Acne Development – Medication for acne & its potential side effects

Acne is a condition that affects the sebaceous follicles & hair follicles of the skin. It is a genetic condition causing the malfunction of the pilo-sebaceous unit characterized by many lesions, from comedones (blackheads) to pustules & cysts.

Development of Acne

An accumulation of dead skin cells & sebum (oil) builds up in the follicle; when there is lack of thick hairs to wick it out, this clogs the pores.

Sebaceous Gland (Sweat Gland)

The sebaceous gland is attached to two types of follicles the hair follicle & a sebaceous follicle. This gland is under the influence of the hormone testosterone, which is stimulated at puberty. In acneic skin the enzyme 5 alpha reductase turns too much testosterone into Di-hydrotestosterone, which increases sebum (oil) production.

Skin Cells

Acne sufferers produce 4 to 5 times more skin cells and also have fewer lamellar granules which are responsible for allowing skin cells to shed, therefore allowing an accumulation of excess skin cells within the follicles.

So there is an overproduction of dead skin cells sticking together with the overproduction of sebum, which is then retained in the follicle & on the surface of the skin, which all contributes clogging the pores.

Propioni Bacterium Acnes

Propioni bacteria is present in all skins , however in acne skin this bacteria feed on the sebum & produce a fatty acid waste product which irritates the lining of the follicle & causes inflammation & swelling of the follicle.

Acne Triggers

Stress
Stress can increase testosterone, which leads to an increase in oil production

Cosmetics
One in three acne sufferers are triggered by cosmetics. Some cosmetics contain ingredients that clog the pores, & some comedogenic (Pore clogging) ingredients can penetrate the hair follicle causing irritation, which stimulates oil production. It is very important to check that cosmetics don’t contain comedogenic ingredient i.e. F D & C colorings, found in most blushers & bronzing powders, isopropyl myristat, lanolin & mineral oil (parafinum liquidum).

Environment
Sun exposure can aggravate acne conditions. The sun irritates & damages the skin. To protect itself from the sun’s UV damaging rays, the skin produces excess skin cells, which build up within the follicle & on the surface of the skin, this leads to clogged pores in Acne sufferers.

Everyone has propioni bacteria present on their skin, which is normal however in acne sufferers the immune system rejects these bacteria.

Acne is an auto-immune response to the naturally occurring propioni bacteria on the skin, meaning the immune system rejects this bacterium in an acne sufferer, causing inflammation.

The sun suppresses the immune system allowing the skin to briefly accept the propioni bacteria giving short-term relief to the acne sufferer.

However due to the sun suppressing the immune system the white blood cells that fight infection are also suppressed, therefore limiting the skins ability to fight acne breakouts.

Pollution
Ground level ozone reduces vitamin E in our skin, which limits our natural protective defenses. Two hours skin exposure on a smoggy day reduces vit E by 25%.

Hormones
Fluctuations in hormones can cause flare-ups. An increase in testosterone increases oil flow, whereas an increase in oestrogen decreases oil production.

Friction
Friction & trauma to the skin can stimulate oil flow. e.g. policemen’s helmets, mobile phones. Remove the cause to eliminate problem.

Heat & Humidity
Increases oil flow i.e. chefs (an increase of 1 degree of heat produces 10% more oil.

Industrial Oils (Mechanics, dusty oily environments)
Hydro-carbonated oils are acnegenic. Extra cleansing necessary.

Diet
Increased sugar can interfere with insulin production, causing hormone imbalance leading to an acne breakout. However diet only effects 5% of acne sufferers & is not a large contributing factor.

Medications for Acne

Isotretinoin (Accutane/Roaccutane)

Used for severe acne. It is a retinoid, vitamin A derivative that reduces oil production.
Form: capsule
Treatment Duration: 15 to 20 weeks
Dose: Depends on weight of patient & severity
Requirement: Take after food as is fat soluble vitamin

Drawbacks:

  • Can cause DISH (Diffuse interstitial skeletal hyperostosis) which may result in aching discomfort which does not resolve after discontinues use.
  • Changes in liver function, so regular checks necessary during use.
  • Dries out mucous membranes; dry nose & eyes, dry cracked lips, dry & fragile skin, increases skin redness & sunburn, hair loss.
  • Headaches, lethargy, & vision problems (like night blindness & slow adaptation to the dark), are all common complaints in isotretinoin patients.
  • Mood changes, depression, suicidal thoughts & attempts.
  • Females must sign a consent form prior to taking accutane that they must not become pregnant while on the drug or for a month after stopping using it, as it causes foetal abnormalities.
  • It should not be used by breast feeding mothers as it can enter the breast milk.
  • Patients should not donate blood while using it & also for one month after stopping its use, as it could be given to a pregnant woman.
  • Alcohol consumption should be limited during its use, due to its toxic levels on the liver.
  • Anaemia needs to be checked for regularly during its use.

Isotretinoin

Form: Topical gel called Isotrex
Action: Assists in shedding excess skin cells that clog pores.
Treatment Duration: 6-8 WEEKS
Unsuitable For: Pregnant women
Requirement: Daily sunscreen essential or avoid sun exposure

Both Retin A & Accutane are Derivitaves of Vit a which increases cell turnover & also shrinks oil glands. Accutane is an oral drug so side effects affect full body, but Retin A is a topical cream/gel used locally.

Oral Antibiotics

Inhibits bacteria which decrease inflammation.
Common Acne Antibiotics: Erythromycin, Minocycline, Doxycycline, Tetracycline
Side Effects: Photosensitivity, upset stomach, dizziness, & skin discoloration, drug resistance, & yeast infections in women.
Treatment Duration: 6-8 weeks for significant benefit & 4-6 months to treat.

Oral Contraceptives

Predominantly oestrogen based which decreases testosterone & gonadotrophin hormones.
Prescribed When: Women don’t respond to antibiotics
Function: Reduce sebum (oil) production by up to 25%
Treatment Duration: 3 – 4 months to see significant results.

Topical Preparations

Tretinoin (Retinoic acid & Retin A)
Function: Prevents build up of skin cells that block the pores
Side Effects: Irritation, redness, dryness, excessive peeling, hypersensitivity, oedema (swelling), blistering, increased sensitivity to sunlight. Hypopigmentation in darker skins
Treatment Duration: 3-6 months

Azelaic Acid

A natural material produced by yeast that lives on normal skin
Form: Topical treatment
Type of Acne: Mild to moderate
Function: Antibacterial & anti inflammatory
Combined: Can be used in conjunction with oral antibiotics or hormonal therapy.
Advantages: Can reduce pigmentation in dark skins that can result from acne
Disadvantage: sensitive skins can develop mild irritant dermatitis
Treatment Duration: Once daily initially till tolerance has built up, then twice daily. Improvement seen after one month, maximum benefits after 6 months.

Adapalene Gel (also known as Differin)

A smooth white gel containing 1mg adapalene, which is a new retinoid-like compound.
Treatment Duration: 12 weeks
Drawbacks: Redness, scaling, dryness, severe itchiness, & burning occurs in 10%-40% of patients. Condition can worsen before improving.
Application: Once daily in evening after washing.
Requirement: Daily sunscreen necessary, as it increases photosensitivity

Topical Antibiotics

Advantage: localized use
Effectiveness: Debatable
Most Popular Ones: Erythromycin & Clindamycin
Treatment Duration: 4-6 weeks, which can be extended if positive results show & no skin irritation is apparent.
Combined Use: Can be used in conjunction with benzoyle peroxide for increased effectiveness.( i.e. BP 5% & Erythromycin 3%).


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