Acanthosis Nigricans: How to Manage

 

Treatment of acanthosis nigricans involves topical treatment and removal of the offending cause of the skin thickening and pigmentation.

Treatment of Acanthosis Nigricans: Treating the Cause
Treatment of Acanthosis nigricans involves treating the Cause

Tips on Dealing with Acanthosis Nigricans

There are certain do’s and don’ts in dealing with acanthosis nigricans. These are important in limiting the spread of the disease and finding the underlying causes.

Do’s in dealing with acanthosis nigricans:

  • The first course open to a patient is of course differentiating the benign and malignant varieties of acanthosis nigricans, preferably with the help of a dermatologist.
  • Diet control and regular exercise to reduce weight is essential in controlling acanthosis nigricans
  • Diabetes, if present, should be brought under strict control through dietary restriction, exercises and effective medications
  • In case of suspected malignant acanthosis nigricans, full panel of laboratory investigations should be carried out without much delay. Tumor markers, hormonal assays, endoscopy, Ultrasound and CT scans and whole body MRI are mandatory in such cases. The appearance of acanthosis nigricans can precede the full expression of cancer even by 5 years.
  • Consultations with a general physician and a gastro-enterologist once in six months is advisable in suspected acanthosis nigricans where no primary focus could be found in previous check ups. The frequency should be increased in cases where the skin changes are rapidly progressing.
  • Any sudden progression of the skin condition, appearance of skin tags or seborrheic keratosis (Leser Trelat sign) calls for urgent medical consultation.

 

Acanthosis nigricans treatments depends upon finding and treating the basic cause

Don’ts in Dealing with Acanthosis Nigricans

There are certain things to be avoided in the presence of acanthosis nigricans:

Most people think that the dirty appearance of the skin in acanthosis nigricans is due to dirt deposition on the skin. This results in constant vigorous scrubbing of the involved skin. This should be avoided at all cost.

So, Don’t

  • Scrub too much, as frequent rubbing will only increase skin thickening and pigmentation
  • Use strong abrasives: tend to irritate the skin more.

Treatment Guidelines for  Acanthosis Nigricans

  1. Correction of underlying cause
  • Removal of tumor
  • Correction of endocrine disorder: In case of Insulin Resistance, Metformin could be useful in treating Acanthosis Nigricans, alone or in combination with Rosiglitazone.
  • Reduction of weight: Low carb diets and exercise will help.
  • Removal of causative drug
  • Dietary supplimentation with fish oil containing omega 3 fatty acids have been reported to be beneficial
  • Cyproheptadine has been found useful in some cases

 2. Management of Skin Lesions:

  • Topical Retin A
  • Salicylic acid application alone or in combination with steroids, alternating with emollient applications to minimize irritation.
  • Calcipotriol
  • In severe unresponsive cases, systemic retinoids are useful.
  • TCA Peels, laser ablation all have been tried with varying results

Read also:


Published by Dr Hanish Babu, MD on 29th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

 

Acanthosis Nigricans: How to Differentiate Malignant from Benign

 

We have already seen the main causes and different types of Acanthosis Nigricans.

As acanthosis nigricans is, at times, a fore-runner of internal cancer, it is important to differentiate between the harmless benign acanthosis nigricans from the malignant variety of acanthosis nigricans, as early diagnosis of cancer could be life saving. It is reported that the appearance of acanthosis nigricans precedes the appearance of internal cancer even before a couple of years!

Malignant Acanthosis Nigricans has to be Differentiated from Benign

Even after treatment of the causative cancer, acanthosis nigricans plays an important role as a followup indicator as well. Usually when the cancer is surgically excised and treated with radiation or chemotherapy, acanthosis nigricans disappears. Any recurrence of acanthosis nigricans later may thus point to recurrence of the cancer.

