Acne Scar Treatment

Scar revision
Many patients are very self-conscious about the pitted and craterlike scars that remain as a permanent record of previous inflammation. Some people will endure any procedure and spare no expense to rid themselves of the minutest scar. A variety of procedures is available to remove or revise scars. A dermatologic or plastic surgeon is best equipped to perform such procedures. Dermatologic surgeons are proficient at many innovative techniques to correct all types of acne scars.
Generally, it is advisable to wait until disease activity has been low or absent for several months. Scars improve with time as they become atrophied. The color contrast is often the most troublesome aspect of acne. Inflamed lesions may leave a flat or depressed red scar that is so obvious patients mistake the mark for an active lesion. The color will fade and approach skin tones in 4 to 12 months. The following techniques are those most commonly used for scar revision.
Dermabrasion.
Dermabrasion has been practiced for years and when performed correctly is a valuable technique for decreasing the depth of pitted scars. The epidermis and part of the dermis is planed away with a high-speed, motor-driven, finely abrasive brush or wheel. A major portion of the face may be treated during a single session. Reepithelialization takes 3 to 4 weeks. The procedure may have to be repeated one or two times to obtain optimum results. Adverse effects include the creation of additional scarring and permanent loss of pigment. The creation of hypopigmented areas is a common side effect, and for this reason many surgeons advise against using this technique for patients with dark skin.
Scar excision.
Many pitted scars are too deep to be planed by dermabrasion. These deep or "ice pick" scars may be excised and closed carefully with gratifying results. Some dermatologic surgeons remove the scars with a punch biopsy. The plug is removed and the scar is separated from the subcutaneous tissue. The remaining round core of fat and dermis is replaced in the round hole and held at the surface with a Steri-strip. The autograft is rapidly fibrosed into place, and the epidermis subsequently regenerates. There are many modifications of this technique.
Gelatin matrix collagen implant (Fibrel).
Fibrel is a porcine collagen suspension that is injected intradermally to correct depressed cutaneous scars. Fibrel is composed of absorbable gelatin powder (denatured collagen types I and III) and epsilon-aminocaproic acid (EAC) in a lyophilized form. Fibrel is reconstituted with equal amounts of the patient's plasma and 0.9% sodium chloride for injection. The reconstituted Fibrel suspension forms a fibrin network within a gelatin matrix, which initially restores the skin's contour. Over a period of months, the implant is colonized by the patient's own connective tissue cells.
Scars should be distensible by manual stretching of the scar borders. A custom needle is supplied with the Fibrel kit and is used for undermining fibrotic scars prior to injection. Improvement is maintained for up to 1 year in 85% of the treated scars. "Ice pick" or extremely fibrotic scars do not respond.
Bovine dermal collagen implants (Zyderm, Zyplast).
Zyderm and Zyplast are bovine collagen suspensions indicated for the correction of scars and wrinkles. A processing technique renders collagen nonantigenic and suitable for augmenting scars in humans (see Chapter Twenty-seven). Collagen is supplied in preloaded syringes for intradermal injection. Soft, distensible lesions with smooth margins are the most amenable to correction, whereas "ice pick" acne and tiny, punched lesions do not respond as well. Zyplast, a newer cross-linked collagen product, can be placed deeper than Zyderm. The duration of correction is shorter than that of Fibrel.

ACNE SURGERY

ACNE SURGERY: includes various surgical procedures used by the dermatologist or plastic surgeon for the treatment of acne and its complications.
An example of acne surgery is the manual removal of comedones and the drainage of pustules and cysts. When done correctly, acne surgery speeds resolution and rapidly enhances cosmetic appearance. Special instruments are used e.g. comedone extractors and a pointed-tip scalpel blade.
Comedones.
Removal of open comedones (blackheads) enhances the patient's appearance. By use of a special type of extractor, most comedones can easily be expressed with uniform, smooth pressure. Lesions that offer resistance are loosened and sometimes disengaged by inserting the point of a special blade into the blackhead and elevating. The orifice of the closed comedone must be enlarged before pressure can be applied. Following the angle of the follicle, the scalpel point is inserted with the sharp edge up approximately 1 mm into the tiny orifice. The blade is drawn slightly forward and up, then pressure is applied with the extractor to remove the sometimes surprisingly large quantity of soft, white material. Macrocomedones (whiteheads, microcystic acne) can also be treated with light cautery.
Pustules and cysts.
After the head of the white pustule is nicked with a special instrument, pustules are easily drained by pressing the material with the acne extractor. Cysts are preferably managed by intralesional injection because incision and drainage may cause scarring. Pustules and cysts that have a thin, effaced roof in which fluid contents are easily felt are drained through a small incision by manual pressure. To prevent scarring, a short incision (about 3 mm) should be made. After drainage, a special instrument may be inserted through the incision on the cyst in order to dislodge chunks of necrotic tissue.

