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International Journal of Research in
Pharmacology & Pharmacotherapeutics
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Print ISSN: 2278 – 2648
Online ISSN: 2278 - 2656
IJRPP | Volume 2 | Issue 1 | 2013
Review article
A Review on Alternative Therapy for Acne
* 1Swalin Parija, 2Sunil Kumar Kanungo, 3Sudhansu Ranjan Swain
1,2
Institute of Pharmacy & Technology, Salipur, Dist- Cuttack, Pin-754202, Odisha.
3
MET Group of Institutions, MIT Campus, Ram Ganga Vihar Phase-2, Moradabad-244001
(UP)
ABSTRACT
Acne is the cutaneous pleomorphic disorder of the pilosebaceous unit involving abnormalities in sebum
production, and it is characterized by both inflammatory (papules, pustules and nodules) and noninflammatory
(comedons, open and closed) lesions. Propionibacterium acnes and Staphylococcus epidermidis are common
pus forming microbes responsible for the development of various forms of acne vulgaris. A number of factors
contribute to the development of acne lesions these include internal hormones, bacteria, some medications,
certain chemicals/products that come in contact with the skin, local pressure to the skin surface, and stress.
Traditionally, attention has focused mostly on over-production of sebum as the main contributing factor of acne.
More recently, more attention has been given to narrowing of the follicle channel as the second main
contributing factor. Common therapies that are used for the treatment of acne include topical, systemic,
hormonal, herbal, and combination therapy. Topically used agents are benzoyl peroxide, antibiotics and
retinoids. Systemically used agents are antibiotics and isotretinolin. While acne cannot be cured, it can be
controlled. The goal of treating acne is to reduce the symptoms and to prevent permanent scarring.
Key words: Acne, Papules, Pustules, Nodules, Propionibacterium acnes, Staphylococcus epidermidis.
INTRODUCTION
Acne is a condition of the skin that is caused by
excessive oil secretion of the sebaceous glands (oil
glands) and the excess production of keratin inside
the hair follicles (hyperkeratinization).These two
conditions cause dead skin cells and excess oil to
be trapped inside the pores, these results in pore
clogging and the formation of a comedo. Trapped
sebum and dead skin cells in the pore are the major
food source of the acne-causing bacteria known as
Propionibacterium Acnes. The availability of more
sebum makes the population of the bacteria grow.1,2
PATHOPHYSIOLOGY3-6
Acne lesions arise from pilosebaceous units, which
consist of sebaceous glands and small hair follicles.
These units are found everywhere on the body
____________________________________
* Corresponding author: Swalin Parija
E-mail address: [email protected]
except the palms and soles. Pilosebaceous density
is greatest on the face, upper neck and chest, at
roughly nine times the concentration found
elsewhere on the body. Obstruction of the
pilosebaceous canal is the primary cause of acne
and occurs because of a variety of factors. The first
factor is sebum overproduction stimulated by
hypersensitivity to androgenic steroids. Excess
sebum production combined with increased
epithelial cell turnover leads to formation of
microcomedones, which can progress to open
comedones, commonly termed "blackheads," or to
closed comedones, often called "whiteheads"
(figure-I). The combination of sebum and
desquamated cells provides an environment that is
ripe for the growth of Propionibacterium acnes, the
principal organism in inflammatory acne lesions.
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Proliferation of P. acnes leads to the conversion of
sebum to free fatty acids, which are irritating and
stimulate the immune response, leading to the
development of inflammatory lesions5 (figure II).
ACNE VULGARIS; MILD TO
MODERATE ACNE VULGARIS
CONSISTS OF THE FOLLOWING
TYPES OF ACNE SPOTS.6-10







cause of acne conglobata is unknown.
Treatment usually includes isotretinoin
(Accutane), and although acne conglobata is
sometimes resistant to treatment, it can often
be controlled through aggressive treatment
over time.

