Acne: It's Causes and Treatments
By: James E. Fulton, Jr., M.D., Ph.D.

INTERNATIONAL JOURNAL OF COSMETIC SURGERY and AESTHETIC DERMATOLOGY
Volume 4, Number 2, 2002
© Mary Ann Liebert, Inc.

Sections:
• ABSTRACT
• CAUSES
• LET'S BURY THE MYTHS
• ACNE AGGRAVATING FACTORS
• OLD TREATMENTS
• NEWER TREATMENTS
• HOW WE REALLY DO IT
• ACNE SCARS
• FIGURES
• REFERENCES

ABSTRACT
By understanding the pathogenesis and treatment of acne it is possible to devise a topical skin care program using a benzoyl peroxide cleanser to kill the Corynebacterium acnes, a Normalizing Tonic containing glycolic acid to dissolve the attachments between skin cells, and vitamin A gels to generate new cells that do not adhere and sludge up the pores. Usually in 2 to 4 weeks the condition is improved, and in 8 to 12 weeks the complexion is clear. Medical facials are combined with the skin care program to extract lesions as they migrate to the surface. An occasional severe patient will also receive systemic isotretinoin for 20 weeks. If they have facial scarring a laser-assisted chemabrasion completes their rejuvenation. With this combination it is possible to improve acne health care.

Background
Acne is a chronic disease of the sebaceous follicles. You can have acne three times in your life - once as a neonate, once as a teenager or young adult, and again following sun damage as an older person. Acne is basically genetic. If it runs in your family, three out of four children may have a problem. There are many aggravating factors but it is a genetic problem brought on by hormones. Neonatal acne can begin at birth from the mother's hormones, especially in the male infants because of the testosterone produced by the male testes. After birth there is a rapid reduction in the maternal hormones and, consequently, the level of testosterone. So, the acne that develops right after birth on the center of the face migrates in a typical fashion across the cheeks and onto the jaw line but usually disappears by six months of age. The problem will only return during the teenage years, especially in males. Although the female children may have a similar problem theirs is usually less severe but tends to be more chronic. Just as with the neonates, teenage acne begins on the center of the face at ten years of age where the sebaceous glands mature first, producing more oil. Then, the acne migrates out onto the cheeks at 15 years of age and across to the jaw line at 18 years of age as more testosterone circulates and these glands mature. Finally, acne burns out below the jaw line around age 23 as there are no more sebaceous follicles in this area.

Those of us with an acne background have a predisposition for the dead cells of the follicular lining to sludge up and impact. These impactions become larger and larger, developing into visible closed comedones. During this evolutionary process a few of these become inflammatory and develop into papules, pustules and scars. Older treatments such as dietary restrictions, sunlight and systemic antibiotics have only been of limited benefit. The modern therapies usually consist of an aggressive topical skin care regimen consisting of vitamin A and glycolic acid conditioning lotions. If the complexion does not respond to this daily treatment, medical facials and isotretinoin may be added to the regimen. If the patient completes their 20 week therapeutic program of isotretinoin there is a possibility of a permanent cure. However, many patients come to us too late and have facial scarring. Now we use the laser-assisted chemabrasion to smooth out this complexion. However, it is more useful to start the skin care program early and avoid both the physical and mental scarring.

CAUSES
Acne is genetic. If it runs in your family and both parents are afflicted, three out of four of the children may have the complexion problem. It is inherited as an autosomal dominant gene. We believe the gene came from a Mediterranean pool and was spread around the world by the early Spanish adventurers. When the Spanish came into the Philippines and intermarried, acne became an epidemic problem in the islands. When the Spanish Conquistadors went to Mexico they penetrated Mexico City and left the cystic acne problem. Further off in the country where there are more Indians there is less acne. This Spanish or Mediterranean gene is particularly troublesome as it leads to the type IV cystic acne.

