Adolescent Acne: A Stepwise Approach to Management

Iris Woodard, BSN, ANP

Disclosures

Topics in Advanced Practice Nursing eJournal. 2002;2(2) 

In This Article

Management

Treatment of acne is aimed at preventing the formation of comedones, papules, and pustules and reducing inflammation. Both topical and oral medications are important. Because treatment is preventive, not curative, improvement may be slow. Patient education should cover both general principals of hygiene and warnings about avoiding manipulation of individual lesions. "Picking" or "popping" pimples only increases inflammation and potential for scarring. These instructions may have to be repeated at each visit, until the patient understands the necessity of all treatment modalities.

Hygiene

The first step in successful acne management is good hygiene. In the author's experience, adolescents (especially males) between the ages of 12 and 14 years lack basic information about skin care. Acne is not a problem of dirt on the skin, as many people believe. Twice-daily washing is sufficient. More frequent exposure to water and medications can cause overdrying and rebound secretion of sebum. If prescription topical medications are given, a mild, nonmedicated soap should be chosen. Strong deodorant soaps, which are effective on the body, can be too irritating to facial skin. Abrasive sponges or cloths (such as the popular "buff puff") should be avoided because they cause microscopic abrasions and create portals for the entry of bacteria. Astringents contain alcohol, which increases skin dryness and sometimes worsens irritation.

Certain moisturizers designed for use on acne-prone skin will help maintain the balance of moisture. Teens can be taught to look for products with labeling that includes the words "noncomedogenic" or "for acne-prone skin." These products will not contain ingredients that worsen acne. Most of these products now contain a sunscreen and will counter the increased sun sensitivity caused by acne medications.

Any topical therapy will initially worsen acne, since irritation is a common early side effect. The teen should be taught that this initial response will last about 2 weeks. Since it takes about 28 days to regenerate skin, the preventive effect of medications will not appear immediately. Improvement should become noticeable after 4 weeks of therapy, if medications are used as directed.[6]

Topical Medications

Popular magazines boast many advertisements for antiacne products, and making an appropriate choice seems overwhelming to an uneducated consumer. Skin reactions to soaps and topical medications may vary. The same medication will have a different effect on different skin types. Much of early acne treatment is trial and error, finding the right product that works best for an individual patient. When OTC products don't work or cause irritation, the expense can add up quickly, so information about products can save consumers time, trouble, and skin irritation.

Topical comedolytics help dry excess sebum and make the excreted sebum less sticky. This prevents occlusion of the pores and consequent formation of comedones. Topical comedolytics also cause sloughing of the stratum corneum and help remove existing sebum plugs along with loose keratinocytes. They also help normalize keratin turnover in the follicle.[7]

Initial selection of a medication will depend on the severity of the adolescent's acne and on the skin type. Most teens have already tried some OTC products before they seek professional help. OTC topical comedolytics include benzoyl peroxide and salicylic acid. Prescription comedolytics include tretinoin, azelaic acid, and adapalene. Individual should generally start therapy at the lowest strength of medication. If an OTC has not yet been tried and acne is mild, benzoyl peroxide or salicylic acid can be recommended. Both benzoyl peroxide and salicylic acid come in a variety of products and in several different delivery systems, such as creams, washes, gels, and cleansing pads (Table 2). The choice depends on how much time the individual has to devote to skin care, how each person reacts to the product, and the cost of individual products. Benzoyl peroxide is more effective, combining antibacterial action with mild comedolytic properties. However, benzoyl peroxide may be more irritating, with a higher incidence of allergic reactions.[6]

If the teen has already tried several OTC products, he or she should start with a prescription for a tretinoin cream 0.025%. Adapalene and azelaic acid are both marketed as less irritating than tretinoin and may provide improvement in persons who have an irritation reaction to tretinoin. Mild acne will often respond to the combination of a topical comedolytic and topical antibiotic. Topical antibiotics include erythromycin, clindamycin, and sodium sulfacetamide. They all come in various vehicles as discussed later. For convenience, Benzamycin (benzoyl peroxide and 3% erythromycin) and Benzaclin are available by prescription, combining both comedolytic and antibiotic in 1 medication. These might prove helpful to a young teen who has trouble remembering to apply topical medications.

