How Does Acne Form?

Acne is not due to a single event but the result of multiple steps going “wrong”. Acne is a disorder of keratinization, meaning the development of cells lining the sebaceous gland is faulty.

These cell walls are sticky, binding together, plugging the gland rather than easily exfoliating themselves onto the surface.

Despite the presence of this plug, the sebaceous glands, triggered by DHT, the active form of testosterone, continue to secrete sebum.

Proprionobacterium acnes (P. acnes), the bacteria that live upon the skin, thrive in this environment. Lack of air and lots of sebum nourish the bacteria, allowing them to flourish. Too many P. acnes contribute to the inflammation within the gland.

Ultimately, a combination of persistent plugging, excessive oil build-up (envision an expanding water balloon) and inflammation produced by bacterial over growth cause the gland to rupture. On the surface, this manifests itself as an inflamed acne papule or cyst.

Intervening at several points along this pathway maximizes acne therapy.

Acne & Food

Was mom right? Until recently, contrary to what your mother may have told you, dermatologists have been taught that it’s not what you’re eating (with the possible exception of nuts) that leads to acne.

Yet a study out of Colorado State University suggests otherwise. Kitivan Islanders of Papua New Guinea who eat traditional low carbohydrate diets are acne free. In contrast, those living in Western Europe and North America, 79 to 95 percent of teens struggle with acne and 40 to 54 percent of adults 25 and older still break out. Is diet the difference?

The theory behind the study rests upon known physiology. A diet with a high glycemic value (high in sugar) sends insulin levels skyrocketing triggering sebum production and indirectly acne. Epithelial cells form more quickly and as they become trapped within the sebaceous gland, the P. acnes feast upon the excess oils. The result - blemishes.

So perhaps those potato chips, chocolate and other junk food mom warned about has some kernel of scientific truth. Not because they’re oily but because they’re loaded with carbs. Should you shun all the goodies? From a realistic standpoint, it’s unlikely to happen. I certainly don’t have that level of permanent willpower. Go for the healthy, well-rounded approach.

NOT ALL ACNE IS CREATED EQUAL

There are different types of acne lesions as well as grades of acne severity. Treatment is based upon the possible permutations.

Types of acneiform lesions

Open Comedone (aka the blackhead)

Inflamed Papule

Pustule (aka the whitehead)

Painful Nodular Cysts
Dermatologists perform acne grading – essentially guesstimating the number of blemishes. This factors into how aggressive to make therapy as well as track improvement or lack thereof. Grade 1 is the mildest, with very few lesions. This graduates to a high of grade 4.

Treatment

Too many acne sufferers go untreated far too long. We have so many effective therapies that weren’t available in the 70’s when I was growing up. Acne can have a real impact on an individual’s self esteem. I can’t emphasize enough that NO ONE needs to suffer from acne.

When a patient presents in my office, I quickly evaluate the overall severity of the acne (the grade) and the types of lesions present. Every dermatologist has their favorite combinations of treatments that have been successful for their patients.

I allow 6-8 weeks for any therapy regimen to show considerable improvement (notice I didn’t say miraculous) improvement. If a patient does not display this, I will often change their medications. Anyone finding themselves on the same medicines for a year and continuing to break out don’t hesitate to broach a change with your doctor!

How do you or your dermatologist decide what needs to be done? Here are the issues that are targeted by treatment:

Kill the bacteria

Reduce unnecessary oils

Unplug the pores

Reduce inflammation
Many acne treatments conveniently provide more than one benefit, helping simplify the process.

Prescription Therapy For Acne Currently On The U.S. Market

Pills

Systemic therapy (pills) is best for inflammatory acne and practically mandatory for acne cysts.

Three categories of oral medication:

Antibiotics (used to help kill bacteria and reduce inflammation)

Hormonal therapy (used to reduce the hormone DHT from triggering acne)

Accutane (considered the closest thing to an acne “cure”)
Antibiotics*

Tetracycline

Minocycline

Doxycyline

Erythromycin

Sulfa
*This list is not meant to be fully comprehensive.

Bacteria drive acne formation. P. acnes thrive upon excess sebum and an environment low on oxygen. Blackheads and cellular debris plug the neck of the sebaceous gland, preventing contact with air. The result of bacterial growth is the formation of free fatty acids – highly inflammatory, causing whiteheads, red bumps and painful cysts. A stray monthly pimple doesn’t warrant a long-term commitment to antibiotic therapy. Yet the patient plagued by these types of blemishes, whether numerous or resistant to topical therapy, may qualify.