Curth HO (Archives of Dermatology, Vol 102, 1970) reports a remarkable case of acanthosis nigricans persisting for years even after excising  a leiomyoma of stomach, squamous cell carcinoma of bladder and nephrectomy of one kidney for transitional cell carcinoma in a 84 year old man.Then one lesion of adenocarcinoma was found in his colon and removed. Surprise! His long standing acanthosis nigricans disappeared within a few days without any treatment!

Moral: To achieve cure you must excise the responsible hormone secreting tumor, not just any tumor!

How to Differentiate Benign from Malignant Acanthosis Nigricans?

If any of the following features are present in a patient with acanthosis nigricans, presence of internal cancer may be suspected:

  1. Age of onset: Benign acanthosis nigricans appear soon after birth, childhood or in puberty. Early age of onset should arouse suspicion.
  2. Speed of Progression: If the typical features of acanthosis nigricans appear and progress rapidly, it is indicative of a malignant origin.
  3. Severity of Skin Changes: In malignant acanthosis nigricans, the skin changes are more pronounced compared to the benign types of acanthosis nigricans. The dark color (pigmentation) is present beyond the area of thickening in the malignant acanthosis nigricans.
  4. Distribution of Skin Lesions: In malignant acanthosis nigricans, there is extensive involvement of the skin, almost all folds and palms and soles and face are involved.
  5. Mucous membrane involvement: In contrast to the benign acanthosis nigricans, mucous membrane involvement is prominent in about 50% of malignant type of acanthosis nigricans.
  6. Skin Tags: Sudden appearance of skin tags in a case of acanthosis nigricans is indicative of serious underlying illness.
  7. Symptoms: Most benign acanthosis nigricans are asymptomatic. Usually there is irritation and itching in the skin lesions of malignant acanthosis. 

Also Read:


Published by Dr Hanish Babu, MD on 29th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

Acanthosis Nigricans, a Marker of Cancer: Types, Causes and Diagnosis

 

Acanthosis Nigricans
Acanthosis Nigricans can be a marker of Internal Cancer

Acanthosis nigricans is a dark and velvety thickening of the skin in the armpits, neck and other body folds. It is considered as a marker for certain internal malignancies and endocrinal disturbances.

Acanthosis nigricans may occur due to a hereditary predisposition or associated with many diseases and medications.  People with acanthosis nigricans are known for their resistance to insulin in diabetics. The importance of acanthosis nigricans lies in the fact that at times it could be associated with certain cancers. Infact, sudden appearance of  acanthosis nigricans at any age calls for a thorough investigation of body systems to rule out any underlying cancers.

What is the Cause for Acanthosis Nigricans?

As mentioned above, there are many causes for acanthosis nigricans. According to the underlying cause, acanthosis nigricans is divided into 5 different types.

  1. Hereditary Benign Acanthosis Nigricans. This type runs in families and there is usually no associated endocrine disorders. This type of acanthosis nigricans appears in childhood and increases at puberty though many regress with age.
  2. Benign Syndromic Acanthosis Nigricans. This is associated with certain endocrine diseases. Insulin resistance is an underlying pathology in benign acanthosis nigricans. Most patients will have any of the following hormonal problems: diabetes, increased androgen secreting tumors, acromegaly or gigantism, Cushing’s syndrome, Addison’s disease , hypothyroidism etc. Course depends upon the management of underlying disturbance.
  3. Pseudo Acanthosis Nigricans  associated with Obesity. Starts at puberty. Common among dark skinned. Obesity—insulin resistance. Regression seen with significant weight loss.
  4. Drug induced Acanthosis Nigricans. High dose nicotinic acid, stilbesterol in young males, systemic steroid therapy, certain OCPs, growth hormone therapy, insulin, pituitary extract, protease inhibitors are some of the medications that can cause acanthosis nigricans
  5. Malignant Acanthosis Nigricans. Associated with adenocarcinoma of GIT and GUT tracts, less commonly with lymphomas. Even as early as 5 years of onset of other signs and symptoms of certain malignancies. Usually regress after successful treatment.

