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Allopathic treatment

Abstract

The conventional, allopathic treatment of acne vulgaris happens through drugs that are used locally and orally. Given the increasing resistance of acne producing bacteria, it is recommended to minimize prolonged use of antibiotics topically or orally in the treatment of acne. In the presence of many comedones, topical application of a retinoid is usually the first choice. In the presence of numerous papules and pustules, benzoyl peroxide is effective in mild to moderate dosage and does not cause resistance. In more severe forms, oral antibiotics may be indicated. To minimize resistance problems, it is recommended not to prescribe antibiotics alone - rather a combination with benzoyl peroxide or a retinoid is better. Oral contraceptives are a treatment option if the woman wants contraception.

In severe acne, systemic treatment with isotretinoin should often be considered with all the precautions that includes among others, contraception.dermatological condition most frequently encountered in adolescents and young adults. It is an inflammatory dermatosis that is partly explained by the proliferation of acne causing bacteria, a multiplication and abnormal differentiation of keratinocytes (with formation of comedones) and an increase of seborrhea (oil secretion) under the influence of androgens.

For many years, antibiotics have occupied a central place in the management of acne, but the significant increase in the resistance of acne causing bacteria in recent years needs reviewing of the recommendations in acne treatment. This article discusses the role of different drugs in the treatment of this condition and proposes some guidelines based on clinical presentation and severity of acne.

 

Topical retinoids

Topical retinoids are tretinoin, adapalene and tazarotene. These derivatives of vitamin A prevent the formation of comedones by normalizing desquamation of follicular epithelium. They are used in forms of acne with a predominance of comedones, as well as to enhance the effectiveness of antibiotic treatment or to consolidate the results obtained after systemic therapy. The main side effects of topical retinoids are pruritus, erythema, rashes, skin bleaching and phototoxicity - a worsening of acne can be observed during the first few weeks of treatment. Retinoids are contra-indicated in women who are pregnant or planning a pregnancy. [Editor's note: The speciality based tazarotene (0.05% and 0.1%) available in Belgium (Zorac®) is registered for the treatment of mild to moderate psoriasis, but not acne].

 

Topical antibacterials

  • The clindamycin and erythromycin antibiotics are conventionally used topically in the treatment of acne vulgaris. They are antibacterial and anti-inflammatory and reduce the number of inflammatory lesions, but they have no effect on comedones. Adverse effects of topical antibiotics are erythema, desquamation, dry skin and burning sensation. Their use is limited by the increasing bacterial resistance [ie, erythromycin is no longer recommended as many germs become resistant Gram-positive bacteria]. According to a recent consensus, it is recommended not to prescribe antibiotic monotherapy locally but to associate benzoyl peroxide or a topical retinoid, in order to increase the effectiveness of treatment and reduce the risk of bacterial resistance. It is also advisable not to use topical antibiotics and oral antibiotics concomitantly in the treatment of acne.
  • Benzoyl peroxide (5 or 10%) is a potent antibacterial that also has an anti-inflammatory effect. Its effectiveness is comparable to topical antibiotics, but unlike them, it does not appear to cause bacterial resistance. Benzoyl peroxide is the first choice anti-bacterial in mild to moderate acne. Adverse effects consist of skin irritation and rarely, contact dermatitis and discoloration of hair, clothing and linens.
  • Azelaic acid is republished here with antibacterial agents as it has antibacterial activity against acne causing bacteria, in addition to its comedolytic effect. It is less effective and takes longer than retinoids, but it causes less skin irritation. Like benzoyl peroxide, azelaic acid also leads to bacterial resistance.

