BY Dr. ZEEL NAIK [PHARM.D (PB)] ASSISTANT PROFESSOR MALIBA PHARMACY COLLEGE, UTU BARDOLI, SURAT, GUJARAT.

1. ACNE VULGARIS
By : Dr Zeel Naik
[B.Pharm, Pharm.D (PB)]
Maliba Pharmacy College
Uka Tarsadia University

3.  Definition:
 Acne vulgaris is the most common type of disease encountered,
affecting over 80% of the total population of the world at some
point in their life time.
 Acne is a skin condition characterized by red pimples on the skin,
especially on the face, due to inflamed or infected sebaceous
glands and prevalent chiefly among adolescents.
 Acne is a skin condition that occurs when your hair follicles
become plugged with oil and dead skin cells. It often causes
whiteheads, blackheads or pimples, and usually appears on the
face, forehead, chest, upper back and shoulders.
 Acne is most common among teenagers, though it affects people
of all ages.

4. Pathophysiology of Acne Vulgaris

12. Risk Factors
 Genetic
 Obesity
 Hyperandrogenism
 A significant positive family history of
acne.
 Aggravating Factors
 1. Stress
 2. Smoking
 3. Facial Therapy or Salon Facial Massage

13.  A. Dietary factors that may exacerbate
acne:
 1. High Glycemic Load Diet.
 2. Milk and Milk Products.
 3. Low Fiber and High Fat Diet

14. Comedonal Acne
 Open comedones (Black Heads) with a
central dark keratin plugs.
 Closed comedones (White heads) with no
visible keratin plug.

15. Papular/Pustular Acne
 Patient present with inflamed , 2-5 mm
papules or pustules.

16. Nodular Acne
 Patients present with red, firm or nodules
that may drain.
 These lesions may leave permanent scars.

17. Types of Acne
 Acne Conglobata
 Occupational Acne
 Cosmetic Acne
 Drug Induced Acne
 Infantile Acne
 Late Onset Acne
 Acne Excoriee
 Acne Fulminans
 Post-Facial Massage Acne

18.  ACNE CONGLOBATA
 Severe Form.
 Lesions take month to heal and on healing leave
behind deep pitted or hypertrophic scars.
 Occupational Acne
 Caused by exposure to industrial chemicals.
 Predominantly comedones.
 Suspected in forearms.

19.  Cosmetic Acne
 Eruption seen in women using cosmetics, especially
oil based ones.
 Almost always comedones.
 Drug – Induced Acne
 Steroids, androgens, anti- TB drugs , iodides, bromides
and anticonvulsant can cause eruption.
 Lesions – Consisting of papules and pustules.
 Trunk especially back and face may be involved.

20.  INFANTILE ACNE
 Due to presence of maternal hormones in the child.
 Higher in males.
 May present at birth and may last for up to 3 years.
 Lesions similar to those of adolescent acne.
 LATE ONSET ACNE/ADULT ACNE
 Acne with onset after 25 years old.
 Predominantly women.
 Presents as deep seated, persistent lesions on lower half on face.

21.  Acne Excoriee
 Seen in young girls, who excessively pick their otherwise mild
acne.
 Results in discrete excoriation on the face, while comedones and
papules are few and far in between.
Acne Fulminans
Acute Onset
Present as crusted , ulcerated lesions.
Associated with fever, myalgia and arthralgia.

22.  Post Facial Massage Acne :
 Predominantly on cheeks, along the
mandible.

23. CHEST ACNE

24. BACK ACNE

25. MENSTRUATION/PERIOD ACNE
 It is specific to female gender.
 Your hormones fluctuate throughout your menstrual cycle.
 Just before your period starts, estrogen and progesterone levels
drop.
 This can trigger your sebaceous glands to secrete more sebum,
an oily substance that lubricates your skin.
 Too much can result in clogged pores and breakouts.

26. Acne Scale

27. ACNE SCALE

28. A Common Goal Of Treatment
 Because there are many differences in the severity and
types of acne lesions, there are a wide variety of acne
treatment options.
 These include over the counter medication people can
purchase without a doctor’s prescription as well as more
powerful, doctor- prescribed medications.
 Acne medication may be taken orally or applied directly
onto the skin in the form of topical treatment.
 Often, oral and topical treatments are combined.
 Once acne outbreaks are eliminated , a special type of
surgery known as skin dermabrasion can lessen acne scars.