The typical skin features of thickening and dark pigmentations in acanthosis nigricans are caused by  certain chemicals secreted by the tumors or the effect of hormones, including insulin on the skin fibroblasts and melanocytes.

How Can Acanthosis Nigricans be Diagnosed?

Acanthosis nigricans has to be differentiated from diseases like Confluent and Reticulated papillomatosis, pigmented pityriasis versicolor, X-linked Icthyosis, retention hyperkeratosis and excessive nicotinic acid ingestion. Diagnosis of acanthosis nigricans is mainly from the history and clinical presentations. A complete workout including a hormonal profile, blood sugar,  biopsy of the skin and histopathological study, and, in case of suspected malignant acanthosis nigricans, a full body imaging and endoscopy is called for.

Clinical Features

Irrespective of the cause, all varieties of acanthosis nigricans show a  dark pigmentation and thickening of the skin, usually in a symmetrical manner, on the neck, axillae, groins, elbows, behind the knees, around umbilicus and in the perianal region. Skin looks dirty and the surface is wavy and rugose with a velvety appearance. Skin lines show up prominently. In acanthosis associated with obesity, the dark, thickened and velvety patches are more pronounced on the apposed surfaces of the folds, especially the thighs. Skin tags appear in large numbers in these patients.

In the severe malignant variety, all features of acanthosis nigricans are accentuated: the skin is  more thickened, dark and velvety and there is often involvement of the palms, soles, oral cavity and the edges of the lips.

Also Read:

Book an Appointment with Dermatologist Dr Hanish Babu, MD


Published by Dr Hanish Babu, MD on 29th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

The Best Treatment for Very Severe Nodulocystic Acne

 

Very Severe Nodulocystic Acne
Very Severe Nodulocystic Acne should be treated on an emergency footing

How to Manage Very Severe Acne

The best treatment options for very severe nodulocystic type of acne include systemic medications, surgical interventions and combined topical therapies.

Very severe acne comprises of numerous pustules, deep fluctuant nodules and cysts on the face, chest, back, and at times, on the buttocks, groin and armpits. The main concern of treating this grade 4 nodulocystic acne is prevention of scarring, which is present in more than 90% of affected individuals.

The Best Treatment for Very Severe Nodulocystic Acne

 The best medication available for very severe nodulocystic acne is oral isotretinoin. The dosage is 0.5 to 1 mg per kg body weight per day as a single dose.

As isotretinoin is teratogenic (causes birth deformities), women of child bearing age group should avoid this medication unless absolutely necessary. Pregnancy should be avoided during and two months after treatment with isotretinoin. All patients should be aware of side effects of isotretinoin and how to avoid them.

For those who would like to avoid isotretinoin, the following are the alternative choices to treat their very severe pimples:

  1. Initiate therapy with Minocycline 100 mg twice a day with topical application of either Benzoyl peroxide 5% or topical tretinoin 0.05% at night.
  2. Deep seated nodules and cysts should be drained to enhance the therapeutic effects of the antibiotics and aid the healing.
  3. Intralesional triamcinolone injection at a strength of 5mg/ml into the nodules hastens the healing process.
  4. In explosive cases of nodulocystic acne (known as pyoderma faciale), which is more common in females, a combination of oral steroids and isotretinoin works wonders in clearing the eruptive bumps at a faster rate.
  5. After 4-6 weeks, the response to treatment is reassessed. If the nodules and cysts have healed, minocycline is continued at a dose of 100 mg per day for another 4-6 weeks.
  6. If there is no recurrence and the acne bumps have healed well, minocycline may be replaced with doxycycline 100 mg daily for another one month and then tapered over a period of 2-4 months.
  7. While the oral medications are tapered, add topical clindamycin as morning applications with topical tretinoin replacing benzoyl peroxide as a maintenance therapy.
  8. If any recurrence is there, a short course of oral minocycline is repeated.
  9. If, after 4-6 weeks of minocycline, the response to treatment is not satisfactory, then the option of oral isotretinoin is explored for the patient.
Acne Conglobata
Very Severe Acne: Acne Conglobata

Females with explosive nodulocystic acne, with or without associated increased hair growth (hirsutism), should be investigated for diseases like polycystic ovarian disease.

