Acne vulgaris (commonly called acne) is a common skin condition, caused by changes in the pilosebaceous units. These units are skin structures consisting of a hair follicle and a sebaceous gland. The changes occur as a result of increased sebum production via testosterone stimulation. Both men and women have varying amounts of testosterone. Acne is most common during adolescence, affecting more than 85% of teenagers, and frequently continues into adulthood. This type of acne affects the areas of skin with the largest amount of sebaceous follicles. These areas include the face, the upper part of the chest, and the back. Whenever acne becomes inflammatory it can damage the skin by destroying the collagen. For most people, acne diminishes over time and tends to disappear-or at the very least decrease-after one reaches one's early twenties. There is, however, no way to predict how long it will take to disappear entirely, and some individuals may continue to suffer well into their thirties, forties and beyond.
Patients may be surprised to learn that development of acne vulgaris in later years is actually quite uncommon. True acne vulgaris in an adult woman may be a feature of an underlying condition such as pregnancy and disorders such as polycystic ovary syndrome or the rare Cushing's syndrome. It is also known that menopause-associated acne occurs as production of the natural anti-acne ovarian hormone oestradiol fails at menopause. The lack of oestradiol also causes thinning hair, hot flashes, thin skin, wrinkles, vaginal dryness, and predisposes to osteopenia and osteoporosis as well as triggering acne (known as acne climacterica). So what is adult acne and why does it occur in later life? Why does it also seem to affect mostly women and occur around the mouth area where there are fewer pilosebaceous units? In fact why does it last for years and not respond to the normal treatments such as Benzoyl peroxide or Salicylic acid 2% (Acnesal) products. I would also ask why is it so common and bothersome for so many people?.
Is adult acne really acne?
I think these effects happen because what we call adult acne is probably a totally different disease. Several factors are known to be linked to acne, including the tendency for the condition to run in families and exposure to certain chemical compounds such as dioxins. Remember the thirties are the decades of rosacea and what we see is often a different disease called perioral dermatitis masquerading as adult acne. Many GPs also call this acne and treat it the wrong way. Stress, through increased output of hormones from the adrenal (stress) glands causes outbreak of the condition. While the connection between acne and stress has long been debated, scientific research indicates that "increased perioral dermatitis" is "significantly associated with increased stress levels.
So what exactly is perioral dermatitis?
Perioral dermatitis is a condition closely related to acne vulgaris that affect young women between the ages of twenty and forty five. Occasionally men or children are affected. Perioral refers to the area around the mouth, and dermatitis indicates redness of the skin. In addition to redness, there are usually small red bumps or pus bumps, and mild peeling. Sometimes the bumps are the most obvious feature, and the disease can look a lot like acne. The areas most affected are within the borders of the lines from the nose, to the sides of the lips, and the chin. There is frequent sparing of a small band of skin that borders the lips. The skin lesions can affect the area around the eyes. It is not uncommon, and has a tendency to recurrence in individuals who have had it once. This condition is often related to stress and become common in summer time as it acts like rosacea, becoming worse with sunlight exposure. Sometimes there is mild itching or burning.
How long does it last?
If not treated, perioral dermatitis may last for months to years. Even if treated, the condition may recur several times, but usually the disorder does not return after successful treatment.
What causes perioral dermatitis?
The cause of perioral dermatitis is unknown. We know it is a neurodermatis and hence related to stress. Some dermatologists believe it is actually a form of rosacea or sunlight-worsened seborrheic dermatitis. We know that strong corticosteroid creams applied to the face can cause perioral dermatitis. Once perioral dermatitis develops, corticosteroid creams seem to help, but the disorder reappears when treatment is stopped. In fact, perioral dermatitis usually comes back even worse than it was before use of steroid creams. Some types of makeup, moisturizers, and dental products may be partially responsible. There is also a suspicion that fluorinated toothpastes are related to an outbreak of this condition.
Can it be prevented?
There is no guaranteed way to prevent perioral dermatitis. Do not use strong prescription strength corticosteroid creams on the face. Your dermatologist may have suggestions about the use of moisturizers, cosmetics, and sunscreens, and may advise against using toothpaste with fluoride, tartar control ingredients, or cinnamon flavouring.
Are laboratory tests needed to diagnose the problem?
Most of the time, no tests are necessary. A dermatologist can usually make an accurate diagnosis by just examining the skin. Sometimes, scraping or a biopsy of the skin is done. Occasionally, blood tests are ordered to eliminate other conditions that can look similar.
