LITERATURE STUDY 

2.7 THE TREATMENT OF ACNE 

2.7.1 When and how to treat acne  

Which treatment measures to pursue is, to a certain extent, a personal decision as some people are much more bothered about their acne than others. According to Day (2005: 65) some patients are devastated by a few pimples, while others take little notice of several lesions. However, it is important to remember that if it is left totally untreated it could have serious negative effects including: scarring, disfigurement and various negative psychological consequences. 

In a study done by Murray and Rhodes (2005:194) teenage participants expressed a perceived diminished capacity to act when it came to contacting a dermatologist as well as a strong desire for parents to be more proactive on their behalf. Teenagers are often so embarrassed about their acne that they go into deep denial about it or develop a kind of psychological paralysis that leaves them incapable of doing something constructive about their problem. In the light of these factors, it becomes clear why it is so important for teachers and parents to be knowledgeable about acne and its treatments and to act when it becomes necessary.  

According to Day (2005:67) there are four factors to consider in deciding when and how to treat acne. The severity of the lesions should be considered – how long the pimples usually last and how painful they are. The duration of the acne is the next important consideration: the longer the acne has been present the more important it becomes to consult a professional. It is also important to consider which previous treatments have been used and whether they have been successful or not. Finally one needs to determine the extent of scarring that has taken place. If one gets only a single acne lesion per month that leaves a scar this could turn into 12 new scars each year. When permanent scarring is a possibility a dermatologist should be consulted as soon as possible. 

A factor that significantly increases the risk of scarring is picking at acne lesions or pimples. According to Murray and Rhodes (2005:190) the reason for this behaviour is a desire to reduce the appearance of pimples and to speed up their disappearance. However it has quite the opposite effect as picking leads to a longer duration of the pimple and a higher degree of infection and pain (Day 2005:65). 

Although most people tend to pick, some people pick pathologically and find it difficult to break this obsessive-compulsive cycle. The linkage between Obsessive Compulsive Disorder (OCD) and skin conditions had only recently begun to be investigated in the psychodermatological literature. Obsessive Compulsive Disorder is an anxiety disorder and is characterised by recurrent, unwanted thoughts (obsessions) and/or repetitive behaviours (compulsions) (NIMH).  Hatch et al. (1992) in Kellet and Gilbert (2001:16) found that many sufferers of OCD make initial contact with health services through damage caused by obsessive picking and that as much of 14% of a sample of general dermatological patients had previously undiagnosed OCD. 

According to Fulton (2002:101) some patients claim to feel “worms” or “mites” under their skin. Cutting the fingernails short and applying ice compresses to the site is recommended, but it is the opinion of the researcher that a psychological intervention may also be necessary in such cases.

2.7.2 The first step: topical treatments 

Many people with mild acne obtain good results from over-the-counter acne treatments. However, when acne does not respond well to local treatments many people tend to over-wash or scrub their skins in an effort to control it.

According to Day (2005:69) over-washing can result in a condition called Dermatitis that mimics acne. The skin appears red and may even develop small cuts. A rash then develops that, combined with the acne lesions, leaves the sufferer looking far worse than before. It is recommended that one should only wash twice a day with a gentle cleaner followed by a good facial moisturizer. 

A wide variety of ointments and salves that control acne is available from most pharmacies, without a prescription. A common active ingredient found in most topical treatments is called Benzoyl Peroxide. According to Fulton (2001:102) peroxide is absorbed into the pore, where it releases free radical oxygen that kills bacteria and opens up acne impactions. Another kind of treatment contains Alpha-hydroxyacids, which speeds up the shedding of dead cells. Finally, Retinoids like Retin A is also used extensively to help release acne impactions.  

It is important to realize that these kinds of treatments take four to six weeks to work and that such time must elapse before this kind of treatment can be deemed ineffective. The skin’s condition often initially seems to worsen as dried up pimples may leave red marks that can last for several weeks. These marks are remnants of previous acne and should not be confused with true acne lesions. These areas are very sensitive and should be touched or picked at as little as possible to allow the skin to recover as quickly as possible (Day 2005:75). 

2.7.3 Oral antibiotics

Oral antibiotics are usually prescribed for moderate to severe inflammatory acne and it is often combined with a topical treatment regime. It works by reducing the number of P. acnes bacteria (cf. 2.2) and contains anti-inflammatory agents, which makes it especially useful for inflammatory acne treatment (Day 2005:105). 

There are few risks and side effects associated with this kind of treatment. The most common include: headaches, increased sun sensitivity and yeast infections in women. Oral antibiotics should never be combined with Isotretinoin (a vitamin A derivative with brand names such as Accutane or Roaccutane) (cf. 4.2.3) as a dangerous condition known as Pseudotumor cerebri, which refers to increased pressure build up on the brain, can develop (Day 2005:113).  

