Acne Treatments

Overview

What is acne?

Acne is a chronic, recurrent inflammatory disease of the pilosebaceous unit (a skin pore, consisting of a hair follicle, a hair shaft, and a sweat (sebaceous) gland).  Three different processes come together to cause acne:

1. The stimulation of excess sweat (sebum) production by sex hormones (androgens)
2. Blocking of the pilosebaceous pores with a type of skin protein (known as keratin)
3. Colonization with bacteria (a specific type, known as acnes), which causes inflammation

Although people typically think of facial acne, it can essentially affect any area of the skin that has pilosebaceous glands, notably the face, neck, back, chest, and shoulders. Acne tends to occur in stages, and each stage is graded according to the severity of the acne:

• Grade 1: Comedomes – these can be open (“blackheads”) or closed (“whiteheads”). These occur when the pilosebaceous glands become plugged, but inflammation has not occurred.
• Grade 2: Inflammatory papules – small red bumps that form around the pilosebaceous gland, with redness around them.
• Grade 3: Pustules – papules that develop white, pus-filled tips.
• Grade 4: Nodulocystic acne – this is the worst form of acne, where pustules coalesce to form nodules (large bumps under the skin) and/or cysts (large pus-filled bumps under the skin). Nodulocystic acne can be quite painful, and can cause significant permanent scarring.

Acne causes

Although acne is caused by three factors (hormonal stimulation, keratin plugging, and bacteria), there are various factors that can bring on or worsen acne:

• Onset of puberty (due to sudden increases and fluctuations in sex hormones)
• Certain medications (such as lithium, steroids, and anti-seizure medications)
• Occlusive clothing (such as underwire bras, headbands, or backpacks)
• Certain hormone-related health disorders, such as polycystic ovarian syndrome
• Pregnancy
• Genetic factors (some inherited genes cause people to make sweat that is more likely to produce acne)
• Foods with a high glycemic index, such as dairy products (which also contain hormones), and junk food (yes, that includes chocolate)
• Oil-based make-up and facial products
• Pre-menstrual syndrome (PMS)
• Emotional arousal, such as anger and anxiety

What treatments are available?

There are a variety of treatments available for acne, and most cases can be managed very effectively. Treatments are of varying degrees of potency, and the choice of treatment depends on the severity of the acne. Generally, mild treatments are tried first, and then stronger treatments are chosen if the acne does not respond adequately. Treatments for acne may be topical (products or treatments that are applied directly to the skin) or systemic (oral medications). Different treatments may be combined, and it is common to combine treatments that each target a different cause of the acne. Each treatment targets one or more of the three specific causes of acne:

1. Keratin blocking of pilosebaceous pores. These dissolve the keratin protein that is blocking the pores (and they are therefore known as keratinolytics), and include:
   • Topical retinoids (retinoic acid, adapalene, and tretinoin)
   • Benzoyl peroxide (also a topical)
   • Combination of topical benzoyl peroxide and retinoids
   • Beta hydroxyl acids (topical) – such as salicylic acid
   • Azelaic acid (topical) – this dissolves keratin and also has antibiotic effects.
2. Excess sex hormone production. Agents that reduce the levels of circulating androgens, and regulate their production to avoid wild fluctuations:
   • Oral contraceptive pill (OCP) – this is an option for female patients
   • Oral spironolactone – can be used in males and females, but females must avoid pregnancy if they take this medication.
3. P. acnes bacteria. Antibiotic medications that kill or control the overgrowth of these bacteria help reduce the infection and inflammation that underlie acne. Antibiotic use can be used at varying doses depending on how active the acne is at any particular time, and includes:
   • Topical antibiotics, such as dapsone
   • Oral antibiotics, such as doxycycline or minocycline. An older medication called tetracycline is seldom used anymore, due to potential side effects.

An oral medication known as isotretinoin (Accutane®) is the ultimate medication used to treat acne. However, it is associated with a significant risk of a number of potentially serious side effects and can cause severe birth defects if a female takes it or even touches it while pregnant. Therefore, it is only used in extreme cases, such as when scarring would be likely if the acne wasn’t treated. Essentially, it is only used after all else has failed. Isotretinoin controls excess sebum production, reduces keratin production, and controls P. acnes bacteria.

