The academy released strong recommendations for isotretinoin, doxycycline and other treatments.
Clascoterone, sarecycline, minocycline, spironolactone and other therapies received conditional recommendations.
The American Academy of Dermatology has released new care guidelines for acne vulgaris, according to a press release.
Published in the Journal of the American Academy of Dermatology, these guidelines are an update to the AAD’s 2016 acne guidelines and include 18 recommendations for topical and systemic therapies and five good practice statements.
The American Academy of Dermatology has released new care guidelines for acne vulgaris. Image: Adobe Stock.
According to John Barbieri, MD, MBA, assistant professor at Harvard Medical School, director of the advanced acne therapeutics clinic at Brigham and Women’s Hospital, associate editor of JAMA Dermatology and co-chair of the AAD Acne Guidelines Work Group, the new guidelines provide important recommendations for novel acne treatments.
John Barbieri
Two of the many recommendations worth highlighting include clascoterone and sarecycline therapy, according to Barbieri.
“Clascoterone is the first FDA-approved treatment that can address hormonal causes of acne in both men and women,” Barbieri told Healio. “Sarecycline is a narrow-spectrum tetracycline that might have some advantages over other tetracycline such as doxycycline and minocycline.”
“It will be important for dermatologists to have access to these valuable new treatments,” Barbieri adds.
New recommendations were also released regarding doxycycline and minocycline.
“Minocycline and doxycycline are currently prescribed in roughly equal proportions for the management of acne,” Barbieri explained. “However, while there is no evidence to suggest minocycline is more effective than doxycycline, it can be associated with rare but serious side effects.”
According to Barbieri, these serious adverse events may include vestibular dysfunction, autoimmune hepatitis, drug-induced lupus and drug reaction with eosinophilia and systemic symptoms. As a result, the academy released a strong recommendation in favor of doxycycline while releasing a conditional recommendation for minocycline.
“We should consider whether reducing use of minocycline might be beneficial to our overall care of patients with acne,” Barbieri added.
The authors also discussed that the use of trimethoprim-sulfamethoxazole, a systemic antibiotic, should be limited due to serious adverse events including Stevens-Johnson syndrome/toxic epidermal necrolysis and acute respiratory failure.
Oral isotretinoin received a strong recommendation for severe acne, acne causing psychosocial burden or scarring, or acne failing standard treatment with oral or topical therapy, whereas spironolactone received a conditional recommendation.
The authors have deemed that frequent laboratory monitoring for young, healthy patients on either isotretinoin or spironolactone is not a high-value practice.
“The updated guidelines provide specific recommendations about laboratory monitoring that can help clinicians and patients who are interested in less frequent monitoring feel more comfortable with these approaches,” Barbieri said.
According to Barbieri, there seems to be a common misconception that a “conditional recommendation” suggests a treatment is less valuable or should not be prescribed. However, the committee would like to make it clear that this is not the case.
“With the Grading of Recommendations Assessment, Development and Evaluation approach, it is expected that many recommendations will be conditional,” Barbieri said. “We think these are also good treatments and a conditional recommendation does not mean they should not be used. It is important that dermatologists have access to these important treatments as well.”
The US Food and Drug Administration has approved several new medications in the last 6 years that address these shortcomings and require only one dose per day, potentially enhancing patient compliance and, as a result, improving outcomes.
Overview of New Medications
Here is the basic approach to acne care, as outlined in 2016 guidelines from the American Academy of Dermatology (AAD):
Topical treatment (eg, benzoyl peroxide [BPO], antibiotics, and retinoids) is generally used as first-line treatment in cases of mild-to-moderate acne with comedonal and inflammatory lesions.
Systemic treatment (eg, oral antibiotics and hormonal therapy) can be used as first-line treatment in cases of moderate to severe acne, in combination with a topical agent.
Dermatologists today rarely use oral clindamycin and erythromycin for acne since antibiotic resistance has severely limited the effectiveness of these drugs. That leaves the tetracycline class as the antibiotic of choice, since it also has a strong anti-inflammatory effect. But tetracyclines can disrupt the gut microbiome, and minocycline in particular may cause rare but serious complications like irreversible hyperpigmentation and hypersensitivity reactions.
Dr Hilary Baldwin
That’s why Hilary Baldwin, MD, a dermatologist and director of the Acne Treatment & Research Center in Brooklyn, New York, welcomed the FDA approval in 2019 of topical minocycline. Far less of the topical formulation is absorbed by the body compared to a 3-week course of oral medication, Baldwin said.
“The concentration in the skin is extraordinarily high, while the concentration in the body is extraordinarily low, which is just the kind of combination we want,” she said. And the drug is effective for inflammatory lesions that previously would have required oral treatment with antibiotics or hormonal therapy.
Baldwin also frequently prescribes sarecycline, a narrow-spectrum tetracycline that has been available since 2018.
“It has all of the nice qualities of tetracycline in terms of its efficacy in treating acne, but it is probably less likely to do damage in the gut and hit off-target organisms,” she said. Another benefit is once-a-day dosing. Although sarecycline hasn’t undergone head-to-head trials with other tetracyclines, Baldwin said she has seen fewer side effects from the drug in her patients.
Dr Arash Mostaghimi
Although much of the drive to reformulate older topical medications is to allow manufacturers to maintain their patents on the products, research into ways to make a cream or lotion easier on the skin is another important avenue of research. “The vehicles do really matter,” said Arash Mostaghimi, MD, MPH, an associate professor of dermatology at Harvard Medical School in Boston. “A lot of the innovation in this space is actually in the delivery.”
The payoffs from this line of research include two new versions of older topical agents, tretinoin and tazarotene, which the FDA approved in 2018 and 2019, respectively. The novel technology for these two agents, as Baldwin explained, allows the active ingredient to deposit on the skin in a honeycomb-like mesh that also contains a protective moisturizer. “It has taken a virtually intolerable drug like tazarotene and made it into one of the mildest formulations of topical retinoids that we have,” Baldwin said.