Back Scrubbing

Gently cleanse and refresh hard-to-reach areas of your back
One of the hardest parts about taking a bath or shower is when it comes time to wash your back. It is virtually impossible to wash your entire back without some sort of assisting device. Usually people opt for clumsy brushes or sponges on the end of a stick because they are traditionally what is used for cleansing ones back. Even with these gadgets it is difficult to do a decent job of washing, the areas cleaned are hit-or-miss, and you are also forced to do a lot of reaching.
Scrub and clean your entire back without straining
An ideal scrubber should be easy to use, clean hard-to-reach places of your back, scrubbing your entire back without contorting yourself, cleaning and exfoliating at the same time and leaving your skin feeling soft and refreshed.
Adding length and angulation to handles makes a scrubber more flexible and convenient.
Exfoliating back skin, while massaging can improve circulation.
Loofah with its natural fibres can be used to stimulate circulation, deeply cleans the pores and gently rub away dead skin. You can use your favorite body soap applied to Loofah, then rinse thoroughly and remove all soap.

Acne on back lesions

Acne on back lesions
Virtually universal in the middle to late teenage years, acne on back affects both males and females, although males tend to have more severe disease. Acne is seen in all races, but it is said to be milder in people of Asian descent. Acne on back in adolescents is believed to occur as a result of physiologic hormonal variations and alterations in hair follicle maturation. The clinical features of acne may be induced or exacerbated by drugs (corticosteroids, adrenocorticotropic hormone, testosterone, gonadotropins, contraceptives, trimethadione, iodides, and bromides), occupational contactants (cutting oils, chlorinated hydrocarbons, and coal tars), and occlusive conditions such as heavy clothing and tropical climates. Some families seem to be particularly affected by acne, suggesting a heritable factor..
Acne on back is divided into noninflammatory and inflammatory types, although both may coexist. The former consists of open and closed comedones. Open comedones consist of small follicular papules containing a central black keratin plug. This color is the result of oxidation of melanin pigment (not dirt). Closed comedones are follicular papules without a visible central plug. Because the keratin plug is trapped beneath the epidermal surface, these lesions are potential sources of follicular rupture and inflammation. Inflammatory acne is characterized by erythematous papules, nodules, and pustules. Severe variants (e.g. acne conglobata) result in sinus tract formation and physical scarring, in addition to the emotional scars.

MORPHOLOGY.
Comedones form as an expanding mass of lipid (sebum) and keratin within the midportion of the hair follicle. With gradual expansion, the follicle becomes dilated and the follicular epithelium and sebaceous glands atrophy. Resultant open comedones have large, patulous orifices, whereas those of closed comedones are identifiable only microscopically. Variable lymphohistiocytic infiltrates are present in and around affected follicles, and extensive acute and chronic inflammation accompanies follicular rupture. Dermal abscesses may form in association with rupture, and gradual resolution, often with scarring, ensues.

The pathogenesis of Acne
Endocrine factors have been implicated (especially androgens) because castrated persons never develop the condition. However, these do not appear to be the sole or primary cause. It has been postulated that bacterial lipases of Propionibacterium acnes break down sebaceous oils, liberating highly irritating fatty acids resulting in the earliest inflammatory phases of acne. Inhibition of lipase production is a rationale for administration of antibiotics to patients with inflammatory acne. The synthetic vitamin A derivative 13- cis-retinoic acid (isotretinoin) has brought about remarkable clinical improvement in some cases of severe acne.