Antibiotics are used not only to kill P. acnes but also to reduce the inflammatory process. IN acne therapy, the tetracycline family is the most effective group of antibiotics.

Tetracycline (aka Sumycin) is most commonly prescribed in doses of 500mg twice daily. Minocin (aka minocycline) is a more aggressive member of this antibiotic family and given in a dosage of 50mg once or twice a day. It also is much more expensive. I reserve Minocycline for patients unresponsive to tetracycline, or patients with primarily cystic acne. Doxycycline is similar to minocycline; however, I have not had nearly the response rate to this medication as I have to Minocin so I tend to avoid its use.

The tetracycline family may cause increased sun sensitivity and are not to be used if pregnant or nursing nor is it appropriate for patients younger than 13 years of age due to potential dental enamel discoloration.

Erythromycin is not as effective for treating acne and tends to cause significant stomach upset. I save this for patients unable to take tetracycline or its family members. Erythromycin should be taken on a full stomach to reduce nausea.

Sulfa is infrequently prescribed for acne therapy but is highly effective. Sulfa allergies are very common, hence the hesitancy for use.

Hormonal/Anti DHT Therapy

Birth Control Pills (Ortho Tricyclen)

Spironolactone (aka Aldactone)
Blame it on the hormones…for the acne, that is. Hormonal imbalance may lead to chronic acne or that once-a-month flare-up. But one woman’s hormonal flare is another woman’s means to a quick fix.

What is it about hormones that create such havoc with the skin? Androgen and estrogen balance creates harmony for the skin, sort of a biochemical Yin and Yang. Upset this delicate balancing act can lead to blemishes, galore.

All women produce androgens and these hormones are there for a reason. It is when androgens outweigh estrogen either through total amounts or genetic hypersensitivity to the mere presence of androgen that a problem may arise.

Women can either make too much testosterone (such as in polycystic ovary syndrome/PCOS); make too little estrogen to mask the testosterone or have a genetic predilection towards highly sensitive skin and hair follicle cells to “normal” levels of androgens. By far the most common cause of androgenic acne is this natural ultra sensitivity to androgens.

Contrary to popular belief, testosterone is not the bad actor; it’s DHT, the undesirable testosterone metabolite that’s responsible for triggering an increase in sebum production, enlargement of the sebaceous glands and generally flares acne, creates rosacea complications and exacerbates oily skin. Control the DHT and you control the acne.

Birth Control Pills

Why do BCPs help control acne? In order to treat acne hormonally, one of the following must occur to stop hormones from wreaking havoc with the skin. The treatment must either:

Block the androgens from reaching the receptors.

Reduce the level of circulating androgens in the bloodstream.

Prevent the formation of the androgens in the first place.
Conveniently, oral contraceptives are capable of all three of these actions. All oral contraceptives are anti-androgenic. OCs increase sex hormone binding globulin (SHBG), which binds to androgens and literally prevent them from going anywhere. Sort of a sponge-action approach.

At the same time, the progestin component (the synthetic form of progesterone) of an oral contraceptive competes to bind to the androgen receptors.

All birth control pills decrease the levels of circulating total and free testosterone.

Oral contraceptives help prevent the formation of active androgens.

The enzyme 5 alpha reductase is vital for converting testosterone into the active metabolite dihydrotestosterone (DHT). Birth control pills interfere with enzyme function. No enzyme, no DHT, no acne.

The FDA has only given its approval for Ortho-Tricyclen to carry the indication for treating acne. This particular medication went through the rigorous testing and studies required to prove to the FDA that it indeed was beneficial for acne as well as its ability to be a quality oral contraceptive.

Spironolactone

Many women are turning to non-contraceptive anti-androgen options in the treatment of their acne. Spironolactone (brand name Aldactone) is a water pill (diuretic) used to help reduce water retention in addition to helping control high blood pressure.

Spironolactone has a curious molecular structure lending itself to mimic androgens. This unique architecture allows it to bind to the androgen receptor and block the true androgen from binding and triggering those undesirable “male” skin and hair traits.

The downside to Spironolactone use includes symptomatic low blood pressure, irregular menstrual cycles, spotting and higher levels of potassium in the bloodstream. Avoiding excessive binging on high potassium-containing foods like bananas is important.

For women who crave the benefits of an anti-androgen but want to be on oral contraceptives, or for those who want to be on a BCP but hate those extra few pounds of water retention that tend to go hand in hand, a new generation pill, Yasmin, may be a solution.

