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Management of acne in adolescents

Alison MacDonald
MB ChB BSc MRCP
Senior House Officer

Susan Holmes
MD FRCP
Consultant Dermatologist
Department of Dermatology Glasgow Royal Infirmary

Acne causes significant distress to teenagers. Although many outgrow the condition in their teenage years, in some it may persist into adulthood. There is a wide spectrum of clinical presentation, ranging from the very mild to very severe.

Why is management so important?
Adequate management of acne in adolescents is important for a number of reasons. First, it affects patients in their teenage years when they are psychologically vulnerable and concerned about self-image. Indeed, teenage acne patients have been found to have levels of social and emotional problems similar to those with arthritis and epilepsy.(2) Secondly, adolescents may find it particularly difficult to seek help because of embarrassment about the condition. Thirdly, teenagers generally have a poor understanding of acne, its treatment and prognosis.(3)
If inadequately treated, acne may cause permanent scarring, often on the face. Effective and prompt treatment can prevent scarring in most cases.

What causes acne?
Acne is a disorder of the pilosebaceous units. These are sebaceous glands associated with small hair follicles and are found predominantly on the face, neck, chest and upper back. Excess sebum, produced by these glands, gives the skin the oily appearance often seen in acne (see Figure 1).(4)

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The central lesion of acne is the comedo. Open comedones (blackheads) appear as brown or black plugs that distend the follicular opening. Closed comedones are known as whiteheads because they appear as whitish papules. Papules and pustules, the typical "spots" of acne, are due to inflammation of the skin following the rupture of comedones. Scarring may occur, and skin darkening may follow inflammation, particularly in those with darker complexions.

Several factors are known to contribute to acne:

  • Abnormal follicular differentiation. The earliest change in the pilosebaceous unit in acne is ­abnormal follicular differentiation.(5) The cells of the upper canal of the follicle become abnormally sticky and form a plug that obstructs the duct. The blocked duct becomes clogged with sebum and keratin, forming a microcomedo. This enlarges to form an open comedo.
  • Hormonal influence/sebum production. Just before puberty, the surge in the production of androgen hormones stimulates enlargement of the sebaceous glands and sebum production. Androgen levels are normal in most patients, but acne sufferers are more sensitive to the effects.
  • Propionobacterium acnes. Acne is not an infectious condition, but P acnes, a bacterium that normally lives on the skin, plays an important role.(6) Microcomedones provide a suitable environment for the bacteria to flourish.
  • Inflammation. This is a direct or indirect result of the actions of P acnes. The organism produces enzymes that stimulate the immune system, ­causing inflammation and comedone formation. Antibiotics and antimicrobials act by reducing the numbers of P acnes.

Role of lifestyle factors
A number of myths surround acne. Among these are suggestions that poor hygiene, greasy food, chocolate or not drinking enough water contribute to the condition. These theories are entirely untrue and only add to the stigma that surrounds acne. Many teenagers themselves attribute their condition to poor hygiene and bad diet.(3)
These myths may contribute to the reluctance of teenagers to seek medical advice. In a study of 11-16 year olds, less than one-third of patients with definite acne sought medical advice, and many dealt with the problem by increased washing.(3)
Greasy makeup or moisturisers may aggravate pre-existing acne, but "noncomedogenic" preparations of these agents are quite acceptable. Patients should always avoid picking lesions, which causes inflammation by local tissue damage.

Treatment of acne
The treatment of acne depends on the severity of the condition. Patients with mild acne will require only topical therapy. Moderate acne is treated with both oral antibiotics and topical therapies. More severe cases should be referred to a dermatologist for consideration of oral retinoids.

Topical retinoids
Retinoids reduce formation of microcomedones.(4) These should be the primary therapy in most patients. They are used once daily, at night, and are available as creams, gels or lotions. They may cause skin irritation, such as redness, burning and peeling. Applying the agent when the skin is completely dry, and washing only twice a day with a mild cleanser, will help reduce this. Increased sensitivity to the sun and exacerbation of pustules may also be seen. Patients should be started on a low dose, with gradual increase if tolerated, but those who are pregnant should not be prescribed them. Improvement may be seen only after 3-4 months of treatment. If patients cannot tolerate retinoids then salicylic acid is a good alternative.(4)

Topical antimicrobials
Benzoyl peroxide is an antimicrobial that reduces the growth of P acnes. It is available in a variety of strengths, ranging from 2.5% to 10%, and as a gel, lotion, cream, soap and wash. The lowest strength is as effective as the highest, so there is little value in increasing strengths, which would serve only to increase skin irritation.(8) If this is a problem, patients should use the wash preparation at night only. Patients should be warned that benzoyl peroxide may bleach hair and clothes, while allergic contact dermatitis is a rare complication.(9)

Topical antibiotics
Topical antibiotics are available as gels, solutions and lotions. Clindamycin and erythromycin are the most commonly used agents. Topical tetracycline is used more commonly in the USA, but it may cause yellow staining of skin and clothes and it fluoresces under ultraviolet light, so it may not be acceptable to younger patients.
Topical antibiotics may lead to the development of resistant strains of P acnes. If improvement is seen, but fails to continue, resistance should be suspected and the antibiotics should be stopped for a period. Alternatively, benzoyl peroxide can be added as this has a nonspecific antimicrobial action, reducing populations of both antibiotic-resistant and antibiotic-sensitive bacteria.

