Acne (part two): Fighting back with Lotions, Potions, and Notions

Aristotle

Hippocrates

Acne is as old as mankind (and womankind) so it is not surprising to see references to it in ancient texts. Aristotle and Hippocrates both referred to it in their writings.

The word acne is actually a plural word, the singular form of which translates to “first growth of the beard.”  In an early Egyptian hieroglyphic dictionary, the word “akut” is defined as “boils, blains, sores, pustules, and inflamed swelling.

Historical treatments

Sulfur has been a commonly used treatment for millenia and is one of the active ingredients included in the FDA monograph on over the counter acne preparations (discussed below.) Its antimicrobial and drying effects are both beneficial. Benzoyl peroxide, the major active in some current products, dates back to the 1920’s but that may have been on an empiric rather than scientific basis.

Because later in the 1930’s, many referred to acne as “chastity pimples” , thinking it was caused by toxins that remained trapped within the bodies of women who were virgins. Radiation treatment and laxatives were the remedy. “You’ve come a long way, baby.” Indeed.

Traditional modern medical treatments for acne

Oral antibiotics

(Note: use of long-term oral antibiotic treatments – once a mainstay of acne care – have been implicated in promoting drug resistance and so are much less commonly prescribed.)

Tetracycline is the most widely prescribed antibiotic for acne. The main drawback for this antibiotic is that it must be taken on an empty stomach to be the most effective. Tetracycline should not be given to pregnant women or children under 9 years of age.

Erythromycin has several advantages over tetracycline. First, it has anti-inflammatory properties that help reduce redness in lesions, in addition to killing bacteria. It can cause stomach upset and nausea, but can be used in pregnant women.

Minocycline is a tetracycline derivative that has been used effectively for decades as a treatment for acne. It does have associated skin pigmentation changes and tooth discoloration although these are usually seen in people who have taken minocycline for a long time.

Doxycycline is often used for people who do not respond to or cannot tolerate erythromycin or tetracycline. Doxycycline is more likely than tetracycline to increase sensitivity to the sun, or cause sunburns.

Clindamycin is very useful as an oral antibiotic for acne, but it is most widely prescribed as a topical antibiotic. The major side effect of clindamycin therapy is serious intestinal infection called pseudomembranous colitis caused by the bacteria, Clostridium difficile.

All antibiotics can cause candida vaginal yeast infections in women. Tetracycline seems to be the antibiotic that most frequently has this side effect. All oral antibiotics can also lessen the effectiveness of birth control pills.

Oral Retinoids

Isotretinoin (first marketed as Accutane by Hoffman-LaRoche) Doctors prescribe isotretinoin solely to treat nodular acne that causes severe disfigurement. Women who take this drug must use a reliable contraceptive method during treatment, as isotretinoin causes severe birth defects in humans. This drug helps the sebaceous glands to mature, which reduces the amount of oil produced.

Tretinoin (Retin-A) helps keep pores clear to prevent the inflammation that causes acne. This drug also helps replace older skin with new skin.

Oral Contraceptives

 Oral contraceptives are sometimes use to treat acne in women. A combination of estrogen and progestin, oral contraceptives work to reduce oil gland secretions by suppressing androgen hormones. They are a good choice for women with acne who need a form of birth control anyway. Oral contraceptives are used in conjunction with topical medications to treat severe acne.

Oral Spironolactone

This medication, actually an aldosterone antagonist diuretic, isn’t a first line of defense against acne breakouts. It has anti-androgenic effect making it effective against acne caused by hormonal fluctuations.

Topical Antibiotics

Topical antibiotics are sometimes prescribed by physicians for more serious and recalcitrant cases, physicians may prescribe topical antibiotic preparations, typically clindamycin and erythromycin.

Topical Retin A (retinoic acid) – Topical retinoic acid increases cellular turnover but can also lead to side effects such as skin inflammation, dryness and flaking.

FDA acne monograph actives

The FDA has published monographs regarding the active ingredients an over the counter product must contain in order to be labels and marketed as an acne treatment. They are:

Permitted single active ingredient products:

Benzoyl peroxide in concentrations of 2.5 to 10 percent. Benzoyl peroxide produces free oxygen radicals that kill the anaerobic P. acnes within the pore.

