The first signs of acne typically occur around the time of puberty; however, certain types of acne occur later in young adulthood and even into the middle years. Despite great variability in the time of onset and appearance of acne, it is basically a genetically determined and hormonally driven disease. As the hormones change, they induce changes in the skin, which include increased production of oil by the sebaceous glands. These glands become plugged up as they make oil or sebum, and the first abnormality which appears is a microcomedone or a small whitehead. These may enlarge to form macrocomedones or larger blackheads and whiteheads. When the skin bacteria act on this retained oil, fatty acids and other irritating substances are released and inflammatory pustules and cysts of acne occur.
Treatment for acne is generally tailored to the type of acne and the severity of the disease. The first line of therapy includes benzoyl peroxides. Many of these products are available over the counter. These are antiseptics with mild comedolytic ability (ability to break up the plugs that begin the process of comedone formation). Should these fail, topical retinoids may be prescribed. These products include Retin-A, Differin, Tazorac, and Avita. The retinoids act to thin the epithelium and break up the plugs that form the early comedone. They may be irritating at first, and careful attention should be paid to the way that they are used. Should retinoids and benzoyl peroxide alone fail, antibiotics may be added. These are available in both topical and systemic forms. Oral treatment tends to be very effective, but carries the (slight) risk of systemic toxicity. Our goal is always to limit exposure to oral agents.
Several types of light therapy are also available. Bluelight or Clearlight is simply a narrow range, visible blue light, which has the ability to decrease the surface bacteria in the skin. Bluelight may be combined with a photosensitizing agent in a procedure called photodynamic therapy. In this process, Levulan, the photosensitizing drug, is applied to the skin and, after a waiting period, Bluelight is then used. This procedure not only decreases the number of skin bacteria, it also seems to diminish the size and activity of sebaceous glands. This effect may last for several months after a few photodynamic therapy sessions. (For more information, see Photodynamic Therapy of Acne).
Oral contraceptives are also often effective in treating acne. One of the mechanisms of their action is to decrease the amount of sebum or oil produced in the sebaceous glands. A diuretic agent, Spironolactone, is occasionally used to control acne in women.
Finally, Accutane has been used for at least twenty-five years and is remarkably effective in cases of acne which resist other treatments. This is a Vitamin A-like drug which has several effects. The most prominent of these is to decrease the oil production in the sebaceous glands and also to decrease inflammation and scarring. A six-month course of Accutane usually results in dramatic and long lasting clearing of acne. No drug is without its problems and it is important to understand the potential toxicities of Accutane therapy before deciding on this therapy.
In short, there are many different acne treatments available. Each case is unique and therapy should be structured individually. It is very common to use the treatment modalities in combination. Compliance with treatment and periodic reevaluation can almost guarantee a good result.
Before and After Photodynamic Therapy Acne Treatment
For concerns with acne scaring, The Center for Laser Surgery also offers laser scar reduction specifically for patients with acne scars.