Skincare is very important for maintaining good skin integrity and good physical appearance. It entails:
- Avoiding excessive sun exposure of to prevent damage from the UV rays
- Staying hydrated with at least the recommended amount of water intake on a day to day basis which is 64 ounces, depending on the amount of water losses during the day
- Avoiding smoking
- Application of moisturizers to keep the skin from becoming dry and cracked
- Among other things…
Many Americans are afflicted with a myriad of skin conditions ranging from acne to rosacea all the way to hidradenitis suppurativa.
Acne is the most common skin disorder in the United States. It occurs as a result of buildup of dead skin cells, oil, and even involves overgrowth of a bacteria called Propionibacterium acnes resulting in a chronic inflammatory skin condition where pimples can occur on parts of the body including the face, the chest upper back among other areas. There are four factors responsible for the formation of pimples, pus filled pockets and even irritation of the skin such as:
- Increased oil production
- Hyper keratinization, which is a rapid shedding of the skin cells inside the hair follicle leading to plugged hair follicle
- Increased colonization by bacteria that already lives inside the hair follicle called Propionibacterium acnes
- An inflammatory reaction that results
The inflammation that occurs in acne involves the pilosebaceous unit which is a hair follicle and the oil (sebaceous) gland that it is attached to. Once the unit gets plugged up with dead skin cells and oil leading to growth of bacteria a process starts to occur. The bacteria begin to break down the accumulated oils leading to substances that cause irritation of the skin and this begins the inflammatory process. Symptoms usually occur on the face, chest upper back and shoulders more commonly.
There are also forms of acne such as cystic acne called acne conglobata, as well as abscesses where pus is formed and acne that can occur with fever and arthritis, a condition called acne fulminant.
Factors that are involved in triggering acne include:
Hormones to that such as the androgens (testosterone) that are primarily responsible for severe acne
- Environmental factors such as humidity
- Excessive sweating
- Working in fast food restaurants where there are aerosolized fats that the skin is exposed to
- Mechanical such as touching, picking or squeezing acne
- Excessive scrubbing with harsh skincare products
- Certain medications such as anabolic steroids or corticosteroids
- Menstrual cycles
Acne is usually diagnosed thorough an evaluation of the skin and identifying the lesions. There’s a wide spectrum lesions that can occur most commonly on the face, neck, chest and back where there are higher concentrations of oil glands. There is noninflammatory acne, where open or closed comedones called blackheads and whiteheads, respectively, can occur. An incomplete blockage of the pilosebaceous unit from oil causes a blackhead to form also known as an open comedone. A complete blockage of it results in a white head also known as a closed comedone. This results in overgrowth of the bacteria called Propionibacterium acnes, which is normally present in the hair follicle leading to inflammatory acne, which may manifest as papules, pustules or nodules.
Differential diagnoses include:
- Bacterial folliculitis
- Hidradenitis suppurativa
- Perioral dermatitis, where papules and pustules are confined to the chin and to the nasal labial folds
- Pseudo-folliculitis barbie, where lesions occur in curly haired individuals who shave very closely and regularly
- Seborrheic dermatitis, which is a condition involving greasy scales
It is important to distinguish what kind of lesions an individual is dealing with before treating appropriately as every individual’s skin is different.
The treatment for acne involves controlling flare ups and after that it involves long term maintenance therapy. Treatment of acne generally is very simple:
- The skin should be washed once or twice a day your skin with mild soap
- Excessive scrubbing with abrasive soaps should be avoided
- Using water based because cosmetics instead of greasy products
Routine measures usually also involve educating the patient supporting them, you know, giving them treatment that’s more individualized based on the severity of acne as well as factors that are causing their acne.
Usually for mild acne, topical drugs are good such as benzoyl peroxide, retinoids or topical antibiotics which help kill bacteria and/or unclog pores.
Benzoyl peroxide has antibacterial effects and it is available over the counter. Now, benzoyl peroxide is very useful in both a noninflammatory and inflammatory acne, as it can help reduce the number of comedones both open and closed. It has anti-inflammatory properties which makes it very useful for the inflammatory lesions. It is usually used in the mornings by patients. Unique characteristic of the benzoyl peroxide is that it is known not to have bacterial resistance. This bactericidal agent comes in different concentrations and is effective for mild to moderate mixed acne. It can be used as monotherapy for the noninflammatory and inflammatory acne, but it can also be used as a combination with antibiotics and/or retinoids to treat inflammatory acne.
Retinoids such as Retin A are prescribed in low concentrations in the beginning and in frequent applications because this medication can make the skin more sensitive to sunlight. Applying sunscreen can help reduce sun sensitivity. Benzoyl peroxide can be used with topical retinoids but because benzoyl peroxide can inactivate the retinae, it is advised that the use of two things apart. Usually benzoyl peroxide is asked to be used in the morning and retinae is asked to be used in the evening so that they are not asked to be applied together. The best tolerated topical retinoid would be adapalene. But alternatives to this topical retinoid are Tazarotene as well as Retin-A.
