Medical Treatment of Acne (Part 2)

The actual medical treatment of acne has undergone significant changes in the last few years for several reasons.   Prolonged antibiotic use was common in the past as sole or adjunctive treatment. Recent research has changed attitudes for using antibiotics long-term because their use has been associated with increasing resistance of bacteria to antibiotics, making treatment of bacterial infections more difficult.  Their prolonged use has been found to increase patient’s chances of developing IBS – inflammatory bowel disease years later, especially tetracyclines. Additionally, the medical importance of the microbiome of the skin and gut is increasingly being appreciated in our general and immune health and even our mental health, especially depression.  Antibiotic use changes the natural microbiome balance in the skin and gut, adversely affecting our immune and psychological health and ability to handle and prevent infections.  Even with a week of antibiotics, it takes the microbiomes three weeks to be restored and ironically if one takes the wrong pre or probiotics to restore the microbiome sooner, it can take as long as a year for the microbiome to recover. (People’s Pharmacy, WUNC) The longer-term use of antibiotics can be even more devastating.  Topical antibiotics have fewer adverse effects on the microbiome because of limited areas of use and little if any absorption through skin. 

The emphasis on early and aggressive medical treatment has also become more mainline with the realization of the adverse effects acne can have on the quality of a sufferer’s life and with the recent studies showing that scars and all the effects acne scar formation cause, can be significantly improved and often prevented with early aggressive treatment. It was also felt that topical treatment for truncal acne was not as important. Recent research has dispelled this as well, showing that truncal acne also adversely affects quality of life and that topical treatment can work well to treat truncal acne. (Tan J, et al. J AM Acad Dermatol. 2019 Epub) Acne has multiple factors at work to cause clinical disease, so it has also become obvious that acne will respond better to treatment if it is attacked therapeutically at multiple points, instead of just one point by single therapy. There is no place for single agent treatment of acne anymore, with exception of Accutane generics

So how is acne treated? First asking about how acne affects one’s life, how long it has lasted, how often and much it breaks out, the family history, any hormonal effects on the acne outbreaks and any other important history, including hat has been used or prescribed for prior treatment.  Then the type of acne is assessed clinically, whether it is mild, moderate or severe, the areas involved and scar potential. 

The mainstay of treatment of mild to moderate acne is a retinoid like adapalene or retinoic acid which is both therapeutic and preventative.  For adults with acne, they also help reverse sun damage and reduce wrinkle progression.  They also reduce scar development and can help reverse mild scarring.  They are effective for both blackhead and papules, pustules.  Usually they are used with benzoyl peroxides which help reduce the propionobacteria acnes that are involved in acne causation.  Often a combination agent of a retinoid and benzoyl peroxide is used for once a day usage and convenience. The strength of the gents can be individualized for each patient.  Azelaic acid cream can be substituted for one of the agents when there is also a problem with post-inflammatory hyperpigmentation. Retinoic acid also can help fade over pigmentation.  Topical antibiotics can be used occasionally such as clindamycin and dapsone. 

Similar or the same topical agents can be used for moderate to severe acne both on the face and truncal areas that are affected clinically.  As the acne worsens, antibiotics will often be used for 3 to 4 months to stabilize and improve the acne, seldom longer.  In women, spironolactone or birth control pills (4 kinds are approved for acne) in place of antibiotics or with the antibiotics and continued for maintenance after the antibiotics are discontinued.  In men, the presentation of severe acne with cysts makes Accutane generics the treatment of choice.  It is the treatment of last resort in women with severe acne that does not respond to antibiotics or hormonal therapy.

When pregnant women have acne that needs treatment, benzoyl peroxide agents can be used safely, but retinoic acid, azelaic acid, antibiotic topicals and dapsone are contraindicated as are hormonal treatments and the more effective antibiotics.  Pregnant women with acne can often be treated with light and laser treatments or with photodynamic therapy treatments before a planned conception, because the remission is often a year or longer and lasts through a pregnancy.

Mild, moderate or severe acne can also be treated with many different devices – lasers, photodynamic therapy with levulan and laser light, infra-red light following gold particle massage, LED lights and others to be discussed in the next blog installment. Acne surgical lesional removals and numerous chemical peels that physician offices and spas offer or home use products.

It should be noted that effective benzoyl peroxide medications are available over the counter and recently an effective retinoic acid-like medicine, Differin, has become available OTC. 

Acne treatment can be very effective, especially if started early and aggressively.  It is also most effective when the patient is included in the treatment decision making process by your professional providing your skin care.