Acne Treatment, Systemic Therapy, Isotretinoin

ISOTRETINOIN

The use of the oral retinoid, isotretinoin, has revolutionized the management of severe treatment-resistant acne. Isotretinoin, like vitamin A, produces side effects, which are not usually severe enough to necessitate interruption of therapy in most cases.
The remarkable aspects of isotretinoin therapy are the completeness of the remission in almost all cases and the longevity of the remission, which lasts for months to years in the great majority of patients.
Isotretinoin therapy, for all practical purposes, is always accompanied by side effects that may mimic those seen in the chronic hypervitaminosis A syndrome. Thus, side effects related to the skin and mucous membranes are most common. Cheilitis of varying degrees is found in almost all cases. Other side effects that are likely to be seen in over 50 percent of patients are dryness of the mucous membranes, xerosis, conjunctivitis, and pruritus. Side effects seen with lesser degrees of frequency include bone and joint pain; thinning of hair; headache and accompanying symptoms associated with increased intracranial pressure; palmoplantar desquamation; and nausea and vomiting.
The laboratory abnormalities that have occurred include elevations in triglycerides, erythrocyte sedimentation rate, platelet count, liver function tests, and white blood cells in the urine and decreases in red blood cell parameters, white cell counts, and high-density lipoprotein levels. The elevation of triglycerides, which is dose-related, is of particular concern because it is often accompanied by a decrease in the high-density lipoprotein levels, which may increase the risk of coronary artery disease.
There are also reports of the development of bony hyperostoses after isotretinoin therapy, but these are more likely to be seen in patients who receive the drug for longer periods of time in higher dosages for diseases of keratinization.
The issue of isotretinoin and psychiatric effects has come to the forefront. From 1982 to May 2000, 37 cases of suicide, 110 cases of hospitalized depression, suicidal ideation or suicide attempt, and 284 cases of nonhospitalized depression in patients on isotretinoin were reported to the FDA's Adverse Event Reporting System. In one population-based cohort study comparing isotretinoin users with oral antibiotic users, the relative risk for development of depression or psychosis was approximately 1.0, indicating no increased risk. Further studies are needed to resolve this issue of causality. Until then, a careful review for signs and symptoms of depression and suicidal ideation should be performed in all patients for whom isotretinoin therapy is considered, and the patients must be carefully monitored during therapy.
Studies show that some of the side effects are dosage related. These same studies demonstrate that clinical results can be obtained with dosages as low as 0.1 mg/kg per day. However, with such dosages, the incidence of relapses after therapy is greater. The recommended daily dosage of isotretinoin is in the range of 0.5 to 1 mg/kg per day. Because back and chest lesions show less of a response than facial lesions, dosages as high as 2 mg/kg per day may be necessary in those patients who have very severe trunk involvement. Patients with severe acne, particularly those with granulomatous lesions, will often develop marked flares of their disease when isotretinoin is started. Therefore, the initial dosing should be low, even below 0.5 mg/kg per day. These patients often need pretreatment for 1 to 2 weeks with prednisone (40 to 60 mg per day), which may have to be continued for the first 2 weeks of therapy. Isotretinoin is usually given for 20 weeks, but the length of the course of treatment is not absolute; in patients who have not shown an adequate response, therapy can be extended, if necessary. Some improvement is usually seen for 1 to 2 months after isotretinoin is discontinued, so that total clearing is not a necessary endpoint for determining when to discontinue therapy. Approximately 10 percent of patients treated with isotretinoin require a second course of the drug. The likelihood for repeat therapy is increased in patients younger than 16 to 17 years of age. It is best to allow at least 2 to 3 months between courses of isotretinoin. Studies suggest that the chances of inducing a long-term remission are greatest if the patient has received a total dose of 120 to 150 mg/kg of isotretinoin during a course of therapy.
