Clinical Appearance and Grading

Acne has been classified from grade 1 to grade 4 depending on its severity. Variations include minor blackheads and whiteheads and clogged pores (grade 1) that can become infected and inflamed (grade 2), leading to large red papules and pustules (grade 3) and cysts and nodules (grade 4). Lesions are often “popped” or picked by the patient. With the larger lesions, scarring is often the result. The usual type of depressed scarring can last throughout a person’s life, and can become an extremely noticeable facial imperfection. Scars can be erythematous, irregular, textured lesions, enlarged pores, or deep icepick and cratered lesions. Treatment is primarily directed at reducing inflammation and preventing scars. However, light-based technologies also make scar reduction and skin remodeling possible to improve appearance.

Internal Causes

There are many contributing factors to the severity of acne, but no clear single cause has been identified. Acne develops as the patient progresses through puberty and the sebaceous glands grow and increase their sebum secretion. Acne is more prevalent and severe in males because of the increased production of testosterone during puberty. Adult-onset acne in women may be attributed to cyclical variations in sex hormones, with an increase in androgenic hormone levels resulting in an increase in sebum production. This increase in sebum, coupled with the keratinization of the hair follicle, causes occlusion of the ducts and in turn the formation of comedones.

There is a correlation between the depth of the hair follicle and the size of the lesion. The deeper the follicle, the deeper the occlusion, which in turn results in a larger lesion.

The bacterium Propionibacterium acnes causes inflammation either because of an immune system reaction, inflammatory enzymes from the bacteria, or a combination of the two. P. acnes is a normal colonizer of the sebaceous follicles; it is a gram-positive, microaerophilic bacterium that, as part of its normal metabolic and reproductive processes, produces and accumulates endogenous porphyrins, namely protoporphyrin, uroporphyrin, and coproporphyrin III. Porphyrins can be visualized using a Wood’s lamp or digital fluorescence photography because they absorb light energy at the near-ultraviolet and blue-light spectrum. This unique attribute of the bacterium lends to the therapeutic effects of some light-based treatments.

External Causes

External factors vary from patient to patient, but there are several factors that can affect the severity of acne. Diet will affect each patient individually, and although dairy products seem to cause problems in women, no other real universal dietary factors have been identified. Thick makeup, hair spray, greasy hair gels, and hats, sweat bands, or athletic helmets are all external factors that contribute to the severity of acne because of the combination of mechanical or chemical irritation, oil gland occlusion, and bacterial colonization. In some work environments, exposure to industrial products like cutting oils may produce acne. In addition, inadequate cleansing contributes to the development of acne. In all cases, the external factors aggravate acne, but are not the root cause of the disease.

Patients should be advised not to rub, scratch, pick, or squeeze their skin because mechanical irritation can aggravate acne and lead to scarring. Careful and controlled extraction of comedones by a trained aesthetician or nurse after steaming and appropriate skin preparation may be beneficial. Some drugs can cause or worsen acne, including iodides, bromides, and oral or injected steroids. A proper skin care regime is helpful to minimize the severity of acne by removing impurities and irritants.

Treatment Options

Because the pathogenesis of acne involves four factors (hypercornification of the pilosebaceous duct, increased sebum production, colonization by P. acnes, and the development of inflammation), a stepwise and systematic approach to treatment is best. Because acne is a chronic disease, its treatment is an ongoing process that requires educating the patient as well as patience on the part of both the patient and the clinician, to allow each step in the treatment process to take effect. Treatments aimed at clearance of P. acnes alone generally provide short-lived improvement; therefore, combination therapy is recommended (Table 50-1).

TABLE 50-1 Treatment Options in Acne Management

The first universal step is appropriate skin care. Cleansing the skin seems to help all patients, if only slightly, but acne is not directly caused by dirt. Cleansers have an antibacterial effect and may reduce bacterial colony counts. Toners may be helpful in restoring the pH balance of the skin after cleansing to an acidic state. Using gentle exfoliation such as microdermabrasion or glycolic facials may be helpful to remove excessive keratin from the epidermis and open pores, allowing sebum to drain freely. Overscrubbing is not recommended because the skin becomes dry, damaged, and inflamed and as a result can become less receptive to topical products. Abrasive home scrubs are therefore not recommended for acne-prone skin. A gentle cleanser is all that is necessary to cleanse the skin properly. Moisturizers that are noncomedogenic are helpful to prevent skin dehydration and to counteract the drying effect of many other active ingredients, such as benzoyl peroxide. The most commonly used cleansers are available over-the-counter and include Clearasil and PHisoderm, but aesthetic physicians’ offices and spas also have a variety of excellent brands available to their clientele.