Patients who have been treated satisfactorily should modify their life style and follow the specific tips to prevent recurrence of acne in the future.


Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

 

Very Severe Nodulocystic Acne: FAQ

 

Frequently Asked Questions about Very Severe Acne

Sudden, very severe eruptions of nodules and cysts on the face, chest and back have to be dealt with on an emergency basis as these are potentially deep scar forming conditions.

Very Severe Nodulocystic Acne FAQ
Very Severe Nodulocystic Acne

What is Nodulocystic Acne?

Nodulocystic acne is the very severe grade 4 acne consisting of deep seated fluctuant nodules and cysts and numerous pus filled bumps. Most of the face, front of chest and back is commonly involved in nodulocystic acne.

How is Nodulocystic Acne Formed?

The basic pathogenesis of nodulocystic acne is similar to formation of other types of acne. Increased sebum secretion and inflammation caused by the bacteria P.acnes causes stretching and weakening of the wall of the sebaceous gland and hair follicle. This leads to rupture of the contents in to the dermis. A severe foreign body reaction takes place and the whole inflammatory debris and cells are segregated into fluctuant nodules and cysts deep within the dermis. Thus is formed the nodulocystic acne.

What is the Best Treatment for the Very Severe Nodulocystic Acne?

The best treatment for the very severe type of nodulocystic acne includes drainage of the pus, intralesional steroids, and oral isotretinoin. Isotretinoin gives very good results in this type of very severe acne, but its toxicity reduces its appeal to many patients. It is absolutely contraindicated in pregnancy. The second line of treatment involves use of minocycline in place of isotretinoin.

Other principles of treatment of acne also have to be observed in the case of nodulocystic acne. Avoiding acne triggers is also an important part of the management of nodulocystic acne.

What are the Complications of Very Severe Pimples?

Acne Conglobata
Very Severe Acne: Acne Conglobata result in deep scars

The nodules and cysts in the very severe type of pimples are situated deep within the dermis and when they heal, leave depressed, deep scars. Chances of hypertrophic scars are also high and in those with keloidal tendency, these will form disfiguring keloidal scars. Immediate institution of isotretinoin and other measures help reduce the severity of scarring in nodulocystic acne.

 

What are the Side Effects of Isotretinoin?

The main side effect of isotretinoin is the teratogenic effect on the fetus. Because of the risk of deformities, women should take care that they do not become pregnant during and two months after the course of isotretinoin. Most other side effects of isotretinoin in acne are related to the extreme dryness caused by the medication.

What are the Other Different Types of Very Severe Acne?

In addition to the nodulocystic acne, acne conglobata, pyoderma faciale and acne fulminans are the most severe types of pimples that are seen in patients.

What is Acne Conglobata?

Acne conglobata runs a chronic course with involved areas of the face and trunk filled with communicating cysts, abscesses and draining sinuses. The healing is with hypertrophic and atrophic scars. Recurrent episodes of joint inflammation may also be present in some patients. Treatment is similar to nodulocystic acne.

What is Pyoderma Faciale?

Pyoderma faciale commonly affects females and presents with an explosive eruption of large, tender, red cysts, mainly in the central part of the face. Spontaneous purulent discharge is present from the cysts. Comedones are conspicuous by their absence in this type of acne. Treatment is with drainage, oral isotretinoin and systemic steroids. In fact this is one of the rarer forms of acne where a short course of systemic steroids can bring fast relief to the patient.

What is Acne Fulminans?

