Dr Aileen McPhillips discusses the management of acne vulgaris with cosmeceutical topical treatments and presents two case studies
Acne is an inflammatory skin condition that most commonly occurs during puberty or teenage years.1 However, this is not always the case. In fact, acne is the eighth most common skin disease worldwide1 and therefore it is something we see, as medical professionals, frequently in practice. Many adults continue to have acne well into their 30s and beyond. It is not uncommon for acne to develop for the first time in adulthood.
Research has suggested that acne persists into the 20s and 30s in around 64% and 43% of individuals, respectively, however a much lower percentage will seek professional treatment.2 I find that this is because people ‘learn to live with it’ or wait for the condition to self-resolve. This article will look at how an effective skincare regimen with medical-grade products can provide a satisfactory long-term outcome for patients with mild-moderate acne.
First of all, it is important to note that acne can have long-term consequences. The longer the acne is present, the more likely scarring or an impact on psychological wellbeing can occur. Research has shown that the presence of acne can negatively affect quality of life, self-esteem and mood, along with increasing anxiety, depression and suicidal ideation amongst patients of all age groups.3-6 Therefore, early recognition and treatment is key.
Acne is a common inflammatory skin condition affecting the pilosebaceous units of the skin.7 It consists of open comedones (blackheads), closed comedones (whiteheads) and inflammatory lesions, such as nodules, pustules and papules.7
The four pathological factors involved in the development of acne are; increased sebum production, irregular follicular desquamation, propionibacterium acnes proliferation and inflammation of the area.8 In my experience, a successful treatment for acne will generally aim to reduce oil production, speed up skin cell turnover, fight bacterial infection and/or reduce inflammation – which helps prevent scarring.8 The goal of acne treatments is to control and treat existing lesions, prevent permanent scarring, limit the duration of the disorder and minimise morbidity.8 Patients are often initially treated with topical agents, such as benzoyl peroxide, retinoids or antibiotics.
Depending on response and/or severity they may be treated with systemic treatments, such as oral antibiotics, hormonal treatments (contraceptive pill) or isotretinoin.9-11 I have prescribed many of these treatment options whilst working in general practice – with variable outcomes.
However, I often felt management options within primary care were lacking. Topical treatments available on the NHS, although effective in some patients, generally do not contain the added ingredients that cosmeceuticals have for additional skin benefits and soothing effects, therefore are often more difficult for patients to tolerate, due to skin irritation. I have found that this can lead to lack of treatment compliance.12
Within my aesthetic practice there are many treatment options available to patients, including the use of cosmeceutical topical treatments. I have found that patients often decline systemic treatment due to potential adverse effects, discussed in more detail below. It is my experience that many patients are reluctant to take antibiotics long term given the potential side effects, such as gut disturbance and the increasing concern regarding antibiotic resistance. Another systemic treatment option is isotretinoin which has many potential significant side effects.10
Although not common, serious side effects include mental health disturbance, raised intracranial pressure, inflammatory bowel disease and hepatitis.10 As the medicine is teratogenic, patients must not become pregnant whilst taking it and it is advised that they should use two forms of contraception during treatment.11 With all of this in mind, it is understandable that many patients do not want to opt for this treatment approach.
Once I have discussed all of the above with my patients, I then consider what topical treatments would be most beneficial to them. The main ingredients in such treatments that have been shown to be of benefit include salicylic acid, benzoyl peroxide, sulphur, alpha-hydroxy acids and retinoids.12,13 I will discuss these in more detail below.
Salicylic acid has keratolytic and comedolytic properties along with being mildly antiinflammatory. Salicylic acid produces desquamation of hyperkeratotic epithelium by dissolving the intercellular cement.14 It works as an exfoliant and prevents comedonal acne by slowing follicular shedding of cells and therefore prevents clogging of follicles.15 It also decreases secretion of sebum,6 which is an added benefit in patients with acne.
A number of studies have shown the benefit of using salicylic acid in the management of acne. One study demonstrated that twice daily use of 2% salicylic acid impregnated pads showed significant benefit over placebo at four, eight and 12 weeks where total lesion counts were assessed.16 A further review of three placebo-controlled studies concluded that the use of salicylic acid pads reduced the number of primary lesions and therefore the number and severity of all lesions associated with acne.17
A doubleblind, placebo-controlled trial looked at the use of 2% salicylic acid cleanser in the treatment of acne.18 Thirty patients with mild-moderate acne were reviewed over an eight week period. Expert grading of lesions was performed at regular intervals through the study period. Results showed that the cleanser was well tolerated and provided significant reduction in acne lesion counts throughout the entire study interval.