Isotretinoin should be used only in those patients with severe acne. Furthermore, laboratory monitoring is indicated. It is appropriate to obtain a baseline complete blood count and liver function tests, but the greatest attention should be paid to following serum triglyceride levels. Baseline values for serum triglycerides should be obtained and repeated at 3 to 4 weeks and 6 to 8 weeks of therapy. If the values are normal at 6 to 8 weeks, there is no need to repeat the test during the remaining course of therapy unless there are risk factors. If serum triglycerides increase above 500 mg/dL, the levels should be monitored frequently. Levels above 700 to 800 mg/dL are a reason for interrupting therapy or treating the patient with a lipid-lowering drug such as gemfibrozil. Eruptive exanthemas or pancreatitis can occur at higher serum triglyceride levels. In rare instances, exuberant granulation tissue has appeared in some lesions. If this occurs, the dosage of drug may have to be decreased or the drug may have to be discontinued. Glucocorticoids may have to be administered either systemically or intralesionally to control the granulation tissue.
The greatest concern during isotretinoin therapy is the risk of the drug being administered during pregnancy and thereby inducing teratogenic effects in the fetus. The drug is not mutagenic; its effect is on organogenesis. Therefore, the production of retinoic embryopathy occurs very early in pregnancy, with a peak near the third week of gestation. Theoretically, based on animal studies and the pharmacokinetics of the drug, there should be more safety in the use of isotretinoin than either vitamin A or etretinate. However, that is not the case, and a significant number of fetal abnormalities have been reported after the use of isotretinoin. For this reason, it should be emphasized that isotretinoin should be given only to patients who have not responded to other therapy. Furthermore, women who are of childbearing age must be fully informed of the risk of pregnancy. The patient must either avoid sexual exposure totally or should employ two highly effective contraception techniques such as the use of an oral contraceptive and condoms with a spermicidal jelly. Contraception must be started at least 1 month before isotretinoin therapy. The patient must have a negative serum pregnancy test at the time when therapy is decided upon and on the second or third day of the next menstrual period or 11 days after the last unprotected intercourse in a woman who is amenorrheic. The woman must thoroughly understand the contraception techniques she is using and continue them throughout the course of isotretinoin and for 1 month after stopping treatment. No more than 1 month's supply of drug should be given to a female patient so that she can be counseled on a monthly basis on the hazards of pregnancy during isotretinoin therapy. The pregnancy test should be repeated monthly to maintain patient awareness. The manufacturer and the FDA have recently instituted a verification process requiring that authorization stickers be affixed to prescriptions to insure that pregnancy-prevention procedures are followed. As stated above, retinoic acid embryopathy results from the effect of isotretinoin on early organogenesis. Therefore, because the drug is not mutagenic, there is no risk to a fetus conceived by a male who is taking isotretinoin. Although it may seem obvious, it is important to remind men who are taking isotretinoin not to give any of their medication to female companions under any circumstances.
The mechanism of action of isotretinoin is not completely known. The drug produces profound inhibition of sebaceous gland activity, and this undoubtedly is of great importance in the initial clearing. In some patients, sebaceous gland inhibition continues for at least a year, but in the majority of patients, sebum production returns to normal after 2 to 4 months. Thus, this action of the drug cannot be used to explain the long-term remissions. The P. acnes population is also decreased during isotretinoin therapy, but this decrease is not often long lasting. Isotretinoin has no inhibitory effect on P. acnes in vitro. Therefore, the effect on the bacterial population is probably indirect, resulting from the decrease in intrafollicular lipids necessary for organism growth. Isotretinoin also has anti-inflammatory activity and probably has an effect on the pattern of follicular keratinization. Once again, it has not been demonstrated that these effects are long lasting. Thus, while the drug may influence the course of severe acne through several different mechanisms, the explanation for the long-term remissions remains obscure.

