Dr. Tinny Ho, Specialist in Dermatology June 29, 2004 Acne Causes & Treatment Dr. Tinny Ho, Specialist in Dermatology June 29, 2004

Acne is one of the most common skin diseases, there are about 17,000,000 Americans affected by acne. According to the data in US research, close to 100% of people between the ages of 12 to 17 have acne. After the age of 15, around 40% of adolescents have acne severe enough to require treatment by a physician.

Half Respondents Suffer From Acne At Least Twice A Month Frequency of having acne: 47% valid sample:506

Nearly 50% Respondents Thinks The Cleanliness Of Skin Is The Major Cause of Acne What are the causes of having acne? valid sample:503 (multiple responses)

Causes of Acne Acne is caused by the plugging of follicles, which is mostly due to excessive sebum production by sebaceous glands stimulated by the influence of androgens (male sex hormones). Skin keratinization and plugging of follicles speed up the formation of acne. A normal skin bacteria called P. acnes, produces irritating substance that can cause inflammation.

Androgens & Acne Androgens (male hormones) are present in females as well as females, but in higher amounts in males. Androgens cause the sebaceous (oil) glands of the skin to produce more sebum (oil), excess androgens will cause excess sebum production. If excess production of sebum plugs the opening of the follicles, it may increase the amount of bacteria which cause inflammatory acne. Despite having normal level of androgen, if the sebaceous glands are over-sensitive to androgens, excess sebum is thus produced, acne results.

Types of Acne Whitehead: a closed comedo is a sebaceous follicle plugged with sebum. Its appearance is that of skin- colored or slightly inflamed “bump” in the skin. Blackhead: a comedo is open. The surface of the plug in the follicle has blackish appearance.

Types of Acne Papules Pustules Papules Pustules Pustules: Papules: a small, solid lesion slightly elevated above the surface of the skin. It is caused by localized cellular reaction to the process of acne. Pustules: a dome-shaped, fragile lesion containing pus that typically consists of mixture of white blood cells, dead skin cells and bacteria. Papules Pustules

Types of Acne Nodules Cysts Cysts Nodule: Cyst: is characterized by inflammation, extends into deeper layers of the skin and may cause tissue destruction that results in scarring. It may be very painful. Cyst: It may be severely inflamed, extends into deeper layers of the skin, may be very painful, and can result in scarring. Cysts

Variation of Acne Severe Moderate Light Characterized by whiteheads, blackheads, papules, pustules. Inflammatory increases and becomes more serious. It usually happens on surface but sometimes have deeper pustules. Characterized by cysts and nodules, many are in the body, scars are easily formed. Severe Moderate Light

50% Of Respondents Have Acnes On Forehead Where is the acne you usually having？ valid sample:506 (multiple responses)

Normal Distribution of Acne Acnes lesions are most common areas with sebaceous (oil) glands, mainly on the face, but they can also occur on the upper back and chest. Face Upper back

Causes of Excess Sebum Production & Increase of Androgen Hormonal secretion becomes higher during puberty, which causes the sebaceous glands becoming larger and producing more sebum. Women’s menstrual cycle, being pregnant, starting or ending to take contraceptive pill will cause hormonal changes. Others causes: Heredity Taking drugs containing androgens and lithium

Facts about Causes of Acne... Eat chocolate and greasy food (e.g. French Fries) will case acne？ No scientific proof on the correlation between the formation of acne and food. Will dirty skin cause acne? Acne is caused by the excess production of sebum from skin. Stress causes acne! Some studies have demonstrated there is no relationship between acne and stress. However, recent studies show that corticosteroids (which are increased during times of stress) may stimulate sebum production, hence worsen the acne. A 2003 study targeting medical students also shows patients with acne may experience worsening of the disease during examinations, suggesting stress may have a significant influence.

