Nurses Notes: Acne

Acne is a common skin condition that affects most people at some point. It causes spots to develop on the skin, usually on the face, back and chest.

The spots can range from blackheads and whiteheads which are often mild, to inflamed pus-filled pustules and cysts, which can be severe and long lasting and can lead to scarring.

Causes Acne

Hormones

Bacteria

Acne has many subtypes. Acne neonatorum and acne infantum occasionally affect newborns and infants, usually boys. A pimply rash appears on the face and usually clears within weeks with no lasting effect. However, acne infantum may last longer, be more severe, and cause scarring.

People who escaped their teen years almost pimple-free may develop persistent adult-onset acne as they get older. Despite the normal increase in androgen levels during puberty, some doctors believe that flare-ups of acne have less to do with androgen levels than with how a person's skin responds to an increase in sebum production or to the bacteria that causes acne. The bacteria Propionibacterium acnes occurs naturally in healthy hair follicles. If too many of them accumulate in plugged follicles, they may secrete enzymes that break down sebum and cause inflammation. Some people are simply more sensitive than others to this reaction. Sebum levels that might cause a pimple or two in one person may result in widespread outbreaks -- or even acute cystic acne -- in another person.

Acne Treatment

Self-Care at Home

Wash once or twice daily with soap and water to remove excess oil from the skin. An acne cleanser purchased over-the-counter in any drug store can also be helpful. Avoid scrubbing or using abrasives because this can actually irritate the skin and cause acne to worsen.
Over-the-counter acne medications can be used either at bedtime or during the day. Always follow the directions on any acne product. These products generally do not have any beneficial effects on inflammatory lesions, pimples, and are essentially used to prevent the development of new lesions. Therefore they should be applied to all of the skin in affected areas.
Many cover-up products are available without a prescription to improve the appearance of blemishes while they have a chance to heal. Most work well and should not worsen acne. If makeup is worn, it should be water-based, and the ingredients of the makeup should list water as a major component.
Some cosmetics and other skin-care products, however, can cause acne to worsen. Look for makeup, cosmetics, and skin-care products labeled with the word noncomedogenic. This means that it does not cause or worsen acne.
Recent, very preliminary, reports seem to associate cow's milk with more severe cases of acne.
It is of major importance that the patient with acne does not manipulate their lesions. Manipulation (pinching, squeezing, etc) of any type is almost uniformly going to result in worsening of any existing disease, potentially enhancing the chance for scarring and producing more long-lasting pimples.

Medical Treatment

The purpose of medical care is to prevent scarring until the disease characteristically spontaneously remits after the conclusion of puberty. Many treatment options are available to treat all forms of acne. Medications are the main treatment for acne and usually work well. Several preparations are available over the counter, while others require a prescription from a doctor.

Over-the-counter medications: Nonprescription or over-the-counter medications for acne are plentiful and can be effective for milder forms of acne. They come in the form of soaps, washes, and cleansers.

Many contain benzoyl peroxide, which does two things. First, benzoyl peroxide kills the acne-causing bacteria, which are thought to play a role in acne. Second, benzoyl peroxide can cause drying and flaking off of skin, which can help prevent the pores from becoming plugged. Plugged pores can develop into acne blemishes.
Scrubbing excessively with any over-the-counter preparation can actually cause acne to worsen by additionally irritating the hair follicles.

Prescription medications: Doctors can prescribe medications when acne becomes moderate to severe or is not controlled by over-the-counter medications. Prescription drugs can be used effectively alone or in combination with other prescription and nonprescription medications.

Antibiotics: Antibiotics can be effective in treating most inflammatory acne (papules and pustules). They work by decreasing inflammation caused by bacteria and other irritating chemicals present in the sebaceous follicle.

Antibiotics may be applied to the skin in the form of gels and lotions or by way of pills. Giving an antibiotic by mouth is often needed for acne that is more extensive, red, and tender.
Antibiotics may be combined with benzoyl peroxide, which is contained in over-the-counter medications, to form a topical solution that can be obtained with a doctor's prescription.
Antibiotics taken by mouth for relatively extended periods can be very effective in controlling acne. Although the development of resistant bacteria is a theoretical concern as a result of protracted courses of antibiotics, this does not seem to occur commonly for the antibiotics used most frequently by dermatologists for acne. As with any systemic medication they can be associated with more side effects than if applied to the skin and may interact with other drugs. Sensitivity to the sun can result in a "bad sunburn" in some people who take antibiotics in the tetracycline family.

Retinoids: Medicines structurally similar to vitamin A are useful in preventing several types of acne lesions. Topical retinoids are effective in treating the noninflammatory types of acne (blackheads and whiteheads).

Topical retinoids (applied directly to the skin) help to open clogged pores and produce a mild peeling effect. Drying and redness of the skin can be a frequent side effect and in some patients limit its usefulness.

An oral retinoid (isotretinoin) may be prescribed for treating the more extensive nodular type of acne or severe inflammatory acne, which has not responded to other treatments. All patients on isotretinoin will experience a peeling and drying of the skin. Most patients who take the appropriate dosage for an appropriate duration should expect a permanent remission in their acne. Isotretinoin is associated with a number of serious side effects, including birth defects in babies of women who become pregnant while taking the medicine. The drug can also cause elevated blood lipids and damage to the liver. Your doctor must perform certain blood tests to check for these problems and to make sure you are not pregnant (assuming that it is possible) if you are given oral retinoids. Depression and inflammatory bowel disease have been reported while taking oral retinoids. All patients on isotretinoin in the United States must be registered in a government-mandated program, the I PLEDGE PROGRAM, which is accessible online or by telephone. Beside the patient, the patient's physician and the dispensing pharmacy must also register with this program.

Other medications: A doctor may recommend other types of drugs or therapy to improve acne. For women, medications such as birth control pills or certain "water pills" may be helpful. These drugs counteract the acne-causing effect of male hormones. Newer treatments for acne include the use of light or zinc. Your doctor can advise you whether these types of acne therapy might be good for you.