Acne treatment is one of the most common reasons patients come to our clinics. Although acne tends to affect most of the population in their teenage years, it is still very much prevalent in adults with up to 40-50% occurring in their 20s and 10-20% in their 40s.
The cause of acne is multi-factorial and comprises of four main components – increased sebum or oil production, follicular hyperkeratinisation causing clogged pores, presence of the bacteria, Propionibacterium acnes, and inflammation. Therefore acne treatment needs to be aggressive from the start using a combination of treatments against each of the factors. However there is no single universal treatment plan for all patients with acne as each individual has a different clinical presentation of acne and also responds differently to treatment. A customized acne treatment plan needs to be formulated after consultation with the doctor and may be even be changed along the way during treatments.
The various components of an effective acne treatment plan is made up of the following:
A. Topical Medications
This includes the application of retinoids, antibiotics and benzoyl peroxide that are in a cream or gel form. This aims to reduce the clogged pores (comedones), kill the bacteria and decrease inflammation. The doctor will advise the appropriate combination and frequency of use. Topical retinoids and antibiotics may sometimes cause mild skin irritation such as redness, itch or dryness.
B. Oral Medications
Retinoids and antibiotics may also be given orally. However these are usually reserved for more severe or resistant cases and is still combined with topical medications.
Oral isotretinoin is a very effective form of acne treatment. However it is associated with significant side effects. These include dry mouth, dry skin, nose bleeds and an increase in blood lipid levels. Patients are required to have blood tests before and during treatment. Isotretinoin also causes abnormalities in fetuses and is therefore not allowed in pregnant women. Female patients must also be counseled on contraception before they start treatment to avoid accidental pregnancies. Patients are also not eligible for laser and chemical peel treatments until 12 months after they have stopped oral isotretinoin. Oral antibiotics are more effective and work faster when compared to topical antibiotics. However their use increases the risk of antibiotic resistance in patients.
Hormonal therapy is also a useful part of acne treatment for female patients. Androgens acting at the sebaceous follicles cause an increase in sebum production. Hormonal therapy is indicated when oral isotretinoin is not appropriate for the patient or when the patient suffers from relapses very quickly after taking repeated courses of isotretinoin. It is also useful when the patient wants to control her menstrual cycle or wishes to have contraception along with acne treatment.
C. Adjunctive Therapy
The above forms of acne treatment mentioned are the conventional treatments that have been practised for many years. Lately, several forms of physical treatments have emerged as adjunctive therapy which aims to make acne treatment more effective and work faster. These include new technologies and clinic procedures such as light and laser therapy, photodynamic therapy, chemical peels and comedone extraction and injections into the inflamed nodules. These forms of acne treatment are growing in popularity in patients who are not keen on taking oral medications or are not comfortable with the potential side effects of medications.
Light and laser therapy include intense pulsed light (IPL), broad-spectrum continous-wave visible light (blue and red) and lasers. The bacteria responsible for acne, Propionibacterium acnes, produces a certain chemical called porphyrins. Porphyrins, when activated by blue light, damages the bacteria thus destroying it. While blue light kills the bacteria, it does not penetrate the skin very deeply. Red light, although less effective in killing the bacteria, can reach deeper into the sebaceous glands and also has anti-inflammatory properties.
In photodynamic therapy, chemicals are applied first so that subsequent light therapy may be more effective in killing the bacteria.
Chemical peels are used in acne treatment to encourage exfoliation of dead skin as well as decrease the clogged pores. Chemical peels using glycolic acid or salicylic acid are commonly used although salicylic acid is felt to better penetrate into the sebaceous glands and also have an additional anti-inflammatory effect compared to glycolic acid. Daily acne cleansers are formulated with a lower concentration of salicylic acid compared to chemical peels.
Occasionally large painful, persistent nodules or cysts can develop. The doctor can administer intralesional injections of triamcinolone, a form of steroid, to quickly reduce the pain and swelling.
Acne will always be a challenging condition to the doctor as its presentation and response to treatment varies among individuals. Acne scars are the result of the inflammatory lesions and patients who have the habit of picking at their acne. Currently options for the treatment of acne scars include excision, punch excision, subcision, cryosurgery, dermabrasion, microdermabrasion, chemical peels, ablative lasers, nonablative lasers and fractional lasers. Acne treatment needs to be started early and aggressively to reduce the resulting physical and psychological scarring on patients.
