Nurse prescriber Amanda Wilson shares an introductory overview of treatment options for acne concerns
Acne is a very common skin disease seen in aesthetic medicine which affects up to 80% of young adults and adolescents, although it can be seen across all age groups.1 It affects the pilosebaceous unit of the skin and, if not well managed, it can leave the patient with severe acne scarring. It may also have significant psychological impact on the patient, sometimes leading to loss of self-esteem and depression, as well as physical symptoms such as soreness and pain.1,2 Several factors contribute to the pathogenesis of acne, including follicular epidermal proliferation, excess sebum production, inflammation and the presence of Propionibacterium (p.acne) bacteria (Figure 1).2 Early treatment intervention for these patients is key to reduce the risk of acne scarring, which can be difficult to manage, often needing multiple modalities to treat, some of which will be discussed later in this article.
Acne
In aesthetics, a number of different treatment modalities have been developed to treat acne; a full patient assessment is crucial in order for them to have appropriate treatment options prescribed to help improve the acne and reduce the risk of scarring. Many clinical papers look at the use of different topical and oral treatment modalities, the main treatment options being:1-4
Systemic (retinoids, antibiotics and hormonal control)
Oral antibiotics (tetracyclines such as lymecycline or doxycycline)
According to the 2018 National Institute for Health and Care Excellence (NICE) guidelines for the management of patients with mild to moderate acne, a topical retinoid is the first-line treatment option used alone or in combination with topical benzyol peroxide.5
Figure 1: Pathogenic factors contributing to the normal development of acne1
Oral therapy should be considered where first line treatment with retinoid +/- antimicrobial fails. It relies on patients complying with their treatment regime and has a high side effect profile, including peeling and irritation. There is also the risk of antibiotic resistance; therefore topical medication has been considered as the mainstay of treatment in patients with mild to moderate acne – nodular and cystic acne is excluded from this.2 It is essential for practitioners to counsel patients effectively on the use of these products and the side effects that can be associated with them. Topical retinoids work by expelling mature comedones, reducing the microcomedone formation and exerting anti-inflammatory effects. They can be prescribed alongside topical or oral antibiotics if inflammatory acne is present.6 As the topical retinoids are able to target the hyperproliferation and hyperseborrhea, they can prevent the central precursor to lesson formation of inflammatory comedones, papules and pustular nodules.
As they exert a very good safety profile and have no antibiotic resistance, they are safe as long-term medications. Combination therapies using benzoyl peroxides (BPO) or antibiotics can treat existing acne lesions faster than individual use (see diagram below for types of acne and treatment options).4
Sinott et al, 2016 and Walsh, 2016, showed that there were high levels of antibiotic resistance to certain antibiotic groups, namely the macrolides and clindamycin, which have been commonly resistant in studies carried out across the globe.4,7 Antibiotic resistance has been shown by Walsh to be as high as 50%.4 As antibiotics can be added into treatments for patients, the choice of antibiotic should be carefully considered to reduce the risk. In the case of the decision to use long-term antibiotics, there should always be a BPO in addition.4,8
Figure 2: Pathogenesis of acne resulting in inflammation1
Adding BPO product kills the bacteria and reduces the risk of developing antibiotic resistance. A case study using Obagi Nuderm MD System which contains 5% BPO is demonstrated in Figure 7. As antibiotic resistance is a major increasing concern, practitioners should, where possible, avoid the use of macrolides and tetracyclines as these have a corresponding rate of antibiotic resistance of 65% and 20%.2,4 Cyclines (such as lymecycline and doxycycline) have shown to be preferable for use in the treatment of acne patients due to their reduced antibiotic resistance.2 Other antibiotics should only be used where there is no other option due to allergies/contraindications. Before the use of isotretinoin, there is often a trial of antibiotics to see if this can control the acne; if ineffective patients can then be referred to secondary care. There is clearly a need for further guidance due to conflicting information from various sources, for example, the NICE guidelines state that antibiotics can be continued for up to six months,5 whereas the American Academy of Dermatology and other authors3-6 agree that antibiotic usage should be limited to three months. Given the global increase in antibiotic resistance there is a perceived need for greater evidence around antibiotic usage for acne patients.
