Acne Vulgaris

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Acne Vulgaris

Pathogenesis of Acne:

– Acne is a Multifactorial Process at Pilosebaceous Unit – the sebaceous gland and hair follicle (1). The main contributing factors are;

  • Genetics
  • Androgens
  • Cortisol
  • Stress
  • Barrier dysfunction
  • Diet
  • Propionibacterium acnes (bacteria commonly found on human skin)
  • IGF/1 – Insulin like growth factor – hormone

Acne and inflammation

  • Stimulates the secretion of interleukin IL/6 and IL8 by follicular keratinocytes and IL/8 and IL/12 in macrophages, giving rise to inflammation (2).
  • Can induce IL/17 production by T cells suggesting that acne might be a T helper type 17 (Th17)/mediated disease (3)

Treatment may take at least 1-2 months before improvements will be seen.

Treatment goals

  • Prevent new pimples/lesions/scarring
  • Address underlying inflammation

Naturopathic Treatments

  • Diet: Anti-inflammatory diet, low glycemic, low/no dairy
  • High dose Vitamin A (in males and non/childbearing females)
  • Topical options
    • Non/oil moisturiser
    • Tea Tree oil
  • Heliotherapy/Bluelight treatment
  • Stress management

Choices for Topical Treatment of Mild Acne

  • Salicylic acid
  • Azelaic acid
  • Benzoyl peroxide
  • Tretinoin – Retinoid
  • Topical antibiotics
  • Combinations
    • Tretinoin and clindamycin
  • Tea Tree Oil
  • Herbal Formula

• Use topical for 6/8 weeks before judging efficacy

Don’t forget a non/oil based moisturiser for barrier repair

Topical Retinoids – friendly effects

  • Reduce;
    • Expression of hyper proliferative keratins
    • Matrix metalloproteinases (MMPs) /> dermal matrix degradation
    • Toll/like receptor 2 /> decreases pro/inflammatory cytokines
  • Use pea size for entire face
  • Apply TID x 2 wks, then qhs
  • Increases photosensitivity
  • Flare reaction is common
  • Start with 0.025% tretinoin or 1% Retinol (natural Vitamin A)

Other Conventional Options

  • OCP can be effective
  • Low dose anti-biotic’s can be used as an anti-inflammatory
  • Isotretinoin (eg. roaccutane) – “miracle drug” – long/lasting remissions or cures, but serious potential adverse effects

Barrier Repair in Acne

  • Inherent abnormalities and many treatments stress the skin barrier
  • Bacterial and androgen penetration through damaged barrier leads to increased inflammation

Naturopathic Therapeutics

Remove “obstacles to cure”/identify and remove the underlying cause/s of disease.

  • Androgen excess
  • Comedones
  • P. acnes
  • Oil/based cosmetics
  • Diet
  • Chronic irritation
  • Stress
  • Medications

Carbohydrate Intake and Acne

  • There is an absence of acne in two non-Westernized societies (Papua New Guinea and Paraguay)
  • They have a low glycemic load diet, devoid of refined foods
  • Diet/induced hyperinsulinemia may lead to a cascade of androgens, IGF/1, IGF binding protein/3, and retinoid signaling

Cordain et al Biochem Physiol 2003;136:1591/112

Low glycemic load vs. High glycemic load diet for 6 days in pilot study of 12 males showed significant improvement in insulin sensitivity in LGL vs HGL group

  • HGL group significantly increased androgen bioavailability

Smith et al. Mol Nutr Food Res 2008;52:718/26

Limit Milk Consumption

  • No association seen with yogurt or cheese
  • Nonfat milk and ice cream are the main culprits
  • Contains oestrogens, progesterone and androgens as well as glucocorticoids and IGF/1
  • IGF/1 stimulates synthesis of androgens in ovaries and testicles and inhibits Sex Hormone Binding Globulin resulting in increased bioavailability of androgens
  • IGF/1 and androgens increase sebum production

Moderate/severe Acne Closely Associated with:

• Family history of acne in first degree relatives

• Obesity (BMI?30)

• High consumption of milk, in particular skim milk/cheese/yogurt

• Sweets/cakes, chocolate

• Low consumption of fish

• Limited intake of fruits/vegetables

– Grossi E et al. The constellation of dietary factors in adolescent acne: a semantic connectivity map approach. J Eur Acad Dermatol Venereol. 2016 Jan;30(1):96/100.