Acne fulminans is a rare, ulcerative type of acne that mainly affects young adolescent males. There is an abrupt eruption of inflamed, necrotic acne leaving superficial and deep ulcers on the skin surface. Associated systemic symptoms of fever, weight loss, muscle and joint pains give the patient a toxic and weak appearance. Treatment is similar to pyoderma faciale.

Nodulocystic acne and other types of very severe types of acne are dermatological emergencies which need to be treated aggressively in early stages to avoid permanent deep scars.

Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

How to Treat Severe Acne

The Best Treatment for Severe Acne: Treat Early to Prevent Acne Scars

The best treatment for severe acne is a combination of oral retinoids or antibiotics and topical anti-acne medications.

Severe acne, with high number of inflammatory pustules and nodules, should be treated promptly to prevent deep ice pick and hypertrophic acne scars.

Severe Acne
Severe Acne: Early Treatment Prevent Scar

In severe acne, there are pus filled lesions, formed fresh or from already existing papules, and a few nodules. Numerous red, painful, pus filled bumps and humps are seen on the face, chest and back.

 How is Severe Acne Treated?

 As with other types of acne, there are specific and general measures to deal with the severe type of acne. In general, the specific treatment of inflammatory acne consists of oral retinoids, oral antibiotics, topical antibiotics, benzoyl peroxide and topical retinoids.

What is the Best Treatment for Severe Acne?

 Oral isotretinoin is the single best treatment for acne. But it is a medication to be used with care and only under the supervision of a dermatologist. It is absolutely contraindicated in pregnancy .

Following is the treatment protocol for severe acne followed by most dermatologists:

  1. Treatment is started with oral isotretinoin at a dose of 1-2 mg per kg body weight per day in males and non pregnant females who are on double contraception during and two months after the medication.
  2. From family history, depth and severity of the inflamed acne bumps, if there is less chance for scar formation, and in those where oral retinoids are not advisable the treatment is initiated with oral antibiotics (minocycline, tetracycline or doxycycline), with a gradual tapering of dosage over a period of 6-8 weeks. In pregnancy, only if severe pustular or nodular bumps are there is systemic treatment advised. The drug of choice for inflammatory acne in pregnancy is erythromycin. All medications are best avoided in the first trimester of pregnancy.
  3. Topical therapy of severe acne is same as in the moderate type of acne. Morning topical clindamycin/erythromycin and evening benzoyl peroxide 5% gel is the preferred combination used in severe acne.
  4. Once the pustules regress, topical benzoyl peroxide is replaced with topical isotretinoin.
  5. Benzoyl peroxide and Topical Tretinoin cause irritation in some patients because of their peeling effect on the epidermis. The following steps will help reduce the irritation in sensitive individuals:
    • Tretinoin and benzoyl peroxide should be applied at night only.
    • A non-comedogenic water based sun screen is used during daytime to avoid sun-sensitization.
    • If redness and scaling occur and skin becomes dried up, wash off the benzoyl peroxide or tretinoin cream/gel after 2 hours in the first week of application. Once the skin starts tolerating the medication, overnight application can be restarted.
    • In these patients, lower strengths of benzoyl peroxide and tretinoin is used in the first two weeks, later shifting to higher strengths, if necessary.
    • At times, after 2-3 weeks of treatment, topical retinoids can cause a flare up. This indicates an inflammatory blowup of the acne bumps and is a good sign. There is no need to discontinue the application.
    • A post inflammatory reddish brown pigmentation is seen after treatment with benzoyl peroxide. This will gradually disappear on continued treatment. A sun protection cream should be used during daytime till the pigmentation subsides.

What are the General Measures in the Treatment of Severe Acne?

 General measures include advices on skin care, washing, diet and life style management. These and the tips on preventing new acne eruptions are the same for all types of acne.

 What are the Complications of Untreated Severe Acne?

Untreated severe acne causes deep ice pick scars and hypertrophic scars in most patients. Post inflammatory pigmentation is common, especially in the dark skinned individuals.