Although acne was originally believed to be related to the level of oil or sebum production in the skin or the level of bacteria in the pores of the skin, these turned out only to be aggravating factors. A certain level of oil production is necessary to support the colonization of the pore by the bacteria, called Corynebacterium acnes. These bacteria live off the triglyceride in oil, producing free fatty acids as a byproduct and using the glycerol from the triglyceride as carbon source. The free fatty acids aggravate the lining of the pore and in genetically predisposed individuals the cells that line the pore begin to sludge up, stick and develop microimpactions. These finally become visible as open and closed comedones. Or, if there is an inflammation attacking the follicle these lesions develop into inflamed papules or pustules. If several of the papules erupt together or become quite inflammatory they appear as nodules or cystic acne (Fig. 1). The dermatologists have separated this phenomenon into Grade I, blackheads and open comedones; Grade II, whiteheads or closed comedones; Grade III, inflammatory papules or pustules; or Grade IV, cystic inflammatory acne (Figs. 2-5). Not only is acne inherited but the type of acne and the location on the face, back or chest is also genetically predisposed. For example, if mother only had acne of the back, usually the children will have the same pattern.

Although the level of oil or sebum production is important it is not an absolute causative factor. There are many people with oily skin without acne and some with rather dry complexions with severe acne. However, the oil does provide the nutrients for the bacteria. As these bacteria populate the pore they produce free fatty acids and glycerol. The free fatty acids irritate the pore lining. However, there are other components of sebum such as the wax esters, which are irritating to the pore and also lead to the impaction of the pores. This process of cellular impactions has been nicknamed retention hyperkeratosis by Dr. Albert M. Kligman (1). The epithelium that lines these pores produces cells at a rapid rate and the cells stick together, almost like a cancer.

These bacteria in the skin maintain the "acid mantle" of skin. They excrete a lipase that splits the triglyceride into fatty acids and glycerol. They use the glycerol as carbon source. The lipase operates down to pH 5.2. After that the lipase is inactive (2). This explains why the pH of skin on the face is 5.2. This pH barrier protects the skin from other bacteria such as streptococci and staphylococci. In healthy skin they cannot enter into the bacteria flora of the pore. However, the use of systemic antibiotics such as tetracycline or topical hexachlorophene soap such as Phisohex® soap, or the combination of the two can destroy this normal relationship and lead to peculiar gram-negative bacterial infections or the gram-positive folliculitis from the streptococci and staphylococci.

As mentioned, acne begins on the nose. As these are the pores that are the most susceptible to testosterone they mature first. The acne process destroys these pores and as other pores mature on the cheek and jaw line these pores that are genetically defective become impacted and are then destroyed. So, acne comes across the face like a fire and then burns out (Fig. 6). Once the fire has reached approximately one inch below the jaw line it stops because the pores on the neck are not susceptible to testosterone. However, acne can jump onto the back and chest and be a problem for those pores down to the belt line and occasionally across the buttocks.

In summary, acne is genetic and runs in certain families. The treatment is best done topically to prevent the cells from sludging up and becoming impacted. Treatments which attack the secondary problems of acne such as the oil production with birth control pills or the bacteria with systemic antibiotics only lead to temporary marginal improvement. Acne is more complex than simply the fatty acids or the bacteria populations

LET'S BURY THE MYTHS

Dirty Skin
One of the most common myths is that acne is related to dirty skin. The comedones, as they cone to the surface and dilate the pore, develop into open lesions that become black. They darken for two reasons: (a) the oxidation of the oil, and (b) the build-up of the melanin from the melanocytes that live in the orifice of the pore. These are deep-rooted impactions that cannot be simply washed away.

The acne is coming up from below and is not related to dirty skin. Even if you wash your face 20 times a day you cannot remove these impacted pores easily. The only cleanser that is useful is a benzoyl peroxide scrub cleanser. The benzoyl peroxide diffuses down into the pore, kills the bacteria and additionally irritates the cells of the pore so they will no longer stick. This treatment program can be combined with alpha hydroxyacid conditioning lotions and vitamin A gels to loosen up the impacted pores. In summary, the problem is not due to dirty skin or hair on the forehead.

Dietary Factors
Another favorite myth is the dietary factors. Doctors at the University of Pennsylvania fed 50 teenagers a pound of chocolate a day (3). Two got better, two got worse and the rest stayed the same. Ever since then the dietary factors have not been discussed as a major event. Basically, acne is genetic and it doesn't make a lot of difference what you eat. The one exception is dietary iodides (4). Excessive iodides are excreted out through the oil gland and may flare up the acne impactions. Experimentally, when acne sufferers ingest a saturated solution of potassium iodine (15 drops twice a day) they will secrete iodide into the hair oil in about 10 days and their existing acne impactions will flare up in about 2 weeks.

