Acne. Etiology and treatment

Acne is one of the most frequent dermatological dysfunctions of the skin. It affects 80% of the population in some of its forms. It can occur at any stage of life, although it usually appears at puberty. Therefore, it is women who experience it before, but the incidence is higher among men and, although it usually responds well to treatments, in some cases it occurs again suddenly after a few weeks.

Acne is a chronic inflammatory condition of the pilosebaceous units of the skin, characterized by the formation of papules, cysts, eaters, pustules and, in some cases, nodules or scars. These injuries are usually located on the face and shoulders, although they can spread to the trunk, arms and legs.

Acne aetiology

There are mainly three causative factors for acne lesions:

• Hyperseborrea. It is an increase in sebum production by the sebaceous gland as a consequence of hormonal action. In adolescence, testosterone levels are increased. Through the action of the enzyme 5-alpha-reductase, testosterone is transformed into dihydrotestosterone (DHT). This metabolite has a specific receptor in the sebum cells of the sebaceous gland and, as a consequence of this union, stimulation of increased sebum production occurs.
• Hyperkeratinization. It is the formation of retentional lesions or microcomedones caused by the accelerated and abnormal proliferation of the keratinocytes of the sebaceous glands.
• There are two types of microcomedones, depending on the degree of blockage of the duct. Open comedones or black dots, and closed comedones or white dots. The most significant difference between an open and a closed comedone is that the open comedone does not usually lead to inflammatory lesions if it is not manipulated, whereas the closed comedone can cause them. In addition, the latter usually gives rise to papules, pustules and / or nodules when inflammation occurs.
• Bacterial proliferation. Due to excess sebum and hyperkeratinization, an anaerobic environment is created that favors the bacterial proliferation of some bacteria that are part of the normal skin flora, such as Corinebacterium acnes and Propionibacterium acnes . These microorganisms release lipases and proteases that hydrolyze sebum triglycerides causing free fatty acids, which are irritating and comedogenic. On the other hand, the fatty acids themselves have chemotactic capacity and attract neutrophils and macrophages that are involved in the appearance of the inflammatory lesion.

When the infected areas are deep, cysts usually form. These are hard lumps located under the skin, since the follicle wall is enlarging with the continuous production of fat by the sebaceous gland.

Genetic and hereditary factors, psychological and emotional states, important hormonal changes (pregnancy and menstruation), some medications and some cosmetics are also involved in the appearance of acne.

Types of acne

Although there are numerous criteria to classify the types of acne, one of the most common is according to the cause that causes it:

• Non-inflammatory acne. This type of acne is a consequence of hyperseborrhea and hyperkeratinization. The injuries it produces are called comedones.
• Inflammatory acne. It appears for the same causes as non-inflammatory acne, but in this case it is accompanied by bacterial overgrowth. The lesions it produces are papules, pustules, and nodules.

Another type of classification is made based on the severity of the injuries. In this case, three types are distinguished:

• Mild. Comedones and some papules and pustules are seen.
• Moderate. The number of inflammatory lesions (papules and pustules) is greater. In some cases they will end up leaving scars.
• Serious. All kinds of injuries appear. These include nodules, cysts, and a large number of nodular abscesses. The sequelae left by acne are more pronounced than in moderate acne and the scars are permanent.

Pharmacotherapy

The purpose of pharmacological treatment is to heal the previous lesions and prevent the formation of new ones, which is achieved by regulating the sebaceous secretion, preventing the hair follicles from clogging, reducing inflammation and preventing bacterial proliferation.

Most acnes require topical treatment, either individually or in association with systemic treatments. The combination of several treatments manages to greatly reduce the amount, and even the severity, of acne in a large number of cases.

It is very important that there is a medical follow-up so that the treatment is more effective and to control the adverse effects that may arise with its use. Awareness of the patient by his doctor is essential, since in many cases the improvement is not immediate and there may even be a worsening at the start of treatment. It is common for the dermatologist to combine various active ingredients, and even during the same treatment to vary them according to their evolution. It is very important that the patient is informed of all this at all times.

