Acne Vulgaris

Acne, also termed acne vulgaris, is one of the biggest challenges to women with brown skin who seek clear, glowing complexions. In addition to the acne, women with brown skin must also face hyperpigmentation—skin darkening in spots or patches— which occur in response to the acne outbreak. Therefore, acne may have profound psycho-social effects in women with brown skin. Too often acne is dismissed as a minor problem not worthy of treatment. This may result in long-lasting skin discoloration, permanent scarring of the skin and even social inhibition. Acne and hyperpigmenation often lead to embarrassment and frustration, but with effective treatment, women with brown skin can have flawless skin.

To understand exactly what acne is, we must begin below the skin’s surface deep in the hair follicle. The follicle, which is lined with skin cells, contains sebaceous glands that produce oil (sebum). Normally the skin cells that line the follicle are shed and brought to the skin’s surface by the sebum and washed away. However, when the cells stick together instead of shedding, they form a plug or blockage. A clogged pore is a commonly used term for a plugged follicle. Beneath the plug, a sac is formed (known as a microcomedone) that contains dead skin cells and oil. Bacteria (proprionibacterium acnes) grow freely in this environment, feeding on the dead skin cells and oil for fuel. As the sac continues to grow, either a whitehead (known as a closed comedone), or a blackhead (open comedone) forms. In more serious cases, the sac will become larger spurred on by the cells that the body sends into the sac to fight the infection, inflammation will result; and a bump (papule or pustule), painful nodule or cyst will develop.

Many different factors contribute to the development of acne in women with brown skin, heredity and stress-related hormones being the most important. Diet may also contribute to acne (see below). Since dark marks or blemishes are such a problem for women with brown skin, we often use heavy, oil-based makeup or foundation to cover the marks. This can both cause and exacerbate acne. Vigorous washing of the skin with rubbing and scrubbing, or using puffs or abrasive sponges can also cause or worsen acne. In women of African descent, hair oils or pomades may contributed to acne, especially on the forehead and temple areas. This type of acne is called “pomade” acne.

When acne appears, it does so on the face, particularly in areas where sebaceous glands are abundant, such as the T-zone—the forehead, nose and chin. Often in adult women, it occurs along the jawline and lateral cheeks. But depending on the source of the acne, pimples or cysts can also appear on your neck, shoulders, chest and back, adding to frustration and embarrassment.

Acne is divided into four types:

  • Comedones (closed and open): Whiteheads and blackheads
  • Papules: Small or larger red or skin-colored acne bumps.
  • Pustules: Bumps filled with white or yellow pus..
  • Nodules and cysts: Very large pus-filled, often painful acne lesions.

ACNE AND DIET

It is still unclear if diet has a direct link to acne. However, there is evidence to suggest that elements of our Western diet may contribute to it. Studies of two non-Western populations (the Kitavan Islanders of Papua New Guinea and the Ache hunter-gatherers of Paraguay) found that they do not suffer from acne. Their diet is composed of fresh fruit, fish, game, and tubers. Unlike westerners, the people in these regions do not consume carbohydrates (breads, cakes, chips, cereals) or other sugars. The study investigators concluded that the sugars and carbohydrates in Western diets increase the level of insulin and other hormones in the body that then stimulate the sebaceous gland to produce oil. (Oil production is one of the triggers for acne). Another study, this one of individuals in the US, demonstrated that teenage girls who drank milk had more acne. In the study, other foods that were associated with acne were instant breakfast drinks, sherbet, cottage cheese and cream cheese. But in this particular study, soda, french fries, chocolate candy and pizza were NOT significantly associated with acne. These findings suggest that foods in which the hormones found in milk are present in sufficient quantities can possibly cause acne. Athough we do not know for certain how our diet impacts acne, we all can agree that a well balanced, healthy diet comprised primarily of fruits, vegetables, and protein is best for our bodies.

ACNE TREATMENT

The treatment of acne involves reducing the bacteria, decreasing the oil, unplugging the follicles and reducing the inflammation. Additionally, in women with brown skin, it is important to treat the hyperpigmentation. There are many medications available for the treatment of acne and most are listed below. Often several medications will be required to effectively treat your acne, which may include one or two topical medications and one oral medication. It is important to know that there is no cure for acne. In general, your medications will clear existing acne lesions and prevent new ones from developing, as long as you continue to use the medication.

Topical antimicrobials
Topical benzoyl peroxide has both antimicrobial (inhibits or kills bacteria) and comedolytic (reduces comedones) properties. It has been used for many years in the treatment of acne. Even though newer comedolytic agents, antibiotics and antimicrobial agents have been recently developed, benzoyl peroxide remains important for the treatment of acne. Unlike other medications, benzoyl peroxide has no reported bacterial resistance (meaning the bacteria are no longer killed by the antibiotic). In fact, combining benzoyl peroxide with topical or oral antibiotics may decrease the development of resistance to the other antibiotic.