 

Oral antibiotics

The main antibiotics used orally in acne are tetracycline (300-600 mg), doxycycline and minocycline (100-200 mg). Macrolides are no longer first choice. Antibiotics exert both an antibacterial effect against acne causing bacteria as well as have an anti-inflammatory effect. Minocycline and doxycycline have similar efficacy in this indication and appear more effective than tetracycline. With minocycline, it should take into account the risk of side effects such as liver damage, possibly severe lupus with arthralgia and reactions during prolonged treatment, as well as its high cost. Doxycycline is associated with a greater risk of phototoxicity. Tetracyclines are contra-indicated during pregnancy. The efficacy of antibiotic therapy should be evaluated after 3 months and in case of an improvement, antibiotics may be extended up to 6 months in general, but always in combination with local treatment with benzoyl peroxide or retinoids. In the absence of results after 3 months, the antibiotic should be discontinued and an alternative treatment (eg isotretinoin) should be considered. As mentioned above, it is recommended to administer concomitant antibiotics topically and orally.

 

Hormonal treatment

For women in whom contraception is desired or indicated for another reason (eg. Irregular cycles), the prescription of oral contraceptives alone or in combination with other acne treatments may be useful . Although it does not seem to be of much difference in efficacy between oral contraceptives, preference is often given to contraceptives containing a progestin with the least androgenic properties (eg. Desogestrel, gestodene or norgestimate ). In case of insufficient efficacy, an oral contraceptive containing 2 mg cyproterone acetate and 0.035 mg ethinyl estradiol is opted for. Hormonal treatment should be continued for at least 2-4 months.

In severe cases, cyproterone acetate at 10 mg per day for the first 15 days of the cycle, may be offered for women in combination with an oral contraceptive. [Editor's note: In Belgium, cyproterone acetate is the only anti-androgen used.]

 

Isotretinoin

Isotretinoin is a derivative of vitamin A, which inhibits the secretion of sebum (the body oils) and prevents the formation of comedones by normalizing desquamation of follicular epithelium. Isotretinoin is indicated in severe nodulocystic acne and other forms of acne rebellious to conventional treatment. The recommended dose is 0.5 mg / kg / day, which may possibly be increased after one month up to 1 mg / kg / day. The optimal treatment regimen consists of a cumulative dose of 120-150 mg / kg and for a cure, a treatment period of several months is usually necessary. [Editor's note: Due to variations in individual efficacy and side effects, the treatment is usually started with lower daily doses (0.3 to 0.5 mg / kg), and then the dose is individually adjusted.] In case of a relapse after discontinuation of treatment, it is recommended to wait two months before starting a new treatment. Side effects of isotretinoin are numerous: dry lips, skin and eyes, alopecia, decreased night vision, headache, neck pain, musculoskeletal pain, hyper-calcemia, central nervous system disorders and psychiatric disorders. Rare cases of benign intracranial hypertension have been reported, some with the concomitant use of tetracyclines. Isotretinoin can also cause elevated liver enzymes and triglycerides - blood tests are therefore recommended before initiation of treatment, after one month, then every 2 to 3 months and the concomitant use of vitamin A is to be avoided. Isotretinoin is teratogenic and effective contraception is required throughout the duration of treatment and for one month after stopping it. Caution is also advised during blood donations.

 

Practical recommendations

 

Mild to moderate acne, especially with comedones

Adapalene or tretinoin, at the rate of one application per day is the treatment of choice. Effect occurs within 12 weeks. Adapalene 0.1% causes less skin irritation than tretinoin 0.05% and its cost is also lower. Azelaic acid (2 applications per day) is less effective but may be offered in case of contra-indication of retinoids. Oral contraceptives may be offered if the woman wants contraception.

 

Mild to moderate papular and pustular acne

This form of acne is usually treated locally by benzoyl peroxide (1 to 2 applications per day), an antibiotic (2 applications per day) or retinoid (1 application per day). Benzoyl peroxide is the first choice here as it is effective, costs less and there is only a low risk of resistance development. As mentioned above, it is inadvisable to prescribe a topical antibiotic alone and it should be prescribed preferably in combination with benzoyl peroxide or a topical retinoid. Antibacterial treatment is usually continued for at least two to three months - in the absence of effects after this period, it is necessary to review the treatment. For women who want contraception, oral contraceptives may be useful.

