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Adult Acne

Adult acne first develops in the twenties or later. The strict definition of Adult Acne is Acne that first develops after 25, but definitions vary slightly.

Adult acne is common. In America 50% of adult women has Acne in their twenties, 35% in their thirties, 26% in their forties and 15% in their fifties.

Teenage and adult acne is due to excessive sebum production from oil (sebum) glands. The increased sebum production leads to changes in the mouth of the hair follicle, the infundibulum, which enlarges and becomes plugged with open comedones (black heads) and closed comedones (white heads). A bacterium that normally occurs on the skin, Propionibacterium Acnes, proliferates in the excess sebum, which leads to inflammation, pimples and worse blackheads and whiteheads via biofilm formation.

Adult Acne is common around the jaw line area and is mostly inflammatory (pimply), whereas teenage acne occurs more in the T-panel and is often a mix of inflammatory lesions (pimples) and comedones (blackheads and whiteheads).

In the teenage years increased sebum production is due to the natural surge in hormones that occurs at puberty. This clearly cannot be the cause of Adult Acne.

The causes of Adult Acne include unnaturally increased testosterone levels from a variety of sources, a genetically increased sensitivity to testosterone, increased insulin-like growth factor 1 (IGF-1) that mimics the effect of testosterone, oral medication, cosmetics, smoking and possibly raised insulin levels.

Causes of unnaturally increased testosterone levels:

  • Polycystic ovarian disease
  • Overproduction of testosterone from a tumor of the ovaries or testis
  • Overproduction of testosterone from adrenal gland hyperplasia or an adrenal gland tumor
  • Overproduction of testosterone in the skin, due to stress induced increased release of Corticotrophin Releasing Hormone (CRH) from the brain
  • a Relative excess of testosterone versus estrogen around the middle of the menstrual cycle
  • a Relative excess of testosterone versus estrogen around the menopause

Causes of increased Insulin-like growth factor (IGF-1):

  • High glycemic index foods causes a spike in IGF-1
  • Pregnancy

Oral medications that can cause Adult Acne:

  • Oral Contraceptive pills (OCP’s) that contain 1st generation progestins, like norgesterol
  • OCP’s that contain 2nd generation progestins, like norethindrone, ethynodiol diacetate, and levonorgestrel
  • OCP’s that contain third generation progestins, like norgestimate or desogestrel
  • Vitamins B2,B6,B12 and D2
  • SSRI’s, like Prozac
  • Lithium
  • The Tuberculosis drugs, Isoniazid and Ethionamide
  • The epilepsy drugs, Phenytoin and Phenobarbital
  • Glucocorticosteroids, like Prednisone
  • Anabolic steroids
  • Corticosteroid creams and ointments
  • Iodides and Bromides. Iodides are found in cold and asthma preparations, kelp and vitamin & mineral supplements. Bromides are found in sedatives, analgesics and cold remedies

Other causes of Adult Acne;

  • Cosmetics, especially occlusive petroleum bases moisturizers
  • Smoking
  • Increased insulin levels (hyperinsulinemia) can stimulate sebum production.

Often, what appears to be Adult Acne, is in fact another condition mimicking acne. These Acne mimics include:

The diagnosis of Adult Acne requires a detailed history and careful examination. In addition to Adult Acne an irregular or absent menstrual cycle, excess hair on the face and body (hirsutism), loss of hair from the scalp (androgenetic alopecia), oily facial skin (seborrhea), a milky discharge from the breasts (galactorrhea), enlargement of the clitoris (cliteromegaly), a coarser voice and infertility are all signs of raised testosterone levels.

If the diagnosis is Adult Acne the next step is to identify and treat any underlying cause. If there is an identifiable cause for the Adult Acne, eliminating it will most likely clear the Acne.

Laboratory blood tests for FSH & LH (brain/pituitary gland origin), DHEA-S (adrenal gland origin) , Free Testosterone & Total Testosterone (ovarian origin), Prolactin (brain/pituitary gland origin), SHBG (liver origin), delta-4-androstenedione (adrenal gland origin), 17-hydroxyprogesterone (adrenal gland origin) and insulin might be requested. In women blood tests must be done within a few days of menstruation, when hormonal levels are naturally at their lowest, to avoid confusing results and women should also not be on the oral contraceptive pill. Abnormal hormone values might require closer examination of the ovaries, adrenal glands or pituitary gland.

Oral medication, vitamin supplements and cosmetics might be stopped or changed. Adult acne patients need to stop smoking. A low glycemic index (low carbohydrate/high fat – LCHF) diet to lower IGF-1 release and insulin levels might be required. Lower stress levels, to reduce Corticotrophin Releasing Hormone (CRH) levels, could be helpful.

