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Theskinclinic.org.ukCLINICAL - CASE STUDY
Acne affects 80% of people at some point in their lives slightly more than males (9.8% vs 9%) and affects people of all ethnic and is the most common skin condition that people groups. It is caused by changes in hormone levels at significant points consult their doctor about. About 20% of acne sufferers in our lives. Puberty is the most common time to develop acne and it is will have acne so severe that they will require aggressive caused by an increase in testosterone, regardless of sex. This testosterone medical treatment to avoid the risk of secondary surge affects the pilosebaceous unit and causes enlargening of the scarring. Acne can have profound and devastating psychosocial sebaceous gland, a microscopic gland in the skin. This triggers increased consequences and needs to be treated quickly and effectively. sebum production from the gland. Sebum is the body’s natural oil that acts to lubricate the skin and helps maintain the integrity of the skin Many acne sufferers state that their acne has robbed them of their barrier. Areas most densely populated by sebaceous glands are the face, happiness and it is not uncommon for an acne sufferer to break down in chest and upper back hence acne typically affects these areas. tears during a consultation. Often they have spent years trying over the Increases in sebum and keratin in the pilosebaceous unit cause a counter and internet products, beauty salon facials and the like, with little hyperkeratotic plug to form called a microcomedone. Microcomedones or no success. This leads to feelings of helplessness and isolation and it is are the earliest acne lesion and are basically blockages in the follicle. important that we help them rebuild their sense of self-esteem. Treating and managing acne for this reason is very rewarding professionally and In these conditions the naturally occurring (but largely commensal) helps to build a good local reputation for your aesthetic skin clinic.
organism Propionibacterium acnes uses sebum for growth and then Although the diagnosis of acne is straightforward and effective proliferates. In a sebum rich blocked follicle P. acnes contaminates the treatments are available, acne is still a challenging dermatological follicle and causes significant localised inflammation. problem. There are several reasons for this. Firstly, people commonly delay consulting their doctor for acne in the hope that it will just go away. Any effective treatment regime for acne needs to target all four of In adolescents, the average time between the onset of acne and seeking medical help is about one year, despite the significant impact it has 1) Excess sebum production
on self-esteem and psychological wellbeing. The second reason is that 2) Follicle plugging
acne is a chronic skin condition with no quick fixes or overnight cures. 3) Propionibacterium activity
Treatments often take six to eight weeks (or longer) to be effective with 4) Subsequent inflammation.
the result that many people give up on their treatments thinking that they haven’t worked. This results in suboptimal or under treatment and is A treatment that targets just one of these processes is likely to fail. This is another reason why acne presents such a challenge.
why most effective treatments for acne are combination treatments.
With the NHS already overstretched we are at risk of seeing even more There are many treatments available for acne, most of which are safe, acne sufferers feeling helpless and isolated. Many people feel that they effective and well tolerated. Treatment options for acne include topical shouldn’t trouble their Gp with problems such as acne whilst others feel skin creams, oral antibiotics, hormonal preparations, oral isotretinoin that acne is just a normal part of adolescence and trivialise this medical (Roaccutane) or more commonly, a combination of these. More recently condition. Acne is in fact a dermatological disorder that, if undertreated clinical evidence about the efficacy of blue light has been established or ignored, can result in significant physical (and emotional) scarring. in the treatment of acne and provides an exciting new direction. The It is not uncommon for acne sufferers to report having spent vast latter part of this article will cover a trial that we undertook at our skin amounts of money on products for their acne that just haven’t worked. clinic in Sevenoaks, Kent with the new Lustre Pure Light Pro device. The With the sudden popularity of aesthetic skin clinics many acne sufferers results were extremely positive and all participants showed a reduction in are finding their way into the private medical sector. For those of us inflammatory acne lesions over a 6 and 12 week period with no reported involved in this industry it is therefore important that we know how to side effects. Blue light therapy is especially useful for those who cannot tolerate conventional medical treatment due to side effects or who wish Acne affects approximately 650million people globally. It affects females 32 www.cosmeticnewsuk.com
There are many safe and effective treatments for acne available over the effects can greatly enhance compliance and overall outcome. For example, if counter and as a prescription. The main challenge with acne treatment is starting a patient on a salicylic acid cleanser advise them that their skin WILL patient compliance. Many patients suffer early side effects such as dryness and become dry for a few weeks but that with continued use this will settle. Advise irritation and stop their treatment thinking they are having a skin reaction. them on a good aqua based skin hydrator so they don’t then go and put oily Those that proceed often don’t give the treatment the required six to eight mass produced OTC moisturisers on their skin that will just negate any good weeks to take effect and stop using the treatment thinking that it hasn’t the salicylic has done. Attention to detail can be extremely helpful in advising worked. Six to eight weeks can feel like a very long time when you have facial patients on their regimes and can help avoid delayed results. Acne treatments work to address the four basic processes causing acne: they reduce sebum, normalise shedding into the pore to prevent blockage, kill It is important to take a thorough medical history and a detailed acne history propionbacterium acnes and are anti-inflammatory.
