Combined Treatment with Isotretinoin, Salicylic Acid Peels and CO2 Laser for Acne Grade 3: A Case Report

Dr. Nitika Nijhara

MBBS, MD (DERMATOLOGY)

Visiting Consultant

BLK-MAX Super Speciality Hospital, New Delhi

Consultant-Fortitude Skin and Hair Clinic, Dermaworld Skin and Hair Clinic, New Delhi

Introduction

Acne is a common skin condition that affects millions of people worldwide. It is a disease of the pilosebaceous units, clinically characterized by seborrhea, comedones, papules, pustules, nodules and, in some cases, scarring.

1 It is a disorder of the skin caused by inflammation of the skin glands and hair follicles. Acne vulgaris is the most common type of acne, which occurs when hair follicles are blocked with dead skin cells, bacteria and oil (sebum).2,3,4

Nodulocystic acne is a severe form of acne that can cause nodules and cysts that typically resolve with scarring.1 Acne vulgaris can be graded using different grading systems. One of the grading systems used by Indian authors is a simple grading system that classifies acne vulgaris into four grades. Grade 1 includes comedones and occasional papules, grade 2 includes papules, comedones, and few pustules, grade 3 includes predominant pustules, nodules, abscesses and grade 4 includes mainly cysts, abscesses, widespread scarring.1 Acne grade 3, also known as moderately severe or nodulocystic acne, is characterized by numerous papules and pustules, along with occasionally inflamed nodules. Lesions occur primarily on the face, but the back and chest may also be affected. It is more severe than grade 1 and grade 2. 5

The etiology of acne is multifactorial, with the hypersensitivity of the sebaceous glands to a normal circulating level of androgens being the primary cause. Environmental exposures are important exogenous factors in the etiologies of acne, which leads to a group of environmental factorsinduced acne. Research found that the occurrence of acne was strongly attributed to the exposure of skin in the natural environment, obesity and other built environment characteristics for transport. However, the correlation between environmental factors and acne has yet to be fully investigated.

Other factors that can aggravate acne include P. acnes and inflammation, food with a high glycemic number like dairy products, junk food and chocolates, which cause insulin-like growth factors that stimulate follicular epidermal hyperproliferation. 5,6,7,8 Hormonal changes, particularly during puberty, can cause the sebaceous glands to enlarge and make more sebum, leading to acne. Other possible triggers of an acne flare-up include friction or pressure on the skin, certain medications and some cosmetic products. However, most of the biological reactions that trigger acne occur beneath the skin, not on the surface, so having dirty skin and poor hygiene is not a direct cause of acne.3

Acne vulgaris lesions are studied in two groups: noninflammatory (blackheads and whiteheads or comedones) and inflammatory (papules, pustules, nodules and cysts). Histologically, acne vulgaris is characterized by hyperkeratosis, follicular plugging and inflammation. The closed comedo can rupture and form a pustule. Inflammatory acne lesions are characterized by the presence of neutrophils, lymphocytes and macrophages. The inflammatory response is triggered by the release of pro-inflammatory cytokines, chemokines and other mediators. 9,10,11

Case Report

A 20-years-old male patient who has presented the complains of acne with the painful comedones, papules, pustules, nodules and scars and the major involvement of cheeks. Patient history revealed he had acne since long time and still had this presentation. There was a strong family history of acne. After the physical examination and all the detailed history of his clinical presentation, considering his case to be grade 3 acne. After made the diagnosis of grade 3 acne, the oral treatment of isotretinoin 20mg was prescribed for 6 months along with salicylic acid peels 20% 4 sessions was done and 4 sessions of fractional CO2 laser was done. Asked patient to follow the daily skincare to avoid any side effects or skin complications. Combined treatment of these 3 showed significant result and it was really helped the patient to clear his acne and minimise scars. The pictures are taken before treatment and after the treatment effects on patient.

