Treating Your Acne Through Topical Retinoids
Acne vulgaris is a skin condition that commonly affects adolescents and young adults, including athletes. Acne rarely precludes athletic participation, except in cases as described above. Athletes using anabolic steroids may develop recalcitrant cystic acne on their backs and shoulders. Occasionally, acne is indicative of systemic illness, such as polycystic ovary syndrome. Most commonly, however, acne is a skin problem resulting in poor cosmetic appearance. Although poor cosmesis may seem of minor importance to the physician, this may be quite devastating to patients.
Identifying the correct subtype and severity of acne will allow the practitioner to tailor a treatment strategy to each patient’s specific needs. Physicians have a wide variety of options available for the treatment of acne, and some are more effective for particular acne subtypes than others. Side effects of acne therapy are generally low, although oral antibiotics and isotretinoin carry potentially significant side effects. Appropriate therapy will allow the athlete with acne to continue participating in sports, minimize medication side effects, and improve self confidence as well as the appearance of the skin.
Although the diagnosis of acne vulgaris is fairly straightforward, other acneiform disorders must be included in the differential diagnosis. Hot tub folliculitis, Malassezia folliculitis, and rosacea are common disorders that may be confused with acne vulgaris.
Hot tub folliculitis is a self-limited condition caused by colonization of follicles with Pseudomonas aeruginosa. The condition generally develops after the patient sits in a communal hot tub, and it resolves spontaneously within 1 to 2 weeks.
Another type of folliculitis is caused when the yeast Malassezia ovale colonizes the follicles. It is characterized by pruritic follicular papules and pustules on the trunk, back, and upper arms. Absence of comedones and response to antifungal creams helps differentiate this condition from acne vulgaris.
Although rosacea is a distinct condition, it is a chronic disorder affecting the face that commonly coexists with acne vulgaris. Early stages of rosacea are characterized by persistent erythema and development of telangiectasia. Later stages of rosacea involve the development of papules and pustules that may be mistaken for the lesions of acne vulgaris.
Initiating Treatment
Effective acne therapy begins with patient education. Myths surrounding etiologic factors are widely believed by adolescents. A survey of teenagers revealed that many believed that consuming greasy food (64 percent) or chocolate (50 percent) was responsible for the development of acne.
Dispelling these widely held misconceptions and instructing the patient on an appropriate gentle cleansing regimen are cornerstones of acne therapy. For most patients, washing twice a day is sufficient. Patients must also be counseled to avoid comedogenic substances found in many cosmetics, whenever possible. An exception to this advice is the use of sunblock for athletes competing in outdoor activities and for patients using oral antibiotics that cause photosensitivity. Some sunblock and sunscreen lotions contain comedogenic substances; in general, an oil-free water-based sunscreen is best.
After educating the patient, the physician may choose to start therapy with medications, including topical retinoids, topical antimicrobials, oral antimicrobials, and oral isotretinoin. These medications are effective in treating acne vulgaris by one or more of four key mechanisms of action: correcting altered follicular keratinization, decreasing sebum production, reducing bacterial colonization, or producing an anti-inflammatory effect.
Topical retinoids, derivatives of vitamin A, treat acne by promoting normal epithelial desquamation. These medications act as keratolytics and reduce comedo formation. Topical retinoids are first-line agents for comedonal acne, and, because comedones are precursors of inflammatory lesions, they are effective adjuncts in the treatment of inflammatory acne. Commonly used topical retinoids are adapalene, tazarotene, and tretinoin.
Use of the topical retinoids for treatment of both comedonal and inflammatory lesions is supported in the literature. A randomized controlled trial comparing the effectiveness of tazarotene 0.1 percent and 0.05 percent gels with a placebo gel noted a 52 percent reduction in total lesions with tazarotene versus a 33 percent reduction with placebo for mild to moderate facial acne.
The topical retinoids vary slightly in efficacy when compared with one another. A meta-analysis of five randomized trials involving 900 patients with mild to moderate acne vulgaris revealed that with monotherapy, total lesion counts dropped by 53 percent with tretinoin 0.025 percent gel and by 57 percent with adapalene 0.1 percent gel. Adapalene demonstrated more rapid efficacy and considerably greater local tolerability than tretinoin.
A randomized controlled trial comparing tazarotene 0.1 percent gel and tretinoin 0.025 percent gel found a 54 percent reduction in the number of inflammatory lesions with tazarotene compared with 44 percent with tretinoin. Another randomized controlled trial revealed that tazarotene 0.1 percent gel reduced inflammatory lesions by 70 percent and noninflammatory lesions by 71 percent, compared with reductions of 55 percent and 48 percent observed with adapalene 0.1 percent gel. Both treatments were well tolerated, and tazarotene was more cost effective.
Common side effects of topical retinoid therapy include photosensitivity, erythema, dryness, and desquamation. Adapalene 0.1 percent gel was compared with isotretinoin 0.05 percent gel and 0.05 percent tretinoin cream for treatment of inflammatory acne in two recent studies. All three preparations significantly reduced inflammatory lesions, but adapalene was associated with significantly fewer side effects. Tazarotene is associated with more local inflammation when compared with adapalene and tretinoin.
In summary, the topical retinoids have been shown to be effective monotherapeutic agents for comedonal and mild inflammatory acne. The greatest reductions in total lesion counts were observed with tazarotene 0.1 percent gel. Adapalene 0.1 percent gel induces fewer adverse effects, which may improve patient compliance and overall outcomes. Because topical retinoids induce photosensitivity, active patients must avoid excessive sun exposure and liberally use sunblock when participating in outdoor venues.
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