Management of Acne - How to Control and Cure!!
Acne is a common yet a disfiguring skin condition seen among teenagers and young adults. However, it is too often neglected as a minor skin ailment not worthy of treatment, as it is considered as an event occurring associated with the puberty. Because of the risk of severe disfiguring with extensive scarring if left untreated, it is important to be aware of the condition and when to seek dermatological attention as well as the available modalities of treatment.
Management of acne involves several aspects. Here the severity grade of the lesions is very important. Acne lesions are divided into inflammatory and noninflammatory lesions. Noninflammatory lesions consist of open and closed comedones. Inflammatory acne lesions are characterized by the presence of one or more of the following types of lesions: papules, pustules, and nodules (cysts). Papules are less than 5 mm in diameter. Pustules have a visible central core of purulent material. Nodules are greater than 5 mm in diameter. Nodules may become suppurative or hemorrhagic. Suppurative nodular lesions have been referred to as cysts because of their resemblance to inflamed epidermal cysts. Recurring rupture and reepithelialization of cysts leads to epithelial-lined sinus tracks, often accompanied by disfiguring scars.
A severity grade based on a lesion count approximation is assigned as mild, moderate, or severe. The severity grading of inflammatory lesions are as follows;
· Mild- Papules and pustules are few to several and no nodules
· Moderate- Papules and pustules are several to many, and few to several nodules
· Severe- Papules and Pustules numerous or extensive, and nodules many
Treatment is targeted on the pathogenesis of acne which involves increased amounts of keratin blocking the pores, increase amount of sebum secretion and proliferation of Propionibacterium acnes in sebum causing inflammation. Therapeutic agents with each action are stated below;
1. Normalize the pattern of follicular keratinization
2. Inhibit sebaceous gland function
· Estrogens( oral contraceptive pill)
· Anti-androgens spiranolactone
3. Antibacterial effect
· Benzoyl peroxide
· Topical antibiotics
· Oral antibiotics
Individuals having the mild disease with comedones are treated with retinoid which is sufficient since there is not much of inflammation. Closed comedone acne (whiteheads) respond slowly. A large mass of sebaceous material is impacted behind a very small follicular orifice. The orifice may enlarge during treatment, making extraction by acne surgery possible.
Retinoids are applied at bedtime. The base and strength is selected according to skin sensitivity. Start with a low concentration of the cream or gel (available in 0.05% and 0.1%) and increase the concentration if irritation does not occur. Medications are used more frequently if tolerated. Benzoyl peroxide, topical antibiotics or combination medicine later is added to discourage P. acne and the formation of inflammatory lesions. The response to treatment is slow and discouraging. Several months of treatment is required. Large open comedones (blackheads) are expressed; many are difficult to remove. Several weeks of treatment facilitates easier extraction. Topical therapy may have to be continued for extended periods.Mild inflammatory acne with papules/pustules should be started on Benzoyl peroxide, a topical antibiotic, or combination medicine and a retinoid. It is initially applied on alternate evenings and lowest possible concentrations are used. After the initial adjustment period, the retinoid is used each night and benzoyl peroxide or antibiotic each morning. The strength of the medications is increased if tolerated. Oral antibiotics are introduced if the number of pustules does not decrease. Topical therapy may have to be continued for extended periods.
Patients who have moderate-to-severe acne (more than 20 pustules) are treated with twice-daily application of a topical antibiotic, benzoyl peroxide, or combination medicine or the combination of benzoyl peroxide and sulfacetamide/sulfur. This drying agent program can be very effective. Patients using drying agents should adjust the frequency of application to induce a mild, continuous peel. Response to treatment may occur in 2 to 4 weeks. Oral antibiotics are used for patients with more than ten pustules. Treatment should be continued until no new lesions develop (2 to 4 months) and then should be slowly tapered. If there are any signs of irritation, the frequency and strength of topical medicines should be decreased. A retinoid can be introduced if the number of pustules and the degree of inflammation has decreased. Those who have responded well may begin to taper and eventually discontinue oral antibiotics.
If patient has severe nodulocystic acne including localized cystic acne (few cysts on face, chest, or back), diffuse cystic acne (wide areas of face, chest, and back), pyoderma faciale (inflamed cysts localized on the face in females) and acne conglobata (highly inflammatory, with cysts that communicate under the skin, abscesses, and burrowing sinus tracts), a different approach is required. The patient is assured that effective treatment is available since they are psychologically depressed due to the disfiguring disease condition. A primary therapeutic goal is to avoid scarring by terminating the intense inflammation quickly; prednisone is sometimes required. Isotretinoin is oral retinoid which is important in treating severe disease and if patient is not suitable for that since it has high degree of teratogenicity, oral contraceptive pills combined with spiranolactone can also be considered. Cysts with thin roofs are incised and drained. Deeper cysts are injected with triamcinolone acetonide. Patients who show little tendency to form scars can be treated as patients with moderate-to-severe inflammatory acne.
Treatment of acne is difficult since patients are sensitive over the issue and they easily get disappointed since they do not get the results to meet their expectations. The time taken for results to appear should be explained so that there will be proper compliance from the patient.
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