Whiteheads (Most Common): Whiteheads
result when a pore is completely blocked,
trapping sebum (oil), bacteria, and dead skin
cells, causing a white appearance on the
surface.
Blackheads: Blackheads result when a pore
is only partially blocked, allowing some of the
trapped sebum (oil), bacteria, and dead skin
cells to slowly drain to the surface. The black
color is not caused by dirt. Rather, it is a
reaction of the skin’s own pigment, melanin,
reacting with the oxygen in the air.
Papules: Papules are inflamed, red, tender
bumps with no head.
Pustules: A pustule is similar to a whitehead,
but is inflamed, and appears as a red circle
with a white or yellow center.
Nodules: (more severe type) As opposed
to the lesions mentioned above, nodular acne
consists of acne spots which are much larger,
can be quite painful and can sometimes last for
months.
Cysts: (more severe type) An acne cyst
can appear similar to a nodule, but is pusfilled, and has been described as having a
diameter of 5mm or more across.
The stages of acne are illustrated in figure IV.
This is an abrupt onset of acne conglobata
which normally afflicts young men. Symptoms
of severe nodulocystic, often ulcerating acne
are apparent. As with acne conglobata,
extreme, disfiguring scarring is common. Acne
fulminans is unique in that it also includes a
fever and aching of the joints. Acne fulminans
does not respond well to antibiotics.
Isotretinoin (Accutane) and oral steroids are
normally prescribed.

Acne Conglobata
Severe cystic acne characterized by cystic
lesions, abscesses, communicating sinuses, and
thickened, nodular scars. Conglobata acne is
the most severe form of acne and is more
common in males. It is characterized by
numerous large lesions, which are sometimes
interconnected, along with widespread
blackheads. It can cause severe, irrevocable
damage to the skin, and disfiguring scarring. It
is found on the face, chest, back, buttocks,
upper arms, and thighs. The age of onset for
acne conglobata is usually between 18 and 30
years, and the condition can stay active for
many years. As with all forms of acne, the
Gram-Negative Folliculitis
This condition is a bacterial infection
characterized by pustules and cysts, possibly
occurring as a complication resulting from a
long term antibiotic treatment of acne vulgaris.
It is a rare condition, and we do not know if it
is more common in males or females at this
time. Fortunately, isotretinoin (Accutane) is
often effective in combating gram-negative
folliculitis.

Pyoderma short time
This type of severe facial acne affects only
females, usually between the ages of 20 to 40
years old, and is characterized by painful large
nodules, pustules and sores which may leave
scarring. It begins abruptly, and may occur on
the skin of a woman who has never had acne
before. It is confined to the face, and usually
does not last longer than one year, but can
wreak havoc in a very short time.
THE MOST SEVERE TYPES OF
ACNE INCLUDE6-10:

Acne Fulminans
THE DIAGNOSIS OF ACNE
Acne is classified into four grades according to the
comedones present, amount of inflammation
present, breakout severity, how widespread the
acne is and the areas affected in the body.
Grade I: The mildest form of acne with symptoms
of blackhead, whitehead and minor pimples.
Grade II:
There are more blackheads and
whitehead on the skin; papules and pustules are
frequently found.
Grade III: Grade III acne displays the
characteristic redness and inflammation.
Grade IV: Also known as cystic acne, grade IV is
the most severe category of acne. The skin will
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exhibit numerous pustules,
blackheads and whiteheads.
nodules,
cysts,

TREATMENT
BASIC OF ACNE TREATMENT17-23
o
o
o
o

Antibacterial
Examples: Benzoyl Peroxide (Topical),
Azelaic Acid (Topical), Topical and Oral
Antibiotics
Keratolytic/Comedolytic
Examples: Alpha-Hydroxy Acid Family
(Glycolic Acid, Lactic Acid), Beta-Hydroxy
Acid Family (Salicylic Acid), Retinoids
(Retinoic Acid)



Anti-Androgens
Examples:
Spironolactone
(Aldactone,
Spiritone), Cyproterone acetate (Androcur,
Climen, Diane 35, Ginette 35), Flutamide
(Eulexin), nilutamide (Anandron, Nilandron),
Finasteride (Proscar, Propecia)


Sebosuppresive agents
Example of oral sebosuppresive agent: Oral
Isotretinoin (Accutane), Example of topical
sebosuppresive agents: (Zinc Oxide, Copper
Peptide, Isolutrol, Topical Niacinamide)
SYSTEMIC THERAPY FOR ACNE
Recommendations: 5

TREATMENT VEHICLE2
In the treatment of acne, the vehicle (cream, gel,
lotion or solution) may be as important as the
active agent. Consequently, it is important to assess
the patient's skin type. Creams are appropriate for
patients with sensitive or dry skin which require a
nonirritating, nondrying formulation. Patients with
oily skin may complain of an "oily" feel with
creams. Patients who have oily skin may be more
comfortable with gels, which have a drying effect.
However, gels may cause a burning-type irritation
in some patients and may prevent certain kinds of
cosmetics from adhering to the skin. Lotions can be
used with any skin type, and they spread well over
hair-bearing skin. Yet lotions contain propylene
glycol and thus may have burning or drying effects.
Solutions are mainly used with topical antibiotics,
which are often dissolved in alcohol. Like gels,
solutions work best in patients with oily skin.





