An overview of comprehensive treatment
Acne vulgaris is a common skin condition in adolescents, with a reported prevalence of 70% to 87%.1 Acne is classified as inflammatory, noninflammatory, comedonal, pustular, papular, nodular or a combination of these.2 It is categorized as mild, moderate or severe based on the number and type of lesions and the amount of skin involved.1 Mild acne features open and closed comedones without inflammatory lesions. Moderate acne includes a mixture of noninflammatory comedones and inflammatory papules and pustules. Severe acne is characterized by numerous inflammatory papules, pustules and nodules.3,4
Acne is thought to be caused by increased gonadal androgens during puberty.4,5 Acne develops from the pilosebaceous unit, which consists of a hair-containing shaft, hair follicle and sebum-producing glands.3,4,6,7 It commonly occurs on the face, neck, chest, back, upper arms, shoulders and buttocks.3,8,9
Acne pathogenesis involves the interplay of four factors: sebaceous hyperplasia under the influence of increased androgen levels; hyperkeratinization; Propionibacterium acnes colonization of the follicle; and inflammation.1,2,6,8 Cells accumulate abnormally, mix with sebum, and partially obstruct the follicular opening, forming comedones (closed “whiteheads” and open “blackheads”).1 P acnes proliferate in this anaerobic, sebum-rich environment,6,10 and colonization leads to the formation of inflammatory papules and pustules.1 Severe nodular or nodulocystic lesions are characterized by an inflammatory infiltrate consisting primarily of lymphocytes and giant cells.2 Nodular acne has a greater likelihood of scarring due to its delayed and specific inflammatory response.2,6
Treating acne at the earliest opportunity is necessary to prevent scarring and minimize post-inflammatory hyperpigmentation in patients with darker skin.11 These secondary changes occur in this group because melanocytes in black skin have a heightened response to cutaneous stimulation and damage.11
Acne may be caused by drugs such as corticosteroids, bromides, lithium, antiepileptics and medications containing iodide.4,6 Family history is a risk factor,4,6 along with hormonal changes during the menstrual cycle and pregnancy.6 Conditions such as polycystic ovary syndrome, congenital adrenal hyperplasia, and Cushing syndrome may lead to the development of acne.1,6 Stress, smoking and occlusion of the skin surface with grease, clothing or sweat may aggravate acne.6 The influence of diets containing foods with high glycemic load1,5 may aggravate acne.12
The psychosocial impact of acne is influenced by factors such as age, disease severity, social and familial networks, and individual personalities.1 Acne may lead to embarrassment and psychological distress in adolescents.4 Acne can have a significant adverse impact on quality of life1 by causing some teens to become more self-conscious and potentially develop a poor body image.5 Acne may impact self-esteem and in some cases has been linked to depression and suicide.5 When the impact on the psychosocial health of the patient is particularly burdensome, effective treatment of acne may result in improvements in self-esteem, affect, body image, social assertiveness, and self-confidence.1 A referral to mental health services may be needed.5
Numerous over-the-counter (OTC) regimens are available to treat mild acne. Salicylic acid has shown some benefit, however, research shows that benzoyl peroxide is one of the more versatile, safe, inexpensive and effective acne therapies.1 Available in concentrations of 2.5% to 10%, benzoyl peroxide penetrates the stratum corneum, enters the pilosebaceous unit, and oxidizes proteins in the P acnes cell wall, minimizing the development of antibiotic resistance.1
Benzoyl peroxide is a topical antimicrobial frequently used as monotherapy or in combination with topical or systemic antibiotics.2,6 Benzoyl peroxide should be applied in a thin layer over the entire area where acne may occur-not dabbed on the lesion alone.13 It may cause bleaching of hair or clothing, dryness and erythema of the skin, and increased risk of sunburn.1
Topical retinoids are used routinely for the treatment of acne as monotherapy and in topical combination products.1 Retinoids prevent the formation of new micromomedones, which are precursors to both comedonal and inflammatory lesions.1,2 Tretinoin, adapalene and tazrotene are available by prescription in the United States.1,2 Common side effects are burning, stinging dryness and scaling.1,2 Topical retinoids can be used as a second-line therapy for severe nodular acne in patients who cannot tolerate isotretinoin.2 Topical dapsone, a synthetic sulfone, has demonstrated a rapid response in reducing noninflammatory and inflammatory lesions and is more effective against inflammatory lesions.1
Azelaic acid is a topical agent that can be utilized to treat mild to moderate acne.14,15 It may be combined with oral antibiotics or hormonal therapy.15 Azelaic acid can be useful in treating both inflammatory acne and comedonal acne.15 It works as an antibacterial agent and is also keratolytic and comedolytic.14,15 The most common side effect is mild irritation.15 Safety and efficacy have not been established in children younger than 12.16
