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