The best treatment for severe acne is a combination of oral retinoids or antibiotics and topical anti-acne medications. The treatment is individualized according to the extent, type of acne and sex and age of the patient.



Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

Severe Acne: Frequently Asked Questions

 

Because of the predominance of inflammatory acne lesions, severe grade type 4 acne calls for prompt aggressive systemic and topical therapy.

 What Comprises Severe Acne?

Severe Grade 3 Inflammed Acne
Severe Grade 3 Inflammed Acne
Severe Grade 3 Acne
Severe Acne consists of Inflamed papules and pustules

 Inflammatory pustules and deep acne bumps (nodules) are predominant in severe acne or acne grade 4. More than 100 comedones, or more than 50 papules or pustules and more than 5 nodules with a total count of more than 125 acne bumps comprise severe acne.

Severe Inflammed Acne
Grade 3 Severe Pustular Acne

How is Severe Acne Formed?

The initial pathogenesis behind severe acne is similar to other types of acne, viz, hormone stimulation of the sebaceous glands, thickening of the follicular wall and blockage of the hair pores.

In severe acne, the resident bacteria of the hair follicle, P.acnes, multiplies in the medium of the sebum causing breakdown of its components. This causes a chemical irritation, attracting inflammatory white blood cells known as neutrophils.

Neutrophils release some chemical mediators and enzymes which cause the typical characteristics of an inflammatory reaction within the sebaceous glands and the associated hair follicles: calor, rubor, dolor, tumor and functio-lesa, meaning: heat, redness, pain, swelling and loss of function of the affected area.

The inflammation and the resultant destruction of the follicular walls, sebaceous glands and the debris from the inflammatory reaction results in formation of pus filled bumps known as pustules.

The wall and sheath of the gland and hair follicle expand in the dermis with the pus to form deep seated nodules.

What are the Triggers of Severe Acne?

The acne triggers inducing, aggravating and maintaining severe acne is similar to all other types of acne. Picking at the acne bumps and application of topical steroids worsen the severe acne. Picking at the acne bumps and application of topical steroids worsen the severe acne.

What is the Best Treatment for Severe Acne?

The best treatment for severe acne is systemic retinoids. Because this is a strong medication with local and systemic side effects and chances of fetal abnormalities, it is not usually advised to females of child-bearing age group and during pregnancy. Females and their partners should use a double contraception of barrier plus pills while on retinoids.

How Long Should Severe Acne be Treated?

The duration of treatment varies from individual to individual and the response to anti-acne treatment. The average duration of treatment with oral isotretinoin is 18-20 weeks up to a maximum of 24 weeks. An interval of 3 months is given in between before a fresh course is started.

Those on oral antibiotics and topical applications may have to continue treatment for longer duration, till the active acne bumps stop appearing. Then, the dosage is reduced gradually, and stopped over a period of 1-2 months. The topical antibiotics are also stopped like wise. Topical benzoyl peroxide is continued till no fresh acne bumps appear for a period of 2-3 months.

Maintenance therapy of healed severe acne is with topical tretinoin, usually with the 0.025% concentration. This is important in preventing recurrences. Any recurrence is dealt with the same way as new acne bumps and the best treatment for severe acne re-instituted at the earliest to prevent formation of acne scars.


Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

 

Treatment of Moderate Acne

Grade 3 or Papulopustular Acne
Moderate Acne: Grade 3 or Papulopustular Acne

Moderate acne is a transition state between the non-inflammatory and inflammatory pimples. Skin colored bumps (papules) and comedones predominate in moderate acne, also called grade 2 acne. A moderate amount of pustules (pus filled bumps) is also seen in some patients.

Is it Necessary to Treat Moderate Acne?

The aim of treating acne is to reduce and clear the unsightly bumps thus preventing scarring. Being non-inflammatory acne, expert advice should be sought and treatment started in moderate acne without delay. Remember early, appropriate treatment drastically reduces the chances of acne scar formation.

