Hormonal treatment

Hormonal regimens are indicated usually where standard antibiotic regimens have failed, where concomitant period control or contraception and acne therapy is required, and where oral isotretinoin is inappropriate or not available. Topical therapy should be prescribed alongside hormonal regimens.Antiandrogens are a logical approach to the treatment of acne, as they suppress sebum production to an extent that depends on the drug and dose prescribed. The antiandrogen cyproterone acetate (CPA) is commonly used antiandrogen. CPA (2mg) combined with 35 micrograms of ethinyl oestradiol (Diane 35/Dianette) is an oral contraceptive that ameliorates acne. It is also of potential benefit in women with acne resistant to other therapies. In women, the side-effects of CPA with oestrogen are no different from those of conventional contraceptive pills, apart from a possible slight risk of weight gain. Diane 35/Dianette can be given for 6-8 years; thereafter, a conventional contraceptive pill, possibly one of the triphasic pills such as Trinordiol (ethinyl oestradiol+levonorgestrel ), which suppresses sebum excretion. The main side-effects are menstrual irregularity, occasional fluid retention and, rarely, melasma. A question mark remains over its long-term use because of possible neoplastic (breast cancer) potentiation. This has been shown in animal but not human studies. All hormonal regimens should be combined with appropriate topical therapies. For the patient with intractable moderate or severe acne, or if appropriate antiandrogens are unavailable, isotretinoin is the treatment of choice. Isotretinoin is more effective than Dianette for acne patients. Spironolactone also has antiandrogen properties and can also be used for females over 30 years of age. Its effects are dose dependent and it is usually prescribed at a dose of 100-200mg for 6 months.Now a days rarely used for acne treatment.

Oral antibiotics

Oral antibiotics are the most widely prescribed oral therapy worldwide. Tetracyclines (tetracycline, oxytetracycline, doxycycline and minocycline) are the antibiotics of choice.but erythromycin is preferable in the female who is or might become pregnant or is breastfeeding. Trimethoprim is also sometimes used. However, reducing the P. acnes bacteria will not, in itself, do anything to reduce the oil secretion. Additionally the antibiotics are becoming less and less useful as resistant P. acnes are becoming more common. Acne will generally reappear quite soon after the end of treatment—days later in the case of topical applications, and weeks later in the case of oral antibiotics. Furthermore side effects of tetracycline antibiotics can include yellowing of the teeth and an imbalance of gut flora, so are only recommended after topical products have been ruled out. Now a days doycycline and minocycline are more often used than tetracycline. Minocycline produces a blue-black pigmentation in a dose-dependent way, and in the skin this presents in three forms: pigmentation in inflamed acne lesions, in scars (acne and non-acne) and, more rarely, generalized dark-grey discoloration. The pigmentation is due to a melanin-drug complex and it lasts for an average of 8-15 months posttherapy.The brown-grey pigmentation due to minocycline may also occur in the nails,oral mucous membranes and sclera.
The serious side-effects are of three types, all of which are rare. Hypersensitivity syndrome reactions (including pulmonary eosinophilia) and serum sickness-like reactions occur within 3 months of treatment and are characterized by fever, malaise, and arthralgia possibly with major organ involvement. The late-reaction pattern occurs much later, usually at about 6-48 months. These patients, predominantly female, present with a symmetrical polyarthritis or polyarthralgia in the small joints. Some of these patients have concomitant liver disease, which may occur in the absence of joint symptoms. A liver biopsy shows chronic active hepatitis, and serology for lupus is usually positive. Thus, minocycline should be avoided in patients with a personal or family.

Tea tree oil

The essential oil of Melaleuca alternifolia , also known as tea tree oil or Melaleuca oil, has been used medicinally in Australia for more than 80 years.The tree itself has been used therapeutically for even longer, being one of the plants used in traditional medicine by the Bundjalung aborigines of northern New South Wales.Tea tree oil (TTO) is well characterized and contains approximately 100 terpenes and their related alcohols.The physical and chemical properties of commercial TTO are regulated by an international standard.
Tea tree oil has broad-spectrum antimicrobial and anti-inflammatory activity in vitro .These properties have formed the basis of its use in the treatment of a range of superficial dermatoses such as cuts, insect bites, boils and dermatophytosis., There are study reports suggesting the use of 5% tea tree oil for the treatment of acne vulgaris and showing the efficacy of tea tree oil gel against Propionibacterium acnes.

Nicotinamide

The marked anti-inflammatory properties of topical nicotinamide, the amide derivative of vitamin B3 (niacin), have been used to treat acne vulgaris.Nicotinamide, (Vitamin B3) used topically in the form of a gel, has been shown in a 1995 study to be more effective than a topical antibiotic used for comparison, as well as having fewer side effects. Topical nicotinamide is available both on prescription and over-the-counter. The property of topical nicotinamide's benefit in treating acne seems to be its anti-inflammatory nature. It is also purported to result in increased synthesis of collagen, keratin, involucrin and flaggrin.It is often combined with topical antibiotics

Azelaic acid

This dicarboxylic acid, derived from Pityrosporum yeasts. Among its many properties is broad-spectrum antibacterial activity. It is useful in mild to moderate acne. Azelaic acid does not affect the rate of sebum excretion.Used as a depigmenting agent in melasma, post inflammatory hyperpigmentation. This is ideal cream if the person has mild acne with many pigmented marks.

