Today's Treatements for Adolescent Acne

by Jill Rollet

Adolescent acne is a great leveler. Even pop stars get it, if you believe Jessica Simpson, spokeswoman for a well-advertised treatment product. And increasingly, typical teenagers hold themselves to celebrity standards when it comes to their looks.

"Anymore, we're a society [in which] people want to look good, and advertising supports that. If teenagers have one little blemish, it bothers them," says Peggy Vernon, a nurse practitioner with Sorkin Dermatology in Greenwood Village, Colo.

Vernon sees a lot of acne, and most of it's not the "one little blemish" variety. Although acne isn't life threatening, severe acne is disfiguring during outbreaks, and it can leave scars both physical and emotional. Parents are often sympathetic and willing to seek treatment for their teens because they had acne themselves at that age, Vernon says. Happily for her patients, today's treatments are more effective than what was available to earlier generations.

Clearing Up Misconceptions

Treating acne begins with busting some myths, says Theodore Scott, NP. A clinical preceptor for the University of San Diego and a family nurse practitioner with a medical group in San Marcos, Calif., Scott is also a dermatology certified nurse practitioner, one of the first to pass the new exam offered by the Dermatology Nurses' Association.

Here's how Scott explains acne to his patients: The surge of testosterone that accompanies puberty — in both boys and girls — irritates oil glands in the skin. The angry oil glands respond by overproducing oil (sebum). Normally, sebum is carried to the skin's surface along the hair follicle through the pilosebaceous duct in which the oil gland sits. During puberty, the glut of oil moves slowly through the duct, which is also inflamed and irritated, picking up dead skin bits and hair fragments along the way. This sebaceous mess thickens and forms a plug — a comedo or acne papule — at the end of the duct.

This acne papule reacts with oxygen to become a classic blackhead. It can also become colonized by Propionibacterium acnes, bacteria commonly present on the skin. When this happens, the body responds by sending neutrophils and lymphocytes to the site, creating pus in the blocked follicle. The result is a whitehead, a pimple, a zit. Repeat this process hundreds of times, and deep, scarring cysts form.

Contrary to the folklore, diet, dirt and even stress do not cause acne. Although avoiding chocolate, washing more often and reducing stress might have other health benefits, they won't clear up skin, Scott confirms. And products not intended to treat acne don't.

Scott has heard of teens using Listerine mouthwash and Ajax and other household cleaners on their skin.

Adolescents also sometimes get bad advice about acne from their parents, who grew up with different products and treatments. Parents who used scrubs or harsh, alcohol-based astringents for their own skin continue to buy these products for their acne-prone children, Scott explains. These products can further irritate sensitive skin.

And as for the age-old practice of "popping" pimples, Scott advises, "Do not attempt this at home." Picking and popping can drive bacteria deeper into the skin, making acne worse. The habit can also cause permanent scars.

Self-Management

Scott recommends a stepwise approach to treating adolescent acne. Many cases can be controlled with self-management and over-the-counter products.

The first step is good basic skin care. Scott advises using a cleanser that contains an alpha-hydroxy acid (such as glycolic acid or lactic acid) or beta-hydroxy acid (salicylic acid), which are gentle chemical exfoliants that help dissolve the matter plugging the sebaceous ducts. Scott offers as an example Neutrogena Oil-Free Acne Wash, which contains 2% salicylic acid. But he notes that many other acceptable and inexpensive products are also available.

Wash gently and no more often than twice daily, Scott recommends: "This condition has nothing to do with dirt or the oil on your skin, only what's clogged up inside the oil gland."

After washing, teens should use an over-the-counter benzoyl peroxide product to kill P acnes on the skin. Scott prefers an aqueous gel to creams or lotions. Choices in this category are vast.

Prescription Options

If a patient's skin isn't clearing with over-the-counter products, several prescription options can easily be managed in primary care settings. Scott advises giving each option at least 6 weeks to produce improvement and then adding a product to the regimen if needed.

First try one of the topical retinoids, a class of medication that revolutionized acne treatment in the 1980s. To the self-management regimen, Scott adds one of the following: adapalene (Differin), tretinoin (Retin-A, Avita) or tazarotene (Tazorac), in order of increasing strength. These vitamin A derivatives increase skin turnover, which helps unclog pilosebaceous follicles and prevent new clogs from forming. They might also act on sebaceous glands to reduce oil production.

