Acne is a skin disease, inflammatory or non-inflammatory and affects humans in physical and physiological ways. The term comes from the greek word ‘ακμή’ (akmē) which means point or edge. It affects the face, the upper chest, the shoulders and the back but significantly it affects mood. The social life of the person is negatively affected as acne cause depression, increases stress and anxiety that lower self-esteem and decrease employment rates of acne patients. Acne treatment involves antibiotics, retinoids, contraceptive pill and other procedures like phototherapy and laser therapy. Oral antibiotics are shown to be the most appropriate option but always in combination with topical retinoids, therefore in order to prevent resistance its use must be restricted for maximum a year.
In United Kingdom acne patients are more than 80% and most of this percentage is referred to teenagers because of the high testosterone levels. Family history studies show that 81% of acne is caused due to genetic factors where the rest 19% is due to environmental or other factors (Purdy and Berker, 2006). It usually starts in young age, has its maximum effects in adultness but it can also persists over years. Even if the condition occurs in adolescence it can also be present in postmenopausal years (Adult Female Acne).
Acne pathogenesis has four major processes according to Salvaggio and Zaenglein (2010). Primarily, the follicular hyperkeratinization plugs the follicle and its contents (sebum and bacteria) creating a comedone. Afterwards, entrapped sebum increases, result in follicular extension that ruptures and inflames the area. This inflammation causes papules, pustules and nodules. Eventually hyperproliferation of the inflammation results from Propionibacteria acnes present on the skin surface. Although most of the studies show that P.acnes is mainly responsible for acne (as its name also states) Hassanzadeh et al (2008) suggest it’s caused by Staphylococcus aureus as the percentage of S.aureus present in anaerobic cultures of acne patients was higher than P.acnes. P.acnes strains increase their resistance especially over the last fifteen years. A UK study showed that the antibiotic resistance of P.acnes strains in 1991 was 34.5% and rose up to 64% only after six years, in 1997 (Purdy and Berker, 2006). Antibiotic resistance upgraded therapies of P.acnes reduction, which were only focused in the decrease of inflammation, to the use of combination of treatments. Combination better results are due to the prevention and reduction of existing resistance.
This condition can be classified, according to acne lesions, in three stages: Mild, Moderate and Severe. There are many types of acne: the most common one called ‘Acne Vulgaris’ and ‘Acne Rosacea’ that affects humans from forty to seventy years old. ‘Cystic Acne’ affects deeper skin tissue and forms large nodules (Purdy and Berker, 2006). Mild acne can be treated with topical treatment but if there is no change, topical antibiotics are given to the patient. The treatment of moderate acne includes oral antibiotics with a supplementary topical non-antibiotic. Kim (2008) believes that the absence of a perfect animal model results in the all those ineffective acne treatments. Patient’s diet and the presence of other syndromes like polycystic ovary syndrome (PCOS) can worsen the disease. Treatment firstly focuses to the reduction of symptoms, for example to get hormones in their normal levels.
Benzoyl peroxide has antibacterial and anti-inflammatory effects and is available in many forms like gels, lotions, creams, solutions. It was suggested from Fishman in 1958 for the treatment of acne (Dutil, 2010). Its most important characteristic is that the bacterial resistance doesn’t affect it. Its action is based on its lipophilic characteristic which allows it to get into follicles and oxidize bacterial proteins, by the release of oxygen and benzoic acid. Any concentration of Benzoyl peroxide will have the same results but large concentrations can cause dermatitis. Its oxidation action can bleach cloths and hair. Azelaic and Salicyclic acid can also be used for topical treatment.
Topical retinoids include Tretinoin, Isotretinoin, Tazarotene, Adapalene and have a certain role in the reduction of lesions by the inhibition of both neutrophil chemotaxis and lipoxygenase pathway. Most of them have irritating side effects in contrast to Adapalene’s side effects. Oral Isotretinoin should be avoided because of its teratogenic side effects but if there is no other option as treatment (usually in severe acne) patients get into a ‘pregnancy prevention program’ (Purdy and Berker, 2006). Isotretinion is very effective in the reduction of mood symptoms, especially in depression. Topical retinoids are used in combination with antibacterial drugs in order to eliminate three of the pathogenic factors, although oral Isotretinoin can eliminate all four of them.
Oral antibiotics have the major role in the treatment of moderate and severe acne mainly by the reduction of the inflammation because of their action against P.acnes strains. There are many types of antibiotics and the most common are Tetracyclines and Macrolides. The first groub includes Oxytetracycline, Lymecycline, Tetracycline, Doxycycline, Minocycline. Tetracyclines, and in particular Doxycycline and Minocycline, have the most frequent use in acne treatment, because of their effects on P.acnes strains, in order to reduce the severity of acne. Minocycline’s high resistance to P.acnes makes it a lot more effective than other Tetracyclines. Erythromycin and Azithromycin are Macrolides but their sensitivity to P.acnes strains has significantly reduced their use. Some other antibiotics, efficient in the treatment of acne are Clindamycin and Trimethoprin/Sulfamethoxazole(TMP/SMZ). TMP/SMZ cause very severe side effects, such as skin hemorrhages, therefore it has a very limited use (Leyden and Rosso, 2011).
Generally, antibiotic’s action is against bacteria, parasites and fungi but they cannot interfere with viruses. Antibiotics act on the immune system, each one on its own way of absorption and distribution to the body. Prolonged or short exposure to antibiotics is the main reason for antibiotic-resistance development. On the one hand, excessive use of antibiotics for minimal infections and diseases, reduces their principally function and they can’t act on their target. On the other hand, inadequate use will eliminate a small number of bacteria and the ones that survived from the low antibiotic action will develop resistance and cause more severe problems. As it can be shown wrong prescriptions can cause resistance and induce bigger problems.
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| me a year ago with acne |
References:
1. Addor F. and Schalka S. (2010). Acne in adult women: epidemiological, diagnostic and therapeutic aspects. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0365-05962010000600003&lng=en&nrm=iso&tlng=en
2. Dunn L., O’Neill J. and Feldman S. (2011). Acne in Adolescents: Quality of life, self-esteem, mood, and psychological disorders. http://dermatology.cdlib.org/1701/1_review/1_10-00256/feldman.html
3. Dutil M. (2010). Benzoyl Peroxide: Enhancing Antibiotic Efficacy in Acne Management. http://www.skintherapyletter.com/2010/15.10/2.html
4. Hassanzadeh P., Bahmani M. and Mehrabani D. (2008). Bacterial resistance to antibiotics in acne vulgaris: an in vitro study. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2763741/?tool=pubmed
5. Irby C., Yentzer B. and Feldman S. (2008). A Review of Adapalene in the Treatment of Acne Vulgaris. http://www.jahonline.org/article/S1054-139X(08)00271-1/fulltext
6. Kim J. (2008) Acne Vaccines: Therapeutic Option for the Treatment of acne vulgaris. http://www.nature.com/jid/journal/v128/n10/full/jid2008221a.html
7. Leyden J. and Rosso J. (2011). Oral Antibiotic Therapy for Acne Vulgaris. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3050614/?tool=pubmed
8. Purdy S. and Berker D. (2009). Acne. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1633755/?tool=pubmed
9. Salvaggio H. and Zaenglein A. (2010). Examining the use of oral contraceptives in the management of acne. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2971728/?tool=pubmed
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