29. A common Goal Of Treatment
 No matter what form of treatment is used, all
acne treatments share a common goal:
 To control the sequence of events that cause
acne outbreaks in order to prevent new
outbreaks from occurring.
 To reduce bacterial colonies.
 To decrease sebaceous gland activity.
 To prevent the follicles from becoming plugged.
 To reduce Inflammation and combat secondary
infection.
 Experts agree that since there are so many
different acne treatment option available, most
cases of acne outbreaks can be controlled.

31. Types of Skin

32. Pharmacological Treatment
 An acne is a chronic disease, pharmacological
treatment can be divided into 2 phases:
 1. Induction Therapy:
 This phase of treatment aims to induce acne
remission which can be achieved using
topical or systemic agents.
 2. Maintenance Therapy : Recurrence of
acne lesions after successful treatment is
common. Hence, maintenance therapy is an
important modality as part of comprehensive
management of acne. The main stay of
maintenance treatment is topical therapy.

33. NON-PHARMACOLOGICAL
TREATMENT
 It includes physical therapy such as laser,
phototherapy, chemical peels and
comedones extraction.

34. Topical Treatments
 Pharmacological Treatment:
 Salicylic Acid
 Benzoyl Peroxide
 Other antibacterial ointments and Vitamin
A.

35. Salicylic Acid(Keratolytic Agent)
 It is a popular topical treatment that is easily
available.
 Salicylic acid does not treat infection or inflammation.
 Therefore, it is mainly used to treat comedones.
 When salicylic acid is rubbed on the skin, it
penetrates the pores and gets inside clogged hair
follicles.
 Salicylic acid causes dead skin cells inside the follicles
to dissolve.
 This allow oil trapped in the follicles to reach the skin.
 Many patients report that the treatment with salicylic
acid helps eliminate acne outbreaks.
 Can be used in all types of acne.

36. A dermatologist will mostly recommend or
prescribe salicylic acid containing face wash.
FORM Percent of Salicylic
Acid
Use
Gel 0.5-5% Once per day
Lotion 1-2% 1 to 3 times a day
Ointment 3-6% As needed
Face Wash 0.5-2% 3 times a day
Soap 0.5-5 % As needed

37. Saslic is the brand name of the face wash containing 1% of salicylic
acid manufactured by Cipla.
SaliAc is the brand name of the face wash containing 2% of salicylic
acid manufactured by Zydus Liva.
ADRs: Dryness and peeling of skin, hives or itching, redness of the
skin, swelling of eyes, face and lips, unusually warm skin.

38. Benzoyl Peroxide (Oxidizing Agent)
 It is the main ingredient in most over-the-counter acne
preparations.
 Used to treat mild inflammatory acne, benzoyl peroxide is
available in different strengths.
 It is often used with products that contain salicylic acid.
 Benzoyl peroxide is an oxidizing agent, meaning it releases
oxygen.
 The bacteria that cause acne can exist in an oxygen free
environment, such as a clogged hair follicle.
 When benzoyl peroxide gets penetrated into the hair
follicles and releases oxygen, acne-causing bacteria are
killed.
 This not only relieves existing infection but stops new
pustules from forming.

39.  Benzoyl peroxide has three actions - it kills
germs (bacteria), it reduces inflammation and it
helps to unplug blocked pores.
 You can buy benzoyl peroxide without a
prescription at a pharmacy.
 It comes in different brand names
and strengths - there is a 2.5%, 4%, 5% and
10% strength.
 Available as Cream(5% and 10%,
gel(2.5%,4%, 5%,8%,10%)and Face
wash(2.5%).

40. ADRs: Redness of skin, dryness, peeling , burning , itching
and rash.

41. ANTIBACTERIAL TOPICAL AGENTS
 Topical antibiotic treatment for acne is common.
 Topical antibiotics suppress the growth of P. acne
and reduce superficial free fatty acid levels and
decrease comedones, papules and pustules.
 Some times these agents contain sulfur in
combination.
 Common topical preparations include
tetracycline, clindamycin and erythromycin.
 Although these products do control infection,
they have no effect on clogged hair follicles.
 Therefore these products are often combined
with salicylic acid or retinoids.

