Effective Acne Treatment Aims to Target Multiple Pathogenic Mechanisms

Acne (acne vulgaris, or common acne) is one of the conditions that most frequently prompts people to consult a dermatologist. According to epidemiological studies, acne affects 50–95% of adolescents in economically developed countries, regardless of race, ethnicity, or sex, depending on the method used to assess skin lesions. Moderate to severe acne is diagnosed in 20–30% of these individuals.

In some people, particularly women, acne may develop at any stage of life. This is known as adult acne. In more than 40% of cases, the disease is severe and requires long-term treatment.

We discussed Lithuanian specialists’ approach to acne, its pathogenesis, and new treatment methods with Dr. Rūta Gancevičienė, a dermatologist at the Dermatovenereology Centre of Vilnius University Hospital Santaros Klinikos.

You Have Described Acne Vulgaris as “Truly an Extraordinary Disease.” Why Is This Condition So Complex?

Acne is a chronic inflammatory skin disease affecting the pilosebaceous unit, which consists of the hair follicle and sebaceous gland. It causes eruptions, most commonly on the face and less often on the chest and back. The disease is characterized by periods of exacerbation and remission.

Acne is often mistakenly regarded as a disease affecting only young people or simply as a skin condition associated with adolescence. In reality, it often affects adults, particularly women. The term “adult female acne” is even used, reflecting the fact that adult acne occurs more frequently in women than in men.

Acne has many forms and clinical presentations. Its primary target is the pilosebaceous unit located deep within the skin. What is visible on the skin surface is merely the “tip of the iceberg,” while the inflammatory process extends much deeper.

One of the main factors contributing to acne is excessive activation of the sebaceous glands and increased sebum production. Certain hormones, particularly active androgens, increase sebaceous gland activity, resulting in excessive sebum secretion.

The composition of sebum changes, abnormal keratinization develops within the hair follicle, and hyperkeratinization obstructs the sebaceous gland duct through which sebum is normally released. This creates favorable conditions for Propionibacterium acnes (P. acnes) bacteria to produce inflammatory substances, leading to inflammation and the formation of inflammatory lesions.

Increasing evidence supports the view that acne is primarily an inflammatory disease because inflammatory mediators are also found in acne lesions that do not yet show visible inflammation. These include lesions that later develop into inflammatory pustules. Following the healing of deep lesions, pigmentation changes and scars may remain, and these also demonstrate signs of inflammation.

Acne is therefore correctly classified as an inflammatory disease. Current research focuses particularly on bacteria, keratinization processes, and inflammatory mediators.

What Are the Main Causes and Symptoms of Acne, and Which Age Group Is Most Commonly Affected?

There are four major pathophysiological factors involved in acne:

• androgen-induced enlargement and increased activity of the sebaceous glands;
• altered keratinocyte differentiation and hyperkeratinization of the hair follicles;
• colonization of the hair follicle by P. acnes and the release of inflammatory mediators;
• changes in the skin’s immune response.

Heredity, dietary habits, climate, inappropriate skin care, and other factors have also been shown to play an important role in the onset and course of the disease.

Recent studies are contributing to a new understanding of acne. This includes findings regarding sebum quality, local hormonal regulation within the skin, androgen activity and influence, changes in factors that promote or suppress inflammation in the sebaceous glands, interactions with neuropeptides, the effects of smoking, and other mechanisms.

Both innate and adaptive immune responses, as well as inflammatory mechanisms, contribute to acne pathogenesis.

How Is the Understanding of Acne as a Skin Disease Changing, and Why Is Treatment Necessary? What Are the Main Principles of Treatment, and Which New Options Are Available?

When selecting a treatment strategy, acne is usually evaluated from two perspectives: disease activity, based on visible and objective signs of skin involvement, and the impact of the disease on the patient’s quality of life.

The risk of scarring must also be assessed.

The main principle of acne treatment is to target as many key mechanisms of disease pathogenesis as possible. Priority is given to the four principal mechanisms: reducing excessive sebaceous gland activity, normalizing altered keratinization, suppressing inflammation, and reducing the bacteria that sustain the inflammatory process.

Specific treatment recommendations and principles should be followed. Particular emphasis is placed on avoiding antibiotic monotherapy, whether topical or systemic.

Because pharmacological treatment, both oral and topical, is usually prolonged, fixed-combination topical medications are recommended. Oral antibiotics should be combined with topical retinoids or anti-inflammatory agents to reduce the risk of bacterial resistance.

One of the main advantages of fixed-combination topical medications is greater convenience because patients do not need to apply several separate products. Their effectiveness is generally greater, while adverse effects on the skin are milder. They may therefore be used safely for longer periods, which is important because acne is a chronic disease.

Treatment always depends on the form and severity of the disease, the predominant type of lesions, and the degree to which the patient’s quality of life is affected.

A stepwise treatment approach should be followed. The most appropriate evidence-based treatment is selected initially and should be changed promptly if the expected response is not achieved or adverse effects occur.

Maintenance therapy is also important because it helps delay or reduce acne exacerbations. Appropriate skin care should be recommended alongside medication.

Clindamycin and Tretinoin Combination Gel (Treclinac) Is One Effective Acne Treatment. What Is Its Mechanism of Action?

In clinical practice, we have medications that reduce inflammation rapidly and effectively. However, treatment is often accompanied by signs of skin irritation.

Treclinac is a broad-spectrum fixed-combination medication containing the antibiotic clindamycin and a retinoid.

Retinoids act on almost all major aspects of acne pathogenesis. They reduce sebaceous gland secretion, inhibit follicular hyperkeratinization, and suppress inflammatory processes.

When tretinoin is combined with clindamycin, inflammatory signs are reduced and the overall effect of treatment becomes more comprehensive.

Is This Medication Suitable for Adolescents?

This medication may be used to treat acne in both adolescents and adults.

Could You Share Your Personal Experience Using Treclinac to Treat Acne?

This medication became available in Lithuania in the spring. We had been waiting for a treatment of this type, although we initially had some concerns about tolerability and whether it might cause skin irritation and dryness.

However, in practice, it has caused relatively little irritation, while its effect has been rapid and effective.

The only disadvantage I would mention is that additional sunscreen must be used during the summer.

Interview by R. Pečeliūnienė