Acne Treatment 101: A Comprehensive Guide

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Promising Botanicals for Acne Treatment

Singapore Dermatologist, Dr. Teo Wan Lin, proposed in her paper on maskne published in the Journal of the American Academy of Dermatology (JAAD) that the topical treatment of acne in a post COVID-19 world should move away from traditional active ingredients such as salicylic acid, retinoids, benzoyl peroxide, sulphur which have an astringent effect on skin, to botanical actives which exert an anti-inflammatory effect. One of the key active ingredients that we have incorporated in the treatment of acne in our practice is berberine.

Acne is one of the most common skin disorders in the world that affects all age and ethnic groups. Key pathogenic factors such as the proliferation and colonisation of the bacteria P. acnes, increased sebum production and inflammatory mechanisms can all lead to the development of acne. Additionally, factors like genetic history and diet also play significant roles in acne development. There has been growing research on plant derived secondary metabolites. These have shown to be effective in the treatment of acne. In this article, we are going to share about the botanical ingredients that are effective in the treatment of acne – without any drying effects or risk of irritant contact dermatitis.

Berberine for Acne Treatment

Acne Treatment with Berberine
The Berberine acne treatment cream is delivered with a 100% vegetal mask, a polysaccharide material that innately delivers moisture to the skin without other additives. It is also biodegradable and designed to be reusable several times for up to 7 days.

Berberine is a traditional Eastern herb derived from various plants such as berberis vulgaris L, and phellodendron amurense. Research has shown that it is effective as an anti-acne active ingredient as it targets various mechanisms in acne formation. 

Here are the four main ways Berberine targets acne formation: 

1. Bactericidal 

Berberine promoted bacterial killing in our body’s immune cells, known as macrophages, by increasing proteins that detected pathogens. This targets the proliferation of P.acnes, and other acne-causing bacteria. 

2. Anti-inflammatory 

It has also demonstrated anti-inflammatory activity by inhibiting the release of proteins involved in inflammation in the body – namely, proinflammatory cytokines IL-6 and TNF-α. In addition, the extract regulates signalling pathways in our skin cells that can lead to inflammation. 

3. Reduce oxidative stress

Oxidative stress is an imbalance of free radicals and antioxidants in the body, which can lead to cell and tissue damage. Research also shows that oxidative stress is also one of the factors that can exacerbate acne formation. Berberine has shown to decrease free radicals in the body, reduce breakdown of lipids in the skin, and DNA fragmentation from oxidative stress. It also helps to increase the activity of enzymes that break down free radicals in the body, and stimulate production of glutathione – the body’s natural antioxidants. 

4. Oil control

In addition, berberine also prevents androgen synthesis in the skin. This is important in preventing the formation of acne as androgens are hormones that stimulate the sebaceous glands, leading to more sebum production. Berberine helps to decrease sebum production by suppressing lipogenesis of sebaceous glands in our skin. 

Additionally, research has also shown that berberine helps to treat acne scarring, erythema, and post-inflammatory hyperpigmentation. Accumulation of excess melanin can lead to pigmentation and scarring. Berberine helps to reduce these blemishes on the skin by inhibiting melanin synthesis and tyrosinase – the enzyme that catalyzes melanin production. 

Curcumin

Curcumin is a polyphenol extract from Curcuma Longa (Turmeric) and has a wide range of benefits for the skin. Polyphenols are potent antioxidants that are naturally occurring in a wide variety of plants. Polyphenols protect plants from damage by exposure to UV radiation. One study found that Curcumin loaded vehicles could accumulate significantly in the skin, prohibiting the growth of P. acnes. The results showed that when combined with lauric acid, curcumin exerted antibacterial activity against a number of bacteria – including P. acnes.  Furthermore, it has shown potent antioxidant and anti-inflammatory effects through regulation of inflammatory pathways in the body. 

Ellagic Acid

Ellagic acid is a polyphenol naturally occurring in many raspberries, strawberries, and other fruits and nuts. One study showed that a combination of ellagic acid and tetracycline (oral antibiotics) made P. acnes more susceptible to antibiotics and the human immune system’s natural defenses. It has also demonstrated anti-inflammatory activity, decreasing the expression of various proinflammatory proteins. Additionally, it’s also a potent antioxidant that exhibits suppression of oxidative stress through free radical scavenging activity, and decreasing of ROS production. 

