Acne vulgaris is an inflammatory skin condition that is predominantly found in adolescents but may be seen in older individuals as well. It affects approximately 40-50 million Americans every year (1), and typically involves the face and upper trunk. Multiple factors affect severity including genetic predisposition and hormones. One of the initial developments in acne is the formation of comedones (blackheads and whiteheads) resulting from blockage of the upper aspects of hair follicles. As the comedones grow, their walls rupture with leakage of cyst contents and oil into the skin with resultant inflammation. The bacteria Propionibacterium acnes is a major contributor to acne and works partly by releasing rupture-inducing enzymes and by further increasing inflammation. (1) The inflammation progresses to development of follicular papules, pustules, cysts, nodules, and scarring in severe cases.
Acne in NJ vulgaris may be divided into three categories:
“1. Mild acne: characterized by the presence of comedones (noninflammatory lesions), few papules and pustules (generally <10), but no nodules.
2. Moderate acne: presence of several to many papules and pustules (10 to 40) along with comedones (10 to 40). The presence of >40 papules and pustules along with larger, deeper nodular inflamed lesions (up to five) denotes moderately severe acne.
3. Severe acne: presence of numerous or extensive papules and pustules as well as many nodular lesions.” (2)
Treatments for acne include benzoyl peroxide, retinoids, topical and oral antibiotics, birth control pills in females, comedo extraction, intralesional steroid injections, and other therapies. The treatment regimen is determined by the severity of one’s acne. Key goals of therapy include reducing inflammation, decreasing the size and number of active lesions, preventing new breakouts, and minimizing scarring.
Benzoyl peroxide reduces inflammation and inhibits bacterial growth. Retinoids act by increasing cell turnover and helping move contents from the bottom of pores to the surface of the skin. They are utilized to eradicate comedones and prevent new breakouts. Initially retinoids can be very irritating, especially during the first 2 weeks. Patients may use retinoids every other night for 2 weeks until the irritation diminishes and the skin adjusts. After this period the medication should be used nightly. Retinoids may induce an initial flare of acne which resolves with continued use. (1) Commonly used retinoids are tretinoin, adapalene, and tazarotene. Oral antibiotics work primarily by inhibition of Propionibacterium acnes, but also by directly reducing inflammation. Commonly used oral antibiotics for acne include doxycycline, tetracycline, and minocycline.
Isotretinoin (Accutane) is indicated for severe acne resistant to other therapies. Although the mechanism of action is not completely understood, it works primarily by decreasing the size and production of sebaceous glands. The duration of Accutane therapy is generally 20 weeks, but the course may be extended depending on individual circumstances. There are many side effects, but Accutane can be literally miraculous for patients with severe acne. Accutane, side effects, and the Accutane iPLEDGE program will be discussed in future columns on our website blog.
1. Bolognia, Jorizzo, and Rapini. Dermatology. Elsevier Limited, Second Edition. Online Version, Chapter 37: Acne Vulgaris.
2. Ferri’s, F. (2011) Acne Vulgaris, Ferri: Ferri’s Clinical Advisor 2011, 1st ed. (Mosby). An Imprint of Elsevier.