DermHelpCentral

Acne and Stress

This is an interesting piece from the Huff (Fluff) Post.  It's way too simplistic and "fluffy" but it holds some important truths.  Not just for acne -- but perhaps for many other skin disorders and other dis-eases and disorders as well.  Read it with an open mind -- and a few grains of salt.  We will ask our "Mind-Body Guru" Dr. Art Brownstein to comment. 

Huffington Post, Febryary 7, 2011 (by Srinivasin Pillay)

These days, when we think of the brain, it is not hard to understand how it may be connected extensively with other body regions, as it directs so much of our bodies. And while a connection between the brain and heart is easy to imagine, with the heart pumping blood to the brain and the brain having an effect on heart rate, the connection between the brain and skin is not quite so obvious. Even less obvious is the connection between the brain and acne ... until we consider an article e-published today in the journal, Gut Pathogens (Acne vulgaris, probiotics and the gut-brain-skin axis - back to the future?  Bowe WP, Logan AC.). Enter dermatologists John H. Stokes and Donald M. Pillsbury, who, over 70 years ago, postulated that the brain and the skin were connected through the gut -- partially explaining how acne occurs.

How, you may wonder, are those bumpy aberrations on your skin connected to your brain through your gut? If, at first, it is difficult for you to believe that the brain and the gut could be connected at all, consider the following: We generally associate depression and anxiety with abnormalities of the brain chemical serotonin, but the majority of serotonin receptors are in the gut. Yup -- it is not that strange after all that anxiety is associated with a "queasy" effect on the stomach. In fact, Stokes and Pillsbury suggested that how we feel might alter the normal intestinal microflora (those creatures that keep us company in the gut, breaking things down so that we can adequately digest them).

Thus, if you are depressed or anxious, this may affect the organisms in your gut. This may increase the permeability of the intestine, and as a result, may increase inflammation throughout your body -- including on your skin. After those long 70 years, we now have evidence that gut microbes -- and even drugs that promote gut microbe growth -- can have diverse effects on the body. Apart from increasing inflammation, these small creatures can affect glucose control, oxidative stress, tissue fat content and mood, too. And all of these factors can contribute to Acne. The skin condition has been associated with stress and diet for eons. Now finally, we can see how the stress-diet connection may be reconceptualized as the brain-gut connection that impacts the skin.

I highlight this somewhat not-so-obvious connection to make the point that when we think of our health, we need to think of multiple factors at the same time. Often, people focus on just one element. We see people who are in great moods, but overweight. We see people who are in perfect shape, but miserable. And we see people who are in great shape and eat well, but are very stressed. Any one of these problems -- being overweight, miserable or stressed -- can have widespread effects on the body. This emphasizes very overtly that our physical and emotional lives are interconnected and that this interconnection works in both ways.

The Latin "mens sana in corpore sano" translates to "a healthy mind in a healthy body" sometimes translated as " a sound mind in a sound body." These words can be traced back to far more than 70 years ago -- to the Roman poet Decimus lunius luvenalis, known as Juvenal, who was active in the last first and early second century AD.

This wisdom, known so long ago, was somehow lost in the deconstruction of our humanity into "mind" and "body." And I believe that it is time for us to challenge ourselves beyond simply recognizing this connection, to actually living it. This real integration, I believe, is one of the biggest challenges we can face and the following situations raise questions that we would benefit from considering:

1. Does the physical exercise you are doing stress you out? If so, can you get your exercise more happily?
2. Does your job make you unhappy and is it worth sacrificing your body over?
3. Does your romantic relationship make you eat differently than is good for you?
4. Is your skin a victim of your brain, through alcohol, sun addiction, sensory deprivation (when was the last time you were touched lovingly?) or fatty foods?

In these examples, I hope that you will find not judgments, but inspiration to see yourself as whole again.

 

Reference:  Stokes JH, Pillsbury DH: The effect on the skin of emotional and nervous states: theoretical and practical consideration of a gastrointestinal mechanism. Arch Dermatol Syphilol 1930, 22:962-93.