Patients should apply a pea-sized amount of the product to the face at bedtime, at least a half hour after washing (to reduce irritation), every other night. After 2 weeks, patients should increase the frequency of application to every night.

If the patient has pus-filled comodones, indicating infection with P acnes, Scott replaces the benzoyl peroxide in the regimen with a topical antibiotic gel or solution. Clindamycin (Cleocin T) and erythromycin kill bacteria on the skin and reduce inflammation.

Combination topical antibiotics and benzoyl peroxide are also available: Benzamycin with erythromycin and Benzaclin and Duac with clindamycin. For each of these products, patients should apply a pea-sized amount or enough to provide a thin film on the face at bedtime.

For more severe cases, such as deep cysts or nodules, Scott adds an oral antibiotic: tetracycline 500 mg twice daily, doxycycline 100 mg twice daily or minocycline 100 mg twice daily. For patients who don't tolerate tetracyclines, he'll prescribe erythromycin 500 mg twice daily. Like the topicals, these antibiotics kill P acnes and reduce inflammation.

Accutane

Patients with severe acne that hasn't responded to other treatments should be referred to a dermatology practice to evaluate appropriateness for treatment with isotretinoin (Accutane, Sotret, Amnesteem, Claravis), an oral retinoid. Isotretinoin reduces the size of sebaceous glands and inhibits sebum production.

Because the side effects of isotretinoin can be severe, it is strictly controlled by the Food and Drug Administration. Prescribers, patients and pharmacies that handle the medication are required to register with the iPledge program. See the sidebar accompanying this article for more information about this treatment choice.

For Women Only

Because sebum production is fueled by testosterone, reducing testosterone levels may reduce excess sebum and help clear up acne, especially acne linked to a woman's menstrual cycle.

Oral contraceptive pills, spironolactone and low-dose corticosteroids all work to suppress androgen levels. These therapies can be managed in primary care, but Scott suggests referring to dermatology or gynecology specialists for spironolactone and corticosteroids.

Oral contraceptives suppress androgen production in the ovaries. Ortho Tri-cyclen (0.18 mg, 0.215 mg, 0.25 mg norgestimate/0.035 mg ethinyl estradiol pills), Estrostep (1 mg norethindrone acetate with 20 mcg, 30 mcg, 35 mcg ethinyl estradiol) and Yaz (3 mg drospirenone/0.02 mg ethinyl estradiol) are approved by the Food and Drug Administration for acne treatment, but similar contraceptive formulations are also effective. Vernon prefers this treatment route for teenage girls with hormonally linked acne.

Spironolactone, typically used as a diuretic, is an androgen antagonist; it reduces sebum production by binding to androgen receptors, thereby blocking the effects of testosterone. Its use for acne treatment is off label. Vernon frequently prescribes spironolactone (Aldactone 50 mg to 100 mg daily in divided doses) for her adult acne patients. She cautions that although it can be effective against acne, it can't be prescribed during pregnancy because it feminizes male fetuses.

Low-dose corticosteroids, such as prednisone (Deltasone) or dexamethasone (Decadron, Hexadrol) can also reduce hormonally induced surges of sebum production by suppressing androgens produced in the adrenal glands. Vernon says she never prescribes corticosteroids for acne since the risk of abuse or steroid rebound acne is great and good alternatives exist. Scott sometimes sees dermatologists in his practice prescribe oral prednisone (40 mg to 60 mg for 5 days) for special cases, such as an approaching wedding day.

Aesthetics Treatments

For patients who want to improve the appearance of their skin, in conjunction with other acne treatments or not, a variety of aesthetics procedures are available. Lisa Williams, NP, owns Ultra Smooth Skin, an aesthetics practice in Scottsdale, Ariz., and many of her teenage acne patients — both boys and girls — are the children of existing patients.

Williams' primary concern is instilling good skin care habits: avoiding the sun, gently washing and drying delicate or irriated skin, keeping hair off the face, eschewing foundation makeup and, most importantly, not picking at blemishes.

Her patients' primary concern is to avoid pain. "When I first started in this industry," Williams says, "I was working with a physician who treated teens, and I remember the tears flowing. I made the decision that I wouldn't treat them with painful procedures."

That decision leaves out some treatments, such as fractionalized skin resurfacing, that William finds are effective for adults.

