Management of Acne Vulgaris: What Are Your Treatment Options

Acne vulgaris remains one of the most commonly diagnosed and treated skin conditions seen in dermatology clinics today. While it affects most, if not all, adolescents, this can also continue well into adulthood. Published data suggests that about 12 per cent of women over 35 years old continue to have acne.

Untreated acne can lead to lasting disfiguring scars and result in substantial impact on one’s quality of life. Psychological complications of acne include low self-esteem, stress, depression and anxiety. There are many causes that can lead to you being more susceptible to acne breakouts, and this includes hormonal changes, genetics, consumption of certain medications, and even underlying health conditions like polycystic ovarian syndrome (PCOS).

In order to get rid of acne effectively, the first step is to diagnose the type of acne you have by identifying the lesions and their severity. This will help in deciding which course of treatment is suitable for your acne condition.

Grading severity of acne

Your dermatologist will conduct a visual assessment to determine the type and severity of your acne, including the distribution (location of the acne), type and number of lesions, and the presence or absence of scarring. In general, acne can be classified into one of these four stages:

Grade 1: Mild – Open and closed comedones with occasional papules and pustules.

Grade 2: Moderate – More comedones, papules and pustules, mainly occurring on the face.

Grade 3: Moderately severe – A greater number of comedones, papules and pustules with a few inflammed nodules present. These can also appear on the chest and back.

Grade 4: Severe – Large, painful pustules and nodules are common, with pronounced inflammation and scarring present at the face, chest and back.

Timely intervention by a dermatologist is key. Effective treatment for acne vulgaris should aim to reduce the severity and recurrence of skin lesions as well as to improve one’s appearance. The approach will depend on several factors like the acne severity, age and treatment preferences of the patient.

Various acne treatments target different processes in the pathogenesis of acne, from decreasing sebum production by counteracting androgens, to reducing P. acnes proliferation and inflammation.

Topical therapy

For mild to moderate acne, topical treatment may be adequate, and this may typically include retinoids and antimicrobial agents. They can appear in gel, wash, lotion, cream and ointment forms to soothe the inflammation and prevent new lesions.

Topical retinoids such as tretinoin and adapalene are important first-line topical treatments for comedonal acne. They act on follicular keratinocytes to prevent follicular blockage and lower the release of proinflammatory cytokines. The number of comedones and inflammatory lesions can be expected to reduce by 40-70%.

Topical antimicrobials such as benzoyl peroxide have anti-inflammatory properties and work fast to kill P. acnes. Available in varying strengths, benzoyl peroxide is also recommended for use with topical antibiotics (such as clindamycin and erythromycin), as it can help to prevent the resistance of P. acnes bacteria to antibiotic therapy.

Combination therapy may also be prescribed, as the use of retinoids and antibiotics can be more effective than using either one alone. For instance, if inflammatory lesions are present, topical retinoid and topical antibiotics containing benzoyl peroxide can be combined. In a review of 3 clinical studies, it was found that a combination of benzoyl peroxide 5% and clindamycin 1% has more effective results than using the latter alone to reduce lesions and suppress P. acnes.

Systemic therapy

When topical agents are insufficient, especially in cases of moderate to severe inflammatory acne with lesions on the chest, back and shoulders, systemic therapy is considered the next line of treatment. This includes oral antibiotic treatment, hormonal therapies and isotretinoin.

Oral antibiotics like doxycycline and erythromycin reduce P.acnes within the follicles, which inhibits the production of bacterial-induced inflammatory cytokines. These agents also have anti-inflammatory effects. Topical retinoids with oral antibiotics may give a faster response, but once the acne has subsided, oral antibiotics can be discontinued while topical retinoids can be used for maintenance therapy.

Oral contraceptives and spironolactone can also be an effective second-line treatment for women with acne due to hormonal changes. They can be used with topical agents or oral antibiotics, which have been suggested to deliver a superior response compared to the use of anti-androgen therapy alone – which may recur when it is discontinued.

Isotretinoin is typically reserved for more severe, recalcitrant, scarring acne that has not responded to other acne medication. It decreases sebum production, reduces P. acnes colonisation, and has anti-inflammatory effects. However, isotretinoin therapy must be monitored carefully due to its potential adverse effects such as dry skin, photosensitivity, and the risk of liver inflammation and raised cholesterol levels.