This excessive iodide becomes important in three scenarios: (a) Dietary supplements such as mineral and vitamin pills that contain elemental iodide. Excessive doses can be excreted out through the oil glands and flare up acne. (b) Some diet programs emphasize seaweed. Some cults sprinkle dried seaweed on all of their food. Certain seaweeds concentrate iodide. This heavy load of iodide can be excreted out through the oil glands and irritate the follicles. (c) Some drinking water is high in iodide and can aggravate the problem. This is especially true in island cultures where the water is desalinated and then some seawater is added back into the water to make it a little tastier. This combination may have a high iodide level that can lead to acne flare-ups. However, the usual dietary intake from fish or continental water is not enough to aggravate the complexion in most individuals.

Sexual Frustrations
The community often feels that acne is aggravated by sexual frustrations. This is related to couples becoming married around age 22. The acne often soon disappears. However, it is not related to the marriage, it is just that acne tends to burn out around age 23. However, the marriage scenario can also aggravate acne as, in the case of the female, the use of birth control pills can aggravate acne during the first several months of use. This may be an aggravating problem during the early months of marriage.

In conclusion, these myths often have a grain of truth - for example, hair on the forehead may contain hair conditioners aggravating acne, or dietary factors such as iodide may be important, or the flare up of acne from birth control pills is possible. However, it is important to bury these myths and realize that acne is basically genetic, runs in certain families, and the treatment usually can be done with a topical skin care program.

ACNE AGGRAVATING FACTORS

Stress
One of the key aggravating factors is stress. There are two types of stress involved. The acute stress of exams coming up causing existing impactions to break down, becoming inflammatory and developing red nodules and pustules. These are existing comedones that flare up. With an aggressive skin care program and removal of all the impactions the flare-ups will disappear.

Chronic stress is more difficult to manage. An impending divorce or loss of a family member, for example, may lead to chronic stress. This increases the hormone levels and causes more oil to be produced, more cells to impact and aggravate the complexion problems in genetically predisposed individuals. These stress problems are usually red, inflammatory nodules of the chin and respond to ice compresses, topical skin care programs and removal of the stress. Sometimes low doses of a steroid such as prednisone (5 mg) are needed to reduce this stress-hormone cycle.

Hormones, Birth Control Pills
Usually during a pregnancy the acne is aggravated in the first trimester, improved in the last trimester and then flares again 90 days after birth. The same thing happens with birth control pills. During the first two or three months the acne may get worse. After six months however, the complexion may be improved. However, it is a double-edged sword because five years later, or whenever the birth control pills are discontinued, the acne may flare up again, similar to the flare-ups seen 90 days after a pregnancy. We do not rely on birth control pills as our main therapeutic regimen as a topical skin care program is effective, especially when combined with synthetic isotretinoin. Some birth control pills are more aggravating than others. The high progestin pills such as Ovral® and Lo Ovral® may flare up acne severely. The more estrogen dominant pills such as Ortho-Novum®, Demulen® and Ortho-tricyclen® are friendlier and usually improve acne until they are discontinued.

Cosmetics
Your favorite cosmetic could be destroying your skin. Cosmetics may contain irritating oils such as your own skin oils. The big offenders are isopropyl myristate, acetylated lanolin and certain D&C red dyes. The isopropyl myristate is put into cosmetics and skin care products as an emulsifier. It is a cousin of the fatty acids found in your own skin. The myristic acid is a C-14 fatty acid (14 carbon segments long) and when it is hooked to isopropyl (3 carbon lengths long) it becomes isopropyl myristate. It is more soluble and can go down into the pore to cause a problem. Lanolins by themselves are too thick to be much of a difficulty. However, the cosmetic chemists like to make lanolins more water-soluble by adding acetate, making acetylated lanolin. These more water-soluble lanolins can penetrate the pore and cause an aggravation. Certain D&C red dyes are coal tar derivatives and when solubilized in cream rouges can penetrate into the pore and cause comedonal type II acne in the cheek area where the rouge is applied. It is best to use a water-based makeup or pressed powder that doesn't contain these aggravating factors.