For teens, Williams recommends a laser facial package that alternates a light treatment with a chemical peel. The first step is the light treatment, which combines the prescription topical solution aminolevulinic acid (Levulan) with 450-nm-wavelength blue light from the BLU-U Blue Light Photodynamic Therapy Illuminator. Williams applies the medication, and the patient waits 30 minutes to an hour to let it penetrate the skin. Then Williams has the patient sit under the blue light for 16 minutes.

Blue light is FDA approved for acne treatment. Used alone, its heat kills P acnes on the skin. Aminolevulinic acid is indicated for actinic keratosis and is used off label to treat acne. The solution photosensitizes skin cells, allowing the light to penetrate and degrade them. The dead cells are sloughed off over the next few days.

The treatment is aggressive but painless and effective, Williams says. It produces progressive reddening and peeling, so teenagers don't return to school the next day. She counsels patients to stay out of the sun and avoid even fluorescent lights for the first few days after treatment.

Three to 4 weeks after the light treatment, Williams has her patients come back for a superficial chemical peel. She uses SkinMedica's Vitalize peel, which contains glycolic acid and salicylic acid and is particularly mild. The solution causes the top layers of skin to slough off, taking with them blemishes and red spots. After treatment, Williams advises patients to avoid sun exposure. This approach requires little or no downtime, and teens can return to school.

Williams alternates the light treatment with the chemical peel every 3 to 4 weeks, but she acknowledges that her adolescent patients are less compliant with the light treatment — the downtime affects their busy lives — and they often come in for the chemical peel only.

Self-Esteem

Acne treatment can have positive effects beyond clearer skin. As their acne disappears, teens often find new self-confidence, Vernon says.

Williams notes that her patients often don't realize the change until she shows them photos: The "before" photos show blemished skin and glum expressions, while the "after" photos show clear skin and big smiles.

Documented evidence of improvement and compliments from family and friends can be life changing — making the cost of treatment worth it for teens and their parents, Vernon notes. Insurance typically covers the treatments she provides, but some patients with no health insurance or with high deductibles can face large out-of-pocket expenses on top of the time given to office visits.

"But," she adds, "I can tell you, I have families who pay that expense for their kids because they need it."

Jill Rollet is the managing editor. You can reach her at jrollet@advanceweb.com.

For Severe Acne: Isotretinoin

by Tami Dobbs, NP

Acne affects 85% of people between the ages of 12 and 24, and it is the most common skin disorder treated.¹Isotretinoin is a medication for severe acne that is resistant to standard treatments. It is an oral retinoid available under the brand name Accutane and in generic form as Amnesteem, Claravis and Sotret.

Standard dosing for isotretinoin is 0.5 mg to 1 mg/kg/day split in two doses, for a total of 4 to 8 months.²The drug dramatically reduces sebum excretion, follicular keratinization and surface P acnes. These effects are maintained during treatment and persist at variable levels after therapy.²Typically, 85% of patients are clear of acne in 4 months at the recommended dose; 15% require longer treatment.²

Adverse Effects

Serious adverse effects of the drug include teratogenesis, elevated triglycerides and, to a lesser degree, elevated cholesterol and liver enzyme levels.³Skeletal abnormalities are possible when the drug is used longer than recommended, and a possible association with depression or suicide has been noted.³ ecause the medication dries the sebaceous glands, dry mouth, lips and nasal passages are common.

This medication must not be used by women or adolescents who are pregnant or who have childbearing ability. It is considered a category X drug. The offspring of women who take isotretinoin between 15 days after conception and the end of the first trimester have a 35% increased risk for fetal abnormalities.⁴The risk of spontaneous abortion and premature birth is also increased.⁵(Men and adolescent boys who take isotretinoin cannot cause fetal abnormalities while on the regimen.)

In recent years, mental health problems associated with isotretinoin have attracted attention. No formal epidemiologic evidence from treatment cohort studies or large population studies have identified an association between isotretinoin use and depression, but some case report evidence exists.⁶A recent pilot study suggests that treatment with isotretinoin may be associated with changes in brain functioning and that it may be associated with depression in vulnerable patients with acne.

In light of these reports, prescribers should monitor patients for behavioral changes.⁷A patient with any history of depression or psychosis should see a psychiatrist before receiving an isotretinoin prescription.

Laboratory Requirements

Before taking isotretinoin, all patients should have a baseline lipid panel, complete blood count and liver function test. Repeat tests after 2 to 3 weeks of treatment, and then monthly until the medication is discontinued.⁸ angerously elevated lipids warrant discontinuing the medication.

