It bears repeating that chocolate, stress and dirt are not causes of acne. This article will look at the physiological chain of events that lead to acne and how specific treatments disrupt the different stages in acne formation.

With the onset of puberty, there is an increase in androgen production. This stimulates sebum production, the oil/ waxy substance that is produced by microscopic hair and skin glands whose function is to lubricate the skin. These sebaceous glands are found all over the body except on the palms and soles of the feet.

Acne develops when there is an excess of sebum production combined with abnormal production of keratin, the key ingredient in skin, hair and nail formation. Excess sebum production and keratin plugs cause follicles to become inflamed.

Specific bacteria, Propionibacterium acnes, live off the sebum because it’s high in fats. Once this happens, the follicle becomes even more inflamed until eventually, the follicle wall ruptures and the classic whitehead appears surrounded by a red base.

If the whitehead does not come into contact with the air, it is said to be a “closed comedo”. If it opens up, a blackhead appears and the structure is defined as an “open comedo”.

Treatment is aimed at interfering with any of these various stages in acne production:

• ways to unplug the sebaceous ducts
• killing the bacteria that live off the sebum
• normalizing keratin formation
• decreasing testosterone/androgen production via regulating hormones

Unplugging the sebaceous ducts

A good skin cleanser that contains either an alpha-hydroxy acid (glycolic or lactic acid) or a beta-hydroxy acid (salicylic acid) will help dissolve the material that plugs up the duct. By removing the debris, there is nothing for the bacteria to live off.

Salicylic acid 2% is an over-the-counter product that gently dissolves the debris.

Avoid products that are labeled “scrubs”, “exfoliants” or “micro-dermabrasives” – they only irritate an already inflamed skin.

Target the bacteria

There are 2 ways to do this:

1. using benzoyl peroxide – an over-the-counter antimicrobial agent
2. using prescription antibiotic topicals or orals

Because Propionibacterium acnes lives in an environment without oxygen, an agent that introduces oxygen in the sebum creates a hostile environment for the bacteria to survive. Benzoyl peroxide does just this. It can be purchased in cream or gel form and in various strengths ranging from 2.5% to 10%. The downside to this is that it can cause skin dryness and because it’s a peroxide, it can bleach hair and clothing. However, it’s inexpensive and effective.

Prescription medications include topical and oral antibiotics. Rather than creating a hostile environment for the bacteria, these agents work by killing the bacteria. Antibiotic choices include:

• erythromycin
• clindamycin
• sulfacetamide
• tetracycline
• doxycycline
• minocycline
• trimethroprim/sulfamethoxazole

Taking tetracyclines can cause severe skin burns with minimal sun exposure and patients need to be aware of this. In addition, antibiotic resistance is developing with some of the topical agents. Used in conjunction with benzoyl peroxide, treatment is more effective.

Normalize keratin formation

This is where the retinoids work – they reduce the plugging, normalize sebum excretion and reduce inflammation. Nowadays, if a patient has severe acne, they are referred to the dermatologist for treatment with retinoids because these agents are highly toxic to a developing fetus. The patient, pharmacy and medical provider must register with iPledge, a national database of all isotretinoin users. In addition, women must submit to pregnancy testing and 2 forms of birth control. Prescribers must also carefully document that all safety measures have been met.

Reducing testosterone production

Because high levels of sebum production is linked to testosterone, hormone therapy with oral contraceptives can be helpful since they suppress androgen production in the ovaries.

Sometimes the side effect of a medication helps treat another problem even though the medication was not intended for that particular use. This is the case with spironolactone, a diuretic used to treat high blood pressure. It blocks androgen rather than suppressing the production. As we know, blocking androgen helps decrease sebum production. Because its use in acne treatment is off-label, it is best used by a dermatologist. It is also toxic to a developing fetus so strict birth control measures must also be adhered to.

There are various stages of acne and treatment should be appropriate to the severity. A trial of over-the-counter agents is warranted in mild to moderate cases. Severe acne is scarring both physically and emotionally so seek treatment when needed.

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