2.7.4. Hormonal therapy 

According to Fulton (2002:102) it has proven to be an effective measure against acne in many female patients. Oral contraceptives are used to block the effects of androgens on the sebaceous glands and the skin cells lining the pores. This kind of treatment is recommended for women who suffer from inflammatory acne and who has seen little or no improvement in their acne even after multiple courses of antibiotics. 

Although many kinds of oral contraceptives are effective in the treatment of acne, there is a kind of contraceptive that contains only Progestins, instead of a mixture of Progestin and Estrogen, which can potentially worsen existing acne. Therefore women with an acne problem should be careful to use a suitable kind of contraceptive (Day 2005:143). The most obvious disadvantage of this kind of treatment is that it is an option that is only available to women. 

2.7.5 Oral Isotretinoin (e.g. Accutane or Roaccutane)

Oral Isotretinoin is the preferred treatment for severe or cystic acne that does not respond to topical treatment, systemic antibiotics or hormonal therapy. (Day 2005:121).

It works by shrinking the sebum glands, while promoting the shedding of old skin cells and inhibiting the growth of P. acnes bacteria. It also has a strong anti-inflammatory effect (Fulton 2002:102). As it addresses all the underlying causes of acne it is an extremely effective way of treating acne.  

However, it remains a controversial treatment because of its potential side effects.  Common side effects include: very dry and peeling skin, photosensitivity, dry nose, eyes and lips, nosebleeds and headaches. In some cases abnormal liver function has also been reported.  

Isotretinoin is contraindicated in pregnancy and can cause serious birth abnormalities and even the death of the foetus when used during pregnancy (Hong & Schweitzer 2003:78). For this reason it has become common practice to do a pregnancy test before commencing treatment as well as prescribing oral birth control for the duration of the treatment for female patients. Sexually active females are also sometimes advised to use more than one form of contraception. 

According to Day (2005:129) some physicians believe that Isotretinoin can produce significant mood changes, depression and other psychiatric side effects. However, no causal relationship between Isotretinoin therapy and depression has yet been established. On the contrary, many researchers believe that depression only occurs as an idiosyncratic side effect of the acne and that this highly effective anti-acne treatment can actually contribute to the psychological welfare of sufferers. However, it still seems prudent to adequately inform patients and their families about these risks until more conclusive answers can be found (Hong & Schweitzer 2003:83). 

Finally it is important to inform patients that Isotretinoin treatment can sometimes cause the acne to get worse or to flare up before it gets better. This is normal and patients can expect to see positive results only after a one or two month period, depending on the severity of the acne (Day 2005:127). An additional benefit of this kind of therapy is that in most cases, the acne stays clear for years after treatment is discontinued and in many cases is permanently erased (Fulton 2002:102). 

2.7.6. Procedures done in a doctor’s room

According to Day (2005:151) a variety of procedures that can improve acne and reduce scarring is available including: chemical peels, cryotherapy and electrocautery.  

Chemical peeling is useful to address surface scarring and light pigmentation. Peeling agents like fruit acids or trichloroacetic acid are used on the skin to penetrate the sebum-heavy follicles (Day 2005:151). Cryotherapy involves the application of liquid nitrogen or carbon dioxide slush to pimples. It is used to exfoliate localized areas of the skin where the acne is concentrated (Day 2005:154).

Electrocautery is where an electric current is passed through a fine point and applied to the skin as the heat exfoliates the skin and kills the bacteria. This procedure is not often used as there is a risk of scarring (Day 2005:155). 

It is important that these kinds of procedures are performed by a qualified dermatologist, as it could cause damage to the skin if done incorrectly. Which treatment is suitable depends on the skin type, the severity of the acne and how much scarring has already occurred. 

Tragically, some patients reach a dermatologist’s office too late and as a result have already accumulated extensive facial scarring. Dermabrasion, punch grafting and surgery can be used to treat permanent scarring. According to Day (2005:152) dermabrasion is the process of removing the upper and middle layers of the skin. It is a painful process that requires local anaesthetic and is unsuitable for very deep pitted scars. These kinds of scars are treated by filling them with temporary fillers like collagen or by using punch grafting. This refers to using a cookie cutter type of blade  to punch out the scar and then filling the indentation with skin taken from another site. Unfortunately these procedures are very expensive, considered cosmetic and therefore not covered by medical aids.  

The fact that so many people have to live with severe facial and psychological scars for the rest of their lives, underscores the importance of teachers and parents being knowledgeable about acne and its treatments.