The next trick is to use these technologies to create combination products. Although often prescribed together, topical retinoids and BPO creams cannot be applied at the same time because BPO oxidizes the retinoid, reducing its activity. Both drugs also cause significant skin irritation.
A technology called microencapsulation gets around these obstacles. A silica shell traps the active ingredients, which prevents them from interacting with each other while allowing their slow release. Microencapsulated drugs can be packaged in the same bottle and used at the same time, so that patients do not need to apply one medication in the morning and the other at night.
Trifarotene, initially developed for psoriasis, is another topical retinoid worthy of mention. Retinoids are vitamin A derivatives that bind different retinoic acid receptors (RARs); trifarotene is known as a next generation retinoid, because it is the first to selectively bind to RAR-gamma, the most common RAR in the skin. This affinity allows the drug to be effective at low concentrations, reducing systemic absorption and side effects. Studies have shown trifarotene is safe to use over large areas of the skin, so many dermatologists recommend it for people with acne extending to the shoulders and back.
The newest combination drug on the market, approved in October, is the first fixed-dose triple-combination topical treatment for acne. Containing clindamycin, BPO, and adapalene, a retinoid, the product should be available to consumers in 2024. “The amazing thing about the data is that it really looks as though the combination of all three have a synergistic effect. It is not just better — it’s dramatically better,” Baldwin said.
Mostaghimi said he also has been impressed with the data, and predicted providing triple treatment in a non-irritating fashion once daily would dramatically increase adherence.
Topical clascoterone, approved in the United States in 2020, is the first acne drug with a novel mechanism of action to reach the market in 40 years. Clascoterone addresses hormonal acne, which is related to elevated androgen levels. The condition is most common in adult women, particularly during menses, but also affects men.
Androgens bind androgen receptors present in the skin and stimulate the production of sebum. Although its precise mechanism of action is not well understood, clascoterone inhibits binding to androgen receptors, and may work by disrupting sebum production. The drug also inhibits pro-inflammatory cytokines and inflammatory follicular activity.
Dr Leslie Baumann
Leslie Baumann, MD, founder of the Baumann Cosmetic & Research Institute in Miami, said she considers clascoterone a significant improvement over spironolactone, which often is used to manage hormonal acne in women. “In the past, people took spironolactone pills, which would block testosterone in their whole body,” Baumann, a cosmetic dermatologist, said. “Now we can just do it in their skin, which is a lot safer.”
A study published earlier this year in JAMA Dermatology found prescriptions for spironolactone for women with acne rose nearly fourfold between 2017 and 2020, nearly matching orders for oral antibiotics by the end of that period.
Almost everyone suffers from acne at some point in their lives. The AAD estimates that acne affects 85% of people between the ages of 12-24. Although pimples might be considered a rite of passage for teens or dismissed as a cosmetic problem, acne is associated with significant anxiety and depression, and a study published this month found that individuals with acne face stigma affecting their personal and work lives.
So why don’t more people get treated successfully, and why do so many people drop out of treatment?
“Let’s think about who uses these medicines,” Mostaghimi said. “They’re kids, right? That may be the first medication they ever take.” Many adolescents have trouble using the drugs consistently, put on the wrong amounts, or are unable to stick to regimens involving multiple medications that must be applied at different times of the day. He advised that the best regimens are “anything that is easier to use — and a combined product is better.”
Another reason that people don’t seek medical help for acne: “There are a lot of people who feel like they’re very actively doing something about their skin,” Mostaghimi said. “But they’re not doing it based on physician expertise. They’re doing it based on things that they see online.”
As for compliance, Baumann likened the behavior of acne patients to people joining a gym after New Year’s. “I notice that 3 weeks is the drop off rate,” she said. “It’s human nature to want to see results right away, and acne takes at least 8 weeks to see a difference.”
And getting in to see a healthcare provider can be a barrier, especially for teens. ” Their parents don’t think it’s important or cannot afford the visit,” Baumann said. “Or they [the teen] don’t drive, and [the] parents are at work.”
Baumann said she has also seen young women with hormonal acne respond well to oral contraceptives, but their parents may have issues with their teenage daughter taking birth control pills.
This list of reasons implies that most patients need more education about what to expect from acne treatment and the medications they are taking: how long they need to be taken before symptoms improve, how to apply them properly, why they might need to use more than one medication, and what side effects to expect.
Many patients experiencing irritation from topical retinoids can manage the condition with moisturizers and milder cleansers. Or they could be switched to a newer topical retinoid in a vehicle that will be better tolerated.
Baldwin generally does her own patient education, but she understands that busy primary care clinicians who must also address patients’ other health problems might not have that luxury. Her advice is to train staff on the basics of acne care and use patient cheat sheets with medication instructions and side effects. If patients aren’t improving on follow-up visits, the key is to find out how well they have been sticking to the recommended regimen — or not. To get the full story from teenage patients, she added, “You really want to question compliance with the mom not in the room.”
As for deciding when patients can be treated in primary care settings and when to refer to dermatology, Mostaghimi said primary care clinicians should feel comfortable treating comedonal acne using topical agents, which should work for a majority of patients. And all three dermatologists felt patients with more severe acne — those that may require oral isotretinoin or oral antibiotics — should be managed by dermatologists.
The availability of newer better-tolerated retinoid formulations, along with combination drugs that improve compliance, should make management in primary care settings more feasible.
But given the effectiveness of oral isotretinoin, why aren’t more adolescent boys with severe acne taking the drug, since they wouldn’t be affected by pregnancy restrictions? “Denial is the number one reason, but also lack of insurance,” Baldwin said. The costs of drugs, multiple visits, and lab tests can add up.
