Acne
Bill V. Way, D.O.
Dermatology Residency
Program Director
What is Acne?
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Acne is a skin disorder resulting from
the action of hormones on the skin’s oil
glands (sebaceous glands) which leads
to plugged pores and outbreaks of the
lesions of papules, pustules,
comedones, inflammatory cysts
commonly called pimples or zits.
Acne
Over 17 million people in the US have
acne today. It is the most common skin
disease.
 Not a serious health threat, but severe
acne can lead to disfiguring, permanent
scarring, low self esteem.
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Acne
The disease of the pilosebaceous units
of the skin.
 Most commonly on the face, neck,
chest, back and shoulders were more of
the pilosebaceous units are located.
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Acne
The basic acne lesion is called the
comedo (KOM-e-do), simply an
enlarged and plugged hair follicle.
 If it remains below the surface it is
called a closed comedo and produces a
whitish bump called a whitehead, this is
not a milium.
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Acne: Comedo
If the comedo reaches the surface, it is
called an open comedo or blackhead
 The black color is not dirt, but is from
the oil oxidizing when it reaches the
surface of the skin

Acne: Papule
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Inflammed lesions that usually appear
as small pink bumps on the skin and
may be tender to the touch
Acne: Pustule
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Inflammed papules with a pustule on
the top that may be red at the base and
usually tender. (Pimple)
Acne: Nodules
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Large, painful, solid lesions that are
lodged deep within the skin
Acne: Cysts

Deep,painful, pus-filled lesions that can
cause scarring
What causes Acne?
Exact cause of acne is unknown.
Several factors may play a role.
 One important factor is an increase in
androgens (male hormones). These
increase in both boys and girls during
puberty and cause the sebaceous
glands to enlarge and make more
sebum.

What causes Acne?
Other factors: heredity or genetics;
medications, androgens, lithium; greasy
cosmetics; occlusive clothing
 Hormone changes related to pregnancy
or starting and stopping birth control
pills can also be a cause of acne.
What causes Acne?

Propionibacterium acnes (P.acnes) are the
anaerobic bacteria responsible for causing
acne.
 Other factors: heredity or genetics;
medications, androgens, lithium; greasy
cosmetics; occlusive clothing
 Hormone changes related to pregnancy or
starting or stopping birth control pills can also
be a cause of acne.
Propionibacterium acnes

Anaerobic bacteria in hair follicle.
 These bacteria use the sebum as food and
break the sebum down into irritating
substances, which cause inflammation.
 The abnormal flaking of the cells inside the
hair follicle and the irritating substances lead
to a plug formation and the to follicle swelling
and then rupturing and developing into the
papule then to the pustule.
What can make Acne worse?
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Changing hormone levels in adolescent girls
and adult women 2-7 days before their
menstrual period starts
Friction by leaning or rubbing skin
Pressure from helmets, backpacks
Environment: pollution and high humidity
Squeezing or picking at pimples
Hard scrubbing of the skin
Myths about causes of Acne
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Foods; chocolate, greasy or fried foods. No
foods cause acne.
Dirt. Acne is not the result of uncleanliness or
infrequent washing.
Stress. Just the opposite, Acne may cause
the patient more stress.
Sunlight or tanning clears acne. No tanning
will lead to sundamaged skin, wrinkles and
skin cancers.
Skin must be scrubbed. No, too much
scrubbing may actually make acne worse.
Who gets Acne?
People of all races and ages.
 Most common in adolescents and
young adults
 85% between ages 12-25
 Resolves with time around age 25-30
 Few patients may have persistent acne
into their 40’s and 50’s
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Who should be treating Acne?
Family Practice
 Pediatrics
 Internal Medicine
 Dermatology

What are the goals in treating
Acne?
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Heal existing lesions
Stop new lesions from forming
Prevent scarring
Minimize the psychological stress and
embarrassment, thus improving self-esteem
and self-confidence and avoiding depression
Teach the patient what acne is, how to treat
their acne and what to expect from treatment
Acne Treatment

Medical treatment is aimed at reducing
several problems that play a role in
causing acne; abnormal clumping of
cells in the follicles, increased oil
production, bacteria and inflammation.
Grading Acne
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Scale 0-4
0 – no acne, clear
+1– mild acne, comedos, papules, few
pustules
+2 – moderate acne, comedos, multiple
papules and pustules
+3 – moderately severe, multiple comedos,
papules and pustules, mild scarring
+4 – severe, multiple comedos, papules,
pustules, inflammatory cysts, nodules,
scarring
Treatment for Blackheads,
Whiteheads and mild
inflammatory Acne
OTC or Rx
 Benzoyl peroxide, resorcinol, salicyclic
acid and sulfur
 Benzoyl peroxide products kill P.acnes
and may reduce oil production
 Resorcinol and salicyclic acid and sulfur
help break down blackheads and
whiteheads

OTC Treatment
Benzoyl peroxide washes and gel
 Salicyclic Acid washes
 Must be used twice daily regularly for 812 weeks, then reevaluate

Treatment of Moderate to Severe
Inflammatory Acne
Prescription topical and or oral
medications alone or in combination
 Recheck patient every 4-8 weeks for
results and to adjust acne treatment
program