Diagnosis

The diagnosis of acne is based on the history and physical examination. It is always important to ask about the patient's medical history, including any medications they are taking and their family history of acne, the onset, duration, and progression of the acne, as well as any associated symptoms such as pain or itching. The physical examination will involve a thorough inspection of the skin to identify the type and severity of acne lesions. An acne grading system may be helpful in patient care. Acne grade 3 or nodulocystic acne, is characterized by numerous papules and pustules, along with occasionally inflamed nodules. Acne grade 3 primarily occurs on the face, but the back and chest may also be involved. The histopathology of acne is important for understanding the pathogenesis of the disease and for developing effective treatments.12,13,14,15,16

Limited information is available on the histopathology of acne grade 3. However, nodulocystic acne, which is a severe form of acne characterized by nodules and cysts that typically resolve with scarring, may be similar to acne grade 3. Histopathologically, noninflammatory lesions (comedones) are a kind of follicular retention cysts. These tiny cysts may consist of cornified cells, hair shafts, sebum, and bacteria. In early nonpustular lesions, telangiectasia is in the foreground and perifollicular and perivascular mixed type inflammation (lymphocytes, plasmocytes, macrophages, eosinophils, and polymorphonuclear leucocytes) draw attention. Abnormal keratinization, sebaceous gland hyperplasia, and inflammation are the main histopathological features of acne vulgaris. The severity of acne is correlated with the degree of inflammation and scarring can occur in severe cases of acne, particularly in nodulocystic acne.9

Treatment

Treatment options for acne depends on the severity of the condition. It may include prescription medications such as topical or oral antibiotics, isotretinoin or hormonal therapy, as well as overthe-counter treatments like benzoyl peroxide or salicylic acid. Mild acne can be treated with over-the-counter topical agents such as benzoyl peroxide, salicylic acid and topical retinoids. Topical antibiotics and medications with bacteriostatic and antiinflammatory properties are effective for treating mild to moderate acne. Moderate to severe acne may require prescription-strength topical or oral medications, such as antibiotics, hormonal therapy, isotretinoin, corticosteroids or procedures like chemical peels, lasers or combination of treatment. Acne treatment can take several weeks or months to show results and it may worsen before it gets better. 3,4,12,17

Topical treatment is usually ineffective for nodulocystic acne or grade 3 acne. So the treatment for acne grade 3 may require different lines of treatment. Different therapeutic options are available, including oral antibiotics, hormonal antiandrogens for female patients, oral isotretinoin and other combination therapies. Oral antibiotics such as tetracycline, doxycycline, minocycline and erythromycin can be effective in controlling surface bacteria that aggravate and cause acne. Isotretinoin is a vitamin A derivative that reduces sebum production and prevents the formation of new acne lesions. It is the most effective treatment for nodulocystic acne. 5,12,14, 18,19,20,21,22 Isotretinoin is a highly effective treatment for severe acne, including acne grade 3. The recommended dose of isotretinoin is based on the patient's weight and it is usually started at a low dose of 0.5 mg/kg/day for 4 to 6 months. A study found that 20 mg/day of isotretinoin was effective in the treatment of moderate to severe acne vulgaris and both isotretinoin regimens were well tolerated and found to be an effective treatment for moderate to severe acne vulgaris. The efficacy of isotretinoin in the treatment of moderate to severe acne vulgaris was found to be 90%. Low-dose isotretinoin (20 mg/day) was found to be effective in the treatment of moderate to severe acne vulgaris. Treatment with isotretinoin often results in prolonged clearance of acne, which can be permanent for some patients. However, isotretinoin is a strong medicine that has the potential for serious side effects, including birth defects, depression and liver damage. It is important to follow the prescribing guidelines and to monitor patients closely for adverse effects. Patients taking isotretinoin should also avoid sun exposure and use effective contraception to prevent pregnancy. The use of isotretinoin in acne is recommended for severe acne as well as many cases of more moderate disease that are unresponsive to other treatments. The appropriate use of isotretinoin also includes patients with moderate-to-severe acne or lesser degree of acne producing physical scarring or psychological distress and unresponsive to adequate conventional therapy. The safety and efficacy of lowdose isotretinoin in the treatment of moderate to severe acne vulgaris have been studied and it has been found to be an effective and safe treatment option.