The mode of action of benzoyl peroxide in acne is three-fold; reduction of sebum, comedolysis and inhibition of p.acnes.19 Its lipophilic properties permit penetration of the pilosebaceous duct and its efficacy is largely related to superficial inflammatory lesions.9
Benzoyl peroxide has been used as an effective treatment for many years. A systemic review of randomised vehiclecontrolled trials for determining the efficacy of benzoyl peroxide topical therapy reviewed 12 trials with 2,818 patients receiving benzoyl peroxide and 2,004 receiving vehicle treatment. Results showed that the average percentage reduction in total number of acne lesions was significantly more for the treatment group versus the vehicle group – 44.3% versus 27.8% reduction and 41.5% versus 27% reduction in non-inflamed lesions.20 Another study compared benzoyl peroxide to topical erythromycin and found that although both preparations showed similar reduction of inflamed lesions, the benzoyl peroxide also significantly reduced the number of non-inflamed lesions.21
Benzoyl peroxide formulations may contain a range of particle sizes. Benzoyl peroxide is often micronised, which ensures a consistent particle size. It has been suggested that micronised benzoyl peroxide particles that are smaller than the follicular orifice (approximately 10μm) penetrate the pilosebaceous unit more effectively.22 A smaller particle size may increase anti-acne efficacy by enhancing bioavailability and intra-follicular penetration of the benzoyl peroxide.22
Sulphur is used to treat various skin conditions due to its anti-inflammatory and antibacterial properties. It inhibits bacterial dihydropteroate synthase within the skin. This prevents the conversion of p-aminobenzoic acid to folic acid, which causes a bacteriostatic effect on the growth of several gram-negative and gram-positive organisms, including p.acnes.23
It is also reported to have a keratolytic effect, along with absorbing excess sebum. The keratolytic action is due to the formation of hydrogen sulphide through a reaction that depends upon direct interaction between sulphur particles and keratinocytes.24 The combined antibacterial action and drying properties have been shown to reduce the number of inflammatory lesions and comodones.23 A study was carried out looking at the effect of a topical sodium sulfacetamide/sulphur lotion on patients with mild-moderate acne. Results showed a 78% reduction of total acne lesion count and 83% reduction of inflammatory acne lesions over a 12-week period, with all participants reporting significant clinical improvement by the end of the study period.25
Alpha-hydroxy acids (AHAs), in particular glycolic acid, are a class of chemical compounds frequently used in dermatology.26 AHAs induce desquamation and keratolysis, meaning they have been shown to be of benefit in acne patients.26
Depending on the pH of the finished products, they also exhibit comedolytic as well as antimicrobial properties.26 A randomised double-blind placebo-controlled trial was carried out to look at the effect of 10% glycolic acid oil-in-water emulsion as monotherapy in mild acne. The results showed the acne improved significantly after 45 days and continued to improve up to the 90-day study period.27 Baldo et al. reviewed the tolerability and efficacy of a cream with a mix of AHAs in 248 patients with mild-moderate acne in a multicenter, nonrandomised, open study in 2010.28 Results confirmed high tolerability (scoring good to excellent) and efficacy (high in 64.2%) of the AHA-based cream.
Recent evidence-based guidelines from the American Academy of Dermatology and the European S3 guidelines from the European Dermatology Forum have agreed that retinoids have an essential role in the management of acne.29,30 Retinoids function by slowing the desquamation process, therefore decreasing the number of comedones and microcomedones; they are the most effective comedolytic agent in use and are also anti-inflammatory.31
Evidence has shown that topical retinoids are effective in reducing the number of comedones and inflammatory lesions by around 40 to 70%.32 Efficacy may improve with higher concentrations of product, however these preparations may be more difficult to tolerate due to risk of irritation.32 A randomised controlled trial was carried out to compare the retinoid adalapene 0.3% against adapalene 0.1% and gel vehicle only.
Within the trial, 653 patients were randomly allocated to each treatment and observed over 12 weeks. A consistent, dosedependent effect was demonstrated for all efficacy measures, showing that adapalene gel was more effective than placebo and efficacy further improves with higher potency.33 A systemic review was carried out to evaluate the efficacy, safety and tolerability of topical retinoids in the treatment of acne vulgaris.34 During this, 54 clinical trials were included and reviewed. It was concluded that retinoids are safe and efficacious for the treatment of acne vulgaris, however should be used in combination with benzoyl peroxide to optimise results in patients.
Based on what I have discussed in this article, I ensure that I include the mentioned ingredients in my clinical practice and look for skincare that incorporates this. Following a thorough history and skin examination, I establish the patient concerns and expectations. Skincare options and regimens are discussed, along with the timeframe required and long-term plan. I have found that best results are achieved when the patient uses several products in combination on a regular basis. The combination aims to address the mechanisms of pathogenesis as discussed previously; reduce oil production, speed up skin cell turnover, fight bacterial infection and/or reduce inflammation. Review appointments are arranged to allow the patient and practitioner to assess progress. I feel this aids treatment compliance and allows for alteration of management as required.
Although topical treatments are generally well tolerated, some topical treatments may cause local skin irritation, especially at higher doses.34 This may limit patient compliance. Acne treatments with the active ingredients mentioned previously are often not recommended for use in pregnancy, due to absence of safety data and lack of evidencebase.35 Length of time required for effective treatment may also be a limiting factor.
Most topical preparations require at least six to eight weeks before an improvement is seen and at least six to eight months for significant benefit.36 I arrange regular review appointments with each patient as this allows time to discuss how the treatment plan is going along with reviewing photographs.Patients are generally more motivated when they can see changes and improvement.
Treatment with topical agents may be more difficult if acne lesions cover a larger body area (for example, face and back) and so systemic treatment may be more appropriate. As well as this, cost of cosmeceutical products is also a consideration in long-term treatment. To manage this, I always form a long-term plan and discuss cost at initial consultation so patients are aware from the beginning.
Topical treatments are not suitable to treat severe acne, which may include cysts or nodules. Assessment and management by a dermatologist is advised.
Acne is an extremely common condition affecting a wide age range of patients. It can have severe and long-term consequences, therefore early and effective treatment is important in the management of this patient group. An effective topical treatment regimen, with medical-grade ingredients can provide successful and long-term treatment with minimal negative impact on the patient.