Acne

In this article:

• Treatment
• Topical medications
• Oral medications
• Therapies
• Treating children
• Alternative medicine
• Effect of dietary supplementation with omega-3 fatty acid and gamma-linolenic acid on acne vulgaris: a randomized, double-blind, controlled trial
• Herbs
• Lifestyle and home remedies
• Cosmetic treatments
• References

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Treatment

Acne vulgaris is a common chronic inflammatory disease of the skin. It is found in about 80% of young adults and adolescents. It is a disease that affects the pilosebaceous units of the skin and may result in inflammatory or non-inflammatory lesions. Strauss et al. defined acne as a chronic inflammatory dermatosis which consists of open comedones (blackheads), closed comedones (whiteheads) and inflammatory lesions such as nodules, pustules and papules.

Acne is best treated by a dermatologist, who can evaluate severity of the problem and discuss all available options of treatment.

The usual first-line treatment consists of a 12-week course of 1 of the following first-line treatment options:

1. A fixed combination of topical adapalene with topical benzoyl peroxide for any acne severity
2. A fixed combination of topical tretinoin with topical clindamycin for any acne severity
3. A fixed combination of topical benzoyl peroxide with topical clindamycin for mild to moderate acne
4. A fixed combination of topical adapalene with topical benzoyl peroxide, together with either oral lymecycline or oral doxycycline for moderate to severe acne
5. Topical azelaic acid with either oral lymecycline or oral doxycycline for moderate to severe acne.

As an alternative treatment to the above options the topical benzoyl peroxide monotherapy is considered if:

• these treatments are contraindicated, or
• the person wishes to avoid using a topical retinoid, or an antibiotic (topical or oral).

National Institute for Health and Care Excellence (NICE) in London, UK came up with a guidance of acne care in Britain:

Treatment choices for mild to moderate and moderate to severe acne vulgaris

Acne severity	Treatment	Advantages	Disadvantages
Any severity	Fixed combination of topical adapalene with topical benzoyl peroxide, applied once daily in the evening	Topical Does not contain antibiotics	Not for use during pregnancy Use with caution during breastfeeding (see recommendation 1.5.8) Can cause skin irritation (see recommendation 1.5.7). photosensitivity, and bleaching of hair and fabrics
Any severity	Fixed combination of topical tretinoin with topical clindamycin, applied once daily in the evening	Topical	Not for use during pregnancy or breastfeeding (see recommendation 1.5.8) Can cause skin irritation (see recommendation 1.5.7), and photosensitivity
Mild to moderate	Fixed combination of topical benzoyl peroxide with topical clindamycin, applied once daily in the evening	Topical Can be used with caution during pregnancy and breastfeeding.	Can cause skin irritation (see recommendation 1.5.7), photosensitivity, and bleaching of hair and fabrics
Moderate to severe	Fixed combination of topical adapalene with topical benzoyl peroxide, applied once daily in the evening, plus either oral lymecycline or oral doxycycline taken once daily	Oral component may be effective in treating affected areas that are difficult to reach with topical treatment (such as the back) Treatment with adequate courses of standard therapy with systemic antibiotics and topical therapy is a Medicines and Healthcare products Regulatory Agency (MHRA) requirement for subsequent oral isotretinoin (see recommendation 1.5.8 and the MHRA alert on isotretinoin for severe acne: uses and effects)	Not for use in pregnancy, during breastfeeding (see recommendation 1.5.8), or under the age of 12 Topical adapalene and topical benzoyl peroxide can cause skin irritation (see recommendation 1.5.7), photosensitivity, and bleaching of hair and fabrics Oral antibiotics may cause systemic side effects and antimicrobial resistance Oral tetracyclines can cause photosensitivity
Moderate to severe	Topical azelaic acid applied twice daily, plus either oral lymecycline or oral doxycycline taken once daily	Oral component may be effective in treating affected areas that are difficult to reach with topical treatment (such as the back) Treatment with adequate courses of standard therapy with systemic antibiotics and topical therapy is an MHRA requirement for subsequent oral isotretinoin (see recommendation 1.5.8 and the MHRA alert on isotretinoin for severe acne: uses and effects)	Not for use in pregnancy, during breastfeeding (see recommendation 1.5.8), or under the age of 12 Oral antibiotics may cause systemic side effects and resistance Oral tetracyclines can cause photosensitivity