23,24,25,26,27,28,29

Chemical peels, including glycolic acid, salicylic acid, Jessner's solution, retinoic acid, lactic acid, mandelic acid and pyruvic acid are effective for mild to moderate acne. Salicylic acid peels are effective in treating acne. Salicylic acid is a Beta Hydroxy Acid (BHA) that powerfully penetrates pores deep, making it an effective treatment for people prone to acne breakouts. Salicylic acid peels are available in different strengths, including 3%, 15%, and 25%, and are perfect for at-home usage. Salicylic acid is an oil-soluble type of acid that works nicely on acne and oily skin types to accelerate the exfoliation process. A study found that glycolic acid and salicylic acid peels not only clear the acne lesions but also show improvement in post-acne scar and hyperpigmentation to some extent. Salicylic acid 20% peel is a medium-strength peel that can help with acne and acne scarring as well as fine lines and wrinkles. 30, 31,32

Lasers are effective in treating acne. Fractional CO2 laser treatment is effective in treating acne scars. The fractional CO2 laser works by poking microscopic holes into the deep layers of the skin, which regenerates collagen growth and evens out pitted acne scars. Fractional CO2 laser works very well for acne scars and typically needs at least 1 to 3 treatments, depending upon the severity of acne scars. Fractional CO2 laser skin resurfacing is an internationally recognized technique to improve acne scars. As the name suggests, only a fraction of the skin is treated, leaving the surrounding tissue intact for faster healing. Fractional CO2 laser is a non-invasive procedure that uses laser, specially made of carbon dioxide, to remove the outer layers of damaged skin. It is a type of skin treatment used by dermatologists or physicians to reduce the appearance of acne scars, deep wrinkles and other skin irregularities. Fractional CO2 laser is a game-changer for aesthetic dermatology and can help to nix acne scars for good. 33,34,35

Discussion

Acne is a common dermatological condition, which can present with inflammatory and noninflammatory lesions chiefly on the face but can also occur on the upper arms, trunk and back. Acne is classified into four grades, with grade 3 (moderately severe or nodulocystic acne) showing numerous papules and pustules, along with occasionally inflamed nodules.5 Acne can cause significant embarrassment and anxiety in affected patients. It can affect an individual's self-esteem and both cystic and nodular acne can lead to permanent skin damage in the form of scarring. The treatment and prevention of acne depend on the severity of the condition. It is important to follow a consistent skincare routine, avoid picking or squeezing acne lesions and protect the skin from sun damage. Acne prevention involves washing the face twice a day with mild soap-free wash, warm water and a soft face cloth, using sun protection, such as a widebrimmed hat and avoiding oily or greasy cosmetics. Good basic skin care and other selfcare techniques can also help to avoid or control mild or moderate acne. 12,15,36,37

An acne grading system may be helpful in patient care. To facilitate therapeutic decisions and assess treatment response, clinicians can use a consistent method of grading and classifying acne using the characteristics such as number of acne lesions, type of acne lesions, disease severity, anatomical sites, scarring, quality of life and microbiologic and endocrinologic testing.1 Limited information is available on the epidemiology of acne grade 3. A study conducted on males found that 15 (45.5%) had grade 2 acne, 5 (15.2%) had grade 3 acne and 12 (36.4%) had grade 4 acne. Another study found that 5.5% of acne cases had grade 3/4 scarring. Acne vulgaris is the most common type of acne and it affects up to 85% of people at some point in their lives. Acne is more common in adolescents and young adults, but it can affect people of all ages and ethnicities. Family history, age, BMI, skin type, and certain lifestyle factors like diet and stress have been associated with acne presentation and severity. It is important to consult a dermatologist for proper diagnosis and treatment of acne. A dermatologist can help determine the best treatment plan for an individual based on their skin type, acne severity, and medical history.

6,13,15,16,38

Conclusion

Acne is a commonly-seen skin disease with a considerable impact on the quality of life. It can have a devastating physical and psychological effect on the lives of vulnerable adolescents. It is a common inflammatory disorder of the pilosebaceous unit, which runs a chronic course and is self-limiting. It can present with inflammatory and non-inflammatory lesions with the range from mild pimples, through blackheads, whiteheads and papules, to deep, inflamed, pus-filled cysts and nodules. Acne is graded by dermatologists based on its severity, with grade 3 or nodulocystic acne being a severe form of acne that can cause numerous papules and pustules, along with occasionally inflamed nodules. There have been a growing number of epidemiological, medical, demographic and sociological researches focusing on various influencing factors in the occurrence of acne. Treatments include lifestyle modifications and medications. Effective and safe treatments for acne are available. Treatment of acne should be started early to prevent scarring and the most effective agent with the minimum risk of adverse effects should be chosen. Health education should ensure that patients have accurate information about the causes of acne and also that they have realistic expectations about the time for treatment to work.

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