Preferred treatments by types of acne vulgaris

Comedonal (non-inflammatory) acne: local treatment with azelaic acid, salicylic acid, topical retinoids, benzoyl peroxide.Mild papulo-pustular (inflammatory) acne: benzoyl peroxide or topical retinoids, topical antibiotics (such as erythromycin).Moderate inflammatory acne: benzoyl peroxide or topical retinoids combined with oral antibiotics (tetracyclines). Isotretinoin is an option.Severe inflammatory acne, nodular acne, acne resistant to the above treatments: isotretinoin also known as Accutane, can be prescribed by a doctor, or contraceptive pills with cyproterone for females with virilization or drospirenone

Acne scars

Richard L. Gallo and colleagues recently noticed that patients with rosacea had elevated levels of the peptide cathelicidin and elevated levels of stratum corneum tryptic enzymes (SCTEs). Antibiotics have been used in the past to treat rosacea, but antibiotics may only work because they inhibit some SCTEs. See the August 5, 2007 issue of Nature Medicine for details.Rosacea has a hereditary component and those that are fair-skinned of European or Celtic ancestry have a higher genetic predisposition to developing it. Women are more commonly affected. People of all ages can get rosacea but there is a higher instance in the 30-50 age group. The first signs of rosacea are said to be persisting redness due to exercise, changes in temperature, and cleansing.It has also been hypothesised that rosacea is in fact a neurological disorder resulting from hypersensitization of sensory neurons by bradykinin following activation of the plasma kallikrein-kinin system due to exposure to intestinal bacteria in the digestive tract.[11] This hypersensitivity then produces neurogenic inflammation upon dermal stimulation causing the flushing symptoms and vasodilation that are characteristic of the disorder. This hypothesis has been recently supported by the finding that rosacea patients exhibit a very significantly increased prevalence of bacterial overgrowth in the small intestine vs. controls (p<0.001)>[12]Triggers that cause episodes of flushing and blushing play a part in the development of rosacea. Exposure to temperature extremes can cause the face to become flushed as well as strenuous exercise, heat from sunlight, severe sunburn, stress, anxiety, cold wind, moving to a warm or hot environment from a cold one such as heated shops and offices during the winter. There are also some foods and drinks that can trigger flushing, these include alcohol, foods and beverages containing caffeine (especially, hot tea and coffee), foods high in histamines and spicy food.Certain medications and topical irritants can quickly progress rosacea. If redness persists after using a treatment then it should be stopped immediately. Some acne and wrinkle treatments that have been reported to cause rosacea include microdermabrasion, chemical peels, high dosages of isotretinoin, benzoyl peroxide and tretinoin. Steroid induced rosacea is the term given to rosacea caused by the use of topical or nasal steroids. These steroids are often prescribed for seborrheic dermatitis. Dosage should be slowly decreased and not immediately stopped to avoid a flare up.Studies of rosacea and demodex mites have revealed that some people with rosacea have increased numbers of the mite, especially those with steroid induced rosacea.[13] When large numbers are present they may play a role along with other triggers. On other occasions Demodicidosis (Mange) is a separate condition that may have "rosacea-like" appearances.[14]Rosacea is a systemic disease. There is no study that shows a long-term benefit of topical treatment alone. Typical signs in the facial region or the chest are always accompanied by other symptoms. The vascular disfunction provoke local hypoxemia (face, extremities, bowels). Sometimes these minor symptoms remain unrecognized. Vascular dysfunction, hypoxemia and the temporal obstruction of the orthograde intestinal passage induce a vicious circle with maldigestion and bacterial overgrowth syndrome.

See Acne scarring.Acne often leaves small scars where the skin gets a "volcanic" shape.Physical acne scars are often referred to as "Icepick" scars. This is because the scars tend to cause an indentation in the skin's surface. There are a range of treatments available. Although quite rare, the medical condition Atrophia Maculosa Varioliformis Cutis results in "acne like" depressed scars on the face.Ice pick scars - Deep pits, that are the most common and a classic sign of acne scarring.Box car scars - Angular scars that usually occur on the temple and cheeks, and can be either superficial or deep, these are similar to chickenpox scars.Rolling scars - Scars that give the skin a wave-like appearance.Hypertrophic scars - Thickened, or keloid scars.