42. Topical
Antibiotic
Brand Name Strength and
Form
Effects
Clindamycin Cleacin T,
Clindagel,
Evoclin
Gel, Lotion,
Foam- 1%
Most effective
of the topical
antibiotics.
Apply twice
daily.
Erythromycin Emgel, Emcin Gel, ointment,
solution , 2%
Antibiotic
resistance may
develop. Apply
twice daily

43. ADRs: Skin redness, dryness, itching, peeling, mild
burning/stinging.

44. Retinoids
 The Retinoids are a class of chemical compounds that are
vitamer of Vitamin A.
 Topical Retinoid are the first line-treatment for
comedonal acne.
 Therapy is usually initiated with the lowest strength
retinoid to minimize the redness and dryness. The strength
of retinoid may be increased if needed.
 Vitamin A applied to skin, it slows the growth of skin cells.
This is important in preventing acne because when new
skin cells form, old skin cells are shed.
 Slowing the growth of skin cells keeps away the building up
of the dead skin cells from inside the hair follicles.
 This stops new comedones from forming.
 E.g. Retinol, Tretinoin, Isotretinoin, acitrecin,adapalene,
tazarotene.

45. •Retin- A is one of the most commonly used brand of retinoids.
•It consists of tretinoin and available in the form of 0.05%
cream,0.025% cream and 0.04% gel.
•It is used to smooth rough facial skin and to reduce excessive oil
production of the skin.
•ADRS: Dry lips, skin redness(Erythema),Dry Skin , Skin irritation,
itching and increased sensitivity to light.

46. Generic Name Brand Names Formulation Notes
Tretinoin Retin-A, Avita,
Tretin-X
Cream(0.025
%,0.05% and
0.1%)
Gel (0.01%,
0.025%,
0.04%, 0.1%)
Start
treatment with
lower
concentrations
and apply at
night.
Adapalene Differin Cream (0.1%)
Gel( 0.1%,
0.3%)
Lotion (0.1%)
May be better
tolerated than
tretinoin.
Apply at night.
Tazarotene Tazorac Cream(0.1%)
Gel (0.1%)
More effective
but more
irritating than
other
retinoids.
Apply at night.

47. Combination Medications
Generic Name Brand Name
Examples
Formulation Notes
Tretinoin +
Clindamycin
Ziana Gel, tretinoin
0.025% +
Clindamycin
1.2%
Apply at night.
Effective for
papular/pustular
acne.
Benzoyl Peroxide
+ Clindamycin
Duac Benzacin Gel, Benzoyl
Peroxide 5% +
Clindamycin 1%
Apply twice
Daily. Effective
for
papular/pustular
acne.
Benzoyl Peroxide
+ erythromycin
Benzamycin Gel
Pack
Gel, Benzoyl
Peroxide 5% +
erythromycin
1%
Same as above.

48. Oral Medication or Systemic
Pharmacotherapy
 Antibiotics
 Hormones
 Isotretinoin

49. Antibiotics
 Oral antibiotics such as tetracycline,
doxycycline, minocycline, erythromycin,
azithromycin and clindamycin can be
administered in small doses over a long
period and are very effective in treating
moderate and severe acne, especially
when the acne is inflammatory and
results in pustules and scarring.

50. Medication Dosage Side Effects
Tetracycline 500 mg two to four
times daily
Same as doxycyline
Minocycline 50 mg once or twice
daily
Same as doxycyline
Erythromycin 250 mg twice daily Nausea , vomiting,
diarrhea , anorexia ,
pruritus , rash,
abdominal pain and
cramps
Doxycyline 50 mg once or twice
daily
Ataxia, dyspepsia,
nausea , vomiting,
diarrhea,
photosensitivity,
stomatitis, dizziness,
vertigo, head ache.
Azithromycin 250 mg twice daily Same as
erythromycin

51. Oral Retinoids
 Synthetic Vitamin A compounds i.e. Retinoids
are used in patients who are unresponsive to
conventional therapy.
 Isotretinoin is used for active inflammatory
papular pustular acne that has tendency to
scar.
 Isotretinoin reduces sebaceous gland size
and inhibits sebum production.
 It also causes the epidermis to shed, thereby
unseating and expelling existing comedones.

52. Medication Dosage Side Effects
Isotretinoin 10 mg
20 mg
40 mg
daily for 15-20 weeks
Cheilitis, dry skin and
mucous membrane,
itching, epitaxis,
decreased night
vision,
photosensitivity,
hepatotoxicity ,
neutropenia,
thrombocytopenia,
depression.

53. Hormone Therapy
 Estrogen therapy including progesterone-
estrogen preparations suppress sebum
production and reduces skin oiliness.
 Estrogen in the form of estrogen –
dominant oral contraceptive compounds
can be administered on a prescribed cyclic
regimen.
 This therapy is not applicable to male
patients because of undesirable side
effects.

