Medical Drugs

Acne and Drug Medical Treatment

Introduction

You may have been told that if you wash your face several times each day to keep it clean, that will help keep acne away. Is this true or just an old wives-tale? Though it may be difficult to believe, washing your face that often can actually make your acne worse! If you want to learn more about acne and ways that you can help yourself treat this skin condition, read on!

What is it?

Acne, also called acne vulgaris, is a common inflammatory skin condition that is characterized by pimples, blackheads, and red, swollen bumps on the skin (usually the face, neck, shoulders, or back). The term acne is used to describe the condition when a person has between 5 to 10 pimples, blackheads, or red and swollen bumps on his or her body at the same time. Acne is typically thought to occur in adolescence, but it can also occur in adulthood. While not a life-threatening condition, acne can have a significant psychological and physical impact on a person's life, causing poor self-image, anxiety, depression, and permanent scarring of the skin.

What causes it?

Acne is thought to be the result of several different factors occurring either separately or at the same time. Most commonly, acne develops because of excess sebum (oil) production by the sebaceous glands (oil glands) in the skin. Excess oil production is typically triggered by an increase in androgen hormones ("masculine hormones") such as testosterone or androsterone. Both males and females produce androgen hormones, and their production normally increases during adolescence to help the body mature. Increases in androgen hormone levels lead to increased sebum production, which in turn increases the likelihood for developing acne.

Along with excess sebum production, skin cells can plug a pore and allow normally-occurring bacteria to flourish. A bacterium called Propionibacterium acnes or P. acnes is normally found on the skin, but if it gets trapped inside hair follicles, it can trigger acne. All of these processes can result in inflammation.

Certain medications can also cause acne. Specifically, hormone medications like contraceptive agents [medroxyprogesterone injections (Depo-Provera) and older oral contraceptives--newer birth control pills such as Ortho Tri-Cyclen and Estrostep can actually improve acne], testosterone, corticosteroids [prednisone, methylprednisone, dexamethasone, prednisolone, betamethasone, cortisone, hydrocortisone, and triamcinolone], and anabolic steroids [danocrine (Danazol) and stanozolol (Stomba)] can all make acne worse. Other medications known to exacerbate acne include certain antidepressants, drugs used to treat tuberculosis, anti-seizure medications, and cyclosporine (Neoral, Sandimmune).

Oftentimes, it is difficult for doctors to determine the exact cause of acne for a particular patient. Because of this, it may take time and multiple trials of medication to find the medication most effective for the treatment of your acne.

Disregard the Myths

You've heard your mother say, "Don't eat that chocolate! It will cause your face to break out!" But is this really true or merely a misperception? There are numerous myths regarding the causes of acne. Read below to learn more about these common misperceptions.

• Acne is caused by not washing your face often enough. This is not true! Some people think they must vigorously scrub their face numerous times a day to avoid acne breakouts. However, acne is not caused by dirt, dead skin cells, or oils on the skin surface. Actually, if you wash your face too often and too hard, you may make acne worse. Most dermatologists recommend gently washing your face twice daily with a mild soap and the use of appropriate acne medications if needed.
• Acne is caused by the foods you eat. This myth has been around for a long time, but contains no truth. A considerable amount of research has been performed to determine if certain foods, for example, chocolate, pizza, and french fries, may cause acne or make it worse. Research has shown there is no connection between what you eat and the development of acne. If you still think that certain foods cause you to breakout then you can simply avoid those foods. Typically, if your acne is being treated appropriately, there is no need to worry about what foods you eat.
• Acne is caused by stress. Again, this is a misperception. No evidence exists to support this claim. Normal day-to-day stress does not cause acne. However, if you are taking medications to treat stress, anxiety, or depression, the medication may contribute to or worsen acne check with your pharmacist or doctor if you think any of your medications could be contributing to acne breakouts.

Who has it?

Acne is the most common skin disease in the United States affecting between 40 and 50 million people. Many teenagers regardless of race or ethnicity develop acne. Acne affects approximately 80% of people who are between the ages of 12 to 25 years old. Although a large majority of teens are affected by acne, it can also occur in adults. Acne is relatively common in women in their 20s to 30s due changes in hormone levels associated with the menstrual cycle and pregnancy. Acne is more common in males than in females during adolescence, but more common in females than in males during adulthood.

What are the risk factors?

Risk factors are characteristics that predispose people to develop a condition. Common risk factors for acne include the following:

• Family history of acne: Some dermatologists believe that the type, pattern, duration, and severity of acne that you may experience is related to the experiences of your parents. However, it is impossible to predict which type you will develop. While studies have been highly suggestive of a hereditary link for acne, no "acne gene" has been discovered yet.
• Hormone levels: Higher levels of sex hormones (like testosterone and androsterone) stimulate oil production by the glands surrounding hair follicles. This excess oil clogs these follicles or pores, thus causing a pimple.