Some patients will have no identifiable cause for their Adult Acne. Also, patients that have eliminated possible causes of Adult Acne, might still get Adult Acne. These patients will require general anti-Acne therapies, as used for Acne in puberty.

Acne in pregnancy

Acne in pregnancy is not uncommon. The course and severity of Acne in pregnancy is unpredictable. Pregnancy can lead to an improvement or worsening of Acne. It is possible to get Acne and pimples for the first time when pregnant. The treatment of Acne in pregnancy is complicated by the fact that only certain medications and procedures can be used safely.

The Food and Drugs Administration (FDA) have graded medications into 5 categories of safety:

Category A: Adequate and well-controlled studies have failed to demonstrate a risk to the foetus in the first trimester of pregnancy, and there is no evidence of risk in later trimesters.

Category B: Animal reproduction studies have failed to demonstrate a risk to the foetus and there are no adequate and well-controlled studies in pregnant women.

Category C: Animal reproduction studies have shown an adverse effect on the foetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Category D: There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Category X: studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.

Only medication from category A, category B and occasionally category C can be used in pregnancy. Personally, I’ll only consider medications from category A or category B. At present (March 2014), there are no medications in category A for the treatment of Acne in pregnancy. That leaves us with the following category B medications.

Topical anti-Acne products (creams and lotions) that can be used in pregnancy:

  • Clindamycin phosphate (e.g. Dalacin T™)
  • Erythromycin (e.g. Ilotycin T.S.™)
  • Azeleic Acid (e.g. Skinoren™)
  • Benzoyl peroxide gel and wash (e.g. Benzac AC 5™) – Category C, not an option for me.
  • Topical glycolic acid and salicylic acid – Not categorised by the FDA, so also not an option for me.
  • Topical retinoid agents – Category C, so not an option for me.

First line oral anti-Acne medications that can be used in pregnancy:

  • Amoxicillin 250mg-500mg 2 x per day
  • Cephalosporins i.e., Cephalexin 500mg PO BD

Second line oral anti-Acne medications that can be used in pregnancy:

  • Azithromycin 500mg on Monday, Wednesday and Friday
  • Erythromycin stearate (not Erythromycin estolate or Erythromycin ethylsuccinate) 250mg-500mg 2-4 x per day

Third line oral anti-Acne medications that can be used in pregnancy:

  • Clindamycin 75mg-150mg 2 x per dag

Anti-acne procedures that can be used in pregnancy:

  • Red light therapy
  • Intense Pulsed light therapy
  • Skin needling
  • Pulsed-dye laser therapy
  • Photodynamic therapy with Aminolevulinic acid (ALA) as light sensitiser has been described in the literature, but ALA is FDA category C and therefore not something I would use.
  • Narrowband (311nm) UVB light therapy has also been described in the literature, but this is also not a treatment option for me, because prolonged UVB exposure leads to depressed Folic Acid levels.

For very mild cases of Acne in pregnancy I generally start with Clindamycin phosphate with or without Azeleic Acid combined with a sebum reducing face wash.

More severe cases might require the addition of an oral antibiotic, like Amoxicillin or Cephalexin. If the patient is allergic to one of these antibiotics, or the Acne is non-responsive to the antibiotics, Azithromycin or Erythromycin stearate is the next choice of oral antibiotic.

Clindamycin can be used in the unlikely scenario where none of the previous antibiotics can be used.

The only safe Erythromycin in pregnancy is Erythromycin stearate. Erythromycin estolate causes reversible liver toxicity in 10% of patients. Erythromycin ethylsuccinate can cause fetal heart defects when used in the first trimester. To avoid accidental dispensing mistakes, it is perhaps best rather to avoid all Erythromycins in the first trimester.

My approach for the most severe cases of Acne in pregnancy is the combination of a topical product plus an oral antibiotic plus skin needling. Skin needling has the added advantage of improving skin texture and acne scarring.

The treatment of Acne in pregnancy is challenge. There is no medication that is 100% safe. Even if a medication has shown no negative effects on a fetus, the mother can still have a reaction to a medication, which in turn might affect the pregnancy.

Acne in pregnancy can be treated successfully, but the pros and cons of the different treatment options needs to be weighed up carefully.

Types of Acne scarring

There are three types of Acne scarring.

1. Elevated scars, called Hypertrophic scars.

2. Flat scars, due to a colour change. These can be white, red or brown.

3. Indented scars. There are 2 types of indented Acne scars.

  • Pulled down areas. These type of scars are known as Rolling scars due to the overlying skin being pulled down by underlying scar tissue.
  • Punched out lesions due to loss of actual skin substance. Small, pinpoint lesions are known as Icepick scars and bigger lesions as Boxcar scars.