From: Acne vulgaris: management

Skin care advise

• People with acne should use a non-alkaline (skin pH neutral or slightly acidic) synthetic detergent (syndet) cleansing product twice daily on acne-prone skin.
• Select skin care products (for example, moisturisers) and sunscreens to avoid oil-based and comedogenic preparations.
• Make-up should include only products to avoid oil-based and comedogenic products; remove make-up at the end of the day.
• Remember that persistent picking, squeezing or scratching of acne lesions can increase the risk of scarring.

Topical medications

Topical retinoids like retinoic acid, adapalene, and tretinoin are used alone or with other topical antibiotics or benzoyl peroxide. Retinoic acid is the best comedolytic agent, available as 0.025%, 0.05%, 0.1% cream, and gel.[8]

Topical clindamycin 1% to 2%, nadifloxacin 1%, and azithromycin 1% gel and lotion are available. Estrogen is used for Grade 2 to Grade 4 acne.

Topical benzoyl peroxide is now available in combination with adapalene, which serves as comedolytic as well as antibiotic preparation. It is used as 2.5%, 4%,and 5% concentration in gel base.[9]

Azelaic acid is antimicrobial and comedolytic available 15% or 20% gel. It can also be used in postinflammatory pigmentation of acne.

Beta hydroxy acids like salicylic acid are used as topical gel 2% or chemical peel from 10% to 20% for seborrhoea and comedonal acne, as well as, pigmentation after healing of acne.

Topical dapsone is used for both comedonal and papular acne, though there are some concerns with G6PD deficient individuals.

Oral medications

• Doxycycline 100 mg twice a day as an antibiotic and anti-inflammatory drug as it affects free fatty acids secretion and thus controls inflammation.
• Minocycline 50 mg and 100 mg capsules are used as once a day dose.
• Other antibiotics such as amoxicillin, erythromycin, and trimethoprim/sulfamethoxazole are sometimes used, and if bacterial overgrowth or infection is masquerading as acne, other antibiotics such as ciprofloxacin may be used in pseudomonas related ‘acne.’ 
• Isotretinoin is used as 0.5 mg/kg to 1 mg/kg body weight in daily or weekly pulse regimen. It controls sebum production, regulates pilosebaceous epidermal hyperproliferation, and reduces inflammation by controlling P. acnes. It may give rise to dryness, hairless, and cheilitis.
• An oral contraceptive containing low dose estrogen 20 mcg along with cyproterone acetate as anti-androgens are used for severe recurrent acne.
• Spironolactone (25 mg per day) can also be used in males. It decreases the production of androgens and blocks the actions of testosterone. If given to females, then pregnancy should be avoided because the drug can cause feminization of the fetus. 

Therapies

Scars are treated with submission, trichloroacetic acid, derma roller, micro-needling, or fractional CO2 laser.

Lasers are also employed in acne therapy. Compared to light therapy, lasers have the ability to concentrate coherent light on a smaller area of tissue. Potassium titanyl phosphate (KTP) 532 nm green light pulsed laser therapy is believed to penetrate deeper than blue light and activate porphyrins to target P. Acnes. KTP has been shown to have short-term effects on improving acne severity with minimal side effects, although randomized controlled trials are scarce. 

Similarly, the effects of pulsed dye laser (PDL) at 585 nm yellow light on reducing acne lesions are controversial. While PDL significantly reduced total lesions and inflammatory lesions compared to sham treatment in one study, a split-face trial showed no differences between PDL treatment and non-treatment. 