Heat and Humidity
Heat and humidity can swell the stratum corneum 300%. This can block the pore and lead to aggravations in certain climates. Acne seems to do better in a dry climate such as the mountains of Colorado and be worse in the heat, humidity and wet climates such as New Orleans. This can also be important if a person gets a daily steam in a spa. The steam can swell the pore and cause a flare-up. If there is an option a cool dry climate is more therapeutic. If there is not an option the skin care program must be more aggressive.

Iodides
Most dietary factors are insignificant. However, the excessive ingestion of iodides for therapeutic uses such as saturated solution of potassium iodide (15 drops twice a day) for bronchitis, or sprinkling kelp onto food as a religious program, or taking excessive health food vitamins that contain iodide can cause flare-ups of the complexion. Certain drinking waters also contain excessive iodide and should be avoided.

Drugs
Some drugs flare up the acne problem. The most significant are some drugs that affect the brain. These seem to increase the oil production. The classic example is Dilantin®. When Dilantin is taken the collagenase in the body is inhibited and collagen builds up. The gums become hypertrophied, the face swells up and the pores become blocked. Some patients can be taken off Dilantin and not have difficulty with epilepsy. This will improve their complexion. Others need to maintain the Dilantin, maybe at a decreased dose, and speed up their skin care program.

Another drug that causes difficulties is lithium or adamosis. It affects the brain and causes an acne flare-up. The exact mechanisms are unclear except these drugs that affect the brain's metabolism can be potential acne aggravators.

Other drugs such as fluorinated steroids can sensitize the pores to acne. The chronic use of prednisone for inflammatory conditions can lead to the development of the moon face, a buffalo hump and an acne flare-up. These should be limited as much as possible. Topical steroids can also aggravate the complexion and should be avoided in those individuals who are acne prone.

Sunlight
Some complexions are better in the sunlight, some are worse. There is a condition in Europe called Majorca acne, named after the island of Majorca. The Germans and the English go down to the island for a couple of weeks and have intensive sun exposure. When they return to their homeland they break out with inflammatory papules and nodules, usually of the chest and back area. The sunlight irritates the pores similar to the fatty acids and causes a flare-up in some individuals. A good exfoliating skin care program that peels the skin will release these impactions and clear up the problem.

Fingernails
Fingernails are a key problem in some individuals. Some people have minor acne and a habit of picking. Almost everybody picks but some people pick pathologically. When they begin to feel "worms" or "mites" in the skin they are beyond the realm of the usual picker. We recommend ice compresses to reduce the inflammation and no fingernails. Some patients need to break this obsessive-compulsive cycle. We recommend Paxol®. The fingernails can also carry bacteria and cause infections such as impetigo. We authorize "controlled" picking after we have explained to the patient how to do the acne extractions. If they live a far distance from the medical office they can learn how to very gently do their own extractions after the skin care program has loosened up the impactions.

Hormones
The main aggravating factor continues to be their own hormones. There is no good control for the oil production except isotretinoin, which will temporarily reduce the oil level. Interestingly enough, after isotretinoin is discontinued the oil production may go back up but the acne complexion may stay clear. Of course, one therapeutic approach to oil control is castration of the testes but there are not too many volunteers for this program. Extra hormones should be avoided such as dehydroepiandrosterone (DHEA).

OLD TREATMENTS
Over the years many treatments have been tried for acne. In the 1940s the new synthetic vitamin A was the rage; however the usual dose of oral vitamin A to control acne was several hundred thousand units. This chronic use led to vitamin A toxicity which consisted of hair loss, headaches, arthralgias and depression. The program never became very useful. When Kligman, Plewig and Fulton developed vitamin A acid it was a topical alternative which did not cause toxicity and became a major therapeutic breakthrough (5). More recently the use of a synthetic modified molecule of vitamin A called isotretinoin has become popular as a systemic treatment. This compound is effective in reducing the oil production. It can be taken 4 or 5 months on a safe basis. There are still the same side effects of vitamin A such as hair loss, migraine headaches, dry skin, arthralgias, depression and birth defects. However, isotretinoin is quite useful if the patient is having chronic severe cystic acne with the development of lifelong scarring.

