Acne is a chronic, inflammatory skin condition resulting in the presence of comedones (or blackheads and white heads), red bumps, including papules and nodules, and pus filled bumps known as pustules on the face, chest, and back. These lesions can progress into dark or hyperpigmented spots and scars. Acne is a highly prevalent condition that traditionally occurs among adolescents, but there are increasing cases of hormonal acne in individuals in their 20’s and 30’s. The condition has been associated with increased risk of poor self esteem, depression, and anxiety. A number of board-certified dermatologists, including those at New Bloom Dermatology, serve as specialists who are best equipped to treat patients suffering from acne.
Acne is a multifactorial condition affected by a number of factors. Colonization of the hair follicle by Cutibacterium acnes, a bacteria previously known as Propionibacterium acnes, has been shown to be responsible for causing inflammatory acne. Hormonal changes, including conditions such as polycystic ovary syndrome (PCOS), increased levels of dehydroepiandrosterone (DHEA) and testosterone have been shown to activate hormone receptors on the skin and increase sebum or oil production. Increased keratin surrounding the hair follicle is responsible for causing comedone or blackhead formation.
Recent studies have shown that hormonal intrauterine devices (IUD) with levonorgestrel, a testosterone derivative, is associated with worsening of acne. Furthermore, intake of foods with high sugar content and low-fat dairy have been shown to increase acne severity. The use of whey protein powder commonly used in body building supplements has also been associated with increased prevalence of acne.
While there are no reported studies, clinical experience has shown that reduction of caffeine, alcohol, protein shake consumption, reduction of stress patterns, and removal of hormonal and non-hormonal IUD can decrease acne flares.
Acne is characterized by the presence of blackheads and whiteheads, red bumps or papules, pus bumps or pustules, and firm bumps such as nodules or cysts on the face, chest, and back. Other signs of chronic acne include pitted scars and dark marks from old acne lesions, known as post inflammatory pigment alteration (PIPA). There may or may not be increased oil production, which occurs on the nose and mid-cheeks.
Risk factors for acne include age, especially among adolescents and young adults experiencing hormonal changes. Patients with polycystic ovarian syndrome are more likely to experience acne as a result of increased testosterone levels. Individuals who inject or consume testosterone are at increased risk of acne. Other risk factors include the consumption of a high amount of sugar, low fat dairy, and hormonal IUD placement.
Acne is diagnosed by the presence of blackheads, whiteheads, red papules, pustules, and firm bumps such as nodules or cysts on the face, chest, and back. For women, the presence of acne especially on the lower cheeks, chin, chest, and back suggests hormonal changes as the main culprit. The majority of patients with hormonal acne have normal hormone levels, but usually have increased activity of hormone receptors on the skin. Hormone levels are recommended to be checked by an endocrinologist among women with acne who experience irregular periods, increased hair growth on the face, and hair loss.
Patients with mild acne are recommended to use topical treatments. Benzoyl peroxide as a cleanser or gel has been shown to kill C acnes and remove blackheads. Benzoyl peroxide can cause irritation and patients can use lower concentrations to minimize this. Salicylic acid wash can also be used as an antibacterial agent and remove blackheads. Glycolic acid wash gently exfoliates excess keratin around the hair follicle and helps reduce dark marks or PIPA.
Topical antibiotics such as clindamycin, dapsone, erythromycin, and minocycline have antibacterial and anti-inflammatory properties. However, their efficacy improves when used in conjunction with benzoyl peroxide and salicylic acid washes, as there is decreased antibiotic resistance that develops.
Topical retinoids or vitamin A derivatives including tazarotene, tretinoin, adapalene, and trifarotene remove blackheads, reduce inflammation, and can decrease hyperpigmentation as a result of PIPA. The main side effects of these medications include burning, redness, irritation, and photosensitivity. Tazarotene should not be used in women who are planning or are pregnant due to the risk of birth defects.
Azelaic acid also has antibacterial, anti-inflammatory, and comedolytic properties. They also can be used to treat hyperpigmented lesions. Azelaic acid can be safely used in pregnancy.
Clascoterone is a topical anti-androgen that inhibits inflammation as a result of binding of hormone receptors on the skin. It is recommended to treat hormonal acne twice daily.
