: the possibility of methaemoglobinaemia.

Prognosis for acne vulgaris: the chronic nature of the disease at an early age is a major psychological problem. Acne treatment, often lasting several years, is a difficult and complex problem. When starting treatment, you should always consider:

1. the degree of severity of the lesions,
2. duration of the disease,
3. risk of side effects,
4. the patient’s financial capacity.

Only the right therapy, individually matched to the patient, can bring a satisfactory effect. Acne lesions constitute a separate treatment problem.

As part of the treatment of acne, it is worth supporting yourself with natural methods, e.g. the herbal tea recommended for acne EKO, which you can buy at Medonet Market.

Skin affected by acne should be properly cared for. The Cannaderm brand has created a set of hemp-based cosmetics for the care of acne-prone skin. The preparations are rich in natural extracts that strongly moisturize, soothe symptoms of acne and tone the skin. Try Cannaderm cosmetics and forget about acne.

LITERATURE:

1. Bolognia JL, Jorizzo JL, Rapini RP: Dermatology, Mosby 2003, 531-534, 538-543.

2. Cunliff e W.J., Gollnick H.P.M.: Acne. Diagnosis and management, Martin Dunitz Ltd, 2001.

3. Dreno B. i wsp.: An expert view on the treatment of acne with systemic antibiotics and/or oral isotretinoin in the light of the new European recommendations, Eur J Dermatol 2006, 16(5), 565-571.

4. Update on the pathogenesis and management of acne vulgaris, J Am Acad Dermatol 2004, 51 (1), 36-38.

5. Webster G.F., Rawlings A.V.: Acne and its therapy, Informa Healthcare USA, Inc, 2007.

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