 

Moderate to severe papular and pustular acne

Treatment is usually based on the administration of oral antibiotics (eg. Doxycycline or minocycline 100-200 mg per day), in combination with topical benzoyl peroxide or a retinoid. The administration of antibiotics alone is not recommended. Treatment is often required for several months, but in case of lack of results after 3 months, the treatment should be reviewed. In case of failure, isotretinoin may be considered. For women who want contraception, the administration of oral contraceptive cyproterone acetate may be considered.

 

Severe nodulocystic acne

The severe nodulocystic acne and other severe forms of acne like acne fulminans, pyoderma, facial acne conglobata and acne recalcitrant to treatment require systemic treatment (oral antibiotics, isotretinoin, hormonal treatment) .

 

Should we stop treating acne during the summer?

This question has been asked by several experts in dermatology and their responses can be summarized as follows. Almost all acne medications are photosensitizing (either phototoxic or photoallergic) and should be used with caution in sunny periods. The decision to treat or not treat acne during the summer depends on several factors: initiation or continuation of treatment, amount of sunshine, severity of acne and so on.

As regards local treatment, it may be preferable to enforce it only in the evening and possibly use a preparation or product under less irritating doses (eg. Adapalene instead of tretinoin).

With regard to oral treatments, it is recommended not to initiate treatment phototoxicity (eg. Tetracycline or isotretinoin) when sun exposure is anticipated, for example, before going on vacation. When treatment is already underway, it may possibly be pursued by reducing the dose, as phototoxicity is dose-dependent. In all cases, it is recommended to use a sun protection during the day and avoid prolonged exposure to sunlight.

Homeopathic treatment

Let us take the big question head-on. Does homeopathic treatment give permanent relief from those recurrent pimples? The answer is a big yes, but the treatment is quite different from the conventional ones. Homeopaths realise the truth in skin disorders. All forms of pimples (acne) are due to an internal disorder - thus the usage of external application does not yield permanent results. Internal homeopathic medication is often the best natural option to stop the recurrence of acne and that too without side-effects. Medically speaking too, acne results out of an internal disorder. It is a disorder resulting from the action of hormones on the skin's oil glands (sebaceous glands), which leads to plugged pores and the outbreak of lesions commonly called pimples or acne. They usually occur on the face, neck, back, chest, and shoulders. An important causative factor is an increase in hormones called androgens (male sex hormones). These increase in both boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum (oil). Hormonal changes related to pregnancy or starting or stopping birth control pills can also cause acne - another factor is heredity or genetics. Researchers believe that the tendency to develop acne can be inherited from parents. For example, studies have shown that many school-age boys with acne have a family history of the disorder. Certain drugs, including androgens and lithium, are known to cause acne. Greasy cosmetics may alter the cells of the follicles and make them stick together, producing a plug. The following factors also influence the growth of acne: Changing hormone levels in adolescent girls and adult women two to seven days before their menstrual period starts; friction caused by leaning on or rubbing the skin pressure from backpacks, or tight collars; environmental irritants such as pollution and high humidity; squeezing or picking at blemishes, hard scrubbing of the skin, etc.

Medicines for acne- Belladonna: It is very useful in an acute flare-up where pus formation hasn't started and acne is red and fiery looking. 30c potency of Belladonna taken internally 3-4 times a day can be used to treat this acute stage. Pulsatilla: It is often the most indicated medicine in the treatment of acne in girls. Acne associated with menstrual abnormalities are often best treated with Pulsatilla. It is strongly indicated in a mild, yielding and sensitive personality with a weeping disposition. Sulphur: No other medicine is more effective than Sulphur, which covers nearly all kinds of acne. Dirty unhealthy skin and abuse of cosmetics are leading indication for its use. It is very useful in stopping the recurrence of pimples. Sulphur is a very deep acting medicine and should be used only in consultation with an experienced homoeopath. Hepar sulph: Hepar sulph. is very appropriate for treating acne that has an easy tendency to develop into pustules (filled with pus), as well as where acne is very painful to touch. Silicea (also called Silica): It is often indicated in cases of long-standing acne along with general low resistance and is often used for its scar-dissolving properties. Developing a natural resistance towards acne: Once the acute flare-ups have been attended to, one would like a natural resistance towards acne. A thorough constitutional treatment by an experienced homoeopath would do the needful.

