Acne Treatment Requires a Stepwise Process

Acne vulgaris is a global concern that affects 650 million individuals, making it the eighth most prevalent disease and the most frequent reason for dermatologist appointments.^1,2 This chronic, relapsing/remitting inflammatory disease of the pilosebaceous unit affects more than 85% of adolescents to some extent and often continues into adulthood.³

Acne peaks between 16 and 20 years of age, with women more likely to be affected than men.⁴ Lesions tend to develop in areas with abundant pilosebaceous units, such as the anterior chest, the face, and the upper back. Although most teens outgrow the self-limiting disease, it may take several years.^5,6 Acne’s effects can be long lasting if patients develop postinflammatory hyperpigmentation or permanent scarring. Acne has also been linked to anxiety, depression, low self-esteem, and poor quality of life.^7,8 Early diagnosis and treatment can prevent some of these residual effects.

Pathophysiology

Four factors that are attributed to predisposing individuals to acne include the following^9-11:

• Abnormal follicular growth
• Androgen-driven sebaceous gland hyperplasia with increased sebum production
• Colonization of Cutibacterium acnes (C acnes; formerly called Propionibacterium acnes)
• Increased keratinization of the follicular epithelium

Diet, lifestyle factors, and neuroendocrine regulatory mechanisms may ontribute to this condition.^9-11 Targeting as many factors as possible increases the likelihood of successful results. The Table¹² defines several types of acne.

Treatment is a stepwise process that escalates based on the condition’s extent, severity, and treatment response.^9-11 Mild acne presents with noninflammatory comedones alone, and treatment starts with topical retinoids such asadapalene, tazarotene, and tretinoin.^9-12 Topical retinoid-based therapy is recommended as a first-line approach for almost all patients with acne, because retinoids address abnormal desquamation and sebaceous hyperplasia. Retinoids also inhibit microcomedone formation, which can be present even in normal-appearing skin. This way, they prevent the appearance of new acne lesions and help treat active disease. Common adverse effects include dryness, erythema, peeling, and skin sensitivity.^9-11

Alternative treatments include azelaic acid, benzoyl peroxide (BPO), and salicylic acid for patients who cannot tolerate or should not use retinoids, such as those who are lactating or pregnant. Evidence comparing these medications’ effectiveness is scant.^9-11 Often, patients must try different medications to determine what works.

Mild papulopustular acne, which affects less than half the face,¹² is treated similarly to noninflammatory comodones, with monotherapy with BPO, topical retinoids, or alternatively, azelaic acid.^9-11 Moderate papulopustular acne, with comedones, papules, and pustules affecting more than half the face, requires topical combination regimens using medications with complementary mechanisms of action, including antibiotic/BPO, antibiotic/retinoid, or BPO/retinoid. Retinoids tend to reduce keratinization and sebum production, whereas antibiotics and BPO better reduce C acnes counts and inflammation. Their synergistic effects result in faster and more complete clearance of acne lesions than monotherapy. If a trial of topical medications is ineffective, clinicians may need to step up to topical combination BPO/retinoid plus an oral antibiotic.^9-11

Severe papulopustular acne is characterized by highly inflammatory papules and pustules over the entire face and often the back and chest.¹² These patients need a topical combination BPO/retinoid plus an oral antibiotic.^9-11 Tetracyclines are the usual first-line choices for inflammatory acne, as they possess antibacterial and anti-inflammatory properties. They downregulate inflammatory cytokines, inhibit neutrophil chemotaxis, and inhibit metalloprote ases, with doxycycline and minocycline used most often. Systemic azithromycin, erythromycin, or trimethoprim-sulfamethoxazole can be used. Clinicians should assess antibiotic use after 3 to 4 months to reduce the risk of resistance. Isotretinoin (13-cisretinoic acid) can also be employed in severe papulopustular cases resistant to other therapies or associated with scarring or significant patient distress.^9-11

Oral isotretinoin is the treatment of choice for conglobate, cystic, and nodular acne.^9-11 Isotretinoin alters ductal microenvironment; decreases follicular hyperkeratinization; inhibits sebocyte differentiation, proliferation, and lipid synthesis; and reduces C acnes count, which decrease inflammation. Among patients who take isotretinoin, 85% respond almost completely within 4 months. Many patients experience durable responses but up to 30% may need a second 16-week course of treatment. The risks include teratogenicity, necessitating the use of 2 forms of contracep-tives and routine pregnancy testing. Isotretinoin’s common adverse effects include blepharoconjunctivitis, cheilitis, and dry lips and skin.^9-11

Once acne clears, patients must use maintenance therapy to maintain remission, and topical retinoids are recommended. These reduce microcomedone formation, postinflammatory hyperpigmentation, and scarring.

Oral or topical antibiotic monotherapy is no longer recommended, as it increases the risk of antibiotic-resistant C acnes.^9-11

Conclusion

Acne can be troubling for patients and requires a commitment to ongoing treatment for best results. Honoring patient preferences and knowing when to step up care can lead to good results.

References

1. Tan JK, Bhate K. A global perspective on the epidemiology of acne. Br J Dermatol. 2015;172(suppl 1):3-12. doi:10.1111/bjd.13462

2. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2163-2196. doi:10.1016/S0140-6736(12)61729-2

3. Bhate K, Williams HC. Epidemiology of acne vulgaris. Br J Dermatol. 2013;168(3):474-485. doi:10.1111/bjd.12149

4. Tan JK, Tang J, Fung K, et al. Prevalence and severity of facial and truncal acne in a referral cohort. J Drugs Dermatol. 2008;7(6):551-556.

5. Dill SW, Cunningham BB. Acne and other disorders of the pilosebaceous unit. January 17, 2017. Accessed October 7, 2022. https://obgynkey.com/acne-and-other-disorders-of-the-pilosebaceous-unit/

6. Dréno B. What is new in the pathophysiology of acne, an overview. J Eur Acad Dermatol Venereol. 2017;31(suppl 5):8-12. doi:10.1111/jdv.14374

7. New survey finds teen acne can take the ‘self’ out of selfie. December 8, 2017. Accessed September 5, 2022. https://apnews.com/article/22c-d19e9cf924453b3037f786741577f

8. New survey reports on acne, social media behavior and teenagers’ self-esteem. News release. Cutanea Life Sciences, Inc. December 5, 2017. Accessed September 5, 2022. https://www.prnewswire.com/news-releases/new-survey-reports-on-acne-social-media-behavior-and-teenagers-self-esteem-300566154.html

9. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74(5):945-73.e33. doi:10.1016/j.jaad.2015.12.037

10. Xu J, Mavranezouli I, Kuznetsov L, Stephen Murphy M, Healy E; Guideline Committee. Management of acne vulgaris: summary of NICE guid-ance. BMJ. 2021;374:n1800. doi:10.1136/bmj.n1800

11. Conforti C, Chello C, Giuffrida R, di Meo N, Zalaudek I, Dianzani C. An overview of treatment options for mild-to-moderate acne based on American Academy of Dermatology, European Academy of Dermatology and Venereology, and Italian Society of Dermatology and Venereology guidelines. Dermatol Ther. 2020;33(4):e13548. doi:10.1111/dth.13548

12. Dréno B, Poli F, Pawin H, et al. Development and evaluation of a Global Acne Severity Scale (GEA Scale) suitable for France and Europe. J Eur Acad Dermatol Venereol. 2011;25(1):43-48. doi:10.1111/j.1468-3083.2010.03685.x