Acne is not a serious disease that can cause disability or lead to death, but their psychological impact can be remarkable, especially as it affects predominantly young adults and adolescents. At this stage of life, appearance and social acceptance are very important, and severe cases of acne may even lead to depression.
As a result, there is a high demand for treatments against blackheads and pimples. It is estimated that the global market for products for the treatment of acne move about 10 billion dollars.
There is no single treatment to stop blackheads and whiteheads that fits all cases. In general, the combination of more than one treatment is the recommended choice.
We will describe the most common treatment options for acne. Experimental treatments, very old, ineffective or underutilized by most dermatologists will not be covered in this article.
Retinoids are chemical derivatives of vitamin A, which act by binding to receptors in the skin by stimulating the renewal of epidermal cells, reducing the production of sebum (oiliness) and helping to expel and to inhibit the formation of new comedones.
Among the topics retinoids (to pass the skin) can cite the retinoic acid (also called tretinoin), adapalene and tazarotene. Retinoids can also be found in association with antibiotics, such as in cases of clindamycin + tretinoin or adapalene + benzoyl peroxide.
Retinoids are indicated for the treatment of non-inflammatory acne (blackheads only) and inflammatory acne (blackheads and whiteheads). In general, it is the first prescribed treatment for most patients.
The creams containing retinoids are to be administered once a day, usually at night, thin layer, not only individually on each spine, but through the area subject to the formation of acne. Ideally, the skin should be washed 30 minutes before. At the time of application, the skin should be completely dry.
The treatment should last at least 3 months. Before this period can not evaluate the effectiveness of retinoids.
Formulations available on the market
Retinoic acid cream 0.025% 0:05% or 0.1%.
Retinoic Acid Gel 0:01% or 0.025%.
Adapalene cream 0.1%.
Adapalene gel 0.1% or 0.3%.
Lotion Adapalene 0.1%.
Tazarotene cream 0.05% or 0.1%.
Tazarotene gel 0.05% or 0.1%.
Side effects of retinoids
The topical retinoids can cause irritation (redness), dryness and flaking of the skin, an adverse effect which is more common during the first month of treatment. To minimize irritation, patients should avoid the concomitant use of other products that may irritate the skin, such as abrasive soaps, astringents, or acids, such as salicylic acid. If the irritation is severe, the application frequency can be reduced to alternate days.
In the first month there may be a worsening of acne, effect disappears with continued use of the creams.
Retinoids leave thin and sensitive skin, requiring careful when exposing it to the sun. In general, during the treatment is suggested to avoid the sun. We note the frequent use of sunscreen and hat when going out on the street.
Retinoids are prohibited during pregnancy because of the risk of fetal malformation.
Tazarotene is the most effective retinoid, but is the most cause skin irritation. Adapalene is what causes less irritation, particularly as 0.1% (gel or cream). Its effectiveness is not reduced because of this minor irritation.
The use of topical antibiotics is indicated in cases of inflammatory acne, ie, blackheads and whiteheads, mild to moderate severity. The prescription of antibiotics aims to reduce the population of the bacterium Propionibacterium acnes, which is responsible for the inflammatory process that leads to the spine.
Antibiotics are commonly used topical benzoyl peroxide, clindamycin, erythromycin or azelaic acid.
Benzoyl peroxide
Benzoyl Peroxide is one of the antibiotics most commonly prescribed topical because in addition to its activity against Propionibacterium acnes, it also does away with the nails, inhibiting the comedones.
There are several formulations in the market, either in gel, cream or lotion, at 2.5% presentations, 5% or 10%. In general, benzoyl peroxide 2.5% is less irritating manner.
The combination of benzoyl peroxide with the retinoid adapalene shows good results and is more effective than either drug alone.
Erythromycin or clindamycin
Erythromycin and clindamycin are two antibiotics with action against the bacteria Propionibacterium acnes . Erythromycin is generally prescita formulation of 2%, 3% or 4% (or gel) and clindamycin 1% in formulations (gel, lotion or solution).
Usually not indicated the isolated use of these antibiotics, and the association with benzoyl peroxide or a more effective retinoid.
Some options available on the market include:
Benzoyl Peroxide Gel + 5% clindamycin 1%.
Benzoyl Peroxide Gel + 5% erythromycin 3%.
Benzoyl Peroxide Gel 2.5% + clindamycin 1.2%.
Clindamycin Gel 1.2% + tretinoin (acid retinoic) 0.025%.
