Tretinoin can be bought without an antibiotic

Pimples, papules, pustules


Pimples, papules, pustules

By Daniela Biermann


Almost everyone has had pimples in their life. When the right care alone no longer helps, self-medication and prescription drugs are used.


Acne is one of the most common dermatological diseases. 80 to 95 percent of all adolescents suffer from pimples, papules and pustules. But acne is not just a teenage disease: every fifth adult suffers from the lesions. In addition, some drugs, for example barbiturates, anabolic steroids, gestagens with restandrogenic effects, chloroquine, lithium and phenytoin, can cause acne.


Various factors such as genetics and psyche come together in the development of acne. Above all, however, hormonal influences such as during puberty and pregnancy play a major role.


In common acne (acne vulgaris), the keratinization of the skin in the area of ​​the sebum glands is disturbed. The keratinocytes multiply excessively, while desquamation is insufficient. Horn material accumulates and closes the hair follicle. In addition, the sebum glands (sebocytes) produce too much sebum, which accumulates in the hair follicle. A comedo (blackhead) develops. If Propionibacterium acnes also colonizes the hair follicle, the comedo becomes inflamed and develops into a papule (nodule) or pustule (pus vesicles).


Stay clean


Acne is not caused by poor hygiene. But once the pimples are there, thorough hygiene is essential. The daily cleaning of the affected areas of the skin therefore comes first. pH-neutral products such as syndets or washing gels remove excess sebum. The products must not be heavily regreased. In addition, facial toner with a low alcohol content (5 to 10 percent) degreases the skin. If there is no inflammation, weekly scrubs can be used. They improve the exfoliation of the top layer of skin so that the sebum can flow away better. Oil-free gels, moisturizing creams based on oil-in-water or nourishing creams with fruit acids are suitable for care. Washcloths and towels should be changed every day because of the acne bacteria.


However, not everyone can get their pimples under control with cleaning alone. Up to 30 percent of acne diseases have to be treated with medication. Salicylic acid and benzoyl peroxide (BPO), which have an antibacterial and keratolytic effect, are available for self-medication. In the recipe, salicylic acid is processed in a concentration of 5 to 10 percent as acne alcohol (NRF 11.23.). In this concentration it has a comedolytic effect. Due to different pH optima and the instability of erythromycin, it must not be combined with it. If such a prescription appears, the pharmacy should suggest an alternative to the doctor, for example two separate formulas.


Finished medicinal products such as Sanoxit® Gel or Cordes® BPO gel contain up to 10 percent benzoyl peroxide. Caution: the active ingredient can also bleach clothes. For use on the face, a concentration of 3 percent BPO should not be exceeded due to possible skin irritation. In general, all topical drugs can lead to redness, skin irritation and similar symptoms. Benzoyl peroxide, along with retinoids, is the drug of choice in local treatment.


A prescription alternative is azelaic acid (Skinoren® 15 percent gel or 20 percent cream). Other keratolytics such as resorcinol and sulfur have meanwhile received negative monographs. They should therefore no longer be used. When using pull ointments, the shale oil sulfonates (for example Aknichthol® or Aknederm® Ointment New) contain, because of their phototoxic and nephrotoxic potential, the risk-benefit ratio must be carefully weighed, especially since they themselves (applied to the face) can cause tar acne. In the guidelines for acne treatment of the German Dermatological Society (DDG), zinc, along with BPO and azelaic acid, is rated positively as an antimicrobial alternative to antibiotics, as there is no development of resistance.


On prescription


Antibiotic therapy is only an option for inflammatory acne. Erythromycin (for example Aknemycin® Solution) and clindamycin (for example Basocin® Acne gel) are the means of choice in this case.


Tetracycline (Imex® Ointment) or nadifloxacin (Nadixa® Cream) are less suitable because of their lower effectiveness or higher probability of resistance. The therapy should last a maximum of four to six weeks in order to avoid the formation of resistance from the acne bacteria and the staphylococci that live on the skin. In combination with zinc, BPO or azelaic acid, topical application can be extended to six to eight weeks. A combination can also shorten the treatment. There are numerous combination products available, including those with retinoids.


Topically applied retinoids are considered to be particularly effective for acne and therefore as a first-line therapy. Since they are not only comedolytic but also anti-inflammatory, they should be used early. Tretinoin (Airol® Cream or solution, Cordes® VAS cream) and isotretinoin (Isotrex® Cream or gel) are non-aromatic first-generation retinoids. Motretinide is a second generation monoaromatic which is only approved for acne therapy in Switzerland. Adapalene (Differin®) is a polyaromatic representative of the third generation. It is considered to be the retinoid with the most favorable side effect profile. It is also the only retinoid that is chemically stable enough to be combined with BPO (Epiduo® Gel). Otherwise, such chemically and galenically incompatible drugs must be applied alternately (for example, morning and evening or every other day). The teratogenic retinoids are also contraindicated in pregnant women in this form of application, as there are individual reports of malformations under local tretinoin or isotretinoin treatment.


Proceed systemically


The only systemic retinoid is isotretinoin (for example roaccutane® or Aknenormin®) for use. It inhibits the proliferation of the sebocytes and thereby suppresses the formation of sebum. According to guidelines, isotretinoin is the most effective remedy for acne. Serious side effects include depression, psychosis and rhabdomyolysis. It must not be combined with oral tetracyclines, as this can lead to increased intracranial pressure.


Isotretinoin is absolutely contraindicated in pregnancy. Women must use reliable contraception while taking it (start at least one month before and end no earlier than one month after treatment). Hormonal contraceptives with the antiandrogens cyproterone acetate, chlormadinone acetate or dienogest in combination with the estrogen ethinylestradiol (e.g. Diane® 35, Neo-Eunomin® or valette®). They not only protect against pregnancy, but also indirectly inhibit excess sebum production.


In combination with a systemic antibiotic, the contraceptive effect may be weakened. In this case, patients should also use non-hormonal methods of contraception. Systemic long-term antibiosis is carried out with tetracyclines (doxycycline, minocycline), clindamycin or trimethoprim / sulfamethoxazole.


hands off


Regardless of whether you have mild or severe acne and what treatment: It is always important to gently cleanse the skin and not to express the pimples yourself. Scars and inflammation can result. A trained beautician is required here. While the sun only improves the complexion for a short time, targeted therapy with UV rays can be tried. A special acne diet is not necessary. A healthy diet, adequate sleep and fresh air are always recommended.