Yasmin contains the progestin Drospirenone that is very similar structurally to Spironolactone. Because of its resemblance to Spironolactone, Yasmin can help avoid those extra few pounds of weight gain and may be beneficial in addressing androgenic acne.

Accutane

Many patients with the most severe form of acne, grade 4 cystic acne fail more traditional “aggressive” therapy.

Accutane has been a blessing for these patients.

A Vitamin A derivative in capsule form, this is the closest medication to acne "cure". Accutane helps normalize what’s really wrong within the sebaceous gland that contributes to the formation of acne in the first place –the keratinization process.

Therapy is limited to 5 months unlike chronic antibiotic acne therapy. The success rate is high and the results impressive. Rarely, patients with significant acne unresponsive to other aggressive treatment might also be placed on Accutane.

Accutane is a drug to be taken seriously.

It can have serious possible side effects. Similar to what occurs with excessive systemic Vitamin A, problems include dryness of skin, eyes and mucosal membranes; chapped, cracked lips; increased blood fats called triglycerides; low blood counts; liver enzyme abnormalities; hair loss; pressure behind the eyes; headaches; nausea, concerns about depression and most importantly birth defects.

Pregnancy must be avoided while on Accutane and 1 month after discontinuing treatment. Two methods of birth control should be used. Birth defects affect the developing fetus exposed to the medication. It is important to understand that the medication does NOT affect ovaries, eggs, sperm or future pregnancies.

While on Accutane, blood work is done for screening, every 2 weeks for the first month of use and monthly for the final 4 months of use. This monitors early changes in blood counts, liver and kidney function and triglyceride levels that can skyrocket during Accutane use.

Injectable Steroids

The stray cyst can rapidly be resolved with a small shot of steroid solution known as Kenalog (triamcinolone). The up side is the rapid resolution for those "little emergency" situations like weddings, prom, etc. The downside - this is simply not the way to treat widespread recurrent acne. Nor is it pleasant should you experience the atypical "sink" spot where fat atrophy has taken place as a side effect from the shot. Fortunately this is unusual and spontaneously fills in over several months.

Knowing how and why acne forms and the role that so many effective oral medications play is indispensible in really understanding acne. That leaves topical therapy, appropriate skin care, the latest Sci-Fi treatments and exciting new developments for us to discuss.

Topical Therapies

A hot topic in acne therapy is how to best handle breakouts with topicals. Some don’t want to take pills; others have extenuating circumstances and can’t take pills. Most simply want to get clear fast and understandably want to incorporate whatever measures they can to maximize treatment. Topicals are as varied in their actions as systemic therapy. They are an invaluable means for treating minor outbreaks and rounding out therapy.

Synthetic Retinoids

These derivatives of Vitamin A are indispensable in acne therapy. Similar to the actions of Accutane, they help normalize the keratinization process (formation of those aberrant cells lining the sebaceous gland). Topically they help eliminate blackheads, dry up excess oils and squelch papular and pustular acne. Those in the prescription category are more potent but if this is not an option, retinols can be beneficial.

Tazarotene (Tazorac)

Tretinoin (Retin A, Avita)

Adapalene (Differin)

Retinoids are a source of complaint when overused or too potent for a patient. Make sure to follow these steps:

Begin use just every other night.

Wait 30 minutes after washing before application.

Apply a PEA sized amount of cream to your finger.

Dab the cream/gel around the area to be treated and rub it in well.

Avoid getting in the eyes and wash hands well.

Do not layer with any other skin treatment or moisturizer.

Reduce frequency of use if skin becomes irritated.

Vitamin A topicals whether OTC or prescription should not be used while pregnant or nursing and may increase sun sensitivity. Wear an SPF 30 daily.

Topical Antibiotics

As previously mentioned, bacteria drive acne formation. And a myriad of topicals exist that possess bacteria-killing abilities. These products are typically applied twice a day when treating whiteheads and small inflammatory acne lesions.

Clindamycin (Cleocin T)

Erythromycin (Erycette, Emgel)

Metronidazole (MetroGel/Lotion/Cream & Noritate)

Plexion Lotion & Cleanser (Sulfa based)
This is an abbreviated list of brand options.

Benzoyl Peroxide

Benzoyl peroxide is a tried and true acne treatment. Strengths range from 21/2/% all the way through 10%. Gels, creams, lotions, soaps, masques and even shaving creams provide formulations for every need. Its benefits are also based upon its bacteria thwarting abilities, although it’s not technically classified with the antibiotics. Benzoyl peroxide can be found in both over-the-counter and prescription treatments, often at the same levels! Recent variations have married benzoyl peroxide with other ingredients vs. mono-therapy.

