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Journal of the Royal Society of Medicine Supplement No. 10 Volume 78 1985

Neglected aspects in the management of

B Gordon
MB BS

acne

Consultant Dermatologist, The Royal Infirmary, New Durham Road, Sunderland SR2 7JE

Acne, 'the scourge of adolescence' -'the commonest skin disease of adolescence', if not in fact the commonest of all diseases of adolescence, is possibly the most unsuccessfully treated of all skin diseases in general practice, and not so successfully treated in many skin clinics either. The reason for failure is often blamed on poor patient compliance but patient compliance can only be expected if patient instruction is adequate. Inadequate patient instruction is, in my belief, the main cause of the patient not becoming fully involved in his own management and not being totally committed to success and is ultimately the main cause of failure in so many cases. In this paper I want to highlight this failure of communication and I want to deal with it in a very practical manner, i.e. in the words GPs would use themselves when talking to their acne patients. I therefore include no statistics, graphs or histograms and no detail from the vast amount of academic research into the aetiology of acne which has been carried out in recent years, and is still going on. In order to master the treatment of acne and especially the neoalected aspects, which I intend to emphasize, it is necessary to understand firstly the psychology of the acne patient, and secondly the pathophysiology of the acne lesion itself. Acne starts at puberty and proceeds through adolescence. Age at onset is often as young as 12 or 13 but only tends to resolve in most cases between the ages of 20-25. It may therefore affect many adolescents for ten years or more - more or less a seventh part of a total lifespan - through a period when they are subjected to considerable and stressful hormonal, emotional and sociological changes. These young patients are often bewildered by and apprehensive of the pubertal changes which they are going through. They are trying to establish and assert themselves in an adult world and consequently tend to reject parental and teacher authority so that their behaviour sometimes becomes quite antisocial or, at least, difficult to manage. Unless they have extremely loving, caring and understanding parents, friction and estrangement between parents and child occurs, and despite their desire for

self-assertion and independence, they probably develop a subconscious feeling of insecurity. On top of all this they develop acne, facial spots and pimples, to add to their self-consciousness, shyness and misery. To obtain their cooperation in the treatment of their acne it is very important to obtain their confidence. From the outset the practitioner, general or specialist, must present himself to patient and parent as a caring, interested and sympathetic counsellor. To tell the patient that 'he only has teenage spots and he'll grow out of them' is not only cruel and unkind, but also destroys any hiape of patient compliance eventhougfi thedoctorwrites out and hands to the patient a prescriiption for an antibiotic and a peeling agent. Tem to fifteen minutes spent with the patient and parents explaining the nature of the disease and its longterm management wil be time spent well and

rewardingly.
Successful therapy depends on an understanding of what we are aiming to achieve and then how to achieve it. I would ike to discuss the histological structure of the pilosebaceous unit which is the anatomical site of the acne lesion. Under the influence of androgenic hormones at puberty the following changes occur: (1) The sebaceous glands enlarge and activate, producing an abundance of sebum. (2) There is a greatly enhanced flow of sebum along the sebaceous duct, along the infundibulum to the skin surface - hence the greasy skin of acne. (3) The infundibulum becomes colonized with Propionibacterium acnes (the acne bacillus) and with Staphylococcus epidermidis (S. alba). (4) The amount of keratin increases in the pilosebaceous unit, especially in the infundibulum and surrounding the ostium. These changes and events lead to the formation of the comedone: closed (the whitehead) or open (the blackhead). The comedone is the basic lesion of acne and all other acne lesions: the papule, pustule, the hard lump and the fluctuant cyst all develop from this comedone. I will therefore consider the management of acne from these four basic changes.

