Acne is the most common skin disorder in the United States and worldwide. Although it is commonly a problem for the teenage population, it is not limited to that age group. Acne Vulgaris peaks at the ages of 14 to 19 and is frequently resolved by the mid twenties.
Classification of Acne
- Adolescent Acne (Acne Vulgaris)
- Post-adolescent Acne- Female adult onset and male adult- onset acne
- Acne-like disorders- Rosacea, Perioral Dermatitis, Neonatal Acne, Drug-Induced Acne, Endocrinopathic Acne, Occupational Acne
Acne of adulthood is not similar to adolescent acne. Although there are similarities and overlapping of the appearance, the treatment can vary. Acne-like disorders such as Rosacea, Neonatal acne and drug induced acne are considered separate diseases because of the differences in the pathogenesis.
Acne is characterized by the formation of open and closed comedones, erythematous papules and pustules. In more severe cases, deep pustules, severe nodules and pseudo-cystic formation. In these cases, scarring is common. Teenage acne has a strong tendency to be hereditary. It is less likely to occur in Asians or dark -skinned people. In puberty, androgenic hormones cause follicular keratinization which can cause a blockage of the sebaceous duct. This blockage is a microcomedone that enlarges and becomes visible. It can then become an inflammatory nodule.
The development of inflammatory lesions occurs in the following sequence;
- Hormones stimulate sebaceous glands to increase in size and produce more sebum
- Skin now becomes oiler
- Growth of the bacteria Propionibacterium (P. Acne)
- Acne produces lipases that digest lipids into fatty acids causing an inflammatory cell response
Acne is not an infectious disease but there are 3 major bacteria commonly associated and usually inhabit the skin and the pilosebaceous duct of patients with acne:
- Propionibacterium acne
- Staphylococcus epidermidis
- Malassezia furfur
Lesions of Acne
- Papules- superficial red pimples
- Pustules- superficial raised lesions containing purulent material
- Macules- the remains of a former inflammatory lesion. Usually red or purple that slowly heal and may develop into a depressed scar
- Nodules- large deep papules of pustules comprised of inflammatory material
- Open comedones (blackheads)- open and black due to oxidized melanin
- Closed comedones(whiteheads)- have small openings
- Follicular- dilated pores on the nose and cheeks
Severity (classified into mild, moderate or severe)
- Mild-occasional papules or pustules
- Moderate- more inflammatory, superficial papules and pustules but healing lesions may scar
- Severe- greater degree of lesions with depth and inflammation, cysts and abscesses present frequently scar
Acne is considered a significant clinical problem with severe social, psychological and emotional implications. Treatment has the main goals of emotional support, prevention of scarring and improvement of appearance. Although topicals are the first line treatment of acne, frequently more than one agent is needed in combination for adequate control.
- Benzoyl Peroxide- improve both inflammatory and non-inflammatory lesions since they are potent anti-bacterial agents. Very drying often irritating
- Retinoids- very anti-inflammatory. Produce sun sensitivity and cannot be used in pregnancy
- Topical Antibiotics- Action against P.acne also anti-inflammatory, Drug resistance reported
Patients who have moderate to severe disease who are not responding to topicals or significant acne on back and chest area where topicals are less responsive. Systemic therapy has a more rapid onset of action, side effects are more prevalent and can be severe such as allergic reaction. This cannot be used in pregnancy or becoming pregnant or breast feeding.
