Treatement

*Killing the bacteria that are harbored in the blocked follicles. This is done either by the intake of antibiotics like the "three 'cyclines" (tetracycline, doxycycline and minocycline), or by treating the affected areas externally with bactericidal substances like benzoyl peroxide or erythromycin. However, reducing the P. acnes bacteria will not, in itself, do anything to reduce the oil secretion and abnormal cell behaviour that is the initial cause of the blocked follicles. Additionally the antibiotics are becoming less and less useful as resistant P. acnes is becoming common. Benzoyl Peroxide has the advantage of being a strong oxidiser and does not appear to generate resistance. Acne will generally reappear quite soon after the end of treatment—days later in the case of topical applications, and weeks later in the case of oral antibiotics.

*Reducing the secretion of oils from the glands. This is done by a daily oral intake of vitamin A derivatives like isotretinoin (marketed as Accutane) over a period of a few months. It is believed that isotretinoin works primarily by reducing the secretion of oils from the glands, however some studies suggest that it affect other acne-related factors as well. Isotretinoin has been shown to be very effective in treating severe acne and is effective in well over 80% of patients. The drug has a much longer effect than anti-bacterial treatments and will often cure acne for good. The treatment requires close medical supervision by a dermatologist because the drug has many known side effects (which can be severe). About 25% of patients may relapse after one treatment. In those cases, a second treatment for another few months may be indicated to obtain desired results. It is often recommended that one lets a few months pass between the two treatments, because the condition can actually improve somewhat in the time after stopping the treatment and waiting a few months also give the body a chance to recover. The most common side effects are dry skin and nosebleed. There are reports that the drug has damaged the liver of patients. For this reason, it is recommended that patients have blood samples taken and examined before and during treatment. In some cases, treatment is terminated due to changes in various l evels of chemicals in the blood, which might be related to liver damage. Others claim that the reports of permanent damage to the liver are unsubstantiated, and routine testing is considered unnecessary by some dermatologists. However, routine testing are part of the official guidelines for the use of the drug in many countries. Some press reports suggest that isotretinoin may cause depression but as of September 2005 there is no agreement in the medical literature as to the risk. The drug also causes birth defects if women become pregnant while taking it or take it while pregnant. For this reason, female patients are required to use two separate forms of birth control or vow abstinence while on the drug. Because of this, the drug is supposed to be given as a last resort after milder treatments have proven insufficient. Very restrictive rules for use will be in force in the USA beginning in 2006.This has occasioned widespread editorial comment.

*Normalizing the follicle cell lifecycle. A group of medications for this are topical retinoids such as tretinoin (brand name Retin-A), adapalene (brand name Differin) and tazarotene (brand name Tazorac). Like isotretinoin, they are related to vitamin A, but they are administered as topicals and generally have much milder side effects. T hey can, however, cause significant irritation of the skin. The retinoids appear to influence the cell creation and death lifecycle of cells in the follicle lining. This helps prevent the hyperkeratinization of these cells that can create a blockage. Retinol, a form of vitamin A, has similar but milder effects and is used in many over-the-counter moisturizers and other topical products. Effective topical retinoids have been in use over 30 years but are available only on prescription so are not as widely used as the other topical treatments.

* Exfoliating the skin. This can be done either mechanically, using an abrasive cloth or a liquid scrub, or chemically. Common chemical exfoliating agents include salicylic acid and glycolic acid, which encourage the peeling of the top layer of skin to prevent a build-up of dead skin cells which combine with skin oil to block pores. It also helps to unblock already clogged pores. Note that the word "peeling" is not meant in the visible sense of shedding, but rather as the destruction of the top layer of skin cells at the microscopic level. Depending on the type of exfoliation used, some visible flaking is possible. Moisturizers and anti-acne topicals containing chemical exfoliating agents are commonly available over-the-counter.

* Hormonal treatments. In females, acne can be improved with a combined oestrogen/progestogen contraceptive pill. Cyproterone (Diane 35) is particularly effective at reducing androgenic hormone levels and until recently was the best oral contaceptive treatment. It is not available in the USA, but a newer oral contraceptive containing the progestin drospirenone is now available with fewer side effects than Diane 35 / Dianette. Both can be used where blood tests show abnormally high levels of androgens, but are effective even when this is not the case.

* Phototherapy. It has long been known that short term improvement can be achieved with sunlight. However studies have shown that sunlight worsens acne long-term, presumably due to UV damage. More recently, visible light has been successfully employed to treat acne - in particular intense blue light generated by purpose-built fluorescent lighting, LEDs or lasers. Used twice weekly, this has been shown to reduce the number of acne lesions by about 64% [9]; and is even more effective when applied daily. The mechanism appears to be that porphyrins produced by P. acnes generate free radicals when irradiated by blue light. Particularly when applied over several days, these ultimately kill the bacteria . Extensive basic science and clinical work first initiated by dermatologists Yoram Harth and Alan Shalita have shown that intense blue/violet light (405-425 nanometer) can decrease the number of inflammtory acne lesion by 60-70% in 4 weeks of therapy. Since porphyrins are not otherwise present in skin, and no UV light is employed, it appears to be safe, and has been licensed by the U.S. FDA [11].

The treatment apparently works even better if used with red visible light; and overall it has better clearance than benzoyl peroxide. Unlike most of the other treatments few if any negative side effects are typically experienced, and bacterial resistance is unlikely. After treatment, clearance can be longer lived than is typical with topical or oral antibiotic treatments, several months is not uncommon. However, the e quipment is relatively expensive, and the treatment works best for mild-moderate acne.

Less widely used treatments include:

* Azelaic acid (brand names Azelex, Finevin, Skinoren) is suitable for mild, comedonal acne.

* Zinc. Orally administered zinc gluconate has been shown to be effective in the treatment of inflammatory acne, although less so than tetracyclines.

* Insulin treatment - insulin treatment has been reported to work, although no big studies have been performed

* Chromium - Chromium supplementation appeared to work in a small study

* Alternative treatments. Nicholas Perricone's controversial book The Acne Prescription proposes an alternative treatment for adult acne, including a strict diet (dairy is totally avoided in all but two recipes) and topicals containing alpha lipoic acid. Perricone's claims did not seem to be backed up by strong scientific evidence until the publication of the acne / milk link in early 2005. T here are no double-blind studies proving the effectiveness of fatty acids against acne.

Home remedies:

Future treatments

* to burn away the follicle sac from which the hair grows

* to burn away the sebaceous gland which produces the oil

* to induce formation of oxygen in the bacteria, killing them

Preferred treatments by types of acne vulgaris

*Comedonal (non-inflammatory) acne: local treatment with azelaic acid, salicylic acid, topical retinoids, benzoyl peroxide.

*Mild papulo-pustular (inflammatory) acne: benzoyl peroxide or topical retinoids, topical antibiotics (such as erythromycin).

*Moderate inflammatory acne: benzoyl peroxide or topical retinoids combined with oral antibiotics (tetracyclines). Isotretinoin is an option.

*Severe inflammatory acne, nodular acne, acne resistant to the above treatments: isotretinoin, or contraceptive pills with cyproterone for females with virilization or drospirenone.