Women and adolescent girls who have the ability to become pregnant must undergo serum pregnancy testing during the first 5 days of their menstrual cycle, prior to receiving the prescription, and then monthly. Every female patient must also use two forms of birth control for 30 days prior to dispensing of the prescription.

The iPledge Program

Because of the medication's teratogenicity, isotretinoin is approved for marketing only under a restricted distribution program. All prescribers, pharmacies and patients who handle the drug must be registered and activated by the iPledge program.⁹This program is a computer-based risk management system that uses verifiable, traceable links among prescriber, patient, pharmacy and wholesaler to control the medication. Each entity must follow the guidelines to qualify for iPledge. Among the requirements are frequent verifiable pregnancy testing and a tight window for filling prescriptions. All patients must be seen in office monthly.

Despite iPledge requirements, 122 pregnancies occurred in the program's first year. Another 19 pregnancies occurred in women who managed to get the drug despite never enrolling in iPledge.⁹Although isotretinoin is often limited to dermatology offices, this does not have to be the case. Pediatric or primary care NPs with adequate time for education and for following the iPledge program can achieve impressive result for their patients. Patients are generally elated with the results of the medication and would argue that this is a life-altering medication.

References

1. Morris H, Roberts GH. Accutane and its effects. J Contin Educ Top Issues. 2005; 7(1):12-17.

2. Habif TP. Habif: Dermatology. 4^thed. Edinburgh, Scotland: Mosby; 2004:166-186.

3. Goldsmith LA, et al. American Academy of Dermatology consensus conference on the safe and optimal use of isotretinoin: summary and recommendations. J Am Acad Dermatol. 2004;50(6).

4. Behrman RE, et al. Nelson Textbook of Pediatrics. 17^thed. Philadelphia: W.B. Saunders; 2007.

5. Accutane package insert. Available at: http://www.rocheusa.com/products/accutane/pi.pdf. Accessed May 13, 2008.

6. Hull PR, D'Arcy C. Acne, depression, and suicide. Dermatol Clin. 2005; 23(4): 665-674.

7. Bremner JD. Brain imaging studies suggest a link between Accutane and depression. Am J Psychiatry. 2005; 162(5):983-991.

8. Amichai B, et al. Low-dose isotretinoin in the treatment of acne vulgaris. J Am Acad Dermatol. 2006; 54(4):219-240.

9. Food and Drug Administration. iPLEDGE — Committed to Pregnancy Prevention. Washington, D.C.: FDA; 2006. An Overview of Acne Treatments

OTC

• Salicylic acid: encourages shedding of dead skin, which helps clear clogged pilosebaceous follicles.

• Benzoyl peroxide: kills P acnes by supplying oxygen to the anaerobic bacteria; this does not lead to resistant bacteria. Also causes skin dryness and shedding, which can help clear clogged follicles.

Rx

• Topical antibiotics: Clindamycin (Cleocin T), erythromycin and others kill P acnes and reduce inflammation. Combination topical antibiotics and benzoyl peroxide are also available (Benzamycin with erythromycin, and Benzaclin and Duac with clindamycin). Their use can lead to resistant bacteria.

• Oral antibiotics: Tetracycline (500 mg twice daily), doxycycline (100 mg twice daily), erythromycin (500 mg twice daily) and others kill P acnes and other bacteria and reduce inflammation. Their use can lead to resistant bacteria.

• Azelaic acid (Azelex): Derived from a substance found in wheat, azelaic acid kills P acnes (mechanism of action is unknown) without leading to resistant bacteria. It also encourages shedding of dead skin, which helps clear clogged follicles.

• Topical retinoids: Tretinoin (Retin-A, Avita), tazarotene (Tazorac) and adapalene (Differin) are derived from vitamin A. They increase skin cell turnover, which helps clear clogged follicles and may reduce sebum production.

• Oral retinoid (isotretinoin [Accutane, Sotret]): derived from vitamin A; increases skin cell turnover, which helps clear clogged follicles, and shrinks oil glands to reduce sebum production.

• Oral contraceptives: suppress endogenous testosterone to reduce sebum production in women. Ortho Tri-cyclen, Estrostep and Yaz are FDA approved for acne treatment.

• Corticosteroids (for women): Low-dose prednisone or dexamethasone suppress androgens, which reduces sebum production.

• Spironolactone (Aldactone, off label, for women): An aldosterone (androgen) antagonist, spironolactone can reduce sebum production.