Benzoyl Peroxide (BPO) 

BenzaClin (combination of BPO and Clindamycin)

Benzamycin (combination of BPO and Erythromycin)

Clinac BP (combination of Clinac O.C. and Benzoyl Peroxide)

This is an abbreviated list of brand options.

Benzoyl peroxide can cause dryness, redness and irritation if overused. There are even an unfortunate few who are allergic to benzoyl peroxide. Pay attention to what your skin is telling you and reduce your use should these symptoms develop.

Azelaic Acid

Azelaic Acid is a naturally occurring dicarboxylic acid found in grains like wheat, rye and barley. Azelaic acid has been shown in lab studies to possess antibacterial activity against common skin bacteria Proprionobacterium acnes (P. acnes) and Staphylococcus epidermidis (S. epidermidis). It may also play a role in normalizing the keratinization process within the gland, bestowing it with anti-acne/anti-comedogenic talent. Look for it in prescription acne medications Azelex 20% Cream, Finacea (15% for rosacea) and nonprescription.

DHT

If only one could prevent DHT from revving up the sebaceous glands; thus reducing acne flare-ups and oily skin. We know birth control pills and Spironolactone can, but is there any topical hope?

Nordihydroguiaretic acid (NDGA) is a natural, plant derived lipooxygenase inhibitor, meaning its function is to reduce inflammation. What’s interesting about NDGA is that journal articles such as The Journal of Biochemistry and Pharmacology (March 2002) suggest NDGA possesses the ability to reduce 5-alpha reductase function; the enzyme responsible for changing testosterone into DHT. contains NDGA and can help make your acne regimen more tolerable and effective by reducing the amount of sebum available to nourish bacteria or able to plug pores and help clear blemishes already visible.

Sulfur

Sulfur helps inhibit the growth of P. acnes and unclog pores. Used solo one can find it in either OTC or Rx options. In combination with Sulfa, it’s approved for use in acne rosacea and seborrheic dermatitis.

(Sulfur and Resourcinol)
Peter Thomas Roth Sulfur products
Sulfacet R (Sulfur and Sulfa)
Rosula (Sulfur, Sulfa and Urea)
Ovace (Sulfur and Sulfa)
Plexion (Sulfur and Sulfa)


                   This is an abbreviated list of brand options.

General Skin Care For Acne Patients

How to keep skin fresh, healthy, glowing and blemish free? Acne is not due to a lack of cleansing. But, removing pore-plugging oils and surface cellular debris goes a long way to minimizing breakouts.
Glycolic and salicylic acids help dissolve grease and grime, lifting away cells plugging the pores. Glycolic acid tends to be most versatile, found in cleansers, treatments and toners. BHA often assists glycolic acid in AHA/BHA products.

Reducing oiliness eliminates a main source of nourishment for acne-causing bacteria. Sebum Sequestering Micro-Particles, which rapidly absorb excess skin oils without causing parching; mattifying skin all day long.

Here’s what dermatologists recommend their acne patients use in routine skin care:

Glycolic Acid (an AHA)

Salicylic Acid (BHA)

Combination AHA/BHA Products

Oil Control

Procedures

Dermatologists may include procedures in their approach to acne. Most commonly, "acne surgery" is performed. This essentially refers to the use of a comedone extractor being firmly applied around a blackhead and pushed out of the skin.

Other possibilities include chemical peels, microdermabrasion and the old-time application of liquid nitrogen to an acne cyst. I have personally found these rather limited in my approach to acne therapy and turn to them on a limited basis.

PIH – The Great Fake Out

I lost count long ago of the number of acne patients concerned about newly formed acne scars when there wasn’t a scar in site. What they were really noticing was skin discoloration where the pimple existed. This post inflammatory hyperpigmentation (PIH) is not an acne scar. It’s a normal remnant of the skin’s inflammatory process.

For those with pale skin tones, this aftermath color is usually pink, red or purple in color. Patients with darker skin tones may notice brown or black spots where acne once was.

Mederma is helpful for treating newly healed wounds and resolving acne, helping hasten the resolution of reddened spots. Although a light gel formulation unlikely to flare acne, it is important not to apply it too generously, as acne prone skin may not tolerate any product smothering the skin. It’s senseless to trigger acne in an attempt to fade discoloration.

