Resolving Acne without pharmaceuticals: it is possible!

Introductory concepts

Acne is one of the most frequent afflictions in dermatology. The most common form is teen (pubertal) acne because, as the name suggests, it occurs during the period of sexual development (puberty).
Acne may, however, continue after this phase or, may appear for the first time at around the age of 20 or beyond. In this case, the acne is referred to as ‘adult’. Both forms of acne can be mild, medium or severe. Clinically, acne can be divided into: comedogenic acne, comedogenic/cystic acne, cystic acne or nodular/cystic acne etc. The causes of acne can lie within a family or, simply, an individual may be predisposed to the condition. Psychological stress can also be a cause or aggravator of acne. At one time, acne was thought to be the consequence of an imbalance of sex hormones, however this theory has been disproved by clinical evidence that shows acne can occur in individuals who do not have any form of hormonal alteration. It is now understood that it is the skin of the face and trunk itself that produces androgens, particularly when the individual is under psychophysical stress. Since the androgens that cause acne are produced by the skin itself, it is at best useless and at worst harmful to resort to anti-androgen treatments with systemic drugs. These create imbalances and do not resolve acne.

The most common errors in acne treatment

The fight against bacteria

In the past, it was believed that skin bacteria, and particularly propionibacterium acnes, were the key causes of acne. This belief spawned the use of systemic or topical antibiotics and/or powerful antiseptics. However, these treatments were found to be more harmful than helpful, and in particular, the use of long-term antibiotics increases an individual’s risk of dysbiosis, changes to the liver, and the development of antibiotic-resistant bacteria. In the 1980s, it was realized that acne was the result of inflammation, not bacteria, which saw the introduction of retinoic acid derivatives (e.g. vitamin A) to heal acne without the use of antibiotics. However, despite this evidence, antibiotics and antiseptics are still prescribed in the treatment of acne today.

The pill and hormonal therapy

The fact that acne often develops at puberty led many to think that it was the result of an imbalance in sex hormones. It is true that, in some individuals with endocrinological conditions, the androgens can cause acne.
Despite the fact that, generally, acne has little to do with hormone dysfunction, the birth control pill or antiandrogens have been often prescribed to women with acne. In reality, if a hormone assay is done on individuals with acne, the results will likely be perfectly normal.

Another misinterpretation on the causes of acne came from ultrasonography of the ovaries. A woman of childbearing age will have “microfollicular follicular” ovaries on an ultrasound, that is, with ovarian follicles in evidence. This was often confused with the “micropolicular” appearance associated with ‘polycystic ovaries’. Polycystic ovary syndrome is actually a complex disease that is rarely accompanied by acne. From this misinterpretation comes the prescription of high-dose estrogen hormones and antiandrogens to treat acne.
Today, it is known that it is the skin itself that produces androgen hormones according to stimuli unrelated to the activity of the ovaries. For this reason, the birth control pill or other hormones should not be used to treat acne.

Chemical peeling

Chemical peeling involves the application of trichloroacetic, glycolic, pyruvic or salicylic acid to the skin. At the correct concentration, these acids burn the epidermis (surface of the skin), causing it to detach and then repair itself. When applied to acne-prone skin, these acids exert a “cleansing” action that is, unfortunately, only temporary. Repeated peeling treatments over time leads to negative results such as skin damage, pigmentary spots and the worsening of acne.
Therefore, chemical peeling is an impractical treatment method that is not recommended.

The retinoid era

Retinoic acid, and in particular its derivative 13-cis retinoic acid, are potent pharmaceuticals that target acne. 13-cis retinoic acid prevents the formation of plugs at the outlet of the sebaceous glands and is a powerful drug against acne of any kind. Unfortunately, this drug has multiple drawbacks when taken orally, the most serious of which is the high risk of complications it poses to developing fetuses in the womb. Moreover, retinoic acid has been linked to increased cholesterol, calcification of tendons, and depression.
When applied directly to the skin, retinoic acid is unlikely to cause serious side effects, other than causing dryness and redness (retinoid dermatitis).

Micropeeling

Micropeeling involves the application of peeling substances at a low concentration, causing a sort of forced skin cleansing through accelerated desquamation. Micropeeling achieves two important curative results for acne: firstly, the elimination of comedones or cysts, and secondly, it guarantees long-term results, as the cream can be used for as long as required. Micropeeling does not damage the skin and can be used for years.

Micropeeling agents and concentrations

An effective micropeeling product that is suitable for daily use while combating acne must have perfectly balanced micropeeling agents so as not to cause irritation. Salicylic acid and glycolic acid are naturally occurring acids that have synergistic properties and act by detaching the corneal lamellae.