Journal of the Royal Society of Medicine Supplement No. 10 Volume 78 1985

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The greasy skin

There has been much research into the composition of sebum which need not be expanded upon here; but acne vulgaris only occurs in a greasy skin, it does not occur in a non-greasy skin or in an adequately degreased skin. Dealing with the greasy skin is therefore the most important part of the treatment of acne. The grease on the skin may be: (1) Endogenous: sebum and disintegrating epithelium. (2) Exogenous i.e. applied from without. (i) Greasy cosmetics. (ii) Cleansing creams. (iii) Moisturizing creams. (iv) Superfatted soaps. It may not be strictly true, but it forms a good working hypothesis, that the severity of acne is proportional to the amount of grease on the skin. Endogenous grease alone may be sufficiently excessive to produce acne but in many cases the natural grease of the skin is insufficient to cause acne until some extraneous grease is added and I believe this is why many girls only develop acne when they begin using cosmetics, even if only occasionally, at about the age of fifteen. Most cosmetics are grease based. Acne is a non-specific reaction to grease and any grease applied to the skin, adding to the natural sebum, can cause acne. Other examples of this are well known. (1) In days gone by when camphorated oil was commonly applied to the chests and backs of babies with chesty colds and coughs, it frequently caused infantile acne. (2) Oil acne on the thighs of industrial workers whose dungarees become oil sodden is well

recognized. (3) Severe acne and its resultant scarring is often evident in TV close-ups of actors and actresses who are subject to regular applications of heavy grease paint. Such cosmetics and grease paints are then removed by the use of cleansing creams which simply replaces one grease with another. (4) The use of widely advertised superfatted soaps, such as Camay, Knight's Castille, Palmolive, Imperial Leather, leave a thin film of fat on the skin and so add to the natural greasiness of the skin and can precipitate and aggravate acne vulgaris. A superfatted soap has 6-7% free fatty acids as opposed to 1 % or less in ordinary soap.) The avoidance of all exogenous grease is a very important aspect in the management of acne.

The aggravation of greasiness by handling Most teenageers with acne are students, either still at school or at college. Often when studying, especially at home, they will sit reading or writing with one hand firmly pressed to their forehead or their chin. This grease present on the hand is added

to the grease already on the face and often explains, in some patients, the localized concentration of acne lesions on one or other site. An attempt to hide acne on the forehead by wearing a fringe will often aggravate the acne because the grease from the hair adds to the grease on the forehead. Apart from this, one should dispel the mistaken belief that greasy hair is the cause of the acne; even doctors will sometimes refer a patient with a letter stating that the acne has not improved despite the use of this or the other shampoo! How then in practical terms does one deal with greasy skin? Lowering the level of sebum production with anti-androgens or by the use of the vitamin A derivative, the retinoid 13-cis retinoic acid or Roaccutane, is certainly not a first line treatment and, at present, is not licensed for use in general practice. Neither should the oral contraceptive type of pill Diane be used as a first line treatment of acne, but should only be considered if basic treatment, which is dealt with below, is not entirely satisfactory. Diane should, of course, be considered for the acne patient who is already taking or wishes to start the pill for contraceptive purposes. Therefore, endeavours to deal with greasy skin must be aimed at degreasing the skin by the use of suitable soaps or other degreasing agents and peeling agents. Once achieved, peeling will, in lay terms, unblock the pores and prevent further blockage, thus avoiding the development of blackheads and subsequent papules, pustules, etc. Degreasing the face is best achieved by washing the face at least three times a day using Neutrogena acne cleansing soap (not available on FP1O), Acne Aid Bar, pHiso-Med or similar products and, after each wash, applying a peeling agent. In the past, sulphur and resorcin were commonly used as peeling agents but the most commonly used today, and probably the most effective, is benzoyl peroxide in 2.5%, 50o or 1007o strengths. It is sometimes combined with sulphur, as in Benoxyl or with hydroxyquinoline, as in Quinoderm. The use of a gel formulation makes most of these preparations aesthetically acceptable to patients for daytime use. It is advisable to start with a weak preparation, i.e. 2.5%, and, if well tolerated, to step up to 5% or 10%o, which will produce a mild but evident peeling. It is very important to explain to patient and parent what they are trying to achieve. With gentle peeling the skin will feel dry and a little tight; this is not only to be expected but should be encouraged and maintained. Such dryness and peeling, provided it does not become excessive, is not a reason for stopping treatment and on no account should moisturizing creams be used to counteract the dryness. If, despite concerted attempts to degrease the