56. Treatment Of Acne Scars
 Even though acne medication can lessen and even eliminate acne outbreaks,
many patients are left with permanent scars.
 For these patients, treatment with a form of surgery known as skin
dermabrasion can help give the skin a smoother appearance.
 In this procedure, patients are given a local anesthetic to eliminate pain.
 Then a high speed instrument that resembles a wire brush is used to scrape
away the top layer of skin and alter the contour of acne scars.
 Small scars may be completely removed, while the depth of large scars is
reduced considerably.
 Because the top layer of skin is removed, after the procedure the patient’s skin
often appears red and may remain for a month or more.

57. Risk and Side Effects of Acne Treatment
 Isotretinoin and Serious Health Problems.
 Isotretinoin and Psychiatric Problems.
 Isotretinoin and Birth Defects.

58. Three Types Of Alternative
Treatments For Acne
 The most widely used alternative treatments for acne fall into 3 categories-
those that are taken internally, those that are applied on the skin, and those
that eliminate stress.
 Dietary supplements such as herbs, vitamins and minerals are among the most
popular internal treatments.
 In fact, herbal remedies have been used to treat many diseases, including
acne, for thousands of years, and herbs still remain the primary treatment for
acne.
 Herbal remedies use the leaves , roots and stems of plants that are known to
have healing properties.
 Usually taken ground up in capsule form or a tea, herbal remedies for acne
consist of herbs that balance hormone levels, boost the immunity, and reduce
inflammation.
 Because herbs are natural, many people feel that they are gentler and safer
than conventional medicines.

59. HERBS That Balance Hormone
Levels
 Herbs that balance hormone levels are the most commonly
prescribed herbs for acne.
 They mainly includes red clover, black cohosh, wild yam, evening
primrose, chaste berry, and dong quai, all of which are prescribed
for women.
 These herbs contain phytoestrogen, a plant based female
hormone- like compound.
 Therefore, although they are useful for women, they are
inappropriate for males due to chemical differences in the male
and female body.
 Herbalists believe phytoestrol increases the effect of the female
sex hormone, estrogen, on the body while counterbalancing the
action of androgen.

60. HERBS TO COMBAT INFECTION
AND INFLAMMATION
 The various other herbs used in the treatment of
the acne are echinacea, burdock, licorice and
dandelion root, are thought to contain
compounds that attack bacteria, thus reducing
infection and inflammation.
 Herbs like salvia and red peony, on the other
hand, are thought to improve circulation and
tissue growth, which increases the skin’s ability
to heal.

61. Vitamins and Minerals
 Treatment with Vitamin B5 , is another widely used alternative treatment for
acne.
 Also known as pantothenic acid, Vitamin B5 is believed by some experts to be
effective in reducing the production of sebum as Isotretinoin.
 When there is a shortage of Vitamin B5, fat that is normally burned for fuel or
stored in cells for future use cannot be processed properly.
 Instead, it accumulates in the bloodstream.
 The excess fat in the form of sebum is eliminated through the skin.
 Thus the presence of excess fat in bloodstream causes the body to increase
the sebum production for the removal of excess fat.
 Therefore, when acne patients increase the level of vitamin B5 in their bodies,
they improve the processing of fat.

62. NON- PHARMACOLOGICAL TREATMENT
 Laser/Light Based Therapies
 Chemical Peeling.
 Apply apple cider vinegar
 Take a Zinc Supplement
 Make a honey and cinnamon mask
 Spot Treat with tea tree oil.
 Apply green tea to your skin.
 Moisturize with aloe Vera.
 Take a fish oil supplement.
 Exfoliate regularly.
 Follow a low glycemic load diet.
 Cut back on dairy products.
 Reduce Stress.
 Exercise Regularly.
 Use jojoba Oil.
 Drink Green Tea.
 Try rubbing pure, virgin coconut oil directly to the area with acne.
 Cucumber Face Pack.
 Avoid oily , spicy and fried food.
 Avoid caffeine containing beverages.

63. Non- Pharmacological Treatment.
 Never touching pimples.
 Choosing the right cleanser.
 Using oil-free skincare.
 Stay hydrated.
 My personal recommendations:
1. Use salicylic acid containing face wash(for oily to normal
skin).
2. Use Face Mask made up of chickpeas flour, curd, milk or
cream or honey, turmeric, lemon juice and cinnamon.
3. Wash your face regularly and at least 2 times a day with
cleanser(face wash).
4. Apply skin toner after using the cleanser and then apply
day cream moisturizer and sunscreen lotion.
5. At night after washing face with cleanser, apply night
cream moisturizer.
6. For acne spots , you can use spot corrector gel.

64. Skin Dermabrasion