Micropeeling in practice

Apply Glicosal Lotion in the evening to areas affected by acne. To ensure effective make-up removal and cleansing before application, use the non-foaming Eudermic Base Wash, which helps maintain skin softness and prepares it for micropeeling. Apply seven to ten drops of Glicosal Lotion onto a moistened cotton pad. Gently massage in circular motions over the entire face until the lotion has been absorbed and the pad is dry. Avoid vigorously rubbing the pad against the skin, as the friction can cause skin redness. Do not wash the face or use any other products after applying Glicosal Lotion. The morning after, only wash the face with tap water and apply no other products, including moisturizers. For make-up, use only mineral-based products, such as Sun Clay or Argillina Skin Color which are both non-comedogenic and remain exclusively on the skin’s surface. Foundation and other colored creams must not be applied as they can penetrate follicles, causing comedones and folliculitis.

Side effects of micropeeling

Some possible side effects of micropeeling can be skin dryness and an initial worsening of the skin condition.
Dryness is caused by the peeling agents and the fact that moisturizers cannot be used following application. While dryness can be irritating, it will improve as the treatment progresses.
Similarly, the results from micropeeling are not immediate, with improvements appearing after the second or third month of treatment. It is important to be aware of this, so as not to feel discouraged or tempted to stop the treatment before it has had a chance to work.
Moreover, cases of acne may actually worsen during the first two months of treatment. While it doesn’t always happen, this phenomenon is due to the treatment bringing cysts and comedones up to the surface and, although it may appear the acne is getting worse, it is in fact a sign that micropeeling is working well.

Combined micropeeling: when micropeeling isn’t enough

In more severe forms of acne, or where the skin is very seborrheic, micropeeling alone may not be sufficient to control acne. In such cases, combined micropeeling is recommended, where friction with retinoic acid lotion is added to the micropeeling routine described above (Airol Lotion, available in pharmacies). While this product is sold without a dropper, it is recommended to purchase a bottle with a pipette lid in order to correctly measure the seven to ten drop dose. The drops should be applied to a cotton pad and applied to the face as Glicosal Lotion is. To avoid retinoid dermatitis, use once or, at most twice, per week instead of Glicosal Lotion. The decision whether to follow simple or combination micropeeling treatments is for the dermatologist to decide, following an evaluation of acne type, skin type, and seasonality.

Micropeeling rules

The technique of Simple or Combined Micropeeling is very practical, but certain rules must be observed to ensure that the treatment is as effective as possible.
These rules are:
During the treatment remember to:
Do not use soaps or cleansing milk but wash/make-up with a non-foaming cleanser (such as Eudermic Cleansing Base)
Do not use coloured make-up creams
For make-up it is advisable to use mineral Make-up such as Sun Clay which does not penetrate the skin.
Those who wish to mask skin imperfections during the Micropeeling treatment can apply Argillina Skin Color. This concealer does not cause folliculitis or comedones.

• Do not use moisturizing or emollient creams during the day
• Do not have facials or other types of intense facial cleansing.
• Do not squeeze pimples or blackheads.
• Do not expose yourself to UV lamps or sunlight.
• Do not use other medications or vitamins.
• Do not follow specific diets.
• Do not use sunscreens, as they are loaded with chemical compounds. To protect the skin from UV rays, apply the mineral, light reflectant Sun Clay.

During the treatment, the skin becomes dry and flaky to allow the acne to be eliminated. If burning or redness appears, the Micropeeling is suspended for a few days, the skin returns to normal and then the treatment can be resumed using fewer drops or carrying out Micropeeling on alternate evenings.
In the summer months, when sun creams cannot be used, the Sun Clay mineral photoreflectant is used.
When the skin is too dry and tight and cannot use moisturising/emollient creams, a layer of Extreme Emollient Ointment can be applied in the morning , which does not penetrate the skin and is therefore non-comedogenic. The same Ointment can be used as an under make-up for mineral make-up. If Argillina Skin Color is used, which also has a moisturising effect, it is not necessary to use Emollient Ointment Extreme.

From micropeeling to photodynamic therapy

Simple or combination micropeeling treatment is a very effective treatment for most forms of acne. However, another equally effective treatment, photodynamic therapy (PDT), is also now available.
Photodynamic therapy involves applying an aminolevulinic acid (ALA)-based cream to the area of acne, which then penetrates inside the inflamed acne follicles. Following exposure to a particular intensity and wavelength of LED light, the cream will have transformed into the protoporfirina IX compound after just two hours.
This light activation causes the immediate release of oxygen radicals which sterilize the follicle and, in the days after treatment, make inflammation disappear.
Photodynamic therapy is efficient in eliminating inflammation and, because it does not involve pharmaceuticals, it is harmless and can be performed time and time again. However, it requires much more time and money than micropeeling, with each session lasting for around three hours at varyingly high costs.