Acne Treatment, Systemic Therapy, Hormonal

Hormonal therapy of acne

Sebum secretion is increased by agents with androgenic activity, including synthetic anabolic steroids, and decreased by agents that counteract or interfere with androgen action, namely estrogens and antiandrogens. The goal of hormonal therapy is to counteract the effects of androgens on the sebaceous gland. This can be accomplished with the use of estrogens, antiandrogens, or agents designed to decrease the endogenous production of androgens by the ovary or adrenal gland, including oral contraceptives, glucocorticoids, or gonadotropin-releasing hormone (GnRH) agonists.

ESTROGENS

Any estrogen given in sufficient amounts will decrease sebum production. The dose of estrogen required to suppress sebum production, however, is greater than the dose required to suppress ovulation. Although some patients will respond to lower-dose agents containing 0.035 to 0.050 µg of ethinyl estradiol or its esters, higher doses of estrogen are often required. If estrogen therapy is indicated and if the physician is unfamiliar with its usage or side effects, it is best to work with a gynecologist. Breast examinations and Pap smears are recommended for women receiving estrogen therapy. The incidence of more serious side effects such as clotting and hypertension that follow the use of estrogens is, fortunately, rare in young healthy females. Nevertheless, the physician and patient should be aware of the possibilities, and the risk/benefit ratio should be carefully considered before undertaking estrogen therapy. Although the use of estrogen therapy for acne has decreased dramatically since oral isotretinoin has been available, there are specific patients in whom its use is still appropriate. As mentioned below, estrogens can be used in combination with glucocorticoids.

ORAL CONTRACEPTIVES

With the use of estrogen-progestin-containing oral contraceptives rather than estrogen alone, side effects such as delayed menses, menorrhagia, and premenstrual cramps are uncommon. However, other side effects such as nausea, weight gain, spotting, breast tenderness, amenorrhea, and melasma can occur. The third-generation progestins, desogestrel, norgestimate, and gestodene (not available in the United States), have the lowest intrinsic androgenic activity. Two oral contraceptives are currently FDA approved for the treatment of acne (Ortho Tri-Cyclen and Estrostep). Ortho Tri-Cyclen is a triphasic oral contraceptive comprised of a norgestimate-ethinyl estradiol (35 µg) combination. In an effort to reduce the estrogenic side effects of oral contraceptives, preparations with lower doses of estrogen (20 µg) have been developed and are being studied for the treatment of acne. Estrostep contains a graduated dose of ethinyl estradiol (20 to 35 µg) in combination with norethindrone acetate. An oral contraceptive containing a low dose of estrogen (20 µg) in combination with levonorgestrel (Alesse) has also demonstrated efficacy in acne. Side effects from oral contraceptive use include nausea, vomiting, abnormal menses, weight gain, and breast tenderness. Rare but more serious complications include thrombophlebitis, pulmonary embolism, and hypertension.

GLUCOCORTICOIDS Because of their anti-inflammatory activity, high-dose systemic glucocorticoids may be of benefit in the treatment of acne. In practice, their use is usually restricted to the severely involved patient. Furthermore, because of the potential side effects, these drugs are ordinarily used for limited periods of time, and recurrences are common after therapy is discontinued. Prolonged use may result in the appearance of steroid acne. Glucocorticoids in low dosages are also indicated in those female patients who have an elevation in serum DHEAS associated with an 11- or 21-hydroxylase deficiency or in other individuals with demonstrated androgen excess. Low-dose prednisone (2.5 mg or 5 mg) or dexamethasone can be given orally at bedtime to suppress adrenal androgen production. The combined use of glucocorticoids and estrogens has been used in recalcitrant acne in women, based upon the inhibition of sebum production by this combination. The mechanism of action is probably related to a greater reduction of plasma androgen levels by combined therapy than is produced by either drug alone.

GONADOTROPIN-RELEASING HORMONE AGONISTS GnRH agonists act on the pituitary gland to disrupt its cyclic release of gonadotropins. The net effect is suppression of ovarian steroidogenesis in women. These agents are used in the treatment of ovarian hyperandrenogenism. GnRH agonists have demonstrated efficacy in the treatment of acne and hirsutism in females both with and without endocrine disturbance. Their use, however, is limited by their side-effect profile, which includes menopausal symptoms and bone loss.

ANTIANDROGENS Cyproterone acetate is a progestational antiandrogen that blocks the androgen receptor. It is combined with ethinyl estradiol in an oral contraceptive formulation that is widely used in Europe for the treatment of acne. Cyproterone acetate is not available in the United States. Spironolactone functions both as an androgen receptor blocker and inhibitor of 5a-reductase. In doses of 50 to 100 mg twice a day, it has been shown to reduce sebum production and to improve acne. Side effects include potential hyperkalemia, irregular menstrual periods, breast tenderness, headache, and fatigue. As an antiandrogen, there is a risk of feminization of a male fetus if this medication is taken by a pregnant female. Risk to a fetus and the symptoms of irregular menstrual bleeding can be alleviated by combining spironolactone treatment with an oral contraceptive. Flutamide, an androgen receptor blocker, has been used at doses of 250 mg twice a day in combination with oral contraceptives for treatment of acne or hirsutism in females. Liver function tests should be monitored as cases of fetal hepatitis have been reported. Pregnancy should be avoided. Use of flutamide in the treatment of acne may be limited by its side effect profile.

