Acne and Sun-Damaged Aging Skin

Acne affects 90% of people at some point in their lives.  While it usually starts in the teenage years, it can start later.  Acne is a disease of the oil glands.  A plug of dead skin, oil, and bacteria forms as a blackhead or whitehead. Oil then backs-up and escapes into the surrounding skin causing inflammation.  Heredity can play an important role.  Hormone imbalances are not involved.  Acne is not due to an infection although bacteria can aggravate the inflammation.  It is recommended that people with acne avoid iodides (salt, kelp, seaweed), oil-based cosmetics, and excessive washing or harsh scrubbing. 

Topical antibiotics like clindamycin, erythromycin or tetracycline with zinc, the cream tretinoin (Retin-A), the gel benzoyl peroxide and the oral antibiotic doxycycline are standard treatments for acne.  These will help the large majority of acne sufferers.

Only isotretinoin changes course of disease, but this is a very powerful drug that can cause liver damage and will seriously harm any developing fetus if a woman becomes pregnant while taking it. Consequently, isostretinoin should only be prescribed by dermatologists with experience in working with it and then only for very severe acne failing other treatments.  Any fertile female patients using at least two forms of birth control. 

One study found benzoyl peroxide plus erythromycin was better than zinc plus erythromycin Br J Derm 2/97.  It is not clear zinc adds to benefit of erythromycin (Br J Derm 3/94), but see Br J Derm 10/89 which says it does. Oral zinc alone has some benefit (Acta Derm Vener 8/92), but at 200 mg/day (Acta Derm Vener ’89;69:541), that's a lot of zinc with some side-effects. Zinc inhibits lipase in Propionibacterium on skin. Topical zinc alone didn’t help in Int J Derm 4/85. Tetracycline was far superior to oral zinc in Br J Derm 9/79. 

An article in naturopathic magazine Taste for Life 4/99 is typical of the alternative medicine community which doesn't have much to offer in effective treatments for acne.  It makes no mention of antibiotics and suggest the usual truckload of naturopathic cure-alls, e.g. garlic, echinacea, and milk thistle despite a total lack of research with these substances and acne (not one report on PubMed 3/25/99). One naturopath claims zinc as effective as antibiotics without side-effects despite clear research showing it to be inferior and despite research showing intolerable nausea at higher doses of zinc.  Many in the naturopathic community recommend high doses of oral vitamin A, but this has long since been abandoned by mainline medicine because of the side-effects caused by high dose vitamin A including an increased risk of death from cancer and heart disease.  Tretinoin is a useful synthetic, topical medicine with a vitamin A type effect without the systemic side-effects.

Some bacterial resistance to oral doxycycline and especially topical erythromycin and clindamycin, the most popular treatments, is reported in Europe. Many dermatologists, but few other physicians were carriers of resistant P. acnes bacteria (Br J Dermatol. 2003 Mar;148(3):467-78).  A New Jersey study found resistance so high that erythromycin cream had become useless (Acta Derm Venereol. 2002;82(4):260-5); in one recent Connecticut study, benzoyl peroxide formulations suppress the follicular population of P. acnes more rapidly and to a greater degree than topical antibiotics such as clindamycin (J Dermatolog Treat. 2002 Sep;13(3):107-10); but using both benzoyl peroxide plus an anti-bacterial cream was better than benzoyl peroxide alone (Am J Clin Dermatol. 2001;2(1):33-9).

A variety of light treatments have been found of some value for acne.  Laser treatments have helped remove acne scarring and improve skin quality.

A worthwhile general acne information site on acne is http://www.acne-resource.org/

Acne: Inexpensive Medications: Doxycycline (long acting tetracycline) is $9 per month for 100 mg twice a day. Benzoyl peroxide gel costs a little over $4 per tube. Gentamicin cream is only $4.15 a tube, but I haven't been able to figure out if it works as well as other topical antibiotics. Erythromycin topical 2% solution is only $5.50 for 2 ounces. Unfortunately, many of the bacteria that cause acne have developed resistance to many of the commonly used topical antibiotics.  Generic tretinoin (Retin-A) is also available for $5 for a 20 g. tube.  