Baldwin said acne is more culturally acceptable for men than women, who care more about a clear complexion because they feel they are being judged on their appearance. “It’s Mars/Venus stuff,” she said. ” Sometimes I see a male patient with really bad acne who has come in for treatment of a wart on his hand and is uninterested in acne treatment.”
In Baumann’s experience, concerns about side effects associated with oral isotretinoin, such as bone aches and risk for injury to the joints or tendons, may be a bigger deterrent for male athletes engaging in contact sports. And for any athlete who participates in outdoor sports, photosensitivity can be a problem.
“If you’re dealing with someone who has primarily comedonal acne, the newer tretinoin lotion, the newer tazarotene lotion, and the new trifarotene cream are your best bets,” Baldwin said. She added that the average successfully treated acne patient requires two to three medications, making the fixed combination medications a logical next step. “I think that [triple therapy] will make a huge difference,” she said.
Lastly, clascoterone offers a good alternative to oral isotretinoin for treatment of hormonal acne. According to Baumann, “If you have a cystic acne person, it’s hard to get that under control with just topicals.” But for patients with hormonal acne, she recommended a trial of topical clascoterone first, with oral contraceptives as another option for women.
And Mostaghimi’s parting advice to primary care clinicians? “We can do a lot of good for patients with pretty simple and accessible drugs. Don’t be afraid.”
Feeling bad about breakouts isn’t shallow—especially if they’re messing with your quality of life.
Bright red zits between my eyebrows have immediately thrown me into a downward spiral of hopelessness and panic. Dark spots across my chin were the very reasons I wouldn’t let a soul—not even my boyfriend at the time—see me without color-correcting concealer in high school.
As someone who dealt with persistent acne in my teens (and still does, at 25), let me tell you that it controlled my entire life—whether I was ditching school because I was too sad to get out of bed or making a habit of avoiding eye contact with anyone and everyone. If you can relate to any of these experiences, I don’t have to convince you that constantly battling breakouts can do a number on your mental health.
“I also had terrible acne as a teenager, and the impact it made on my life was so significant,” Ife Rodney, MD, board-certified dermatologist and founding director of Eternal Dermatology Aesthetics in Fulton, Maryland, tells SELF. “I was so stressed. It really messed up my self-esteem.”
Breakouts aren’t just a teen issue, of course, but regardless of when—or how—they show up, take it from me and the experts: Their impact isn’t only skin deep.
Here are some of the ways acne can hurt your mental health
It can shatter your confidence.
As a dermatologist, Dr. Rodney says many of her patients with active acne or scarring feel insecure and embarrassed about the way they look.
This self-consciousness can be so intense that you might avoid having your picture taken on your family’s annual beach vacation, for instance. Or, perhaps you have a mini breakdown after examining your hormonal cysts under the unforgiving glow of fluorescent fitting-room lighting. One 2011 study even found that folks with moderate to severe acne were less likely to pursue romantic relationships.
“Worrying about your skin might seem like a superficial concern, which is one reason why many people feel embarrassed opening up about it,” Dr. Rodney says. “But the fact of the matter is, it does affect your quality of life, and for that reason, it should be taken seriously.”
It can cause you to isolate yourself from even your favorite people.
If you’re anything like me, you might be convinced that everyone is zeroing in on those flesh-colored bumps or dimpled, ice-pick scars. So naturally, the solution to escaping any unwanted stares, double takes, or perceived glares of disgust is isolating yourself—which might include canceling plans at the last second or holing up until your skin is magically “better.”
Staying home once or twice isn’t necessarily a warning sign that acne is ruining your life. But if withdrawing during “bad skin days” becomes a habit, that means those stubborn zits are controlling your daily choices and relationships, Shasa Hu, MD, board-certified dermatologist and assistant professor at the University of Miami Miller School of Medicine, tells SELF. Hiding from the world might seem like a harmless way to protect your well-being, but research shows that social support can improve mental health and self-esteem. I also know from experience that connecting with loved ones can make a big difference in how you’re feeling about your skin.
It can make you depressed.
We’re not just talking about one gnarly zit cropping up before a big work presentation and putting you in a crappy mood (though to be clear, that’s miserable too). Sometimes acne can make you feel so overwhelmingly sad that you become clinically depressed.
There’s plenty of evidence that folks with acne are more likely to develop depression compared to those without the condition (two to three times more likely, according to one study). This connection makes sense, since not wanting to be seen or hating the way you look is a heavy emotional burden to bear, and it can make even the simplest tasks (like getting out of bed, taking a shower, or dragging yourself to work) feel impossible, Dr. Hu says.
In extreme cases, some people may also have thoughts of suicide, research shows. “I have a lot of patients come in and say they’ve tried everything—every product, every dermatologist, every prescription medication,” Dr. Rodney adds. “So there can be this feeling of hopelessness when you feel like you’ve tried everything and nothing is working.”
What to do when acne is destroying your mental health
It’s no surprise that treating your acne can help your skin and your mood, and seeing a dermatologist (if you can) is a great place to start. These pros can assess your breakouts, recommend the best over-the-counter and/or prescription treatments, and offer some much-needed peace of mind, Dr. Hu and Dr. Rodney say.
But even if you have research-backed ingredients and highly educated experts on your side, it can still take months—years, even—to figure out what works best for your particular skin and get the results you’re after, both dermatologists note.
There are ways to feel better in the meantime, though—and stepping away from the mirror (especially if it’s a magnifying one) is an excellent first step, according to Dr. Hu. “It’s more harmful to focus on every single pore and black dot,” she says. In other words, zeroing in on your zits can make the issue seem bigger in more ways than one. And whatever you do, try your best to avoid picking at your bumps in an attempt to flatten them or make them go away ASAP. This, Dr. Rodney says, can lead to more inflammation and cause stubborn scars, which will probably make you feel even worse.
