How to Treat Mild, Moderate and Severe Acne
TREATING MILD ACNE
Mild acne consists of small lesions, such as blackheads, whiteheads or pustules, which appear at or near the surface of the skin. As such, mild cases of acne can sometimes be controlled at home by:
• Gently washing the affected area(s) with warm water and a mild soap twice a day to remove dead skin cells and excess oil
• Using a topical (applied to the skin) over-the-counter acne treatment containing benzoyl peroxide or salicylic acid.
Most mild acne can be controlled by gently washing the affected area(s) and using a topical preparation, such as benzoyl peroxide.
At-home treatment requires 4-8 weeks to see improvement. Once acne clears, treatment must be continued to prevent new lesions from forming.
Even mild cases of acne may require the help of a dermatologist. If the acne does not respond to at-home treatment, a dermatologist can assess the situation and determine an appropriate therapy. In these cases, combination therapy (two or more treatments) may be used. Combination therapy may include use of a prescription topical antimicrobial or topical retinoid. These prescription topicals can be very effective in clearing mild acne.
TREATING MODERATE TO SEVERE ACNE
In moderate to moderately severe acne, numerous whiteheads, blackheads, papules and pustules appear that cover from ¼ to ¾ of the face and/or other affected area(s). Moderate to moderately severe acne usually requires the help of a dermatologist and combination therapy (using two or more treatment options).
Treatments used to treat moderate to moderately severe acne are:
• Physical methods, such as comedo extraction or light therapy
• Prescription Medications
o Topical (applied to the skin) antimicrobials
o Topical retinoids
o Oral antibiotics
o Oral contraceptives
• Over-the-counter topical acne medications
Dermatologists recommend early treatment for moderate to moderately severe acne
Dermatologists recommend early treatment for moderate to moderately severe acne because when moderate to severe acne is not treated early, scars can develop. Acne scars take two forms—as raised thickened tissue or as a depression, such as pits or pock marks. The only reliable method of preventing or limiting the extent of these scars is to treat acne early in its course, and for as long as necessary. Additionally, anyone with acne who has a known tendency to scar should be under the care of a dermatologist.
TREATING SEVERE ACNE
Severe acne is characterized by deep cysts, inflammation, extensive damage to the skin and scarring. It requires an aggressive treatment regimen and should be treated by a dermatologist. Severe, disfiguring forms of acne can require years of treatment and may experience one or more treatment failures. However, almost every case of acne can be successfully treated.
Physical methods and prescription medications that dermatologists use to treat severe acne include:
• Drainage and surgical excision
• Interlesional corticosteroid injection
• Isotretinoin
• Oral antibiotics
• Oral contraceptives
Drainage and Surgical Excision:
Some large cysts do not respond to medication and may require drainage and extraction. Drainage and extraction, or "acne surgery" as it is also called, should not be performed by patients. Dermatologists are trained in the proper technique and perform acne surgery under sterile conditions. Patient attempts to drain and extract comedones by squeezing or picking, can lead to infection, worsening of the acne and scarring.
Severe acne requires an aggressive treatment
regimen and should be treated by a dermatologist.
Interlesional Corticosteroid Injection:
When an acne cyst becomes severely inflamed, there is a good chance it will rupture and scarring may result. To treat these severely inflamed cysts and prevent scarring, dermatologists may inject such cysts with a much-diluted corticosteroid. This lessens the inflammation
and promotes healing. An interlesional corticosteroid injection works by "melting" the cyst over a period of 3 to 5 days.
Isotretinoin:
Isotretinoin is a potent drug reserved for treating severe cystic acne and acne that has proven itself resistant to other medications. Isotretinoin is a synthetic (man-made) retinoid (form of vitamin A) that comes in pill form. It is usually taken once or twice a day for 16 to 20 weeks.
Today, it is the most effective acne treatment available because it is the only acne treatment that works on all four factors that predispose a person to acne - excess oil production, clogged skin pores, P. acnes and inflammation. The remissions achieved with isotretinoin usually last for many months to many years. For many patients, only one course of isotretinoin therapy is needed.
Other possible severe side effects that may occur while taking isotretinoin include:
• Severe pain in the chest or abdomen
• Trouble swallowing or painful swallowing
• Severe headache, blurred vision or dizziness
• Bone and joint pain
• Nausea or vomiting
• Diarrhea or rectal bleeding
• Depression
• Dryness of the skin, eyes and nose
• Thinning hair
If any side effect occurs, the patient's dermatologist or other healthcare practitioner should be contacted immediately because some of these side effects can lead to serious health problems.
While taking isotretinoin, patients are regularly monitored for side effects through follow-up visits. For most people, these side effects are tolerable and not a reason to discontinue therapy before remission is achieved. However, it is important to keep appointments for follow-up visits because monitoring can reveal conditions that a patient might not notice. For example, a patient may not realize a rapid increase in bad cholesterol that is detected through a blood test.
The decision to use isotretinoin should be made jointly by patient and dermatologist. When used with all due caution under close medical supervision, isotretinoin can resolve severe acne that has not responded to other therapy. It has proven especially effective in resolving cystic acne, a severe form of acne that usually does not respond to other therapies.
For a substantial number of patients, one course of isotretinoin therapy is all they will ever need. A small number of patients require more than one course of isotretinoin therapy to control severe acne.
It is important to take isotretinoin as prescribed—even if the skin clears before all of the pills have been taken—to prevent relapse. At the end of an effective course of isotretinoin therapy, all or most of the acne lesion will have cleared. Patients may notice residual erythematous (reddish) macules (flat spots) where acne lesions were present. These macules are not scars, and they will fade in 6 to 8 weeks.
