Causes, Types, and Treatments for Acne Vulgaris | Isotretinoin for Severe Cases

What is acne (acne vulgaris)?

Acne (acne vulgaris) is a chronic skin condition caused by clogged pores, proliferation of acne bacteria, and inflammation. Modern acne treatment has advanced significantly, and many people can regain clear skin with appropriate topical and oral medication.

Self-care and over-the-counter medications have limitations

Many cases are exacerbated by excessive face washing, insufficient moisturizing, or ineffective over-the-counter medications. Prescription medications (adapalene, benzoyl peroxide, etc.) are far more effective than over-the-counter medications, and significant improvement can be achieved with appropriate treatment.

Mechanism of acne formation

Acne occurs when the following four factors overlap:

• Excessive sebum secretion (hormones, stress, genetics)

• Clogged pores (keratinization abnormality blocking pores)

• Proliferation of acne bacteria (multiplication in anaerobic environment using sebum as nutrient)

• Inflammation (immune reaction to acne bacteria)

Acne types and stages

The best time for treatment is at the "comedo (white/blackhead)" stage, before inflammation occurs. Since the risk of scarring increases if it progresses to red acne, we recommend consulting us as soon as you notice small bumps.

Acne severity classification and overall treatment approach

Acne treatment options vary depending on the severity. Let's first organize the overall picture.

Treatment Options

Topical Medications (Daily Basic Treatment)

Adapalene and benzoyl peroxide can cause redness, peeling, and dryness in the first 1-2 weeks. This is a sign that the medication is working, and usually subsides within about 2 weeks. The trick is to start with a small amount once at night while moisturizing sufficiently.

Oral Medications

Long-term use of antibiotics carries a risk of antibiotic resistance, so use for a maximum of 3 months is generally recommended. Combining them with topical medications (especially benzoyl peroxide) can help prevent resistance.

Option for Severe/Intractable Cases: Isotretinoin

For moderate to severe acne that has not improved with topical medications or oral antibiotics, or for extensive nodular acne with a high risk of scarring, we offer isotretinoin as a self-pay treatment.

What is Isotretinoin?

Isotretinoin works by suppressing sebum production and reducing the size of the sebaceous glands. It also normalizes keratinization and has anti-inflammatory effects, making it effective for treating moderate to severe acne.

Who is recommended to use Isotretinoin?

• Individuals with widespread nodular acne (to minimize scarring)

• Individuals suffering from moderate to severe acne

• Individuals whose previous acne treatments with insurance-covered antibiotics were ineffective

• Individuals with high sebum secretion

• Individuals experiencing severe depression or physical and mental distress due to acne

Who cannot use Isotretinoin?

• Individuals with a history of malignant tumors, stroke, heart failure, or multiple endocrine neoplasia type 2.

• Individuals with pancreatitis, liver failure, coronary artery disease, high triglycerides, or severe liver or kidney dysfunction.

• Individuals under 18 or over 70 years of age.

• Individuals who are pregnant or may become pregnant.

• Individuals planning to conceive (including men).

• Breastfeeding individuals.

• Individuals with an allergy to this medication.

• Individuals scheduled for major surgery.

Important Considerations for Isotretinoin Use

Isotretinoin is teratogenic (the risk of fetal malformations when a pregnant woman takes the drug). It should never be used by pregnant women or women who may become pregnant during treatment.

• Strict contraception must be observed for at least one month before starting, during treatment, and for one month after treatment.

• It is recommended to start taking the medication on the 2nd or 3rd day of a normal menstrual cycle.

• Avoid taking supplements containing Vitamin A.

• Approximately 10-20% of patients may experience a temporary worsening of acne at the beginning of treatment, but this usually improves within about a month (healing crisis).

• During and after treatment, dryness of the mucous membranes may worsen discomfort when wearing contact lenses.

• Do not donate blood during treatment and for one month after discontinuing the medication.

• May cause depression, psychosis, and, rarely, suicidal ideation, suicide attempts, or suicide (mechanism of action is not clear).

Side Effects of Isotretinoin

Side effects are dose-dependent and can be reduced by lowering the dose (except for teratogenicity).

• Teratogenicity

• Approximately 10-20% of patients experience a worsening of acne in the early stages of treatment.

• Severe lip inflammation, severe facial dermatitis, vestibular inflammation, blepharoconjunctivitis, photosensitivity, nosebleeds (protect with lip balm, moisturizer, artificial tears, sunscreen).

• Although very rare, contact the clinic immediately if you experience severe or persistent headache, visual disturbances, nausea, or vomiting.