There’s another topical therapy, that is called azelaic acid, it is considered for use in pregnancy. It is approved by the FDA for treatment of acne and it has antimicrobial and anti comedone effects and is used for mild to moderate inflammatory or mixed acne
For people who have mild to moderate acne, usually antibiotics are prescribed topically. Topical antibiotics are better for inflammatory acne or mixed acne and usually it is recommended for anything that’s mild to moderate. There are two topical antibiotics for the treatment of mild to moderate acne, erythromycin and clindamycin. Erythromycin has emerging resistance problems and so clindamycin is becoming more favorable. Clindamycin, also known as Cleocin, is a bacteriostatic and bactericidal, which helps heal the skin better by eradicating the bacteria that is responsible for irritation. Sometimes they’re used as monotherapy but oftentimes they can be in combination with a topical retinoids.
Topical antibiotics and/or oral antibiotics are options for moderate acne. Typically, the oral or systemic antibiotics include:
- Tetracycline 250 mg four times a day or 500 mg twice a day
- Minocycline 50 mg twice a day or 100 mg daily
Again, these can be given in combination with topical antibiotics or alone for a duration of weeks to months or even years in order to prevent recurrence. One of the things to look out for in women who are on antibiotics are antibiotic induced yeast infections. Oftentimes, woman need to use over the counter antifungal vaginal suppositories to help counter these effects of the antibiotics or your doctor may even prescribe an oral antifungal agent to use while you on antibiotic regimen.
Oral antibiotics for more moderate to severe acne. The American Academy of Dermatology recommends using doxycycline and minocycline rather than tetracycline again due to emerging resistance problems. Bactrim or trimethoprim alone can be used if the tetracycline cannot be tolerated. Due to resistance problems the use of an oral antibiotic usually is recommended with the benzoyl peroxide to help curb that problem.
Accutane is used for severe acne. It helps in reducing oil production. Usually in doses of 0.5 to 1 mg per kg body weight per day for at least 20 weeks. Initial flare ups can be minimized. Physicians usually help prevent pregnancy in patients taking this medication, especially if this is a woman who is reproductive aged, sexually active without birth control. It causes abnormalities of the face, eyes, skull, central nervous system, heart, thymus and the parathyroid glands in the developing fetus. It is very important to check a woman with a pregnancy test and make sure it is a negative pregnancy test before starting therapy and to recheck for pregnancy every month before refilling the prescription. So women who are taking it must be on contraceptive so they do not become pregnant while they’re on Accutane.
Accutane can cause side effects such as depression and increase the risk of suicide so it’s important to assess the patient from time to time for depression symptoms. It can also cause abnormalities in cholesterol levels and liver enzymes so a doctor must order labs from time to time to look for this. Other common side effects are dry mucous membranes leading to cracking of these areas, which can be painful.
Women who experience acne that worsens around their menstrual cycle can be given oral contraceptives (low dose estrogen birth control such as ortho tri cyclin) to help treat their acne. Sometimes the use of oral contraceptives could help with women who have adult onset acne and are having premenstrual flare ups. If she is experiencing high androgen levels, resulting in excessive hair and worsening acne, oral contraceptives can help best.
Also, spironolactone, a potassium sparing diuretic, is used in treatment of acne especially due to its effects of blocking the androgen receptors. Because it is a potassium sparing diuretic, it may cause elevated potassium levels and this needs to be monitored through blood tests. It can be prescribed in a dose of 150 to 200 daily.
Complications include scarring, a more permanent condition that results from an individual picking or squeezing their acne. Squeezing pimples or trying to open them increases inflammation and the depth of injury to our skin, making scarring more likely to last a lifetime, and can really be your source of stress, and many patients will seek out treatment at our dermatologists office for cosmetic reasons to maintain skin appearance.
A condition called rosacea is not only inflammation of the same pilosebaceous unit, mostly of the face, but it too is a chronic condition. In addition, it also involves increased reactivity of the smallest blood vessels in our body called the capillaries that respond to heat leading to flushing.
The most common age group that rosacea occurs is usually 30 to 50 years, and women are more affected than men. It usually happens in the northern European populations. The history will be very specific where consumption of hot liquids or exposure to heat may worsen the flushing. Alcohol can increase the flushing also and is noted on physical exam usually present on the face involving the cheeks the chin, nose and forehead. Treatment involves limiting alcohol intake or hot beverage intake and application of topicals that are prescribed by your provider such as a topical antibiotic called Metro gel. It’s prescribed as 0.75% strength applied to the skin twice a day, or even a 1% gel or a 1% cream that’s applied once daily and it can take up to one to two months for a response. Other treatments include:
- Azelaic acid in a cream or gel form applied twice daily.
- Benzoyl peroxide can be applied once or twice