There are several types of pharmacological treatment: topical, systemic, hormonal and surgical.

Topical treatment is the most frequent and is used in the first instance. When this does not work, or when it is a case of severe inflammatory acne, systemic treatment is used. Hormonal treatment is used in women who have not experienced improvement after several months of antibiotic treatment. Finally, surgical treatment is used only in the most severe cases, to improve scars and the hyper and hypopigmentations associated with this disease.

Topical treatment

Keratolytic drugs and antibiotics are used in topical treatment. The most common are:

• Mild keratolytics. Salicylic acid (1-5%), sulfur (210%) and resorcinol (1-5%). They favor superficial desquamation. They are mainly used in light acnes, since their action is very smooth. It is frequent to find associations of this type of drugs.
• Strong keratolytics with antimicrobial action. Like azelaic acid and benzoyl peroxide. Azelaic acid is a straight-chain saturated dicarboxylic acid derived from Pityrosporum ovale , which in concentrations of 20% is effective in treating acne. It has a bacteriostatic and comedolytic effect. Benzoyl peroxide is obtained from benzoic acid. It is available in the form of an ointment, gel, cream and soap solution, in different concentrations (2, 5 and 10%). Its predominant action is antimicrobial against P. acnes . Its keratolytic action is low. Because it can cause irritation, treatment is started at low concentrations.
• Other keratolytics. Alpha hydroxy acids decrease the cohesion between corneocytes. Glycolic acid is the most used in concentrations of 5-15%. It can be formulated in solution, hydroalcoholic gel or hydromiscible creams. It is mainly used to combat mild acnes, associated with other more powerful products, and in maintenance treatments.
• Topical antibiotics. The mechanism of action of erythromycin and clindamycin is antimicrobial, particularly applicable to clindamycin, which reduces the number of P. acnes on the surface and at the level of the pilosebaceous duct.

Systemic treatment

Oral antibiotics, isotretinoin, and corticosteroids are used. The most frequent are:

• Oral antibiotics. Tetracyclines and erythromycin. The most widely used tetracycline is minocycline. It exerts a bacteriostatic, bactericidal and anti-inflammatory action. Erythromycin is an alternative for patients who cannot use tetracyclines, although it is less effective and has greater gastrointestinal intolerance.
• Isotretinoin. It is the drug indicated for cases of severe acne with a predisposition to form nodules. It has an antiseborrheic, anticomedogenic, anti-inflammatory and antibacterial action. This drug quickly and efficiently suppresses sebum production and comedogenesis. The problem with this treatment is the multiple adverse effects it produces. The most frequent are dry skin and mucosa. Furthermore, it is a highly teratogenic drug, so it is absolutely contraindicated in pregnant women.

Hormonal treatment

It is common to use hormones to treat acne in women who have not improved after a few months of antibiotic treatment. Cyproterone acetate is the most widely used and can be used alone or in combination with ethinyl estradiol. Cyproterone acetate inhibits the binding of androgens to sebaceous gland receptors, bypassing testosterone to dihydrotestosterone and thus decreasing sebum production. In addition to reducing sebum production, cyproterone acetate reduces the formation of comedones.

Spironolactone is indicated for women for whom oral contraceptives are not recommended. Spironolactone has anti-androgenic effects, that is, it is capable of inhibiting 5-alpha-reductase receptors, thus preventing increased testosterone formation.

Surgical treatment

It is the most aggressive treatment. It is mainly used to reduce the sequelae that may have been generated as a result of aggressive acne, such as hyper scarring or hypopigmentation.