Figure 3: Algorithm to improve outcomes in acne treatment4
Scarring
Facial scarring as a complication from acne can occur in up to 95% of patients and affects both sexes equally.9 The high incidents highlight the need for early intervention to prevent acne scarring, which requires multimodalities for treatment and can be frustrating for patients. For acne scarring, the treatment decided upon will depend on the type of acne scar. The types commonly encountered are ice pick scars, rolling scars and box pick scars (Figure 4).8 The most common type of scar seen on the face is atrophic, while keloid and hypertrophic are more often seen on the trunk.9 Treatment options include laser resurfacing (CO2 and YAG), microneedling, TCA peels, dermal fillers and autologous fat transfer. Acne scars result from an altered woundhealing response to cutaneous inflammation with inflammatory cell infiltrates found in 77% of atrophic scar tissue.8 Severity of the formation of acne is down to the phylotypes; these differentially activate epidermal innate immunity.8 Generalised, atrophic scars are the most common, seen in 80-90% of patients. A multimodality approach is often needed using a combination of lasers, chemical peels, dermabrasion, microneedling and radiofrequency.8
Caution needs to be taken in patients with Fitzpatrick IV-VI as these patients can develop erythema, transient or permanent dyschromias and hypertrophic scarring in all of the above procedures.9
Figure 4: Types of acne scars8
Microneedling
Microneedling is an effective and well-researched treatment option for acne scarring. It works most effectively for rolling scars and box pick scarring; however, when combined with radiofrequency it can also work well for ice pick scar tissue. Harris et al., 2015, showed significant improvement of scar tissue with microneedling treatment of up to 31% as scored by the patient groups.10
Fabbrocini et al., 2014, looked at microneedling for all skin types Fitzpatrick I-VI and found there were variations in the side effects following on from treatment. Phototypes I-II showed more posttreatment erythema than phototypes III-VI; regardless of the intensity, this did disappear after 24-48 hours in all groups. There were also no hyper or hypo-pigmentation changes in any of the groups, or hypertrophic scar formation, making the complication rate very low.9
Figure 5: Effectiveness of treatments for acne scarring8
The skin needling triggers a cascade of growth factors that then stimulate wound healing; these include inflammatory, proliferative and the remodeling phase. This causes a release of growth factors including platelet-derived growth factor (PDGF), fibroblast growth factor (FGF), epidermal growth factor (EGF), transforming growth factor and alpha and beta (TGF-a and TGF-b). The histology of fibroblast cells are shown to proliferate within 48 hours of needling, particularly collagen type 3, which is gradually replaced with collagen type 1.8,9 The major advantages of this type of procedure over chemical peels and laser resurfacing is that it is minimallyinvasive with rapid healing and low downtime. The results can be observed eight to 12 months postoperatively and as the epidermis regenerates quickly, this can avoid some of the negative side effects of a chemical peel, dermabrasion or laser skin resurfacing. The procedure can safely be performed on Fitzpatrick I-VI, with pigment complications low to nil.8,9
Chemical peels
Peels can be used to effectively treat scar tissue. The depth of the peel selected will be dependent on the depth of the scar tissue to be treated. Peels vary according to their chemical ingredient; medium to deep depth peels are often required for treatment of scar tissue and solutions for this include TCA peels. These peels can reach the papillary dermis, whereas deep peels (phenol) can go as deep as the mid to reticular dermis in the skin. These peels do, however, carry a higher level of risk with prolonged erythema, infection, PIH, scarring, as well as cardiac toxicity related to the systemic absorption of the peels.8 Therefore the medium depth peels are sometimes preferred by both practitioners and patients due to their lower complication risks.
Figure 6: Before and after one treatment of Intracel microneedling with RF for ice pick acne scarring. A course of three treatments was recommended.
Figure 7: Before and after 25 weeks of using Clenziderm MD system with 5% BPO, from the Obagi Medical range, for treatment of an active acne patient.
Summary
Acne scarring is a common problem facing a significant number of patients and many seek treatment for cosmetic improvement. Treating acne early needs to be a priority for practitioners to avoid the complications of acne scarring. Treatment options need to be tailored depending on the type of scars the patients present with and then a patient-centered, multi-step approach that takes into account the type of acne scarring and patient goals will achieve the highest satisfaction and good cosmetic results.
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