Grading scale

There are multiple grading scales for grading the severity of acne vulgaris,[51] three of these being: Leeds acne grading technique: Counts and categorises lesions into inflammatory and non-inflammatory (ranges from 0-10.0). 'Cook's acne grading scale: Uses photographs to grade severity from 0 to 8 (0 being the least severe and 8 being the most severe). Pillsbury scale: Simply classifies the severity of the acne from 1 (least severe) to 4 (most severe).

Blackhead

A blackhead (medically known as an open comedo[1] , plural comedones [2]) is a yellowish or blackish bump or plug on the skin. A blackhead is a type of acne vulgaris. It is caused by excess oils that have accumulated in the sebaceous gland's duct. The substance found in these bumps mostly consists of keratin and modified sebum (an oily secretion of the sebaceous gland), which darkens (resembling dirt) as it oxidizes

Keratosis pilaris

Keratosis pilaris (KP, also follicular keratosis) is a very common genetic follicular condition that is manifested by the appearance of rough bumps on the skin and hence colloquially referred to as "chicken skin". It most often appears on the back and outer sides of the upper arms (though the lower arms can also be affected), and can also occur on the thighs and tops of legs, flanks, buttocks or any body part except glabrous skin (like the palms or soles of feet). Less commonly, lesions appear on the face and may be mistaken for acne

Classification

Worldwide, KP affects an estimated 40 to 50% of the adult population and approximately 50%-80% of all adolescents. It is more common in women than in men. Varying in degree, cases of KP can range from minimal to severe.There are several different types of keratosis pilaris, including: keratosis pilaris rubra (red, inflamed bumps), alba (rough, bumpy skin with no irritation), rubra faceii (reddish rash on the cheeks) and related disorders.Many people with keratosis pilaris do not know they have it. While KP resembles goose bumps, it is characterized by the appearance of small rough bumps on the skin. As a result, it is often confused with acne. Squeezing them may cause bleeding and eventually scarring.

Symptoms and signs

Keratosis pilaris occurs when the human body produces excess keratin, a natural protein in the skin. The excess keratin, which is cream color, surrounds and entraps the hair follicles in the pore. This causes the formation of hard plugs (process known as hyperkeratinization). Bearing only cosmetic consequence, the condition most often appears as a proliferation of tiny hard bumps that are seldom sore or itchy. Though people with keratosis pilaris experience this condition year round, it’s during the colder months when moisture levels in the air are lower that the problem can become exacerbated and the “goose bumps” are apt to look and feel more pronounced in color and texture.Many KP bumps contain an ingrown hair that has coiled. This is a result of the keratinized skin "capping off" the hair follicle, preventing the hair from exiting. Instead, the hair grows inside the follicle, often encapsulated, and can be removed, much like an ingrown hair, though removal can lead to scarring.

Treatment

There is currently no known cure for keratosis pilaris, however, there are effective treatments available which make its symptoms less apparent. The condition often improves with age and can even disappear completely in adulthood, though some will show signs of keratosis pilaris for life. Some treatments are largely symptomatic and may need repeating. Regardless, exfoliation, intensive moisturizing cremes, lac-hydrin, topical retinoids such as Retin A and medicated lotions containing alpha hydroxy acids or urea may be used to temporarily improve the appearance and texture of affected skin.Depending upon the severity of keratosis pilaris in a patient, some who have the disorder may be prescribed Triamcinolone Acetonide cream. The cream is a synthetic corticosteroid and is highly effective in reducing the amount of keratin in pores. It often dramatically reduces the visibility of the red, inflamed bumps and leaves patients with xeroderma feeling as if their dry skin has been quenched. Triamcinolone is typically applied after bathing once every one to two days.Also, beta hydroxy acids can help improve the appearance and texture of the afflicted skin. Milk baths may provide some cosmetic improvement due to the lactic acid—a natural alpha hydroxy acid in milk.[citation needed] Sunlight may also be helpful but increases risk of skin cancer. Coconut oil may also be helpful if applied to afflicted areas while in the shower.[citation needed] Scratching and picking at KP bumps causes them to redden, and in many cases will cause bleeding. Excessive picking can lead to scarring. Wearing clothing that is looser around the affected areas can also help reduce the marks, as constant chafing from clothing (such as tight fitting jeans) is similar to repeatedly scratching the bumps.

