Acne Vulgaris

Aggravating Factors

THE TREATMENT OF ACNE

DIETARY SUPPLEMENTATION

	Diets rich in saturated  fat increase sebum production and may induce acne. Recommend a low-fat, high-fiber, nutrient-dense diet that is adequate in vitamins and minerals and low in sugar, and refined foods. Fast foods should be avoided. Excessive iodine should also be avoided as it may cause or exacerbate acneiform eruptions.
	Fast food may be low in omega-6 essential fatty acids, and this might account for follicular hyperkeratosis in acne. For that reason, recommend flax seed oil to your clients.
	Vitamin A supplementation has long been known to be effective against acne (hence the popularity of cod liver oil in folk remedies. Because surplus vitamin A circulating in the blood gets absorbed into the liver after about 4 hours, I recommend that vitamin A should be taken in divided doses: e.g. 10,000 i.u. Twice a day. There is no danger of vitamin A intoxication at this dose. One would have to go to doses of about 300,000 i.u. Daily for an extended period before that becomes an unusual possibility.
	Dr L H Leung from Hong Kong has suggested that mega-doses of vitamin B5 (pantothenic acid) may completely obliterate signs of acne. The doses used were as much as 10 gms per day but effects were also seen at 500 mg per day. Vitamin B5 is involved in energy production from the metabolism of fats. Such high doses may cause diarrhoea and there is a chance off a relative vitamin B1 deficiency that is easy to treat by eating nuts or red meat. Recommend starting with Vitamin B5 100 mg twice and day and increasing to higher doses.
	It is not clear why this should happen but vitamin C supplementation of 1000 mg per day (which can for convenience be taken as 500 mg twice a day) can cause a significant reduction of acne. This could be a result of decreased lipid peroxidation and more stable sebum.
	Vitamin E facilitates the absorption of vitamin A, and also assists the action of selenium, which is involved, in the inflammatory response. Supplementation of selenium increases the immune system and helps to control infection. Recommend 200 micrograms of selenium, and 400 i.u. Alpha tocopherol a day.
	Blood levels of Zinc are often low in patients with acne so it is wise to supplement about 15 mg per day.

REDUCTION OF SEBACEOUS GLAND HYPER-ACTIVITY

	Using topical vitamin A either in the kinder cosmetic form or retinyl palmitate or through the harsher medicinal form, retinoic acid, does this best. In some people only a very low dose of vitamin A is required to reduce the activity of the sebaceous glands and produce less sebum. It seems that the nature of the sebum is also changed. Whatever the nature of the acne that you are treating, always make sure that topical vitamin A is part of the treatment because ultimately, when the acne is controlled, one needs to promote a healthier skin with controlled sebum production and one can only get this from vitamin A.
	In many people higher doses of vitamin A are needed before they reduce the action of the sebaceous glands. In these cases, the therapist should refer the client to a doctor who can prescribe cis-retinoic acid to control the acne. These cases need a great deal of emotional support and encouragement because cis-retinoic acid therapy may cause depression.
	As we know, the production of sebum is affected tremendously by hormones. The therapist cannot really help in affecting hormonal problems, and if the treatments are not being successful then the client should be referred to a doctor for evaluation and treatment. Hormone therapy, however, does have risks of causing or aggravating pigmentation problems. However, the therapist can help by using plant-derived anti-androgens in topical formulations. A most interesting anti-androgen is glabridin which is a water soluble fraction derived from liquorice. Glabridin reduces the effects of androgens on the sebocytes and changes the quantity and nature of the sebum.

REDUCE THE POSSIBILITY OF SEBACEOUS GLAND OBSTRUCTION

	The surface of the skin should be kept as smooth as possible. Topical vitamin A is effective in compacting and smoothening the stratum corneum. In fact what we are trying to achieve is a more controlled release of the corneocytes on the surface of the stratum corneum. Paradoxically, topical vitamin A may initially aggravate acne - possibly as a result of speeding up the release of the uppermost corneocytes by its action on the desmosomes of the horny layer.
	Alpha hydroxy acids, and in particular, lactic acid and its salts also help to produce a very smooth horny layer. Lactates are fundamentally important in promoting skin hydration. The moister the epidermis is, the smoother the surface will be.
	Exposure to harsh UV rays should be reduced because this promotes a thickened, basket-weave type of horny, layer with much more exfoliation.
	The thickened Horny layer can be treated with cosmetics or medications containing benzoyl peroxide which smoothens the horny layer (and also has an anti-septic effect).
	Salicylic acid will also smoothen the horny layer.
	By changing the nature of the sebum one could reduce the chance of obstruction, however, again the skin care therapist cannot use hormones.
	Do not use scrubs to smoothen the skin because this may promote sebum production.

DISSOLVE THE KERATIN PLUGS.

	Sensible skin cleaning: Dried up sebum is like a wax, and in order to dissolve it, one has to use a substance that dissolves oil. Water-based products cannot do this. One could use alcohol, but that would irritate skin and aggravate the condition. On the other hand, highly refined mineral oil is able to dissolve sebum and it should be used to help to clean out the obstructed follicle. It is important to use it to carefully massage the skin and work the plugs loose. A firm brush is useful for massaging mineral oil into the follicles and the mechanical action will help to release the attachment of the plugs to the sidewalls of the follicle. Then wash off thoroughly with water or a cleanser. Try not to use harsh soaps
	AHA may also be useful in helping to get rid of the keratin plugs by facilitating the breakdown of the corneo-desmosomes, and thereby allowing release of the plug from the skin.
	Peeling has a similar action, though one has to be sure that when exfoliation occurs, that the surface is kept as smooth as possible. However, remember to use an extremely mild scrub so that you do not stimulate sebum production.

PREVENTING INFECTION BY REDUCING THE pH OF THE ACID MANTLE:

	Use an acid based skin toner after cleansing. Lactic acid is useful and tends to sting less than glycolic acid.
	Acid peeling is a more dramatic lowering of the pH but this only lasts for a limited time.

TREAT THE INFECTION

	Australian tea tree oil is a powerful anti-septic that works at very low concentrations. A few drops of tea tree oil can be dropped into a bowl of water to wash the acne areas and this usually dries up the infection within a very short time. I recommend tea tree oil based products for cleansing and toning at least.
	Benzoyl-peroxide is another power anti-septic and can be extremely useful and should not be neglected in resistant cases.
	This is the prime indication for peeling of the skin. Peeling can be used as a "spot treatment" and will sterilise the acne spots almost immediately (many people can feel that the pain in the spot stops within 20 minutes of a treatment. However, this has to be repeated for subsequent crops of acne until the basic skin problem has become controlled. Once the skin is controlled then peeling is no longer required. Peeling can also be very useful in controlling the potential acne eruption when one starts applying vitamin A creams.
	Skin care therapists cannot use antibiotics but in some cases they are essential to control the infection and the client should be referred to a doctor.

It is important to understand that vitamin A applied topically is essential for every acne case. That is the mainstay. If the acne does not respond to this simple treatment then other modalities of treatment should be added to the regime. AHA’s, benzoyl peroxide or salicylic acid should be considered next and then if that does not succeed, peeling might solve the problem. These treatments have minimal side effects, which are reversible. Important point is that when we treat acne we only treat the symptoms so the treatment must be long lasting. Another discouraging fact is that generally the treatments for acne first make the condition worse before the acne improves. This aggravated phase may last several months.