during the initial consult, including any OTC and prescription strength The treatments discussed below are by no means exhaustive as it goes beyond treatments previously tried. It is worth noting down which ones the patient the scope of this article to detail all available treatments. What they represent felt worked and which ones didn’t and why. Careful selection of treatments is a collection of effective and commonly used products that will help your and proper guidance about the chosen treatment including possible side patients manage their acne long term.
Salicylic acid (OTC)
Salicylic acid is a beta hydroxyacid derived from willow Topical antibiotics commonly used in the treatment of acne bark that is lipid soluble so can penetrate sebum and help rid the follicle include clindamycin and erythromycin. Erythromycin is particularly useful as of excess oil. It is a very powerful tool in the treatment of acne and the it is one of the few acne treatments thought to be safe during pregnancy and effects are fast acting. Salicylic is available over the counter in many acne breastfeeding, alongside benzoyl peroxide. Oral antibiotics are often reserved cleansers at a 2% or 3% concentration. It causes an initial dryness of the for more severe cases of acne but with increasing resistance of P. acnes skin but this rapidly settles with continued use. Salicylic cleansers can be worldwide they are becoming less effective. Commonly used antibiotics include oxytetracycline, lymecycline, doxycycline and erythromycin. Antibiotics need to be used for at least two to three months before any assessment of efficacy Glycolic acid (OTC)
can be made. Often they are continued for six months or longer if they are Glycolic acid is an alpha hydroxy acid and is generally thought to be of benefit. Side effects can include vomiting, diarrhoea, nausea, considered one of the safest alpha hydroxy acids. It is derived from sugar skin pigmentation and candidal yeast infections.
cane and chemically exfoliates the stratum corneum to remove dead skin cells/microdebris and helps prevent follicular plugging. It is generally felt Hormonal preparations
that doses above 10% are needed to be of any clinical effect. Salicylic and (prescription)
glycolic acid cleansers can be alternated depending on clinical severity, extent of sebum (seborhhea) and follicle plugging. Both of these acids In females, acne can sometimes be improved with hormonal treatment. The alter the microsurface of the skin and must be accompanied by high most effective hormonal preparation is the anti-androgen pill Dianette. It is a combination of cyproterone acetate and ethinylestradiol which reduces androgenic hormone levels. It has however been linked to the deaths of 6 UK Benzoyl peroxide (OTC)
women from blood clots and needs to be carefully monitored. Despite this the Benzoyl peroxide has been used for over 30 years in clinical MHRA insists it has ‘no new concerns’ regarding Dianette. Caution should be dermatology and is the cornerstone of treatment for mild to moderate used however and other options exhausted in the first instance. The combined acne. To date it seems to have avoided any issues with antimicrobial estrogen/progestogen pill Yasmin might be a better alternative and has some resistance since it is technically an antimicrobial not an antibiotic. Benzoyl peroxide has several functions, it works as an oxidizing agent to kill P. acnes, it unblocks pores and increases skin cell turnover. Benzoyl Topical retinoids (prescription)
peroxide is available in 2.5%, 5% and 10% concentrations over the Retinoids are potent medicines that help normalise the follicle cell counter, all of which are thought to be equally as effective. It is generally cycle, improve cellular turnover and unblock pores. They are related to Vitamin agreed that patients should start at the lowest dose and increase the A and can have powerful effects on the skin, including skin irritation that tends to concentration if necessary. It can be quite irritating to the skin (can cause settle with use. They often cause an initial flare up of acne so warn patients that an irritant dermatitis) so lower doses and tapered use are preferred when their acne may get worse before getting better. This class of medicines include treti- commencing treatment. A small number of people are very sensitive noin (Retin A), adapalene (Differin) and tazarotene (Tazorac). Topical retinoids to benzoyl peroxide and will have a severe reaction to it. These people are especially helpful for stubborn outbreaks of comedones, for inflammatory should be advised to refrain from its use in the future. This topical acne and can help improve and resurface superficial scarring. Maintenace of acne treatment increases sensitivity to the sun so once again a facial SPF needs remission is usually with a topical retinoid or benzoyl peroxide. It is common to need maintenance treatment for many years after the outbreak has settled.