Rosacea

Rosacea is a common but often misunderstood condition that is estimated to affect over 45 million people worldwide. It affects mostly caucasians of mainly north-western European descent, and has been nicknamed the 'curse of the Celts' by some in Britain and Ireland, but can affect African Americans and Hispanics also. It begins as erythema (flushing and redness) on the central face and across the cheeks, nose, or forehead but can also less commonly affect the neck and chest. As rosacea progresses, other symptoms can develop such as semi-permanent erythema, telangiectasia (dilation of superficial blood vessels on the face), red domed papules (small bumps) and pustules, red gritty eyes, burning and stinging sensations, and in some advanced cases, a red lobulated nose (rhinophyma). The disorder can be confused with, and co-exist with acne vulgaris and/or seborrhoeic dermatitis. Rosacea affects both sexes, but is almost three times more common in women, and has a peak age of onset between 30 and 60. The presence of rash on the scalp or ears suggests a different or co-existing diagnosis, as rosacea is primarily a facial diagnosis.

Subtypes and symptoms

There are four identified rosacea subtypes[1] and patients may have more than one subtype present.Erythematotelangiectatic rosacea: Permanent redness (erythema) with a tendency to flush and blush easily. It is also common to have small blood vessels visible near the surface of the skin (telangiectasias) and possibly burning or itching sensations.Papulopustular rosacea: Some permanent redness with red bumps (papules) with some pus filled (pustules) (which typically last 1-4 days); this subtype can be easily confused with acne.Phymatous rosacea: This subtype is most commonly associated with rhinophyma, an enlargement of the nose. Symptoms include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea can also affect the chin (gnatophyma), forehead (metophyma), cheeks, eyelids (blepharophyma), and ears (otophyma).[2] Small blood vessels visible near the surface of the skin (telangiectasias) may be present.Ocular rosacea: Red, dry and irritated eyes and eyelids. Some other symptoms include foreign body sensations, itching and burning.There have been other descriptive terms applied to presentations of rosacea, but these are not formally accepted as subtypes of rosacea:[3]Granulomatous rosacea.[4]The rare and severely scarring Rosacea fulminans (pyoderma faciale) occurring exclusively in women after adolescence and most commonly in their early 20s,[5][6]Perioral dermatitis, which is better described as periorificial dermatitis, but similarly treated with topical metronidazole.[7]Persistent edema of rosacea.[citation needed]Rosacea Conglobata.[citation needed]Persisting redness and oedema of the upper half of the face has been termed Morbihan disease.[8][9]Rosacea sufferers often report periods of depression stemming from cosmetic disfigurement, painful burning sensations, and decreases in quality of life

Causes

Richard L. Gallo and colleagues recently noticed that patients with rosacea had elevated levels of the peptide cathelicidin and elevated levels of stratum corneum tryptic enzymes (SCTEs). Antibiotics have been used in the past to treat rosacea, but antibiotics may only work because they inhibit some SCTEs. See the August 5, 2007 issue of Nature Medicine for details.Rosacea has a hereditary component and those that are fair-skinned of European or Celtic ancestry have a higher genetic predisposition to developing it. Women are more commonly affected. People of all ages can get rosacea but there is a higher instance in the 30-50 age group. The first signs of rosacea are said to be persisting redness due to exercise, changes in temperature, and cleansing.It has also been hypothesised that rosacea is in fact a neurological disorder resulting from hypersensitization of sensory neurons by bradykinin following activation of the plasma kallikrein-kinin system due to exposure to intestinal bacteria in the digestive tract.[11] This hypersensitivity then produces neurogenic inflammation upon dermal stimulation causing the flushing symptoms and vasodilation that are characteristic of the disorder. This hypothesis has been recently supported by the finding that rosacea patients exhibit a very significantly increased prevalence of bacterial overgrowth in the small intestine vs. controls (p<0.001)>[12]Triggers that cause episodes of flushing and blushing play a part in the development of rosacea. Exposure to temperature extremes can cause the face to become flushed as well as strenuous exercise, heat from sunlight, severe sunburn, stress, anxiety, cold wind, moving to a warm or hot environment from a cold one such as heated shops and offices during the winter. There are also some foods and drinks that can trigger flushing, these include alcohol, foods and beverages containing caffeine (especially, hot tea and coffee), foods high in histamines and spicy food.Certain medications and topical irritants can quickly progress rosacea. If redness persists after using a treatment then it should be stopped immediately. Some acne and wrinkle treatments that have been reported to cause rosacea include microdermabrasion, chemical peels, high dosages of isotretinoin, benzoyl peroxide and tretinoin. Steroid induced rosacea is the term given to rosacea caused by the use of topical or nasal steroids. These steroids are often prescribed for seborrheic dermatitis. Dosage should be slowly decreased and not immediately stopped to avoid a flare up.Studies of rosacea and demodex mites have revealed that some people with rosacea have increased numbers of the mite, especially those with steroid induced rosacea.[13] When large numbers are present they may play a role along with other triggers. On other occasions Demodicidosis (Mange) is a separate condition that may have "rosacea-like" appearances.[14]Rosacea is a systemic disease. There is no study that shows a long-term benefit of topical treatment alone. Typical signs in the facial region or the chest are always accompanied by other symptoms. The vascular disfunction provoke local hypoxemia (face, extremities, bowels). Sometimes these minor symptoms remain unrecognized. Vascular dysfunction, hypoxemia and the temporal obstruction of the orthograde intestinal passage induce a vicious circle with maldigestion and bacterial overgrowth syndrome