Types of acne Scarring

The treatment of Acne scarring depends on the type of scar.

Pimples – what are they?

From a dermatologist’s point of view the term pimple are meaningless. Some people use the term as a synonym for Acne. Other people use the term to refer to any red bump with a superimposed pussy area (pustule) or without a superimposed pussy area (papule).

What are Pimples

Pimples can be found in a long list of skin conditions. To confirm the diagnosis of Acne in someone presenting with “pimples” one or more of the following additional findings are required:

  • Black heads (open comedones)
  • White heads (closed comedones)
  • Scarring
  • Distribution of the pimples on the face, chest and back

So, if you have pimples, but none of the above findings, you probably do not have Acne!

Side-effects of Roaccutane

The side-effects of Roaccutane are common, but normally easy to manage.

Dry lips are the most common side effect. Lip balm must be applied every 30 to 60 minutes to prevent the lips from cracking. It is not too difficult to manage the lip dryness.

Dry skin is the second most common side-effect. The skin dryness can be easily managed by the regular application of skin moisturizer.

The third most common side effect of Roaccutane is sun sensitivity. Winter is the easiest time to be on Roaccutane, but Roaccutane can also be taken in summer. The regular application of a sun block is essential.

The other potential side effects are much rarer. Mild joint pain and lower back pain are rare side effects and almost never required treatment. Dry eyes can occasionally be a problem, but moisturising eye drops easily controls the eye dryness.

It is unclear if Roaccutane can trigger depression. Some studies have found no link between Roaccutane and depression. However, if patients have a family history of depression, prescribing Roaccutane should be carefully considered.

Females must be on contraception while on Roaccutane, because Roaccutane can cause birth defects.

It is extremely rare for Roaccutane to cause liver, kidney or bone marrow abnormalities, but we still recommended monitoring the function of these organs with blood tests where indicated.

In general Roaccutane is an extremely safe drug if used correctly. It has the potential to prevent Acne from scarring, which can cause lifelong suffering and psychological problems.

 

Roaccutane

 

Roaccutane package
Roaccutane

 

The active ingredient in Roaccutane is Isotretinoin. There are three drugs available in South Africa that contain Isotretinoin: Roaccutane, Oratane and Acnetane. These drugs are equally effective and it does not matter which one are prescribed.

Isotretinoin, is derived from Vitamin A. Many years ago, before Isotretinoin was discovered, dermatologists used high doses of Vitamin A to treat severe Acne. These high doses of Vitamin caused severe side-effects.

The side effects caused by Isotretinoin is much less severe than high doses Vitamin A. If patients are given the correct advise, before starting Isotretinoin, the side-effects are normally easy to control.

Roaccutane has received a lot of bad press regarding the side-effects, but this has been completely blown out of proportion in the media. Roaccutane, when used correctly, is the most effective drug to treat Acne and should be seriously considered in cases of severe Acne, scarring Acne and Acne that is not responding to other treatment option.

 

How to remove post acne brown spots

There are two types of post acne marks: Acne scars and Brown Spots. Scars are a result of damage to the dermis. Brown Spots are a result of excess pigmentation. The rest of the article will focus on the treatment of the post acne brown spots, which is far more common than post acne scars.

Sometimes, after acne clears up, it leaves small, flat dark marks in place of where the pimples was. These marks are due to excess pigmentation that is a result of the inflammation induced by the acne. Pressing or squeezing pimples can also contribute  inflammation which will worsen the post acne brown spots. People with darker skin types are particularly vulnerable to post acne brown spots.

There are 2 main treatment options for post acne brown spots:
1. Wear a sunblock on a daily basis. This will prevent the sun from further tanning and darkening the dark spots.
2. Apply a skin lightening cream to the brown spots once or twice a day. Effective skin lightening creams are prescription medication and include products like Hydroquinone and Retinoids.

Lightening the post acne brown spots can take weeks to months.

Acne and diet

Common questions I here are: “Am I eating something that gives me pimples”, “Which foods cause acne” or “Does chocolate cause Acne”?

 

acne and diet

A recent article evaluating this question stated the following: “Unfortunately, convincing trials are lacking, because it turns out that no meta-analyses, randomized controlled clinical studies, or well-designed scientific trials have followed evidence-based guidelines for providing solid proof in dealing with the issue of Acne and diet”.

In short, nobody knows for sure what the relationship is between Acne and diet. If an Acne patient has elevated insulin levels, low glycaemic index foods might help.

Until this question is answered scientifically, a useful approach is to only exclude foods that you strongly associate with your own Acne flare-ups.