A lot of studies have been conducted to understand the effects of acne on the psychological well-being of an individual. Every study concludes that more than 50% of the test participants suffer with anxiety, lower self-esteem and depression in worse cases.
The social stigma attached to acne due to the perceived impairment and un-attractiveness hampers the growth of a person. The onset of acne usually being in the teenage years when the body is going through significant physical, psychological and behavioural changes, can compound its impact and prove detrimental to the mental health of an individual.
Acne has affected millions of people across the globe and continues to be one of the major skin disorders for which people seek medical assistance and consultations. Diagnosing the severity of acne becomes important in the process of treatment.
Acne appears on the skin as comedones widely known as Blackheads and Whiteheads (open and closed skin pores respectively clogged with oil, dead skin cells and bacteria), tender red raised bumps (papules), pustules (when these bumps contain pus) and occasionally as nodules and cysts (large pimples with deeper skin involvement, can be solid or filled with pus). Papular form is most common and commonly termed as 'acne' or 'pimples'.
The severity of acne depends on its distribution (back, chest, upper arms), type and number of lesions (comedones, papules, pustules and nodules) and the presence or absence of scarring. The grading of severity of acne is as follows:
Mild Acne : Black heads and white heads with few inflammatory papules and pustules
Moderate Acne : Papules and pustules, primarily on face
Moderately Severe Acne : Numerous papules and pustules and occasional inflamed nodules, also present on chest and back
Severe Acne : Mainly large, painful nodules and pustules
How to treat Acne?
There is no "one size fits all solution" when it comes to treating acne as it is multifactorial and thus each person responds differently to different treatments. It is important to identify the cause and understand the severity of the condition and patient expectations to find the best workable solution. It is important to consult a dermatologist as soon as you observe the symptoms of acne in order to prevent the condition from aggravating further and leaving long-lasting acne scars.
The treatment of acne is aimed at managing the acne lesions, reducing its severity and preventing recurrences. The treatment approach depends on the severity of acne, age of the patient, treatment preferences and their adherence and response to their previous therapy.
Various treatments target different steps in the course of acne: from counteracting androgens and decreasing sebum production to preventing follicular occlusion, reducing P.acnes proliferation and decreasing inflammation.
How to treat Mild acne?
Mild acne is the most minor form of acne that involves some comedones and occasional papular or pustular acne, but they are not widespread or inflamed. Most cases of mild acne can be treated with topical medicines (gels, solutions and lotions) that can be obtained over-the-counter without prescription. Such treatments are active at application sites and can prevent new lesions.
Gels, face washes and solutions are helpful for oily skin whereas, lotions, creams and ointments are beneficial for dry and usually irritated skin. Topical treatments require at least 6-8 weeks for you to observe any visible improvements.
A few self-care measures that you can implement to manage mild acne are:
Use a gentle cleanser to wash your skin twice a day, especially after exercise. Do not forget to remove your make-up at night since long-standing make up on your. skin will clog pores and trigger acne.
A face wash with salicylic acid, glycolic acid or benzoyl peroxide is good for oily and acne-prone skin.
Avoid harsh scrubbing and repeated skin washing.
Do not squeeze, scratch, pick or rub pimples as it can lead to scarring and increase the inflammation.
Avoid any excessive exfoliation as it causes dryness and irritation of your skin.
Avoid usage of oily and greasy products in cosmetics or hair styling products.
Few acne medicines may cause skin peeling and drying. Use non-comedogenic products or water-based moisturisers or creams to keep your skin soft and supple.
Discontinue using a product if severe irritation occurs and consult a doctor for advice.
Make sure you use a sun block (sunscreen) since sun exposure can itself trigger acne and some of the acne products contain retinoids which are photosensitive.
Keep your scalp clean- oily scalp is also a sign of oily facial skin which could aggravate your acne. Use a good anti-dandruff shampoo if you have oily, flaky scalp.
Some topical medicines are listed below :
Benzoyl peroxide : Benzoyl peroxide can be used to treat acne of any severity as it kills P.acnes by releasing oxygen within the follicle. Benzoyl peroxide products are available over-the-counter in a variety of topical forms including soaps, washes, lotions, creams and gels. Water-based and alcohol-based formulations of benzoyl peroxide are also available and the most appropriate form depends on your skin type.
Salicylic acid : Salicylic acid helps in preventing plugged hair follicles and are available as both wash-off as well as leave-on products. They are moderately effective but less potent compared to other topical products.
Azelaic acid : Azelaic acid is a naturally occurring acid with antibacterial properties usually found in whole-grain cereals and animal products. A cream with 20% azelaic acid is reported to be as effective as many conventional acne treatments when used twice a day for at least 4 weeks. Minor skin irritation and discoloration can be seen on use in some patients.
Retinoids : The main target of acne treatment is the micro comedones. Topical retinoid therapy prevents excessive cornification (formation of horny layer of skin) and follicular blockage. It can decrease the number of comedones and inflammatory lesions by 40% to 70%. Topical retinoids are initiated as first-line therapy for both comedonal as well as inflammatory acne lesions and when continued as maintenance therapy, they prevent flares and inhibit further micro-comedone formation. Make sure you use retinoids at night since they are photosensitive drugs. Also make sure to use a sunscreen when on retinoinds therapy.