Treatments

Treating rosacea varies from patient to patient depending on severity and subtypes. A subtype-directed approach to treating rosacea patients is recommended to dermatologists.[15]Trigger avoidance can help reduce the onset of rosacea but alone will not normally cause remission for all but mild cases. The National Rosacea Society recommends that a diary be kept to help identify and reduce triggers. A recent publication discusses how managing pre-trigger events such as prolonged exposure to cool environments can directly influence warm room flushing.[16]It is important to have a gentle skin cleansing regimen using non-irritating cleansers. Protection from the sun is important and daily use of a sunscreen of at least SPF 15 containing a physical blocker such as zinc oxide or titanium dioxide is advised although chemical sunscreens, if non-irritating to the skin, are also an option.Oral tetracycline antibiotics (tetracycline, doxycycline, minocycline) and topical antibiotics such as metronidazole are usually the first line of defense prescribed by doctors to relieve papules, pustules, inflammation and some redness.[17] Topical azelaic acid such as Finacea (15%) or Skinoren (20%) may help reduce inflammatory lesions, bumps and papules. Oral antibiotics may help to relieve symptoms of ocular rosacea. If papules and pustules persist, then sometimes isotretinoin can be prescribed.[18] Isotretinoin has many side effects and is normally used to treat severe acne but in low dosages is proven to be effective against papulopustular and phymatous rosacea.The treatment of flushing and blushing has been attempted by means of the centrally acting α-2 agonist clonidine, but there is no evidence whatsoever that this is of any benefit. The same is true of the beta-blockers nadolol and propanolol. If flushing occurs with red wine consumption, then complete avoidance helps. There is no evidence at all that antihistamines are of any benefit in rosacea.People who develop infections of the eyelids must practice frequent eyelid hygiene. Daily scrubbing the eyelids gently with diluted baby shampoo or an over-the-counter eyelid cleaner and applying warm (but not hot) compresses several times a day is recommended.Dermatological vascular laser (single wavelength) or Intense Pulsed Light (broad spectrum) machines offer one of the best treatments for rosacea, in particular the erythema (redness) of the skin.[19] They use light to penetrate the epidermis to target the capillaries in the dermis layer of the skin. The light is absorbed by oxy-hemoglobin which heat up causing the capillary walls to heat up to 70 ºC, damaging them, causing them to be absorbed by the body's natural defense mechanism. With a sufficient number of treatments, this method may even eliminate the redness altogether, though additional periodic treatments will likely be necessary to remove newly-formed capillaries.CO2 lasers can be used to remove excess tissue caused by phymatous rosacea. CO2 lasers emit a wavelength that is absorbed directly by the skin. The laser beam can be focused into a thin beam and used as a scalpel or defocused and used to vaporise tissue. Low level light therapies have also been used to treat rosacea. Photorejuvenation can also be used to improve the appearance of rosacea and reduce the redness associated with it[20][21][22].One alternative skin treatment, fashionable in the Victorian and Edwardian eras, was sulphur. Recently sulphur has re-gained some credibility as a safe alternative to steroids and coal tar.Recently, a clinically-trialled product range combining plant-sourced Methylsulfonylmethane (MSM) and Silymarin has been used to treat rosacea, skin redness and flushing

Treatment horizon

Treatment is longterm, usually 1-2 years before the disorder is under control. Lifelong treatment is often necessary, although some cases resolve after a while and go into a permanent remission.

