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.
|
|
|
|
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).