Antibiotics are used to reduce P acnes colonization of the skin and follicles, however, resistance to both topical and systemic antibiotics has been increasing at an alarming rate.1 Monotherapy with the first-line topical antibiotics clindamycin and erythromycin is not recommended due to slow onset of action and the greater likelihood of resistance.1,6 Combination products containing benzoyl peroxide and antibiotics are available.1,6
Commonly used oral antibiotics are tetracycline derivatives including tetracycline, doxycycline and minocycline.1,2 Erythromycin use has decreased related to worldwide P acnes resistance.1,6
Alternative oral antibiotic agents include azithromycin and trimethoprim/sulfamethoxazole.1 Common side effects include photosensitivity, gastrointestinal upset and pill esophagitis.1 Minocycline may prompt reactions such as hypersensitivity syndrome, Stevens-Johnson Syndrome or lupus-like syndrome.1
Isotretinoin is an oral retinoid that has been widely prescribed for acne due to its clinical effectiveness.2 Isotretinoin is the only drug that affects all the principal pathogenetic factors in acne.1,2,6 It is most commonly prescribed as 0.5 mg/kg/day to 1 mg/kg/day in two divided doses for 16 to 30 weeks and may be titrated by dermatologists as tolerated by the patient to produce optimal clinical results.2 The lowest dose should be used for the first 4 weeks to avoid initial flares; an increase to the full dose should then occur.1
Although it is quite effective, isotretinoin is associated with a wide range of dose-dependent adverse events with a range of severities.2 Dryness of the lips and skin, and to a lesser extent dryness and inflammation of the nasal lining and conjunctivae, is common.2 The most frequent systemic adverse effects are arthralgias and myalgias.2
Isotretinoin is one of the strongest known teratogens among prescription medications in any amount, even for short periods of time.2,16 In 2007, the FDA mandated the implementation of a computerized risk management program (iPledge), which registers all isotretinoin patients, prescribers, pharmacies and manufacturers and ensures monthly monitoring of pregnancy status in girls.1,2,10,16 Women of childbearing age are tested to ensure that they are not pregnant before starting treatment. They are required to use two contraception methods during treatment with isotretinoin.2,16 Blood counts, liver function tests and fasting lipid profiles at baseline and after the first and second months of treatment are monitored closely.2 Fifteen percent of patients experience an increase in liver enzyme function, and 25% experience hypertriglyceridemia. However, these complications generally resolve after cessation of therapy.2
Three controversial groups of adverse effects are attributed to isotretinoin.1 Hyperostoses may occur with long-term systemic retinoid therapy used to treat disorders of keratinization.1 Premature epiphyseal closure appears to be a rare event and may occur when isotretinoin is used for extended periods of time, possibly related to treatment of conditions other than acne.1,10 An association between inflammatory bowel disease and isotretinoin may occur in a small subset of patients.1 Serious mental health conditions including depression, psychosis and suicide have been linked to isotretinoin.1,16
Hormonal therapy for acne is directed at suppressing ovarian androgen production, blocking the effects on the sebaceous glands that lead to reduction in sebum production.1,6 Currently, the oral contraceptive brands Ortho Tri Cyclen, Estrostep and Yaz have FDA-approved indications for the treatment of acne.1 A risk for thromboembolism is associated with some oral contraceptives, thus a family history of thrombotic events and smoking history should be obtained.1 Oral contraceptives should be used cautiously in patients with hypertension, cardiovascular disease, obesity, diabetes or bleeding disorders.17
Spironolactone is another drug used for antiandrogenic effects, offered to women with ovarian or adrenal hyperandrogenism, polycystic ovarian syndrome, premenstrual acne flares, and jaw line acne.2 The most common adverse effects of hormonal therapy are nausea/vomiting, breast tenderness, headache, weight gain, and breakthrough bleeding.1
The use of devices to treat acne is an active area of research.8 Radiofrequency devices use radio waves to heat the dermis and subcutaneous tissue while sparing the epidermis. This is believed to kill bacteria and shrink sebaceous glands.8,9 Side effects include pinpoint bleeding at sites of treatment, pain and redness.8 Radiofrequency does not cause hyperpigmentation and may be promising for patients with darker skin types.8 Light and laser treatments harness the photochemical effect of ultraviolet light to cause damage to P acnes.8
