treating acne

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The Cause of Acne

The oil is produced by oil glands known as sebaceous glands. These glands are bigger and more active in the region of the nose than any other areas of the face. This is why the nose tends to be a trouble area. The pores in this area are also larger, in order to accomodate the large flow of oil produced. Other areas on the body where sebaceous glands are most heavily concentrated are the neck, chest, and back-areas where body acne can be common.

The amount of oil that an individual makes is determined by genetics. It is affected by hormones and what is called an "end organ response". The oil gland is considered the end organ because it is this gland that is acted upon by hormones. Many people have the same level of hormones, but make different amount of oil because their oil glands respond differently. During adolescence, a surge in the level of sex hormones, known as androgens, creates a problem of oily skin where sometimes there was none. The reason is that androgens enlarge and stimulate the sebaceous glands, causing them to produce more sebum.

In addition, there is present in acne patients an abormal desquamation (exfoliation) of follicle epithelium*, which results in altered keratinization. This is known as comedogenesis. This process creates a microcomedone, which is still invisible to the eye. This lesion will evolve into either a non-inflammatory lesion (blackhead or whitehead), or an inflammatory lesion. If the comedo ruptures, the area becomes inflamed and results in either papules, postules, or cysts. If there is a large presence of the bacterium Propionibacterium acnes it will facilitate ongoing infection and inflammation.

*Membranous tissue composed of one or more layers of cells separated by very little intercellular substance and forming the covering of most internal and external surfaces of the body and its organs.


Caring for Acne

The first step towards proper care and treatment of acne partly lies in the diagnosis of the type of acne. There are other skin disorders that may resemble acne, but are unrelated. This includes rosacea and gram-negative folliculitis. This is why it is important to see a dermatologist to get a correct diagnosis. This way, incorrect treatment may be avoided.

Acne can be diagnosed either by the age of onset, or the predominant type of lesion: comedonal, papulopostular, or cystic. Examples of comedonal lesions include blackheads "open comedo") or whitehead ("closed comedo"). Lesions that become infected or inflamed become red and raised - the milder and more common ones called papules or postules. The large, painful lesions wich seem to be buried within the skin are known as cysts. these lesions are the ones responsible for most acne scarring. Once the acne is diagnosed, it is then determined as mild, moderate, or severe.

In the treatment of acne, the four main factors that contribute are taken into account - Comedogenesis, Sebum production, P. acnes (the bacteria), and inflammation.

Acne Treatments and their Targets
Comedogenesis

Retinoids
Benzoyl Peroxide
Isotretinoin
Sulfur
Salicylic Acid
Azelaic Acid
Alpha hydroxy acid
Sebum Production

Retinoids
Antiandrogens
Low-dose oral contraceptives
P.acnes

Antibiotics
Retinoids
Benzoyl peroxide
Mandelic Acid

Inflammation

Oral Antibiotics
Retinoids


For non-surgical treatment of acne, there are two man categories, topical or systemic. Topical treatments include Benzoyl Peroxide, alpha hydroxy acids, topical antibiotics, Retin-A, and other cleansers, soaps, or astringents. Systemic treatments include oral antibiotics, isotretinoin (Accutane), or hormonal therapies. A combination of treatments is usually ascribed in order to target all four of the acne contributors.

Keratolytic (Exfoliating) Agents:

These products affect the comedogenesis (see table above) process by normalizing desquamation (the exfoliation process). This makes it easier for the proper exfoliation and softening of the follicle epithelium, the tiny tissue covering pore openings. The two most commonly available items in this category are alpha-hydroxy acids and benzoyl peroxide.

Alpha hydroxy acids: Glycolic acid, the most well-known of the bunch is a useful adjuvant therapy for mild acne. Mandelic acid, a lesser known one, but one that combines the keratolytic properties of glycolic acid with natural antibacterial properties that help reduce the presence of P. acnes, may be considered a more effective alpha hydroxy acid in treating acne lesions. It is also much less irritating than glycolic acid, a factor that may be very important to those with sensitive skin who are unable to use other agents such as Retin-A, benzoyl peroxide, sulfur, or salicylic acid. It is effective in treating mild cases of acne on its own, and can be used successfully with other therapies on moderate acne.