CLINICAL - CASE STUDY
Patient 1 before and after
Blue light therapy (OTC)
Blue light (405-420nm) represents an exciting new direction in
the treatment and management of acne. It has been clinically proven to kill Propionibacterium acnes and improve inflammatory acne. The mechanism is that a prophyrin produced within P. acnes generates free radicals that kill the bacteria. The great advantage of this treatment is that it has no side effects (no UV light is employed) and can be used in clinic or in the comfort of the patient’s home.
Ambicare Health market the leading home blue light device called Lustre Pure Light Pro. It was developed by a number of leading UK scientists and dermatologists and delivers the safe, visible part of the blue light spectrum at Patient 2 before and after
420nm. The newer Lustre Pure Light device (the one we used in our trial) was designed to be used for 20 minutes everyday. When used as recommended it delivers a total dose of 42j/cm2 of blue light per week. This allows patients to achieve results in only 20 minutes per day as opposed to 1 hour with the original device. This new device will be commercially available from June 2013.
Clinically published date shows that Lustre Pure Light Pro delivers: -A 60% improvement in inflammatory acne-A 50% improvement in comedone counts at 12 weeks-And 65% of users reported a moderate to marked improvement in their acne The trial we conducted consisted of six patients ranging from 16 to 64. The trial aim was to demonstrate the efficacy of blue light using the Lustre Pure Light Pro home device. Exposure to blue light was 30 minutes each day and the Oral Isotretinoin
group was split into those that used only blue light for their acne and those that used blue light in conjunction with topical products (Obagi Clenziderm). (prescription)
The vitamin A derivative Isotretinoin (commonly known as All participants had facial acne ranging from mild to moderately severe. They Roaccutane) is reserved for severe cases of acne, acne that is had all tried various other treatments including topical prescription products, causing scarring or cases that have proved resistant to all other oral antibiotics and Roaccutane with little success. All participants were milder treatments. It is a powerful and potent medicine that needs looking for a new treatment to help them manage their acne in the short and to be supervised by a dermatologist because of its known side effect profile (it can affect serum lipids and is a known teratogen). Isotretinoin has received some negative press and editorial Participants were evaluated at week seven and week 12 for clinical comment recently linking it to teenage depression and suicide but improvement. They were extensively photographed and their comments these links are yet to be substantiated definitively in the medical and reflections were filmed. All participants at week seven noticed an literature. It should however be reserved for those with more improvement in their inflammatory lesions, comedones and the general severe acne and when monitored closely and used appropriately appearance of their skin. At week seven however those on combination can result in huge improvements in acne. Isotretinoin works by treatment (Clenziderm and blue light) showed the most significant reducing secretions from the sebaceous gland so skin dryness and improvements. At week 12 all participants had noticed significant occasional nosebleeds (secondary to dry nasal mucosa) can be a improvements in their acne measured by a reduction in inflammatory lesions, reduction in comedone count and reduction in seborrhea. Objectively, all participants experienced significant improvements in their facial acne at week 12 regardless of which treatment group they belonged to.
Blue light treatment is an exciting new development in the treatment and Dr Johanna Ward BA Hons MBBS DRCOG
management of acne. It offers an alternative treatment for acne that carries MRCGP Dip Clin Derm (distinction)
no risk of side effects and works over a six to 12 week period to improve all Dr Johanna Ward is a GP with a special interest in dermatology, minor grades of acne. It does not require a prescription and can be used as a primary surgery and cosmetic medicine. She is passionate about clinical dermatology treatment for acne, in combination with topical products or to maintain a and raising dermatology standards in the aesthetics industry. Dr Ward is the remission and help promote a stabilisation of acne in the long term. Medical Director of The Skin Clinic Sevenoaks and its sister clinic The Skin Clinic Brentwood and also works as a clinical fellow in dermatology. She holds the prestigious Diploma in Clinical Dermatology from the University of London. Her area of special interest is the management of acne and acne scarring.
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