Summary

Acne is one of the most common diseases with a point prevalence of up to 100% among adolescents and often persists into adulthood, with detrimental effects on self-esteem. The conception of acne has been refined towards ‘chronic disease.’ Therefore, the strategy of acne treatment is not only a critical intervention but also maintenance. Acne medications are very efficient, but only when patients use them correctly. Oral isotretinoin is the most effective acne treatment developed to date. Earlier procedures, such as intralesional steroids, chemical peels, and microdermabrasion have been replaced by newer methods. Newer methods include radiofrequency, light or laser, and photodynamic therapy that represent treatment alternatives for systemic medications.

Acne is one of the most common diseases with a point prevalence of up to 100% among adolescents and often persists into adulthood, with detrimental effects on self-esteem. Sixty percent of all acne cases are so-called ‘physiologic acne,’ the other 40% are those that need continuous help with a specialist to prevent physical or psychological scarring. Acne is still the most frequent primary diagnosis for visits to dermatologists.

What Causes Acne or Pimples?

Acne is one of the most common diseases with a point prevalence of up to 100% among adolescents and often persists into adulthood, with detrimental effects on self-esteem. Sixty percent of all acne cases are so-called ‘physiologic acne,’ the other 40% are those that need continuous help with a specialist to prevent physical or psychological scarring. Acne is still the most frequent primary diagnosis for visits to dermatologists. Acne is currently understood as a chronic inflammatory disease of the pilosebaceous unit, characterized by androgen-induced increased sebum production, follicular hyperkeratinization, inflammation, and altered adaptive immune response. Bacterial colonization by Propionibacterium acnes aggravates the course of the disease in various manners, but its role as a prerequisite of the induction of acne is disputable.

What are the Types of Acne or Pimples?

Noninflammatory acne is characterized by both open and closed comedo formation. The inflammatory lesions of acne originate with comedo formation but then expand to form papules, pustules, nodules, and cysts of varying severity. As the severity of the lesion progresses, nodules form and become markedly inflamed, indurated, and tender. The cysts of acne are deeper and filled with a combination of pus and serosanguineous fluid. In patients with severe nodulocystic acne, these lesions frequently coalesce to form massively inflamed complex plaques that include sinus tracts.

Acne fulminans

Acne fulminans is the most severe form of cystic acne and is characterized by the abrupt onset of nodular and suppurative acne associated with variable systemic manifestations. While affected individuals often have typical mild to moderate acne before the onset of acne fulminans, without warning, micro-comedones erupt. These soon become markedly inflamed and coalesce into painful and oozing friable plaques with hemorrhagic crusts. The face, neck, chest, back, and arms are all affected. Ulcerated lesions can lead to significant scarring. Osteolytic bone lesions may accompany the cutaneous findings. Systemic manifestations include fever, arthralgias, myalgias, hepatosplenomegaly, and severe prostration.

Acne Conglobata

Severe, eruptive nodulocystic acne without systemic manifestations is termed acne conglobata. These recalcitrant lesions are part of the follicular occlusion tetrad, dissecting the scalp’s cellulitis, hidradenitis suppurativa, and pilonidal cysts. The association of sterile pyogenic arthritis, pyoderma gangrenosum, and acne (PAPA syndrome) is part of a related group of inflammatory disorders that includes inflammatory bowel disease, uveitis, and psoriasis.

Solid facial edema

An unusual and disfiguring complication of acne vulgaris is solid facial edema (Morbihan’s disease). Clinically, there is a distortion of the midline face and cheeks due to soft tissue swelling. The woody non-scaling induration may be accompanied by erythema. Similar changes have been reported with rosacea and Melkersson– Rosenthal syndrome. Although fluctuations in severity are common, the spontaneous resolution does not occur.

Acne Mechanica

Acne Mechanica occurs secondary to repeated mechanical and frictional obstruction of the pilosebaceous outlet. Comedo formation is the result. Well-described mechanical factors include rubbing by helmets, chin straps, suspenders, and collars. Linear and geometrically distributed areas of involvement should suggest acne mechanica. Treatment is aimed at eliminating the inciting forces.