ENZYME INHIBITORS The development of 5a-reductase inhibitors, such as finasteride, that block the conversion of testosterone to DHT in the prostate suggested the possibility of an approach to interfering with androgen action on the sebaceous glands that would be appropriate for use in males. However, finasteride does not inhibit sebum secretion. Its lack of action is attributed to the existence of two different 5a-reductases, with the enzyme in the prostate being blocked by the drug while that in the skin is unaffected. Specific inhibitors of the type 1 5a-reductase are being developed. If these agents reduce sebum production, they may be efficacious in the treatment of acne.

Acne Treatment, Systemic Therapy, Antibiotics

SYSTEMIC THERAPY Over the years, many different agents have been used systemically. The major systemic modalities that are currently being used include antibiotics and antibacterial agents, hormones, and an oral synthetic retinoid.

Antibiotics and antibacterial agents

Currently, the broad-spectrum antibiotics are widely used in the treatment of acne. Although the oral administration of tetracycline does not alter sebum production, it does decrease the concentration of free fatty acids while the esterified fatty acid content increases. This decrease in free fatty acids is seen with dosages ranging from 250 mg/day to 1 g/day. The free fatty acids are probably not the major irritants in sebum, but their level is an indication of the metabolic activity of the organism and its secretion of other proinflammatory products. The decrease in free fatty acids may take several weeks to become evident. This, in turn, is reflected in the clinical course of the disease during antibiotic therapy, as several weeks are often required for maximal clinical benefit. The effect, then, is one of prevention; the individual lesions require their usual time to undergo resolution. However, the fact that a decrease in free fatty acids does occur strengthens the rationale for the use of tetracycline. Tetracycline may act through direct suppression of the number of P. acnes, but part of its action may also be due to its anti-inflammatory activity. Decreases in free fatty acid formation also have been reported with erythromycin, demethylchlortetracycline, clindamycin, and minocycline. Most studies support the efficacy of tetracycline and its derivatives in the treatment of acne. In clinical practice, tetracycline is usually given initially in dosages of 500 mg/day to 1000 mg/day. While the dose is often decreased as improvement occurs and may be continued at a level of 250 mg/day or less, there is increasing concern that this may generate resistant strains. Tetracycline should be taken on an empty stomach to promote absorption. Erythromycin has been used in the past in patients who have difficulty in taking tetracycline on an empty stomach, but there is increasing evidence of the development of erythromycin-resistant strains of P. acnes from both the topical and systemic use of erythromycin. Therefore, it is wise to limit the use of oral erythromycin to those cases where tetracyclines are contraindicated, that is, in pregnant women and young children. Increasingly, doxycycline and minocycline are being used as alternatives for tetracycline or in tetracycline-unresponsive cases. These two drugs appear to be more effective than tetracycline, and drug resistance is less likely to occur, especially with minocycline. Doxycycline should be administered in dosages of 50 to 100 mg twice daily. The major disadvantage of the use of doxycycline is that it can produce photosensitivity reactions, and patients should be switched to another antibiotic, if possible, during the summer months. Minocycline is given in divided dosages at a level of 100 mg/day to 200 mg/day. Patients on minocycline should be monitored carefully as the drug can cause blue-black pigmentation, especially in the acne scars, as well as the hard palate, alveolar ridge, and anterior shins. Minocycline-induced autoimmune hepatitis and a systemic lupus erythematosus-like syndrome have been reported during minocycline therapy, but to date, these side effects are very rare. Oral clindamycin has been used in the past, but because of the potential of pseudomembranous colitis, it is now rarely used for acne. Although long-term, low-dosage antibiotic therapy is often continued for many months, very few side effects have been observed. Tetracyclines have an affinity for rapidly mineralizing tissues and are deposited in developing teeth, where they may cause irreversible yellow-brown staining; also, tetracyclines have been reported to inhibit skeletal growth in the fetus. Therefore, they should not be administered to pregnant women, especially after the fourth month of gestation, or to babies. The tetracyclines also should not be given to children younger than 8 years of age. The only safe antibiotic to administer to pregnant women or children is erythromycin. A rare complication, but one that can easily be missed, is the development of a gram-negative folliculitis. With prolonged antibiotic therapy, gram-negative organisms may proliferate in the anterior nares and spread out onto the surrounding skin. The physician should be alerted to this diagnosis if there is a sudden flare with pustules or nodules in a patient who is otherwise improving. Two types of lesions are seen. Most commonly there are multiple pustules with an intense inflammatory areola. This type of lesion is often caused by Enterobacter or Klebsiella. The patient may also have deep indolent nodules from which Proteus organisms are most often isolated. Culture confirmation is necessary, and antibiotic therapy should be governed by the results of sensitivity studies. Ampicillin is often the antibiotic of choice. Patients who do not show a response to antibiotics should be treated with a full course of isotretinoin . Tetracycline in dosages ranging from 1500 mg/day to 3500 mg/day has been used in patients with very severe acne. The results of this form of therapy are encouraging, particularly because the treated patients have otherwise been resistant to therapy. Patients under treatment with high-dose tetracycline should be carefully monitored with frequent laboratory evaluation. Trimethoprim-sulfamethoxazole combinations are also effective in acne. In general, because the potential for side effects is greater with their use, they should be used only in patients with severe acne who do not respond to other antibiotics. If trimethoprim-sulfamethoxazole is used, the patient must be monitored for potential hematologic suppression approximately monthly.