Salicylic acid in concentrations of 0.5 to 2 percent. Salicylic acid is a keratinolytic betahydroxy acid (BHA) that promotes exfoliation i.e. the removal of dead skin cells.

Sulfur in concentrations of 3 to 10 percent. Sulfur has both anti-bacterial and keratolytic properties.

Permitted combination active ingredient products.

Resorcinol in 2 percent concentration in combination with sulfur in concentrations of

between 3 and 8 percent. Resorcinol monoacetate in 3 percent concentration in combination with sulfur in concentrations of between 3 and 8 percent. Resorcinol has antibacterial and disinfectant properties.

 “When I see acne, I don’t see pus, I see gold”

In 1995, dermatologists Katie Rodan and Kathy Fields teamed with mass marketing gorilla Guthy-Renker to market their proprietary acne formulation. In 2012, more than $200 million was spent buying airtime for broadcast infomercials starring paid celebrity pitchpersons. Proactiv is a three-part acne treatment kit that is sold on subscription basis. Its active ingredients are benzoyl peroxide and glycolic acid.

An eighty person Consumer Reports study concluded that ProActiv and much cheaper drugstore products were equally effective. It’s all about the marketing.  Duplicitous, in some people’s opinion, since in the UK, some of the company’s commercials were banned when it was learned that some paid celebrities, extolling the superior results from ProActiv, were not even using it.

The High Price of Treatment

The cost of ProActiv is about $40 for the three-piece starter supply, which lasts  about 30 to 60 days, depending on the condition of your skin. Over-the-counter preparations like Oxy Balance (a 5% solution) and Oxy Maximum (a stronger 10% solution) sell for about $5 for a 30 to 60-day supply. Alternately, Neutrogena’s On The Spot Acne Treatment contains the milder 2.5% benzoyl peroxide solution in a preparation closer to ProActiv, and it sells for about $6 for a 30 to 60-day supply.

Zapping Pimples Away

This high tech gizmo goes by the name “ZENO”

Recently cleared by the FDA, the device purportedly works by supplying a small amount of controlled heat directly to the acne lesion for two to three minutes, causing the bacteria to self-destruct and ultimately the pimple to clear. According to the manufacturer, most zits require a single treatment and are completely gone in just hours. Others may require up to three treatments in 24 hours to see results. It’s not for widespread acne, or moderate to severe breakouts.

Laser Light

Laser light is used to destroy bacteria, as well as shut down excess oil production. They may also have antiaging benefits by stimulating collagen production, making it an attractive treatment for midlife acne.

Although treatment is pretty much painless, it is expensive, costing between $500 and $800 per session, with at least five to seven treatments necessary to see results. Moreover, those results are frequently not permanent.

LED Light Treatment

LED light therapy is performed using blue wavelengths, or combinations of blue and red.  Blue light works by activating porphyrin compounds within the P. acnes bacteria, essentially killing them from the inside out. Red light, while less researched, may help reduce inflammation and improve healing. LED treatments using home devices take considerable time (e.g. 30 minutes twice a day). More powerful devices are used by health and skin professionals.

Treatments on the Horizon

New investigational therapies exploit pathways of bio-molecular control of the  causative aspects of acne. Topical androgen blockers, acetylcholine inhibitors and PPAR modulators seem to be promising options for controlling sebum production. (PPARs are nuclear receptor proteins that control gene expression.) Retinoic acid metabolism-blocking agents and IL-1α inhibitors (IL-1α is a strongly inflammatory cytokine) have the potential to become legitimate alternative options to retinoid therapy.

There are also new uses for old molecules with potent antibacterial and anti-inflammatory effects, such as boron based compounds. Notoriously difficult to get past the barrier of the stratum corneum, new chemical enhancements allow lipid vehicles that can accomplish this elusive goal.

BFT will stay on top of this story and bring you the latest and greatest. After all, there’s nothing sexy about a zit. No one wants to wear that accessory to the prom, no matter what the color of their dress.