And if your acne is getting in the way of your daily functioning—as in, you’re skipping work or regularly experiencing symptoms of depression like hopelessness or irritability—it might be time to find a therapist you click with. These mental health professionals can teach you tools to manage your mood as you work on clearing your complexion.
I know how much it sucks—I really do. But if you’re going to take anything from this article, I hope it’s this: Don’t make the same mistake I did for years and let your acne completely rule your life, if you can help it. Celebrate the small victories (like an annoying nose pimple finally giving in) and, most importantly, try to focus on the things and people that make you so damn happy, you forget about your appearance, even if just for a moment. These little perspective shifts helped me finally feel okay about my skin during the angriest of flare-ups—better than any cleanser or spot treatment could.
In Western medicine, acne is considered a skin condition where the pores of the skin become blocked by hair, sebum, bacteria, and dead skin cells.
Traditional Chinese medicine looks deeper at the root cause of the skin condition: an experienced Chinese traditional medicine practitioner can identify the underlying internal organ issues by looking at the location of the acne.
Acne on the Forehead: Heart Needs Cooling
If you get acne on your forehead, in traditional Chinese medicine, it could be a sign of the heart “having too much heat,” which is due to stress or lack of sleep. Usually, when someone is stressed and can’t sleep at night, acne could show up on their forehead.
Therefore, from the traditional Chinese medicine’s point of view, one would focus on “cooling the heart” to remove acne on the forehead. Relieving stress, adjusting sleep schedule, and staying hydrated are highly recommended.
Lotus seed and lily bulb soup: Place a handful of lotus seeds, lily bulbs, and dried jujubes in enough water to cover the ingredients, bring the water to boil, then simmer for 40 minutes.
The soup can cool the heart, strengthen the yin in the heart, and eliminate the acne on the forehead.
There are two acupuncture points that can be helpful in getting rid of acne on the forehead: the Shen Men point on the wrist and Tai Chong point on the foot. Massaging these points can calm the heart and unblock the liver.
Acne Between Eyebrows
If the acne appears in between the eyebrows, it might have something to do with the heart and lungs. Other symptoms such as heart palpitations and chest tightness might accompany this, or one may find breathing difficult when running. This could be caused by a sedentary lifestyle.
If one does not exercise much, one should not eat salty or heavily seasoned preserved foods, to prevent the body from bloating and to lighten the burden of the heart.
Massaging the Da Ling point and Nei Guan point on the wrist can have a calming effect.
Foods that help people sleep, help nourish the heart and lungs can target the root problem and eliminate the acne between the eyebrows. These include ophiopogon root tuber (maimendong), Chinese asparagus roots (tianmendong), American ginseng, and lotus seeds.
Turnip and two roots soup: First prepare a thick broth with 3 grams of ophiopogon root tuber, 3 grams of Chinese asparagus roots, 5 grams of American ginseng, and boiling water.
Then add your favorite stock, white turnip, 15 dried jujubes, 10 lotus seeds, and the broth into the pot. Put the pot lid on and simmer. Add a little salt before serving.
Acne on and Beneath the Nose: Spleen and Stomach Need Tonification
Traditional Chinese medicine believes that the tip of the nose corresponds to the spleen, while the sides of the nose correspond to the stomach. So if blackheads and pimples show up on the nose, it might be because of the excessive consumption of nuts, fried or BBQ’d foods, and/or spicy foods. These foods put a heavy burden on the spleen and stomach and can cause acne on the nose.
Those with acne on the nose could also suffer from bloating, sour regurgitation, and difficulty with bowel movements. All of these symptoms are caused by the digestive tract having excessive “dampness and heat.”
Massaging the Zu San Li point and Feng Long point on the leg can help rebalance one’s appetite: if someone’s appetite is too strong, massaging these points can decrease their appetite; when someone does not want to eat, massaging these points can increase their appetite. In addition, diarrhea can be treated by warming these two points.
A traditional recipe called “four spirit soup” can nourish the digestive tract. Parents commonly use it to increase a child’s appetite and improve digestion.
Four spirit soup: Prepare equal amounts of Gordon Euryale Seeds (qianshi), lotus seeds, Chinese yams, Poria (fuling), and Job’s tears, boil and simmer them with pork ribs. Add a small amount of Chinese Angelica root (danggui) and rice wine to taste.
Acne on the Left Cheek: Liver Needs Tonification
When looking at the cheeks, there is a saying in traditional Chinese medicine: “Left liver; right lung.” So acne on the left cheek might be related to the liver.
Staying up late at night and alcohol intake can cause liver malfunction, and the symptoms can show up on the left cheek.
According to traditional Chinese medicine, to treat acne on the left cheek, one can massage Gong Sun point and Tai Chong point.
Foods that can cool the liver are mung beans, small cucumbers, and winter melons.
Wolfberry chrysanthemum tea is also very effective. Wolfberries (goji berries) can nourish the liver and moisten the lungs. Chrysanthemum flowers can cleanse the liver, brighten the eyes, and strengthen the gallbladder.
Acne on Right Cheek: the Lungs Need Tonification
Many people with allergic rhinitis have acne on their right cheek. This is because their lungs have too much “heat” or other imbalance.
Massaging the Lie Que point and Chi Ze point can help cool down and moisten the lungs, so as to remove acne on the right cheek.
Foods that are beneficial to the lungs are Job’s tears, wood ear mushrooms, almonds, and pears. They can thus improve the acne.
Honeysuckle flowers can reduce heat and inhibit the action of germs. American ginseng can replenish the energy in the lungs. This tea can moisten the lungs and is also very tasty.
Acne Around the Temples
The temples are related to the gallbladder. If one has acne around their temples, maybe this person has an irregular meal schedule, and they often skip meals, or just have one larger meal per day.
