G. S. Storwick, MD, BSc, MSc, FRCPC
Faculty of Medicine, University of Calgary, Calgary, Canada
Almost everyone at some point in his or her life will be troubled with mild acne. It can be related to athletic activities, travel, cosmetics, or hormonal changes. The peak incidence of acne occurs during adolescence, affecting approximately 85% of young people 12–24 years of age. However, adult onset acne is common and the first lesions can appear in the 20s or 30s. Even seniors can be troubled with it on occasion. It can be transient, recurrent, or persistent. Fortunately many good treatments are available. When seeing patients for other reasons, do not hesitate to address their acne, because they are often reluctant to bring it up themselves and are very grateful when offered treatment.
It is a multifactorial disorder of the pilosebaceous units located on the face, chest, and back. For some patients it is mildly annoying, for others it can be very distressing, causing a poor self image, withdrawal and even depression and suicidal ideation.
Mild acne has the following features:
- No scarring however subtle
- However, remember that some people with even mild inflammatory acne can develop scars; if scars do develop, the acne should be reclassified.
- Mild papular, pustular and/or comedonal
- Regional, i.e., on the forehead, nose, chin, back
- New onset and of short duration
- Cyclical, i.e., related to menstrual periods
Approach to Therapy
Treatment can be directed toward abnormal follicular keratinization (with retinoids), sebaceous gland activity (using oral contraceptives), or bacterial Propionibacterium acnes (P. acnes) activity (with oral and topical antibiotics). It is important to begin treatment as early as possible in order to prevent mild acne from becoming worse and causing scarring.
Cleansers and Washes
Cleansers are always a good place to start. Have patients use them in the shower, leave on for a few minutes and wash off. Washes tend to be more drying, which is sometimes better for occlusion-induced acne on backs.
- Benzoyl peroxide (BP) washes
- Salicylic washes
- Antibacterial washes
- Topicals essentially prevent new lesions of acne, so they need to be applied to the whole acne-prone area.
- Establish proper expectations about when to expect to see improvement. Improvement is likely to be approximately 25% per month.
Benzoyl Peroxide Lotions
- Lower-strength preparations are available over-the-counter (OTC) in most areas.
- There is no evidence to suggest that higher concentrations work better than the low concentrations of benzoyl peroxide.
- BP is available as an inexpensive OTC or prescription product. OTC is generally less costly than prescription.
- A contact dermatitis can develop in a small minority of patients.
- Care must be taken because BP can bleach clothing and towels.
- Should be used for short-term or intermittent use to minimize antibiotic resistance.
- Good for inflammatory and pustular acne. Not to be used for purely comedonal acne.
- e.g., tretinoin, tazarotene, adapalene. Especially for comedonal acne.
- Mechanism of action involves normalizing follicular keratinization.
- Aid in the expulsion of existing comedones and prevent the formation of new ones.
- Can be difficult to use, because they are irritating, though some topical formulations are less irritating than others.
- Creams are generally better tolerated than gels.
- Start with intermittent use and apply sparingly at night. Applying a small quantity on an unwashed face may reduce irritation. Apply a bland emollient over top of the retinoid to minimize irritation.
- Short-contact application, e.g., for a couple of minutes initially, can be helpful for those with sensitive skin or a history of eczema.
- It is possible that the retinoid receptors in the skin are fully engaged only after 1 hour of contact; so for some patients this means that overnight application may be unnecessary.
Topical combination agents are more effective than either agent alone, maximizing therapeutic potential. They are more convenient to use, and some do not require compounding. Available combination agents include:
- a cleanser plus a topical agent
- a topical agent plus an oral contraceptive for acne that is unresponsive to topical treatment
- an antibiotic and a topical BP or retinoid
- reduce the potential for antibiotic resistance.
- care must be taken because BP can bleach clothing and towels.
- useful for both comedonal and inflammatory acne.
- minimize the risk of developing antibiotic resistance.
Oral contraceptives (OCs)
- OCs may be a good way of controlling mild unresponsive acne in women.
- Use in combination with topical therapy.
- Maximum effectiveness seen at 3–6 months. Excellent choice for women who need birth control and have mild acne.
- Estrogen effects include decreasing adrenal and ovarian androgens and increasing sex hormone binding globulin, which decreases free testosterone.
- Some OCs contain cyproterone acetate, a potent antiandrogenic progestin, which blocks androgen activity at the pilosebaceous unit.
- Suitable as long as there are no contraindications.
- If patient is responsive, it can be continued as long as required.
- Spironolactone 100–200mg daily is also an option for adult females.
With a little patience and compliance your patients should be able to gain control of their acne. When mild acne is persistent, or extremely upsetting to the patient, consider more aggressive therapy.