Acne Excoriée (Fes Jeunes Filles)

Acne excoriée des Jeunes Filles, as the name implies, occurs primarily in young women. Typical comedones and inflammatory papules are systematically and neurotically excoriated, leaving crusted erosions that may scar. Linear erosions suggest self-mutilation, and an underlying psychiatric component should be suspected. Patients with an anxiety disorder, obsessive-compulsive disorder, or personality disorder are, particularly at risk. Antidepressants or psychotherapy may be indicated in such patients.

Drug-Induced Acne (Acneform)

Acne lesions or eruptive acneiform lesions can be seen as a side effect of several medications, including anabolic steroids, corticosteroids, corticotropin, phenytoin, lithium, isoniazid, iodides, and bromides. Less often, azathioprine, cyclosporine, tetracyclines, vitamins B1, B6, B12, and D2, phenobarbital, PUVA, propylthiouracil, disulfiram, or quinidine are the cause.

An abrupt, monomorphous eruption of inflammatory papules and pustules is often observed in drug-induced acne, in direct contrast to the heterogeneous morphology of lesions seen in acne vulgaris. This explains why some clinicians use the term’ folliculitis.’ When a history of prescription medication use is not elicited, a comprehensive review of all over-the-counter medications and supplements, as well as recent medical procedures, may reveal the responsible agent. Iodides are found in many cold and asthma preparations, contrast dyes, kelp, and combined vitamin-mineral supplements. Sedatives, analgesics, and cold remedies often contain bromides.

Occupational Acne

Exposure to insoluble, follicle-occluding substances in the workplace is responsible for occupational acne. Offending agents include cutting oils, petroleum-based products, chlorinated aromatic hydrocarbons, and coal tar derivatives. Comedones dominate the clinical picture, with varying numbers of papules, pustules, and cystic lesions.

Chloracne

Chloracne, the term used to define occupational acne caused by chlorinated aromatic hydrocarbons, develops after several weeks of exposure. The following agents, found in electrical conductors and insulators, insecticides, fungicides, herbicides, and wood preservatives, have all been implicated. Prevention of exposure is integral to the safety of at-risk employees. Treatment is aimed at the vigorous removal of chemical agents at the time of exposure. Topical or oral retinoids and oral antibiotics may be necessary for therapeutic interventions.

Neonatal Acne

Neonatal acne occurs in more than 20% of healthy newborns. Lesions appear at about two weeks of age and generally resolve within the first three months of life. Typically, small, inflamed bumps arise on the cheeks and across the nasal bridge. However, topical 2% ketoconazole and benzoyl peroxide is effective therapies.

Infantile Acne

If acne presents at 3-6 months of age, it is classified as infantile. Clinically, comedo formation is much more prominent than neonatal form and may lead to pitted scarring. Deep cystic lesions and suppurative nodules are occasionally seen. During the first 6-12 months of life, infant boys have elevated luteinizing hormone (LH) levels and its stimulatory product testosterone, with levels transiently equivalent to those measured during puberty. In addition, the infantile adrenal gland is immature in both boys and girls, leading to elevated levels of DHEA. At approximately 12 months, these levels usually decrease and remain at nadir levels until puberty, around 9 or 10 years of age. Testicular androgen is also minimal throughout most of childhood.

Premenstrual Flare

About 70% of women complain of a flare 2–7 days premenstrual. It is unlikely that any possible variation in sebum excretion during the menstrual cycle could be substantial enough to explain the flare. Possibly, flaring is related to a premenstrual change in the hydration of the pilosebaceous epithelium. Progesterone and estrogen also have both pro-and anti-inflammatory effects.

Sweating and Acne

Up to 15% of acne patients notice that sweating causes a deterioration in their acne, especially if they live or work in a hot, humid environment; for example, ductal hydration may be the responsible factor for a cook.

Ultraviolet Radiation and Acne

Patients and doctors alike believe that natural sunlight improves acne, but there is no scientific c evidence for this belief. The cosmetic effect of tanning may be the entire explanation.

Diet and Acne

Dermatologists can no longer dismiss the association between diet and acne. Compelling evidence exists that high glycemic load diets may exacerbate acne. Dairy ingestion appears to be weakly associated with acne, and the roles of omega-3 fatty acids, antioxidants, zinc, vitamin A, and dietary fiber remain to be elucidated.