A change in either topical or oral medication is suggested only if there is severe erythema and scaling, indicating that the medication is too strong for that skin type, or the medication is consistently used for 6 to 8 weeks and there is no improvement, indicating that the medication is not strong enough.[11]

Choice of Medication Vehicle

When choosing topical products, it is important to understand the effect on the skin of the vehicle in which the medication is delivered. Gels and solutions, such as astringents or the solution version of topical antibiotics, have a higher alcohol content and increase the drying effect. Creams and lotions are in an emollient base and are more moisturizing. Washes are better for acne on the torso, because they are easier to apply to large areas of the body. Cleansing pads are more portable and may be more convenient to carry in a gym bag, school bag, or suitcase.[6] Generally, individuals should start with a cream and judge the reaction -- change to a gel if cream is not effective and change to a lotion if cream is too irritating.

Alpha Hydroxy Acids (AHAs)

A recent development in skin care is the AHAs, such as glycolic or lactic acid. These products have been used for many years by dermatologists at concentrations of 20% to 30% for facial peel procedures. More recently, AHAs have been added to OTC washes and moisturizers at concentrations of 4% to 6%. AHAs have been found to soften the stratum corneum, remove dead cells, and change free radicals on the skin.[12,13] These products combine well with both topical comedolytics and topical antibiotics. They can be used as the daily facial cleanser or morning moisturizer before application of prescription medication. AHAs in the 20% to 30% strength help to improve discoloration and scarring. Mild benefit can also be seen at the 4% to 6% strength.[13] As with all other topical products, irritation is a problem, especially during the first few weeks of treatment. Many well-known brands of skin care products, such as Oil-Of-Olay, Ponds, Clinique, and Neutrogena, now have product lines containing AHAs, and consumer preference should guide product choice.

A Comment About Topical Vitamins

Increasingly, vitamins are being used for several purposes in acne care. Vitamins A, C, and E all have antioxidant capabilities and are being included in a variety of topical skin care products. Free radicals damage DNA and are believed to be the cause of many diseases, from cancer to colds. Antioxidants applied topically have been shown to be effective in stabilizing free radicals on the skin.[14] Theoretically, topical application of vitamin C should help correct wrinkles and sagging due to loss of elasticity of aging or sun-damaged skin. Manufacturers bombard the consumer with information about one formulation or another, and it is difficult to judge their true value. No studies have yet provided absolute proof as to the clinical value of topically applied vitamins.[15]

Retinol, a derivative of the antioxidant vitamin A, has recently started appearing in OTC skin care products. Retinoids as a class of medications (with retinol being one example) regulate growth and differentiation in cells, diminish malignant cell growth, and strengthen immune function. Both topical and oral versions are available. (The oral retinoid isotretinoin is discussed later in this article.) Topical retinoids, at a mild strength, are found in moisturizers, washes, and lotions and work much like OTC AHA products.[14] The prescription comedolytic tretinoin is also a retinoid, but at a higher concentration. Retinol, the vitamin itself, has grandfather status with the US Food and Drug Administration (FDA) and is exempt from regulation. The dose contained in many products is very small and has not been shown to be of benefit in skin care. In stable formulations and in appropriate concentrations, it can produce some benefit on the skin. Few products currently available meet this standard.[15]

The same situation applies to the addition of Vitamin E to skin care products. There is a theoretical basis for believing the product will work, but no controlled studies have documented clinical value. Vitamin C and E stored in the skin are degraded by UV light. Daily application of these substances in a good moisturizer cream will not cause harm and may help prevent photodamage.[15]

Prescription Treatments

Topical comedolytics. As mentioned previously, topical comedolytics dry excess sebum and cause exfoliation, thus reducing comedo formation, and are the basis for acne therapy (Table 3). Therapy should begin with a topical comedolytic and with patient education about routine skin care. The choice of medication depends on individual skin type and severity of condition.