Salicylic Acid: Salicylic Acid is a Beta-hydroxy acid. It's exfoliating action is similar to that of glycolic acid, but it remains on the top of the skin, cleansing out pores. Salicylic acid is particularly effective at decreasing the number of noninflammatory lesions such as blackheads and whiteheads.

Benzoyl peroxide: As one of the more potent antimicrobial agents used in the treatment of mild acne, benzol peroxide is available in a variety of formulations and concentrations. There appear to be no differences in the efffectiveness of the different formulations and concentrations in the average acne patient. "Benzoyl peroxide rapidly improves both inflammatory and noninflammatory lesions by reducing the population of P. acnes, and facilitating a decrease in the free fatty acids that ultimately lead to retention hyperkeratosis, and microcomedo formation." - Cosmetic Dermatology April 1999

Sulfur and resorcinol: These older medications tend to work mostly on the surface of your skin to help heal existing blemishes by unclogging pores.

Tretinoin: (Retin-A): Tretinoin works on acne by normalizing the exfoliation of the follicular epithelium, drains and promotes healing of existing blemishes, and prevents new ones from forming. Tretinoin also removes microorganisms that stimulate inflammation."...tretinoin may enhance penetration of other drugs, such as topical antibiotics and antimicrobials (Benzoyl Peroxide), by facilitating the unplugged follicle to become less anaerobic and more accessible. This inhibits the growth of P. acnes and minimizes the rupturing of comedones into surrounding tissue. As a results, tretinoin is a first line agent for both inflammatory and non-inflammatory acne." - Cosmetic Dermatology April 1999 Side effects associated with tretinoin are peeling, redness, irritation, dryness, and increased sun sensitivity. Topical tretinoin, applied at acne sites in small amounts does not alter plasma Vitamin A levels, suggesting that it is a safe drug for use during pregnancy.

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Tretinoin formulas - Tretinoin is available in a variety of formulations such as cream, gel, and liquid. The selection of the formulation is dependant upon skin type,skin condition, as well as environment. More will be said later on on choosing the right type for you. New developments in the tretinoin industry include the introduction of generic formulations as well as a new microsphere formulation. The new micorsphere formulation was developed to help reduce irritation associated with traditional tretinoin. The formulation keep the tretinoin entrapped in a microsponge. Rather than releasing the tretinoin into the skin upon application, the microsponges first attach to the hair follicle, then release the drug. Improvements are seen in as little as two weeks. Including the benefit of decreased irritation, the micosphere formulation was shown to reduce twice the number of inflammatory and non-inflammatory lesions as the regular formulation. The first generic version of Retin-A®, known as Avita™, was approved by the FDA in 1997. Both formulations contain the same active ingredient, but the delivery system varies. While a study was made that found the efficacy of the two were comparable, there are some concerns with generic substitutes. The main concern is when a patient is started on the original product, then decides to switch. Differences in innovator products and generic products may lead to allergic reactions (this is a concern in all products and not just tretinoin). Switching to a generic product can result in an unsatisfactory result or treatment failure.
Topical Antibiotics:

Clindamycin and erythromycin are the two most common of this type of acne treatment. The efficacy of these products, which are clinically equivalent, lies in the reduction of the P. acnes bacteria on the skin's surface and in the follicle. Although they are also naturally anti-inflammatory, they have no comedolytic effects, and thus do not help preexisting blemishes. Topical clindamycin is available in solution, gel, and lotion formulation; Topical erythromycin is available in cream, solution, gel, pledget and wipes. Topical erythromycin reduces lesions by 50%-60%. The addition of zinc to erythromycin ehances the effectiveness of the product, reducing blemishes even further.

If improvement with topical antibiotics starts to diminish, then the treatment should be temporarily discontinued. This will prevent a tolerance or resistance to the drug from developing.

