Acne is a chronic inflammatory skin disease of the sebaceous glands, with a prevalence of 70% to 87%. Treatment options for acne vary widely among dermatologists, with some treatments having uncertain efficacy, lacking a basis in the literature from clinical trials, and some even causing harm to patients, resulting in a bad social impact and economic damage to the patient. Therefore, for clinicians who are currently practicing clinical dermatology without formal dermatology specialty training, it is essential to have a set of proven guidelines for the treatment of acne to standardize their treatment. In order to standardize the treatment of acne, I have listed the treatment methods for acne based on evidence-based medicine.
Topical treatment of acne
1. Topical washing
Wash your face with water to remove the mixture of oil, dander and bacteria from the skin surface. However, excessive washing should not be done. Do not squeeze or scratch the acne. In addition, avoid using oily, greasy, powdered skin care cosmetics and ointments and creams containing glucocorticoid hormone ingredients.
2.Treatment with topical drugs
(1) Vitamin A acid drugs: including
(1) 0.025%~0.1% retinoic acid (all-trans retinoic acid) cream or gel: This drug can regulate the differentiation of epidermal keratin-forming cells and make acne dissolve and discharge.
②13-cis-tretinoin gel: regulates the differentiation of epidermal keratin-forming cells and reduces sebum secretion.
(3) 2nd generation retinoids: 0.1% adapalene gel, which has good efficacy in the treatment of mild and moderate acne.
(2) Peroxybenzoyl: It is a peroxide, which slowly releases neo-oxygen and benzoic acid after topical application, and has the effects of killing Propionibacterium acnes, dissolving acne and astringent.
(3) Antibiotics: Erythromycin, chloramphenicol or clindamycin (clindamycin) are formulated with ethanol or propylene glycol at a concentration of 1% to 2%, which is more effective.
(4) Azelaic acid: It can reduce the flora on the skin surface, hair follicles and sebaceous glands, especially has an inhibitory effect on Propionibacterium acnes and acne lysis, and is effective for different types of acne.
(5) Selenium disulfide: 2.5% selenium disulfide lotion has the effect of inhibiting fungi, parasites and bacteria, and can reduce the free fatty acid content of the skin.
(6) Sulfur lotion: 5%~10% sulfur lotion has the function of regulating the differentiation of keratin-forming cells and reducing free fatty acids in the skin, and also has a certain inhibitory effect on Propionibacterium acnes.
Antibiotic treatment of acne
Oral antibiotics are an effective treatment for acne, especially for moderate to severe acne. Among the many colonizing microorganisms (including Staphylococcus epidermidis, Propionibacterium acnes, Malassezia and other gram-negative bacilli), only live Propionibacterium acnes has a clear association with an increased inflammatory response to acne, so it is important to select antibiotics that are sensitive to Propionibacterium acnes.
In addition to infection-induced inflammation, immune and nonspecific immune responses are also involved in the process of inflammatory damage in acne, so antibiotics that both inhibit Propionibacterium acnes colonization and take into account nonspecific anti-inflammatory effects should be given priority.
Treatment of acne with retinoic acid
Oral isotretinoin is the standard treatment for severe acne and is currently the most effective treatment for acne. Isotretinoin acts on all pathophysiological aspects of acne pathogenesis, and although the therapeutic effect is significant, it is not the treatment of choice for mild acne as much as possible, considering its adverse effects.
Hormonal treatment of acne
1. Application of estrogens and anti-androgenic drugs
(1) Estrogens Estrogens include estrogen and progestin. It is currently believed that androgens play a role in the development of acne. Female patients with moderate or severe acne should be treated with estrogen and progestin in a timely manner if they also have high androgen levels, signs of high androgen activity such as seborrhea, acne, hirsutism, androgenic alopecia (SAHA) or the presence of polycystic ovary syndrome (PCOS).
Combination contraceptives may also be considered for female patients with late-onset acne and for those whose acne worsens significantly before menstruation. The U.S. Food and Drug Administration (FDA) has approved birth control pills for the treatment of female acne patients aged >15 years.
(2) Other anti-hormone treatments The two main types of anti-hormone treatment are anaesthetics and metformin (cimetidine).