As with many other cosmetic treatments, combination therapy is the best approach to treating acne, which brings us to the second step of treatment. Using topical products, such as topical retinoids, maximizes the effect that an intense pulsed-light (IPL) treatment will have on the acne. Retinoids are comedolytic and act on the keratinization of the hair follicle. They are therefore beneficial for acne grades 1 and 2 where comedones predominate. Differin (adapalene) is the least irritating, but others, such as Retin-A (tretinoin) or Tazorac (tazarotene), may also be used. There are many over-the-counter retinoid creams on the market, but these do not usually deliver consistent levels of retinoid to the dermis.

Retinoids result in a decrease in sebaceous duct occlusion, preventing oil from accumulating in the sebaceous glands and creating a favorable habitat for bacterial colonization. Inflammatory acne, on the other hand, responds better to topical antibiotics and photodynamic therapy (PDT; Fig. 50-1). Preparations that combine antibiotics like clindamycin with benzoyl peroxide are available for better efficacy than single antibiotics alone. In addition, blue light (415-nm wavelength) has excellent antibacterial properties against porphyrin-producing bacteria because porphyrins release singlet oxygen when activated by this wavelength of light. Singlet oxygen is toxic to the bacteria (see Chapter 60, Photodynamic Therapy).

Figure 50-1 Treatment of inflammatory acne with scars. Five intense pulsed-light treatments were performed with the Vasculight (Lumenis, Yokneam, Israel) SR handpiece combined with three photodynamic therapy treatments with incubation periods lasting 30 to 90 minutes. A, Before treatment. B, After treatment.

Hormonal therapy is a useful adjunct in the treatment of acne in female patients. The onset of acne is triggered by the increased production of androgens. Oral contraceptives inhibit ovulation, thereby preventing androgen production by the ovaries. Lower serum androgen levels reduce sebum secretion, which consequentially exerts an antiacne effect. The mean reduction in total facial acne lesions with the use of drospirenone and cyproterone acetate (components of birth control pills) has been shown to be 62% and 59%, respectively. Other contraceptives with antiacne effects include norgestimate and levonorgestrel.

Oral antibiotics and isotretinoin (Accutane) constitute the next level of traditional therapy. However, the availability of lasers, IPL devices, and PDT now provides excellent treatment options that avoid possible systemic side effects, leaving oral treatment as an alternative for severe and unusually refractive cases. Intralesional steroids are infrequently used and are more appropriate for early nodular lesions; they should not be a standard treatment for acne. Newer devices that extract comedones in the course of IPL treatment are excellent for grades 2 and 3 acne. Gently extracting large comedones and draining superficial cysts may be helpful when providing full-face treatments such as IPL and PDT. Strong pressure should never be applied to avoid spreading infection. Oral antibiotics such as minocycline are very effective in treating acute flare-ups of papulopustular acne. Oral antibiotics also reduce the severity of acne in conjunction with or before the initiation of light-based therapy. Combining tetracyclines with light therapy is a relative contraindication because the skin is more photosensitive, but in my experience the increased post-treatment erythema is worth the benefit. Patients need to be informed of the possible side effects.

Rosacea

Although rosacea is a different disease from acne vulgaris, it warrants discussion here because of the many similarities between the two, including an inflammatory component and small papules and pustules. When treating rosacea, skin care should be restricted to mild, hypoallergenic products. Prescription metronidazole preparations such as Rosasol and Metrogel are effective at controlling the disease activity, and IPL and PDT treatments can be highly effective in reversing erythema, telangiectasia, and the activity of the disease (Fig. 50-2).

Figure 50-2 Treatment of refractory rosacea acne with five intense pulsed-light treatments with the Vasculight and three photodynamic therapy treatments with incubation periods of 60 to 120 minutes. A, Before treatment. B, After treatment.

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