Acne and Rosacea
There are 2 types of acne
- comedonal (enlarged pores, blackheads, whiteheads)
- inflammatory cystic acne (boils, painful cysts, pustules and a propensity to scarring).
The basic underlying factors behind acne are hormonal ( excess androgenic hormones) and an overgrowth of bacteria (p.acnes) on the skin surface.
Treatment is stratified according to the type and severity of the leisons, and the presence/absence of scarring.
- First-line treatments for comedonal acne consist of drying agents( benzoxyl peroxide), topical retinoids - Vit A acid gel/Differin; and topical antibiotics - Dalacin, Staticin .
- Second line treatments include long term oral antibiotics - Tetracycline, Minocin, Doxycycline; and hormonal manipulation - oral contraceptive pills, antiandrogens -(eg cyproterone acetate , contained in Diane 35).
- Third line treatment would be Accutane, an oral retinoid and Vit A derivative , usually prescribed for 4-5 months,with the goal of long term .suppression of cystic or scarring acne. This medication has been associated with significant side effects , including night blindness, birth defects, depression,and elevations in blood lipids among others, and will interfere with skin healing, so an interval of at least 6 months, and possibly a year, should be observed following treatment with Accutane and before undertaking any laser treatments.
Non pharmacologic approaches to active acne involve the use of
- glycolic, lactic, and salicylic peels
- blue LED light ( which targets the p.acnes bacteria)
- photodynamic therapy, which involves the use of a topical photosensitizing drug such as Levulan, followed by red or blue light exposure.
Acne scarring
There are different types of acne scars- small pocks, or ice-pick scars, rolling scars - peaks and hollows; or tethering of tissue with dense collagenous scar tisse.
Approaches to acne scarring include
- Dermal fillers
- Subcision (cutting)of dense scar tissue ( either with the point of a needle under local anaesthesia, or chemical subcision with the enzyme collagenase)
- TCA (acid) application to the base of small pocks - with the idea of stimulating filling in of the hole with collagen
- Platelet-rich fibrin matrix (Selphyll)- the growth factors attached to the platelets stimulate the gradual filling in of the scars with normal tissue
- Resurfacing lasers - Smartxide DOT fractional CO2 laser ( gold standard for acne scarring), or the non ablative Affirm Multiplex laser
Keloids
These are hypertrophic scars following acne, injury or surgery, and are extremely difficult to resolve, as attempts to excise them may result in more extensive scarring. Smaller scars may respond to intraleisonal injections of steroids, or fluorauracil; and some may resolve with cautious fractional CO2 resurfacing.
Post-inflammatory Hyperpigmentation
Most commonly seen in persons with darker skin tones, this will fade gradually over time,Sometimes bleaching agents such as kojic acid, azeliac acid, or 4% hydrquinnone with vit C, or tretonin, may be beneficial.
Red acne or surgical scars - will respond to pulse dye lasers
Rosacea
There are 4 main types of rosacea
- erythematotelangiectatic ( flushing )type best treated by avoiding triggers for flushing, and responds to IPL Intense Pulsed Light
- papulopustular (red bumps,pimples, pustules plus spider blood vessels) benefits from topical (metronidazole)or oral antibiotics ( tetracycline, minocin, doxycycline or erythromycin) topical tretonin,or azeliac acid ;plus IPL or PDL.(pulse dye laser)
- phymatous - characterized by thickening of the skin, often the nose - ( called rhinopyma) may require laser or cryosurgery
- occular -characterized by redness, dry eye, burning, light sensitivity or blurred vision: treatment - artificial tears, cleansing eyelashes daily with baby shampoo and wet face cloth, oral antibiotics and possible steroid eye drops. Rarely corneal lesions may result in loss of visual acuity.