Omega 3’s and Acne

• Higher content of omega 3’s in Kitavan and Acne’ societies may have also played role in

absence of acne

• maintenance of the stratum corneum permeability barrier

• maturation and differentiation of the stratum corneum

• formation and secretion of lamellar bodies

  • inhibition of pro/inflammatory eicosanoids

High/dose Vitamin A

• First/line therapy – same precautions as with isotretinoin

• Treats multiple pathogenic factors: prevents comedones from forming, keratinocytes

from sticking and plugging follicles, decreases sebum production

• Anti/inflammatory?

• Immunostimulating against P. Acnes?

  • 150,000 IU qd – Kligman et al. Int J Dermatol 20:278/285, 1981

IL/17 in Acne, Vitamin A & D

• IL/17 is induced by P. acnes and expressed in acne lesions

• Vitamin A & D inhibit genetic expression of P. acnes/induced Th17 differentiation

Agak GW. Propionibacterium acnes induces an IL/17 response in acne vulgarise that is regulated by vitamin A and vitamin D. J

Invest Dermatol. 2014 Feb;134(2):366/73.

Youssef DA et al. Antimicrobial implications of vitamin D. Dermatoendocrinol. 2011 Oct;3(4):220/9

Zinc

• Hormone activation

• Retinol/binding protein formation (enhances retinoid therapy)

• Wound healing

• Enhanced immunity

• Similar in efficacy to tetracycline, fewer side effects; antimicrobial to P. acnes

  • Zinc gluconate/citrate: 30 mg qd (daily) 

Bae JY, Park SN. Evaluation of antimicrobial activities of ZnO, citric acid, and a mixture of both against Propionibacterium acnes. Int J Cosmet Sci. 2016 Mar 4.

Zinc gluconate

• 66 patients with inflammatory acne

• 30 mg elemental zinc or placebo x 2 mo.

• 24/32 patients in zinc group responded vs. 8/34 in placebo group

Dreno B et al. Acta Derm Venereol 1989;69:541/543 Meynadier J. Eur J Dermatol

2000;10:269/273

Pyridoxine

• Premenstrual flares (in 63% of acne/prone women; 25% increase in total lesions)

Lucky, Arch Dermatol. 2004 Apr;140(4):423/4

• Role in normal metabolism of steroid hormones

• Dose: 50 mg 7d mid/cycle til menses

• Other options for PM flares: OCPs, spironolactone, drospirenone, chlorpheniramine

(Teldrin/OTC)mg hs from mid-cycle til menses

Combination Supplement Effective for Acne

• “Azerizin”(nicotinamide, azelaic acid, quercetin, curcumin ) 700 mg

• Zinc oxide 12 mg

• Pyridoxine 8 mg

• Copper 2 mg

• Folic acid 500 mcg

– Shalita AR et al. Inflammatory acne management with a

novel prescription dietary supplement. J Drugs Dermatol. 2012 Dec;11(12):1428/33.

Topical Natural Agents

• Tea Tree Oil

• Aloe vera

• Herbal formula

• Azelaic acid

• Ascorbic acid

• Nicotinamide

Tea Tree

Tea tree oil = 5% solution compared to 5% PB (common topical lotion), fewer side effects.

Aloe Vera

Tretinoin/Aloe vera gel was significantly more effective in reducing non/inflammatory (p = 0.001), inflammatory (p = 0.011) and total (p = 0.003) lesion scores than tretinoin alone.

Oral Nicotinamide  750mg daily

Kamedis Topic medis body cream – Excellent oil free moisturiser. good for any dermatitis.

References

1. Adebamowo et al. JAAD Feb 2005;52(2):207/214 Low/glycemic, Anti/inflammatory Diet

2. Bowe W, Joshi S, Shalita A, Diet and acne. JAAD, July 2010. 63(1):124/141

3. Mahmood SN, Bowe W. Diet and acne update: Carbohydrates emerge as the main culprit. J Drugs Dermatol 2014 Apr 01;13(4)428/435 /Review reaffirms that the role of diet in the development of acne is no longer a myth

4. High glycemic load food and milk may induce increased tissue levels of 5 alpha dihydrotestosterone Exp Dermatol. 2009 Oct;18(10):821/32

5. High levels of insulin promotes expression of enzymes responsible for androgen biosynthesis and conversion J Am Coll Nutr 2009 Aug:28 Suppl: 450S/445S

6.  Hajheydari Z et al. Effect of Aloe vera topical gel combined with tretinoin in treatment of mild and moderate acne vulgaris: a randomized, double/blind, prospective trial. Dermatolog Treat.2014 Apr;25(2):123/9.

7. Bassey IB, et al. Med J Aust 1990;153:455/458