Oral Antibiotics:

Typically reserved for moderate to severe acne, oral antibiotics such as tetracycline, minocyclene, and erythromycin, these medications are prescribed for prolonged periods of time, typically 4-6 months. These agents suppress P. acnes and have antiinflammatory properties. As with topical antibiotics, combined use with Retin-A will enhance results, speed response time, and minimize side effects.

Isotretinoin:

Also known as Accutane, this drug affects all four of the contributing factors to acne. It increases exfoliation, preventing comedogenesis. It also decreases sebum production (which may also result in dryness in the skin, mucous membranes, and eyes). it also precipitates a diminished growth of P.acnes, resulting in less inflammation. This therapy is resevered mainly for those with severe and/or cystic acne or patients who have not responded positively to other treatments. The length of treatment is typically 4 months, doses varying according the the severity of the acne. This treament is associated with long-lasting remissions, allowing for acne-free skin even after medication is finished. Teenagers with cystic acne are at higher risk of relapse after the course of medication is finished. In this case, another session of treatment will be required. Sometimes it may take two to four courses of treatment before permanent remission occurs.

Some other causes for treatment failure are inadequate dosing and interferance of other medications such as lithium and phenytoin. Those with a history of sinus tract disease may also be presented with some minor complications and should speak to their doctor.

Side effects of the drug may include dryness of the skin, eyes and/or mucous membranes, headaches, nasal irritation, increased sun sensitivity, hair loss, diminished night vision, and birth defects if pregnancy occurs during the course of treatment. Female patients must not be pregnant when using Isotretinoin. Two forms of reliable birth control are essential during treatment. A safe cushion before becoming pregnant after the therapy is approximately 2 to 3 months.

(A New Treatment) Azelaic Acid:

Recently approved for use by the FDA, azelaic acid cream has antikeratinizing, antibacterial, and antinflammatory properties. "Azelaic Acid Cream (20%) has been shown to significantly reduce inflammatory and non-inflammatory acne lesions with an efficacy comparable to that of tretinoin (0.05%), benzoyl peroxide (5%), and topical erythromycin (2%), for the management of mild to moderate acne." - Cosmetic Dermatology, April 1999.

Anti-Inflammatory Ingredients:

There are a number of ingredients that could fit into this category as there are numerous anti-inflammtory ingredients. These help to reduce the size and swelling of infected comedones. They are also usedful for scar prevention. We will list just a few of the most popular and most effective:

Vitamin C
Green Tea
Alpha Lipoic Acid
Algae Extract
There has been some confusion as to whether algae extract is an appropriate therapy for acne since it is listed on some lists as being very comedogenic and irritating. There are different types and different grades of algae. Most of the extracts found in acne formulations are forms of algae extract that have been tested and shown to be non-comedogenic and very gentle. Unless you have an allergy to marine plants, you should be safe.


Other Useful Tips

Remember, there is no way to completely prevent breakouts from occurring, but hopefully these tips will help keep the oil and acne under control:

Although dirt and oil on the surface of the skin do not cause acne, excessive oil on your skin may exacerbate the clogging of pore openings, so proper washing is often a good way to keep the situation from becoming worse. Washing with very hot water, harsh soaps or cleansers will not improve existing acne or prevent future flare-ups. In fact, these methods can dry and irritate your skin so badly that you will not be able to use effective acne medications in cream or gel form. Most topical acne medications have a drying effect on oily skin.
Try a mild cleanser that cleanses without drying.
Do not use any oil-based cosmetics, which will only aggravate oily skin and create further blemishes. Use water-based, non-comedogenic cosmetics.
Always remove your makeup before going to bed, but avoid cold creams and lotions, which may leave a greasy film on your skin.
Watch your diet. However, it is not chocolate or sweets that you need to watch, some doctors believe that an increased consumption of iodine aggravates acne, and they suggest reduction or elimination of fish and iodized salt.
Relax! Doctors have seen a connection between stress and acne for a long time. Studies have shown that the body produces more androgens when a person is under stress. The increase may trigger acne flare-ups by stimulating the sebaceous glands to pump out more sebum. Even physical stresses, such as colds, allergies, surgery, or menstration, can trigger break-outs.