Benzoyl peroxide is available in gels, creams, lotions, pads, and washes, and in various concentrations ranging from 2.5% to 10%. Increasingly, benzoyl peroxide is being formulated in combination with other antibacterial agents, such as clindamycin and erythromycin because the combinations are more effective than either agent alone and as discussed above, there is less antibiotic resistance. The selection of the formulation of the benzoyl peroxide will depend on your skin type and personal preference, with solutions and gels more appropriate for oily-prone skin and creams and lotions for drier skin types. Pads are useful for people with active travel or exercise schedules Benzoyl peroxide products are typically applied twice daily to the skin. A thin layer is applied to the entire affected area to treat the existing acne and to prevent new acne lesions from developing.

As with all topical medications, it is important to use the medication as directed by your dermatologist. Side effects may occur, and it is your dermatologist who can evaluate the severity of any possible reactions and determine if the medication should be discontinued. This is especially important for women with brown skin in whom dark marks or discolorations of the skin may occur as a result of a side effects from the medication. The most common side effect of benzoyl peroxide products is mild redness and flaking during the first few days or weeks of treatment. This may also occur at the change of seasons, especially as the summer turns into the fall and winter. Your doctor may direct you to use a smaller amount of the medication, a milder concentration of the benzoyl peroxide or apply a moisturizer to the skin beforehand to lessen these side effects. Finally, it is important to know that benzoyl peroxide is a bleaching agent that may lighten clothing or bed sheets that come into contact with the treated skin. You may consider wearing a white camisole or t-shirt and using white sheets and pillow cases while using benzoyl peroxide medications.

Below is a list of commonly prescribed benzoyl peroxide medications.

  • Brevoxyl Creamy Wash (4%, 8%)
  • Brevoxyl Cleansing Lotion (4%, 8%)
  • Brevoxyl Gel (4%, 8%)
  • Triaz Cleanser (3%, 6%, 9%)
  • Triaz Gel (3%, 6%, 9%)
  • Triaz Pads (3%. 6%. 9%)
  • Zoderm Cleanser (4.5%, 6.5%, 8.5%)
  • Zoderm Cream (4.5%, 6.5%, 8.5%)
  • Zoderm Gel (4.5%, 6.5%, 8.5%)

Topical Antibiotics
To kill the bacteria (P. acnes) that cause and exacerbate acne pimples and cysts, your dermatologist may prescribe topical antibiotics. Antibiotics are also helpful in decreasing the inflammation that is characteristic of acne. The topical antibiotic is applied to the face once or twice daily and must be used for a period of 6-8 weeks before improvement is noticed. Topical antibiotics come in the form of creams, solutions, gels, foams, lotions, and pads. The selection of the formulation of the antibiotic will depend on your skin type and your personal preference. Solutions and gels are often more appropriate for oily-prone skin, whereas creams and lotions are for drier skin. Pads are useful for people with active travel or exercise schedules. Foams are useful when the medication is to be applied to large areas of the skin, such as the chest or back. The active ingredient, the antibiotic, will be the same or similar in the different formulations. The types of antibiotics most often used in topical formulations are sulfur, erythromycin or clindamycin. Since antibiotics have been used for many years in the treatment of acne, increasing bacterial resistance to the antibiotics mean that the antibiotics are not as effective in the treatment of acne as they once were. Recent scientific studies have demonstrated less bacterial resistance to the clindamycin type of topical antibiotics. Additionally, antibiotic combinations that contain benzoyl peroxide also demonstrate less bacterial resistance. All of the combination products, including clindamycin/benzoyl peroxide, and erythromycin/benzoyl peroxide are better for the treatment of acne versus either ingredient used alone. (The clindamycin/benzoyl peroxide combination gel has an advantage over erythromycin/benzoyl peroxide gel because the former does not require refrigeration.)