Generally, tretinoin cream is the first choice, due to its availability as a generic and reduced cost. Avita is another tretinoin available in 0.025% cream and gel. Retin A Micro (tretinoin formulated in a less irritating vehicle[17]), adapalene (Differin), tazarotene (Tazorac), and azelaic acid (Azelex) are not yet off patent and are generally more expensive. The teen should be advised that only a small quantity of medication is necessary (a dab about the size of a pea is placed in the palm, then spread over the face).

A note on the cost of topical medications: some insurance companies consider treatment of acne a cosmetic issue and do not cover cost of the medications. For persons covered by these plans, acne treatment can be expensive, possibly limiting medication options.

Topical antibiotics. Topical antibiotics combined with prescription comedolytics form the foundation of acne therapy. Topical antibiotics such as erythromycin, clindamycin, and sodium sulfacetamide are equally effective (Table 4). Metronidazole is not thought of as an acne medication, but is also effective. Again, there is a wide choice of vehicle, with cream, solution, gel, lotion, and wipes available. The choice of vehicle is based on skin type and patient preference. For example, a solution or gel containing alcohol, which will increase the drying effect, might be more appropriate for a person with very oily skin. On the other hand, a person with sensitive skin may benefit more from a lotion or cream, which will not contribute to dryness. (Sensitive skin is a problem if the teen has a history of atopic dermatitis as a child.) Active teens may prefer wipes as more convenient and portable. Using a lotion with an emollient base will help balance the drying effect of topical comedolytics.

Topical antibiotics should not be used alone due to increased bacterial resistance. Instead, combination with benzoyl peroxide or another comedolytic is recommended. Benzamycin is a prescription-only alcohol-containing gel with benzoyl peroxide 5% and erythromycin 3%. BenzaClin is a prescription-only alcohol-free water-based gel containing 5% benzoyl peroxide and 1% clindamycin. Both are effective, but expensive. Benzamycin gel requires refrigeration, making quick access difficult. BenzaClin no longer requires refrigeration. The same result can be obtained by using an OTC benzoyl peroxide and topical erythromycin or clindamycin, which are available by prescription.[11]

Oral antibiotics. Oral antibiotics act by killing P acnes and reducing the concentration of fatty acid in the sebaceous follicles. Tetracycline has been the preferred antibiotic for the treatment of acne since 1951. Tetracycline is lipophilic with anti-inflammatory action, making it a safe, inexpensive choice. Its most common drawback is that it cannot be taken with foods containing calcium or iron because they bind with the medication and inhibit absorption. Tetracycline is also photosensitizing and can cause either a severe sunburn or a pruritic rash on exposed skin. Tetracycline should not be prescribed to individuals younger than age 12 years as it may stain developing permanent teeth.

Doxycycline and minocycline, which are both in the tetracycline family, make excellent alternatives to tetracycline. Doxycycline is more photosensitizing than tetracycline and can cause erosive esophagitis if not taken with a full glass of water. It has fewer food restrictions than does tetracycline and is more convenient because of once-daily dosing. Minocycline is excellent for short treatment of approximately 1 year or less. With prolonged use, minocycline has the potential to cause bluish staining of the teeth and skin. Erythromycin is also an excellent alternative to the tetracycline family of drugs, especially in the summer when photosensitivity is of greatest concern. Amoxicillin and cephalexin are alternatives when other oral antibiotics have been ineffective. Trimethoprim-sulfamethoxazole is avoided by many clinicians due to the high potential for erythema multiforme and Stevens-Johnson reactions (Table 5).