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Journal of the Royal Society of Medicine Supplement No. 10 Volume 78 1985

skin and produce peeling, the skin remains greasy, extra cleansing of the skin after washing will often succeed using a white cotton handkerchief soaked in isopropyl alcohol. This is highly inflammable: the patient should be warned to keep it away from a naked flame, not to smoke while applying it and to keep the bottle in a cool place and tightly stoppered when not in use. After cleaning with the alcohol the peeling agent is then applied. If during the course of treatment, especially in the early stages, the degreasing and peeling process goes beyond the required slight flaking and mild tightness, the treatment could be discontinued for only a very short time, perhaps 24 or 48 hours, until the excessive soreness has eased; it should then be resumed at a slightly lower level, i.e. perhaps reducing to twice a day until tolerance is achieved and then again trying thrice daily washing and application, or by reducing the strength of the peeler to a lower percentage: from 1007 to 5% or 5% to 2.5%7o. Quinoderm is more likely to produce redness of the face than other benzoyl peroxide preparations. This is probably due to the hydroxyquinoline content of Quinoderm and when this happens it is advisable to change to a different

benzoyl peroxide preparation. Once the finely balanced degree of peeling is achieved the patient must strive to maintain that state by continuing regular treatment for several years until the early or mid-twenties when, in most patients, the tendency to acne spots will cease.

excessively greasy pilosebaceous follicles, converting the triglycerides of the sebum into free fatty acids. Possibly the presence of excess free fatty acids in turn causes the thickening of the keratin layer in the follicle and on the skin surface, leading to blockage of the follicles and the formation of blackheads and whiteheads. It is likely, however, that clusters of these organisms trapped in the follicle increase the degree of inflammatory reaction leading to the formation of pustules and abscesses. Adequate degreasing and peeling by improving follicle 'drainage' probably greatly reduces the harmful effects of the organisms without recourse to antibiotic therapy. However, suitable antibiotics have been shown to reduce the colonization of the follicle and so reduce the number of blackheads and pustules. But I am sure that degreasing and peeling without antibiotics is a more effective treatment of acne than antibiotics alone without degreasing and peeling. Nevertheless, it is reasonable to assume that the combination of both is more beneficial. The use of antibiotics, therefore, is only a part, and a minor part at that, of the treatment of acne. The use of antibiotics needs to be low-dose and long-term and patients and parents need to be reassured of the safety of such a regimen. I have never been convinced of the need to start antibiotic therapy for acne with a full-dose regimen such as one would use for an overt infection. Why risk side effects? Why complicate the instructions you have to give the patient more than is necessary?

Alternative peeling agents

These are rarely needed. Sulphur lotion 6%o in calamine. Sulphur and resorcin paste. Retin-A gel.

Which antibiotics?

Long-term safety, efficacy and cost are the main considerations. Oxytetracycline is probably the most commonly used antibiotic in acne. In low dosage it has proved to be safe for long-term use and it can be continued The use of antibiotics in acne May I remind you of the four pathological changes in a dose of 250 mg twice daily for two or three years if necessary. It should never be given for less which I mentioned earlier: than six months. It is certainly effective and it is (1) Overactivity of sebaceous glands. relatively cheap. It is said to interfere with the (2) Excessive greasiness of the skin. (3) Colonization of the infundibulum by P. acnes action and effectiveness of oral contraceptives, but I believe this has recently been strongly disputed. and S. epidermidis. (4) Increase of thickness of the keratin lining the Pregnancy and breast feeding are, of course, infundibulum of the pilosebaceous duct, and contraindications and relevant patients should be surrounding the ostium of the follicle at the skin so warned. However, the use of oxytetracycline is one of the most mismanaged aspects in the surface. I have dealt with 1, 2 and 4; 1 is presently not treatment of acne. Most doctors are aware that controllable by ordinary basic treatment; 2 and 4 oxytetracycline is bound by calcium and serum can both be corrected by the processes of albumin and by alkalies, so the drug loses much of its effectiveness if taken with food; the patient degreasing and peeling if properly carried out. This leaves us with the presence of the acne is, in any case, only taking a low dose and if most bacillus and the S. epidermidis in the ducts. The of this is lost by binding the benefit obtained will role of these organisms in acne is not fully be negligible. This must be carefully explained to understood or agreed upon. It is probable that they the patient, whose compliance is likely to be much are not primarily concerned in causing acne but, greater if he understands why he is being asked to instead, they are 'opportunists' which thrive in the do certain things. Detailed, and preferably printed,