Isotretinoin and Inflammatory Bowel Disease

This is a recent article which addresses this area.  Many of the other references are to a small number of patients only.

Bernstein CN, Nugent Z, Longobardi T, Blanchard JF.  Isotretinoin is not associated with inflammatory bowel disease: a population-based case-control study.  Am J Gastroenterol. 2009 Nov;104:2774-8.  University of Manitoba IBD Clinical and Research Centre, Winnipeg, Manitoba, Canada

Abstract:
OBJECTIVES: There is anecdotal evidence that isotretinoin use is associated with development of colitis. We aimed at determining whether there is an association between isotretinoin use and development of inflammatory bowel disease (IBD).

METHODS: The population-based University of Manitoba IBD Epidemiology Database and a control group matched by age, sex, and geographical residence were linked to the provincial prescription drug registry, a registry that was initiated in 1995. The number of users and duration of isotretinoin use were identified in both IBD cases and controls.

RESULTS: We found that 1.2% of IBD cases used isotretinoin before IBD diagnosis, which was statistically similar to controls (1.1% users). This was also similar to the number of IBD patients who used isotretinoin after a diagnosis of IBD (1.1%). There was no difference between isotretinoin use before Crohn's disease compared with its use before ulcerative colitis.

CONCLUSIONS: Patients with IBD were no more likely to have used isotretinoin before diagnosis than were sex-, age-, and geography-matched controls. Although there may be anecdotes of isotretinoin causing acute colitis, our data suggest that isotretinoin is not likely to cause chronic IBD.

Isotretinoin and Psychiatric Symptoms

For a good review of "Isotretinoin, Depression and Suicide" see this full text adticle.

Conclusions of this article

"Consideration of the limited data available would suggest that the incidence of depression and suicide during isotretinoin therapy may be no greater than the background incidence. A causal relationship has not been demonstrated. The occurrence of an idiosyncratic reaction to isotretinoin producing major depression and suicidal ideation, as suggested by case studies, remains a possibility — although, if so, this would seem to be a relatively rare occurrence. Given the evidence suggesting that isotretinoin treatment may attenuate psychiatric associations of acne, and given the evidence that acne is often not a trivial complaint, withholding therapy because of concerns regarding depression or potential for suicide is not justified. Nevertheless, there are grounds for carefully monitoring patients undergoing treatment with isotretinoin for the emergence of depressive and suicidal ideation. Ideally, the patient's GP, as well as their dermatologist, should be involved in this surveillance."

Isotretinoin and Inflammatory Bowel Disease

There have been a few articles on a possible association between inflammatory bowel disease (IBS) and isotretinoin (Accutane).  As with many of these relationships, there is no hard and fast evidence.  Here is a commentary from "Journal Watch" by a respected dermatologist, Dr. Jeffrey Callen.  If you are a patient or the parent of a patient who is (or is contemplating) taking isotretinoin, this is something to consider and study.  You may want to discuss this with your dermatologist:

from Journal Watch, November 2009.  Isotretinoin and IBS

"Isotretinoin use was no more common in patients with IBD than in the general population.

Recently, questions about a link between isotretinoin treatment of acne vulgaris and development or exacerbation of inflammatory bowel disease (IBD) have been debated in the medical literature (and in the lay press). Several lawsuits have been filed against pharmaceutical companies and individual prescribers. Gastroenterologists with whom I have discussed this issue have given mixed answers as to whether they think the association is real or a coincidental observation. IBD is believed to result from a genetic susceptibility awakened by an environmental trigger; peak onset occurs in the third decade of life, with steady increases through the second decade.

Investigators at the University of Manitoba performed a province-wide case-control study to look for an IBD–isotretinoin association. They identified 2008 patients younger than 40 with physician and hospital claims coded for Crohn disease or ulcerative colitis, a method previously verified as highly sensitive and specific for identifying IBD. The investigators matched each case by age, sex, and geographic residence with 10 controls from the general population and then checked a pharmaceutical database for prescriptions to all study participants.