Along with risk factors for developing acne, certain factors can aggravate acne. These aggravating factors include the following:

• Environment: Individuals living in humid areas may develop more severe acne breakouts.
• Cosmetics: Certain ingredients within cosmetics may worsen acne. These ingredients include lanolin, petrolatum, vegetable oils, butyl stearate, lauryl alcohol, and oleic acid. These ingredients may be contained in moisturizers, foundations, and pomades.
• Petroleum oils: Individuals who work in fast food restaurants and those exposed to motor oil regularly may be more prone to acne break-outs. This occurs because the grease or oil in the air causes the skin to become irritated.
• Pressure from wearing headbands or chinstraps: People who wear helmets or sporting equipment should continue to do so for safety reasons. However, oils can collect on headbands, chinstraps, and helmets and lead to acne breakouts. Thus, it is important to clean and thoroughly rinse these items after wearing them.

What are the symptoms?

Most dermatologists consider an outbreak of more than 5 to 10 lesions in one area at one time to be acne. Different types of lesions can occur. A person may even experience more than one type of lesion at the same time. Below is a list and a description of the different types of lesions.

Noninflammatory Lesions

1. Blackheads or open comedones. Blackheads result when sebum (oil) and skin cells become clogged in the sebaceous hair follicle. They appear to be black in color.
2. Whiteheads or closed comedones. Whiteheads result when the sebaceous follicle is completely clogged with sebum and skin cells. They appear to be either white or skin colored, hence the name "whiteheads." Whiteheads can form as small bumps on top of the skin or under the skin.

Inflammatory Lesions

1. Papules are small, firm, red-colored lesions. Although they may contain pus, is not easily seen because of the redness. Papules often continue to grow in size and become pustules.
2. Pustules are small papules but they are round, red, swollen, and contain pus. Although they contain pus, they generally don't have a lot of bacteria inside.
3. Nodules also referred to as cysts. Oftentimes, nodules are very red, swollen, and contain a large amount of pus. They develop deep in the skin and may be painful. Unlike the other types of lesions, upon healing, nodules generally leave scars.

Based on the type and number of lesions present, a doctor or dermatologist can classify acne as mild, moderate or severe.

You should see your doctor or dermatologist if any of the following apply to you:

• A lesion or nodule becomes infected, turns purple in color, increases in size, becomes painful, or does not get better with self treatment
• A scar develops following healing
• Acne interferes with your normal daily routine or makes you feel embarrassed or depressed
• Acne leads to dark patches on the skin (this is more common in people with dark skin)

How is it treated?

There are several treatment options for acne. Most options reduce or prevent new lesions and take at least 8 weeks to produce results. An important goal of acne treatment is to prevent or minimize scarring. Specific treatment regimens will vary from person to person, depending on acne severity and tolerance to the medication. Generally, mild acne is treated with topical products, including topical retinoids, antimicrobials (benzoyl peroxide, clindamycin, or erythromycin), salicylic acid or azelaic acid. Moderate acne can be managed with topical retinoids in combination with oral antibiotics and possibly benzoyl peroxide. Severe acne that is not responsive to conventional treatments may require treatment with oral isotretinoin (Accutane).

Below is a list of commonly used medications. They are divided into topical medications and oral medications. Remember, if you have any questions about which products to use, talk with your doctor, dermatologist, or pharmacist.

• Topical Acne Products
• Oral Acne Products

Topical Acne Products

1. Benzoyl Peroxide
• Benzoyl peroxide if often used to treat mild to moderate acne, and can produce a response in as few as five days. It is available in several strengths, some of which are only available by prescription. Benzoyl peroxide is available in soaps, lotions, washes, gels, and creams. Gel formulations are typically the most potent. Care should be taken when applying products containing benzoyl peroxide to avoid bleaching hair, sheets, towels and clothing. A common side effect of benzoyl peroxide is dryness and irritation of the skin. To help avoid this side effect, start with a lower potency formulation (2.5%) and increase the strength (5% to 10%) as needed for acne control. You can also start by applying every other day then work up to a maximum of twice daily applications. Applying benzoyl peroxide products to cool, clean, dry skin will also decrease irritation. If you have sensitive skin, benzoyl peroxide and other topical acne treatments may be applied as a spot treatment to pimples only, reducing irritation to the skin surrounding acne lesions.
2. Azelaic Acid
• Azelaic Acid is a cream used in the treatment of mild to moderate acne. It has antibacterial effects and may help with skin inflammation. Azelaic acid is generally well tolerated with a low incidence of temporary side effects such as skin redness, itching, and burning. Darker complexions may develop hypopigmentation during treatment. Azelaic acid should be applied to clean, dry skin.
3. Sulfur, Sodium Sulfacetamide and Salicylic Acid
• Sulfur, sodium sulfacetamide, and salicylic acid products are not considered as effective as benzoyl peroxide but may be tried for treating mild acne. Many of these products are available without a prescription. These products are less irritating than benzoyl peroxide, but some have a strong smell and may cause the skin to turn brown.
4. Topical Antibiotics
• Topical antibiotics are used to treat moderate to severe acne when acne is resultant from bacteria. Topical antibiotics include clindamycin and erythromycin. These antibiotics are available in lotions, solutions, gels, and disposable pads, and are typically applied twice daily. Topical clindamycin and erythromycin are most effective when they are combined with other acne medications (such as benzoyl peroxide). The combination also helps decrease the risk of the bacteria becoming resistant to the antibiotic. Topical antibiotics, while effective, can cause occasional skin irritation and stinging upon applications.
5. Tretinoin
• Tretinoin is a topical retinoid available in various strengths and forms (creams, gels, solutions, a microsphere gel, and liquid polymer). It works by preventing the formation of microcomedones and has anti- inflammatory actions. For mild acne, weaker strengths are typically used first and increased as needed for moderately severe forms of acne. A "flare" of acne may occur after starting tretinoin, but clears after about 8 to 12 weeks of therapy. Tretinoin works well for moderate to severe acne when combined with benzoyl peroxide, topical antibiotics, and oral antibiotics. Tretinoin can cause skin irritation, redness, and peeling which are usually noticed within the first week of use but can be minimized by slowly increasing application frequency. The doctor may recommend you use it every other day and, over a period of time, increase to a maximum of twice daily. Tretinoin can also increase sensitivity to sun, wind and cold.
6. Adapalene
• Adapalene is a topical retinoid available as a gel, cream or solution and is used to treat mild to moderate acne. Adapalene is typically used as an alternative to tretinoin in patients who cannot tolerate tretinoin. It can also be used in combination with topical and oral antibiotics. Improvement is generally seen by 12 weeks of therapy. Some patients may notice redness of the skin and peeling. It is recommended that patients avoid contact with mucus membranes, including the eyes, mouth, and nostrils. Patients should also try to avoid UV ray exposure through sunlight and tanning because drying of skin, scaling, redness, burning, and itching may occur after exposure.
7. Tazarotene
• Tazarotene is a topical retinoid, available as a gel or cream, and used to treat mild to moderate acne. Although it is effective for acne, it can cause skin irritation, itching, burning, and redness (similar to tretinoin). It is recommended that patients avoid other medications or cosmetic products that have strong drying effects as these could further irritate the skin.