How Dermatologists Treat Acne or Pimples?

Topical Retinoids & Retinoid-Based Fixed Combination  for Acne or Pimples

Topical retinoids act against comedones and micro-comedones. New delivery systems continuously improve the drawback of low cutaneous tolerability of topical tretinoin to facilitate controlled release, including; Retin-A Micro® gel 0.1% or 0.04%, Avita 0.025% gel or cream or micronized tretinoin Atralin® Gel 0.05%. Another advantage of microsphere and micronized formulation is marked protection against tretinoin photodegradation and oxidation by BPO. Adapalene, a synthetic third-generation topical retinoid, is available as 0.1% gel, cream, solution, and recently as lotion and 0.3% gel (Differin®). Topical tazarotene is approved for acne treatment only in the USA (Tazorac®). Recently introduced retinoid-based fixed combinations with high-quality clinical efficacy evidence include fixed combinations of tretinoin 0.025% and clindamycin phosphate 1.2% (Ziana®) and Veltin® Gel, and adapalene 0.1% and BPO 2.5% (Epiduo™, Tactuo™), representing the only fixed-dose combination product available that combines a topical retinoid with BPO.

Topical Anti-microbials & Their Fixed Combinations for Acne  or Pimples

Topical antimicrobials are an essential part of the therapeutic armamentarium for mild-to-moderate acne vulgaris and represent an alternative for patients who cannot take systemic antibiotics. Clindamycin, erythromycin, tetracycline, or nadifloxacin are bacteriostatic for P. acnes and have also been demonstrated to have anti-inflammatory activities. Their use as monotherapy is no longer recommended. They should be applied preferentially in combination with BPO – an approach that reduces the emergence of P. acnes strains that are resistant or less sensitive to antibiotics. Combining a topical retinoid plus an antimicrobial is a rational choice because of the complementary modes of action that increase the speed of response and enhance efficacy against comedones and inflammatory lesions. At the moment, three fixed combination products of clindamycin and BPO are on the market: two containing clindamycin 1% and BPO 5% (Duac®) and Benzaclin®) and an optimized formulation of clindamycin phosphate 1.2%/BPO 2.5% aqueous gel (Acanya®).

Other Topical Treatments for Acne or Pimples

For almost two decades, azelaic acid 20% in a cream formulation has been established as an effective and safe topical drug. Azelaic acid 15% gel is approved for the treatment of rosacea in the USA but also has approval for the treatment of acne vulgaris in Europe and recently proved productive in treating postinflammatory hyperpigmentation in acne. Azelaic acid is currently recommended as a second-line option for treating mild-to-moderate papulopustular acne and comedonal acne or in combination with systemic antibiotics for severe acne forms as an alternative treatment for isotretinoin. A new aqueous gel formulation of dapsone 5% (Aczone) was more effective than tazarotene monotherapy for the treatment of comedonal acne, suggesting that anti-inflammatory agents such as dapsone might effectively treat early stages of acne (both comedonal and non-comedonal) when used in combination with a retinoid.

Oral Antibiotics for Acne or Pimples

Systemic antibiotics are recommended to manage moderate-to-severe inflammatory acne after the failure of topical treatment and in acne covering large parts of the body surface. Substances reported to be effective in acne therapy are tetracycline, doxycycline, minocycline, lymecycline, trimethoprim-sulfamethoxazole, clindamycin, roxithromycin, and azithromycin, but particularly minocycline and doxycycline, with their potent anti-inflammatory effects on neutrophil chemotaxis or inhibitory effects on cytokines and matrix metalloproteinases. For this reason, they are routinely used as the first-line oral antibiotic therapy in acne. Current treatment guidelines recommend combining oral antibiotics with retinoids, azelaic acid, BPO, or a combination of retinoid/BPO for moderate-to-severe forms of acne. The use of sub-antimicrobial doses of antibiotics may offer promise. Instead, the primary mechanisms of action of sub-antimicrobial-dose antibiotics are anti-inflammatory mechanisms. To limit the emergence of resistant strains, the use of antibiotics should be restricted. Regarding indication and duration, topical and systemic antibiotic therapy should always be combined with broad-spectrum antibacterial agents (e.g., BPO). I should avoid the combination of topical antibiotic and systemic antibiotic therapy and antibiotic monotherapy.