- Tetracyclines- Inhibit the growth of P.acne also have anti-inflammatory activity Major side effect profile can stain teeth and have long term side effects of liver and kidney disease
- Minocycline and Doxycycline- Similar to Tetracycline and can cause a Lupus like syndrome
- Erythromycin- less effective than tetracycline class , multiple drug interactions
- Trimethoprim-Sulfa- Very active against P.acne however associated with severe side effects and allergic reactions
Oral contraceptives or systemic anti-androgens are used in women whom hormonal treatment may be needed as an adjuvant treatment in refractory cases
- Oral Birth control pills
- Spironolactone- anti-androgen
- Synthetic derivative of Vit A that can produce long term remissions. It drastically reduces the size and output of the sebaceous glands. Reduces the sebum and thus decreases the food supply of P.acne
- HIGHLY teratogenic and cannot be taken by women pregnant or thinking about getting pregnant. Can last in the system for months
- Can cause joint pain
- Can cause thinning of hair
- Allergic reactions common
- Depression and suicide can also occur
Intralesional Corticosteroid injections
- Can reduce the inflammatory response but atrophy and scarring can occur
Lasers, Lights and Photodynamic therapy can be used as an alternative or in combination to other therapies. Chemical peels are also being used however not as effective as an anti-inflammatory
Platelet-Rich-Plasma (PRP) is an autologous concentration of platelets rich in growth factors that play an important role in the inflammatory process and tissue healing. Since it is autologous, there are no side effects such as skin dryness or allergic reaction. Platelet-Rich-Plasma is a good choice for the treatment of acne and acne scars. PRP accelerates the healing process, regulates inflammation and promotes healing. PRP has an anti-infectious mechanism that inhibits the P.acne bacteria.
In studies comparing PRP vs. topical erythromycin there was a significant difference between the sides of the face treated. 55% of the PRP group showed good to excellent improvement and 35% showed moderate improvement in the PRP group. The PRP group had better patient satisfaction and lower rate of recurrence than the erythromycin group.
The author concluded PRP is effective and a safe treatment option for inflammatory acne and an alternative to other systemic modalities.
(PLATELET-RICH-PLASMA INJECTION vs TOPICAL ERYTHROMYCIN 2% in TREATMENT of ACNE VULGARIS
Dermatolog Treat 2020 JUL 20;1-8 PMID 32643473)
In acne scarring, Platelet-Rich-Plasma was found to provide statistically significant improvement in validated outcomes over microneedling or subcision alone.
(PLATELET-RICH-PLASMA in NONINVASIVE PROCEDURES FOR ATROPHIC ACNE SCARS
J COSMET DERMATOL 2020 APR;19(4) 836-844 PMID 32061047)
In a comparison between PRP and microneedling alone, PRP was found to be superior in the treatment of acne scarring on the same face.
(SPLIT-FACE COMPARATIVE STUDY of MICRONEEDLING with PLATELET-RICH-PLASMA versus MICRONEEDLING ALONE in TREATING ACNE SCARS
SKINMED 2019 SEPT 9;17(3) 207-209 PMID 314 96480)
Finally, in a significant study of 40 patients ages 20-40 in a split face study, comparing PRP vs non-cross linked hyaluronic acid, 85.4% of the PRP showed improvement in comparison to 82.9% improvement in the non-cross linked hyaluronic side. Although the author found this to be statistically insignificant, there was an overall difference between the two sides of treatment.
(COMBINED AUTOLOGOUS PLATELET-RICH-PLASMA with MICRONEEDLING VS> NON-CROSSED LINKED HYALURONIC ACID IN THE TREATMENT OF ACNE SCARs: SPLIT FACE STUDY
Dermatology Therapy 18 SEPT 2021;34:e14457 DOI:10.1111/dth.14457)
Juventix Regenerative Medical offers a FDA approved Platelet-Rich-Plasma kit that is low cost and proven to provide reproducible results from the same sample. It is simple and easy to use in the office. Juventix Regenerative Medical also provides a patented Platelet-Rich-Plasma Kit with enclosed Non-Crossed Linked Hyaluronic Acid.
The Kit chosen for these applications makes a difference in the outcomes. With our Juventix Photo-Activation Process, the platelets do not have to be exposed to Calcium Chloride or Thrombin for activation to occur.
Restore, Revive, Regenerate, Juventix
Dr. Robert McGrath