Famous people

Famous people with Rosacea include:Bill Clinton[24]J. P. Morgan[25]Diana, Princess of Wales[citation needed]W. C. Fields[24]Rosie O'Donnell[26]Mariah Carey[27]Margaret Bobonich[28]Ricky Wilson[29]Lisa Faulkner[30]Rembrandt

Chloracne

Chloracne is an acne-like eruption of blackheads, cysts, and pustules associated with over-exposure to certain halogenated aromatic compounds, such as chlorinated dioxins and dibenzofurans. The lesions are most frequently found on the cheeks, behind the ears, in the armpits and groin region.The condition was first described in German industrial workers in 1897 by Von Bettman, and was initially believed to be caused by exposure to toxic chlorine (hence the name "chloracne"). It was only in the mid-1950s that chloracne was associated with aromatic hydrocarbons[1]. The substances that may cause chloracne are now collectively known as chloracnegens.Chloracne is particularly linked to toxic exposure to dioxins (byproducts of many chemical processes, including the manufacture of herbicides such as Agent Orange) — so much so that it is considered a clinical sign of dioxin exposure. The severity and onset of chloracne may follow a typical asymptotic dose-response relationship curve.

Treatment

Once chloracne has been identified, the primary action is to remove the patient and all other individuals from the source of contamination. Further treatment is symptomatic.Severe or persistent lesions may be treated with oral antibiotics or isotretinoin. However, chloracne may be highly resistant to any treatment.The course of the disease is highly variable. In some cases the lesions may resolve within two years or so; however, in other cases the lesions may be effectively permanent (mean duration of lesions in one 1984 study was 26 years, with some workers remaining disfigured over three decades after exposure).[3]Recent research by groups at University of Cincinnati School of Medicine in Ohio and the University of Western Australia indicated that PCB poisoning, including chloracne symptoms, can be treated with fat substitute olestra

Feline acne

Feline acne is a common problem seen in cats. In most cases symptoms are mild and pass unnoticed. More severe cases, however, may respond slowly to treatment and seriously detract from the appearance of the cat. Feline acne can affect cats of any age, sex or breed.

Sebaceous glands are mostly found in the skin of the chin, base of the tail, eyelids, lips, prepuce and scrotum. They are connected to the hair follicles. In acne, the follicles become clogged with black sebaceous material, forming comedones (also known as blackheads). These comedones become irritated, swollen and infected, leading to pustules. The cats may also experience itching and discomfort due to swelling and bacterial growth inside infected glands.

Causes

The main causes of feline acne include:Hyperactive sebaceous glandsPoor grooming habitsFood allergiesPlastic food bowls (because it is hard to remove bacteria)Stress on the animal

Future treatments

A 2007 microbiology article reporting the first genome sequencing of a Propionibacterium acnes bacteriophage (PA6) said this "should greatly enhance the development of a potential bacteriophage therapy to treat acne and therefore overcome the significant problems associated with long-term antibiotic therapy and bacterial resistance

History of some acne treatments

The history of acne reaches back to the dawn of recorded history. In Ancient Egypt, it is recorded that several pharaohs were acne sufferers[citation needed]. From Ancient Greece comes the English word 'acne' (meaning 'point' or 'peak'). Acne treatments are also of considerable antiquity:Ancient Rome[citation needed]: bathing in hot, and often sulfurous, mineral water was one of the few available acne treatments. One of the earliest texts to mention skin problems is De Medicina by the Roman writer Celsus.1800s: Nineteenth century dermatologists used sulphur in the treatment of acne. It was believed to dry the skin.1920s: Benzoyl Peroxide is used1930s: Laxatives were used as a cure for what were known as 'chastity pimples'. Radiation also was used.1950s: When antibiotics became available, it was discovered that they had beneficial effects on acne. They were taken orally to begin with. Much of the benefit was not from killing bacteria but from the anti-inflammatory effects of tetracycline and its relatives. Topical antibiotics became available later.1970s: Tretinoin (original Trade Name Retin A) was found effective for acne.[46] This preceded the development of oral isotretinoin (sold as Accutane and Roaccutane) in 1980.[47]1980s: Accutane is introduced in America, and later found to be a teratogen, highly likely to cause birth defects if taken during pregnancy. In the United States more than 2,000 women became pregnant while taking the drug between 1982 and 2003, with most pregnancies ending in abortion or miscarriage. About 160 babies with birth defects were born.[48] [49]1990s: Laser treatment introduced2000s: Blue/red light therapy