TOPICAL THERAPY FOR ACNE
Recommendations5


Topical therapy is a standard of care in acne
treatment.
Topical retinoids are important in acne
treatment.
Benzoyl peroxide and combinations with
erythromycin or clindamycin are effective acne
treatments.
Topical antibiotics (eg, erythromycin and
clindamycin) are effective acne treatments.
However, the use of these agents alone can be
associated with the development of bacterial
resistance.
Salicylic acid is moderately effective in the
treatment of acne.
Azelaic acid has been shown to be effective in
clinical trials, but its clinical use, compared to
other agents, has limited efficacy according to
experts.
Data from peer-reviewed literature regarding
the efficacy of sulfur, resorcinol, sodium
sulfacetamide, aluminum chloride, and zinc are
limited.
Employing multiple topical agents that affect
different aspects of acne pathogenesis can be
useful.
However, it is the opinion of the work group
that such agents not be applied simultaneously
unless they are known to be compatible.
Systemic antibiotics are a standard of care in
the management of moderate and severe acne
and treatment-resistant forms of inflammatory
acne.
Doxycycline and minocycline are more
effective than tetracycline, and there is
evidence that minocycline is superior to
doxycycline in reducing P acnes.
Although erythromycin is effective, use should
be limited to those who cannot use the
tetracyclines (ie, pregnant women or children
under 8 years of age because of the potential
for damage to the skeleton or teeth). The
development of bacterial resistance is also
common during erythromycin therapy.
Trimethoprim-sulfamethoxazole
and
trimethoprim alone are also effective in
instances where other antibiotics cannot be
used.
Bacterial resistance to antibiotics is an
increasing problem.
The incidence of significant adverse effects
with antibiotic use is low. However, adverse
effect profiles may be helpful for each
systemic antibiotic used in the treatment of
acne.
HORMONAL THERAPY FOR ACNE
Recommendations5

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Estrogen-containing oral contraceptives can be
useful in the treatment of acne in some women.
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

Oral antiandrogens, such as spironolactone and
cyproterone acetate, can be useful in the
treatment of acne. While flutamide can be
effective, hepatic toxicity limits its use. There
is no evidence to support the use of finasteride.
There are limited data to support the
effectiveness of oral corticosteroids in the

treatment of acne. There is a consensus of
expert opinion that oral corticosteroid therapy
is of temporary benefit in patients who have
severe inflammatory acne.
In patients who have well-documented adrenal
hyper androgenism, low-dose oral cortico
steroids may be useful in treatment of acne.
Table 1. Treatment and Adverse Effects of Different Acne Types
Acne type
Treatment
Drugs used
Adverse effects
Comedonal
Topical retinoid and other
agent
Isotretinoin
Tretinoin
Adapalene
Azelaic acid
Skin irritation
Skin irritation and low tolerability
Skin irritation
Local irritation
Papulopostular
Topical retinoid and/or
benzoyl peroxide
Benzoyl peroxide
Cutaneous irritation, dryness, bleaching
of hair and clothes
Mild acne
Moderate acne
Papulopostular
Oral antibiotics and topical
retinoids/ benzoyl peroxide
or oral isotretinoin
Oxytetracycline
Minocycline
Doxycycline
Erythromycin
Azithromycin
Nodular
Oral antibiotic and a topical
retinoids/ benzoyl peroxide
or oral isotretinoin
Oral isotretinoin
Severe acne
Oral isotretinoin or hormonal
Spironolactone
or high-dose oral antibiotics
Oral contraceptive
and topical retinoids and
Corticosteroids
benzoyl peroxide
Gastrointestinal upset and vaginal
candidiasis
Vertigo and hyperpigmentation of skin
Gastrointestinal upset and
photosensitive
Gastrointestinal upset and vaginal
candidiasis
Gastrointestinal upset
Teratogenicity
Menstrual irregularities
Vascular thrombosis, melasma and
weight gain
Adrenal suppression
Table 2. Cutaneous Side-effects From Topical Acne Treatments and Potential Novel Systems for
Agent Delivery115
Common Topical Acne
Treatments
Cutaneous Side-effects
Potential Novel Systems for
Agent Delivery
Retinoids (e.g., adapalene,
tazarotene, tretinoin)
Burning, peeling, erythema, dryness,
photosensitivity
Microsponges, liposomes,
nanoemulsions, aerosol foams
Benzoyl peroxide
Dryness, erythema, peeling, hair and clothing Polymers, fullerenes
discoloration
Clindamycin phosphate
Erythema, dryness, allergic contact dermatitis Aerosol foams, polymers,
nanomemulsions
Erythromycin
Dryness, erythema, peeling, allergic contact
dermatitis
Aerosol foams, polymers,
nanomemulsions
Salicylic acid
Dryness, erythema, peeling
Polymers, microsponges
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273]
MISCELLANEOUS THERAPY FOR
ACNE5
Recommendations