Journal of the Royal Society of Medicine Supplement No. 10 Volume 78 1985

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instructions should be given. Oxytetracycline administration depends on two principles: (1) It must be taken on an empty stomach, i.e nothing (except water) can be taken for two and a half to three hours before taking the tablet. (2) Nothing is to be eaten or drunk (except water) for at least half an hour after taking the tablet. This is so that the tablet has time to disintegrate in the stomach and be absorbed into the blood stream before it has had an opportunity of coming in contact with food in the stomach and so becoming 'bound'. My advice to patients is to take the first tablet each day as soon as they wake up in the morning, washing it down if necessary with water only, no tea or coffee. They should place a tablet and glass of water by their bedside when they retire to bed the previous evening; by the time they get up, go to the toilet, wash, dress and comb their hair, a half hour will have elapsed and they may then have, if they wish, a cup of tea or breakfast. The second tablet of the day is best taken half an hour before the evening meal, ensuring that nothing is eaten or drunk during the afternoon, i.e. no afternoon cups of tea and biscuits, at home or the office, no sweets, chocolates, crisps etc. at school or on the way home from school. The actual time of taking the second tablet is not critical and may vary but it must always be taken in accord with the above

with little or no facial acne. Trunk acne u'sually involves the upper back and chest and shoulders, but in some cases it may extend well down the back, even as far as and onto the buttocks. Trunk acne may be precipitated in patients with facial acne by wearing wool or wool-like clothing in direct contact with the skin, e.g. sweaters or the fluffy inside of a sweat shirt. The skin should be insulated from such garments by wearing a smooth cotton blouse, shirt or T-shirt next to the skin. A sweat shirt can be worn inside-out so that the smooth surface is next to the skin. If acne is accentuated around the neck, enquire if a wool scarf or muffler is worn, or even a furry collared overcoat.

Topical therapy of trunk acne It is not practical to apply proprietary peeling agents packed in tubes to the fairly extensive areas of trunk that need to be treated. A sulphur lotion is much more practical, and economical. I invariably prescribe:

Sulphur precipitate Teepol Calamine lotion ad Mitte 500 ml

6% 1.5% 100%

principles.
The advantage of this pre-evening meal dosage is that it leaves the whole of the evening after the evening meal free of restriction, a time when most people watch TV while eating crisps and chocolates or go out for a drink, or visit socially or entertain others and wish to eat and drink.

Sulphur preparations tend to have an unpleasant smell and therefore this application is only used at bedtime and should be dabbed on with a cotton handkerchief. The help of a parent or friend is needed for application to the back. Antibiotics are, of course, beneficial for trunk acne as well as facial acne.

Alternative antibiotics If oxytetracycline is contraindicated, i.e pregnancy or lactation, a suitable alternative would be erythromycin, 250 mg twice daily. If the acne is rather severe and slow to respond, despite adequate and intensive local therapy, it might be worth changing to minocycline, 50 mg twice daily. This may possibly be a little more effective than oxytetracycline and it does not have the same food restrictions, but it is very much more expensive - an important consideration especially in long-term use. The third choice of antibiotics after tetracyclines and erythromycin is co-trimoxazole, one tablet twice daily.

Summary
Acne is the result of excessive grease on the skin. The successful treatment of acne depends essentially on the degreasing of the skin to an extent which produces peeling, which is the observable index of adequate treatment. The use of antibiotics is supplementary to degreasing and peeling. Degreasing is best achieved by thrice daily washing with Neutrogena acne cleansing soap, followed by the application of a benzoyl peroxide preparation of a suitable strength. If necessary, further degreasing can be achieved by cleansing with isopropyl alcohol after washing with the Neutrogena soap.

Avoid

Acne of the trunk Acne of the trunk quite often occurs in association with facial acne, but not necessarily so. Some facial acne may have no accompanying trunk acne at all and, less commonly, severe trunk acne will occur

Picking, squeezing or any other form of handling; greasy cosmetics - water-based foundation lotion may be used; cleansing creams; wearing fibroussurfaced garments, i.e. wool or wool-like material next to the skin.

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Journal of the Royal Society of Medicine Supplement No. 10 Volume 78 1985

Antibiotics Oxytetracycline can be administered unless contraindicated; low dosage long-term (250mg twice daily). Give careful instructions about taking oxytetracycline and explain why.

Printed instructions Name of soap: Neutrogena acne cleansing soap, in red pack. Instructions for taking oxytetracycline.
Follow-up Repeated encouragement and moral support is required; treatment must be reviewed at two or three month intervals.

Alternatives: minocycline, erythromycin, trimoxazole.

co-