Twenty-five of the patients (1.2%) had been prescribed isotretinoin before receiving an IBD diagnosis, and 23 started isotretinoin after such diagnosis; the rate of isotretinoin use in patients who developed IBD did not differ from the rate of use among controls. The researchers found that isotretinoin use was rare in young IBD patients before IBD diagnosis and that isotretinoin use was neither more nor less prevalent in IBD patients than in the general population.

Comment: This well-designed and well-performed study used data that were easily obtained in a population covered by a single payer and whose drug use was recorded in a large database. The power of such a study to answer this and other questions is immense. This study did not address whether isotretinoin has an adverse effect on gastrointestinal mucosa, but the findings clearly demonstrate a lack of association between isotretinoin use and the development of IBD in the general population.

Unfortunately, some gastroenterologists, influenced by individual case observations, strongly believe in this association (as in the editorial by Shale and colleagues.), and some, perhaps, are willing to aid plaintiffs in complaints against pharmaceutical companies and prescribing physicians.

Jeffrey P. Callen, M.D.

Overview of Acne Therapy

This fine article was co-authored by James Shaw from the University of Toronto.  There have been no substantial advances since it appeared.  If you are interested in the approaches we use in acne management, you may want to read this lucid article.

Treatment of Acne Vulgaris  (Full Text Link)

Aamir Haider, MD, PharmD; James C. Shaw, MD, FRCPC

JAMA. 2004;292:726-735.

Context  Management of acne vulgaris by nondermatologists is increasing. Current understanding of the different presentations of acne allows for individualized treatments and improved outcomes.

Objective  To review the best evidence available for individualized treatment of acne.

Data Sources  Search of MEDLINE, EMBASE, and the Cochrane database to search for all English-language articles on acne treatment from 1966 to 2004.

Study Selection  Well-designed randomized controlled trials, meta-analyses, and other systematic reviews are the focus of this article.

Data Extraction  Acne literature is characterized by a lack of standardization with respect to outcome measures and methods used to grade disease severity.

Data Synthesis  Main outcome measures of 29 randomized double-blind trials that were evaluated included reductions in inflammatory, noninflammatory, and total acne lesion counts. Topical retinoids reduce the number of comedones and inflammatory lesions in the range of 40% to 70%. These agents are the mainstay of therapy in patients with comedones only. Other agents, including topical antimicrobials, oral antibiotics, hormonal therapy (in women), and isotretinoin all yield high response rates. Patients with mild to moderate severity inflammatory acne with papules and pustules should be treated with topical antibiotics combined with retinoids. Oral antibiotics are first-line therapy in patients with moderate to severe inflammatory acne while oral isotretinoin is indicated for severe nodular acne, treatment failures, scarring, frequent relapses, or in cases of severe psychological distress. Long-term topical or oral antibiotic therapy should be avoided when feasible to minimize occurrence of bacterial resistance. Isotretinoin is a powerful teratogen mandating strict precautions for use among women of childbearing age.

Conclusions  Acne responses to treatment vary considerably. Frequently more than 1 treatment modality is used concomitantly. Best results are seen when treatments are individualized on the basis of clinical presentation.

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Rosacea

Rosacea is a red facial rash that most often affects those aged 30 to 60, especially those with fair skin, blue eyes and of Celtic origin. It may be transient, recurrent or persistent. (The image is from Fitzpatrick's Handbook)

Rosacea used to be called ‘acne rosacea’ but it is quite different from acne. There are red spots (papules) and sometimes pustules in both conditions, but in rosacea they are dome-shaped rather than pointed and there are no blackheads, whiteheads, deep cysts, or lumps. Rosacea may also result in reddened skin, scaling and swelling of affected areas.

You can read more at DermNet.org.nz.

or eMedicine.com

or the the Rosacea Factsheet (Printable Version):

Only the patient can decide how much rosacea affects her or him.  For the more serious cases, oral therapy is quicker and more predictable.  While there is no cure for rosacea, it can be controlled in most persons with therapies that are not too onerous or expensive.  Oral antibiotics are more successful for the acne-like lesions of rosacea than the erythema (redness).

