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Acne 101: Causes & Treatments

Acne 101: Causes & Treatments

Acne Vulgaris, more commonly referred to as “acne,” is one of the most common Dermatological skin conditions worldwide. In fact, it is estimated that yearly, 40-50 million individuals in the United States alone, suffer from acne.  Approximately 85% of teens and young adults (between 12 and 24 years) are affected. However, the disorder may persistent well into adulthood. Because of the prevalence of acne and its significant social and psychologic impact, it is important to understand the disorder and treatment options available.

What is Acne? Acne is more than clogged pores and pimples; it’s actually an inflammatory skin disorder involving the pilosebaceous unit, which refers to the hair follicle and associated oil-producing sebaceous gland.  Acne is most common on areas with the highest number of these units including the face, chest and back. Development of acne is due to a combination of:

  • accumulation of dead skin cells and oil (sebum) within the hair follicle,
  • excessive sebum production,
  • inflammation caused by bacteria,
  • and hormonal influence.

Acne is classified as either inflammatory or non-inflammatory. Inflammatory acne is characterized by papules, pustules and nodules (deep, often painful lesions), while non-inflammatory acne is characterized by open comedones (blackheads) and closed comedones (whiteheads).

What Causes Acne? The causes of acne can be complicated and multifactorial. Although acne is influenced by environmental aspects and skin care, it also results from a combination of genetics, hormonal influence, and the immune system. Due to hormonal influence, acne most commonly begins around puberty. Patients with certain endocrine disorders such as Polycystic Ovarian Syndrome may be at increased risk. There is even some literature documenting a relationship between intake of milk (especially skim milk), protein supplements such as Whey Protein and acne risk, highlighting the important influence of diet on acne. Drug-induced acne is caused by certain medications such as steroids which is often abrupt in onset. Finally, acne may be secondary to certain occupational exposures, cosmetic products, mechanical friction and heat exposure.

How Do You Treat Acne? Early treatment can be important to prevent long-term scarring.  Treatment regimens are tailored based on the type of acne present and individual factors. Options range from topical lotions and cleansers, to laser therapy and oral prescription medication. It is important to seek evaluation with a board-certified Dermatologist, Plastic Surgeon or PA/NP specializing in Dermatology for proper evaluation and discussion of treatment options that are best for you.  

  • Topical Treatments—typically first-line treatment for mild-moderate inflammatory and non-inflammatory acne. Common agents include retinoid gels/ creams (i.e. tretinoin, adapalene, tazarotene) alone or in combination with benzoyl peroxide or salicylic acid cleansers.  These products are available both over-the-counter and as prescription-strength medications.  
  • Antibiotics—both topical and oral antibiotics (i.e. clindamycin, erythromycin) have a long history of use for the treatment of mild-moderate and severe inflammatory acne. However, given growing concerns regarding antibiotic resistance and disruption of the microbiome, use of these agents has fallen out of favor. Antibiotic products are only available as prescription medications.
  • Hormonal Therapycombined Oral Contraceptive Pills are an established second-line treatment option for female acne patients, with three agents currently FDA-approved for this indication. Spironolactone, an androgen-receptor blocker, is another option for adult female patients with hormonally-driven acne. There are many potential side effects and risks to hormonal therapy and therefore patients should seek evaluation with a licensed medical professional prior to initiating therapy.
  • Photodynamic  Therapy—use of topical photosensitizing agents (i.e. 5-aminolevulinic aid, methyl aminolevulinate) in conjunction with artificial light sources in the form of blue, red, or intense pulsed light or laser is a newer documented treatment modality for moderate inflammatory acne. This is a great option for patients who have failed conservative treatment, or those in which oral treatment is contraindicated, as the side effect profile is minimal. PDT treatments are typically not covered through insurance.
  • Oral Isotretinoin (Accutane)—reserved for patients with severe, nodulocystic acne that has failed conservative treatment. This treatment is the only documented modality to alter the course of the disease. However, given severe risk of teratogenicity, prescription use of isotretinoin in the US requires both patient and provider registry through the iPLEDGETM program mandating monthly office visits and pregnancy testing for female patients.
  • Procedural Optionsprocedures such as manual comedo extraction and intralesional corticosteroid injections are reserved for persistent acne lesions to aid in therapeutic responsiveness.  These procedures should be performed by a licensed medical professional specializing in Dermatology.

References

Bolognia JL, Schaffer JV, Cerroni L, Callen JP. Dermatology. Edinburgh: Elsevier; 2018.

Jennifer Fisher

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