Acne is a frequent problem in young people. It is estimated that about 90% of men and 80% of women have had acne at some point. Usually, acne clears up spontaneously after puberty. However, it is important to intervene in time with acne, especially for psychological reasons and to avoid complications such as scars.
Acne vulgaris is a disease of the sebaceous follicle. These are mainly found in the face and to a lesser extent in the upper part of the chest and arms. The sebaceous follicle consists of the hair follicle or follicle, the associated sebaceous or sebaceous gland and their connection to the skin, the infundibulum. The sebum or sebum passes through the infundibulum to the skin and maintains the moisture supply of skin and hair. Sebum and cell breakdown products form the horn plug in the infundibulum. This is the white comedo or blackhead.
The open comedones or 'black dots' consist of accumulations of keratin and more or less oxidized fats. The black color of the comedone is due to this oxidation together with a deposition of melanin (the natural pigment of dead cells) originating from the infundibulum. Bacterial
growth, especially in the open comedones, breaks down the sebum and triggers an inflammatory response. These inflamed hair follicles then become a hard red pimple (papule), a soft pimple with pus (pustle) or a larger inflammation (cyst) with possible abscesses and scars later on.
To arise
The sebaceous follicle is a sensitive target organ for androgenic (male) hormones. That is why acne mainly occurs during puberty. Under the influence of those androgens (which also occur in women), more sebum is secreted. That in itself is not a problem as long as that sebum can be removed. Then the skin only looks a bit oilier. But sometimes the hair follicles get clogged by cornification of dead cells. Other factors that may play a role:
- Heat. The increase in acne in the tropics can be attributed to humid heat.
Most acne patients improve after sun exposure, especially if the lesions are located on the back and chest. In 20% of patients, an aggravation of the acne is found. The latter would be especially elicited if the patient was also exposed to moist heat. Greasy sunscreens could also make acne worse. - External products can play a role: oils, fats, waxes, tar products, chlorinated hydrocarbons, cosmetics. This is called contact acne.
• Medicines. Certain drugs can cause acne: steroids, halo-genes (iodine, bromine, fluorine), lithium, cyclosporine, INH, barbiturates, vitamin B, anticonvulsants, disulfiram, quinine and azathioprine. Excessive use of androgens (for example, in bodybuilding) can cause acne. - Power supply. Diet has not been shown to play a role. Total calorie intake and type of food (e.g. chocolate) have not been proven to play a role as a causative factor for acne.
- Stress. The role of stress is controversial. Stress could exacerbate existing acne.
- Pregnancy. The influence of pregnancy is unpredictable.
- Contraceptive pill. The influence of the contraceptive pill on the course of acne varies greatly depending on the type (see treatment: hormonal therapy).
- Local irritation or friction, eg shaving, playing the violin
- Sex: There is no evidence that sex can cause or exacerbate acne.
- Cosmetics: many make-up products contain fats and can promote the formation of comedones. Use little and preferably water-based products and never go to sleep with make-up on your face. Make-up is removed with soap and water, not with a cleansing cream.
Therapy
Acne is slow to respond to treatment. There is usually little improvement in the first month; the next two months, improvement occurs in 40% of cases. After six months of treatment, there is at least an 80% improvement in the lesions.
- Since anxiety can make acne worse, it's important not to dramatize the condition.
- It has not been proven that a diet is useful for acne. In individual cases, avoiding certain nutrients may make sense.
- One must be careful with the acne lesions, so that the acne does not become additionally infected. In this way there will be as few scars as possible. For example, it is not recommended to push out the blackheads. If you can't resist, limit yourself to the blackheads and use a clean cloth. Disinfect the pimple afterwards.
- Hygiene
The skin should preferably be washed with water that is not too hot and preferably with as little soap as possible. Preferably use non-alkaline soap ('soap without soap') for skin cleansing. An alternative is to use cleansing gels. The skin is patted dry after washing and certainly not scrubbed.
Medicines
The type of treatment depends mainly on the severity of the acne and, in the case of young women, on the possible desire to have children, because certain products may not be used before pregnancy.
In most cases, a local, external treatment is sufficient. The appropriate product should be chosen according to the most common type of acne, skin type and personal preference. Sometimes, however, oral antibiotics must be used. If the acne is more severe, isotretinoin can be used. For women, a specific hormonal product will be used, depending on the desire to have children.
Acne with mainly blackheads
The following preparations for external use can be used in this form of acne: tretinoin, adapalene, azelaic acid and salicylic acid. No preparation stands out above the others.
- Tretinoin
is the best known product. Tretinoin has the disadvantage that the rash worsens in the first weeks of use due to skin irritation. Improvement only occurs after six weeks. The skin can also become hypersensitive to the sun. Should not be used during pregnancy and lactation. Only available on prescription. - Adapalene
is a newly synthesized retinoid-like molecule with antiproliferative and anti-inflammatory activity. It is currently the preferred product. It has the same therapeutic effectiveness as tretinoin but causes less irritation. Should not be used during pregnancy and lactation. Only available on prescription. - Salicylic acid
is less effective and is suggested as a second choice. The effect depends on the percentage of active substance and the form of administration. Not recommended during pregnancy and breastfeeding. Only available on prescription. - in women who wish to have contraception: pill with norgestimate (see below)
Acne: mainly with papules and pustules
Can be treated externally with benzoyl peroxide, azelaic acid and antibiotics (erythromycin, clindamycin, and tetracycline). Oral treatment is with antibiotics.
