Definition and Epidemiology:
Acne vulgaris is a chronic inflammatory disease of the pilosebaceous unit. Acne lesions favor the face neck, upper back, chest, and upper arms. Multiple clinical variants exist and they include comedonal acne (blackheads and whiteheads), papulopustular acne, nodulocystic acne, acne conglobate, and acne fulminans.
Acne is predominantly a disorder of adolescence; affecting 85%of individuals between 12 and 24 years of age; but may affect all age groups and tends to be more severe in males. Precipitating factors include: genetic predisposition, endocrine disorders (polycystic ovarian syndrome), stress, mechanical factors (friction, pressure, occlusion), contact with acnegenic materials (oils, chlorinated hydrocarbons, cosmetics), and drugs (anabolic steroids, lithium, androgens, hydantoin).
Many patients with nodulocystic acne have a first-degree relative with a history of severe acne. The primary pathophysiology involves altered follicular keratinization resulting in obstruction of sebaceous follicles, increased sebum production, hyperproliferation of Propionibacterium acnes, and increased production of chemotactic factors which result in inflammation. Untreated acne upon resolution may result with residual hyperpigmentation or scarring.
A careful history and physical exam is essential to determine the differential diagnosis of acne rosacea, steroid acne, acne mechanica, Pityrosporum folliculitis, and bacterial folliculitis. Usually no laboratory studies are needed unless the physical exam suggests other concerns. Free and total testosterone, DHEA, FSH/LH , or other hormone levels may be checked especially in women with moderate-to-severe acne, hirsutism, irregular menses, and weight gain. Diet may also play a role in flares of acne. High glycemic diets may exacerbate acne.
Acne can take on a chronic course but usually remits spontaneously in the early-to-mid-third decade in the majority of patients.
Early treatment of acne is essential for the prevention of dyschromia or associated scarring. Most acne patients benefit from combination therapies. A thorough history and physical examination are paramount to administering a maximally effective plan. This should include current cosmetics and sunscreens, skin type, lifestyle, occupation, medications, past treatments and response, diet, menstrual and oral contraceptive history.
a. Topical Treatment
Topical treatment may be required for the duration of this condition. Topical formulations should be applied to the lesions as well as to the adjacent acne-prone clinically normal skin.
- Retinoids: tretinoin, adapalene, tazarotene
- Antibacterial agents: benzoyl peroxide, clindamycin, erythromycin
- Keratolytic agents: salicylic acid, hydroxyl acid, azelaic acid, sodium sulfacetamide, and sulfur
b. Systemic Treatment
- Antibiotics: Tetracycline, doxycycline, minocycline are most commonly used. Alternatives include erythromycin, azithromycin, and amoxicillin
- Hormones: oral contraceptives or spironolactone for women with persistent acne on lower face, chin, and neck.
- Isotretinoin: for severe nodulocystic acne that has failed other topical and systemic therapies.
This is a primarily effective for comedomal acne (blackheads and whiteheads). It is usually performed every 2 to 3 weeks until the acne lesions have resolved and then monthly for maintenance. Epi-Infusion delivery with DermaSweep combines therapy using precision bristle exfoliation with simultaneous topical delivery formulated to treat acne with salicylic acid, witch hazel, azelaic acid, vitamin C and other medications.
d. Light Treatment
The Intense Pulsed Light system releases yellow, green, and red light that is emitted in a series of short pulses. The yellow/green light destroys the bacteria that live in the skin and cause acne, while the red light directly targets the overactive sebaceous glands that cause outbreaks of pustules. This targeted light deep in the skin causes shrinkage of the inflamed sebaceous glands and helps to prevent over-production of excess sebum. Almost everyone is a candidate for IPL Phototherapy except for very dark skinned, tanned, pregnant, or recently treated Accutane patients. A typical treatment session will take approximately 20 minutes and is combined with a glycolic acid facial peel for maximum results.
Typically, 6 IPL treatments and 6 glycolic acid peels will result in significant improvement, depending on the severity of the condition.
DermaSweep Microdermabrasion with anti-acne epi-infusion +
IPL-Phototherapy with glycolic acid peel
Series of 6 performed every 2 to 3 weeks: $2000 ($333/session)