Tetracycline
Tetracycline became a major treatment agent in the 1950s and 1960s. The ingestion of tetracycline would diffuse into the pore and inhibit the Corynebacterium acnes. However, this antibiotic only inhibited about 50% of the bacteria and reduced the fatty acids about 50%. The remaining residual bacteria, fatty acids and other components of sebum were enough to continue on with the acne problem in most patients. In a few patients the results from the tetracycline was really dramatic but in most it was hardly better than a placebo.

One lipid soluble tetracycline called minocycline still remains popular today. This is the one antibiotic that occasionally does help in pustular acne. However, by the time the patients come to our medical office they have often received several tetracyclines including minocycline, so we have found the topical skin care program more effective. However, if the patient comes in on minocycline and feels they are improved we will leave them on the antibiotic for several weeks until the topical skin care program takes hold.

Birth Control Pills
Pochi (5) developed the use of birth control pills for acne treatment. The high level of estrogen decreased the production of testosterone in the female patients. The acne improved. Lower doses of estrogen are used today (Demulen®, Ortho Novum 777®, Ortho Tri-Cyclen®). The acne is often improved after several months of use. However, the acne often returns when the hormone therapy is discontinued. We prefer a topical treatment program combined with isotretinoin, if needed.

Acne Facials
Acne facials and extractions have always been popular in the dermatologist and esthetician office. This, combined with a good skin care program that releases the acne impactions and makes the extractions easy, can be therapeutic. However, if no topical treatment is being done and the acne impactions are very tight the lesion can be forced deeper and cause a flare-up of inflammatory acne. Thus, it is necessary to use a topical treatment first and extract later. Many of our patients live a long way from the office and we teach them authorized extraction and how to remove these lesions gently. Extraction continues to be an effective treatment when combined with the skin care program.

X-Ray Treatment
In the early 1900s x-ray treatments became a mainstay. The early machines were not well calibrated and the acne patient often received a burn from the x-ray. Unfortunately, later in life this led to the development of thyroid nodules or epilepsy. Unfortunately, the treatment did not work and the acne continued on. This treatment is no longer in vogue today

NEWER TREATMENTS

Vitamin A Acid
1969, doctors at the University of Pennsylvania developed vitamin A acid for the topical treatment of acne (6). This therapeutic agent was commercialized by Johnson & Johnson and became tretinoin or Retin-A®. It was a major breakthrough in the topical treatment of acne. No topical treatments had really been effective to that point. The use of vitamin A caused the skin to peel and this released the acne impactions. Sometimes the acne would get worse before it got better as the pores were evacuated. It was helpful to combine this treatment with effective acne facials or extractions to remove the impactions once they had been loosened up.

Benzoyl Peroxide
In 1972 doctors at the University of Miami developed the gels of benzoyl peroxide (6). The benzoyl molecule pulled the peroxide into the pore where it released free radical oxygen that killed the bacteria and opened up the acne impactions. This has become a mainstay of treatment not only in the doctor's office but also in the esthetician office and in the drug store. The combination of vitamin A in the morning and benzoyl peroxide at night became the main active therapeutic program. This cleared the complexion in about 2 months. The birth of an effective topical treatment was accomplished.

Alpha Hydroxyacids
Van Scott's development of the alpha hydroxyacids paralleled Kligman, Fulton and Plewig's development of tretinoin (8). The alpha hydroxyacids such as glycolic acid or lactic acid worked differently. They dissolved the attachment plaques between cells and caused the dead cells to fall off rapidly. This generated new skin cells from below that did not stick. The combination of benzoyl peroxide scrub cleanser in the morning, followed with an alpha hydroxyacid lotion, and later on the application of a vitamin A gel is currently the treatment of choice for our topical therapy for acne.

Isotretinoin (Accutane®)
In 1979 isotretinoin became available for the systemic use in the treatment of acne (9). When ingested orally over a 5 month period the oil glands shrunk, the oil sebum level fell and the acne cleared up. Interestingly, the acne stayed clear on many individuals after the drug use was discontinued and the oil production resumed. The reason for this is unknown. Accutane® is still a major treatment for severe cystic acne. Patients must read, understand and sign a detailed informed consent form before starting therapy.