Hormonal Therapy for Acne or Pimples

Androgens, estrogens, growth hormones, and insulin-like growth factors play an essential role in the development of acne. Various systemic hormone preparations are available for acne in female patients. These may be indicated when: standard antibiotic regimens have failed, menstrual control and contraception are required alongside acne therapy, and oral isotretinoin is inappropriate or not available. Topical therapy can and should be prescribed in conjunction with hormonal regimens. Potential hormonal treatments for acne include inhibitors of androgen production by the ovary (oral contraceptives) or adrenal gland (low-dose corticosteroids), androgen receptor blockers, and anti-androgens that block the effect of androgens on the sebaceous gland.

Hormonal therapy represents an alternative or additional treatment regimen, especially in late-type female acne, polycystic ovary syndrome, other signs of hyperandrogenism, such as seborrhoea, androgenetic alopecia or hirsutism in combination with acne (SAHA syndrome), and the case of parallel wishes of contraception or as a requirement for systemic isotretinoin treatment. It can be combined with topical therapy or systemic antibiotics in moderate-to-severe acne forms but is not a primary monotherapy for uncomplicated acne.

The combinations of Ethinyl estradiol with cyproterone acetate, chlormadinone acetate, dienogest desogestrel, and drospirenone have shown the most muscular anti-acne activity. Oral contraceptives generally contain estrogen (most commonly ethinyloestradiol) and progestin. Estrogens act on the liver to increase the synthesis of sex hormone-binding globulin (SHBG), which binds testosterone and reduces the level of free circulating testosterone. Hence all oral contraceptives will potentially improve acne. In addition, oral contraceptives suppress ovulation by inhibiting the production of ovarian androgens, which results in reduced serum androgens and lower sebum production.

Drospirenone is a novel progestin derived from 17á-spironolactone, and as with the parent, the compound has anti-mineralocorticoid and antiandrogenic activity, making it potentially helpful in acne. Yasmin® contains drospirenone 3 mg combined with ethinyloestradiol 30 ug, and Yaz® contains the same dose of drospirenone with 20 ugs of ethinyloestradiol. Low-dose prednisolone is only to be administered at late-onset congenital adrenal hyperplasia and dopamine agonists at hyperprolactinemia. Low-dose glucocorticosteroids (i.e.2.5 mg prednisolone on waking and 5 mg on retiring) to suppress adrenal androgens, with or without a contraceptive pill, will reduce sebum production by up to 50% with a concomitant improvement in acne.

Androgen Receptor Blockers for Acne or Pimples

The anti-androgen CPA directly inhibits the androgen receptor and serves as a progestogen in oral contraceptives. Dianette® and Estelle 35® are oral contraceptives that ameliorate acne. It is as effective as oral tetracycline one g/day given over six months. I can enhance the clinical efficacy of this combination by giving an extra 50 mg or 100 mg CPA from the fifth to the 14th day of the cycle. It is also of potential benefit in women with acne resistance to other therapies. Spironolactone is an effective treatment (not a contraceptive) and reduces sebum excretion by 30–75%, depending on the dosage used. Its effects are dose-dependent, and it is usually prescribed at a dose of 50–100 mg daily with meals, but many women with sporadic outbreaks do well with doses as low as 25 mg daily. Flutamide is a potent antagonist of the androgen steroid. Although most commonly used in treating prostatic conditions, flutamide is efficacious in several androgen-mediated problems, including acne, administered at 250 mg daily. Fatal hepatotoxicity has been reported, and therefore use in acne is not generally advocated. There is concern about the potential reduction in the efficacy of oral contraceptives as a result of systemic antibiotics used in conjunction with COCs. The risk is theoretical, based on the hypothesis that broad-spectrum antibiotics reduce bacterial flora in the gut and thus interfere with estrogen absorption.