PIH can fade unassisted. Unfortunately, the darker the PIH, the longer it may take to resolve. And while it is not a true scar, when it lasts a year, it certainly seems that way. This form of PIH may require some intervention in order to hasten the process. Ask your doctor about prescription bleaches like Glyquin or Lustra.  Don't overlook the importance of wearing sunscreen when trying to fade PIH.

SCI-FI TREATMENTS

The future is truly here. Light is being used as never before in medicine in an effort to conquer acne.

Acne Blues?

Those who make their way to a dermatologist often credit summer’s natural sunlight as helpful reduce acne severity. Studies indeed support the benefits of sunlight in acne therapy. But with concerns of UV induced skin cancer (not to mention wrinkles), indiscriminate use of medical ultraviolet phototherapy is not the treatment de jour. Leave it to medical science to find a way to get that summertime-like improvement.

P. acnes bacteria produce a natural byproduct of metabolism called porphyrins. Porphyrins are light sensitive and exquisitely vulnerable to narrow band visible blue light. When porphyrins are exposed to this light (or to a lesser extent, natural sunlight which contains less concentrated blue light), a chemical reaction toxic to P. acnes takes place. Kill the P. acnes, improve the acne. P. acnes literally self-destruct as a result of their metabolic process.

A process called Acne PhotoClearing (marketed under the name ClearLight) employs a high intensity, enhanced narrow band beam of visible blue light to destroy P. acnes and clear acne.

ClearLight is FDA approved for the treatment of mild to moderate inflammatory acne, i.e., small red inflammatory papules and pustules (whiteheads). ClearLight is unlikely to resolve blackheads or cysts, minimize pore visibility, or reduce oiliness.

Not all cases of acne are triggered by, so the procedure is not for everybody.

Remission with ClearLight usually lasts between 4-8 months. Repeat series of ClearLight may be required for maintaining a clear complexion.

Smoothbeam

This laser takes aim at the root of the problem-the root of the sebaceous gland, so to speak. After a series of treatments Smoothbeam is able to alter the structure and function of the sebaceous glands. Heat in and around the sebaceous gland creates a thermal injury.

Eventual results are fairly impressive. Improvement can be seen as early as 3 weeks and rapidly reaches 98% after 4 treatments. In one study, at a 24-week follow up, 100% clearance was seen in just one of the original 27 patients.

Therapy Down The Pike

Two candidates in the acne pipeline include topical versions of oral medications already used to treat severe caess of cystic acne. Isotrex is essentially Accutane mixed in a protective sunscreen base and is available in Canada and Europe. I have had some patients present who have been given "homemade" forms of this product which consisted of their pharmacist poking holes in the Accutane capsule and applying the liquidy gel straight to the skin. So far they have reported all this method did was locally irritate and dry the skin without helping clear the acne lesions. I have read mixed reviews out of Canada and Europe from dermatologists. It will be interesting to see if this medication makes its way through the FDA and onto the U.S. market and how it will truly perform.

Dapsone is occasionally prescribed for severe cystic acne when Accutane cannot be used or has not been effective. Dapsone is typically used in the treatment of certain forms of blistering disorders and systemic infections like . It has both antibiotic and antiinflammatory actions. Known as Atrisone, it is still in the clinical trials phase. It sounds interesting in initial reports. Should it be passed by the FDA it would offer an entirely new category of acne therapy.

Tips About Acne Treatment

Blackheads frequently need some form of topical vitamin A-containing ingredient for best results.

Cysts respond best to pill therapy.

A corollary: If you’re under 13, nursing or pregnant, tetracycline based medications are off limits as they can permanently discolor the tooth enamel. If you really need oral medication, usually it’s limited to Erythromycin.

Consistency of treatment results in a better outcome.

Don’t pick, it can lead to scar formation.

Allow at least 6-8 weeks for any new therapy to take effect before giving up on it.

Don’t scrub the face or have facials if you’re acne prone. These actions may traumatize sebaceous glands and lead to further flare-ups.

Keep bangs off the forehead and hands off the face. Bad habits like these deposit pore-plugging oils on the skin.

Avoid the use of heavy skin care products like cocoa butter, they will smother the skin and flare your acne.

Don’t apply your acne creams/lotions, etc. heavily like a masque (unless it is one). There is no reason that your product needs to be seen in order to work.

Remove your make-up when you’re at home. Let your skin breathe!

Too many acne sufferers go untreated far too long. No one need suffer with acne; today there are more effective therapy options than ever. If you have acne that doesn’t respond to over-the-counter treatment, please check with a board certified dermatologist.

Audrey Kunin, M.D.
(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

Article posted March 10, 2004.

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