Current Treatment Comedonal Acne: Comedones are blackheads and whiteheads, which are associated with increased oil production on the nose, forehead and chin (T-zone). This form of acne often develops in pre-teens and in the early teenage years. The treatment for this type of acne consists of a topical comedolytic agent.
The standard choice is a retinoid such as Retin A (tretinoin cream or gel) Newer topical retinoid medications include adapalene gel (Differin gel) and tazarotene gel (Tazorac gel). Retinoids can be associated with temporary side effects such as peeling, flaking, dryness, redness and irritation. They can cause non-inflamed comedones to become inflamed (red) and should be started at the lowest concentration possible and increased as tolerated. Retinoids should not be used in women who are pregnant or nursing.
It is also important to use a daily moisturizer with an SPF of 15 or greater when using retinoid acne medication. Tazarotene gel is a stronger retinoid and comes in two strengths. It is helpful in very stubborn comedonal acne. It often needs to be used every other day, due to its frequent side effects of dryness, peeling, and irritation. Alternative comedolytic agents include: azelaic acid (Azelex cream), alpha hydroxy acid products, and salicylic acid products, which are commonly found in astringents and acne cleansers/products over the counter.
When a comedone ruptures, and the body mounts an immune response against it, an inflammatory reaction occurs. Acne lesions get very red, with small pustules coming to a head in the center of the acne bump. This type of acne responds well to topical antibacterial solutions, gels or lotions. Benzoyl peroxide is a very potent bacterial killing agent. It is the gold standard in inflammatory and comedonal acne. It is available in many forms and concentrations, including cleansers, masks, gels and pastes.
Side effects include dryness, redness, peeling, irritation and the possible staining of certain clothing. Erythromycin and clindamycin are excellent topical antibacterial medications, which come in pads, solutions, lotions and gels. These agents are used twice daily and help suppress the growth of a small bacterium, which plays a role in the pathogenesis of acne, called propionobacterium acnes. Antibiotic resistance has been associated more frequently with erythromycin, and develops more often after prolonged use of antibiotics in low concentrations.
Additional topical antimicrobial medications to treat inflammatory acne include azelaic acid (Azelex cream) and sodium sulfacetamide/sulfur preparations. Azelaic acid was originally used to treat brown spots/hyperpigmentation. It is useful for comedonal acne as well as mild to moderate inflammatory acne. It can also help lighten blemishes and old acne marks. It shows no tendency to develop bacterial resistance. It may tingle or sting when applied, which is usually transient during the first few weeks of treatment. It is very effective when used in conjunction with topical clindamycin 1% solution, and is also used twice daily. Sodium Sulfacetamide, when combined with Sulfur, are found in topical medications such as Novacet and Sulfacet R.
These products are very useful in patients with rosacea who have red, ruddy complexions and inflammatory acne. Sulfacet R comes in a tinted and a tint-free preparation. The tint has a color blender, which helps cover up blemishes and dry up oily T-zones. These medications are not to be used in patients who are allergic to Sulfonamide drugs. Klaron lotion does not contain sulfur, and is not as drying as Sulfacet R. It is helpful in patients with dry and/or more sensitive skin, and is also antimicrobial.
Systematic Treatment Options
Tetracycline is an oral antibiotic that has been used to treat acne for many years. It is anti-inflammatory, inexpensive and is absorbed directly into the sebaceous follicles where acne begins. It can stain the permanent teeth if given to a child under nine years of age. It can’t be prescribed to pregnant or nursing patients. Side effects may include: nausea, upset stomach, diarrhea, vaginal yeast infections and sun sensitivity. Tetracycline should not be taken with any milk products, isotretinoin (Accutane), food, iron tablets or antacids.
Doxycycline is similar to tetracycline, yet has superior absorption than minocycline or tetracycline. It is associated with sun sensitivity in less than 1% of patients taking the drug. This photosensitivity can manifest itself with severe sunburn and possibly blistering. Patients taking Doxycycline should try to avoid sun exposure and wear sunscreen daily.
Minocycline is also related to doxycycline and tetracycline. It is an oral antibiotic not associated with sun sensitivity. It is taken with food and is more expensive than either tetracycline or doxycycline. Side effects include headaches, dizziness, upset stomach, nausea, vaginal yeast infections and diarrhea. Less commonly, it can be associated with blue-black staining in the mouth or bruise-like marks on the legs and thighs. This unusual pigmentation from minocycline is usually reversible upon discontinuation of the drug. Rarely, in approximately two out of 100,000 patients, a lupus-like illness can develop with hepatitis. If a patient is taking minocycline and they don’t feel well, they should notify their physician immediately and get blood tests and a check-up.
Erythromycin is an oral antibiotic that is anti-inflammatory and safe if a patient should find out she is pregnant while she is on the antibiotic. If pregnancy does occur, a woman must notify her doctor to let him or her know as soon as possible that she is taking a particular antibiotic for acne. Bacterial resistance is more common with erythromycin as is gastrointestinal upset, nausea and diarrhea. It does come in coated tablets, which can be taken with meals to decrease the chances of upset stomach.
Intralesional cortisone injections are extremely effective in reducing the pain, swelling and redness of acne papules or cysts. It involves a doctor or nurse injecting a very small amount of diluted cortisone solution into the pimple or cyst. In 24-48 hours, the pimple goes down significantly or goes away. It is painful and rarely can result in a superficial dent if too much is injected or too strong a concentration is injected. This dent usually resolves in many months, yet can be permanent.
Facials can be very helpful for deep pore cleansing. An aesthetician should be well trained and not leave skin marks or scabs afterwards. Many blackheads and whiteheads can be extracted using acne masks, steam and manual acne comedone removal.
Physicians and nurses can also remove whiteheads and blackheads which helps reduce the acne count significantly. Astringents and toners help dissolve oil residue on the oil T-zone areas and removes build up of dead cells clogging pores. Many are available over the counter in pharmacies and stronger toners containing glycolic acid are sold in physician’s offices. Acne cleansers are also helpful for exfoliating clogged blackheads and drying oily skin.
Many female patients have tried multiple over the counter and prescription acne medicines, and have seen numerous dermatologists, yet continue to breakout well into their 20′s and 30′s. Some of these women may have androgenic acne, where their body produces higher levels of certain male hormones, which induces acne, oily skin and even facial hair growth. Patients may also have a personal history of irregular periods, infertility, endometriosis and excessive hair growth on the chest, abdomen and face. Their acne tends to be more prominent over the chin, jawbone and lower face.
Premenstrual cysts are more common and tend to be painful. There are dark hairs, which can grow on the chin, neck, jaw and side of the cheeks. Patients have often tried waxing, tweezing, bleaching or electrolysis. Your doctor can order a hormonal panel of blood tests to see if you have any hormonal abnormalities. These hormonal abnormalities can be the cause of the acne.
The treatment of women with this disorder is challenging. The first line of therapy is the birth control pill. The oral contraceptive contains estrogens, which suppress oil production, regulate menstruation and suppress ovulation. This can help regulate hormonal abnormalities only while a woman is taking the pill. Once she stops the pill, her hormonal problems return.
Women receiving the pill need to be counseled regarding its risks, as with any medication, and be followed by their gynecologist for regular pap smears and breast exams. Ortho-tri-Cyclen is a popular birth control pill, which was FDA-approved for the treatment of acne in 1996. If this treatment should fail, your dermatologist, gynecologist or endocrinologist can prescribe other treatment.
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