How is Moderate Acne Treated?

Treatment of moderate acne involves general measures and specific measures. General measures are similar to all other types of acne and involve advice on avoiding the acne triggers, skin care and observing healthy dietary and life styles.

Specific measures in the treatment of moderate acne involve use of topical antiacne medications.

  1. Topical retinoids are the first line of therapy for moderate acne where comedones predominate. Treatment is started with tretinoin or isotretinoin applied sparingly at night. Adapalene or tazarotene are alternative retinoids that may be used.
  2. For papule and pustule predominant moderate acne, a topical antibacterial solution is also added. Clindamycin and erythromycin are the usual topicals used in acne. Azelaic acid is a useful alternative, especially in the healing stages, when mild pigmentary changes are prominent.
  3. If the number of pustules are more, and there is sign of deeper inflammation, an oral antibiotic like doxycycline or azithromycin.
  4. In those with pustule predominant moderate acne, benzoyl peroxide is the second line of treatment, along with either topical retinoids or antibiotics.
  5. Retinoids and benzoyl peroxide are applied at night only, as these can sensitize your skin to sunlight, especially the retinoids.

Some may experience a flare up in the first 2-3 weeks of starting the topical treatment. This is a good sign and there is no need to stop medication, though concentration and frequency may be reduced till the inflammatory blowout is controlled.

 How Long Should Moderate Acne be Treated?

Duration of treatment of acne varies from individual to individual and the type, severity and extent of the zits. In general, treatment should be continued till 6-8 weeks after the acne bumps subside completely and there is no fresh outbreak. A maintenance application with topical retinoids should continue weekly twice or thrice for a few months to years, depending upon previous history of recurrences and the life style of the acne sufferer. Regular treatment will have to be re-instituted, should there be any recurrence.

Treatment of moderate acne involves avoidance of acne triggers , a combination treatment with topical anti-acne medications and following tips on how to prevent acne recurrences.


Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

 

Moderate Acne: Frequently Asked Questions

 

Moderate eruption of acne, being the minimally inflammatory type of pimples, could cause scarring in some affected individuals. This calls for early consultation with a dermatologist to get rid of the acne at the earliest stage itself.

 What is Moderate Acne?

 Acne is divided into different types. Moderate acne comprises of skin colored bumps (papules) predominant acne eruption.

Moderate Acne
Moderate Acne: Minimally Inflammatory Papular Acne

Some comedones and pustules (pus filled bumps) are also present. When the number of comedones are higher than 20, even without the presence of papules or pustules, it may be considered as moderate grade 2 acne. In a nutshell, 20-100 comedones and/or 15-50 inflamed papules or pustules with a total count of 30-125 acne bumps comprise moderate acne.

 How Does Moderate Acne Develop?

The events of acne formation start with the increased production of androgen hormones. These stimulate the sebaceous glands to produce more sebum and also produce changes in the lining of the hair and sebaceous ducts. Keratinous plugs are formed in the opening of the hair follicle, the open and closed comedones. When the normal resident bacteria of the hair follicle, known as Propionibacterium acne, start multiplying within the oily sebum and produce irritant side products, this triggers an inflammatory response within the hair follicle and sebaceous glands.

Mild, Moderate and Severe Acne
Mild, Moderate and Severe Acne

When the inflammation is minimal and contained within, the sebum and the products of the inflammation accumulate within the hair duct, raising the surface of the skin, forming skin colored or slightly reddish bumps.

What is Grade 2 Moderate Acne?
Grade 2 Moderate Acne

When the inflammation is significant, these results in formation of pus, which is actually the debris formed from the inflammatory cells, dead and damaged cells and living and dead bacteria. Thus are formed pustules, the other type of lesions seen in moderate acne, albeit in a limited number.

 

What are the Triggers for Moderate Acne?

The acne triggers inducing, exacerbating and maintaining moderate acne is similar to all other types of acne.