Less widely used treatments

Aloe vera there are treatments for acne mentioned in Ayurveda using herbs such as Aloe vera, Haldi (Turmeric) and Papaya. There is limited evidence from conventional medical studies on these products.[36] Products from Rubia cordifolia, Curcuma longa (commonly known as Turmeric), Hemidesmus indicus (known as ananthamoola or anantmula), and Azadirachta indica (Neem) have been shown to have anti-inflammatory effects, but not aloe vera.[37]Azelaic acid (brand names Azelex, Finevin and Skinoren) is suitable for mild, comedonal acne.[38]Heat: local heating may be used to kill the bacteria in a developing pimple and so speed healing. [39]Naproxen or ibuprofen are used for some moderate acne for their anti-inflammatory effect.Nicotinamide, (Vitamin B3) used topically in the form of a gel, has been shown in a 1995 study to be more effective than a topical antibiotic used for comparison, as well as having fewer side effects.[40] Topical nicotinamide is available both on prescription and over-the-counter. The property of topical nicotinamide's benefit in treating acne seems to be its anti-inflammatory nature. It is also purported to result in increased synthesis of collagen, keratin, involucrin and flaggrin.[citation needed]Tea Tree Oil (Melaleuca Oil) dissolved in a carrier (5% strength) has been used with some success, where it is comparable to benzoyl peroxide but without excessive drying, kills P.Acnes, and has been shown to be an effective anti-inflammatory in skin infections. [36][41][42]Rofecoxib was shown to improve premenstrual acne vulgaris in a placebo controlled study.[43]Zinc: Orally administered zinc gluconate has been shown to be effective in the treatment of inflammatory acne, although less so than tetracyclines.[44][45]

Phototherapy

'Blue' and red light

It has long been known that short term improvement can be achieved with sunlight. However, studies have shown that sunlight worsens acne long-term[citation needed]. More recently, visible light has been successfully employed to treat acne (phototherapy) - in particular intense violet light (405-420nm) generated by purpose-built fluorescent lighting, dichroic bulbs, LEDs or lasers. Used twice weekly, this has been shown to reduce the number of acne lesions by about 64%;[28] and is even more effective when applied daily. The mechanism appears to be that a porphyrin (Coproporphyrin III) produced within P. acnes generates free radicals when irradiated by 420nm and shorter wavelengths of light.[29] Particularly when applied over several days, these free radicals ultimately kill the bacteria.[30] Since porphyrins are not otherwise present in skin, and no UV light is employed, it appears to be safe, and has been licensed by the U.S. FDA.[31] The treatment apparently works even better if used with red visible light (660 nanometer) resulting in a 76% reduction of lesions after 3 months of daily treatment for 80% of the patients;[32] and overall clearance was similar or better than benzoyl peroxide. Unlike most of the other treatments few if any negative side effects are typically experienced, and the development of bacterial resistance to the treatment seems very unlikely. After treatment, clearance can be longer lived than is typical with topical or oral antibiotic treatments; several months is not uncommon. The equipment or treatment, however, is relatively new and reasonably expensive to buy initially, although the total cost of ownership can be similar to many other treatment methods (such as the total cost of benzoyl peroxide, moisturiser, washes) over a couple of years of use.

Photodynamic therapy

In addition, basic science and clinical work by dermatologists Yoram Harth and Alan Shalita and others has produced evidence that intense blue/violet light (405-425 nanometer) can decrease the number of inflammatory acne lesion by 60-70% in 4 weeks of therapy, particularly when the P.acnes is pretreated with delta-aminolevulinic acid (ALA), which increases the production of porphyrins. However this photodynamic therapy is controversial and apparently not published in a peer reviewed journal.