• High triglycerides can cause pancreatitis.

• Depression, suicidal ideation.

• Worsening of inflammatory bowel disease.

• Pustular granuloma, diarrhea.

Recommended Dosage

• Initial: 0.5-1mg per kg of body weight, divided into two doses per day. Maximum 2mg per kg of body weight.

• Maintenance: 0.5-2mg per kg of body weight, divided into two doses per day. Treatment duration: 16-20 weeks (can be ended earlier if the number of nodules decreases by 70%).

• Cumulative dose is important; a cumulative dose of 120mg/kg or more is strongly associated with better long-term remission. This can be achieved by treating for 4 months at a dose of 1mg/kg of body weight.

References

• https://anmc.org/wp-content/uploads/ClinicalGuidelinesMaster/Isotretinoin.pdf

• https://wakako-clinic.jp/service/イソトレチノイン内服/

Characteristics and Causes of Adult Acne

Adult acne, occurring after the age of 20, has different characteristics than adolescent acne.

Characteristics of adult acne

• Often appears on the chin, around the mouth, and along the jawline (U-zone).

• Difficult to treat and prone to recurrence.

• Many worsen before menstruation.

• Worsens with stress, lack of sleep, and irregular eating habits.

• Hormonal balance is involved (PCOS, stress-related).

Aggravating factors for adult acne

• Hormonal imbalance (menstruation, pregnancy, changes in birth control pills, etc.)

• Stress, lack of sleep

• High GI diet, excessive dairy consumption

• Irritation from cosmetics and skincare

• Dry skin (excessive face washing, insufficient moisturizing)

• Mask-induced humidity and friction (maskne)

• Drug-induced (steroids, lithium, etc.)

Treating Acne Scars

Acne scars are broadly divided into three types, and each requires a different treatment approach.

Once crater-like scars form, treatment becomes difficult, so the best prevention is to treat acne early to prevent scarring. Start treatment at the red acne stage.

Basics of Proper Skincare

Face Washing

• Wash twice a day (morning and night), gently lathering with a foaming net to create plenty of foam.

• Rinse thoroughly with lukewarm water.

• Do not rub vigorously or wash too frequently (this can lead to excessive sebum secretion).

• After washing, gently pat your face dry with a towel.

Moisturizing

• Moisturizing is essential even for acne-prone skin (dryness can paradoxically increase sebum secretion).

• Choose non-comedogenic products that are low in oil and high in moisture.

• Lotions and milky lotions containing ceramides and hyaluronic acid.

• Avoid oil-based products as they can clog pores.

Sunscreen

• Especially during acne treatment, UV radiation exacerbates hyperpigmentation, so sunscreen is essential.

• Choose non-comedogenic, oil-free formulations.

• Use SPF 30 or higher and PA++ or higher daily.

Acne prevention through lifestyle habits

Diet

• Reduce high-GI foods (white rice, bread, sugar).

• Avoid excessive consumption of dairy products (especially skim milk).

• Balance vegetables, fish, soy, and fermented foods.

• Be mindful of B vitamins, zinc, and dietary fiber.

• Drink 1.5 liters or more of water daily.

There is no established evidence that chocolate or fried foods directly cause acne. Rather, high-GI foods (foods that rapidly raise blood sugar) are considered to have a stronger correlation. Extreme dietary restrictions are not necessary, but refined sugars and sweet beverages should be limited.

Lifestyle Habits

• Sleep 7+ hours, go to bed by 11 PM.

• Promote metabolism with moderate exercise.

• Stress management (yoga, deep breathing, hobbies).

• Wash pillowcases and towels frequently.

• Keep hair off your face.

Harmful Actions to Avoid

• Popping pimples (spreads inflammation, causes scarring).

• Touching or picking with nails.

• Washing your face multiple times a day.

• Using alcohol-based sanitizers on your face.

• Daily use of harsh scrubs or peels.

• Neglecting moisturization.

• Trying many different over-the-counter drugs or supplements.

• Applying topical steroids to acne (worsens it).

Our Clinic's Prescription Process

• ① Provisional Payment and Pre-Consultation: Select your desired plan and place an order. Please provide detailed information about your current skincare, medications, and acne condition.

• ② Online Consultation: A doctor will confirm the type and severity of your acne via video call and prescribe appropriate topical medications, oral medications (or isotretinoin).

• ③ Same-Day Shipping at the Earliest: Orders completed via video call by 3:00 PM daily will be shipped the same day, delivered in discreet packaging that prioritizes your privacy.