Massaging Tai Chong point, San Yin Jiao point, and Dan Nang point might help with the situation.
A fixed meal schedule also helps. Furthermore, bitter melon juice and winter melon soup can help alleviate the burden of the digestive tract.
Acne Around the Mouth
Acne around the mouth might occur if someone eats too much spicy food, too much meat, and an insufficient amount of vegetables. These people should eat more foods that are high in fiber.
Massaging Zu San Li point and Qu Chi point can help.
People with acne around their mouth can drink a type of tea called Yin Qiao, which consists of honeysuckle flowers, fructus forsythiae (lianqiao), mint, cassia seeds, and jujubes.
The cassia seeds must be fried before consumption. They can help reduce the edema caused by eating heavy and salty/spicy foods. Honeysuckle flowers and fructus forsythiae can clear fever and heat. Mint can regulate digestive functions.
Acne on the Chin: Endocrine System Needs Regulation
In traditional Chinese medicine, the chin corresponds to the genitourinary system. So acne on the chin might indicate an unbalanced endocrine system. Women might experience issues with their ovaries and uterus during monthly menstrual periods. Men might suffer discomfort in the genitourinary system. Resolving these issues first will clear up the acne.
Speaking from his clinical experience, Dr. Dawei Guo, president of the Fu Yuan Chinese Medicine Clinic in Taiwan, said that 80 percent of those who have acne on the chin enjoy eating overly spicy food.
He recommends they eat water spinach and bamboo shoots to encourage intestinal motility and clear the residual feces in the intestines. Men can also eat a lot of tomatoes, which are beneficial for their lower urinary tract.
Massaging the Xue Hai point and Shen Guan point can also help.
They can also drink tea made from honeysuckle flowers, fructus forsythiae, mint, cassia seeds, and jujubes.
We have new insights into the microbial mechanism of acne and how probiotic and bacteriophage therapies could regulate the skin microbiota to maintain healthy skin.
The skin is the largest organ in the body and forms a protective barrier between the inner body and the environment. The skin contains hundreds of microorganisms that are organized into communities and guard against invasion by pathogens.
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Studies have provided evidence of association between the skin microbiota and a range of diseases, the most common of which is acne vulgaris. Acne affects some 80% to 85% of the population. It is most prevalent among adolescents and rarely occurs in those over the age of 50. While not life-threatening, acne often causes pain and scarring and may have considerable psychosocial consequences.
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Acne affects the pilosebaceous unit—commonly referred to as the hair follicle. While its pathogenesis is multifactorial and remains incompletely elucidated, there appears to be a role for the Gram-positive lipophilic anaerobe Propionibacterium acnes. Paradoxically, P. acnes is also believed to contribute to the health of the skin, militating against colonization by opportunistic pathogens by converting sebum into free fatty acids and maintaining an acidic skin pH.
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A recent study by Barnard and colleagues provides new insights into the microbial mechanism of acne.
“Bacteria have been believed to play a role in acne for decades, but the exact role of the skin microbiome, either protective or pathogenic or both, has not been clearly understood,” said Huiying Li, PhD, a co-author of the Barnard study affiliated with the Department of Molecular and Medical Pharmacology at the David Geffen School of Medicine and the UCLA-DOE Institute for Genomics and Proteomics.
Studying the skin microbiota presents can be daunting. “One of the challenges is to understand the role of the skin microbiome in acne (causal for the disease or not),” said Dr. Li. “In our previous study, we showed that some bacterial strains are associated with acne while some are associated with healthy skin,” Dr. Li explained.
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“In our recent study, we were able to identify the genetic elements of the microbiome associated with acne or health and to classify the healthy/diseased state of the skin based on the microbiome profile with a high accuracy,” Dr. Li noted. “This suggests that the skin microbiome may have a role in the disease,” Dr. Li added.Microbiota analysis using the 16S rRNA marker or other phylogenetic markers offers only limited information about the associations between microbial strains and disease. Analysis via metagenomic shotgun sequencing uncovers not only the taxonomy but also the function of the microbiota, thereby offering greater insight into microbial impacts on health or disease. Barnard and colleagues used metagenomic shotgun sequencing to analyze the skin microbiome in people with and without acne. Their objective was to explore which factors determine the overall virulence of the skin microbiota in the presence of coexisting health-associated and disease-associated microorganisms. Ultra-deep magnetic shotgun sequencing found a higher proportion of propionibacteria and Propionibacterium acnes bacteriophage in healthy skin than in skin with acne. In study participants with acne, the composition of the microbiota was more diverse than that in those without acne, particularly at the level of species and of P. acnes strains. Also among those with acne, the study found a richer assortment of factors associated with virulence and a reduced level of metabolic synthesis genes.
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Using the abundance profiles of the metagenomic elements identified in the microbiomes, Barnard and colleagues developed a highly accurate quantitative prediction model with which they were able to classify the clinical states of the skin of participants in both the study cohort and an independent sample of ten additional participants that included 4 people with acne and 6 without, one of whom was over the age of 50. The results of the analysis suggest that the overall virulence of the skin microbiota is determined not by the presence of microbial strains associated with disease alone, but rather by the overall balance of metagenomic elements.
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“Not all bacteria are bad for us,” said Dr. Li. “Some may be pathogenic, but some may be protective and even beneficial to us. Therefore, when treating acne, we should try to preserve the good bacteria while eliminating the bad ones,” Dr. Li noted.
Recent findings regarding the skin microbiota may yield new options for maintaining healthy skin and treating acne and other skin conditions related to microbial populations inhabiting the skin. “There are basically two promising approaches,” said Holger Brüggemann, PhD, of the Department of Biomedicine at Aarhus University in Denmark. “One involves using probiotics to supply health-beneficial microbes to the skin that can restore a health-associated microbiota,” Dr. Brüggemann explained. “The other is to use prebiotics to supply the right environment (nutrients, changing/reducing the lipid content, oxygen availability) so that health-associated microbes have a growth advantage, colonize the skin and outcompete the disease-associated microbiota,” Dr. Brüggemann added.