Oral Acne Products

1. Oral Antibiotics
• As discussed earlier, bacteria may reside in acne lesions. Oral antibiotics (tetracycline, minocycline, doxycycline, erythromycin, clindamycin, and cotrimoxazole) are often used in combination with topical acne products for moderately severe acne. Tetracycline is the most commonly prescribed antibiotic for treating acne, but it may cause sun sensitivity and predispose a woman to vaginal yeast infections. Minocycline and doxycycline are commonly used in people whose acne does not respond to tetracycline. Minocycline may cause skin discoloration. Clindamycin is not as widely used as the other oral antibiotics due to a side effect of diarrhea. Erythromycin is similarly effective to tetracycline and may have fewer side effects. Cotrimoxazole may be as effective as tetracycline but it is generally reserved for acne that doesn't respond to tetracycline or other antibiotics. The reason for this is to minimize the potential for resistance to develop (meaning that the bacteria that cause acne can become resistant to cotrimoxazole's effects). Though these medications are very effective in the treatment of acne, many people find it difficult to take them as prescribed since they require dosing between two and four times daily. The effectiveness of these products is decreased when they are not taken exactly as prescribed. A new product containing extended release minocycline, which is taken once daily, has recently become available and may make it easier for patients to take their medications correctly. Improvement in acne can generally be seen in 6 to 12 weeks when using oral antibiotic medications.
2. Oral Contraceptives
• Excess sebum (oil) production in the skin is typically triggered by an increase in androgen hormones ("masculine hormones"). In recent years, some oral contraceptives like Ortho TriCyclen and Estrostep have gained FDA-approval for the treatment of acne in females. They work to treat acne by decreasing androgen ("masculine") hormone levels and thus decreasing sebum production. Oral contraceptives may be an effective treatment option for women with moderate acne, but it takes three to six months to see their full effect.
3. Spironolactone
• Spironolactone also decreases androgen hormone levels and thus decreases production of sebum. If oral contraceptive therapy is not effective, spironolactone can be added for additional benefit. Some side effects associated with spironolactone include dizziness, breast tenderness, and painful menstruation in women. It is recommended to get blood pressure and potassium levels checked periodically while on this medication.
4. Isotretinoin
• Isotretinoin (Accutane) is used to treat severe, cystic acne that has not improved with other therapies. Some dermatologists use isotretinoin in mild to moderate acne that has not responded well to 6 months of standard therapies. Treatment with this drug usually continues until there is a 70% reduction in the number of cysts, and usually this can be seen in 15 to 20 weeks. A 6-month course of isotretinoin is sufficient for most patients. While extremely effective for treating acne, isotretinoin is associated with some potentially bothersome side effects including extreme drying of the mouth, nose, and eyes (approximately 90% of patients taking isotretinoin experience these side effects); inflammation and peeling of facial skin, joint aches, muscle stiffness, and sun sensitivity. Isotretinoin can also cause birth defects if used during pregnancy, so contraception (some type of effective birth control) is required in females taking isotretinoin. Contraception should begin one month before starting isotretinoin and continued for three months after stopping isotretinoin. Isotretinoin now has a mandatory registry that was put in place by the FDA, which is known as IPLEDGE. IPLEDGE was primarily put in place to prevent unwanted or potentially dangerous adverse effects.