How is this condition treated?
Dermatologists tend to use oral antibiotics, similar to the ones we use in Rosacea to treat the condition. This means a patient would require taking doxycycline or tetracycline for minimum of 3 months to prevent recurrence. For milder cases or pregnant women, topical antibiotic creams may be used. Occasionally, your dermatologist may recommend a specific corticosteroid cream, just for a short time to help your appearance while the antibiotics are working.
Is this similar to the treatment of acne?
Yes and no. I suppose systemic antibiotics are a mainstay in the treatment of ordinary acne vulgaris. Some of these antibiotics, such as Doxycycline (ByMycin) and Minocycline (Minocin) have anti-inflammatory properties and generally more effective than tetracycline. However, resistance is becoming more common and other antibiotics, including Trimethoprim (Septrim) are reportedly more helpful in acne than perioral dermatitis. Roaccutane (Isotretinoin) is a systemic retinoid that is highly effective in the treatment of severe acne vulgaris. It does this as it depresses sebum excretion by 70%, is anti-inflammatory, and even reduces the presence of acne bacteria. I do not tend to use it with perioral dermatitis as the basis of the condition is not sebum related. Roaccutane is a teratogenic and pregnancy must be avoided. A negative pregnancy test result is required prior to the initiation of therapy. A doctor will also check your cholesterol and liver tests monthly.
Are lasers of any value?
Lasers that use Photopneumatic™ technology such as the PPx and Isolaz has little use treating this condition as the underlying problem is not related to an increase in sebum However IPL (as used in Rosacea) appears to be of some benefit in controlling the condition.
What can be expected with treatment?
Most patients improve within two months of oral antibiotics. If corticosteroid creams were used for treatment, there may be a flare-up when the creams are stopped. If antibiotic treatment is stopped too early, however, the problem can come back.
Are there any other treatments?
There are many OTC products available for the treatment of acne, many of which are without any scientifically-proven effects. Generally speaking, successful treatments show little improvement within the first two weeks, instead taking a period of approximately three months to improve and start flattening out. Many treatments that promise big improvements within two weeks are likely to be largely disappointing. However, short bursts of cortisone can give very quick results to ordinary acne but are not recommended for this condition. .
Topical bactericidals
Topical bactericidal products containing benzoyl peroxide may be used in mild to moderate acne. The gel or cream containing benzoyl peroxide is rubbed, twice daily, into the pores over the affected region. Bar soaps or washes may also be used and vary from 2 to 10% in strength.
I normally do not recommend benzoyl peroxide to be used in this condition as it is a keratolytic (a chemical that dissolves the keratin plugging the pores) and the primary problem is not due to blocked pores. Other antibacterials with less keratolytic effects include triclosan, or chlorhexidine gluconate.
Topical antibiotics
These include ointments such as erythromycin, clindamycin or tetracycline. They act by killing the bacteria that are harboured in the follicles. While topical use of antibiotics is equally as effective in ordinary acne as oral use, I do not find them as effective in this condition. However, sometime I use Rozex and Metrogel (metronidazole) in much the same way I would treat a Rosacea patient.
Hormonal treatments
In females, ordinary acne can be improved with hormonal treatments. The common combined oestrogen/progestogen pill has some effect, but the antiandrogen, cyproterone in combination with an oestrogen (Dianette) is particularly effective at reducing androgenic hormone levels. Most patients with adult acne are too old to use this drug so it is not generally used
Topical retinoids
This group of medications are used to normalise the follicle cell lifecycle. They include brands such as tretinoin (brand name Retin-A), adapalene (brand name Differin), and tazarotene (brand name Tazorac). Like isotretinoin, they are related to vitamin A, but they are administered as topicals and generally have much milder side effects. They can, however, cause significant irritation of the skin and I never use them in this condition.
Phototherapy
It has long been known that short term improvement can be achieved with blue and red light. Recently, visible light has been successfully employed to treat acne (phototherapy) - in particular intense violet light (405-420 nm) generated by purpose-built fluorescent lighting, LEDs or lasers used twice weekly has been shown to reduce the number of acne lesions by two thirds. It is even more effective when applied daily. The mechanism appears to be that a porphyrin produced within P. acnes generates free radicals when irradiated by 420 nm and shorter wavelengths of light. These free radicals ultimately kill the bacteria.
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