Furthermore, PDL in combination with topical acne therapy was no better than topical therapy alone. One reason for the equivocal results by PDL may be the fact that 585 nm is a wavelength that is more strongly absorbed by oxygenated hemoglobin than by endogenous P. Acnes porphyrins. Indeed, PDL therapy has been shown to be effective against vascular lesions such as port-wine stains.

Treating children

As sexual maturation starts earlier now, a big consideration should be given to the treatment of children. Here are some important points:

• Consider the most non-toxic treatments in younger kids
• Compliance is an issue, so try the short-duration treatment with the least limitations in activities
• Prevent picking and squeezing to avoid scarring, try to use behavioral rewards and prize system for good attitude
• Spend time with your child – discuss fears and emotional problems related to acne, try to reassure and raise self-esteem
• Adjust dietary habits and encourage variety of organic healthy foods, discourage snacking on fast food and carbs

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Alternative medicine

Gut microbiome only recently was recognized as a true and potent part of our immune protection. Now a skin microbiome is getting out of the “alternative” medicines and becoming scientifically proven.

The cutaneous microbiome has potential for therapeutic intervention in inflammatory-driven skin disease. Research into atopic dermatitis and acne vulgaris has highlighted the importance of the skin microbiota in disease pathogenesis, prognostication, and targets for therapeutic intervention. Current management of these conditions aims to control the inflammatory response thought to be associated with specific pathogens using both topical and systemic antimicrobials. 

However, commensal microbiota found naturally on the skin have been shown to play an important role in the resolution of disease flares. Although often efficacious, the mainstay treatments are not without adverse effects and raise concerns regarding the development of antimicrobial resistance. Augmentation of microbial communities with targeted biotherapy could revolutionize the way inflammatory conditions of the skin are treated. 

Effect of dietary supplementation with omega-3 fatty acid and gamma-linolenic acid on acne vulgaris: a randomized, double-blind, controlled trial

This study was undertaken to evaluate the clinical efficacy, safety, and histological changes induced by dietary omega-3 fatty acid and γ-linoleic acid in acne vulgaris. A 10-week, randomised, controlled parallel dietary intervention study was performed in 45 participants with mild to moderate acne, which were allocated to either an omega-3 fatty acid group (2,000 mg of eicosapentaenoic acid and docosahexaenoic acid), a γ-linoleic acid group (borage oil containing 400 mg γ-linoleic acid), or a control group. 

After 10 weeks of omega-3 fatty acid or γ-linoleic acid supplementation, inflammatory and non-inflammatory acne lesions decreased significantly. Patient subjective assessment of improvement showed a similar result. Heamatoxylin & eosin staining of acne lesions demonstrated reductions in inflammation and immunohistochemical staining intensity for interleukin-8. No severe adverse effect was reported. This study shows for the first time that omega-3 fatty acid and γ-linoleic acid could be used as adjuvant treatments for acne patients.

Herbs

Herbs have been known for centuries to clear skin rashes and acne. The herbal tea can be used as a compress and daily washes. Here are few herbs known in Middle East for their anti-inflammatory effects(https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475631/ ):

Common name			Persian name		Scientific name	Family
1	Christ’s thorn jujube	Cedr		Ziziphus spina-christi			Rhamnaceae
2	Sweet clover	Eklilolmalek		Melilotus officinalis			Fabaceae
3	Chamomile	Babooneh		Matricaria chamomilla			Asteraceae
4	Myrtle	Moord		Myrtus communis			Myrtaceae
5	Marigold	Hamisheh bahar		Calendula officinalis			Compositae
6	Myrrh	Morr		Commiphora molmol			Burseraceae
7	Marshmallow	Khatmi		Althaea officinalis			Malvaceae
8	Henna	Hana		Lawsonia inermis			Lythraceae
9	Barley	Jo		Hordeum distichon			Poaceae
10	Broad bean	Baghella		Vicia faba			Fabaceae
11	Fenugreek	Shanbalileh		Trigonella foenum-graecum			Fabaceae

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Lifestyle and home remedies

Acne is unavoidable but can be controlled by regular washing of the face by a pH balancing wash which is available as benzoyl peroxide and salicylic acid face wash. Avoidance of high glycemic index and/or dairy-based food plays a role. 

