Preventing and clearing acne
Dr Zein Obagi is on a mission to incorporate physician-based treatments with patient education to encourage patients to make lifestyle changes that will significantly reduce acne flares and promote healthy skin
Instead of just prescribing a “quick fix” topical cream to temporarily resolve a current acne flare, my strategy has been to develop the most effective treatments that focus on cleansing the skin regularly with products formulated to restore the natural balance of the skin. This long-term approach allows patients to achieve renewed equilibrium and to maintain a clear complexion.
Acne classifications in current use (mild, recalcitrant, severe; comedogenic, cystic adult acne (conglobata, necrotica, keloidae) are merely descriptive terms that can cause confusion for physicians as well as patients. I have developed a new classification model that provides more clear objectives and frees physicians from the restrictions that conventional wisdom has imposed on proper treatment.
ZO Acne Classifications
2. Cystic, no scars Acne with cysts but no visible scars
3. Cystic, with scars Cystic acne with visible scars
Type 1 (comedogenic acne) can be prevented. Acne is often attributed to genetics or hormonal imbalance. Contributing factors, or acne triggers, may also include lifestyle choices, such as diet, sleep patterns, hygiene, sun exposure, and stress. Some forms of acne require topical or oral prescription medication with or without clinical procedures. Recommendations for topical acne skincare should be based upon the severity of acne, presence of discolouration, age of the patient, and probability of resultant scarring.
Begin with prevention
My approach to dealing with acne is based on the belief that acne can be prevented. However, it is only preventable when an aggressive therapeutic intervention is introduced in the early stage. Ideally, prevention will be most effective when closed and open comedones begin to appear, but before sebum-induced inflammation can trigger the immune response. Every effort should be made to eliminate these lesions in the early, non-inflammatory 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. Patients should be instructed to avoid any manual picking, as this can drive the sebum and follicular debris deeper and induce inflammation and possibly cyst formation.
An effective acne preventative programme consisting of cleanser, scrub, and a sebum-lowering agent, can help eliminate open and closed comedones in the early stages. However, if inflammatory acne form cysts manifest, intralesional corticosteroid injections (triamcinolone acetonide diluted to a concentration of 2.5 mg/cc), should be used to prevent or arrest the focal inflammation early. Intralesional corticosteroids are commonly used in clinical dermatology as an adjunct to topicals. Local adverse effects are dependent on the strength of the preparation, the amount administered, the area of the body, and the specific skin condition being treated. The most common side effect is atrophy, which can be avoided by a conservative approach to treatment.
It should be noted that 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 may lead to unnecessarily 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.
Optimised treatment plan
When the skin is maintained in a healthy condition, it is less susceptible to acne. Accordingly, the treatment objective should not be to only temporarily slow down sebaceous gland activity and dry up lesions, but to restore skin health while concomitantly correcting all of the contributing factors responsible for causing acne.
A thorough patient history and an in-depth physical examination is a prerequisite of formulating a treatment plan. If an underlying systemic hormonal abnormality is suspected as contributing to the patient’s acne, appropriate blood tests should be ordered and an endocrinology consultation may also be recommended. In teenage females, some birth control pills can be helpful to regulate the hormonal factors that contribute to their acne condition. These include medications that counteract the androgens that drive sebum production. Additionally, spironolactone or insulin resistance agents may also be prescribed in certain cases. You should also determine whether systemic antibiotics or isotretinoin (RoAccutane) are indicated.
The practitioner must determine the acne type (comedogenic, cystic/non-scarring, or severe (cystic/scarring). Based on the acne type observed, then outline the optimal treatment recommendations. 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 multiple steps: 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 necessitated to relieve skin dryness), and broad spectrum sun protection.
Heavy moisturisers, oil-based 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. Furthermore, it has been found that many products currently on the market claiming to be ‘non-comedogenic’ are actually not.
Treatment should begin with appropriate topical agents; systemic agents can be added as needed. Among the most important components of the ZO Skin Health anti-acne regimen is ZO Medical Cebatrol Oil Control Pads that contain three exfoliating agents, 2% salicylic acid, mandelic acid and glycolic acid. These soft pads and infused with an effective acne prevention solution that remove oil, normalise pore size, helps smooth the skin’s surface and soothes irritation. Using these pads twice daily, AM and PM removes dead skin cells, debris and excess oil from pores.
Practitioners should also take steps to resolve some of the patient’s most pressing acne issues when they come into the clinic. These may 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, it may also be helpful to add 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.
Procedures, such as ZO Stimulation Peel 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.
In light of the fact that the pathophysiology of acne vulgaris depends on active sebaceous glands, the selective destruction of sebaceous glands may also prove to be helpful in acne prevention. Several studies have shown clinically and statistically significant improvement of inflammatory acne following a series of treatments. For some patients, this therapy may be an effective method for long-term prevention of acne flares that is well tolerated.
Dr Zein Obagi is a board certified dermatologist in Beverly Hills, California, and the Medical Director of ZO Skin Health and is responsible for the development of new skincare treatments, protocols and products to achieve healthy skin. W: zoskinhealth.com