Acne: Review: British Medical Journal 8/31/02: At puberty, when androgens stimulate the production of sebum, pre-existing comedones become filled with lipid and may enlarge to become visible. Subsequently, some patients also begin to show signs of inflammation. Comedones that become inflamed are nearly always clinically invisible before the pimple develops. Inflammatory acne is the result of the host response to the follicular inhabitant Propionibacterium acnes, which is a member of the normal flora and is a harmless commensal, largely incapable of tissue invasion or serious infection. The organism metabolizes sebaceous triglycerides, consuming the glycerol fraction and discarding free fatty acids. As a consequence of growth and metabolism, P acnes produces neutrophil chemoattractants. P acnes also activates complement and is generally inflammatory when brought into contact with the immune system . acne does not come from bad behavior nor is it a disease of poor hygiene. diet has never been shown to have much effect on acne. diet has never been shown to have much effect on acne. Failure to respond to a regimen within four to eight weeks should prompt a substantial change in drugs, not merely the addition of another product. Comedonal acne 1) Topical tretinoin, adapalene, or tazarotene applied daily, 2) Salicylic acid, 3) Azelaic acid; Mild papulopustular acne: 1) Benzoyl peroxide, 2) Topical gel preparations of benzoyl peroxide with either clindamycin or erythromycin, 3) Oral doxycycline or minocycline 75-100 mg twice daily plus topical retinoid; Severe papulopustular or nodular acne: 1) Oral doxycycline or minocycline plus topical retinoid, 2) Isotretinoin 1 mg/kg a day

Refined Grains and Sugar Blamed: No acne was reported in Eskimos or in New Guinea before the arrival of the western diet. Some doctors claim benefit from a low carb diet. Research is reportedly underway in Australia. New Scientist 12/6/02.  Although one recent report of medical examinations of large numbers of individuals in two different populations in New Guinea found not a single case of acne and concluded that western culture had a lot to due with acne's high frequency in the modern world, I have found virtually no modern research on dietary influences on acne.  It appears that dermatologists decided over 25 years ago that diet plays no role and no research has occurred since then.  Of course, neither dermatologists nor pharmaceutical companies make money on dietary modifications.

Differin, Tazorac No Better than Generic Tretinoin: Two new topical retinoids adapalene and tazarotene just as expensive as brand-name tretinoin (Retin-A). The Medical Letter from Yale University, 6/10/02, says they have not yet been compared to tretinoin but to each other and there was no difference.

Honey: Reader Says It Helped: Case reports aren't worth very much, but honey helps so many skin conditions, I couldn't help including a report by a reader of WebMD Magazine (April, '05) who reported that applying honey with added sugar to her face for 20 minutes a day was beneficial.  After 20 minutes, she used the sugar granules as a type of scrub. To see the research on the many benefits of honey for skin diseases, see Honey.

Acne Common in High School and Many Wish More Medical Care: A random national sample of 12,934 New Zealand high school students found 67.3% reported having acne. 'Problem acne' was reported by 14.1%. Of students with 'problem acne', 46% reported difficulty accessing medical treatment for acne. Acne prevalence in secondary school students and their perceived difficulty in accessing acne treatment. Purvis D, Robinson E, et al, Auckland, New Zealand. N Z Med J. 2004 Aug 20;117(1200):U1018

Retinaldehyde/Glycolic Topical Treatment Successful: In a DB PC study of mild to moderate acne patients, a 0.1% retinaldehyde/6% glycolic acid combination (Diacneal((R))) led to 'important/very important' global improvement at month 2 (50.0 vs. 26.3%), and confirmed by patients at month 3 (86.1 vs. 58.8%). Only 1 patient had to stop the treatment. A Multicentre, Double-Blind, Randomized, Vehicle-Controlled Trial. Poli F, Ribet V, et al. Vigoulet-Auzil, France. Dermatology. 2005;210 Suppl 1:14-21. 

Yasmin Birth Control Pill Better for Female Acne than Ortho Tri-Cyclen: In a 6-month DB study of 1,154 young females with acne, the birth control pill Yasmin (30 microg ethinyl estradiol and 3 mg drospirenone) was better than a triphasic pill Ortho Tri-Cyclen (35 microg EE and 0.180, 0.215, 0.250 mg norgestimate) with fewer acne lesions. The antiandrogenic and antimineralocorticoid activities of drospirenone is thought to be the reason. Superiority of a combined contraceptive containing drospirenone to a triphasic preparation containing norgestimate in acne treatment. Thorneycroft H, Gollnick H, et al. University of South Alabama, Mobile, Cutis. 2004 Aug;74(2):123-30

New Birth Control Pill Found Helpful: Synthetic progesterones used in older BCPs sometimes promoted acne by stimulating the activity of androgens, or "male" hormones. Some newer versions of progesterone, such as desogestrel, avoid this and cut blood levels of acne-promoting forms of testosterone. Women with mild to moderate acne took Organon's DSG-OC for six cycles. By cycle six, three-quarters had no acne or only mild breakouts, and most showed only mildly oily skin. Nearly all said they were satisfied. Side effects included nausea, headache, breast tenderness and weight gain. Ortho Tri-Cyclen is similar. Contraception 10/03