Individuals who get dark marks as a result of PIPA are advised to wear a tinted, mineral sunscreen and can use a lightening agent such as hydroquinone. They are advised to avoid direct sun exposure, as that will darken the lesions.
Patients with moderate acne can take oral antibiotics to reduce the bacteria and inflammation. The FDA approved oral antibiotics are doxycycline, minocycline, and sarecycline. However, these medications have side effects that may limit its use. Side effects of doxycycline include nausea, vomiting, sun sensitivity, and diarrhea. It is best to take doxycycline after food consumption to minimize nausea and vomiting. Minocycline has similar side effects to doxycycline, but can also be rarely associated with drug-induced lupus, skin hyperpigmentation, hepatitis, and drug rash. Sarecycline is considered a more tolerable antibiotic with decreased nausea, vomiting, and photosensitivity, but is not covered by all insurance plans. Patients are advised to limit oral antibiotic use to three months to decrease the risk of antibiotic resistance and greying of teeth.
Women who experience hormonal acne can consider oral contraceptives or spironolactone. Oral contraceptives containing estrogen and progestin treat acne by decreasing androgen production and reduce free testosterone that would bind androgen skin receptors. The FDA approved formulations for oral contraceptives to treat acne include norgestimate/ethinyl estradiol, norethindrone acetate/ethinyl estradiol, norethindrone acetate/ethinyl estradiol/ferrous fumarate, drosperinone/ethinyl estradiol, and drosperinone/ethinyl estradiol/levomofolate. Severe side effects of oral contraceptives include strokes, heart attack, blood clots, breast and uterine cancer. Women who smoke cigarettes are advised to avoid oral contraceptives due to the increased risk of blood clots.
Spironolactone decreases testosterone production and blocks testosterone from binding hormone receptors on the skin. It can be used to treat hormonal acne especially due to the placement of IUD. Side effects include dizziness, headaches, increased potassium, frequent urination, and bleeding between periods. Women who experience irregular periods can take oral contraceptives to relieve these symptoms. Women planning to get pregnant or who are pregnant should not take spironolactone due to the risk of feminization of organs in a male fetus.
Previously known as AccutaneⓇ, isotretinoin is the only FDA approved treatment for severe cystic acne. It is a vitamin A derivative that decreases inflammation and C. acnes, reduces oil production by sebaceous glands, and decreases keratin surrounding the hair follicle. Patients are recommended to take the medication for six months at the full dose determined by weight. Side effects of isotretinoin include dryness, nosebleeds, rectal bleeding, sun sensitivity, hair loss, mood changes, suicidal and homicidal ideations, elevation of liver enzymes and increased triglycerides. Pregnant women and women planning to be pregnant should not take isotretinoin due to the risk of birth defects. The US government requires women to have two negative pregnancy tests at least 30 days apart before starting isotretinoin. Female patients are required to do pregnancy tests each month and must have two modes of contraception if they are sexually active. Furthermore, bloodwork is performed every other month for all patients to check liver function tests and fasting lipid tests.
Other treatments of acne include customized facials, which help decrease inflammation and reduce comedones. Chemical peels can be used to reduce inflammation, dark spots as a result of PIPA, and comedones. Excel V Genesis™V is a non-ablative 1064nm laser treatment that uses pulses of heat to increase collagen production and reduce redness. IPL can be used to reduce bacteria, redness, and inflammation. Lasers targeting sebaceous glands such as Accure and AviclearⓇ are 1726 nm lasers that can be used to reduce inflamed bumps and sebum production. They are not offered at New Bloom Dermatology.
A majority of adolescents and young adults experience acne as a result of hormonal changes. To reduce the severity of acne, individuals are advised to start a benzoyl peroxide, salicylic acid, or glycolic acid wash. Individuals are advised to avoid foods high in sugar, low-fat dairy, and protein shakes. Women who are seeking contraception options should be aware that placement of a hormonal IUD has been shown to increase acne severity.
Acne should be treated immediately by a board-certified dermatologist to help decrease the risk of scar formation. Treatment of acne scars with procedures are not covered by insurance. Additional information for treatment can be found here. Furthermore, untreated acne has been associated with poor self esteem, anxiety, and depression.
Individuals are recommended to immediately see a board-certified dermatologist for a complete medical history and evaluation. At the visit, appropriate treatment options will be discussed, including risks and benefits of each treatment.
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