Acne and rosacea are two seemingly different skin conditions that have one important thing in common: both are chronic and extremely common skin conditions. However, dermatologists recommend that with proper diagnosis, treatment and a healthy dose of good, old-fashioned skin care, acne and rosacea can be less of a nuisance for patients.
Acne and rosacea are two seemingly different skin conditions that have one important thing in common: both are chronic and extremely common skin conditions. However, dermatologists recommend that with proper diagnosis, treatment and a healthy dose of good, old-fashioned skin care, acne and rosacea can be less of a nuisance for patients.
Speaking March 1 at the 68th Annual Meeting of the American Academy of Dermatology (Academy), dermatologist Jenny J. Kim, MD, PhD, FAAD, associate professor of dermatology at the University of California, Los Angeles, (UCLA) David Geffen School of Medicine in Los Angeles, discussed the latest treatments for acne and rosacea and how ongoing research into the causes of these conditions holds promise for future therapies.
“Sometimes it is hard for patients dealing with acne or rosacea to understand why, even with ongoing treatment, they cannot get rid of their symptoms forever,” said Dr. Kim. “I explain to them that these conditions are similar to having any chronic disease, like having diabetes — there is no cure yet, but we can control the symptoms. Just like insulin helps maintain a diabetic’s blood sugar, patients with acne and rosacea need to find a treatment regimen that works for them to maintain clear skin.”
Acne: An Equal-Opportunity Skin Condition
It is estimated that 40 million to 50 million Americans are affected by some form of acne. While acne is commonly associated with teenagers struggling with the growing pains of adolescence, this skin condition can strike at any age. In fact, Dr. Kim emphasized that it affects adults in their 20s, 30s, 40s and even in their 50s, especially in women and even in people who never had acne as teenagers. The causes of acne include excess oil production, skin inflammation, skin cells in the hair follicles that shed too quickly and an increased number of the acne-causing bacteria Propionbacterium acnes. However, hormones also influence both oil production and the shedding of skin cells, thereby contributing to the formation of acne lesions. For example, when androgens (the male hormones present in both men and women) over-stimulate the oil glands and hair follicles in the skin, hormonal acne flares can occur.
In the past, most cases of acne were treated solely with antibiotics. While these treatments can be very successful, a growing concern about long-term antibiotic use is that bacteria are evolving to become resistant to these medications. As a result, the development of other effective therapies and combination therapies has evolved.
For example, Dr. Kim noted that some of the newer therapies for acne are anti-inflammatories, which can be used in some cases to lessen the severity of acne. Controlled-release of lower dose doxycycline is a newer anti-inflammatory oral medication that some dermatologists use to reduce the redness and swelling of acne. Combination therapies, which may include an anti-inflammatory and antimicrobial effects that can decrease resistance and are more convenient to use for patients, has made combination therapeutics increasingly common treatments used to manage acne.
Another newer approach to treating acne is the use of lasers and light-based technologies as a complementary treatment to traditional medical therapies. Dr. Kim noted that these technologies include the pulsed-dye laser, red and blue light, and photodynamic therapy, which target the sebaceous (or oil) glands and can reduce acne flares. While Dr. Kim does not recommend lasers and light-based technologies as first-line therapies for acne, she believes it is a promising new area of research.
“Patients are becoming increasingly concerned about the long-term use of oral medications to fight acne, so lasers and light sources appeal to them,” said Dr. Kim. “The problem is that there are limited large, prospective, well-controlled studies that demonstrate the effectiveness of laser and light technology at this point, so that will be an area we need to explore in the future. It’s very likely that with the advancement in dermatologic research, we will see sebaceous gland targeting lasers in the future that will be effective for the treatment of acne.”
Dr. Kim added that many patients are concerned about scarring that can result from acne, and many acne scars can be very aggressive and difficult to treat. For mild scarring, retinoids, chemical peels, microdermabrasion, and lasers can give mild improvement. In addition, fillers can be used successfully to fill in depressed areas and improve the appearance of scars.
Another therapy that is approved by the Food and Drug Administration (FDA) for acne scarring is fractional laser resurfacing. This laser technology works by targeting damaged skin in columns of microscopic treatment zones, which include the outermost and underlying layers of skin known as the epidermis and the dermis. Fractional laser resurfacing thermally damages the tiny columns of scarred skin while the surrounding healthy skin is left intact.
“One of the main benefits of fractional resurfacing is wound healing and increased collagen production that reduces acne scars,” said Dr. Kim. “However, most patients will notice only a modest improvement in acne scarring and multiple treatments are required. For more severe scarring, such as deep ‘ice pick’ scars, several acne surgical procedures can be used — including punch grafting or punch excision — to remove, raise, fill or separate the scar tissue from the underlying skin. These surgical procedures in combination with other therapies, including lasers and fillers, can produce improvement for severe acne scarring.”
Rosacea Triggers and Treatments
Rosacea, another chronic skin condition, affects an estimated 14 million people in the United States and is characterized by redness, flushing and prominent blood vessels on the face. Dr. Kim explained that rosacea commonly occurs in older people, and there are many known triggers for this bothersome condition — including sunlight, alcohol, spicy foods, caffeine, heat, citric acid, and stress.
While the exact cause of rosacea is not fully understood, Dr. Kim noted that a recent study suggests that the presence of an abnormal peptide (a small protein) in the skin of rosacea patients may contribute to the disease.