TIPS FROM THE PHARMACY

• Daily skin cleansing. Specialists recommend cleaning the area to be treated, with lukewarm water and a suitable soap, twice a day to eliminate excess sebum. Aggressive or alkaline soaps should never be used, as they could worsen the condition of acne.
• Avoid contact of the hair with the affected areas.
• Do not manipulate the lesions, as this can cause superinfections and, in some cases, cause scars.
• Follow a balanced diet. No diet will improve acne symptoms, but it is advisable to follow a balanced diet during treatment.
• People with acne should avoid cosmetics and fatty substances (cocoa butter, lanolin derivatives), including moisturizers, makeups, and sunscreen. These can act as comedogens and cause a worsening of the acne picture. There are special lotions to hide acne blemishes that are formulated with benzoyl peroxide or salicylic acid, which color these lesions the same shade as the skin.
• Completely remove makeup at the end of the day with soap and water.
• Shaving, in men, should preferably be with a razor, should be carried out gently and only when necessary.
• Avoid excessive sweating and hydration.
• The effects of solar radiation must also be taken into account. Solar radiation usually improves acne lesions, since they have a bactericidal and, in turn, anti-inflammatory effect. It is important to note that although moderate sun exposures often improve acne lesions, prolonged exposure can have the opposite effect. In other words, prolonged solar radiation thickens the horny layer and occludes the follicles; the direct consequence is an aggravation of the acne picture.

Phytotherapeutic treatment

It is an alternative to pharmacological treatment. The advantage that it has compared to pharmacological treatment is that it is guaranteed, in most cases, that there will be no adverse effects. The goal of this type of treatment is the elimination of bacteria, the purification and the reduction of fat production. The medicinal plants that are usually used in the treatment of acne are burdock, fenugreek, pansy and aloe.

Burdock

Burdock or Arctium lappa, of the Asteraceae family, is a robust and herbaceous plant over one meter high, with large leaves and tubular purple flowers, whose flower heads are covered with spikes. The leaves, seeds and fresh root are used. It can be consumed orally (sprayed, infusions, etc.) or topically (gels, creams, etc.). This plant has purifying, antimicrobial and bacteriostatic properties, among others. The antimicrobial and bacteriostatic action is due to arctiopicrin, a natural antibiotic especially active against staphylococci. It is useful in the treatment of acne, seborrhea, boils and rashes of certain diseases, such as chickenpox or measles, and even eczema and dermatitis. Its antimicrobial activity extends to urinary tract infections,

Thought

Pansy or Viola tricolor is a wild species, common in Europe. It is a small climbing plant. It belongs to the violaceous family. It can be used orally or topically. Topically it is used essentially to treat acne and seborrheic dermatitis. It has emollient and protective properties for the skin. In combination with burdock, it has a diuretic, anti-inflammatory and cleansing effect. The combination of both plants also favors skin conditions associated with insufficient fluid elimination.

Fenugreek

Fenugreek or Trigonella foenum-graecum is an herb of the fabaceae family, of western Asian origin. From it, the seeds are used, which contain multiple active principles, among which it is worth mentioning the mucilages, proteins, steroidal saponosides, essential oils, traces of alkaloids, flavonoids, vitamins, etc. It is a medicinal plant with numerous related effects, of which its stimulating effect on the digestive tract, emollient and hypoglycemic should be emphasized. It is used orally in infusions and / or decoctions and topically. Topically, it is basically used to treat skin lesions, whether they are burns or boils, ulcers, eczema, etc.

Aloe

Aloe or Aloe vera is a succulent plant of the asphodeláceas family. It is native to northern and southern Africa. From it is obtained the acíbar or aloe and the gel of aloe vera. The acibar is of no interest for the treatment of acne, since it is mainly used as a laxative. In contrast, aloe vera gel is effective in treating skin conditions such as acne. Aloe gel exerts a healing, anti-inflammatory, anti-tumor, antiviral, anti-ulcer action, etc. It is extracted from the pulp of the leaves. The indications of the aloe gel are: treatment of small wounds, burns, skin irritation, eczema, acne and psoriasis, mainly. Its route of administration is topical (gels, lotions and creams).