Topical retinoids

A group of medications for normalizing the cell lifecycle are topical retinoids such as tretinoin, adapalene and tazarotene . Like isotretinoin, they are related to vitamin A, but they are administered as topicals. They can, however, cause significant irritation of the skin. Tretinoin is the most and adapalene is the least irritant. These helps to prevent the hyperkeratinization of these cells that can create a blockage. Retinoids are the choice for treatment of comedonal acne. In appropriate cases, a topical retinoid can be used in the evening and an anti-inflammatory agent in the morning. Retinol, a form of vitamin A, has similar but milder effects and is used in many over-the-counter moisturizers and other topical products. Effective topical retinoids have been in use over 30 years but are available only on prescription so are not as widely used as the other topical treatments. Topical retinoids often cause an initial flare up of acne and facial flushing. Acne starts improving after 4 weeks. These are contraindicated during pregnancy.

Topical antibiotics(erythromycin ,azithromycin and clindamycin etc..)

Only the lipid-soluble forms, for example the base, propionate or stearate, are effective.
A topical 2% erythromycin gel has been shown to be as effective as 1% clindamycin phosphate in patients with mild to moderate acne. Clindamycin is as effective as oral minocycline 50mg twice a day, and oral tetracyline. Clindamycin was found to be as effective as 5% benzoyl peroxide gel in patients with papular or pustular acne in some persons. Erytromycin is commonly used for infantile acne and during pregnancy. Now a days resistance to erythromycin is the more common, and such organisms share a cross-resistance to clindamycin. Topical antibiotic resistance should be suspected in four circumstances:1if the patient fails to respond;2 if the patient relapses while on therapy;3 if the patient has had multiple courses of oral and topical antibiotics;4 if the patient has a history of poor compliance with therapy. In such cases alternative therapy may be necessary depending upon the circumstances. Among the side effects allrgic contact dermatitis is rare bur irritant dermatitis is quite common.

Benzoyl peroxide.

Widely available over the counter(OTC) bactericidal products containing benzoyl peroxide may be used in mild to moderate acne. Benzoyl peroxide is available in concentrations of 2.5%, 5% and 10%, either alone or with a combination of sulphur, hydroxyquinolone, glycolic acid or zinc lactate. The gel or cream containing benzoyl peroxide is applied , twice daily. Bar soaps or washes may also be used and vary from 2 to 10% in strength. In addition to its therapeutic effect as a antimicrobial benzoyl peroxide also has keratolytic(dissolve the excessive skin cells).This is also safe during pregnancy. Care must be taken when using benzoyl peroxide, as it can very easily bleach any fabric or hair when it comes in contact with. However, it routinely causes dryness, local irritation and redness. A sensible regimen may include the daily use of low-concentration (2.5%) benzoyl peroxide preparations. It can also cause pigmentation of skin, if exposed to the sunlight after rubbing on the skin.

Choice of treatment

Patients with mild acne usually receive topical therapy; patients with moderate acne receive topical and some time with oral therapies; patients with severe acne should immediately receive oral therapies.. The severity assessment should include not just the extent of the inflammatory and comedonal lesions, but also the presence of scarring, the psychological effects of the disease, and the lack of success with previous treatment.

In general treatments are believed to work in at least 4 different ways (with many of the best treatments providing multiple simultaneous effects).

1.Anticomedonal: Adapalene, tretinoin, azaleic acid and isotretinoin

2.Antimicrobial: Erythromycin, clindamycin,azaleic acid benzoyl peroxide.

3.Anti-inflammatory: Adapalene, erythromycin, clindamycin, Nicotinamide.

4.Antiandrogen; Cyproterone acetate.

systemic/internal diseases associated with acne

Acne some time associated with cysts in the overies known polycystic ovary(PCO) syndrome. Other manifestations include menstrual irregularities, obesity and infertility.
Some of the ovarian tumours known as virilizing ovarian tumours causes acne,hirsutism(male pattern distribution of hair over the face),amenorrhoea or oligomenorrhoea , alopecia and deepening of the voice.
Adrenal hyperplasia, adrenal tumours and Cushing's disease can also cause acne.

Acneiform /pimple like rash

If the acne like rash appear due to drugs , known as acneiform eruptions. Corticosteroids, orally, topically and intranasally, and by injection, may provoke an acneiform eruptions. Although the precise mechanism is uncertain. Corticosteroids do not affect the number of surface bacteria, but do induce cornification(increase skin cells) in the upper part of the pilosebaceous duct.
Androgens including anabolic steroids and gonadotrophins, may precipitate acne, especially in females and in athletes who take illegal performance-enhancing drugs.
Some time other drugs like bromides, iodides, phenobarbitone, isoniazid and rifampicin can also cause acneiform eruptions.