An Evidence-Based Cookbook for the Treatment of Adolescent Acne Vulgaris

A 14-year-old patient named Shannon presents to their primary care physician for a sports clearance physical. During the visit, the patient’s parent mentions that they are concerned about Shannon’s acne. Shannon is being teased by other students at school. They make comments like, “why don’t you wash your face? You look disgusting.” Shannon appears embarrassed and admits that these comments are very upsetting. The parent reports that they have “tried everything” and when asked for specifics, they cannot name ingredients or brands, but they have tried numerous over-the-counter washes and topical preparations. Shannon reports they have never used any one product for more than about a week because “nothing works”. On physical exam, the patient is noted to have significant comedonal acne over the forehead, nose and chin with a pustular and nodular lesions on their cheeks. There is some mild scarring on the cheeks as well.

Acne vulgaris is extremely common, affecting about 85% of adolescent patients across ethnicities and nationalities.  Some 36% of adolescents experience moderate to severe acne. Adolescents with acne have increased social impairment and mental health problems. Those with severe acne are up to twice as likely to experience suicidal ideation compared to their clear-skinned counterparts.

Many effective treatment options are available over-the-counter, but patients, and their parents, may lack knowledge around which agents will work best for them. It is also important to educate them both about just how long treatment takes.  Most patients can expect to see a difference in their acne after 2-3 weeks of persistent use. Often, patients will cease using effective products too soon because they do not have realistic expectations of the treatment.

Etiology

• Increased androgen levels in adolescence lead to sebaceous hyperplasia.
• Alterations in follicular growth and differentiation affected by genetic factors.
• Colonisation by Propionibacterium acnes (P. acnes).
• Individual immune system response and inflammation.
• NOT poor personal hygiene or too much junk food (education about this is important!).

Types of Acne

Comedonal Acne

This results from increased cell division and cohesiveness of cells within the follicular lumen. These cells mix with sebum (production is increased in response to increasing androgens) and obstruct the follicular opening.

If the follicular opening is closed, comedones appear as whiteheads. If the follicular opening is larger, the keratin build-up is exposed to the air and will thus oxidize and darken. These lesions appear as blackheads.

It is a common misconception among laypersons that the dark colour of blackheads is caused by dirt, reinforcing the myth that adolescents with acne are unclean.

Inflammatory Acne

This is caused by colonization by P. acnes. and leads to inflammation and formation of pus collections within the follicles. These then coalesce to form nodules or pseudocysts.

They may cause scarring and permanent disfigurement.

The type of acne and the presence of scarring determines the severity. It may be classified as mild, moderate, or severe. The severity does not necessarily correlate with the level of distress for the patient. Adolescents may be significantly affected by even mild acne.

Treatment

Choice of treatment should be tailored to the underlying etiology and level of severity.

Different active ingredients address different underlying problems. Ingredients all fall into one of four major categories:

• antibiotic agents.
• agents that reduce production of sebum.
• agents that reduce desquamation of the follicular epithelium.
• chemical exfoliants (i.e. keratinolytics).

Benzoyl peroxide

• Acts as an antibiotic and eradicates P. acnes.
• Advantageous over other topical antibiotics as there is no development of resistance.
• Useful as a spot treatment for inflammatory lesions. Continued generalised use prevents their formation.`
• May be used in combination with topical clindamycin to increase efficacy. It is important to note that topical clindamycin ALONE has not been shown to be effective for most inflammatory acne. 
• Adverse effects – may cause irritation in some patients but this can be mitigated with use of a moisturiser, may cause bleaching of clothing and towels – recommend that patients wash hands after application. May cause a temporary orange discoloration of the skin when used in combination with topical dapsone.

Salicylic acid

• Topical antibiotic, also has some mild exfoliant effects.
• Can be used as spot treatment for inflammatory lesions.
• When tested head-to-head, less efficacious than benzoyl peroxide.

Tea Tree Oil

• Topical antibiotic.
• Spot treatment.
• Less efficacious than benzoyl peroxide.
• May have estrogenic effects in males.
• Strong and distinctive odour.

Minocycline

• Systemic antibiotic, effective for moderate to severe inflammatory acne that is NOT predominantly nodular.
• Dosing is 50-100mg given once or twice daily (i.e. 50-200mg per day total).
• Can cause GI upset, sun-sensitivity.
• Very rarely can cause Stephens-Johnson syndrome.
• Should not be used in children under 8 years.
• Most effective when used in combination with a topical antibiotic.
• Should be discontinued 1-2 months after new lesions have stopped emerging. After cessation, plan to maintain control with a combination of topical antibiotic and retinoid.

Topical Dapsone

• Effective for combination type acne.
• Most effective when used in combination with a topical retinoid or BP.
• Can cause skin dryness, mitigate with daily moisturiser use.

Topical Retinoids

• Work by normalising desquamation of the follicular epithelium.
• Most effective for comedonal acne.
• Also have some anti-inflammatory activity.
• Can cause dryness, irritation, and sun sensitivity. Patients should be advised to apply a pea-size amount all over the face (i.e. do not spot treat) at bedtime and use a moisturiser with SPF during the day.

Chemical exfoliants (hyaluronic acid, glycolic acid, uric acid)

• Decrease build-up of keratin.
• Can be an effective adjunct agent for comedonal acne but not very effective on its own.

Niacinamide

• Decreases oil production.
• Adjunct treatment for comedonal acne.

Oral Isotretinoin

• Effective for very severe nodular inflammatory acne.
• Can cause severe dry skin and myalgias.
• Requires special licensing to prescribe because of teratogenicity. Patients who can become pregnant must also use hormonal contraception and have regular pregnancy tests.
• Generally prescribed only by dermatologists.

Hormone therapy (oral contraceptives)

• Combination oestrogen/progestin with spironolactone are most effective as they block the production of androgens as well as block the effects of androgens on sebaceous glands.
• Using a lower dose of oestrogen can decrease risk of thromboembolism.
• Should not be used in patients who smoke due to increased risk of blood clots.
• Only an option in patients who have achieved menarche and who have no other complicating factors that would make contraindicate use of oestrogen.
• Can be advantageous over oral isotretinoin due to fewer unpleasant side effects and no requirement for monthly follow-up visits.
• Also of note, if a patient has significant acne with other signs or symptoms of hormone access dysfunction (oligomenorrhea, obesity, hirsutism), they should be screened for polycystic ovarian syndrome and congenital adrenal hyperplasia.

Shannon was prescribed a 30-day course of minocycline, along with low-potency topical tretinoin. The paediatrician recommended an over-the-counter benzoyl peroxide preparation to be used as a spot treatment for the inflammatory lesions. She also recommended her favourite moisturiser – an oil-free lotion containing niacinamide with an SPF of 30. The paediatrician also recommended using an alarm app on Shannon’s smartphone to help her remember to use all treatments daily. At follow-up, four weeks after the initial visit, Shannon’s acne had improved. Thus, minocycline was discontinued but the topical retinoid and benzoyl peroxide were continued. Both patient and parent were happy and grateful.