Triggers can  exacerbate your rosacea should be identified and avoided if possible. These factors are unique to each patient and include:
Hot or cold temperatures
Wind
Hot drinks
Caffeine
Exercise
Spicy food
Alcohol
Emotions
Topical products that irritate the skin
Medications that cause flushing (such as niacin)
Remember that not all of these will be triggers in your case, but some may play a role and can, perhaps, be avoided.

Treatment
General Measures

    * Where possible, reduce factors causing facial flushing (see Triggers)
    * Avoid oil-based facial creams. Use water-based make-up
    * Never apply a topical steroid  to rosacea
    * Use light oil-free facial sunscreen
    * If possible eep your face cool
    * Minimize your exposure to hot or spicy foods, alcohol, hot showers and baths and warm rooms if you think these are triggers.

Oral Antibiotics
This is the mainstay for patients with acne-like lesions.  The most effective are doxycycline and minocycline.
Doxycycline can cause a bad sunburn and is used during the winter months
Minocycline does not cause sunburn but can stain teeth if taken for more than six months at a time.  It is used during the summer.
After the rosacea improves the dose can be tapered slowly to find the lowest maintenance level.

Topical Therapy
Metronidazole is the only agent which has been proven effective by multiple clinical studies.  It is available in 0.75%  (used 2 times a day) and 1% strengths (used once a day).  Here's a good overview of topical therapy for rosacea.

Basic Skin Care
Wikipedia has a good page on helpful skin care suggestions fro persons with rosacea.  It does not appear to have commercial bias.

Gadgets for Acne

"A new crop of hand-held aesthetic devices promoted to help acne has been crowding the bathroom shelf, wedged between the latest salon styling tool and multispeed electric toothbrush."  These employ heat and light to hasten the resolution of acne lesions.  How effective are they?  An article in the December 30, NY Times covers his area well.  Gadgets Claim to Fight Acne. 

Hormonal Treatment of Acne in Women

This is an in-depth article that may help certain patients.  Full text is available online.

December 2009

Tobechi L. Ebede, MD, Department of Dermatology, Weill-Cornell Medical Center, New York, New York; Emily L. Arch, MD, Division of Dermatology, NorthShore University HealthSystem, Skokie, Illinois; Diane Berson, MD, Department of Dermatology, Weill-Cornell Medical Center, New York, New York

Disclosure: Drs. Ebede and Arch report no relevant conflicts of interest. Dr. Berson serves as a consultant and/or on the advisory board for Stiefel, Medicis, OrthoNeutrogena, Dusa, La Roche-Posay, and Galderma.

Abstract: Acne vulgaris is a common and chronic disorder of the pilosebaceous unit. Standard treatment protocols include topical retinoids, topical and oral antimicrobials, and isotretinoin. Hormonal therapies can be added to the regimen in some patients. This article will review the hormonal pathogenesis of acne, discuss the basics of an endocrine evaluation, and provide an overview of the current hormonal treatment options in women. (J Clin Aesthetic Dermatol. 2009;2(12):16–22.)

Concerns Regarding Birth Control Pills

"The oral contraceptives Yaz and Yasmin are top-selling products, largely as a result of marketing that presents them as much more than mere pregnancy prevention. [Since they are commonly recommended to women with acne, it is in a patient's best interests to familiarize herself with the risks, even if they are small.]

Yaz, in particular, the top-selling birth control pill in the United States, owes much of its popularity to multimillion-dollar ad campaigns that have promoted the drug as a quality-of-life treatment to combat acne and severe premenstrual depression.

While the risk of blood clots is small, a patient needs to be aware of the data and make her own informed decision."  Reading this fine article:  Health Concerns Over Popular Contraceptives. 

For comparison of similar OCPs, click on image below:

Hormonal Acne in Women

by James Channing Shaw, MD

It is common for women to get acne in their 20s or 30s for the first time. The cause usually centers around hormonal issues.

See Dr. Shaw's valuable post.

James Channing Shaw aka James C. Shaw, MD is an American-trained physician and writer who currently lives in Toronto.  A fuller bio is on his blog.