“There is some evidence to suggest that the peptide cathelicidin within the skin is processed differently in rosacea patients than in individuals not affected by rosacea and induces inflammation that may contribute to rosacea,” explained Dr. Kim. “These findings are encouraging, as we can identify better treatments for the disease if we have a better understanding of what the cause might be.”
Over the years, lasers have been shown to be effective in treating the symptoms of rosacea. For example, Dr. Kim mentioned that pulsed-dye lasers work well for rosacea patients with lots of broken blood vessels, and both pulsed-dye laser and intense-pulsed light treatments are effective at treating redness on the face and flushing associated with rosacea.
“Patients undergoing laser therapy for rosacea will likely need multiple treatments. However, I have found lasers and light treatments to be very effective and produce long-lasting results,” said Dr. Kim.
In addition to oral treatments, a number of topical medications have been introduced to treat rosacea, and Dr. Kim explained that metronidazole and azeleic acid are two topicals that are tolerated well and effective in reducing the symptoms of rosacea.
Good Skin Care: Good for All
For patients with acne or rosacea whose skin is often sensitive, Dr. Kim emphasized that proper skin care is very important as part of their overall treatment regimen. In addition to avoiding products or behaviors that tend to make acne or rosacea worse, patients may find that gentle skin care can help alleviate some of the redness or irritation common with these conditions.
“I advise my patients to use a mild cleanser and sun protection that is non-irritating to the skin every day, particularly a moisturizer that contains sunscreen,” said Dr. Kim. “While skin care products containing too many acids can be irritating to sensitive skin, I find that products containing salicylic acid are useful for some acne patients. Separating treatments, such as using salicylic acid or benzoyl peroxide in the morning and a retinol-based product at night, might be helpful for patients with sensitive skin.”
Dr. Kim also noted that while over-the-counter products containing salicylic acid or benzoyl peroxide may help control mild acne, patients should avoid using too many products at once on their skin to try to manage acne.
“The old adage ‘less is more’ applies to patients with sensitive skin,” said Dr. Kim. “The best advice is to discuss your skin care regimen with your dermatologist who can recommend products based on not only your specific skin condition, but your individual skin type as well.”
Vitamin B12 – found in many meat and dairy products and taken as a supplement for better brain function and to stave off anaemia – appears to alter the genetic make-up of facial bacteria, promoting rapid inflammation that’s been linked to the formation of pimples, researchers in the US have reported.
As many poor souls are well aware, acne isn’t just for teenagers. In fact, it affects most of us at some point in our lives, with an estimated 80 percent of people between the ages of 11 and 30 around the world experiencing a breakout at some point. The unluckiest of us will have to deal with the unsightly lumps and bumps well into our forties and fifties, and the worst part is that despite being an incredibly common affliction, scientists don’t actually know much about what causes acne and how to prevent or treat it.
To investigate, Huiying Li, a molecular pharmacologist at the University of California-Los Angeles, and her team decided to focus on high levels of B12 as a possible culprit, based on research from the past six decades that’s linked it to higher instances of the condition. “It has been reported several times that people who take B12 develop acne,” she told Arielle Duhaime-Ross at The Verge.
The first thing they did was identify the molecular pathway that produces vitamin B12 in the skin bacterium Propionibacterium acnes, and compared it in people with good skin, and people with acne-prone skin. They found that the vitamin B12 biosynthesis pathway in P. acnes was significantly down-regulated in the acne patients as compared to the patients with healthy skin.
Next, they wanted to test the effects of an increased intake of B12 from eternal sources on the levels of naturally produced B12 in these skin bacteria. They gathered 10 volunteers with clear, healthy skin, and asked them to receive a vitamin B12 injection.
As Jennifer Abbasi reports at LiveScience, “The researchers confirmed that the B12 supplement repressed the expression of genes in P. acnes involved in synthesising the vitamin. In fact, the expression of those genes was lowered to levels similar to those of acne patients.”
So it looks like by intaking extra vitamin B12, we could be prompting the bacteria in our skin to slow down on their production of it, which leads to an imbalance that could heighten our risk of developing acne.
According to the paper, which was published in Science Translational Medicine, one of the clear-skinned participants ending up developing acne one week after recieving the vitamin B12 injection. When Li and her team examined the gene-expression in their P. acnes bacteria, they found that it had gone from looking like that of the other clear-skinned participants to that of their acne-affected volunteers 14 days after the injection.
The team followed up the finding by performing lab tests in which vitamin B12 was added to P. acnes bacteria. The bacteria responded by producing compounds called porphyrins, LiveScience reports, which are known to promote the kind of inflammation that previous research has linked to the appearance of severe acne.
“It’s exciting that we found that the potential link between B12 and acne is through the skin bacteria,” Li told Duhaime-Ross at The Verge.
Now, before you decide to stop taking supplements and cut down on anything rich in vitamin B12, such as fish, meat, poultry, eggs, and milk – you know, all the delicious things – remember that this is a small study, and there’s not a whole lot to go on yet, except that vitamin B12 looks like an intriguing candidate for further research.
We really hope another team of researchers picks up on this research and runs with it though, because imgaine how awesome it would be to have a pimple cream that doesn’t cost a fortune and actually works, or a daily treatment that actually prevents acne from appearing that doesn’t burn your face off. We want that.
In Chinese Medicine, it’s believed that acne that flares up on different parts of your face represents health problems on different parts of your body. For example acne on your upper cheeks is a response to stress in your lungs or respiratory system. Smoking is but one of these causes (read on for more). Therefore a good indication of which organs need attention and care is to simply look where your acne is.
UPPER FOREHEAD
Digestive System and Bladder
Drink plenty of water to flush, keep an eye on your diet, eliminate greasy foods and refined sugars. If you’re craving deep fried fatty foods, eat avocado or add a tablespoon of coconut oil to your dish. Make sure you consume plenty of fresh organic fruits and vegetables. Some of the best antioxidant rich foods or drinks include green tea, warm lemon water, and fresh berries. If your diet is not rich in naturally fermented foods such as kimchi, sauerkraut, kombucha, or kefir, consider supplementing with a probiotic capsule daily. Most health food stores carry probiotic capsules.
