Acne vulgaris is a disease of the skin manifested by comedones and
inflammatory lesions. Essentially all adolescents are affected, while only about
3% of the population aged 35 to 44 years suffer from some degree of acne.
Severity of disease is greater in males, but more persistent in females. Acne
affects areas of the skin containing the largest sebaceous glands, including the
nose, central forehead, medial cheeks, middle chin, back, and trunk.
A less common disorder, acne rosacea, is now classified as an acneiform as it
bypasses the comedo stage. It involves dilation of small blood vessels that
leave a prolonged facial redness. It is more prevalent in fair-skinned men and
women, occurs later in life, and predominately afflicts those of Celtic and
Northern European backgrounds.
Neonatal acne begins in the first six weeks of life, resolves within three
months with no scarring, and is not predictive of later acne. Infantile acne
begins at three to six months of age, may result in scarring, and is associated
with increased risk of acne vulgaris.
Acne vulgaris is caused by increased production in the sebaceous gland in
response to elevated androgen activity with subsequent pathophysiologic
responses. The precise etiology of acne rosacea is unproven but thyroid
dysfunction and other triggers seem to provoke the skin condition.
- Greasy/oily cosmetic or hair products containing vegetable or animal
- Genetic predisposition
- Acne at age 10 is predictive of severe acne at age 15
- Humid climates
- Sun exposure
- Occlusion of skin pores
- Oral contraceptive use
- Genetic predisposition
- Personal triggers—diet (cheese, meat, spicy
foods, caffeine, alcohol, hot soup or drink), cold, sun, wind, exercise, stress,
|Signs and Symptoms|
- Open comedo ("blackheads")
- Closed comedo ("whiteheads")
- Inflamed papule
- Cysts and nodules
- Nodulocystic lesions
- Prolonged facial redness
- Pustules, papules
- Ocular rosacea, conjunctivitis, stye formation
- Rhinophyma (enlargement of the nose resulting from tissue
- Flat warts
- Lupus erythematous—for rosacea
- Fungal infection—for
Comedones, papules, pustules, and scarring may all be visible. Emotional
upset of patient may also be evident and should be addressed.
- Overactive sebaceous glands drain into follicular canal, becoming
plugged with keratinous debris that contains Propionibacterium acnes
- Sebaceous gland increases production in response to increased androgen
activity during puberty; girls with severe acne have significantly higher serum
dehydroepiandrosterone sulfate (DHEA-S)
- P. acnes (or possibly Staphylococcus epidermidis or
Pityrosporon ovale) organisms mix with sebum and produce lipolytic
enzymes that convert the sebum to free fatty acids
- Patulous pilosebaceous orifice—open
- Follicular wall ruptures high in the dermis, contents extruded into
subadjacent dermis, induces a neutrophillic inflammatory
response—pustules form if inflammation stays near
surface; nodules form if inflammation develops deeper
- Liquefied masses of inflammatory debris may develop from suppuration
and reaction to giant cells
- Pathogenesis unknown for acne flares one week prior to
- Telangiectasia (permanent dilation of preexisting blood
- Sebaceous hyperplasia and tissue overgrowth results in
Acne cannot be cured but often can be well controlled. Treatment focuses on
curtailing lesions and avoiding scarring. Acne vulgaris is usually
- Tretinoin (Retin-A)—for comedones; a retinoid
that normalizes follicular keratinization; side effects include
photosensitivity, erythema, and peeling; pustule flares possible at beginning of
treatment; response in three to six months; typically 0.025% cream; at least one
study shows addition of polyolprepolymer-2 reduces cutaneous irritation with
- Isotretinoin—for nodulocystic acne, reduces
sebum excretion, decreases inflammation, antibacterial properties for P.
