Antibiotic Resistance in Acne

increased antibiotics resistance in acne
global emerging drug resistance in acne

Global Antibiotic Resistance

Acne Vulgaris continues to be a common skin condition that we see in daily practice. Increasingly, we have noticed a worrying trend that many individuals do not respond to antibiotics, whether topical or oral antibiotics for acne. Antibiotics have been one of the most effective treatments for acne vulgaris over the past few decades, however resistance patterns have emerged worldwide.

Skin Propionebacterium acnes, a bacteria that normally colonizes the skin, is one of the factors implicated in the formation of acne. One of the cornerstones of acne treatment have been to reduce the bacterial load and inflammation. Recent studies have shown that prevalence of resistant strain to antibiotics have increased from 34.5% in 1991 to a peak of 64% in 1997.

Resistance to the antibiotic Erythromycin was the most common. In individuals who were resistant to erythromycin, they have a high probablilty of being cross-resistant to Clindamycin, another commonly prescribed antibiotic. Resistance to the tetracycline class of antibiotics (e.g. doxycycline) have remained low, but this may change in the future.

increased antibiotics resistance in acne

How Do We Combat The Resistance?

To improve the outcomes in acne treatment and reduce antibiotic resistance, we recommend the following:

  1. Topical acne creams that have an antibiotic as an ingredient should be combined with a retinoid and/or benzoyl peroxide to reduce resistance.
  2. Oral antibiotics should only be used for the shortest period of time possible, and only for moderately-severe acne vulgaris.
  3. Avoid combining different classes of antibiotics in the treatment regime i.e. an oral antibiotic combined with a different topical antibiotic cream
  4. Stop the antibiotic based treatment if there is no significant improvement in your acne. There are now many safe and effective treatment options for acne available.
  5. Oral antibiotic therapy should always be combined with topical retinoid and/or benzoyl peroxide based cream to reduce resistant strains from emerging.
  6. For maintenance therapy, use a topical retinoid and/or benzoyl perozide, instead of an antibiotic.

References:

  1. Patel M, et al. The development of antimicrobial resistance due to the antibiotic treatment of acne vulgaris: a review. J Drugs Dermatol 2010;9:655-664
  2. P Coates, et al. Prevalance of antibiotic-resistance propionibacteria on the skin of acne patients: 1--year surveillance data and snapshot distribution study. British J of Dermatology. 2002;146(5):840-848

Aesthetic Rejuvenation 101

aesthetic clinic singapore

What You Need To Know About Aesthetic Treatments

The word 'Rejuvenate' has its roots in latin origins, and is defined as "to make young again, to restore to youthful vigour or appearance." The pursuit to remain youthful has always be highly regarded throughout the centuries. From the allure of Cleopatra to the search for the Fountain of Youth in the 16th century by spanish explorers, rejuvenation appears all but a myth, but is it really?

The dynamic advances in medical sciences, coupled with a greater understanding of cellular & molecular mechanisms and a deeper appreciation of the ageing process has helped us understand how to slow and even reverse the signs of ageing.

There is now a paradigm shift in how we approach ageing. It is no longer just an injection here to relax the frown line, or a laser there to eliminate that dreaded age spot. The approach and consideration of aesthetic treatments must be holistic, taking into account the multiple levels of ageing. Ageing is not only skin, it is skin deep. It affects fat, muscle, connective tissues, bone and the interplay between such components. As an established aesthetic clinic in Singapore, we use an integrated evidence based approach that rejuvenates the multiple layers of ageing giving you better and longer lasting results.

Resurface

The skin is the largest organ in the human body. While there is very little we can do to influence the intrinsic effects of ageing, we can minimise extrinsic ones. Smoking, excessive ultraviolet light exposure and an unhealthy lifestyle can greater impact on skin pigmentation, texture and laxity. Simple measures such as sun protection, seeking help to stop smoking, increasing physical activity and maintaining a  healthy diet can improve overall skin health.

Once the signs of ageing has set it, it may be difficult to alter much of the skin colour, texture and laxity by topical off the shelf products alone. For example, in a 46-year-old Teacher with facial hyper pigmentation and mild skin laxity, we may use a Q-switched laser to break down the melanin causing the freckles, sun spots or melasma, followed by the quasi-long pulsed Nd:YAG laser to stimulate collagen and elastin. In the presence of acne scars, enlarged pores and individuals who desire a more lifted appearance in the neck, face and eye region, we may resurface the skin with either fractional ablative lasers or with the more recent fractional micro needling radio-frequency technology.

Relax

Wrinkles develop from the repetitive movements of muscle that is attached to the skin. In the early stages, your wrinkles only appear when you smile, laugh or frown. This is called dynamic wrinkles, and may progress to more severe static wrinkles that remain even when there is the face is at rest.

In the past, where botulinum toxin was overused to correct dynamic wrinkles, it also came with the undesirable frozen look. With the greater understanding of anatomy and different ethnic standards of beauty, we must modify our approach. Even within Asian countries, the individual beauty standards differ in Vietnam, Malaysia, Korea & China. The strategic use of botulinum toxin to relax the muscles must be balanced by retaining sufficient expression for daily interaction, while recognising the diversity of beauty that we see all around us. Sometimes less is more.