Signs and Symptoms of Acne or Pimples

Typically, acne or pimples appear on the face, neck, chest, back, shoulders and the areas of the skin with the largest number of functional oil glands. Frequently, people with acne or pimples have a variety of lesions. The comedo (plural: comedones) - the basic acne lesion, is simply a plugged, enlarged sebaceous (oil producing) follicle. Acne or pimples can take the following forms :

  • BLACKHEADS : Blackheads, also known as open comedones, are follicles that have a wider than normal opening. They are filled with plugs of sebum and sloughed-off cells and have undergone a chemical reaction resulting in the oxidation of melanin. This gives the material in the follicle the typical black coloUr.
  • WHITEHEADS : Whiteheads, also known as closed comedones, are follicles that are filled with the same material, but have only a microscopic opening to the skin surface. Since the air cannot reach the follicle, the material is not oxidized, and remains white.

    Both whiteheads & blackheads may stay on the skin for a long time.

    Other troublesome acne and pimple lesions may develop, which include the following :
  • PAPULES : A papule is defined as a small (5 millimeters or less), solid lesion slightly elevated above the surface of the skin. A group of very small papules and microcomedones may be almost invisible but have a "sandpaper" feel to the touch. A papule is caused by localized cellular reaction to the process of acne.
  • MACULES : A macule is the temporary red spot left by a healed acne lesion. It is flat, usually red or pink, with a well-defined border. A macule may persist for days to weeks before disappearing. When a number of macules are present at one time, they can contribute to the "inflamed face" appearance of acne, which shows a "red faced" appearance.
  • PUSTULES : A pustule is a dome-shaped, fragile lesion containing pus that typically consists of a mixture of white blood cells, dead skin cells, and bacteria. A pustule that forms over a sebaceous follicle usually has a hair in the center. Acne pustules that heal without progressing to cystic form usually leave no scars.
  • NODULES : Like a papule, a nodule is a solid, dome-shaped or irregularly-shaped lesion. Unlike a papule, a nodule is characterized by inflammation, extends into deeper layers of the skin and may cause tissue destruction that results in scarring. A nodule may be very painful. Nodular acne is a severe form of acne that may not respond to conventional (allopathic) treatment.
  • CYSTS : A cyst is a sac-like lesion containing liquid or semi-liquid material consisting of white blood cells, dead cells, and bacteria. It is larger than a pustule, may be severely inflamed, extends into deeper layers of the skin, may be very painful and can result in scarring. Cysts and nodules often occur together in a severe form of acne called nodulocystic. Systemic therapy with homeopathy is sometimes the only effective treatment for nodulocystic acne. Some acne investigators believe that true cysts rarely occur in acne, and that (1) the lesions called cysts are usually severely inflamed nodules, and (2) the term nodulocystic should be abandoned. Regardless of terminology, this is a severe form of acne that is often resistant to conventional (allopathic) treatment and likely to leave scars after healing.

There can be prominent unsightly scars after resolution of acne or pimple lesions - these can also be set right with the proper homeopathic treatment.

The following are the commonly recognized types of acne :

  • Acne vulgaris
  • Acne rosacea
  • Acne cosmetica
  • Acne conglobata
  • Acne fulminans
  • Acne keloidales nuchae.
What Causes Acne or Pimples ?

Nobody is completely sure what causes acne. Experts believe the primary cause is a rise in androgen levels - androgen is a type of hormone. Androgen levels rise when a human becomes an adolescent. Rising androgen levels make the oil glands under your skin grow; the enlarged gland produces more oil. Excessive sebum can break down cellular walls in your pores, causing bacteria to grow.

Some studies indicate that susceptibility to acne could also be genetic. Some medications which contain androgen and lithium may cause acne. Greasy cosmetics may cause acne in some susceptible people. Hormone changes during pregnancy may cause acne to either develop for the first time or to recur.

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