Laser treatment

Laser surgery has been in use for some time to reduce the scars left behind by acne, but research has been done on lasers for prevention of acne formation itself. The laser is used to produce one of the following effects:to burn away the follicle sac from which the hair growsto burn away the sebaceous gland which produces the oilto induce formation of oxygen in the bacteria, killing themSince lasers and intense pulsed light sources cause thermal damage to the skin, there are concerns that laser or intense pulsed light treatments for acne will induce hyperpigmented macules (spots) or cause long-term dryness of the skin.In the United States, the FDA has approved several companies, such as Candela Corp., to use a cosmetic laser for the treatment of acne. However, efficacy studies have used very small sample sizes (fewer than 100 subjects) for periods of six months or less, and have shown contradictory results.[33] Also, laser treatment being relatively new, protocols remain subject to experimentation and revision,[34] and treatment can be quite expensive. Also, some Smoothbeam laser devices had to be recalled due to coolant failure, which resulted in painful burn injuries to patients.[

Treatment

Available treatments
There are many products available for the treatment of acne, many of which are without any scientifically-proven effects. Generally speaking, successful treatments show little improvement within the first two weeks, instead taking a period of approximately three months to improve and start flattening out. Many treatments that promise big improvements within two weeks are likely to be largely disappointing. However, short bursts of cortisone can give very quick results, and other treatments can rapidly improve some active spots, but usually not all active spots.Modes of improvement are not necessarily fully understood but in general treatments are believed to work in at least 4 different ways (with many of the best treatments providing multiple simultaneous effects):normalising shedding into the pore to prevent blockagekilling P. acnesanti-inflammatory effectshormonal manipulationA combination of treatments can greatly reduce the amount and severity of acne in many cases. Those treatments that are most effective tend to have greater potential for side effects and need a greater degree of monitoring, so a step-wise approach is often taken. Many people consult with doctors when deciding which treatments to use, especially when considering using any treatments in combination. There are a number of treatments that have been proven effective:

Topical bactericidals

Widely available OTC bactericidal products containing benzoyl peroxide may be used in mild to moderate acne. The gel or cream
containing benzoyl peroxide is rubbed, twice daily, into the poresover the affected region. Bar soaps or washes may also be used and vary from 2 to 10% in strength. In addition to its therapeutic effect as a keratolytic (a chemical that dissolves the keratin plugging the pores) benzoyl peroxide also prevents new lesions by killing P.acnes. In one study, roughly 70% of participants using a 10% benzoyl peroxide solution experienced a reduction in acne lesions after 6 weeks.[26]Unlike antibiotics, benzoyl peroxide has the advantage of being a strong oxidizer (essentially a mild bleach) and thus does not appear to generate bacterial resistance. However, it routinely causes dryness, local irritation and redness. A sensible regimen may include the daily use of low-concentration (2.5%) benzoyl peroxide preparations, combined with suitable non-comedogenic moisturisers to help avoid overdrying the skin.Care must be taken when using benzoyl peroxide, as it can very easily bleach any fabric or hair it comes in contact with.Other antibacterials that have been used include triclosan, or chlorhexidine gluconate but these are often less effective, but also have fewer side-effects.Prescription-strength benzoyl peroxide preparations do not necessarily differ with regard to the maximum concentration of the active ingredient (10%), but the drug is made available dissolved in a vehicle that more deeply penetrates the pores of the skin.

Topical antibiotics

Externally applied antibiotics such as erythromycin, clindamycin, Stievamycin, or tetracycline kill the bacteria that are harbored in the blocked follicles. While topical use of antibiotics is equally as effective as oral use, this method avoids possible side effects including upset stomach and drug interactions (e.g. it will not affect use of the oral contraceptive pill), but may prove awkward to apply over larger areas than just the face alone.

Oral antibiotics

Oral antibiotics used to treat acne include erythromycin or one of the tetracycline antibiotics (tetracycline, the better absorbed oxytetracycline, or one of the once daily doxycycline, minocycline, or lymecycline). Trimethoprim is also sometimes used (off-label use in UK). However, reducing the P. acnes bacteria will not, in itself, do anything to reduce the oil secretion and abnormal cell behaviour that is the initial cause of the blocked follicles. Additionally the antibiotics are becoming less and less useful as resistant P. acnes are becoming more common. Acne will generally reappear quite soon after the end of treatment—days later in the case of topical applications, and weeks later in the case of oral antibiotics. Furthermore side effects of tetracycline antibiotics can include yellowing of the teeth and an imbalance of gut flora, so are only recommended after topical products have been ruled out.It has been found that sub-antimicrobial doses of antibiotics such as minocycline also improve acne. It is believed that minocycline's anti-inflammatory effect also prevents acne. These low doses do not kill bacteria and hence cannot induce resistance.