Another popular treatment to create a slimmer V Shape Face using botulinum toxin to the masseter muscles can help individuals contour their facial shape non-surgically. 

Refill

It is with great interest that CT scans have been used to study the ageing process. It was found that there is preferential loss of bone around the eyes, the mid cheeks and jawlines. Coupled with the weakening of connective tissues and the loss of facial fat, we can begin to understand how we get a hollowing beneath the eyes, flattening of the cheeks and sagging around the mouth.

Fillers treatment has evolved and constantly new products are being churned out each year. The ideal filler material is bio-compatible, non-allergenic, free of complications, feel and look completely natural. The filler has to biodegrade naturally overtime because a permanent filler that remains when the rest of the face changes due to aging will lead to an undesirable result.

The ideal filler would be able to stimulate collagen and provide a greater lifting effect. In addition, there  has to be an element of reversibility in case the results are not desirable, and the ability to handle filler related complications. 

Although there is no 'ideal' filler at present, with modern day science we are getting close. 

Restylane is a range of FDA approved hyaluronic acid based fillers that a long track record in terms of providing long lasting results safely. The Restylane range of fillers uses patented stabilised NASAH technology. It provides natural volume, contour, hydration and smoothes away fine lines and wrinkles. 

Enhance

There are several ways to enhance your features without the need for surgery.

Fillers are popular because the results are immediately noticeable soon after the procedure. Fillers to enhance your chin, create fuller and more accentuated lips, and improve the cheek profile are now possible. In the past, where collagen based fillers only lasts 4-6 months, hyaluronic acid based fillers can last up to 2 years.

Thread lifting procedure using absorbable materials  for non-surgical facelift or necklift was popularised and has spread to many parts of Asian. The material, design and delivery of threads have grown with sophistication, allowing longer lasting effects with minimal downtime. Nose threadlift is a very popular procedure to enhance the nose bridge and elevate the tip of the nose without the need to undergo a surgical rhinoplasty. Thread lifting procedures lasts 20-45 minutes in most cases, with temporary swelling and bruising being the most common post procedural effects.

3 Proven Ways to Improve Acne Scars

acne scar removal for rolling scar type

With all the recent advances in medical technology, it can be overwhelming to know which treatments to choose to improve your acne scars. Acne scars remain common despite our best efforts to treat acne early and reduce the damage to the skin. Acne scar revision takes into account not only the acne scar type, grading, but also age, medical history, skin type and the body's unique healing capacity. Scars do change as we age due to the inherent changes in the collagen and elastin matrix within the skin. The types of treatment used for planning for acne scar revision is highly customised and takes into account the above mentioned factors. In this article, we shall discuss the common ways to improve acne scars.

acne scar removal for rolling scar type

1. Generate Collagen

Activating more collagen to improve the appearance of acne scars is the most common and widely used method today. Scarring is often a disruption of the collagen and elastin matrix within the skin, resulting in an uneven skin tone and texture. We perceive the skin to be uneven during daily interactions and in photographs as the result of the loss of light reflectance on scarred skin. Collagen synthesis, breakdown and remodelling is a dynamic process that changes with age.

There are a variety of methods on how we can induce collagen.  For mild scarring; superficial chemical peels, microdermabrasion and non-ablative lasers are suitable. In cases of moderate to severe acne scarring; deeper chemical peels such as TCA CROSS, subcision, dermabrasion, fractional ablative lasers (CO2, Erbium YAG) and micro needling fractional radio-frequency devices are available.

The resurfacing method for acne scars need to take into account the scar depth, scar type, scar grading and skin type. For example, individuals with a darker skin complexion have a higher risk of pigmentation if ablative lasers such as the CO2 lasers are considered. On the other hand, individuals with predominantly ice pick scars may be more suitable for TCA CROSS, rather than subcision and fractional resurfacing.

alter the colour of the acne scars with lasers

2. Amend Colour

The second most common request is to improve the colour of the acne scars. The change in colour may be the result of an over zealous inflammatory response within the skin. Colour changes are more common in Asian type skin, and are more noticeable to the observer. Post-acne scarring colour can be hyper pigmented (light to dark brown), vascular (pink to red) and rarely white (due to the loss of melanin).

The correct terminology includes:

  1. Post-inflammatory Hyperpigmentation (PIH) - Light to Dark Brown Colour
  2. Post-inflammatory Erythema (PIE) - Pink to Red Colour
  3. Hypopigmentation - White Colour

Treatment options for treating PIH depends on how deep the pigments are located within the skin. Lightening creams and sueprficial chemical peels can help with surface PIH, whereas pigment focus lasers such as the Q-switched Nd:YAG laser can target deeper pigmentation. For red acne marks or PIE, good skin care, intense pulsed light and vascular lasers such as the Pulsed Dye Lasers can reduce the blood vessel component in this form of scarring. 

3. Volumize

Acne scar that is due to a loss of volume can benefit from fillers. The loss of collagen in the dermal layer of the skin can cause a depression visible from the skin surface. Fillers come in a variety of materials. Natural fillers such as fat grafting involves a procedure to transfer fat from one place to another. The down side is a scar on the donor site, and longer downtime. Fillers also come in a variety of agents such as hyaluronic acid, collagen and polymethyl methacrylate (PMMA). The choice of fillers will depend on the size of the scar, the expected longevity of the results and the downtime involved.