Sulfer Helps Acne: Sulfur has antifungal, antibacterial, and keratolytic activity. In the past, its use was widespread in dermatological disorders such as acne vulgaris, rosacea, seborrheic dermatitis, dandruff, pityriasis versicolor, scabies, and warts. Adverse events associated with topically applied sulfur are rare and mainly involve mild application site reactions. Sulfur, used alone or in combination with agents such as sodium sulfacetamide or salicylic acid, has demonstrated efficacy in the treatment of many dermatological conditions The use of sulfur in dermatology. Gupta AK, Nicol K., University of Toronto. J Drugs Dermatol. 2004 Jul-Aug;3(4):427-31 

Tea Tree Oil: Acne and Impetigo Helped in Randomized Studies: Positive results were reported for an ointment containing tea leaf extract in impetigo contagiosa infections. Two trials of tea tree oil preparations used for acne and methicillin-resistant Staphylococcus aureus. Herbal medicines for treatment of bacterial infections: a review of controlled clinical trials. Martin KW, Ernst E. Peninsula Medical School, Exeter, UK. J Antimicrob Chemother. 2003 Feb;51(2):241-6.

Tea Tree Oil Gel Helped: In a single blind study of 124 acne patients, a 5% tea-tree oil gel did as well as the standard 5% benzoyl peroxide lotion, reducing the number of inflamed and non-inflamed lesions (open and closed comedones), although the onset of action in the case of tea-tree oil was slower. Fewer side effects were experienced by patients treated with tea-tree oil. A comparative study of tea-tree oil versus benzoylperoxide in the treatment of acne. Bassett IB, Pannowitz DL, Barnetson RS. Camperdown, NSW. Med J Aust. 1990 Oct 15;153(8):455-8.

Sun Damaged, Aging Skin

Tretinoin (Retin-A): Helped with No Detectable Harm After 2 Years for Photodamaged Skin: In a DB PC 2-year study of 204 adults with photodamaged skin, those on tretinoin emollient cream 0.05% had a significantly greater improvement relative to placebo in clinical signs of photodamage (fine and coarse wrinkling, mottled hyperpigmentation, lentigines, and sallowness), overall photodamage severity, and investigator's global assessment of clinical response (p < 0.05). There was no increase in keratinocytic or melanocytic atypia, dermal elastosis, or untoward effects on stratum corneum following treatment with tretinoin compared with placebo. There was a significant increase relative to placebo in facial procollagen 1C terminal, a marker for procollagen synthesis, at month 12 (p = 0.0074). Long-term efficacy and safety of tretinoin emollient cream 0.05% in the treatment of photodamaged facial skin : a two-year, randomized, placebo-controlled trial. Kang S, et al. University of Michigan. Am J Clin Dermatol. 2005;6(4):245-53

Niacinamide (Vitamin B3) Cream Helped Facial Aging: In multiple chronic clinical studies, topical niacinamide (vitamin B3) has been well tolerated by skin and improved the appearance of aging facial skin (eg, reduced hyperpigmentated spots and red blotchiness). In a study of 50 European-American women with clinical signs of facial photoaging, the women applied 5% niacinamide cream to half of the face and its vehicle control to the other half twice daily for 12 weeks (double blind, left-right randomized). Niacinamide reduced fine lines and wrinkles, hyperpigmented spots, red blotchiness, and skin sallowness (yellowing). In addition, elasticity (as measured via cutometry) was improved. Niacinamide: A B vitamin that improves aging facial skin appearance. Bissett DL, et al. The Procter & Gamble Company, Cincinnati, Ohio. Dermatol Surg. 2005 Jul;31(7 Pt 2):860-5

Green Tea Extract Caused No Visible Help to Facial Aging: Green tea extracts have gained popularity as ingredients in topical skin care preparations to treat aging skin. In an 8-week DB PC study of 40 women with moderate photoaging, those using 10% green tea cream and 300 mg twice-daily green tea oral supplementation did no different from the placebo group other than higher subjective scores of irritation in the green tea-treated group. Histologic grading of skin biopsies did show significant improvement in the elastic tissue content of treated specimens (p<.05). Whether longer treatment would have caused visible improvement is unknown. Double-blinded, placebo-controlled trial of green tea extracts in the clinical and histologic appearance of photoaging skin. Chiu AE, et al. Emory University. Dermatol Surg. 2005 Jul;31(7 Pt 2):855-60