The American Acne and Rosacea Society has developed guidelines for the treatment of acne in children and adolescents.1 These guidelines are endorsed by the American Academy of Pediatrics.18 Treatment for acne is based on the severity of lesions and pathogenesis of the disorder.2,8 The therapeutic objectives are to treat as many pathogenic factors as possible, use the least aggressive regimen that is effective, and to avoid regimens that encourage the development of bacterial resistance.1 Goals include the treatment of existing acne lesions, prevention of new lesions, limiting the duration of the disorder, and preventing permanent scarring.1,6
OTC products such as salicylic acid or benzoyl peroxide are generally effective for mild acne.1,4,9 Topical retinoids are also effective as monotherapy.1 If inadequate response occurs despite adequate adherence, topical retinoids, benzoyl peroxide or topical antibiotic combinations may be added.1,4,9
Treatment of moderate acne should start with the therapies for mild acne,1 with addition of oral antibiotics.1,4 Four to 8 weeks of adherence to oral antibiotics are needed before clinical effects are visible.1 If response is inadequate despite adherence, refer to a dermatologist.1
Treatment for severe acne includes the same therapeutic agents as those used in moderate acne. An oral antibiotic should be used with a topical retinoid with benzoyl peroxide, with or without topical antibiotics.1,2 If a patient exhibits an inadequate response with adequate adherence, the oral antibiotic agent or class may be changed.1 Consider hormonal therapy, oral isotretinoin and a dermatology referral.1,2,4 In severe nodular acne, isotretinoin is the first-line treatment.2,6
Young people may struggle with their treatment regimen and become disappointed with what they perceive as a lack of results.3 Educating a patient and parents about reasonable expectations, a medication regimen with multiple agents and treatment-related side effects can maximize both adherence and efficacy.1,6 Patience is important because some therapies may take several weeks-up to 12-to show improvement.13
During antibiotic therapy, educate patients about the need to use appropriate sun protection and how to prevent pill esophagitis by taking medications with a large glass of water, maintaining an upright position for at least 1 hour after ingestion, and using an enteric-coated formulation.1
Adolescents may believe that acne is related to facial hygiene, so they may use harsh astringents, abrasives, or vigorous scrubbing.1,5,6 Education to avoid picking at acne is necessary because this may lead to scarring.6,7 Teaching should provide guidance about appropriate hygiene, including gentle, twice-daily skin washing with a mild, nondrying soap and use of oil-free noncomedogenic moisturizer and sunscreen.1,6,9 Educate patents about the need to wash hair regularly and avoid frequent handling of the skin.7 Cosmetics should be oil-free and noncomedogenic.5-7
Reducing Acne’s Impact
Acne vulgaris requires prompt and effective treatment to reduce its impact on quality of life. Providers who understand its pathogenesis and treatment can make a significant impact through effective treatment and psychological support.
- Eichenfield LF, et al. Evidence based recommendations for the diagnosis and treatment of pediatric acne. Pediatrics. 2013;131(Suppl 3):S163-S186.
- Newman MD, et al. Therapeutic considerations for severe nodular acne. Am J Clin Dermatol. 2011;12(1):7-14.
- Lavers I. Acne: The importance of timely intervention. Brit J Sch Nurs. 2011;6(8):379-384.
- Watkins J. Looking at the potential impact and management of acne. Brit J Sch Nurs. 2013;8(3):115-117.
- Mooney T. Preventing psychological distress in patients with acne. Nurs Stand. 2014;28(22):42-48.
- Lavers I. Diagnosis and management of acne vulgaris. Nurse Prescribing. 2014;12(7):330-336.
- National Institute of Arthritis and Musculoskeletal and Skin Disorders. Questions and answers about acne. September 2016. http://www.niams.nih.gov/Health_Info/Acne/default.asp#acne_k
- Das S, Reynolds R, eds. Recent advances in acne pathogenesis: Implications for therapy. Am J Clin Dermatol. 2014;15(6):479-488.
- American Academy of Dermatology. Acne. https://www.aad.org/public/diseases/acne-and-rosacea/acne
- Jesitus J. Isotretinoin risks in acne treatment. Contemporary Pediatrics. 2014;31(10):34-35.
- Bianconi-Moore A. Acne vulgaris in patients with skin of colour: Special considerations. Nurs Stand. 2014;26(40):43-49.
- Eddey S. Treatment for acne: An historical nutritional perspective. J Austral Traditional-Medicine Society. 2014;20(3):194-196.
- American Academy of Pediatrics. Teens and acne treatment.November 21, 2015. https://www.healthychildren.org/English/ages-stages/teen/Pages/Teens-and-Acne.aspx
- Mayo Clinic. Drugs and supplements: Azelaic acid (topical route). September 1, 2015.
- Oakley, A. Azelaic acid. DermNet New Zealand. 1999. http://dermnetnz.mobify.me/treatments/azelaic-acid.html
- iPLEDGE. 2005 iPLEDGE. https://www.ipledgeprogram.com/
- Vallerand AH, et al. Contraceptive Hormones. In: Davis’s Drug Guide for Nurses. Philadelphia: F.A. Davis; 2015: 342.
- American Academy of Pediatrics. New acne guidelines endorsed by the AAP. May 1, 2013.https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/New-Acne-Guidelines-Endorsed-by-the-AAP.aspx