Optimal management of acne to prevent scarring and psychological sequelae

Acne vulgaris is one of the most common inflammatory dermatoses and is seen in both the hospital setting and in general practice. Multiple factors are involved in the pathophysiology of acne, including: an alteration in the pattern of keratinization within the pilosebaceous follicles resulting in comedone formation; an increase in sebum production which is influenced by androgens; the proliferation of Propionibacterium acnes; and the production of perifollicular inflammation. Genetic and hormonal factors may also contribute to acne. Better understanding of the pathophysiology of the disease has led to the development of novel therapies which are directed at one or more of the implicated etiologic factors. Systemic antibiotics for acne have been the mainstay of treatment for many years. The main cause for concern following the use of systemic antibiotics is the emergence of antibiotic-resistant strains of P. acnes. Concomitant use of non-antibiotic therapies such as benzoyl peroxide helps to decrease the occurrence of resistance and can be effective in the treatment of resistant and nonresistant propionibacterial strains. However, no one agent is able to eradicate resistant strains completely and as resistant strains correlate to poor clinical response to therapy, prescribing strategies are required to minimize the occurrence of resistance to P. acnes. When assessing acne it is important to take an all embracing approach and to examine carefully for both the clinical and psychologic effects of the disease process. There are numerous forms of acne scarring and it is important to be aware of these as patients who are developing scarring merit early effective therapy. Some patients with acne will develop psychologic problems as a consequence of their condition. Even mild to moderate disease can be associated with significant depression and suicidal ideation and psychologic change does not necessarily correlate with disease severity. Acne scars themselves have been shown to produce significant psychopathology. When initiating treatment it is important to consider the aims of therapy. Treatment should be aimed at achieving clearance of acne, prevention of scarring and, where necessary, relief from any psychologic stress resulting from the acne. Therapy should be commenced early in the disease process in order to prevent scarring and it is important to select appropriate therapies according to the clinical signs and psychologic disability. It is also important to ensure that the patient is able to comply with therapy and clear guidelines regarding treatment, possible adverse effects and realistic expectations should be provided.