LOWER FOREHEAD
Heart
Your heart is a massive organ that pumps blood through your entire body. It has a tough job and can become easily stressed due to poor diet, inactivity, and various mental and physical stresses. If you have pimples on your lower forehead make it a point to do regular cardiovascular exercises. Eating pomegranate and coconut oil will also keep your heart healthy and help clear this up.
EARS
Kidneys
When kidneys are not taken care of, you may find large, painful pimples on your ears that just won’t go away. Kidney troubles are often caused by not drinking enough water and eating too much sodium.
This is as good of a time as any to point out that vendors such as Subway, who tout their products as being “healthy” have an excessive amount of sodium added to almost everything on the menu. The next time that you take a look at their nutrition claims with highlighted low-fat content, take a minute to focus on the sodium column. In addition Subway adds genetically modified soy to nearly all of their foods. If you want healthy kidneys it’s best to avoid fast food in general, even the “healthy” restaurants, drink more water, and eat more parsley which is an excellent detoxifier.
EYES, ORBITAL AREA AND BETWEEN THE EYEBROWS
Liver
Oiliness, redness, flakiness and pimples between the eyebrows can indicate that your liver may have been overworked and in dire need of a cleansing. Cut back on greasy foods loaded with vegetable, soy, and canola oil, alcohol and pasteurized dairy (or dairy altogether). Avoid eating late at night as well. If you’re craving a late snack take a spoonful of raw honey. This will let your liver rest while you’re sleeping. Eat more of these during the daytime to cleanse the liver (always choose organic root vegetables):
-garlic
-grapefruit
-green tea
-carrots
-beets
-leafy green vegetables
-lemons and limes.
UPPER CHEEKS
Lungs and Respiratory System
Stresses to the lungs are likely to cause flare ups in the upper cheeks and even break your capillaries. Even if you’re not a smoker you may have noticed an upper cheek breakout due to:
-asthma
-allergies
-lung infections
-living in a polluted area.
The best thing to do is to avoid smoking and second hand smoke.
LOWER CHEEKS
Gum or Teeth Problems
Gum or teeth problems may contribute to acne in the lower cheek area. Be sure to avoid eating refined sugar and soft drinks. Oil pulling is a great habit to take up if you’re experiencing any type of gum or teeth problems. It’s also a good idea to eat plenty of fresh fiber rich fruits and vegetables to strengthen your teeth and gums from chewing honest natural foods.
SIDES OF THE CHIN
Hormones and Genitals
This especially affects women. Flare ups on the sides of the chin are a good indication of hormonal imbalance. This can be due to menstruation, birth control, or a diet high in soy. Sometimes, even emotional or physical stress can cause hormonal imbalances. Get plenty of sleep and make a habit of meditating or doing yoga to keep the mind focused and stress-free. Be sure to take lots of essential fatty acids such as Omega 3s. Follow this link for a list of foods rich in Omega-3s.
Some herbs that can help balance hormones include:
-licorice
-schisandra
-holy basil
-maca
-burdock
-red raspberry leaves
-rhodiola
-milk thisle.
-Green tea is also a brilliant anti-androgen.
CENTER OF THE CHIN
Small intestine and stomach
This is typically caused by a poor diet and food allergies. If your diet is adequate you simply may not be digesting the nutrients you put into it. We were always told that we are what we eat, which is true to an extent. More accurately however, we are what we can digest. If your gut is lacking probiotics and completely out of balance from not eating naturally fermented foods or taking probiotic capsules, it won’t matter how much good wholesome food you’re eating. The nutrients will simply pass right through you. Refer to the upper forehead section to learn more about what to eat to get your gut working properly.
Additionally stress, lack of sleep, and dehydration can wreak havoc on your stomach and small intestine. Getting a good nights sleep, drinking plenty of water, and addressing your stress by making lifestyle changes and practicing yoga/meditation are great non-dietary ways to address your chin acne.
The risk for attempted suicide increases during and after treatment with isotretinoin (Accutane) in patients with severe acne, according to a retrospective study in BMJ.
Swedish researchers assessed suicide attempts requiring hospitalization in nearly 5800 patients with severe acne who were prescribed isotretinoin. Within 6 months after treatment started, patients had an increased risk for first suicide attempt and for all attempts, compared with the general population. Within 3 years after treatment, suicide attempts returned to the background rate.
The authors point to a gradually increasing suicide risk in the 3 years before treatment. They write: “We cannot exclude the possibility that the raised risk of suicide attempts during treatment and six months after treatment is due to the exposure to isotretinoin. However, a more probable interpretation is that the underlying severe acne may best explain the raised risk.”
Editorialists recommend that primary care physicians monitor all patients with severe acne for suicidal intent before, during, and after treatment.
The risk for attempted suicide increases during and after treatment with isotretinoin (Accutane) in patients with severe acne, according to a retrospective study in BMJ.
Swedish researchers assessed suicide attempts requiring hospitalization in nearly 5800 patients with severe acne who were prescribed isotretinoin. Within 6 months after treatment started, patients had an increased risk for first suicide attempt and for all attempts, compared with the general population. Within 3 years after treatment, suicide attempts returned to the background rate.
The authors point to a gradually increasing suicide risk in the 3 years before treatment. They write: “We cannot exclude the possibility that the raised risk of suicide attempts during treatment and six months after treatment is due to the exposure to isotretinoin. However, a more probable interpretation is that the underlying severe acne may best explain the raised risk.”
Editorialists recommend that primary care physicians monitor all patients with severe acne for suicidal intent before, during, and after treatment.
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