Combination topical therapy
Topical agents often work best when used together.(4,9) Some agents are combined in a single preparation, such as Isotrex (Stiefel) [isotretinoin 0.05%, erythromycin 2%], Duac (Stiefel) [benzoyl peroxide 5%, clindamycin 1%] and Benzamycin (Schwarz) [erythromycin 3%, benzoyl peroxide 5%], which is applied twice daily. This reduces the number of prescriptions for the patient and the number of applications required.

Compliance with topical therapies
Patients should be strongly encouraged to use their treatment as prescribed, and it should be explained that response to treatment may take 2-3 months.
Most topical therapies are used in a twice-daily regimen. This can be reduced to once-daily or alternate-day usage if irritation occurs. If two different agents are being used together they may be alternated (ie, one in the morning, one in the evening) to reduce irritation. The preparations should be applied to the entire area rather than individual acne lesions. "Noncomedogenic" moisturisers should be used to reduce dryness. Treatment should be continued as the acne improves.
The vehicle used depends on skin type and patient preference. Creams and lotions are moisturising preparations that most patients find acceptable. Gels are non-greasy and have a drying effect, so are suitable for patients with oily skin. Solutions are drying but useful if applied to large areas.(4)

Oral antibiotics
These are used for moderate to severe acne, if topical therapy has failed, or if acne affects the shoulders and back, where topical application may be impractical. Most oral antibiotics are given in a twice-daily regimen, except Tetralysal (Galderma) and Minocin MR?(Wyeth), which should be used once daily.
Tetracycline will reduce the number of inflammatory lesions by 50% if used for 6 weeks.(10) This should be taken on an empty stomach, which makes it an unpopular choice for some. It can cause gastrointestinal upset, vaginal thrush and increased sensitivity to sunlight. Girls should be warned that it makes the oral contraceptive less effective. Benign essential hypertension is a rare but serious side-effect.
Doxycycline and minocycline are better absorbed from the gastrointestinal tract, so can be used at lower doses and taken with meals. Minocycline acts more quickly than other antibiotics but can cause dizziness, vertigo and ataxia, which are minimised by starting at a low dose and gradually titrating. Erythromycin is as effective as tetracycline but is more likely to cause resistant strains and gastrointestinal upset.(11)
Oral antibiotics should be used for at least 3-6 months, and maximum clinical improvement will not occur before 3-4 months. After this time, if the disease is settled, treatment can be stopped. If it returns, a further course of the same drug should be prescribed. Patients on oral antibiotics should also use topical therapies, particularly a topical retinoid and benzoyl peroxide, the latter to avoid antibiotic resistance.

Other treatments
Hormonal treatments act by decreasing androgen-driven sebum secretion. The most commonly used treatment is Dianette (Schering HC) [cyproterone acetate 2mg, ethinyloestradiol 35mg], an antiandrogen used by some women as an oral contraceptive. This is now recommended for 6 months' use because of an increased risk of venous thromboembolism.
No hormonal therapies are available for men.
If second-line therapy fails, patients should be referred to a dermatologist for consideration of oral isotretinoin.

Advice for patients
Dealing with adolescents with acne may be particularly difficult because of problems with self-image and embarrassment. Acne should be portrayed as a treatable condition, but should not be trivialised. Sadly, some patients still report that they have been told that they will "grow out of it", and they are not given appropriate treatment.

References

  1. Rademaker M, Garioch JJ, Simpson NB. Acne in schoolchildren: no longer a concern for dermatologists. BMJ 1989;298:1217-9.
  2. Mallon E, Newton JN, Klassen A et al. The quality of life in acne: a ­comparison with general medical conditions using generic ­questionnaires. Br J Dermatol 1999;140:672-6.
  3. Smithard A, Glazebrook C, Williams HC. Acne prevalence, knowledge about acne and psychological morbidity in mid-adolescence: a community-based study. Br J Dermatol 2001;145:274-9.
  4. Brown SK, Shalita AR. Acne vulgaris. Lancet 1998;351:1871-6.
  5. Knutson DD. Ultrastructural ­observations in acne vulgaris: the normal sebaceous follicle and acne lesions.J Invest Dermatol 1974;62:288-307.
  6. Leyden JJ, McGinley KJ, Mills OH, Kligman AM. Propionobacterium levels in patients with and without acne vulgaris. J Invest Dermatol 1975;65:382-4.
  7. Shalita AR. Topical acne therapy. Dermatol Clin 1983;1:399-403.
  8. Mills OH Jr, Kligman AM, Pochi P, et al. Comparing 2.5%, 5% and 10% benzoyl peroxide on inflammatory acne. Int J Dermatol 1986;25;664-7.
  9. Berson DS, Shalita AR. The ­treatment of acne; the role of ­combination therapies. J Am Acad Dermatol 1995;32:S31-41.
  10. Leyden JJ, McGinley KJ, Kligman AM. Tetracycline and minocycline treatment. Arch Dermatol 1982;118:19-22.
  11. Eady EA, Cove JH, Holland KT, et al. Erythromycin-resistant ­propionobacteria in antibiotic treated acne patients; association with ­therapeutic failure. Br J Dermatol 1989;121:51-7.

Resources
The Acne Support Group
PO Box 9 Newquay
Cornwall TR9 6WG,
UK:T:0870 8702263
W:www.m2w3.com/acne