Acne vulgaris is a skin infection in which there is the blockage and/or inflammation of pilosebaceous units present in the skin. In India, even though males are more affected than females, it is females who approach the doctor for treatment. There are various medications in the treatment of acne, including antibiotics, retinoids, laser therapy and hormonal therapy. These medications have their own list of advantages and disadvantages. The disadvantages lead to patient non-adherence in some cases. The Indian society’s approach to acne is different from that of the west. In India, along with the modern system of medicine, traditional and alternative systems are also preferred in India.
It is a well-known fact that acne can only be controlled with medications but not fully cured. Various factors are responsible for acne i.e; hormonal fluctuations, stress, comedogenic skin products, genetic factors etc. The treatment of acne aims at reducing the local inflammation, reducing the follicular hyperkeratinization along with unplugging the plugged follicles and reducing the excess sebum production. The current treatment system can control acne efficiently but is not fully capable of preventing relapse. In a significant portion of patients, there is a relapse of acne following treatment. In India, the majority of acne sufferers, view acne as an age-related skin condition and the treatment of acne is not usually the first course of action in acne patients. The treatment of acne usually starts with topical antibiotic or comedolytic agents, followed by retinoids or hormonal therapy.
The pathology of the skin condition is multifactorial and starts from excess sebum production, skin keratinization changes, Propionibacterium acnes, and inflammatory processes. In pediatric patients, acne development may result from endocrine changes brought about by the onset of puberty, increased androgenic hormones, and increased sebum production.
Acne vulgaris a skin condition primarily results from the overproduction of oils in the sebaceous follicles of the skin present on the epidermis, which is heavily found around the face and upper back. Alterations to follicular development, including hyperkeratinization, contribute to acne development. The gram-positive anaerobe P. acnes inhabits the skin and sebaceous follicles. P. acnes releases enzymes that are responsible for the AV-associated inflammation and the creation of inflammatory mediators.
These inflammatory mediators subsequently cause plugged follicles to become inflamed, thus leading to the inflammatory lesions known as papules, pustules, and nodules. New studies have found that various other inflammatory mediators also play a role in acne pathogenesis. These aspects of innate immunity may be the targets for the future development of therapeutic agents. Endocrine abnormalities such as those found during pregnancy or in polycystic ovarian syndrome in women of reproductive age may also lead to acne, regardless of medical history. One of the clinical characteristics of the polycystic ovarian syndrome is hyperandrogenism, which increases sebum production and subsequent acne formation.
These acne patients often have acne lesions not only present on their faces, but also on their neck, chest, and upper back, where sebaceous glands are also prevalent. Sebaceous glands also respond to other hormones such as the corticotrophin-releasing hormone, which increases as a result of stress
Acne vulgaris may be secondary to drug use. Another type is Drug-induced acne typically manifests as inflammatory lesions, with rarely any evidence of comedones on the skin. Moreover, the sudden appearance of acne may be found outside the usual sebaceous-filled areas.
FACTORS AND PRESCRIPTION
The factors leading to a doctor prescribing an anti-acne molecule and patient compliance in that medication can help us understand all the factors that contribute to the efficient marketing of an anti-acne molecule.
Acne vulgaris is defined as a chronic inflammatory skin condition which affects around 85% adolescents with around 40% having persistent acne into their twenties and some continuing into adulthood.
In India, acne vulgaris is viewed as a normal skin condition in India. Hence the acceptance of acne is higher in Indian society in comparison to western society. In India, patients believe that acne vulgaris is caused mainly caused due to diet, season, stress and genetics. The number of patients seeking treatment for acne is increasing, due to the increased knowledge about acne and economic predisposition among people. Topical treatments are preferred more than systemic medications due to the view that systemic medications can cause side effects.But the adherence to topical treatment is less as they can be time-consuming, messy, less effective due to lapses, and due to visible side effects like drying of skin and redness. In India there is a significant amount of patients who concomitantly undergo alternative therapy like Ayurveda, allopathy, homeopathy etc.. Majority of patients believe that combinations of medications would work better than a single medication due to the added benefits offered by each medication.If treatment doesn’t offer the benefits that are promised, then a majority of them switch doctors, use alternative medicine, use OTC products/ skin care products or hide acne with cosmetics.
The demographics of patients usually seeking treatment for acne are:-
1) females seek treatment more than males in the age group of 11-25, despite males suffering from acne more than females
2) there is a direct correlation between an income of household and probabilities of undergoing treatment. Higher the income and social status, higher the probabilities of undergoing treatment.
TREATMENT ASPECTS OF ACNE
Another important aspect in the treatment of acne in India is prescription patterns of doctors. Doctors usually prescribe a topical or oral antibiotic to stop infection and the associated inflammation. The infection and inflammation stop initially but often relapses. Then retinoids and hormonal medications are used for moderate to severe acne. Hormonal medications despite being deemed by doctors as effective are not prescribed widely, due to the perceived side effects. Isotretinoin is the most widely prescribed medication for severe and refractory acne.The average initial prescription pattern in India includes an oral antibiotic and a topical antibiotic/ retinoid/ benzoyl peroxide. For mild acne (grade 1- grade 2), a family physician or an internal medicine specialist is preferred over a dermatologist.And mostly, in India, the first doctor consulted for acne is a family doctor. Then for moderate and severe acne, most dermatologists are sought. This trend is slightly different in the west, where around 88% of patients seek treatment from a dermatologist, 6.8% patients seek treatment from a general physician and 2.7% patients seek treatment from an internal medicine specialist.
The most commonly prescribed medications by a family doctor or a general physician include doxycycline, isotretinoin, tretinoin, benzoyl peroxide and clindamycin phosphate.The most commonly prescribed medications by dermatologists include isotretinoin, minocycline, azithromycin, doxycycline, adapalene, benzoyl peroxide and clindamycin.