Management of stress is extremely important. Teenage years are difficult psychologically for children and parents, so having as much stress-reducing measures will help everyone. It is very important to spend time listening to your teenager and talking about any psychological problems they might be facing in the society and school. 

During COVID-19 epidemics this issue became an overwhelming factor influencing daily life. If you see the signs of severe depression or anxiety, please make sure to address them right away at home and with your doctor.

Sometimes acne is a sign of some underlying hormonal problem. Early detection and treatment of systemic causes, like Ppolycystic ovaries, helps to control acne and preventing other problems later in life.

Steaming is a simple and safe method to soften comedones and moisturize skin.

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Cosmetic treatments

Cosmetologists can offer you a big deal of help if the acne are very disfiguring or psychologically intolerable. Medical spa is a common place where you can receive a professional help and be sure to get the best treatment.

Light treatment

Light and laser therapies that have been used to treat acne include intense pulsed light (IPL), pulsed dye lasers (PDL), potassium titanyl phosphate (KTP) lasers, and broad-spectrum continuous-wave visible light (blue and red). Whereas blue light has been shown to photoinactivate P. Acnes, it does not penetrate skin very far. On the other hand, red light, which is less effective at exciting porphyrins, can reach deeper sebaceous glands and may have an anti-inflammatory effect.

The combination of blue-red light therapy was shown to be more effective at reducing the number of inflammatory lesions than benzoyl peroxide monotherapy and blue light monotherapy. In contrast to single color light therapy, intense pulsed light (IPL) devices employ polychromatic light. IPL devices were introduced commercially in 1994 and are comprised of flashlamps and computer-controlled capacitor banks, which generate pulsed polychromatic light. Subsequent treatment is guided by user determined parameters such as wavelength ranges through the use of filters, fluence, pulse duration, and pulse intervals.

Laser treatment

Compared to light therapy, lasers have the ability to concentrate coherent light on a smaller area of tissue. Potassium titanyl phosphate (KTP) 532 nm green light pulsed laser therapy is believed to penetrate deeper than blue light and activate porphyrins to target P. Acnes. KTP has been shown to have short-term effects on improving acne severity with minimal side effects.

Photodynamic therapy

Photodynamic therapy (PDT) refers to the use of aminolevulinic acid (ALA), methyl-aminolevulinic acid (MAL), or other photosensitizing agents to enhance the effect of subsequent light or laser therapy 

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References

Herbal Remedies for Acne Vulgaris from the Viewpoint of Persian Medicine. Shakiba R, Minaii B, Aliasl J, Shakiba M, Ghods R.Iran J Public Health. 2020 May;49(5):1014-1015.

Chinese herbal medicine on treating obese women with polycystic ovary syndrome: A systematic review and meta-analysis protocol. Ding N, Yue R, Wang L, Yang H.Medicine (Baltimore). 2020 Dec 4;99(49):e22982. doi: 10.1097/MD.0000000000022982.PMID: 33285679 Free PMC article.

A comparative study on the effectiveness of herbal extracts vs 2.5% benzoyl peroxide in the treatment of mild to moderate acne vulgaris. Lubtikulthum P, Kamanamool N, Udompataikul M.J Cosmet Dermatol. 2019 Dec;18(6):1767-1775. doi: 10.1111/jocd.12962. Epub 2019 Apr 23.PMID: 31012999 Clinical Trial.

Jung J.Y., Kwon H.H., Hong J.S., Yoon J.Y., Park M.S., Jang M.Y., Suh D.H. Effect of dietary supplementation with omega-3 fatty acid and gamma-linolenic acid on Acne vulgaris: A randomized, double-blind controlled trial. Acta Derm Venereol. 2014;94:521–525. doi: 10.2340/00015555-1802. [PubMed] [CrossRef] [Google Scholar]