Intralesional corticosteroid injections are
effective in the treatment of individual acne
nodules.
There is limited evidence regarding the benefit
of physical modalities including glycolic acid
peels and salicylic acid peels.
Chemical peels
Both glycolic acid-based
based and salicylic acid based
peeling preparations have been used in the
treatment of acne. There is very little evidence
from clinical trials published in the peer
peer-reviewed
literature supporting the efficacy of peeling
Figure I. Comedonal
regimens.170-172.
2. Further research on the use of
peeling in the treatment of acne needs to be
conducted in order to establish best practices for
this modality.
Comedo removal
There is limited evidence published in peer
reviewed medical literature that addresses the
efficacy
acy of comedo removal in the treatment of
acne, despite its long-standing
standing clinical use. It is,
however, the opinion of the work group that
comedo removal may be helpful in the
management of comedones resistant to other
therapies. Also, while it cannot affe
affect the clinical
course of the disease, it can improve the patient’s
appearance, which may positively impact
compliance with the treatment program.
F
Figure
II. Inflammatory
papule and pustule in acne.
Figure IV. Nodular
odular cystic acne.
Figure
igure IV.
IV STAGES OF ACNE.
(a) normal follicle; (b) open comedo (blackhead); (c) closed comedo (whitehead);
(d) papule; (e) pustule.
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MANAGEMENT OF ACNE
Lesion type(s)
Comedonal
lesions
Mixed comedonal
lesions and
papulopustules
papules and
pustules
Prescribe one of the Prescribe any one
Prescribe Benzoyl peroxide
following:
Retinoid+topical antibody
Topical retinoid
Retinoid+benzoyl peroxide
Azelaic acid
Retinoid+ benzoyl peroxide
Salicylic acid
peroxide+topicalantibiotic
Azelaic acid+
benzoyl peroxide
If results are
Unsatisfactory,
Increase strength or
Change medication
Cystic lesions
Prescribe
course of oral
antibiotic +
mixed topical
therapy
If results are Unsatisfactory,
add course of oral antibiotic.
If results are
Unsatisfactory,prescribe
retinoid+course of oral
antibiotic
If results are Unsati
-sfactory, consider
whether patient is a
candidate for oral
Isotretinoin therapy.
If results are Unsatisfactory,
Consider possibility of
endocrinopathy
If endocrinopathy is identified,
treat.
If no sign of
endocrinopathy is
found, consider repeat
course of oral Isotretinoin.
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CONCLUSION
Much progress has been made to improve the
performance of topical anti-acne care products in
recent years.. Future research will be aimed at
obtaining a greater understanding of the
pathogenesis of acne vulgaris. The pillosebaceous
follicle is the target organ of most of the modern
drug for the treatment of acne. Currently, several
topical and systemic agents are employed for
treating acne that affect at least one of the main
pathologic factors responsible for development of
acne and are associated with several side effects.
New excipients, refined processing techniques, and
a better knowledge of the physicochemical
properties of vehicles and drugs have led to the
development of new delivery systems that may
result in more advanced anti-acne therapies. Novel
drug-delivery systems, such as liposomes, niosoms,
micro emulsion, microsponge, hydrogels and solid
lipid nano particals of these agents, can play a
pivotal role in improving the topical and systemic
delivery of the drug treating acne with a
concomitant reduction in their side effects. Well
controlled clinical trials will be required to confirm
the clinical benefits of these new formulations in
terms of efficacy, tolerability, compliance, and
cosmetic acceptability.
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