The most commonly prescribed topical retinoids are- Tretinoin, Adapalene and Tazarotene. Skin irritation with peeling and scaling are common side effects of this therapy, hence you are instructed to use very small quantities initially starting with lower concentration and can be increased once tolerated by your skin. It may take up to 6-8 weeks to see any optimal results.
How can you treat Moderate Acne?
Acne is said to be moderate when painful papules and pustules are not localised, but widespread across the face or body. Moderate acne break outs are considered to be more stubborn than mild acne as these tend to be inflammatory and have a higher risk of scarring. Treatment for moderate acne includes oral medication along with the topical agents described above.
When topical agents are insufficient or not well-tolerated, especially when the chest, back and shoulders are involved, systemic antibiotics and anti-acne medications are considered as the next line of treatment.
Antibiotics : Oral antibiotics have been found to be effective in reducing the number of inflammatory lesions (52% to 67% reduction). Antibiotics like Tetracyclines and Erythromycin also exhibit anti-inflammatory properties. They can reduce P.acnes within the follicles and thereby inhibit the production of bacterial-induced inflammatory cytokines. Doxycycline and minocycline are considered to be more effective in acne than tetracycline. Erythromycin is mostly prescribed for pregnant women and children under 9 years of age.
Response to oral antibiotics is usually seen after a minimum of 4-6 weeks of therapy. Topical retinoids when taken with oral antibiotics may result in a faster response and are more effective than using the drug alone. Once the severity of acne is controlled, antibiotics are gradually tapered and topical therapy is continued as long-term treatment.
Lights and lasers including Blue Light and Red Light Therapies have been found to be safe and helpful in treating mild to moderate acne when oral medications are unhelpful or unsuitable.
Hormonal Therapies : Hormonal agents are found to be effective second-line treatment in women with acne regardless of underlying hormonal abnormalities. According to some clinical studies, deep-seated nodules on the lower face and neck are especially responsive to hormonal therapy. Oral contraceptives containing estrogen can be equally effective as the various formulations are believed to decrease the levels of free testosterone by increasing sex-hormone-binding globulin. The choice of combined oral contraceptive is based on your tolerance for the medication and potential side effects.
Anti-androgen therapy is usually required for at least three to six months to see significant improvement. The oral anti-androgen Spironolactone can be added if oral contraceptives alone are not effective. Spironolactone is shown to be effective in improving acne when used alone or as an adjunct at doses of 50–200 mg/d. The possible side effects include hyperkalemia, menstrual irregularities and feminization of a male fetus. Although anti-androgen therapy is reported to be successful, acne recurrence is a possibility when it is discontinued. Combination therapy with topical agents or oral antibiotics can provide substantial benefits. All the systemic anti-acne drugs should be started under strict dermatological supervision.
How can Severe Acne be treated?
Severe acne includes large, deep, solid and painful cysts or nodules under the skin. The breakouts cover large areas of the face or body and lasts longer than moderate acne, often staying for several months or years. Patients should be under constant care of a dermatologist. Most of the patients of severe acne are prescribed with Oral Isotretinoin.
Isotretinoin is an anti-inflammatory systemic retinoid that causes normalization of epidermal differentiation, decreases the sebum production by 70% and also reduces the colonization of P.acnes. A baseline blood work is recommended before a patient starts oral isotretinoin therapy. This testing includes serum blood lipid measurements, complete blood count, differential, liver enzyme tests and blood glucose levels and also includes a pregnancy test for women of child-bearing age.
Isotretinoin therapy should be initiated at a dose of 0.3-0.5 mg/kg/d and can be continued for 6-8 months or upto a maximum cumulative dose of 120-150 mg/kg. Co-administration with steroids at the onset of therapy may be useful in severe cases to prevent initial worsening. Some patients may respond to doses lower than the standard recommended dosages. Isotretinoin therapy needs to be carefully administered as the adverse affects of this therapy includes potential teratogenicity, hypertriglyceridemia and pancreatitis, hepatoxicity, blood dyscrasias, hyperostosis, premature epiphyseal closure and night blindness. Severe skin reactions such as erythema multiforme, Stevens–Johnson syndrome and toxic epidermal necrolysis have also been reported.
Physical Treatments and Alternative therapies for Acne
Comedone extraction can be done using cautery or diathermy (electrosurgery).
Intralesional steroid injections can be used to shrink older nodules and pseudocysts
High intensity, narrow-band blue light Photo-dynamic therapy can be used to treat severe acne
Microdermabrasion is helpful in treating mild acne.
Injectable fillers and laser resurfacing are used for acne scarring.
Cryotherapy (freezing treatment) may be useful to control new nodules.
Herbal therapies such as Tea tree oil is said to be effective in treating mild acne and also known to have preventive effects on future acne break outs. Some topical and oral Ayurvedic compounds also seem to be beneficial for some acne patients. However, there is not enough studies and data to prove their efficacy and safety in treating acne. One clinical trial shows that topical tea tree oil was effective but had a slower onset of action than traditional topical agents.