Acne prevention and treatment
Dr Zein Obagi describes his novel approach to preventing comedogenic acne and optimising a treatment plan
Acne is often attributed to genetics or hormonal imbalance. Contributing factors, or acne triggers, may include lifestyle choices, such as diet, sleep pattern, hygiene, sun exposure, and stress. Some forms of acne require medical treatment, oral medication and/or clinical procedures. Recommendations for topical acne skin care should be based upon the severity of acne, presence of discolouration, age of patient, and probability of scarring with acne.
Acne is a common skin disorder that arises from pilosebaceous unit dysfunction, which consists of a hair follicle and its associated sebaceous gland. Acne typically first manifests at puberty, when increasing androgen levels activate the sebaceous glands which begin producing sebum. As androgen levels continue to rise, sebaceous glands become hypertrophic, and the amount of sebum greatly increases.
Sebum is a powerful inflammatory agent that leads to the more severe forms of acne and scarring when produced in excess. Sebum also disturbs the maturation of keratinocytes (dyskeratosis) by inducing epidermal inflammation. These two factors—increased sebum production and the dyskeratotic keratinocytes—cause occlusion of pores and the subsequent appearance of whiteheads. When the trapped material in the pores oxidises and turns dark, whiteheads appear as blackheads. Blackheads are commonly seen in areas with enlarged pores, such as the nose.
The immune system’s response to the excessive sebum on the skin surface, together with the trapped sebum in the hair follicle and the bacterial flora (Proprionibacterium acnes), leads to the appearance of inflammatory cystic lesions that involve the dermis and lead to acne scars. The severity of inflammation leads to the spread of acne lesions and the formation of pustules, inflammatory nodules, and the formation of more cysts.
Inflammation induced by the presence of increased sebum and P. acnes leads to variable degrees of scarring and post-inflammatory hyperpigmentation (PIH) in certain patients. Over time, the chronic inflammation with its destructive effects damages skin texture, producing rolling, boxcar and ice pick scarring. Occasionally hypertrophic scars and keloids can appear in predisposed individuals with severe acne.
New approach to acne
My approach is based on the belief that acne is preventable. Acne is preventable only if addressed at the initial stages, when whiteheads and blackheads begin to appear, but before sebum-induced inflammation can trigger the immune response. Every effort should be made to eliminate whiteheads and blackheads in the early, non-inflammatory acne lesions stage. They can be extracted with a comedone extractor that applies equal pressure circumferentially around the comedone and causes the sebum and follicular debris to be expelled outwards.
Manual picking should be avoided, as it can push the sebum and follicular debris deeper and induce inflammation and cyst formation. Use of a good acne preventive program, consisting of cleanser, scrub, and a sebum-lowering agent, can help eliminate whiteheads and blackheads in an early stage. If, however, some inflammatory acne form cysts appear, intralesional steroid injections (triamcinolone acetonide, diluted to a concentration of 2.5 mg/cc), should be used to prevent or arrest the focal inflammation early.
Moreover, P. acnes does not directly cause acne. Rather, these bacteria play a secondary role in the condition. The complete pathophysiology of acne has not yet been elucidated, and the etiology appears to be multifactorial. Focusing on bacteria does not address the pathogenesis of the condition and, in practice, leads to high rates of reoccurrence and treatment failure. In actuality, sebum and the resulting inflammation are the main problems in acne, and the control of sebum may be the key to acne prevention and treatment.
Acne treatment plan
Acne treatment should comprise only a portion of the broader approach that aims to restore general skin health. Healthy skin is less susceptible to acne. Accordingly, the treatment objective should not be to only temporarily slow down sebaceous gland activity and dry up the pimples, but to restore skin health while correcting all of the contributing factors responsible for causing acne at the same time.
The patient’s initial comprehensive consultation with the healthcare practitioner or skincare professional is especially important to set ground rules for optimising the treatment regimen. It should provide the patient and the practitioner with an idea of what is going on medically and what treatment options are available. This sets the stage for the formulation of both a long—and short-term treatment strategy. As such, the first consultation should include a thorough patient history and an in-depth physical examination.
If an underlying systemic hormonal abnormality is suspected as contributing to the patient’s acne, he/she should have appropriate blood tests ordered during the visit; a consult with an endocrinologist may also be appropriate in this setting. In female teenagers, certain birth control pills can help tremendously to regulate hormonal factors that play a major role in their acne condition. These include medications that counteract the androgens that drive sebum production. Additionally, other agents, such as spironolactone or insulin resistance agents, can be used. The physician must also determine whether or not systemic antibiotics or isotretinoin (RoAccutane) are indicated.
The healthcare practitioner must determine the acne type (comedogenic, cystic/non-scarring, or severe (cystic/scarring) and, based upon the type, inform the patient and then discuss treatment options. Patient compliance with a daily treatment regimen is essential.
The topical approach to treating acne, while at the same time improving overall skin health, includes the following: skin preparation, addition of disease-specific agents (if indicated), exfoliation and stimulation of epidermal renewal, barrier repair, Stimulation of the dermis (for deep repair), hydration and calming (only if needed for skin dryness), and sun protection. It should be noted that moisturisers, heavy foundations and camouflage makeup should be avoided, even if they are labeled ‘non-comedogenic,’ as these can alter skin barrier function and increase skin irritability, which can lead to inflammation and cystic acne.
Treatment should begin with appropriate topical agents; systemic agents can be added when needed. Procedures, such as exfoliative peels and photodynamic therapy (PDT), with blue or red light, can be used to assist treatment, but never as the first line of treatment. For example, if PDT is going to be used, one should start with all essential and supportive topical agents. Once acne is somewhat controlled and skin is more tolerant (for example, after at least six weeks on a topical regimen containing essential topical agents), PDT sessions can be added to the overall treatment plan to accelerate and improve results. The topical photosensitising agent applied before PDT treatment collects preferentially in sebaceous glands, and the subsequent exposure to light of the appropriate wavelength destroys those glands.
Along with the discussion and planning that occurs at a patient’s first visit, the healthcare practitioner can take certain steps to resolve some of the patient’s most pressing acne issues during that same visit. These include extracting comedones, intralesional steroid injection into inflammatory acneform nodules, and initiation of a short course of oral steroids.
Furthermore, to help unclog pores and dry cystic lesions faster, healthcare practitioners should use exfoliative procedures or products, including AHAs, beta hydroxy acids (BHAs), or exfoliative chemical peels after the first maturation cycle of treatment (six weeks) has been completed.
This regimen may include:
• ZO Medical Invisapeel
• Non-irritating ZO Skin Health Ossential Exfoliating Polish once daily
• ZO Skin Health Ossential Advanced Radical Night Repair
• ZO Medical 3-Step Peel
New acne classification
Current acne classifications (mild, recalcitrant, severe; comedogenic, cystic adult acne (conglobata, necrotica, keloidae) are merely descriptive terms that do little more than confuse physicians and patients. Instead, I have developed the following suggested classification that provides more clear objectives and frees physicians from the restrictions that conventional wisdom imposes on proper treatment. Type 1 (Comedogenic Acne) can be prevented.
For more information on Dr Obagi’s Acne Recommendations, buy his breakthrough new book—The Art of Skin Health Restoration and Rejuvenation (CRC Press) at http://www.crcpress.com/product/isbn/9781842145968—with a 15% discount at check-out using the promotional code DBP36