Hormonal treatments

In females, acne can be improved with hormonal treatments. The common combined oestrogen/progestogen methods of hormonal contraception have some effect, but the antiandrogen, Cyproterone, in combination with an oestrogen (Diane 35) is particularly effective at reducing androgenic hormone levels. Diane-35 is not available in the USA, but a newer oral contraceptive containing the progestin drospirenone is now available with fewer side effects than Diane 35 / Dianette. Both can be used where blood tests show abnormally high levels of androgens, but are effective even when this is not the case. Along with this, treatment with low dose spironolactone can have anti-androgenetic properties, especially in patients with polycystic ovarian syndrome.If a pimple is large and/or does not seem to be affected by other treatments, a dermatologist may administer an injection of cortisone directly into it, which will usually reduce redness and inflammation almost immediately. This has the effect of flattening the pimple, thereby making it easier to cover up with makeup, and can also aid in the healing process. Side effects are minimal, but may include a temporary whitening of the skin around the injection point; and occasionally a small depression forms, which may persist, although often fills eventually. This method also carries a much smaller risk of scarring than surgical removal.

Topical retinoids

A group of medications for normalizing the follicle cell lifecycle are topical retinoids such as tretinoin (brand name Retin-A), adapalene (brand name Differin), and tazarotene (brand name Tazorac). Like isotretinoin, they are related to vitamin A, but they are administered as topicals and generally have much milder side effects. They can, however, cause significant irritation of the skin. The retinoids appear to influence the cell creation and death lifecycle of cells in the follicle lining. This helps prevent the hyperkeratinization of these cells that can create a blockage. Retinol, a form of vitamin A, has similar but milder effects and is used in many over-the-counter moisturizers and other topical products. Effective topical retinoids have been in use over 30 years but are available only on prescription so are not as widely used as the other topical treatments. Topical retinoids often cause an initial flare up of acne and facial flushing.

Oral retinoidsMain article: isotretinoinA daily oral intake of vitamin A derivative isotretinoin (marketed as Accutane, Amnesteem, Sotret, Claravis, Clarus) over a period of 4-6 months can cause long-term resolution or reduction of acne. It is believed that isotretinoin works primarily by reducing the secretion of oils from the glands, however some studies suggest that it affects other acne-related factors as well. Isotretinoin has been shown to be very effective in treating severe acne and can either improve or clear well over 80% of patients. The drug has a much longer effect than anti-bacterial treatments and will often cure acne for good. The treatment requires close medical supervision by a dermatologist because the drug has many known side effects (many of which can be severe). About 25% of patients may relapse after one treatment. In those cases, a second treatment for another 4-6 months may be indicated to obtain desired results. It is often recommended that one lets a few months pass between the two treatments, because the condition can actually improve somewhat in the time after stopping the treatment and waiting a few months also gives the body a chance to recover. Occasionally a third or even a fourth course is used, but the benefits are often less substantial. The most common side effects are dry skin and occasional nosebleeds (secondary to dry nasal mucosa). Oral retinoids also often cause an initial flare up of acne within a month or so, which can be severe. There are reports that the drug has damaged the liver of patients. For this reason, it is recommended that patients have blood samples taken and examined before and during treatment. In some cases, treatment is terminated or reduced due to elevated liver enzymes in the blood, which might be related to liver damage. Others claim that the reports of permanent damage to the liver are unsubstantiated, and routine testing is considered unnecessary by some dermatologists. Blood triglycerides also need to be monitored. However, routine testing are part of the official guidelines for the use of the drug in many countries. Some press reports suggest that isotretinoin may cause depression but as of September 2005 there is no agreement in the medical literature as to the risk. The drug also causes birth defects if women become pregnant while taking it or take it while pregnant. For this reason, female patients are required to use two separate forms of birth control or vow abstinence while on the drug. Because of this, the drug is supposed to be given to females as a last resort after milder treatments have proven insufficient. Restrictive rules (see iPledge program) for use were put into force in the USA beginning in March 2006 to prevent misuse, causing occasioned widespread editorial comment.