After therapy, patients should continue to follow the 12 Ways to Get Better Results from Acne Treatment.
Oral Antibiotics:
Oral antibiotics have been a mainstay of therapy for severe acne for many years. Like topical antibiotics, oral antibiotics work to reduce the P. acnes population (a contributing factor in acne), which, in turn, decreases inflammation. Treatment with oral antibiotics usually begins with a high dosage, which is reduced as the acne resolves. Over time, the P. acnes bacteria can become resistant to the antibiotic being used to treat it. When this happens, another antibiotic can be prescribed. Numerous studies support the effectiveness of the following broad-spectrum oral antibiotics that are used to treat acne in the United States: doxycline, erythromycin, minocycline and tetracycline. For information about each of these oral antibiotics, see Prescription Acne Medications.
Oral Contraceptives:
Oral contraceptives have been shown to effectively clear acne in women by suppressing the overactive sebaceous glands. Oral contraceptives can be used as long-term acne therapy; however, this medication should not be prescribed to women who smoke, have a blood-clotting disorder, are older than 35 or have a history of migraine headaches—without the advice of a gynecologist.
Severe Acne: 4 types
Severe acne can affect many facets of a person's life, causing a great deal of embarrassment and stress. Severe acne may significantly limit one's social life and even interfere with opportunities for employment. Since this condition can be disfiguring and require years of treatment, it is important to see a specialist. Dermatologists have the most experience treating the different types of severe acne.
Four types of severe acne, described in detail below, are:
• Acne conglobata
• Acne fulminans
• Gram negative folliculitis
• Nodulocystic acne
Acne Conglobata:
Acne conglobata is a chronic and severe form of acne vulgaris, characterized by:
• Deep abscesses
• Inflammation
• Severe damage to the skin
• Scarring
• Blackheads (open comedones) are usually conspicuous and widespread—often occurring on the face, neck, trunk, upper arms and/or buttocks.
In acne conglobata, inflammatory nodules form around multiple comedones, gradually increasing in size until they break down and discharge pus. Deep ulcers may form under the nodules, leading to keloid-type scars, and crusts may form over deeply ulcerated nodules
Burrowing abscesses commonly result in deep, irregular scarring.
Acne conglobata may be preceded by acne cysts, papules or pustules that do not heal, but instead rapidly deteriorate.
Occasionally, acne conglobata flares up in acne that had been dormant for many years.
Males are more likely than females to have acne conglobata; the age of onset is usually between 18 and 30 years. The cause of the condition is not well understood.
Treatment. Isotretinoin is the usual treatment of choice for acne conglobata. Antibiotics may also be prescribed. Several courses of treatment may be necessary over a period of years. Even after effective treatment, the patient should have regular checkups by a dermatologist for any signs of recurrence. A dermatologist can also treat the scars.
Acne Fulminans:
Acne fulminans is a sudden onset of highly destructive inflammation. It appears suddenly in a person with inflammatory acne and is characterized by:
• Symptoms of severe and often ulcerating acne
• Fever
• Inflammation and aching of joints, especially hips and knees
A person who develops acne fulminans may have had unsuccessful treatment for another form of severe acne, acne conglobata.
Treatment. Corticosteroids or non-steroidal anti-inflammatory medications may be given to reduce inflammation. Attacks of acne fulminans may recur, and the patient may develop acne that requires long-term treatment with isotretinoin.
Nodulocystic Acne
Cysts are relatively uncommon in acne; however, this form of severe acne is characterized by cysts, which may measure several centimeters in diameter.
Cysts may develop singly or be widespread.
Cysts may occur singly, or be widespread over the face, neck, scalp, back, chest and shoulders. And, they can be painful.
The nodular cyst of acne is not a true cyst—an abnormal dilatation of a normal skin structure. Acne cysts are nodules of inflammation. The cysts may arise from a papular or nodular acne lesion, or occasionally from a type of cyst that develops in the outer layer of the skin—a type of cyst not usually associated with acne. A cyst may appear to be filled with thick, yellow pus-like fluid. This is usually an inflamed and infected cyst. If an attempt is made to drain such a cyst, it should be done in a physician's office under sterile conditions, not in front of a bathroom mirror.
Cysts occurring close together may coalesce, producing soft areas undermined with tunnels, cell destruction and inflammation, resulting in another form of severe acne, acne conglobata.
Treatment:
Nodulocystic acne usually requires an aggressive treatment regimen that may include isotretinoin and antibiotics, or intralesional corticosteroids that "melt" the cyst over a period of 3 to 5 days. Some very large follicular cysts that do not respond to medications may require drainage and surgical excision.
Gram-negative folliculitis:
Gram negative folliculitis is an inflammation of follicles caused by a bacterial infection that can result from long-term antibiotic treatment. Patients who are being treated with antibiotics for severe acne may develop Gram negative folliculitis.
The word "Gram" refers to a blue stain used in laboratories to detect microscopic organisms. Certain bacteria do not stain blue and are called "Gram negative."
Treatment:
In Gram negative folliculitis, the bacteria are resistant to many antibiotics. Isotretinoin and antibiotics that are effective against Gram negative bacteria are used to treat this condition.
Anyone with severe acne should be under the care of a dermatologist as dermatologists have the experience needed to control virtually every case of acne.It is important for patients and their families to know that severe, disfiguring forms of acne may require years of treatment and patients can experience one or more treatment failures. During treatment, the support of family and friends can greatly comfort patients.
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