The cause of acne is multi-factorial and comprises of four main components – increased sebum or oil production, follicular hyperkeratinisation causing clogged pores, presence of the bacteria, Propionibacterium acnes, and inflammation. Therefore acne treatment needs to be aggressive from the start using a combination of treatments against each of the factors. However there is no single universal treatment plan for all patients with acne as each individual has a different clinical presentation of acne and also responds differently to treatment. A customized acne treatment plan needs to be formulated after consultation with the doctor and may be even be changed along the way during treatments.
The various components of an effective acne treatment plan is made up of the following:
A. Topical Medications
This includes the application of retinoids, antibiotics and benzoyl peroxide that are in a cream or gel form. This aims to reduce the clogged pores (comedones), kill the bacteria and decrease inflammation. The doctor will advise the appropriate combination and frequency of use. Topical retinoids and antibiotics may sometimes cause mild skin irritation such as redness, itch or dryness.
B. Oral Medications
Retinoids and antibiotics may also be given orally. However these are usually reserved for more severe or resistant cases and is still combined with topical medications.
Oral isotretinoin is a very effective form of acne treatment. However it is associated with significant side effects. These include dry mouth, dry skin, nose bleeds and an increase in blood lipid levels. Patients are required to have blood tests before and during treatment. Isotretinoin also causes abnormalities in fetuses and is therefore not allowed in pregnant women. Female patients must also be counseled on contraception before they start treatment to avoid accidental pregnancies. Patients are also not eligible for laser and chemical peel treatments until 12 months after they have stopped oral isotretinoin. Oral antibiotics are more effective and work faster when compared to topical antibiotics. However their use increases the risk of antibiotic resistance in patients.
Hormonal therapy is also a useful part of acne treatment for female patients. Androgens acting at the sebaceous follicles cause an increase in sebum production. Hormonal therapy is indicated when oral isotretinoin is not appropriate for the patient or when the patient suffers from relapses very quickly after taking repeated courses of isotretinoin. It is also useful when the patient wants to control her menstrual cycle or wishes to have contraception along with acne treatment.
C. Adjunctive Therapy
The above forms of acne treatment mentioned are the conventional treatments that have been practised for many years. Lately, several forms of physical treatments have emerged as adjunctive therapy which aims to make acne treatment more effective and work faster. These include new technologies and clinic procedures such as light and laser therapy, photodynamic therapy, chemical peels and comedone extraction and injections into the inflamed nodules. These forms of acne treatment are growing in popularity in patients who are not keen on taking oral medications or are not comfortable with the potential side effects of medications.
Light and laser therapy include intense pulsed light (IPL), broad-spectrum continous-wave visible light (blue and red) and lasers. The bacteria responsible for acne, Propionibacterium acnes, produces a certain chemical called porphyrins. Porphyrins, when activated by blue light, damages the bacteria thus destroying it. While blue light kills the bacteria, it does not penetrate the skin very deeply. Red light, although less effective in killing the bacteria, can reach deeper into the sebaceous glands and also has anti-inflammatory properties.
In photodynamic therapy, chemicals are applied first so that subsequent light therapy may be more effective in killing the bacteria.
Chemical peels are used in acne treatment to encourage exfoliation of dead skin as well as decrease the clogged pores. Chemical peels using glycolic acid or salicylic acid are commonly used although salicylic acid is felt to better penetrate into the sebaceous glands and also have an additional anti-inflammatory effect compared to glycolic acid. Daily acne cleansers are formulated with a lower concentration of salicylic acid compared to chemical peels.
Occasionally large painful, persistent nodules or cysts can develop. The doctor can administer intralesional injections of triamcinolone, a form of steroid, to quickly reduce the pain and swelling.
Acne will always be a challenging condition to the doctor as its presentation and response to treatment varies among individuals. Acne scars are the result of the inflammatory lesions and patients who have the habit of picking at their acne. Currently options for the treatment of acne scars include excision, punch excision, subcision, cryosurgery, dermabrasion, microdermabrasion, chemical peels, ablative lasers, nonablative lasers and fractional lasers. Acne treatment needs to be started early and aggressively to reduce the resulting physical and psychological scarring on patients.
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