Why photodynamic therapy doesn’t replace micropeeling

Ideally, micropeeling remains the treatment of choice, with photodynamic therapy only introduced in combination with micropeeling in cases of inflammatory acne. Photodynamic therapy could also be considered when the patient wants to accelerate treatment of a sudden worsening of acne, which can often be brought on by stress. From micropeeling to PDT: a comprehensive treatment plan without drugs.
The introduction of first micropeeling and, later, photodynamic therapy radically changed the way in which both teenage and adult acne could be treated. With these methods, clear results are achieved without resorting to the use of any drugs, which is a considerable advantage when acne is a condition often affecting teenagers or women of childbearing age. Treating acne without the use of additional drugs is a notable achievement, but it does require consistency on behalf of the patient and trust in the dermatologist. This is particularly important, as acne is not an acute disease but a chronic one with moments of improvement and worsening that follow each other, often without apparent cause.

Photodynamic therapy in acne treatment

• To accelerate healing, eliminate inflammation, reduce scarring and to counteract periods of worsening acne, photodynamic therapy (PDT) is a modern solution.
• PDT does not require drugs and instead uses photodynamic agents and red light treatment to flare the acne follicle (furuncle).
• An ointment containing a substance called 5-aminolevulinic acid (5-ALA) is applied to the area to be treated. This substance is picked up by the inflamed acne follicles and transformed into a photoactive product, that is, one capable of reacting with light (protoporphyrin IX).
• After applying the ointment containing 5-ALA, the area to be treated is covered with special bandages.
• After about two hours, the area is exposed to visible red light of wavelength around 630 nm for 10 to 20 minutes.
• During light treatment, a sensation similar to sunburn may be felt. This feeling will be stronger the more intense the acne is. Although uncomfortable, these sensations of perceived heat are usually well tolerated, and in cases of intolerance, water spray can be applied.
• After treatment, the skin appears red and should be dressed with a special healing ointment without bandaging.
• Over the next week, the acne furuncles in the treated area will dry out and flake off. During this period, apply PEG Ointment twice a day without bandaging, wash with an appropriate washing base, and do not expose the area to strong sunlight or UV lamps.
• After one week has passed, micropeeling treatment can be resumed as prescribed by a dermatologist.
• As long as there is no damage to the structures of the skin, there is no limit to the number of photodynamic treatment sessions a patient can undertake.

One week after PDT: within the enlarged images, the dramatic decrease in comedones is clear.
Alongside a reduction in comedones, inflammation has also considerably reduced.

Physical treatments

Different physical methods such as UV therapy, photochemotherapy, LASER, and photodynamic therapy have also been used in AA without appreciable results. Needling with 0.5 mm needles, practised on alopecic patches every 15 days, has also, according to some authors, given positive results, but the data is recent and awaits confirmation. Lastly, there is no shortage of studies where, on the wave of the autoimmune theory for AA, oral immunosuppressants such as Methotrexate and Cyclosporine have been used, which have given negative results in the same way as cortisone. In conclusion, the treatments proposed for AA that does not resolve spontaneously are very disappointing both for the dermatologist and, above all, for the patient. This should not make the dermatologist desist from a therapeutic attempt useful if only to give hope to the patient and to stem the anguish generated by the hair loss event.

Treatments of the future

Researchers at Columbia University Medical Centre have identified a receptor expressed by AA sufferers that enables the binding between hair follicles and lymphocytes. This binding is said to be at the root of hair loss.
A monoclonal drug capable of acting as a JAK receptor inhibitor would lead to the resolution of AA in the majority of cases.
DermaClub trusts that the data from the Columbia studies will be confirmed and that the drug will soon be available in Italy.

Adult acne: in this case, inflammation was reduced with PDT, before simple micropeeling to achieve remission.

One week after PDT: within the enlarged images, the dramatic decrease in comedones is clear.

PDT: alongside a reduction in comedones, inflammation has also considerably reduced.

In this patient, PDT was first used to reduce inflammation. Micropeeling was then used to ensure acne remission.

In this case, PDT was first used before combined micropeeling treatment to achieve acne remission.

Adult acne: in this case, inflammation was reduced with PDT, before simple micropeeling performed to achieve remission.