HOW WE REALLY DO IT

We take photographs of the patient and determine if they have dry or oily skin. We count all the lesions on the face to document the complexion problem. Then, we customize the skin care program for the patient depending on whether they have dry or oily skin and also whether they live in a dry or wet humid climate. If they have dry skin and live in a dry climate they will use the Acne Kit I which contains benzoyl peroxide cleanser. The peroxide penetrates down into the pore and kills the bacteria. After that they will use ice compresses to reduce the redness and swelling and open up the skin to let the topical treatments penetrate. Then they will apply the glycolic acid lotion using a cotton ball to strip off all the dead skin cells. These alpha hydroxyacids dissolve the attachment plaques between the cells. Finally, they will apply their vitamin A conditioning lotion which is a vitamin A proprionate formula (10). The short chain proprionate on the vitamin A is metabolized off as it penetrates through the skin. The molecule is converted to vitamin A acid. They will repeat the same program in the evening.

If they have oily skin we will increase the strength of their products to the stronger formulations. They will use the benzoyl peroxide cleanser with granules to strip off the dead skin cells and open up the acne impactions. After the ice compresses they will apply a stronger formulation of the alpha hydroxyacids. They will then apply a vitamin A conditioning lotion which also contains alpha hydroxyacids. When these two compounds are combined they produce a formulation that is more potent than either one alone. Again, they will repeat the application at night.

Quite often after 7 to 10 days the patients will develop an irritating dry rash, called retinoid dermatitis. This is a common problem that develops as the patient adheres to the regimen. Once their skin is hardened or acclimated to the formulations they can continue on without excessive dryness. We often recommend they skip a day or two around day 7, 8 or 9 and apply a non-acneogenic moisturizer. After they have been on the regimen for 4 to 6 weeks the acne impactions will begin coming to the surface and exfoliating spontaneously or can be easily extracted during a medical facial. The patients will continue on the products, increasing their application, if necessary, to maintain a slight peel. If their acne clears, fine. If they still have a tendency for cystic acne we will then consider isotretinoin (approximately one milligram per kilogram of body weight taken daily for 20 weeks). Sometimes it is necessary to reduce their topical skin care products while using isotretinoin because of the dryness from the systemic vitamin A. Later on, after the isotretinoin, they will continue with their skin care program to maintain their clear complexion.

Medical Facials
Every 2 weeks the patients will have a medical facial to extract the acne lesions and have a closed circuit microdermabrasion which uses aluminum oxide crystals to abrade the skin and open up the acne impactions (Megapeel®, DermaMed, Inc., Lenni, PA). The use of this microdermabrasion has benefited our patients to loosen up the acne impactions and make the extractions easier.

Usually by 8 to 10 weeks the complexion is clear. The patients will then continue on their products as needed to keep a clear complexion (Figs. 8-11)

ACNE SCARS
Some patients come to us too late -- they already have facial scarring. Acne, by itself, dissolves the tissue by activating the skin and leukocyte collagenase. The collagenase dissolves the collagen and as the lesion heals a depression develops. The only effective method to remove these is diamond disc abrasion. Now, we combine this sanding with the CO2 laser resurfacing. We do a chemical peel of the neck, laser of the face and, then, do the dermasanding with the extra coarse diamond fraise after the laser resurfacing. The key to our success is the use of an occlusive dressing for 5 days following the procedure (Silon TSR®, Biomed Sciences, Bethlehem, PA). After 5 days of this silicone gel sheeting dressing they are switched to an emollient moisturizing formula (GlucanPro®, Brennen Medical, St. Paul, MN) for another 5 days. Finally, after 10 days they begin to use their moisturizers with sunscreen, and at day 17 or 18 they will begin using their bleaching cream regimen if they are darkly complexioned. Usually by 2 months their skin is able to tolerate the acne control regimen again (Figs. 12-13).

FIGURES
Figure 1. Histology of Acne. Acne can take 2 pathways: the non-inflammatory pathway where the microimpaction develops into a closed comedone/open comedone, or the inflammatory pathway where the impacted pore breaks down. This is the stimulus for the white blood cells to come in from the blood vessels and attempt to digest the acne impaction. However, the body does not have enzymes to dissolve the keratin but uses collagenase instead to digest the surrounding dermis. The lesion is then exfoliated but unfortunately leaves a scar to fill the void after the collagen has been lost. The key for control is the abrasive skin care program to prevent the cells from sticking and developing retention hyperkeratosis.

