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 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
- 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.
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
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 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.
Mild to moderate acne, especially
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 (e.g. 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.
Please e-mail email@example.com for any questions/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.
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.
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
- 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
- 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.