Oral Isotretinoin for Acne or Pimples

Oral isotretinoin exhibits activity against all significant etiologic factors involved in the pathogenesis of acne. It significantly reduces sebaceous glands’ size and sebum production, normalizes follicular keratinization, and prevents the development of micro-comedones and comedones, indirectly inhibiting P. acnes growth by changing the follicular milieu and upregulation of antimicrobial factors and exerts direct immunologic and anti-inflammatory activity. Isotretinoin is considered the first-choice treatment for severe papulopustular, moderate nodular, and severe nodular/conglobate acne, especially when other complicating prognostic factors are present. The rationale behind this recommendation is that the quick reduction of inflammation in acne may prevent clinical and psychological scarring.

The recommended dose to start isotretinoin therapy is now 0.3–0.5 mg/kg for severe papulopustular acne/moderate nodular acne and 0.5 mg/kg for conglobate acne. The duration of the therapy should be at least six months and can be prolonged in case of insufficient response. Side effects of isotretinoin include those of the mucocutaneous, musculoskeletal and ophthalmic systems and headaches. According to currently available evidence, the prescription of oral isotretinoin is encouraged in severe acne patients who usually experience physical and psychological improvement of their disease. The most severe safety issue concerning oral isotretinoin is teratogenicity. Therefore, women of childbearing potential must be treated while adhering to the pregnancy-prevention program (PPP) or iPLEDGE, which requires mandatory registration of all patients receiving the drug. Regarding these legal issues, the use of propagated ‘off-label’ low-dose isotretinoin or intermittent regimens are undoubtedly clinically effective and well-tolerated in the control of moderate acne. The optimal cumulative threshold dose to prevent relapses is an open question of these regimens yet to be resolved.

Before the advent of light, laser, and radiofrequency treatment modalities, physical therapies have been employed to complement medical therapy. Light cautery and aspiration followed by in situ injections of cortisone, respectively, are helpful adjunctive therapies. Other adjunctive therapies will include; steam, facial masks, ultra-sonophoresis, dermal rollers, comedo extraction, and chemical peels.

Steam

This process helps free any dead cells, dirt, bacteria, or other trapped matter causing acne breakouts by opening the pores. It can allow your skin to absorb better any other products you might use after the steaming.

Facial Mask

There are different kinds of masks for different purposes (cleansing, or exfoliating, brightening). Some masks are designed to dry or solidify on the face, almost like plaster; others remain wet. Anti-acne masks suit oily or acne-prone skin.

Ultra-sonophoresis

Ultra-sonophoresis is a technology that uses low-frequency sound wave resonance of approximately 20,000 per second to the skin to increase skin permeability thousands of times. It helps to deep cleansing of the skin, open pores, and reduce the appearance of pigmentation. During your treatment, a soft, high-pitched sound may be audible. The physical sensation felt is one of warmth. Some skins may experience a mild pinkness that resolves quickly.

Intralesional Injections

Corticosteroids are injected, intralesional, to provide a high concentration of steroids within the lesion with minimal systemic absorption. This modality is indicated when a quick response is required. Corticosteroid injections flatten most acne nodules in 48 to 72 hours. Marked improvement in nodular and cystic acne after intralesional steroid injections has been reported. Preparations usually come as triamcinolone acetonide in 10 mg/mL multiple-use vials that may be diluted with sterile normal saline to 5 or 3.3 mg/mL, two commonly used dilutions.

Diamond Peel, Crystal Peel or Micro-dermabrasion

At MSI, we are happy to have the 3^rd generation micro-dermabrasion device” Diamond Tom.” Unlike other exfoliation treatments, the Diamond Tom skin resurfacing system uses no loose abrasives to contaminate you or the environment. It removes this layer of skin by gently exfoliating the skin with natural diamond chips while at the same time vacuuming the dead skin cells away in a sterile and controlled manner, leaving your skin smoother and healthier.