Figure 2. Acne Grade I. The development of open comedones in a teenager is a good prognosis. It means that their pores are handling the problem rather well and have a chance to mature, dilate and develop into open comedones. However, if this is in a younger teenager and the older brother has cystic acne it may be a sign of more severe acne to come in the future.

Figure 3. Acne Grade II. The most difficult type of acne to treat is the myriad of closed comedones that develop in Acne Grade II type. There are often 300 of these impacted pores on the face. They need a very irritating skin care program by using glycolic acid and vitamin A skin conditioners, and a thorough medical facial with expert extractions to get out these closed comedones.

Figure 4. Acne Grade III. These are the inflammatory papules and pustules. These patients have pores that have poor resistance to the acne problem. These pores break down rapidly before they develop into mature open and closed comedones. Small microcomedones break down rapidly and cause an intense inflammatory response. This may lead to scarring.

Figure 5. Acne Grade IV. When the lesions become larger it is called nodular or cystic acne. The patient may have a background of Grade I, Grade II or Grade III acne but then develop these types of cysts. These patients are the more inflammatory patients that can develop severe scarring. The key is to put them on a good skin car program, improve their acne and then switch them, if needed, to isotretinoin.

Figure 6. The Wave. Acne comes across the face like a wave. The pores on the nose mature first around age 10, then the condition progresses across the face to end up at the angle of the jaw in their 20s.

Figure 7. Microdermabrasion. Exfoliation of the face with micro crystals loosens the acne impactions and facilitates the acne control program. The Megapeel system is a closed loop design so the abrasive crystals are recaptured in the reservoir.

Figures 8-9. Before and after the daily use of the skin care regimen. This patient was diligent and used the benzoyl peroxide scrub cleanser, ice compresses, the glycolic acid tonic, followed with the vitamin A conditioning lotion. Within 2 weeks the complexion was improved and it was clear in 8 weeks. The patient then continued on the program to maintain remission.

Figures 10-11. This patient had Grade III acne. She applied the acne control regimen diligently and cleared up her complexion. Note there were a few scars before the treatment that became more visible after the clearing. Make sure you mention this to the patient on their initial visit so they will not be surprised with the scarring that has already developed with the acne process.

Figures 12-13. Before and after dermabrasion. After the acne clears the scars are improved with a combination of laser and sanding called laser-assisted chemabrasion.

REFERENCES
1. Plewig G, Fulton JE Jr and Kligman AM. Cellular dynamics of comedo formation in acne vulgaris. Arch Dermatol Forsch 1971;242:12-29.
2. Fulton JE Jr, Noble NL, Bradley S and Awad W Jr. The glycerol ester hydrolase (BC 3.1.1.3) from Corynebacterium acnes: a serine lipase. Biochem 1974;13:2320-2327.
3. Fulton JE Jr, Plewig G and Kligman AM. Effect of chocolate on acne vulgaris. JAMA 1969;210:2071-2074.
4. Fulton JE Jr, MD, PhD and Black E. Dr. Fulton's Step-by-Step Program for Clearing Acne, Harper & Rowe, New York, 1983, pages 75-82.
5. Pochi PE. Hormonal therapy of acne. Dermatol Clin 1983;1:377-384.
6. Kligman AM, Fulton JE Jr, Plewig G. Topical vitamin A in acne vulgaris. Arch Dermatol 1969;99:469-476.
7. Fulton JE Jr and Shenk A. Benzoyl peroxide topical therapy. Acne Update for the Practitioner (SB Franks, ed), York Medical Books, 1979, pages 141-147.
8. Van Scott EJ and Yu RJ. Hyperkeratinization and alpha hydroxyacids. J Am Acad Dermatol 1984;5:867-879.
9. Peck GL, Olsen TG, Yoder FW, et al. Prolonged remissions of cystic and conglobate acne with 13-cis retinoic acid. New Engl J Med 1979;300:329-333.
10. U.S. Patent No. 5,043,356. Components in and method for rejuvenating skin using vitamin A proprionate.

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INTERNATIONAL JOURNAL OF COSMETIC SURGERY and AESTHETIC DERMATOLOGY
Volume 4, Number 2, 2002
© Mary Ann Liebert, Inc.