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While most cases of acne are mild enough to be treated with over-the-counter medications, some 20 percent of patients require a more aggressive approach to prevent or address permanent scarring that can result from severe acne.
“We’re not sure why some patients have mild acne and others have severe forms of the disease,” explains Christina Kim, MD, a dermatologist in the Clinic for Acne, Rosacea and Aesthetics (CARA) at UCLA. Acne occurs when clogged skin pores become inflamed or infected with bacteria. Family history, hormone changes (such as menstrual cycles and puberty), inflammation, stress and exposure to certain drugs are common primary causes of acne, but some evidence suggests that diet and environment may also play a role, Dr. Kim says.
Common strategies to fight acne include prescription topical treatments, as well as prescription antibiotic pills and creams, often used in combination, which help to reduce bacteria and fight inflammation. Some oral contraceptives also improve acne in women. In severe cases, when first-line treatments are unsuccessful, a form of vitamin A, isotretinoin, may be recommended. Though very effective, isotretinoin is associated with dryness, itching, nosebleeds, muscle ache and sun sensitivity, as well as increased blood triglycerides and cholesterol, increased liver enzyme levels and other problems. It is also associated with severe birth defects if taken during pregnancy. Patients should have a thorough discussion of risks and benefits before starting treatment.
“We have a range of very effective treatments available to address acne, but not everyone can tolerate the side effects,” says Dr. Kim. “At CARA, we treat all patients with acne, including high-risk patients who need higher levels of care, such as people with a history of depression, patients with severe liver or bowel disease, or those who can’t take antibiotics or isotretinoin for other reasons.”
Prolonged antibiotic use increases the risk of developing antibiotic resistance and may cause upset stomach, dizziness, discoloration or increased sun sensitivity.
Newer, device-based therapies can safely and effectively address acne and improve the appearance of discolorations and scars caused by acne, without the use of pills and with fewer side effects, according to Dr. Kim.
Photodynamic therapy (PDT), for example, uses a photosensitizing drug and light source to shrink oil glands, kill bacteria and reduce inflammation in the skin. This reduces acne breakouts, improves the skin’s overall texture and helps to resolve acne-induced skin discoloration. Creams, chemical peels and laser resurfacing techniques can be used to effectively address perceived discoloration and redness associated with acne. A more advanced technique, fractionated laser, is required to address actual changes in skin texture caused by acne.
“Previously, our best option was to cut out the scars, create another scar and then reshape the surface,” says UCLA dermatologist Jenny Kim, MD, PhD, who specializes in the new laser aesthetic techniques. “Fractionated lasers are new lasers that can be used to remodel the dermis so that the scar tissue is less noticeable. In addition, fillers can be used to improve acne scars and remodel skin.”
PDT, fractionated laser and other aesthetic therapies usually require several office visits and are not typically covered by insurance. The newer techniques, however, provide more options for fighting acne than the traditional systemic and topical therapies.