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Skin Care and Topical Treatments for Acne

First of all, there are the topical acne medications that most people with oily sin or acne have tried. Here is a brief descripton of those:

Benzoyl Peroxide This medication works in two ways. First, it goes after bacteria, which are crucial in the development of acne. Without bacteria, the sebum trapped under the skin would not become the fatty acids that cause all the swelling and inflammation in and around acne blemishes. Second, some studies show that benzoyl peroxide may also peel the dead skin cells from inside your hair follicles, to keep plugs from forming. Check out Physician's Choice Acne Cream and the Glytone Acne Treatment Kit.

Sulfur and resorcinol These older medications tend to work mostly on the surface of your skin to help heal existing blemishes by unclogging pores. Check out Physician's Choice Blemish Control Bar .

Topical antibiotics These medicines are used by doctors to treat certain kinds of acne, such as postules and papules, but they may not be strong enough to have an effect on larger cysts. Topical antibiotics work by attacking the bacteria that are strongly linked with acne problems. Like other topical treatments, these tend to dry and irritate the skin, so be sure to use proper cleansing and moisturizing. You can also look for over-the-counter topicals with anti-bacterial or antiseptic properties such as mandelic acid, thyme (see SkinCeuticals Phyto Corrective Gel), or sulfur.

Retinoic acid Also known as Retin-A, this is another topical medicine used by doctors to treat acne. Like benzoyl peroxide, retinoic acid works by peeling skin cells from the hair follicles so that plugs do not form. Be warned that at first it may aggravate your acne, and that it can take two to three months for any real improvement. The vitamin-A also inhibits sebum production, lessening the oil output.

Retinol, a milder cousin of Retin-A has surfaced, creating a gentle vitamin A alternative. It won't create dryness and irritation like Rein-A, but it also means it is not as potent. Vitamin A can breakdown when exposed to light and air, so it is important to find a relatively stable formulation, such as the RoC Retinol Anti-Wrinkle Treatment.

Beta Hydroxy acids and Alpha Hydroxy acids work by keeping the skin exfoliated. This exfoliation process keeps the dead skin cells from sitting on the skin and clogging pores. Beta hydroxy acids such as salicylic acid are particularly effective at exfoliating within pores. Cellex-C has a line of Beta-hydroxy and alpha hydroxy acid products known as the Betaplex products.

The best alpha hydroxy acid for acne though, is mandelic acid, because it works double-time at fighting blemishes. It is a strong exfoliator, stronger than glycolic acid, yet non-irritating, which is important to acne prone skin. It is also naturally anti-bacterial. In the NuCelle Mandelic Marine Complex, the Mandelic Acid is combined with Marine Extracts to further soothe and calm inflamed skin and reduce irritation.


Skin Care

It is important to maintain a regular skin care routine to keep your skin from becoming too irritated or too dried during acne treatments. A good way to tell if your skin is becoming too dry is whether or not you feel you need a moisturizer after your skincare routine. Oily skin may not need a moisturizer. Unless you are on doctor prescribed medications, you may need to adjust your routine if your skin feels too tight or dry. If you are on Retin-A or Accutane and you need a light moisturizer, I would recommend the LRS Lipid Recovery Serum. It is a hypo-allergenic, non-comedogenic serum that is perfect for abused or treated skin. It reduces inflammation, promotes tissue healing and rebuilds the lipid barrier in the skin. For those without extremely oily-skin, the C2S Skin Balancing Serum is a great acne-fighter that will not overdry the skin.

For those with oily skin that need to combat shine, without sacrificing hydration, the NuCelle Mandelic Moisture Shine-Control is the best oil-controll moisturizer we have found.

A good, non-irritating skincare for acne is the NuCelle Mandelic Marine Complex (the Mandelic Acid is an naturally anti-bacterial alpha hydroxy acid) that peels and loosens dead skin that clogs the pores, allowing them to be washed away before they cause a problem. It also kills the bacteria that are responsible for infecting clogged pores and causing blemishes. Oily skin types may not need the moisturizers included in the system, the cleanser, toner, and serum should be enough. It is also safe on darker skin types.