Laser and light therapies

Alternatively, newer therapeutic modalities such as light-based therapy have been developed to address the need for treating acne. Treatment with these light sources, such as visible light, pulsed-dye laser, and photodynamic therapy, may offer improvements in inflammatory acne and acne scarring.

Low-level light therapy

Low-level light therapy can alter the biological activity of the skin and is usually administered via light-emitting diodes (LEDs) as red or blue light. Varying wavelengths of light penetrate the skin at different depths – for instance, wavelengths of 390–600 nm can reach superficial layers while wavelengths of 600–1100 nm can penetrate deeper layers.

Red light therapy helps to reduce the activity of acne vulgaris by increasing the rate of wound healing and reducing the inflammatory response. Blue light has an anti-inflammatory and antimicrobial effect, which makes it effective at killing several types of bacteria in the pores and oil glands.

Photodynamic therapy (PDT)

During PDT, a photosensitiser (solution) is applied to the skin before being exposed to a light source. The pilosebaceous unit undergoes metabolisation to cause oxidative stress, destroying the acne bacteria and modulating the sebaceous gland.

Intense pulsed light (IPL)

Short pulses of intense light are emitted from the applicator and absorbed by the skin which activates porphyrins that reduce P. acnes growth. When used with a topical photosensitiser, IPL can also cause destruction of the glands to reduce the sebum secretion rate.

Infrared laser

Commonly used for nonablative facial skin rejuvenation, infrared lasers are thought to cause thermal coagulation of the sebaceous glands. This helps to reduce the activity of the sebaceous glands, lower sebum production and thereby reduce acne.

Photothermal Therapy (PTT) with Gold nanoparticles and Nd:YAG laser

Gold nanoshell-mediated photothermal therapy is a treatment which uses gold nanoparticles to target the hyperactive sebaceous glands responsible for acne breakouts. During this treatment, ultrasound sonophoresis is first used to deliver gold nanoparticles into the skin pores. These nanoparticles are then heated with a long-pulse Nd:YAG laser which will then modify targeted sebaceous glands. During this process, gold nanoparticles convert photon energy from a laser to thermal energy.

These gold nanoparticles have a high photothermal conversion efficiency, and are able to achieve excellent results with minimal side effects. The heating process modifies targeted sebaceous glands, leading to a decrease in oil production. This treatment deactivates the sebaceous glands without harming the surrounding tissues as with a wavelength of 1064nm, the laser can penetrate deeper layers within the dermis without causing extensive epidermal damage..

Treating all kinds of acne at AYD

Some key points to take away from this article is that topical therapies are the standard care for mild to moderate acne, and a combination of topical retinoid and antimicrobial therapy provides superior efficacy to target different pathogenic factors of acne. This approach can also be complemented with light and laser sources for synergistic effect and optimal therapeutic outcome.

Getting the right acne treatment plan for you lies in the experience and expertise of the skin dermatologist to diagnose your condition. What types of acne you have, when the breakouts appear, and the presence of scarring are just some of the considerations to take note of in creating an effective treatment plan.

At Angeline Yong Dermatology, Dr Angeline Yong is an accomplished dermatologist accredited by the Ministry of Health with over 15 years of medical practice. With a clinical interest in Cosmetic Dermatology, and Dermatological and Laser Surgery, she has the experience and knowledge to carry out a number of laser and light therapies to treat various skin condition including acne.

Acne vulgaris may be challenging to treat, which is why Dr Yong will formulate a bespoke and tailored treatment plan for you which includes oral, topical and laser treatments depending on your skin profile. Apart from acne, she is also well-versed in addressing other common skin problems such as acne scars, wrinkles, and melasma, using treatments like the Pico laser to achieve optimal results.

Get rid of acne once and for all – contact us at AYD to book a consultation with Dr Yong!

Reference:
1. Titus S, Hodge J. Diagnosis and treatment of acne. Am Fam Physician. 2012 Oct 15;86(8):734-40. PMID: 23062156.
2. Kraft J, Freiman A. Management of acne. 2011;183(7):E430-E435. doi:10.1503/cmaj.090374
3. Wooltorton E. Accutane (isotretinoin) and psychiatric adverse effects. 2003;168(1):66.

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Management of Acne Vulgaris: What Are Your Treatment Options