acnes; only drug that alters the course, effect lasts beyond administration;
0.5 to 1.0 mg/kg/day for 16 to 20 weeks; side effects include dry or inflamed
skin, eyes, and mucous membranes, muscle and joint aches; rule out preexisting
liver disease; potent teratogen
- Benzoyl peroxide—a topical keratolytic that
dissolves keratin plugs and follicular debris, allowing sebaceous secretion
outflow, antibacterial properties for P. acnes; prescription (10%) and
OTC preparations (2.5% and 5%) may be used in the morning (begin every other
day) with a retinoid in the evening
- Oral antibiotics—inhibit bacterial lipases,
reduce free fatty acids; enhanced by benzoyl peroxide and tretinoin; commonly,
tetracycline (500 mg/bid)—must not be taken with food;
side effects include phototoxicity, gastrointestinal problems, Candida
vaginitis, teratogenic, decreases contraceptive effectiveness
- Topical antibiotics—less effective than oral;
enhanced by benzoyl peroxide and tretinoin
- Oral contraceptives—inhibit sebum production;
must be estrogen-containing
- Antibiotics—tetracycline (500 to 1000
- Isotretinoin—0.5 to 1 mg/kg/day
- Topical metronidazole 0.75% gel
- Cosmetic and sunscreen
- Glucocorticoid intralesional injections—for
painful nodulocystic lesions; 3 mg/ml
- Dermabrasion—decreases depth of
- Scar excision
- Focal chemical peeling, carbon dioxide laser, scar excision, punch
grafting, and dermabrasion—effective combined treatment
|Complementary and Alternative
Herbal remedies may be effective at balancing hormones and improving
digestion in order to stimulate androgen metabolism. Proper nutrition supports
- Eliminate allergenic foods (especially dairy), caffeine, sugars,
alcohol, and refined foods. Iodine may exacerbate outbreaks. Decrease
pro-inflammatory fats (i.e., animal products) and increase anti-inflammatory
oils (i.e., cold-water fish, nuts, and seeds). Include carotene-rich orange,
yellow, and leafy green vegetables. High consumption of water.
- Vitamin A (10,000 IU/day) or beta carotene (25,000 IU/day), vitamin E
(400 IU/day), and zinc (15 to 30 mg/day) for skin health.
- Vitamin B6 (pyridoxine). Take 50 to 100 mg/day for
- Acidophilus (one capsule with meals) to restore normal bowel
- HCl and pancreatic enzymes may be beneficial especially with acne
rosacea or with concurrent
Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or
tinctures (alcohol extraction, unless otherwise noted). Dose is 1 heaping tsp.
herb/cup water steeped for 10 minutes (roots need 20 minutes). For the following
herbs, take 20 to 30 drops tincture bid to tid, or drink two to three cups tea
- For both acne vulgaris and rosacea, include the following herbs in
equal parts: cleavers (Galium aparine), red clover (Trifolium
pratense), calendula (Calendula officinalis), and coneflower
- For acne vulgaris, add yellowdock (Rumex crispus) and burdock
root (Arctium lappa). For severe cases, substitute Oregon grape
(Berberis aquafolium) for burdock.
- For acne rosacea add: blue flag (Iris versicolor) and yarrow
(Achillea millefolium). For vasomotor instability, substitute oatstraw
(Avena sativa) for yarrow.
- An bitters [e.g., dandelion (Taraxacum officinale), greater
celandine (Chelidonium majus)] plus milk thistle (Silybum
marianum) to stimulate digestive tract.
For increased testosterone levels, add saw palmetto (Serenoa repens)
200 mg bid to tid.
An experienced homeopath would consider the individual's constitution. Some
of the most common acute remedies are listed below. Acute dose is three to five
pellets of 12X to 30C every one to four hours until symptoms
- Belladonna for flushes of heat to the face or inflamed pustular
acne that is better with cold applications
- Calcarea carbonica for severe acne in those with a tendency
toward constipation and dairy allergies, as well as those who are easily
- Rhus tox for acne rosacea that is generally aggravated by cold,
- Sulphur for ruddy complexion with enlarged veins on the cheeks
or nose, or for those who are easily overheated
- Kali bromatum for deep acne in chilled patients and for those
who are suffering from insomnia
External wash bid:
- Calendula soap or tea (1 tsp. herb per cup water) for gentle
- Tea tree oil (15 to 20 ml per cup water) for severe
May be useful in resolving hormonal or constitutional imbalances and
Stimulates circulation and helps to eliminate
Ensure drug treatment compliance.
- Isotretinoin—only preventive drug for acne
- Avoid triggers to prevent
- The potentially serious psychological and social impact of severe
acne, especially during adolescence, warrants prompt and continuing treatment.
- Squeezing of lesions causes local inflammation and ruptures intact
- Vulgaris—symptoms generally diminish after
- Rosacea—requires ongoing management
- Tetracycline and isotretinoin—contraindicated
during pregnancy as they are teratogenic
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Copyright © 2000 Integrative Medicine
CommunicationsThis publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
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