Microdermabrasion is an excellent procedure for exfoliating the skin, refreshing weathered skin. Like a light peel, it can improve superficial acne scars, some effects of sun damage, fine lines and wrinkles, superficial pigmentation, enlarged pores, and blackheads and whiteheads. It also acts to stimulate the formation of new collagen and elastin to improve skin texture and elasticity. The procedure is performed on the face but may also be applied to other areas of the body. Micro-dermabrasion should improve the permeation of topical treatment. A typical course of treatment varies between 6-10 at approximately 2-3-week intervals. It is recommended that you schedule an additional treatment every 1-3 months to maintain your skin condition. Microdermabrasion may also enhance the absorption of topically applied medications, as pretreatment for PDT or to increase the penetration of light into the epidermis. Prof Moawad may recommend micro-dermabrasion as a standalone treatment or more commonly as an adjunct treatment with other nonablative resurfacing procedures.

Microneedling and Microinjections Skin Rejuvenation

A dermal roller is an option for those suffering from open pores, acne scars, fine wrinkles, stretch marks, and even hair loss. Micro-needling works by applying a device that has multiple fine needles to the surface of the skin. This action induces fine shallow punctures on the skin, and these micro-wounds will promote the healing process. When the needle breaks the normal skin barrier, blood vessels will be injured, thus releasing many repair cells in the blood. This repairing process will stimulate collagen and elastin remodeling within the treated skin, thus tightening after effect. The procedure is done by applying a numbing cream to the skin first to be comfortable throughout the procedure. The after-effects of the procedure are redness of the skin with mild swelling that will resolve in several hours. Micro-needling is an excellent treatment to be combined with mesotherapy, electroporation, or PRP for an enhanced effect. You can keep your derma roller to enhance further the effect of prescribed home anti-acne skincare products for active acne lesions and continual scar enhancement at the same time.

No Needles Mesotherapy Skin Treatment

The skin acts as a natural barrier against the entry of foreign substances into the organism. For a substance applied to the skin to be absorbed trans-epidermally, it must pass the corneous stratum. No needle mesotherapy addresses this problem by using electrical currents that help to increase the absorption of any solution into the deeper layers of the skin (transdermal, to be more specific). Compared to iontophoresis, it is 500 times more effective in delivering treatment trans-dermally. MSI Anti-acne topical therapy is not injected into the skin but painlessly passes through deep layers of the skin with the help of an electric current that creates temporary holes in your skin. These holes allow the passage of active ingredients that help treat pimples, dark spots or rejuvenate your skin. In a novel approach, Prof Moawad uses mesoderm to deliver your PRP deep into the skin where it is needed. Temporary holes closed immediately after treatment. It is done as a part of a complete MSI Skin Resurfacing Peel.

Platelet Rich Plasma (PRP) Injections

Vampire Facelift is a name for a non-surgical cosmetic procedure involving the injection of platelet-rich plasma (PRP) derived from a patient’s blood back into multiple areas of the skin of their face to treat wrinkles and “rejuvenate” the face and in a novel approach to treating inflammatory acne. By injecting PRP into the skin, we inject growth factors into the skin, leading to a cascade of activity, cellular and tissue repair, anti-inflammatory, and skin rejuvenation. The PRP is injected into the face with the help of a mesogen. Alternatively, PRP is brushed on the face after using a dermal roller or recently with mesoderm virtually painless. The new advancement of better penetration of PRP is the use of fractional CO2 lasers. Fractional CO2 Laser produces multiple thermal zones (MTZs) or holes in the skin for penetration and absorption of PRP. Fractional CO2 Laser has the added benefit in skin tightening and extended-term new collagen synthesis and hastening the healing process after a laser fractional, improving inflammatory lesions, red spots, dark spots, and acne scars. The results are magnificent, says Prof Moawad.

High Tech Skin Peel (rejuvenation)

The skin is thoroughly cleansed with an agent that removes excess oils at the treatment time, and the eyes and hair are protected. A chemical solution is applied to the skin that causes it to “blister” and eventually peel off. Prof. Moawad may recommend a superficial or medium chemical peel. He favors the medium-depth peel, the combination peel, and repeated lighter peeling regimens. He will select the proper mix of glycolic acid, salicylic acid, lactic acid, TCA, PCA, Phytic acid, or Jessner solution.