Treatment of Severe Nodular or
Cystic Acne
Should be seen and treated by a
dermatologist
 Failure to respond to a variety of topical
antibiotics, topical retenoids and oral
antibiotics
 Consider Accutane Therapy
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OTC Topical Acne Cleansers
Neutrogena Acne Wash
 Cetaphil Facial Cleanser
 Oil of Olay Facial Cleanser
 Various Benzoyl Peroxide Cleansers,
Clearsil, Clean and Clear, others

Acne Treatment
Clean skin gently
 Avoid squeezing, pinching, picking or
scratching the acne lesions.
 Bleeding leads to scarring
 Shave carefully
 Avoid sunburn or suntan
 Choose cosmetics carefully, oil-free,
water based

OTC Acne Topicals
Benzoyl peroxide cleansers
 Sulfur products
 Salicyclic acid pads
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Prescription Acne Cleansers
Benzoyl Peroxide
Brevoxyl 4%, 8%
 Triaz 3%, 6%, 10%
 Benzac 5%, 10%
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Prescription Cleanser
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Plexion Cleanser: Sodium
Sulfacetamide 10% & Sulfur 5%
Topical Antibiotics
Clindamycin: Solution,Gel, Lotion, Pads
 Erythromycin:Solution,Gel,Pads,
Ointment
 Combination: Benzoyl peroxide and
topical antibiotic
 Sodium Sulfacetamide and Sulfur
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Topical Antibiotics
Cleocin T Solution, Lotion, Gel, Pads
 Erycette Pads
 Benzamycin Gel
 BenzaClin Gel
 Klaron Lotion
 Plexion SCT
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Topical Retenoids
Retin A: gel, cream, microgel
 Differin: gel, cream, pad
 Generic Tretinoin: gel, cream
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Retin A Microgel
0.04% and 0.1%
 20gm and 45gm
 Apply at hs
 Recommend sunscreens in am
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Oral Antibiotics
Tetracycline
 Minocycline
 Doxycycline
 Erythromycin
 Azithromycin
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Oral Tetracycline
Generic Tetracycline is ok
 Must be taken correctly, 1 hour before
meal or 2 hours after meal with glass of
water
 Not to taken with milk
 Increased change of inducing vaginal
yeast infections
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Oral Minocycline
Dynacin, Minocin, Adoxa, Generic
 Better absorption, less GI upset
 May be taken with food, minimal loss of
effect
 1-2 times daily
 Avoid 100mg bid for it may induce a
blue gray hyperpigmentation in areas of
cysts, bleeding or brusing
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Oral Minocycline
Increased cost
 Very effective
 May be used long term
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Oral Doxycycline
Doryx, Generic
 Good absorption, less GI upset
 May be taken with food, minimal loss
 1-2 times daily
 Occasional photosensitivity, rare
 Increased cost, very effective, may be
used long term
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Oral Erythromycin
Eryc 250mg 1 bid
 Effective for short times, then bacterial
resistance starts to develop
 Low cost, increased GI upset
 May have other drug interactions
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Oral Azithromycin
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Recommend use only by dermatologist
due cost
Accutane (Isotrenoin)
10mg, 20mg, 40mg
 Used by itself
 Patients must be enrolled into the
SMART Program and rules and
regulations must be followed exactly
 Recommend patient be referred to
dermatologist
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Accutane (Isotretinoin)
Very effective
 Useful to help prevent scarring
 15-20 weeks of therapy
 SMART Program
 Expensive
 Patient must be monitored very closely
 No other acne treatment needed
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Accutane: Disadvantages
Can cause birth defects
 Female patients must not get pregnant
while on Accutane
 Depression, Irritability
 Loss of appetite, hair thinning, curling
 Dry eyes, mouth, lips, nose and skin,
itching, nosebleeds, muscle aches,
sensitivity to sun, poor night vision
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Accutane: Disadvantages
Changes in blood such as increase in
triglycerides and choesterol or a change
in liver function
 Must monitor blood prior to starting and
every 4 weeks while on Accutane
 CBC, CMP, Lipid Panel, UA, Urine
pregnancy test
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Adjunct Derm Treatment
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Acne Surgery
Mild Chemical Peels
Microdermabrasion
New ClearLight treatment
Dermabrasion or Laser tx for scarring
Surgical scar revision
Fillers for scars, fat transfer
Intralesional steroid injections
How often should the Acne
Patient be seen?
Initially every 4-8 weeks
 Then every 8-12 weeks
 Then every 3-4 months
 Acne is monitored and treated for
several years from ages 12-25
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Hormonally Influenced Acne
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Increased excessive androgen levels in
females may present as hirsutism,
premenstrual acne flares, irregular menstrual
cycles, elevated blood levels of certain
androgens
 Birth control pills with increased androgens
will increase acne
 Birth control pills with increased estrogens
decrease acne
Recommend OrthoTri-Cyclen or
Demulen
Occasionally but rare use of low dose
corticosteroid drugs, prednisone or
dexamethasone may be used to
suppress the androgen production by
the adrenal gland
 Occasional use of spironolactone to
reduce excessive oil production.
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Web Sites on Acne
www. aad.org
 www.aocd.org
 www.niams.nih.gov
 www.derm-infonet.com/acnenet
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