Treatment of Acne and Rosacea
What is acne?
Acne is the most common skin disease worldwide and primarily affects the sebaceous glands and hair follicles. Increased production of sebum (seborrhea) and abnormal keratinization in the opening of the hair follicle lead to the formation of non-inflammatory comedones (black heads); later the follicles become inflamed producing papules (pimples), pustules (pus-filled lesions) and nodules (larger bumps). Depending on the clinical appearance, one speaks of comedonal, papulopustular or conglobate acne. Around 90% of adolescents have some degree of acne. The face, chest and back are the most commonly affected sites. Most patients improve after puberty. Around 7% develop significant scars and perhaps 10% have active disease past age 25. There seems to be a genetic predisposition to acne, which does run in families. Additional factors determine the onset and severity of the disease; they include bacterial colonization (Propionibacterium acnes), hormonal status (excessive androgens), comedo-inducing substances in cosmetics, smoking and stress. Picking at or otherwise manipulating pimples causes increased inflammation and resultant scarring. Thus, the best advice is „Hands off“ - hard advice to follow but crucial.
Treatment of acne
The medical therapy of acne attempts to reduce sebum production, restore normal keratinization, eliminate bacteria and reduce inflammation. Each patient deserves an individualized therapy plan adjust to stage and severity. Options include professional skin care to remove blackheads, α-hydroxy acids (gel, lotion, wash solution, peeling), benzoyl peroxide (gel, cream, wash solution), retinoids (gel, cream), antibiotics (gel, cream, tablets) and for women: oral contraceptives with anti-androgen effects.
In severe or therapy-resistant cases, the systemic vitamin A acid derivation isotretinoin may be needed. Often several months of isotretinoin therapy succeeds in permanently stopping excessive sebum production. Isotretinoin cannot be used during pregnancy because it causes severe malformations in the unborn infant. Women taking isotretinoin must also use oral contraceptives.
Treatment of acne scars
One must wait for acute acne to quiet down and heal before trying to treat the residual scars. Many different forms of scarring can accompany acne; fortunately there are a number of treatment options which must be carefully selected for each patient in a personalized consultation.
Solitary small deep scars - ice-pick scars - can be excised with punch biopsies (removing a cylinder of skin including the scar). The result is tiny flat scars which are almost invisible.
Deep broad scars are better treated with subcision. After incising the strands of connective tissue at the base of the scar, it is possible to elevate the scar. Using a sharp Strauss cannula the surgeon penetrates the skin at just one point and then working in a „windshield wiper“ pattern, fans out to undermine and free up the broad scar. In addition, injections of autologous fat or hyaluronic acid can help to level out the skin profile; these injections usually must be repeated several times.
Hypertrophic nodular scars, which are most often found on the chest and back, are best treated with cryotherapy, which involves spraying with liquid nitrogen to deeply freeze the tissue and/or with the intralesional injection of corticosteroids and a cytostatic agent.
When numerous small minimal scars combine to make the face appear uneven, then laser therapy using the modern fractionated lasers is often the best choice. The entire scarred area is treated several times with fractionated photothermolysis, following the aesthetic units (cheeks, nose, mouth, forehead and chin). Often full-face therapy is wise to insure that the entire face has a more uniform appearance in regard to texture and color. Through the stimulation of collagen synthesis, the results continue to improve for at least 6 months after the procedure. Dilated blood vessels and pigmentary irregularities can be treated with intense pulsed light (IPL) devices.
What is rosacea?
Many individuals have increased numbers of small dilated blood vessels on their nose and cheeks. They tend to increase with age and may be the first stage of a skin disease known as rosacea. Rosacea in many ways resembles acne but usually occurs in patients over 40 years of age and does not feature comedones. It favors the nose and cheeks, but also may occur on the chin and forehead; women are more often affected than men.
Depending on the severity of the skin findings, three grades of rosacea are identified. Rosacea (Grade I) features flat red areas on face caused by an increased number of small blood vessels, known as telangiectases. If small papules (bumps) and pustules (pus-filled lesions) develop, we speak of rosacea (Grade II). Another variant of rosacea is rhinophyma or drinker's nose, in which proliferation of sebaceous glands can lead to almost grotesque deformities. This rosacea (Grade III) is quite uncommon and almost exclusively limited to men. Involvement of the eyes with inflammation of the eyelids and conjunctiva is seen in ocular rosacea, so patients should also be followed by an ophthalmologist.
The causes of rosacea are unclear; possible factors include abnormal control of vessel growth, infestation by Demodex mites which colonize sebum, and nerve-stimulated inflammation. The findings are often worsened by excessive consumption of coffee, tea or alcohol, as well as by using sharp spices. Sun exposure also usually worsens the condition.
Treatment of rosacea
The excessive vessels and redness is best treated with intense pulsed light (IPL) which heats its target molecule, hemoglobin (the main red component of blood) within the vessels. They then become occluded and are resorbed, so that they are no longer visible. The red areas thus become pale again. Usually 3-4 treatments at intervals of 2-4 weeks are needed to obtain optimal results. The therapy is relatively pain-free, so that anesthesia is not required. Regular use of non-occlusive sunscreens is required after the treatments and in general wise advice for patients with rosacea.
The medical therapy of rosacea aims to reduce the production of sebum, to reduce bacteria and mites and to counteract inflammation. Each patient deserves an individualized therapy plan adjust to stage and severity. Options include: mild cleansing (wash solutions), antibiotics (gel, cream, tablets), and metronidazole (gel, cream, tablets). In severe or therapy-resistant cases, the systemic vitamin A acid derivative isotretinoin may be required. Often several months of isotretinoin therapy succeeds in permanently stopping excessive sebum production and arresting the disease. Isotretinoin cannot be used during pregnancy because it causes severe malformations in the unborn infant. Women taking isotretinoin must also use oral contraceptives.
Operative therapy is only employed for rhinophyma - rosacea (Grade III). The protuberant excessive tissue on the nose is removed either by tangential excision with scalpel and razor or removed with an ablative CO2-laser.
Last but not least: Brimonidin (gel) is an option to reduce the redness in rosacea for about twelve hours remarkably. This may be an additional useful tool to keep things in working or private life going smoothly.
In a personalized consultation, I will be happy to discuss with you which therapeutic approaches are most appropriate for you.