An excellent keratolytic agent, salicylic acid is helpful against comedones due to its strong lipophilicity and ability to penetrate the pore. Salicylic acid has anti-inflammatory effects and is effective against both inflammatory and anti-inflammatory lesions. Although they do not replace topical or systemic medications, superficial glycolic and salicylic acid-based chemical peels are very effective adjunctive methods to enhance and speed the resolution of acne, both inflammatory and comedonal. They also may be used safely in the skin of color and help resolve post-inflammatory hyperpigmentation. Chemical peels require maintenance treatments to sustain their effect. Based on the limited literature, these appear to be more helpful or appreciated by patients than microdermabrasion for active acne^. Most patients experience a warm to a somewhat hot sensation that lasts about five to 10 minutes, followed by a stinging sensation. A deeper peel may require pain medication during or after the procedure. Depending upon the type of peel, a reaction like a sunburn occurs following a chemical peel. Superficial peeling usually involves redness, followed by scaling that ends within three to seven days. Medium-depth and deep peeling may result in swelling and the presence of water blisters that may break, crust, turn brown and peel off over seven to 14 days.

Following any skin peel, you must avoid any exposure to the sun. Your new skin is susceptible to injury. Prof. Moawad will prescribe a good home skincare treatment program that includes cleansers, moisturizers, and sunscreens with or without anti-acne or bleaching agents to ensure proper healing and maintain the result of your peel. Following a chemical peel, your new skin will be tighter, smoother, and maybe slightly lighter than it was before surgery. The results of chemical peels may also be enhanced by new laser/light-based rejuvenation techniques.

Comedo Extraction

Blackheads are not caused by dirt, sweat, and poor hygiene (this is a myth that people spread) but are caused by the formation of plug-in pores due to abnormal skin cell growth, which gets oxidized by sunlight and turns black. Comedo extraction is a widely used method of treatment for acne vulgaris. A dermatologist or cosmetologist may extract blackheads (open comedones) using gentle pressure around the pore opening and whiteheads (closed comedones) by incision with a large needle or a blade. If performed skillfully, this treatment may be beneficial to the patient. It is usually is done after the superficial salicylic acid peel, which makes extraction easier.

Oxygen Treatments

Propionibacterium acnes lives in the skin and is the strain of bacteria that causes acne. For any acne treatment to be effective, it must kill these microbes, which thrive in the oxygen-deprived environment of a clogged pore. Oxygen has been used in the medical setting for years to speed healing. By introducing it deep into the follicle, it can destroy the acne bacteria. It can be used post-peel or laser treatment to speed the healing process.

Energy-based Acne Treatment (Light, Laser, PDT, and Radiofrequency)

Acne patients notice an improvement in their acne over the summer, although unfortunately, it does not last long. Ultraviolet light (phototherapy) has been used in the management of acne. However, the well-established long-term side effects of skin cancer risks of ultraviolet light/sunbeds have limited their use. Recently, light, heat, and radiofrequency energy devices, as well as photodynamic therapy (PDT), have emerged as valuable co-therapies or, in some cases, replacements for systemic medications. There are two main mechanisms that laser/light treatments may help acne; by destroying Propionibacterium acnes through a photodynamic therapy (PDT) reaction or by destroying the sebaceous glands / entire pilosebaceous unit or both.

In general, light-based treatments target P. acnes levels and disruption of sebaceous gland function and may also have anti-inflammatory effects via action on inflammatory cytokines. Like the effect of antibacterial agents, reducing P acnes levels by light therapy may play a role in improving acne lesions. Many light sources may affect P acnes, including narrowband light sources, IPL devices (broadband light), KTP lasers (532 nm), PDLs (585- 595 nm), and various orange/red light lasers or light sources (610-635 nm); these light sources have wavelengths that correspond to an absorption peak of P acnes porphyrins. Longer wavelengths penetrate more deeply into the skin but are less effective at activating porphyrins.

Lasers Skin Treatment

Several laser systems have been used to treat inflammatory acne vulgaris by destroying the sebaceous glands, including near-infrared lasers, 1320nm Cool Touch®, 1450nm Smooth Beam®, 1540nm erbium glass Aramis®, and diode lasers. KTP 532nm and pulsed dye lasers kill P. acnes, and hemoglobin absorbs the laser energy, reducing vascularity and modulating the inflammatory process of acne. Suppurative skin lesions, including inflammatory acne vulgaris, experienced a clinical improvement in the number and severity of lesions after ablative 10,600- nm carbon dioxide fractional laser treatment. The ablative fractional CO2 laser is beneficial in our patients due to the physical breakage of follicular plugging and thermal stimulation of the follicular epithelium of the pilosebaceous unit.