Azelaic acid
The azelaic acid has multiple shares, bactericidal, anti-inflammatory, comedolytic (combat comedo) and is still able to lighten the darker spots left by pimples. Its topical use is effective against blackheads and pimples. Azelaic acid is usually available in form of cream or gel formulations with 15% or 20%. Association with retinoic acid increases its effectiveness.
The great advantage of azelaic acid is the fact that little annoying and not dry the skin as well as being an option for pregnant women (note: never use it in pregnancy without medical indication).
In darker skinned people it can cause light spots.
The tablet antibiotics are indicated for the treatment of moderate to severe acne. In patients with acne on the trunk, the use of topical antibiotics may be more difficult due to the large area that creams, gels or lotions should be applied. In some of these cases it is more comfortable the use of oral antibiotics.
The oral antibiotics are more effective than topical antibiotics, but cause more side effects like diarrhea and vaginal candidiasis.
The most commonly used antibiotics are tetracyclines (tetracycline, minocycline and doxycycline) or macrolides (azithromycin and erythromycin).
Tetracyclines
Until some years ago, the tetracycline antibiotics was the most orally used by dermatologists due to its low cost and good efficacy. However, recently, new generation of tetracyclines, such as doxycycline and minocycline, have taken their place, because they are more effective and less induce bacterial resistance.
In practice, the most effective antibiotic is minocycline, however, the cost is higher and the results compared to doxycycline are not so superior. Many dermatologists prefer to start treatment with doxycycline and minocycline for exchange only if the answer is not satisfactory.
Tetracyclines are contraindicated in pregnancy and children as delayed bone growth.
The colateirais effects of the tetracycline group include pigmentation of the skin, dizziness and enamel of the teeth changes.
The treatment is usually done for 12 weeks and more doses used are as follows:
Tetracycline: 250 to 500 mg 2 times daily, taken on an empty stomach.
Doxycycline: 50 to 100 mg two times a day or 150 mg 1 time per day (it is not necessary to be an empty stomach).
Minocycline: 50 100 mg 2 times a day (no need to be on an empty stomach).
Macrolides
The macrolides are an effective option of antibiotics against Propionibacterium acnes, however, have less effect and anti-inflammatory more side effects than tetracyclines. Erythromycin and azithromycin are currently used only when the patient has contraindications to the use of tetracyclines.
Erythromycin is used at a dose of 500 mg 2 times a day for 12 weeks.
Azithromycin is used at a dose of 500 mg 1 time per day for 3 days. 3 cycles are made with a week interval between each one.
In women with acne, androgens (male hormones) often play an important role in the production of oil and the development of acne.
In some women, antiandrogens drugs are necessary for a good response to treatment of acne. A common situation is the case of polycystic ovary syndrome. However, not all women with acne is difficult to treat shows high androgen levels, many have only an increased sensitivity to male hormones, causing the skin to respond exaggerated normal androgen levels.
The antiandrogen medications can be used for women with very oily skin, excess by the body, menstrual irregularity, acne start late (after 25 years) or in cases that do not respond to other treatments.
The two drugs with anti-androgenic action most commonly used to treat acne are spironolactone and the birth control pill.
Contraceptive for acne
Not all contraceptives are indicated for the treatment of acne. In fact, some of them can aggravate the situation, such as the mini-pill, a contraceptive without estrogens. The pills with best results against acne are those containing an estrogen, ethinyl estradiol generally, and progesterone, as Acetat cyproterone or drospirenone.
The indication of the contraceptive pill for acne treatment must be balanced against the potential adverse effects, including increased risk of thrombotic events.
Spironolactone for acne
Spironolactone is a diuretic that has weak anti-androgenic action. In general, spironolactone usually indicated for women with moderate to severe acne, unresponsive to conventional treatments and prefer to avoid oral isotretinoin (roacutan).
The usual prescribed dose is 50 to 100 mg per day for at least 12 weeks.
The main side effect is to increase blood potassium, which can lead to cardiac arrhythmias. In healthy people, this effect is uncommon, but if the patient takes drugs for blood pressure, as ARB or ACE inhibitors, are diabetic or have kidney failure, spironolactone should be used with utmost care.
Isotretinoin (Roacutan)
Isotretinoin, better known by Roacutan brand, is a retinoid that can be used orally, is indicated for the treatment of severe acne or difficult to treat.
Isotretinoin acts directly on the causes of acne, causing shrinkage of the sebaceous glands and reduction of sebum production by the skin.
Roacutan treatment usually lasts at least 20 weeks, and the response tends to be excellent in most cases.
Side effects are the biggest problem of isotretinoin, and the dryness of the lips, hair, skin and eyes very common adverse effects that occur with virtually all patients.