Acne Treatment : Local Procedures

ACNE SURGERY This modality, used for the removal of comedones and superficial pustules, aids in bringing about involution of individual acne lesions. Acne surgery was a mainstay of therapy in the past. However, with the advent of comedolytic agents such as topical vitamin A acid, it is not needed as often. Its use is primarily restricted to those patients who do not respond to comedolytic agents. Even in those patients, the comedones are removed with greater ease and less trauma if the patient is treated first with topical vitamin A acid or a similar topical agent for 3 to 4 weeks. This pretreatment should be done in all patients who are going to undergo mechanical comedo removal. Acne surgery is helpful only when properly done, and inaccurate placement of the comedo extractor may serve only to push the inflammatory material further into the skin. Therefore, it is inadvisable to have the patient do acne surgery at home. The Unna type of comedo extractor, which has a broad flat plate and no narrow sharp edges, is preferable. The removal of open comedones does not materially influence the course of the disease because these lesions do not become inflammatory. However, it is desirable to remove them for cosmetic purposes. In contrast, closed comedones should be removed to prevent their rupture. Unfortunately, the orifice of closed comedones is often very small, and usually the material contained within the comedo can be removed only after the orifice is gently enlarged with a no. 25 needle or other suitable sharply pointed instrument.
INTRALESIONAL GLUCOCORTICOIDS Intralesional injection of glucocorticoids, either by the use of a syringe or by the use of an automatic needleless injector, usually dramatically decreases the size of deep nodular lesions. The injection of 0.05 to 0.25 mL per lesion of a triamcinolone acetate suspension (2.5 to 10 mg/mL) is recommended as the anti-inflammatory agent. This is a very useful form of therapy in the patient with nodular acne, but it often has to be repeated every 2 to 3 weeks. A major advantage is that it can be done without incising or draining the lesions, thus avoiding the possibility of scar formation.

Acne Treatment : local therapy

LOCAL THERAPY

Cleansing
There is no evidence that either surface sebum or surface bacteria aggravates acne. Therefore, in order for a soap or topical antibacterial agent to be of aid in the therapy of acne, the topical agent would have to remove the lipids or the bacteria (or both) from within the follicle. Certainly, the action of a soap will not remove open or closed comedones. Any dermatologist can readily describe cases of acne that he or she has seen in compulsive washers. It would appear that washing as a therapeutic measure is often overemphasized, but many acne patients do not have a pronounced seborrhea, and washing or cleansing to remove this excessive oil, if not overdone, provides subjective benefit.