Many of the topical keratinolytics are available over-the-counter, but still need to be used with caution, because they can cause significant skin irritation and redness. They should be tested on the skin for a short period and then washed off prior to using them.

Stronger topical agents and oral medications are available by prescription only. Treatments are often combined so as to target more than one of the three causes of acne. For example, a female patient with stubborn acne may be prescribed the OCP, an oral antibiotic, and a topical keratinolytic.

Cosmetic treatments options

There are a variety of cosmetic treatment options that can help combat acne and its effects, including chemical peels and microdermabrasion. However, cosmetic treatments are typically performed in conjunction with some other treatment modality to produce the best results. Several repeat treatments are usually required to produce optimal results. These are generally available from licensed and specially trained medical professionals, and include:

• Intense Pulsed Light (IPL) – IPL treatment involves the application of pulses of high-energy light at a specific wavelength to the skin. Studies have shown that IPL produces 34-88% improvement, depending on the type and severity of the acne.
• Photodynamic therapy – this involves applying IPL, LED, fluorescent, incandescent, or laser light to skin that has been pre-treated with a topical photosensitizer. Improvements of 70-80% have been reported.
• Laser therapy – several different types of lasers are used (particularly Nd:YAG and KTP lasers). They work by reducing sebum production, coagulating pilosebaceous glands, and destroying bacteria. Improvements of 70-84% have been reported.
• Photopneumatic therapy – gentle suction is applied to the skin while broadband pulsed light is applied. This is a new treatment modality that has yet to be properly evaluated, but success rates of 78-90% have been reported.
• Self-use devices – the FDA has approved several home-use devices for treating acne, such as a blue light device. These devices have not been well studied by proper rigorous investigations, but a patient satisfaction rate of 61% has been reported.

Acne scar removal

It is important to aggressively treat moderate to severe acne – especially nodulocystic acne – in order to prevent permanent scarring. Data vary, but about 85% of young people (age 12-24) get acne, 20% of young people will have moderate to severe acne, and about 50% of people with acne will have some kind of permanent scarring, ranging from mild skin pitting to severe depressions.

Once scarring has occurred, there are treatments available, but they usually have limited success (note for most of these procedures, very little research data is available rating results of treatment). These include:

• Platelet-rich plasma (PRP) – specific blood products are removed from your blood, and are applied to the scarred skin, either topically or under the skin. The blood products provide natural healing and growth factors to stimulate repair by depositing collagen. Reported results rated as “excellent” after three treatments are over 90%.
• Laser resurfacing – laser energy is applied to kill skin and stimulate new growth. Different types of lasers are used. There is usually significant down-time due to skin damage following these treatments. Learn more about laser skin resurfacing options.
• Subcision – needles are inserted under the scar and fanned around to break up the fibrous strands under the scar. 10-20% of patients experience moderate improvement.
• Dermabrasion – facial resurfacing technique that mechanically damages the skin by using a rotating brush to remove the top layer of skin. No data is available for efficacy.
• Microdermabrasion – microdermabrasion is a facial resurfacing technique that mechanically damages the skin, but not as deeply as dermabrasion. 18% of patients experience moderate improvement, and 9% good improvement.
• Microneedling – using a roller with multiple needles on it to puncture the skin multiple times to stimulate new growth and healing. Results in 40-50% improvement in skin texture, and 51-60% improvement in appearance.
• Dermal fillers – injection of gels under the skin that lift the skin up to reduce scar depth. Cosmetic dermal fillers are temporary (usually last 3-6 months).  Improvement is about 55%. Some fillers commonly used to treat acne scars include Bellafill, Juvederm, Radiesse and Restylane injections.
• Chemical peels – using abrasive chemicals to destroy the superficial layer of skin to promote new healing. About one quarter of patients report “excellent” results.

Cost of acne treatments

The cost of acne treatment varies drastically based on a number of factors, such as:

• The type of treatment
• Severity and surface area of the acne/scarring
• Geographical location
• The professional involved
• Number of treatments required

According to the American Society of Plastic Surgeons,  the following are the national average fees, per session:

• Chemical peel – $644
• IPL – $406
• Laser skin resurfacing – $1,201 – 1,963 (depending on the type of laser)
• Microdermabrasion – $136
• Dermal filler injections – $343 – 2,169 (depending on the filler product used)

Over-the-counter products can cost $20 to $60 per month, whereas prescription-based treatments may cost in excess of $200 per month.