What are the Complications of Moderate Acne?

As with other inflammatory acne, there are chances of scar formation in untreated moderate acne patients. Though it is not possible to predict who will get scarring, a family history of scarring and predominance of papules and pustules should alert the acne sufferer to seek early treatment.

While healing, post inflammatory pigmentation (dark spots) may occur in some patients, especially those with dark skin.

Anxiety and depression may affect the individual from fear of disfigurement from the pimples.

What is the Best Treatment for Moderate Acne?

The best treatment of moderate acne is a combination of topical retinoids (isotretinoin, tretinoin, adapalene) and antibacterials, along with oral antibiotics when inflamed bumps are present.

Being the transition state between non-inflammatory and inflammatory types of acne, it is imperative for moderate acne be treated early so as to avoid the complications of scarring and progression to severe type of acne.

 

Published by Dr Hanish Babu, MD on 28th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

Treatment of Mild Acne

 

How to Get Rid of Comedones

Treatment of mild acne involves limiting or controlling triggering factors, life style management and getting rid of the comedones with topical medications.

Mild acne refers to non-inflammatory type of acne presenting with open or closed comedones, the blackheads and whiteheads respectively.

Acne Comedones
Mild Acne: Pathogenesis and Treatment

In most cases of adolescents and teenagers, the comedones on the forehead, cheeks and nose are the first signs of arrival of puberty. In majority of affected cases, the acne eruptions are too mild to necessitate any treatment. But when the eruptions are generalized and appearing in crops, early treatment will effectively control the acne.

 What are the General Measures Advised to Treat Mild Acne

 General advices and tips for dealing with acne are the same for all types of acne. These include advices on washing, skin care and lifestyle adjustments. Teens suffering from comedones, especially the blackheads may try to pick, squeeze and scrub the zits leading to worsening of the condition, and, possibly, inflammatory changes like redness and infection. This should be avoided at all costs. If you want to remove the debris from the blackheads, have it done by an experienced dermatologist or a cosmetologist using a comedone extractor only.

How to Treat the Mild Acne?

Following is a step by step guide to get rid of the comedonal acne:

  1. Wash the skin no more than twice a day with mild soap and water.
  2. In general, the mild acne is treated with a single topical application. Topical retinoids are considered the first line therapy for comedonal acne.
  3. Apply the retinoids only at night.
  4. To begin with, start at the lowest strength of the topical retinoid. Most commonly used retinoids are tretinoin, isotretinoin and adapalene, either in gel or cream forms. Gel has a drying effect and is preferred in those with an oily skin.
  5. Benzoyl peroxide 2.5-5% is the second choice in comedonal acne; but used only if the topical retinoids are not tolerated well. Azelaic acid may be used if the patient cannot tolerate benzoyl peroxide.
  6. During a follow up after 4-6 weeks, the physician will assess the response to treatment. If the response is evident and positive, same regimen is continued till new eruptions cease to appear. A maintenance application of 2-3 times every week is advised till there is no evidence of acne eruptions for at least 2-3 months at a stretch.
  7. A non comedogenic, water based moisturizer is used in the morning if the anti-acne medication is causing excessive skin dryness.
  8. Some patients may experience a flare up of the acne bumps during the first 2-3 weeks of topical retinoid application. This is mistaken as a worsening of the acne and the medication is stopped by the patients. Actually this reaction is an inflammatory blowout of the comedones and indicates the beginning of the recovery period. Hence, the applications should be continued in such cases, albeit at a lower concentration and frequency than before, till the reaction subsides. At times, a course of oral antibiotics may be required to tide over the inflammatory reaction.

In females requiring contraception, a combination pill may be advised, as these also help control the acne eruptions.

It is possible that even minor acne eruptions can cause significant negative psychosocial impacts in the affected teens. The treatment of acne will not be complete unless this issue is also taken care of through relevant supportive therapies.


Published by Dr Hanish Babu, MD on 27th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD