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Acne treatments
by Dr Gavin Chan - Victorian Cosmetic Institute

What causes acne?
There are a number of contributors to the formation of acne. Excess oil and sebum production exacerbated by hormonal influences on sebaceous glands, as well as dead skin physically blocking pores can cause acne. A bacterium named Propionobacterium acnes has also been implicated as a cause of acne. All treatments for acne will address one or more of these issues.

There have been no studies showing that acne is caused or exacerbated by your diet, contrary to the usual belief that certain foods can worsen acne.

What treatments are available?
Acne can be treated in a number of ways. The first step in treating acne is appropriate skin care.

Skin care
A good cleanser is the first step in the treatment of acne. A cleanser containing alpha-hydroxy acids or beta-hydroxy acids, such as those found in ASAP and Cosmedix skin care products, can help remove the oil and dead skin cells from the surface of the skin to prevent the physical blockage of pores and acne. Exfoliants with these ingredients can also be used. Beta-hydroxy acids (including salicylic acid) have the advantage of having anti-inflammatory properties also.

Benzyl peroxide is a good product for reducing active acne lesions and also has anti-inflammatory properties. It is found in well-known products such as ‘Pro-activ’ but is also available more inexpensively over-the-counter at your local pharmacist. It is available in concentrations up to 10%. The higher the concentration, the more flaking and irritation to the skin. Therefore, commencement should be with the lower concentrations.

Retinols, derivatives of Vitamin A, are also used in the treatment of acne. Retinols work by increasing the natural turnover rate of the skin. Therefore there are less dead skin cells at the surface of the skin and less blockages as a result. This property of retinols also means that skin texture and fine wrinkles also improve. The downside of retinols is the initial response of the skin, or the ‘retinoic response’. Skin can usually appear red, flaky, lumpy, and irritated for up to one month after commencement of retinols. Starting slowly is important to reduce these side effects. Sunscreen is also imperative with the use of retinols as they can initially exacerbate sun sensitivity. Retinols should not be used in pregnant mothers, those planning to be pregnant, or those who are breast-feeding.

Examples of Vitamin A derivatives include prescription-only variants such as Stieve-A, and Retin-A. Cosmedix also has a range of retinols of varying strength. Although more expensive than their prescription-only variants, they have the added property of being ‘chirally correct’. Each molecule has a left and a right-sided version, like a pair of hands. In the case of retinols, the left sided version is more active and less irritating to the skin. Cosmedix has more of the left sided version of the molecule and is therefore ‘chirally correct’.

Microdermabrasion is another method of helping to physically remove dead skin cells from the surface of the skin and reduce pore blockage and acne. It is especially effective for comedones (blackheads). It also helps with the penetration of skin care products. Microdermabrasion also improves lymphatic drainage of the face.

Make-up is also implicated in the cause of acne. Foundations, even those claiming to be ‘oil-free’ can physically block pores and cause acne. This often leads to a vicious cycle of applying make-up to cover acne lesions, and in turn this causes more acne, leading to the use of more make-up. Acne due to make-up use is termed ‘acne cosmetica’. Mineral make-up does not block pores, and instead sits on top of the skin. At The Victorian Cosmetic Institute, we recommend Glo-minerals foundations as they have anti-oxidants and anti-inflammatory properties as well as being a mineral make-up. Importantly, they also have a SPF factor to help prevent aging and post-inflammatory hyperpigmentation from acne lesions (see below).

Antibiotics have also been widely used in the treatment of acne. Antibiotics work by reducing the acne-causing bacteria (including Propionobacterium acnes) at the surface of the skin. Antibiotics are most suited to inflamed acne lesions. They do unfortunately also affect the rest of the body as well as the skin, and can result in side effects such as oral and vaginal thrush, diarrhoea, liver function abnormalities, and sun sensitivity. Minomycin has also been associated with hyperpigmentation when used for prolonged periods. Antibiotics such as doxycycline, minomycin, clindamycin, trimethoprim, trimethoprim plus suxamethoxazole (Bactrim), are commonly prescribed for prolonged periods. The author does not believe in the long-term use (greater than 2 months) of antibiotics for acne as their efficacy is low and the potential side effects can be significant. Penetration into the skin can also be minimal. With widespread use of antibiotics for acne, there is increasing resistance of the acne-causing bacteria to the commonly used antibiotics, resulting decrease in their effectiveness.

Topical antibiotics are another option for the treatment of acne. Common examples of topical antibiotics include erythromycin (Eryacne gel) or clindamycin (Clindatech lotion). As for oral antibiotics, they require a prescription from a doctor. The advantage of topical antibiotics is they have no systemic side effects, and can have some anti-inflammatory properties.

Hormonal treatments
Particular hormones, in particular androgens, have also been known to increase oil and sebum production and exacerbate acne.

For females, options for controlling the hormones that cause acne include particular variants of the oral contraceptive pill. The variants that are of particular use are the ones containing Cyproterone acetate or Aldactone. The trade names of the pill containing these ingredients include; Dianne-35 and Yasmin. Cyproterone acetate and Aldactone work by helping to switch off the androgenic hormones, or the hormones that increase oil/sebum production and cause acne. Aldactone can also be used without the pill in those females who do not want to be on the pill. It is, however, not compatible with pregnancy, so it is not suitable for those females who are attempting to fall pregnant or who are pregnant.

Oral Isotretinoin/Roaccutane
Roaccutane, or oral isotretinoin, also a derivative of Vitamin A, is the gold standard in the treatment of acne. Prescribed only by dermatologists, it is mostly used for severe forms of acne only, as it has a number of significant side effects. Generally, a six-month course is prescribed, and involves taking a tablet or two each day. The side effects from Roaccutane are the main problem with treatment and include; dry skin, dry eyes, dry lips, cracked lips, hair loss, mood changes, and liver function abnormalities. Pregnancy must be completely excluded during treatment with Roaccutane, as it is known to cause serious birth defects.

Photodynamic therapy
Recently, there have been advances in the treatment of acne that do not involve drugs with significant side effects, and can be highly effective. Photodynamic therapy is such a treatment that targets sebaceous gland activity. Being a localised treatment, it only has localised side effects, ie on the treated skin. There has been some studies showing that it may be as effective as Roaccutane in some cases. Photodynamic therapy works by placing a substance called 5-aminolevulenic acid on the skin, which is attracted specifically to the sebaceous glands, and then activating the substance with a light source or laser. This specifically disrupts the function of the sebaceous glands and reduces their activity and the acne they cause. The results can last up to a year and some people require no further treatments for acne after their initial treatments.

Sunscreens are important to help reduce pigmentation after an acne lesion has passed. However, some sunscreens themselves can cause acne by blocking pores. At The Victorian Cosmetic Institute, we recommend Reflect sunscreen from Cosmedix. Reflect is a spray on, non-oily sunscreen with Titanium Dioxide.

Overall, acne is a problem that has many arms of treatment. The more of these that can be implemented, the greater the chance of success. There are a number of treatments now that are an alternative to Roaccutane and its side effects, although it still remains the gold standard in acne treatment. Acne is a problem not just only of teenagers, but also of people in their twenties, thirties and forties. It is an important issue to address in all cases, as not only does successful treatment resurrect lost confidence, but prevents scarring that is often irreversible.

Dr. Gavin Chan (MBBS)
The Victorian Cosmetic Institute
Level 6, 200 High St
Lower Templestowe 3107

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