2.Application of glucocorticoids
Glucocorticoids have the functions of inhibiting androgen secretion caused by hyperadrenocorticism, anti-inflammation and immunosuppression. Oral glucocorticoids are mainly used for violent acne or convergent acne, because these types of acne are often related to excessive immune response and inflammation, and the brief use of glucocorticoids can play an immunosuppressive and anti-inflammatory role.
Traditional Chinese medicine treatment for acne
Chinese herbal therapy should be differentiated into types of treatment and added or subtracted according to the symptoms. Treatment of red papulopustular acne is recommended to clear the lungs and stomach; treatment of pustular acne is recommended to detoxify and disperse the nodules; treatment of premenstrual acne is recommended to regulate the flushing method; treatment of aggregated acne, post-pigmentation or scarring is recommended to activate the blood and disperse stasis.
Chinese herbal mask: Chinese medicine dialectic, mask.
Acupuncture therapy: often selected points such as Dazhi, Spleen Yu, Foot San Li, Hegu, Sanyinjiao, etc., the method of flat tonic and flat diarrhea, acupuncture after obtaining qi and stay for 30 min, once a day, 7 times for a course.
Ear acupuncture therapy: the patient’s bilateral ear lung points as the main points, with the Shen Men, sympathetic, endocrine, subcortical points buried Wang Bu Liuxing seeds, external fixed with adhesive tape, massage the upper points 3 times a day, about 10min each time.
Diet therapy: patients are advised to eat less high sugar, high fat, wine, spicy and other stimulating food, more vegetables (bean sprouts, bok choy, pungent high vegetables, winter melon, loofah, bitter melon, water chestnuts) and fruits. Drink mung bean soup regularly to clear lung heat and remove dampness and toxicity. Eating more food containing long fiber and keeping the bowels open is effective in preventing acne. In addition, avoid using oily and powdered skin care cosmetics and ointments and creams containing hormones. Wash your face twice a day with warm water, do not use strong alkaline soap, wipe away facial fat and dirt when washing, and prohibit your fingers from squeezing facial papules, pimples and pustules to prevent scarring.
Physiotherapy for acne
For acne patients who cannot tolerate medication or do not want to receive medication, physical therapy is the best option. At present, the physical therapies commonly used to effectively treat acne are photodynamic therapy, laser therapy and fruit acid therapy.
1.Photodynamic therapy
The use of specific wavelengths of light activates the porphyrins metabolized by Propionibacterium acnes, and achieves acne treatment through phototoxic reactions, induction of cell death and stimulation of macrophages to release cytokines and promote self-healing of lesions. At present, blue light (415nm), blue light and red light (630nm) combined therapy and red light + 5-Aminoketovaleric acid (5-AALA) therapy are mainly used to treat various types of acne vulgaris.
2.Fruit acid therapy
Fruit acids are widely found in nature in fruits, sugar cane and yogurt. They have a simple molecular structure, small molecular mass, non-toxic and odorless, strong permeability, safe action and do not damage the epidermal barrier function. The mechanism of action of fruit acids is to reduce the adhesion of keratin-forming cells by interfering with the binding force of the cell surface, accelerate the shedding and renewal of epidermal cells, while stimulating the synthesis of dermal collagen and enhancing the moisturizing function.
3.Laser therapy
Laser, Intense Pulsed Light (IPL), pulsed dye laser and fractional laser are among the effective methods for treating acne and acne scarring, and can also be combined with medication. Lasers are approved by the U.S. Food and Drug Administration (FDA) for the treatment of acne. Intense pulsed light can help fade the red marks in the later stages of inflammatory acne. Fractional laser has a certain degree of improvement for acne scarring.
4.Other treatments
①Pimple picking: This is one of the effective methods of acne treatment at present, but it is necessary to use medication at the same time to fundamentally inhibit the production and development of acne.
②Glucocorticoid injection in nodules and/or cysts: It helps to eliminate inflammation rapidly and is a very effective treatment for larger nodules and cysts.
③ Cyst excision and drainage: For large cysts, excision and drainage is an effective way to avoid future skin lesion mechanization and scar formation.
This “Complete Guide” is only to help patients make proper decisions about acne treatment and is not a mandatory standard; nor can it include or solve all problems in acne diagnosis and treatment. Therefore, when addressing a specific patient, the best clinical evidence and available medical resources for this disease should be fully understood, and a reasonable treatment plan should be developed based on knowledge and experience, taking into account the patient’s own specific condition and his or her wishes.