Photorejuvenation (IPL and LED)

It is known that the bacteria present in some acne lesions, P. acnes, produce chemicals called porphyrins during their growth and proliferation in the skin pore (follicular unit). These porphyrins may contribute to how non-inflamed acne lesions become inflamed. Recently, non-thermal, non-laser phototherapy (light emitted diode or LED) with visible light has attracted attention as a new treatment option. Blue visible light phototherapy is an effective acne treatment. Red visible light phototherapy improved noninflammatory and inflammatory acne lesions. Phototherapy with mixed blue-red light showed a better treatment response than blue light alone. Visible light as monotherapy is not recommended for the treatment of comedonal, severe papulopustular, and conglobate acne.

The effect of phototherapy is potentiated in photodynamic therapy. Photodynamic therapy is used to treat inflammatory acne and rosacea. PDT is effective for moderate to severe acne with long-term results. The versatility of PDT and the emergence of short-acting photosensitizing agents that can be applied to the skin before activation by light or laser devices have “revolutionized” the treatment of acne vulgaris and other cosmetic dermatologic conditions. The use of short (0.25–1-hr) incubation times and multiple treatment sessions provides optimal clinical efficacy and patient compliance, even in cases of recalcitrant acne.

Radiofrequency (RF) Skin Treatment

Nonablative radiofrequency (NARF) devices have also been used to treat moderate to severe inflammatory acne vulgaris. It has been suggested that the mechanism of action of nonablative RF is mainly a reduction of sebaceous gland activity and the promotion of dermal architecture remodeling by bulk heating of the dermis. Excessive oiliness of the skin, as seen in many of these patients, is decreased. This reverts to normal after a few months. Furthermore, sebaceous glands appear to decrease the volume after a few weeks after treatment with this device. Fractionated RF was used for inflammatory acne vulgaris and dermatologic conditions, including acne scars and enlarged facial pores. As in NARF, the therapeutic effects of the Fractional RF device may have been the result of volumetric tissue. In addition, making closer holes induces regeneration and realignment of irregular and thick collagen bundles through physical breakage, resulting in better clinical scar and skin texture.

Electrical and Optical Synergy (ELOS)

By combining light and RF current, less RF energy of both modalities is needed to provide the desired effect. Together, pulsed light and heat energy are thought to destroy P. acnes and shrink sebaceous glands, decreasing oil production. Photo-pneumatic therapy uses vacuum suction to remove the oil and dead skin cells from within the sebaceous glands. The targeted area is then treated with blue and red-light therapy to destroy P. acnes and reduce inflammation.

Conclusion

The conception of acne has been refined towards a ‘chronic disease’ and instead represents a condition that continuously changes its clinical appearance than teenagers’ acute, self-limited disease. This means the strategy of acne treatment is not only an acute intervention but also maintenance. Dermatologists need to take the lead in educating other clinicians that acne is often a chronic disease and not just a self-limiting disorder of teenagers. Why is this important? Because many of our medical colleagues and a significant proportion of the lay public dismiss acne as a natural part of growing up that has few real consequences. Yet considerable evidence shows that acne can be a psychologically damaging condition that lasts years.

Acne medications are very productive, but only when patients use them correctly. Oral isotretinoin is the most effective acne treatment developed to date. Earlier procedural therapies were adjunctive to medical therapy, such as intralesional steroids, chemical peels, and microdermabrasion. produtveFinally, patients should be taught the proper use of medications (topical agents should be spread over the entire involved area, and oral medications should be taken as directed.

Maintenance therapy to minimize the likelihood of relapse after initially successful treatment of acne is essential, given the chronic nature of the disease. Using a topical retinoid as monotherapy to maintain acne remission is a relatively new concept for many clinicians. Newer methods include radiofrequency, light or laser, and photodynamic therapy that represent treatment alternatives for systemic medications.