Epigallocatechin-3-gallate (EGCG)

EGCG is the main flavonoid occurring in green tea, or Camellia Sinensis. It has anti-sebum and oil control effects, and has shown to decrease sebum by modulating sebum-producing pathways in the sebocyte cell line. This flavonoid has also demonstrated inhibition of the testosterone-induced sebum synthesis in sebocytes and suppressed androgen-related pathogenesis of acne. It also has anti-inflammatory and antioxidant effects. 

Alpha mangostin

Alpha mangostin is a xanthone extract from the certain parts of the mangosteen tree. The plant extract has shown to have anti-inflammatory, antioxidant, antibacterial properties that can be effective in the treatment of acne. It has shown to tamp down inflammation through inhibition of the various inflammatory pathways in the body. Additionally, studies have shown that it exhibits antioxidant activity through upregulating the body’s natural antioxidants such as superoxide dismutase (SOD). Film-forming solutions comprising alpha mangostin rich extract has also shown to inhibit P. acnes growth.  

Resveratrol

Resveratrol is a polyphenol and potent antioxidant found in grapes and red wine. Research has found that resveratrol inhibits Propionibacterium acnes growth for a longer period of time compared to benzoyl peroxide. Lower concentrations of resveratrol were bacteriostatic – which means it inhibits bacteria growth. On the other hand, higher concentrations of resveratrol were bactericidal – meaning it kills bacteria. 

Oral Medications for Acne Treatment

Systemic oral antibiotics 

Systemic oral antibiotics are reserved for patients with moderate-to-severe inflammatory acne and should be used in combination with non-antibiotic topical agents for improved efficacy and to prevent resistance. These antibiotics include tetracyclines, macrolides, trimethoprim/sulfamethoxazole, trimethoprim, penicillins, and cephalosporins.

The American Academy of Dermatology (AAD) recommends doxycycline and minocycline as first-line therapies based on studies done. On the other hand, we should avoid tetracyclines in pregnant women or in children younger than eight years old. In these cases, we can instead use trimethoprim or sulfamethoxazole. Penicillins and cephalosporins are not in the recommendation due to their limited evidence base. However, we may use these medications in special situations where patients are allergic to multiple drug classes or in the case of pregnant women. 

Sarecycline (Seysara) is a tetracycline-derived antibiotic, FDA approved for moderate to severe acne vulgaris in children nine years and older. Sarecycline has been proven effective as an anti-inflammatory agent in two large, multicenter, randomized, double-blind studies

Recent studies, systematic reviews, and consensus expert opinion recommend use of oral antibiotics for the shortest duration possible, at most 3 months, except in special recurring cases. After completing systemic antibiotic therapy, we may use topical retinoids for maintenance therapy.

Oral isotretinoin

Isotretinoin is a vitamin A derivative that is believed to act on all processes of acne development. It directly inhibits sebaceous gland function, resulting in decreased sebum production and hence decreasing P. acnes proliferation. Therefore, inflammation is generally reduced. The efficacy of isotretinoin is well established as well as FDA approved and recommended by the AAD for severe, recurring nodular acne that may be causing significant psychological distress or facial scarring.  

Some common side effects, depending on the dose of isotretinoin include dryness, acne flare-up, cheilitis, dry eyes, headache and increased lipid and hepatic enzyme levels. Some may face depression and become suicidal, however this is controversial and there is a lack of evidence to show this. In fact, some recent studies have shown improvement in depressive symptoms in patients on isotretinoin. Before starting on isotretinoin, dermatologists counsel patients on these potential side effects.

While on isotretinoin, patients are also recommended to have regular liver function tests and lipid panel tests. As isotretinoin has teratogenic effects, it can cause harm to a foetus. Hence before starting isotretinoin, one needs to test for pregnancy monthly and start contraceptive measures prior to starting isotretinoin, as well as continue contraceptive measures after stopping treatment.

Oral Hormonal Agents

Combination oral contraceptives (COCs) are anti-androgenic, they are effective anti-inflammatory and anti-acne agents, FDA approved for females above 15 years old who want contraception. They are best used in combination with other acne treatment as improvement may take at least three months.

There are currently four combined oral contraceptives approved for acne vulgaris treatment (ethinyl estradiol/norgestimate, ethinyl estradiol/norethindrone acetate/ferrous fumarate, ethinyl estradiol/drospirenone, ethinyl estradiol/drospirenone/levomefolate). They all have similar efficacy levels.

Antiandrogens

There are few studies proving antiandrogens’ effectiveness in acne treatment. The AAD consensus panel recommends the use of spironolactone, concurrently with contraception, for its antiandrogenic properties in women with resistant and hormonally mediated acne. Some side effects include breast tenderness, menstrual irregularities, and hyperkalemia.