Topical agents
Topical therapy of acne has undergone periodic change. Many years ago, empirical reliance was placed on the use of sulfur- and resorcinol-containing products, and to a degree, they are still used in the over-the-counter market. Their mechanism of action has not been defined. Products containing salicylic acid, a keratolytic agent, have also enjoyed some popularity. However, the major topical agents now in use are retinoids and antimicrobials such as benzoyl peroxide and topical antibiotics.

Topical retinoids, such as tretinoin and tazarotene, and agents with retinoid activity, such as adapalene, are used extensively for their comedolytic activity. These agents can be irritants; in general, the order of irritancy increases as one progresses from the use of cream preparations to gels to the solution. Most patients can use low-potency tretinoin or adapalene cream daily without developing an irritant reaction. Patients must also be cautioned about sun exposure, because an exaggerated burn may follow what previously was an easily tolerated sun exposure. Unlike tretinoin, adapalene and tazarotene are specific for a subset of retinoic acid receptors (RARs). These two drugs selectively activate RAR-ß and RAR-, but not RAR-a receptors. The binding of these agents to nuclear retinoic acid receptors affects the expression of genes involved in cell proliferation, cell differentiation, and inflammation. At the cellular level, the result may be a modification of several acne pathogenic factors, including corneocyte accumulation and cohesion, and inflammation. Topical retinoids are comedolytic, and reversal of the altered pattern of follicular keratinization has been seen at an ultrastructural level. Epidermal cell turnover is increased in comedones.

Salicylic acid is also comedolytic but is not as effective as topical retinoids.

Benzoyl peroxide preparations are among the most common topical medications prescribed by dermatologists, and benzoyl peroxide is a major therapeutic agent in the over-the-counter acne market. Benzoyl peroxide is a powerful antibacterial agent, and its effect is probably related to a decrease in the bacterial population and an accompanying decrease in the hydrolysis of triglycerides. Benzoyl peroxide preparations are available in both lotion and gel forms, the latter generally being considered more active. The compound can produce significant dryness and irritation, and allergic contact dermatitis has occurred, but this is an uncommon event.

Topical antibiotics are also used for the treatment of acne, the most popular preparations containing erythromycin or clindamycin. These two agents have also been used in combination preparations with benzoyl peroxide. Increased levels of P. acnes resistance have been reported in patients who are being treated with antibiotics. However, the development of resistance is less likely in patients who are treated with a combination of benzoyl peroxide/erythromycin or clindamycin, these combination products are preferable over topical antibiotics alone. Another topical agent is a cream containing 20% azelaic acid.

Azelaic acid is a naturally occurring dicarboxylic acid found in cereal grains. It is available as a topical cream, which is effective in inflammatory and comedonal acne. The activity of azelaic acid against inflammatory lesions may be greater than its activity against comedones. Azelaic acid is applied twice daily and its use is reported to have fewer local side effects than topical retinoids. In addition, it may help to lighten postinflammatory hyperpigmentation. Because comedolytic agents, such as topical retinoids or salicylic acid, and antimicrobial agents, such as benzoyl peroxide or antibiotics, have different modes of action, they are often used together in an individual patient. However, they should be applied at separate times.

Acne Treatment

Acne Treatment
The determination of the therapeutic efficacy of medications used in acne is not a simple task, and it is possible to find many favorable therapeutic reports for agents that are obviously of little value in the treatment of acne. In this post, no attempt is made to be all-inclusive; only the more commonly used or useful modalities are discussed.
In general, there are four major principles governing the therapy of acne, and the individual therapeutic modalities listed below are related to these principles, where possible. These principles are: (1) correct the altered pattern of follicular keratinization; (2) decrease sebaceous gland activity; (3) decrease the follicular bacterial population, particularly the P. acnes population, and inhibit the production of extracellular inflammatory products (either directly or indirectly) by inhibiting the bacterial organisms; and (4) produce an anti-inflammatory effect. The first of these treatment principles, namely, changing the altered pattern of follicular keratinization, should be the primary form of therapy in noninflammatory acne; the rest of the modalities are primarily designed for use in inflammatory acne. Nonetheless, because altered follicular keratinization is the starting point for the development of inflammatory acne, therapy directed at this abnormality also should be of value in inflammatory acne.