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.

Acne vulgaris:

• Greasy/oily cosmetic or hair products containing vegetable or animal fats
• 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
• Constipation

Acne rosacea:

• Genetic predisposition
• Personal triggers—diet (cheese, meat, spicy foods, caffeine, alcohol, hot soup or drink), cold, sun, wind, exercise, stress, menopause

Acne vulgaris:

• Open comedo ("blackheads")
• Closed comedo ("whiteheads")
• Inflamed papule
• Cysts and nodules
• Nodulocystic lesions
• Scarring

Acne rosacea:

• Prolonged facial redness
• Pustules, papules
• Ocular rosacea, conjunctivitis, stye formation
• Rhinophyma (enlargement of the nose resulting from tissue overgrowth)

• Flat warts
• Folliculitis
• Dermatitis
• Lupus erythematous—for rosacea
• Fungal infection—for rosacea

Comedones, papules, pustules, and scarring may all be visible. Emotional upset of patient may also be evident and should be addressed.

Acne vulgaris:

• Overactive sebaceous glands drain into follicular canal, becoming plugged with keratinous debris that contains Propionibacterium acnes (comedo)
• 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 comedo
• 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 menstruation

Acne rosacea:

• Erythema
• Vasodilation
• Telangiectasia (permanent dilation of preexisting blood vessels)
• Sebaceous hyperplasia and tissue overgrowth results in rhinophyma

Acne cannot be cured but often can be well controlled. Treatment focuses on curtailing lesions and avoiding scarring. Acne vulgaris is usually self-limiting.

Acne vulgaris:

• 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 comparable efficacy
• 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

Acne rosacea:

• Antibiotics—tetracycline (500 to 1000 mg/bid)
• Isotretinoin—0.5 to 1 mg/kg/day
• Topical metronidazole 0.75% gel
• Cosmetic and sunscreen protection

• Glucocorticoid intralesional injections—for painful nodulocystic lesions; 3 mg/ml
• Dermabrasion—decreases depth of scars
• Scar excision
• Focal chemical peeling, carbon dioxide laser, scar excision, punch grafting, and dermabrasion—effective combined treatment

Herbal remedies may be effective at balancing hormones and improving digestion in order to stimulate androgen metabolism. Proper nutrition supports skin health.

• 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 PMS-associated acne.
• Acidophilus (one capsule with meals) to restore normal bowel flora.
• HCl and pancreatic enzymes may be beneficial especially with acne rosacea or with concurrent constipation.

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 daily.

• 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 (Echinacea purpurea).
• 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 resolve.

• 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 chilled
• Rhus tox for acne rosacea that is generally aggravated by cold, wet weather
• 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 cleansing
• Tea tree oil (15 to 20 ml per cup water) for severe acne

May be useful in resolving hormonal or constitutional imbalances and facilitating detoxification.

Stimulates circulation and helps to eliminate toxins.

Ensure drug treatment compliance.

• Isotretinoin—only preventive drug for acne vulgaris
• Avoid triggers to prevent rosacea

• 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 lesions.

• Vulgaris—symptoms generally diminish after adolescence
• Rosacea—requires ongoing management

• Tetracycline and isotretinoin—contraindicated during pregnancy as they are teratogenic

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