My ten year old daughter already has acne. I am concerned that she may loose her self-esteem and scars may develop later on. My doctor prescribed antibiotics to treat the acne, but I am worried about the development of antibiotic resistance.
Acne is almost an inevitable part of growing up. Although it is not life-threatening, it has the potential to cause a number of psychological and social challenges such as poor self-esteem, social withdrawal, embarrassment, frustration, anger, and rejection.
Acne occurs in 80-90% of adolescents and accounts for 10% of office visits to primary care physicians. The onset of acne may be a predictor of later severity. If a girl gets acne at age ten, she is much more likely to experience severe acne within the next five years.
Some patients develop acne for the first time as adults. In fact, the incidence of acne in the 25-34 year age group is 8%; in the 35-44 year age group is 3%. For some women, acne is experienced as flare-ups during their premenstrual cycles.
The mechanism behind the formation of acne is based on the concept of plugged skin pores. The scientific name for a blocked pore is a comedone. Essentially, a comedone is an inflamed and plugged follicle in an area where there is a lot of sebum or skin oil production (usually the face, neck, chest, shoulders, and upper back).
The skin normally carries bacteria known as Propionibacterium acnes. Inflammation occurs when the enzyme produced by this bacterium interacts with the sebum. The degree and intensity of inflammation determines the appearance and severity of the acne. The worst cases of acne present as deep cysts, which are often painful and deeply troubling to most adolescent patients.
The term acne includes a range of skin disorders. For example, “whitehead" refers to closed comedones; "blackhead" refers to open comedones, where oxidation of the sebum determines the color of the acne; cysts, know as "papules" and "nodules" indicate a more severe situation, often requiring the opinion of a skilled dermatologist (See www.aad.org for typical photographs of these various forms of acne).
Common acne, occasionally referred to as acne vulgaris, is closely connected to the amount of androgens or male hormones in the body. Acne is rarely part of a bigger picture, as in the case of Polycystic Ovary Syndrome (PCOS).
PCOS is characterized by acne, menstrual irregularities, extra hair formation (hirsitusm) and insulin resistance. Any girl with reduced menstruation (oligomenorrhea) and acne needs to seek further investigation to rule out endocrine abnormalities.
Cosmetics, especially oil-based products as opposed to water-based products, may contribute to acne formation. The same is true for hair gels and sprays. Occlusive clothing such as turtlenecks, bra straps, shoulder pads and sports helmets also play a role in developing acne.
The contribution of diet in causing acne remains controversial. Most dermatologists dismiss the effects of chocolate, peanuts, and colas. Dermatologists do admit that if these foods play a role, as is the case in a small percentage of patients, he or she may want to eliminate them to see if it helps.
According to the landmark Nurses Health Study (NHS) which involved 47,355 nurses, there is an association between milk ingestion and acne. The line of thinking is that hormones contained in milk may be a factor. Given these findings, it is worth noting the use of organic diary products has become increasingly popular recently.
Antibiotics were first used for the treatment of acne in the late 1930's and the early 1940's. However, the rate of antibiotic resistance was 20% in 1978, escalated to as high as 62% in 1996, and continues to climb today.
The three main antibiotics used in treating acne are:
- Tetracycline: should not be used in patients under 12 years old, given the risk of discoloring the enamel of developing teeth.
- Minocycline: often requires lower dosages than tetracycline.
- Erythromycin: less anti-inflammatory qualities than tetracycline, but more likely to cause antibiotic resistance.
Remember when treating acne, oral antibiotics should not be used alone (monotherapy) or for longer than 8-12 weeks at a time.
Accutane, a Vitamin A derivative introduced in 1982, is a potent oral isotretinoin. It is expensive, but 80% of users experience positive changes. However, the potential risks are liver damage, elevated triglycerides, joint and muscle pain, reduced night vision, and a possible association with depression and suicide (See www.FDA.gov for more detail).
Accutane is also highly damaging to a fetus. Therefore, before adolescent girls start using it, pregnancy testing must be done and contraception methods must be in place. The majority of experts consider the prescription of Accutane to be appropriate only in the hands of a dermatologist. Furthermore, Accutane is indicated only when conventional therapies have failed over a 6-month period or when the risk of scarring runs high.
Treatment of acne has improved over the past decade. According to a special article in Pediatrics (Sept 2006), an expert committee working together as the Global Alliance to Improve Outcomes in Acne stated that the foundation of treatment for most patients should be topical retinoid therapy.
Retinoid, a Vitamin A related substance, comes in creams, gels and solutions. The lowest strength is 0.025%, which is the recommended starting dose given one of the common side effects is burning of the skin. This skin irritation is less common when a retinoid administered at night is combined with a topical antibiotic, such as benzoyl peroxide (BPO), which is administered in the morning. Newer topical products contain the antibiotic clindamycin in combination with BPO. Combining BPO with an antibiotic may reduce the risk of resistance.
Rubbing the skin and using astringents may actually worsen acne. Non-pharmaceutical treatments of acne such as grapefruit seeds, flaxseed, UV therapy, Vitamin B5, laser treatment, and blue light therapy all remain controversial and less likely to be successful in the majority of patients.
Scar formation is variable and hard to predict, according to the American Academy of Dermatology. Acne can cause two types of scarring: depressed scars and raised scars. The latter are known as keloids, which result from excessive formation of collagen due to significant inflammation. A cosmetic procedure called Dermabrasion is considered the most effective treatment of scars.
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