Flutamide is not in recommendation by the AAD as it may result in potential serious side effects. 

Corticosteroids

Prednisone is reserved for cases of acne fulminans as a short course of “rescue treatment” simply to quell inflamation. It is not useful in typical cases of acne vulgaris and can in fact be a cause of a type of acne, known as steroid acne. It is reserved for treatment of acne fulminans. Corticosteroids decrease your immune system’s response to various diseases, reducing symptoms of swelling and other allergic-type reactions. In severe inflammatory acne, this can help to reduce inflammatory flares. However, prednisone has potential adverse side effects, hence we should not be taking the medication without proper medical supervision. 

Blue Light & Lasers for Acne Treatment

Laser and light-based therapy may be used for noninflammatory or moderate to severe inflammatory acne. Light therapy, in particular blue light, works by suppressing the growth of the pathogenic bacteria involved in acne, known as propionibacterium acnes. It is part of the spectrum of physical light, and has been harnessed for use in dermatologists offices for the last two decades, as it is helpful for individuals who suffer from acne.

Light Therapy Acne Treatment
Dermatologist-recommended photon light therapy device for skin and hair treatment. Lightweight NEXT GEN photon light therapy device with 7 therapeutic wavelengths. Recommended for use for all skin types, includes dry sensitive aging skin, combination, acne/oily skin, rosacea.

Generally, blue light therapy is in view as an adjunct for those with moderate to severe acne in combination with oral medications. It can be successfully used as monotherapy for mild to moderate acne. This is especially for individuals who are pregnant or breastfeeding and may not be suitable to take other types of oral medications. Blue light is currently in prescription as part of the following regimen for successful treatment of acne: two times a week of half an hour treatment, with duration for a total of eight sessions.

Overall, blue light therapy has significant benefits of not having to take any oral medications and it also shows fairly quick results. The downside to blue light is that treatment costs can add up. For those with moderate to severe acne or hormonal acne, they may require oral medication in any case. In addition, blue light has been of increasing interest in the field of hyperpigmentation research. It has been shown to possibly exacerbate individuals with pre-existing hyperpigmentation problems.

Lasers are not as well studied in the treatment of acne. The Korean laser company, Lutronic, has created a carbon laser peel treatment using the Spectra XT Laser for reducing the activity of oil glands in the skin. I have found this to be useful in my patients with active acne and for the treatment of seborrhea.

Chemical Peels for Acne Treatment

Chemical peels are a useful adjunct in the treatment of various types of acne. It is especially helpful for comedonal acne, because it has the ability to increase the rate of cellular renewal. The formation of comedones starts with micro comedones. Eventually, it is the retention of dead skin cells around the hair follicles that leads to hyperkeratosis or the retention of keratin around each hair follicle. This is what results in plugging of the skin. It begins as a micro comedonal and subsequently becomes a visible black head or a white head.

Chemical peels can entail alpha hydroxy acids or beta hydroxy acids. It is important to use concentrations which are appropriate for your skin type. In Singapore, chemical peels of at least 10% concentration have to be regulated in a healthcare setting. Over the counter products containing low concentrations of alpha hydroxy acids such as glycolic acids and lactic acids, can sometimes result in skin sensitivity. This is because many of these products are leave-on and actually can cause sensitization in a tropical climate like Singapore where we have year round ultraviolet radiation. It is important for you to consult with your dermatologist if you are interested in performing chemical peels. 

Chemical peels when incorporated in the long term maintenance regimen of acne can have good results. I find it especially useful for the maintenance phase of acne treatment after stopping oral medications for individuals with moderate to severe acne. I also recommend it for mild to moderate cases of acne. Hormonal acne especially can benefit from these peels, as it may prevent premenstrual flare ups.

Hydrocolloid Patches for Acne Treatment

In the age of maskne, skin under occlusion of a face mask has led to skin irritations and a higher risk of breakouts and blemishes. Pimple patches have proved to be effective in reducing stubborn spots around the O-zone – acne development around the cheeks, mouth and chin. 

How do pimple patches work? 

Acne patches are often made of hydrocolloid – which have been widely used as primary dressing in wound management. Hydrocolloid patches have a high absorptive capacity, ventilation, and are waterproof, allowing them to be able to absorb sebum production,  decrease inflammation and prevent contamination from hand touching or air pollution. Acne patches are also usually transparent or have a color that is similar to skin, enhancing cosmetic appearance. 