Facts about Treatment of Acne... I wash my face several times a day. Why do I still get acne? Too much washing will only irritate the skin further and worsen their acne. Gently wash your face daily with mild cleanser or soap, pat dry and use appropriate acne treatment. Just let acne run its course! Some acne scar will remain permanent, so patients should use appropriate acne treatment as soon as possible. Is it essential to squeeze the acne? Squeezing forces infected material deeper into skin, causing additional inflammation and possible scarring. If you have severe acne problem, consult the doctor as soon as possible. If the acne cannot be cured in a month, then should try other drugs. Give acne products enough time to do their job. Some medicines might take a few months to take effect. Ask your doctor how much time is needed for each particular product to work.

Acne Treatment

Purposes of Acne Treatment Decrease sebum production Reduce P. acnes (bacteria) Reduce keratinization Eliminate inflammation A dermatologist may combine two or more treatment options to create effective therapy and prevent new lesions from forming.

Treatment for Mild Acne – Topical Treatment External keratolytics may reduce keratinization. Treatment such as: Salicylic acid Alpha hydroxy acids (AHA) Benzoyl peroxide (cannot eliminate inflammation) Retinoids Anti-inflammatory drugs to inhibit P. acnes (bacteria)

Treatment for Severe Acne The Common rationale of some of the treatment method Use anti-androgen (e.g. oral contraceptive pills) to regulate androgen, to prevent excess sebum production. This method is only suitable for women. Use anti-biotic to curb the growth of bacteria. Use retinoids, derivative of vitamin A (e.g. isotretinoin) to reduce sebum production and keratinization. Patients may experience side effects. Beside the above treatment methods, other non-medical treatment may be introduced, for example to keep the skin clean by using skincare products correctly.

Treatment for Severe Acne – Oral Anti-biotic Use anti-biotic, for example tetracycline, erythromycin or co-trimoxazole etc. to curb the growth of bacteria and reduce inflammation. Use with care and prolonged treatment may be necessary to achieve the desire results.

Treatment for Severe Acne – Oral Retinoids (isotretinoin) To reduce sebum production and help skin cells inside follicles to return to normal. Effective but takes 4-5 months before beginning to see an improvement. Early use will cause dryness and shedding of skin, and even cracking around the mouth. Might cause foetal abnormality, hence not suitable for pregnant women or women planning to have babies. Studies show it might cause suicidal attempt. Physician follow-up is required.

Treatment for Severe Acne – Anti-androgen Androgens stimulate sebum production. To tackle of root cause of acne, women should find ways to tackle androgens. Oral contraceptives works by regulating the hormones (estrogen, progestogen and androgen), blocking the effect of androgen on the skin, and thus reducing sebum production. It is effective in acne treatment and sebum control among women.

Antiandrogenic Effect of Different Oral Contraceptives Synthetic Progesterones (active ingredients of most oral contraceptives) e.g: Levonorgestrel, Norgestimate, Desogestrel, Gestodene - Drospirenone (Brand name: Yasmin) + Cyproterone acetate (Brand name: Diane) ++ Source: Pharmacological profiles of progesterone, drospirenone and other synthetic progestogens. Foldert et al. Eur J Contracept Reprod Health Care 2000; 5: 124-34

CPA – synthetic hormone effective in reducing androgen CPA (cyproterone acetate) was developed in 1961. CPA attaches itself to androgen receptors in the skin and then blocks the receptors (like the wrong key jammed in a lock). The androgens then cannot affect the skin. Additionally, it also reduces the activity of the ovaries, so it also works as a contraceptive pill. Diane-35 is the only oral contraceptive that contains CPA.

Treatment for Severe Acne – Anti-androgen: Diane-35 – Acne Treatment with Contraceptive As oral contraceptive pill effective on acne treatment and skin improvement. Clinical studies show: After 3 cycles (months): improvement/healing for 35-50% of patients After 12 cycles (months): improvement/healing rate of acne for 90% of patients The only oral contraceptive approved by the Hong Kong Department of Health for the indication of acne treatment. Oral contraceptives not suitable for pregnant women and cigarette smokers.