Bacterial resistance to oral antibiotics is a growing problem. Resistance should be suspected when a patient whose acne was previously stable begins to worsen. Resistance disappears a few months after the antibiotic has been withdrawn. Suggestions for avoiding antibiotic resistance include: (1) prescribing an oral medication only when topical therapy has failed; (2) discontinuing oral medication during maintenance when the condition has improved; and (3) avoiding the concurrent use of different oral and topical antibiotics.[12]

Isotretinoin. Isotretinoin (Accutane) is a derivative of vitamin A, a fat-soluble vitamin. Isotretinoin is recommended for use with patients who have severe scarring, cystic acne. Isotretinoin is anti-inflammatory and decreases the size of the sebaceous glands, thus decreasing the amount of sebum produced. When appropriately used, it is very effective in achieving long-term remission of acne, and it appears to decrease scarring.

Isotretinoin may be prescribed for the following reasons:[17]

 

  • Less than 50% improvement in acne after 6 months of treatment with combination topical and oral therapy;

  • Appearance of scars;

  • Acne that is associated with significant psychological distress; or

  • Acne that quickly relapses during or shortly after conventional therapy.

 

Isotretinoin is sometimes inappropriately used as a first-line treatment. It has many adverse reactions, including potential hepatotoxicity, increased levels of triglycerides (which, in turn, can trigger pancreatitis), and hypercalcemia with loss of bone mass. It is also teratogenic, so females are required to use 2 forms of birth control during treatment. Oral contraceptives are preferred unless there is some contraindication to their use.

The FDA required the maker of Accutane, Roche, to implement a program called SMART (System to Manage Accutane Related Teratogenicity). Each prescriber is required to sign an agreement to follow prescribing guidelines, which include monthly laboratory monitoring of liver function, cholesterol, and triglyceride levels and pregnancy testing in women. Stickers are provided by the company to affix to the written prescription, which informs the pharmacist that the prescriber is following these guidelines. If no yellow sticker is on the prescription, the pharmacist is not supposed to fill it.

In addition, Accutane prescriptions will no longer be accepted over the telephone. Patients must sign 2 consent forms discussing teratogenicity and depression/suicidal ideation, as well as the need for monthly blood monitoring. These forms can be obtained from the manufacturer by calling 1-800-93-ROCHE or from their Web site at www.rocheusa.com . Medical practitioners should not prescribe isotretinoin unless they are participants in the SMART program.

Recent press reports have linked isotretinoin to depression and suicide. No clinical trials have shown a causative relationship between the medication and depression.[18] However, parents will be required to sign a consent form asserting their understanding of this possibility and should be cautioned to carefully monitor the emotional status of teens being treated with isotretinoin.

Hormonal therapy. Oral contraceptives with low androgenic activity have been shown to be useful in managing female acne since 1951. Newer compounds have fewer side effects and are better tolerated. After 3 months of therapy with oral contraceptives, sebum production can be decreased by as much as 40%.[4]Ortho TriCyclen has been approved by the FDA for the treatment of acne. Norgestimate and desogestrel are members of a new generation of progestins that have proven to be less androgenic, and may be more effective for acne than oral contraceptives with older types of progestins. However, no comparison studies have been done. Therefore, other brands of oral contraceptives may also have the same effect on acne despite lacking FDA approval.[8]

Spironolactone is a potassium-sparing diuretic with proven androgenic receptor blocking properties. Numerous trials have reported the benefit of spironolactone in decreasing sebum production acne and decreasing excess hair growth in women with elevated DHEAS (dehydroepiandrosterone sulfate secreted by the adrenal glands). Doses range from 50 to 200 mg daily. Improvement of acne has been reported to be between 35% and 100%.[8] The combination of spironolactone with oral contraceptives improves the clinical response of both medications significantly. Though spironolactone is generally well tolerated, side effects can be experienced at higher doses and may include menstrual irregularities, breast tenderness, fatigue, and headache. Long-term safety has been proven.[8]

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