- Benzoyl peroxide topical is first choice.
In case of hypersensitivity, minocycline can be used orally. If the result is insufficient, benzoyl peroxide can be used in combination with minocycline. If this combination has insufficient results, treatment with isotretinoin is preferred.
In women who wish to have contraception: pill with norgestimate (see below). - Benzoyl peroxide
has an anti-inflammatory and antibacterial effect, but has little effect on the comedones. Benzoyl peroxide is used in the form of gel (lotion and cream as an alternative base). A 5% concentration is usually sufficient for the face. A 10% concentration can be applied to areas of the body where the skin is thicker (for example, the back). It is best to start with one application per day, preferably in the evening. After all, benzoyl peroxide can provoke an irritating dermatitis with erythema and scaling. If the product is well tolerated, it can be applied twice a day. May be used during pregnancy. Sold over the counter in pharmacies. - Azelaic acid
is antibacterial and anti-inflammatory and also prevents the formation of comedones just like tretinoin. Only available on prescription.
The most common side effect is mild erythema and skin irritation characterized by scaling, itching and moderate burning. Normally, it should be applied in a thin layer to cleansed skin twice a day. When irritation arises, one opts for once a day. Hands should be washed after application. This does not eliminate existing injuries, but prevents the development of new injuries. It should not be used in persons prone to contact allergy to propylene glycol. May be used during pregnancy. - Topical antibiotics:
The topical antibiotics clindamycin, erythromycin and tetracycline are suitable for topical application. In particular, the number of papules and pustules decreases; the number of comedones is not. No topical antibiotic is superior to benzoyl peroxide. Applied once or twice a day for at least three months. Combination preparations are more effective but also much more expensive. Erythromycin for the topical treatment of acne can also be used in pregnant women.
Topical antibiotics are increasingly losing their place in acne treatment. Benzoyl peroxide is therefore first choice and should be given in monotherapy for as long as possible. If the result is insufficient, benzoyl peroxide can immediately be combined with an oral antibiotic. - Oral antibiotics.
Oral antibiotics are prescribed more than topical ones. However, resistance to antibiotics is increasing over the years. Oral antibiotics have two modes of action: a suppression of bacterial growth and an anti-inflammatory effect. Therapeutic recovery is faster than with topical antibiotics. In mild to moderate acne, there is improvement after one to two weeks, while maximum clinical result occurs after three to four months. Treatment should be continued for six months.
Minocycline is the first choice in these antibiotics, because one dose per day is sufficient, it is very effective against the bacteria that occur in acne and causes few gastrointestinal disorders.
Possible side effects are: hyperpigmentation and severe hypersensitivity reactions. The doctor should be notified at the slightest side effect.
The second choice is Doxycycline, the serious disadvantage of which is hypersensitivity of the skin to sunlight. and quite disturbing phototoxicity of doxycycline.
Other antibiotics are not indicated because they are less effective than minocycline and doxycycline or have avoidable side effects.
In general:
- Antibiotics are not the treatment of choice for acne. First, use benzoyl peroxide as an antimicrobial agent.
- the duration of treatment should be kept as short as possible.
- If further antibiotic treatment is necessary, the same antibiotic (unless loss of effectiveness) should be used.
- Use isotretinoin if there is insufficient therapeutic effect with six months of antibiotic therapy.
- Avoid simultaneous use of a different topical and oral antibiotic.
- Good compliance is very important for the success of the treatment and to avoid antibiotic resistance.
- Very severe acne
In very severe acne there is usually some form of severe seborrhea (sebum secretion).
Topical products do not affect sebum production. Soaps are useful for hygiene reasons but not in treatment. Only systemic products can inhibit sebum production.
Isotretoin (Roaccutane) is the preferred product. In women: pill with cyproterone acetate (see below). - Isotretinoin
(Roaccutane) is a synthetic derivative of vitamin A acid. It reduces sebum production, is anti-inflammatory and prevents comedone formation. A treatment usually takes 4 to 7 months.
Isotretinoin would be the drug of choice for most acne sufferers if it didn't have such serious side effects. The most important is its teratogenicity: it should not be given to pregnant women. Even after stopping the treatment, it is necessary that the woman does not become pregnant during the first month. - Other side effects:
- Dryness of the skin, including nasal scabs and conjunctivitis. Preventive measures include moisturizing (day cream and lip care), artificial tears to avoid conjunctivitis and not epilating with wax during the whole treatment as well as for the next two months (because pieces of skin could come along with the wax).
- skin sensitivity to the sun.
- Depression is also a side effect.
- At the start of treatment, the patient's renal function should be evaluated. With elevated fat levels in the blood, a low-fat diet should be followed. A blood test should be performed after one month and then every three months to check blood fats and liver function. In the event of impaired liver tests, treatment should be discontinued.
- Should not be combined with oral tetracyclines or vitamin A.
- Hormonal therapy
In women who wish to use contraception or in women with no contraindications for contraception or in women with painful periods, the choice of hormonal preparation can be important for the treatment of acne.
The contraceptive pill must be given for two to four months before improvement occurs; the recurrence rate is not small. Sometimes years of therapy are necessary.
Pill with norgestimate (Cilest) is preferred because no increased risk of thrombosis has been described.
The pill with Cyproterone Acetate (eg Diane 35) is the most powerful anti-androgen but is more expensive.
