Acne is a beast. A stubborn, multifaceted beast and no two patients are alike. This makes acne one of the most challenging conditions to treat – but the good news is, we’ve got options. Plenty of options. If you’re prepared for a major lifestyle overhaul, and can endure some trial and error, then there is great hope for an acne-free future. Too often, I hear of patients being prescribed the heavy-hitters with major side-effects (accutane & systemic antibiotics) right off the bat for mild/moderate acne; even more troublesome is how many patients were prescribed these medications as teenagers. As skin care providers, we all have tricks-of-the-trade and go-to treatments, but it’s important that we keep up on current and emerging evidence-based therapies, and follow treatment guidelines, not only for good clinical outcome, but for risk-reduction and patient safety. The 24th World Congress of Dermatology took place in Milan, Italy, it is one of the most widely recognized international dermatology meetings in the world, and below are some of the highlights from the expert panel on current and emerging treatments for acne.
TREATMENT FOR SIMPLE COMEDONAL ACNE
This is the mildest form of acne, small blackheads and whiteheads. The global consensus is to being with topical treatment, something like benzoyl peroxide or an alpha-hydroxy acid, a topical retinoid, or azelaic acid paired with nutritional and lifestyle considerations. Both topical and systemic antibiotic therapy, systemic anti-androgen medications like spironolactone, the systemic drug isotretinoin aka Accutane and UV light therapy are discouraged for mild acne as the risks/side-effects outweigh the benefits.
Benzoyl peroxide is thought to have a three-fold activity in treating acne. It is sebostatic, comedolytic, and inhibits growth of C. acnes, the bacteria most commonly behind acne lesions. Because it is not an antibiotic, there isn’t a risk of antibiotic resistance; it can be prescribed on it’s own or in combination with other acne inhibiting medications.
Alpha-hydroxy acids are a class of compounds that chemically exfoliate the skin, which can help to dry up acne lesions, they also brighten complexion and smooth the appearance of fine lines so these are commonly used to promote healthy skin aging as well. Common AHAs for skin include glycolic acid and lactic acid.
Topical retinoids are a class of medications chemically related to Vitamin A. With respect to acne, these products regulate epithelial growth, reduce acne lesions and improve the appearance of acne scars and hyper-pigmentation. Retinol is a specific form of Vitamin A naturally produced by your body. It’s the mildest version of a retinoid as it’s not yet in an active form and does not require a prescription. When applied to your skin, enzymes naturally convert the retinol to retinoic acid over the course of a few weeks. Results are therefore typically slower and more gentle than a retinoic acid which means less side effects (redness, peeling and flaking). Retinoic acid, also known as tretinoin, is a prescription retinoid about 100 times stronger than your average retinol serum. While the results are typically much quicker, they come with side-effects, itching, burning, stinging, redness, flaking and dryness. Newer generation retinoids like adaptelene are much better tolerated than the older tretinoin as they are more selective for retinoic acid receptors in the skin and are now thought to be the the safer version for patients.
Azelaic acid is a medication that kills acne bacteria and decreases the production of keratin. It is also anti-inflammatory so it is used especially in patients with redness, rosacea and is used in the treatment of hyper-pigmentation and melasma.
TREATMENT FOR MILD TO MODERATE PAPULOPUSTULAR ACNE:
This a more inflammatory type of acne, with comedones as well as papules and pustules. In patients presenting with mild or moderate papulopustular acne, particular attention should be paid to diet, lifestyle and a thorough work-up should be conducted. Proper evaluation includes microbiome testing, things like stool samples, breath tests, and skin swabs, to investigate the type of bacteria or yeast responsible, and an endocrine profile should be requested, to evaluate hormonal imbalances, in particular, androgen excess & insulin resistance.
For this type of acne, retinoids like adaptelene paired with benzoyl peroxide, or BPO with clindamycin (antibiotic) are often prescribed. Doctors must carefully consider the use of an antibiotic as the risk for antibiotic resistance is high. Again, global consensus is that topical antibiotics as mono-therapy should never be used, the combination erythromycin & zinc is discouraged, and systemic antibiotics, isotretinoin or UV light are not appropriate given the risk of side-effects. Although European guidelines do not include the use of oral contraceptive pills or anti-androgen therapies, American guidelines support the addition of spironolactone or an oral contraceptive for female patients.
Oral contraceptive pills (OCPs) increase sex hormone binding globulin in the body, which decreases the amount of circulating androgens thereby reducing the activity of oil glands in the skin. Less oil production means less acne. The pill comes with drawbacks, there are side-effects and the potential for serious vascular events, including clot, stroke and death.
Spironolactone is a medication typically used to treat high blood pressure and heart disease. There is actually very little and low quality evidence for it’s use in female acne, but clinically, it works! While the mechanism isn’t fully known, there seems to be an effect on androgens. This medication also comes with unpleasant side-effects and causes male fetal abnormalities.
TREATMENT FOR SEVERE NODULAR ACNE:
Severe acne consists of comedones, inflammatory papules, pustules and the presence of nodules. Here global consensus is that isotretinoin is the first choice of treatment, followed by systemic antibiotics and one of or combination of adaptelene/BPO/azaelic acid. Antibiotics should never be used on their own, and in these cases oral anti-androgen and UV therapy are discouraged.
Isotretinoin is the big gun of acne treatment. As advised in the product monograph, “because of the significant side-effects associated with it’s use, ACCUTANE should be reserved for patients for severe nodular, conglobata or recalcitrant acne when they are unresponsive to first line therapies”. The mechanism of action is unknown, but in acne patients, improvement occurs in association with a reduction in sebum secretion. The decrease in sebum secretion is temporary and directly related to the dose and duration of treatment. Before putting a patient on acctuane, lab testing must be performed and the patient must sign and go through a thorough informed consent form. They must come back monthly for blood work and evaluation because of the following…
Black Box Warning Highlights:
- Contraindicated in pregnancy, causes severe birth defects.
- Contraindicated in patients with kidney or liver disorders, elevated lipids, or have a hypersensitivity to vitamin a or any of the non-medical ingredients in the capsules.
- Some patients taking accutane have become depressed and/or attempted suicide.
- Accutane can cause severe skin reactions which can be life-threatening, disfiguring or even cause death.
- Accuntane can increase blood lipids which may increase a patients risk of a cardiovascular event such as clot, stroke or heart attack.
- Accuntane can cause tinnitus or impaired hearing.
- Accutane can cause elevated fasting blood sugars and a few cases of diabetes have been reported.
- Acctuane use can also cause inflammatory bowel disease, hepatitis, acute pancreatitis, allergic reactions, vasculitis, osteoporosis, fractures, dry eyes, corneal opacities, decreased night vision, alopecia, skin peeling, dryness and redness, headache, fatigue, swollen glands, arthritis, muscle pain, seizures, erectile dysfunction, kidney disease, liver disease, benign intracranial hypertension…
These are not rare complications, these side-effects and diseases happen regularly on this medication. That’s why accutane should be and needs to be reserved as a last resort. On a side note, for those of you with a passion for animal welfare, you should be aware that this drug, like many other drugs, is tested on rodents, rabbits cats, and dogs to name a few.
OTHER TREATMENTS:
Never underestimate the benefit of physical modalities like chemical Peels, lights, laser devices and microneedling. These treatments can be very useful adjunctive tools, rounding up a comprehensive acne protocol.
As always, the path to clear skin begins with a thorough consultation and a willingness to address your diet, lifestyle and stress levels. Be prepared to invest in a regimented at-home skin-care routine and multiple in-clinic treatments.
In Health,