It is important to understand that these topical medications have the potential to lead to dryness and irritation of the skin. Therefore, it is important to use the topical medication as directed by your dermatologist. The concomitant use of gentle, non-drying cleansers and moisturizers may help to alleviate dryness. Commonly prescribed topical antibiotics include:

  • Clindamycin: Cleocin T Solution, Gel, Lotion or Clindagel or Clindet Pledgets or Evoclin Foam
  • Erythromycin Solution, Gel: Emgel or A/T/S solution
  • Sulfacetamide + Sulfur: Sulfacet-R Lotion, Rosula, Plexion cleanser and plegetts, Rosanil cleanser
  • Sulfacetamide: Klaron or Novacet lotions
  • Clindamycin and Benzoyl Peroxide combination gel: Duac
  • Clindamycin and Benzoyl Peroxide combination gel: Benzaclin
  • Erythromycin and Benzoyl Peroxide combination gel, pads, pak: Benzamycin

Oral Antibiotics
Oral antibiotics are generally more effective than the topical variety. Many people with acne will need to take oral antibiotics for many months or even years. However, oral antibiotics simply control but do not cure acne. They work by killing the bacteria (P.acnes) that is responsible for acne and they reduce the inflammation that occurs in acne. Oral antibiotics are usually taken twice daily. There are newer formulations that only require once daily dosing and display the same efficacy. As with the topical antibiotics, there is emerging resistance by the bacteria to the erythromycin class of antibiotics. We therefore rely increasingly on the tetracycline family of antibiotics, including doxycycline and minocycline.

There are side effects associated with the oral antibiotics, including upset stomach, dizziness, headache, increased sun sensitivity, yeast infections, rash and hives. For women with brown skin, there are other possible and potentially serious side effects. The antibiotic, minocycline has been associated with an overall darkening of the skin, particularly on the face and neck. This darkening can be very unsightly, but usually fades over a period of time. There have also been rare reports of a minocycline-induced lupus-like syndrome. Since lupus occurs more often in women with brown skin, this may be of particular concern. Another word of caution: the use of oral antibiotics by women who are on birth control pills could make the pill less effective, subjecting women to the risk of unwanted pregnancy. Discuss with your doctor the use of a second form of contraception when taking oral antibiotics. Also don’t forget to wear sunscreen to avoid the risk of sunburn when taking oral antibiotics. The following is a list of some of the more common antibiotics used for the treatment of acne.

Oral Antibiotic

Dosage

Adverse effects

Information

Tetracycline
250, 500mg BID
GI upset, light sensitivity,
yeast infection
Most widely prescribed antibiotic for acne
Taken on empty stomach
Erythromycin
250, 333, 400, 500mg
GI upset, vaginal yeast infection Many forms absorbed with food
Minocycline (Dynacin, Minocin, Monodox)
50, 75, 100mg
Dizziness, GI upset, headache, pigmentation, lupus-like syndrome Expensive
More effective than tetracycline
Absorption with food
Doxycycline (Doryx, Adoxa)
50, 75, 100mg (Adoxa 1/100 Pack, and 2/100 Pack)
Sensitivity to sunlight,
GI upset, headache

As effective as minocycline
Less expensive than minocycline
Ampicillin, Amoxicillin
250, 500mg
Rash Not widely used for acne
Cephalosporins (Cephalexin)
500mg
Rash, hives, Diarrhea Not widely used for acne
Trimethoprim / sulfamethoxazole
(Bactrim, Septra)
Double strength (DS) tablets
Rash, hives Not widely used for acne

Topical Retinoids

Since topical retinoids are extremely effective at unplugging pores, they are essential to the treatment of acne. They treat both inflammatory lesion of acne (bumps, pus-filled bumps and cysts) and the non-inflammatory lesions of acne (blackheads and whiteheads). The retinoids are topical prescription forms of vitamin A which include adapalene, tretinoin and tazarotene. You may know these medications under their brand names of Avita, Differin, Retin-A, and Tazorac. Retin-A was the first retinoid available for the treatment of acne, with Differin and Tazorac being the latest retinoids to become available. There are several different formulations of each of these prescription medications. Retinoids come in cream, gel, solution and pad formulations. The gel or solution formulations of the retinoids are appropriate for oily skin, whereas creams are most appropriate for dry skin. A pea-size amount of the retinoids appropriate for your skin is applied to the face at bedtime.

There are side effects that may occur with the use of retinoids which include irritation, peeling, redness and drying of the skin. Some women with brown skin complain that their skin is so irritated that it feels and looks “burned” by the retinoids. It is important to discontinue use of any topical product that irritates or burns the skin. Many dermatologists, believe it is worth the trouble of finding ways to improve the tolerability of the retinoids because they prevent that precursor lesion of acne (microcomedo). Improved tolerability can often be achieved by instituting several simple strategies. First, make sure your doctor begins with the lowest dosage of the retinoid and prescribes the retinoid in a cream-base formula (instead of a gel or solution). Initially using the retinoid product every other night, applying a pea-size amount, and utilizing moisturizing lotions or creams before applying the retinoid, can also help minimize side effects. In addition to controlling acne and evening out the complexion, an added bonus of using a retinoid is that it diminishes fine lines and wrinkling of the skin! A word of warning: all retinoids must be discontinued at least 7-days before facial waxing or chemical peels. Failure to do so may result in damage to the underlying skin. Please consult with your dermatologist prior to having any of these procedures while using a retinoid. Common types of retinoids include:

  • Differin Cream, Gel, Solution, Pledgets* (0.1% for each)
  • Tazarac Gel (0.05%, 0.1%)
  • Tazorac Cream (0.05%, 0.1%)
  • Retin A Cream (0.025%, 0.05%, 0.1%)
  • Retin A Micro (0.1%)
  • Retin A Gel (0.025%, 0.01%)
  • Retin A Solution (0.05%)
  • Avita Cream (0.025 %)
  • Avita Gel (0.025%)
    • *a pledget is a compress or pad used to apply medication

Oral Retinoids
A derivative of vitamin A, isotretinoin (Accutane, Sotret) is one of the most powerful and effective oral medications developed to treat acne. It’s indicated for the treatment of severe, cystic acne or scarring acne that does not improve with standard acne medications. Isotretinoin decreases the production of oil by the sebaceous glands and unplugs clogged follicular canals. Isotretinoin is taken for five months either once or twice daily. Although for many patients the acne does not return for many months or even years after treatment with isotretinoin, it is not a cure for acne. (Unfortunately, there is no cure for acne). However, isotretinoin does carry serious potential risks related to birth defects. Therefore, a woman taking isotretinoin must not become pregnant immediately prior to taking the medication, during the five months that she takes isotretinoin, or for 1 month after taking isotretinoin. Other possible side effects include depression and suicide, dry skin, sun sensitivity, muscle and joint stiffness and increased triglyceride levels. Only your dermatologist can determine if isotretinonin is the right medication for your skin. An isotretinoin registry has been recently implemented in the US which means that you, your doctor and pharmacist will be monitored by the government whenever isotretinoin is prescribed.

Hormone Therapy
Oral contraceptives (birth control pills) are a relatively new therapy for the treatment of acne in women. Oral contraceptives with estrogen (e.g., ethynyl estradiol) and progestins of low androgenic activity are the most useful. The hormones progesterone and estrogen, which peak just before ovulation, can stimulate extra oil production in your skin’s sebaceous glands. Birth control pills, which suppress natural hormones, can block this reaction, preventing acne flare-ups.

Women who suffer from acne flare-ups, irregular periods, oily skin and facial hair growth will want to discuss with their doctor the possibility of a hormonal abnormality. Polycystic ovarian syndrome, anovulation, Cushing's disease, and androgen-secreting tumors cause these sudden changes. Tests that your doctor might order to determine if there is a problem include total and free testosterone, DHEA-sulfate, ACTH stimulation, prolactin, luteinizing hormone, follicle-stimulating hormone, lipid profiles, and glucose tolerance tests.

Cortisone Injections
Corticosteroid injections will diminish large, inflamed acne cysts in short order—within a day or two. So if you have a pimple emergency, call your doctor for an emergency appointment to have that huge pimple or cyst injected. Possible side effects are hypopigmentation (light spots) in brown skin or even slight depressions of the skin.

Procedures
There are a variety of procedures that include light, laser, and photodynamic therapy that are currently available for the treatment of acne. Women with brown skin must be cautions when selecting these procedures, as side effects could occur. Both blue and red light have been used, with one targeting P. acnes and the other being anti-inflammatory. Photodynamic therapy (PDT) uses blue light to damage sebaceous glands and lasers are also used to cause sebaceous gland damage and destruction in individuals with acne vulgaris.

Bottom Line
Acne is not an insurmountable problem for women with brown skin. There is effective treatment that will control but not cure acne. Remember to be patient, since most medications can take 6 to 8 weeks before they are fully effective. Your doctor will be able to determine the most appropriate medications for your skin. Make sure that he or she also prescribes medication to treat your hyperpigmentation. If you experience dryness, redness, irritation or any side effects from your medications, it is important that you call your doctor immediately for treatment, as brown skin is especially susceptible to hyperpigmentation. Remember it is important for you to do your part by taking your medications as directed by your physician, washing your skin gently (no rubbing or scrubbing) and no picking or squeezing your bumps. Do use non-comedogenic or non-acnegenic makeup and sunscreen with a sun protection factor (SPF) of at least 15. In a relatively short period of time, you will have the beautiful, flawless skin that you have always wanted.

For scientific information on acne, refer to Dr. Taylor's paper Acne Vulgaris in Skin of Color (Taylor SC, et al Journal of American Academy of Dermatology 46(S2) 98-106, 2002).

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