Pimple patches absorb the impurities that trap under the skin. This helps to flatten breakouts and protect wounds from external bacteria, preventing acne from worsening. These patches help to treat the areas of the skin with active acne bumps. Because, they include an ingredient called hydrocolloid – used for wound healing in skincare. Furthermore, hydrocolloid acne patches create a moist microenvironment for faster healing and tissue repair. They can act as UV protectors which decrease pigmentation, and are usually waterproof. Therefore, you don’t need to reapply them every time you wash your face. 

Rubbing and touching acne lesions can lead to infection and risk of developing scars. Individuals with mild acne may benefit most from hydrocolloid acne patches. To illustrate, in a study by Chao et al, there was a greater reduction in the overall severity of acne and inflammation in participants who wore hydrocolloid patches in just one week. 

Hydrocolloid Patch for Acne Treatment
The HYDROCOLLOID VANISH PATCH helps to reduce scarring, increases absorption, and provides a moist wound healing environment for quick healing of inflamed acne. It is also suitable for treatment of maskne as it prevents touching, provides a moist wound-healing environment, and forms a protective barrier to prevent irritation from the mask.

Do acne patches work as maskne treatment?  

The use of hydrocolloid patches for the treatment of acne is particularly relevant in maskne. Firstly, it provides a barrier between the mask and the skin. Hence, minimizing the element of skin irritation from textile skin friction. Occlusion from face mask wear can make the skin environment more moist and humid. Therefore, these patches help to act as a barrier from bacteria and the increased humidity from your breath. It reduces the chance of bacterial infections which can cause infected acne cysts. It also provides the ideal wound healing environment in order for the exudate from within the acne papule. Releasing in the shortest time possible, so as to promote rapid healing of the acne bump. 

Hydrocolloid patches work by gently absorbing excess fluids, like pus and oil, from acne. At the same time, also protecting wounds from external bacteria. These patches consist of two layers: an inner insoluble layer and an outer water-impermeable layer. Studies have shown that the impermeable layer provides a protective covering and helps prevent the spread of pathogenic microorganisms. Furthermore, studies show the porous lower layer of the hydrocolloid dressing has an absorbing effect on pus and fluids from pimples.

Increases absorption of topicals

Hydrocolloid patches for acne treatment are also a form of transdermal delivery polymer gels in the form of either patches or adhesives. These can increase the absorption of topicals when applying on skin. For example, use the Blemish Spot Cream containing Chlorella Vulgaris together with the hydrocolloid patch to increase the efficacy of acne treatment.

Do pimple patches work on cysts?

Hydrocolloid patches help to treat superficial acne such as pus-filled bumps, blackheads and whiteheads. However, they are not suitable for cystic or deeper types of acne. They also won’t help with pimple or acne lesions that aren’t oozing. 

Cystic acne often requires treatment with dermatologist-prescribed medications and should not be treated with over-the-counter topicals. 

Do acne patches work for acne scars?

While hydrocolloid acne patches help to heal active acne, look instead for polymer patches like the Qraser Cosmeceutical Transdermal Delivery Patch that can help to improve the appearance of acne scars. The custom cut mask for cheek scars is uniquely engineered with several properties. These properties are beneficial for preventing the growth of bacteria, improving the appearance of acne scars, creating a healthy skin microenvironment, and helping the balance of growth factors that stimulate collagen production, reducing wrinkles.

Custom Cut Mask for Acne Scar Treatment
Custom Cut Mask: Anti-Wrinkle Patch for Neck Lifting, Cheek Scars, Stretch Marks

Medicated pimple patches

Acne patches can also contain active ingredients such as salicylic acid or benzoyl peroxide. These may help to treat superficial acne by lowering inflammation and maintaining a moist environment for faster healing of acne. However, as they are astringents, these ingredients may cause sensitivity and irritation, especially under occlusion. 

Hydrocolloid itself is an effective ingredient in treating whiteheads due to its breathable, yet protective barrier that stimulates pimple healing. Other ingredients such as hyaluronic acid in the patches can also help to reduce redness and the visible appearance of bumps. 

When not to use acne patches?

It is important to note, however, that these patches treat acne rather than prevent it. We can wear these patches under a face mask to prevent further aggravation of acne. However, they cannot prevent maskne formation. Therefore, it is important to have a good skincare regimen to prevent further onset of maskne. Cleansing, moisturising, and wearing the correct face mask, will help to proactively decrease future breakouts.

Furthermore, make sure to also use the right sized pimple patches to see the most effective results. A patch too large may irritate the surrounding area of acne and a patch too small will result in an ineffective reduction of acne spots. Overall, hydrocolloid patches have proven to be effective in impeding bacterial infection and promoting wound healing. Hence, making acne patches an ideal way to treat superficial maskne.

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