Feb 9, 2016

By Trevor Shewfelt, Pharmacist at the Dauphin Clinic Pharmacy

"I fell in to a burning ring of fire! I went down, down, down and as the flames went higher." I know the Johnny Cash song is supposed to be a cautionary tale for your immortal soul, but a ring of fire doesn't sound bad on a cold winter day. "Burning ring of fire" also makes me think of famous pharmacist Wilbur Scoville. He didn't invent Sorell boots, the toque, ski-doo mitts or the balaclva, but he still helps me warm up in winter. Because what is better on a cold winter day than a hot bowl of chili. And I don't just mean temperature hot. I mean spiced up until your eyes water hot. Over 100 years ago, Wilbur devised the objective scale which ranks how hot different peppers were. Peppers are still ranked by Scoville Heat Units. On a more serious note, acne is ranked on a scale by pharmacists as well. It is usually broken up into mild, moderate and severe classes. Acne vulgaris or acne is very common and has been reported in up to 80% of people between the ages of 11 and 30. It is not just teenagers who get acne. It can happen as early as days to months after birth and continue into someone's 40's. It is estimated that 20-30% of people 20-40 years old have acne. But it does usually it show up in adolescence. And acne usually goes away with out treatment. However, some cases are severe and difficult to treat. In severe cases, we worry about physical and emotional scarring. Severe acne is 10 times more common in males than females. However acne usually starts earlier females and lasts longer into their 20's and 30's.

Acne lesions begin in pores around hair follicles. Hair follicles have a gland that produces an oily, waxy substance called sebum. Before becoming an acne lesion, the walls of the pore gets thicker and narrower. This causes the sebum to get trapped. At this point you can't see anything going on. But then something happens in the body, and the sebum gland starts producing too much sebum and the trapped sebum starts getting backed up. This increased sebum production is often caused by adolescent changes in hormone levels. If the pore remains open, this turns into a black head. If the pore remains closed, this turns into a white head. People often assume a black head is dirt stuck in a pore. It is actually the sebum oxidizing in contact with the air. Although black or white heads are the first visible signs of acne, they can take 5 months to develop. This stage of white head and black heads is the mild end of the condition and is called noninflammatory acne.

The ever expanding plug of sebum is a great place for Propionibacterium acnes to grow. P. acnes is an anaerobic bacteria which means it grows where there is no oxygen. Once P. acnes arrives, white blood cells, the immune fighters of the body, show up to attack the invaders. This starts the inflammation process and this can form a pustule. A pustle is a raised white lesion filled with pus and usually less than 5 mm in diameter. If it forms near the surface of the skin these pustules usually go away in a few days and leave no scarring. However if the inflammation happens deeper under the skin it can form a nodule. This is the most severe acne lesion and can lead to scarring.

When it comes to acne treatment, there are over the counter and prescription options. For mild acne, benzoyl peroxide is the place to start. It kills the P. acnes bacteria with oxygen, it can break up and drain the black or white head and it has mild antiinflammatory effects. Benzoyl peroxide 5% products can be bought without a prescription. If you have never used one before, first just put a little on a small patch of skin just to make sure you don't get a rash. If you get no reaction after applying to a small area for 3 days, you should be fine to apply to whole affected area. You can get benzoyl peroxide stronger than 5 % with a prescription, but it won't necessarily work better and might irritate the skin more.

If you go to the doctor with your mild to moderate acne, they might start you instead on a vitamin A prescription cream. Vitamin A creams (or topical retinoids) prevent new blemishes by normalizing skin shedding around the hair follicle and reducing inflammation. If either benzoyl peroxide or vitamin a creams don't work, often the next step is a combination of benzoyl peroxide and clindamycin in a cream. Clindamycin is an antibiotic and combined with benzoyl peroxide these combination products work better than either ingredient separately.

If mild acne doesn't respond to a combo of clindamycin and benzoyl peroxide in 2-3 months, oral antibiotics like doxycline or tetracycline are often up next. If the acne is moderate, the doctor might move to the oral antibiotic directly with or without benzoyl peroxide or vitamin a creams. Usually the oral antibiotics take one to two months to take effect. After 12 weeks, usually your doctor will start to taper the antibiotic and then stop it. The topical treatments will usually continue for a few months more.

Instead of oral antibiotics, the acne of some females responds well to birth control pills. Because we think hormone changes increased the sebum production in the first place, birth control pills can work well to reduce acne in some females.

Oral isotretinoin is usually reserved for severe acne. It is an oral form of vitamin a and it is the most effective acne medication we have. However, it also has the most potential side effects. They start with the relatively mild dry skin, lips and eyes. Then there are nosebleeds and muscle aches. Being on isotretinoin requires the doctor to do blood tests to check how your liver is functioning because isotretinoin can be hard on the liver. And isotretinoin causes birth defects. So women who could become pregnant have to be on birth control if they are taking isotretinoin.

Winter in Dauphin is cold. That is as redundant as saying Johnny Cash is the Man in Black. To get you through February, go make some hot chili to warmnyou up from the inside. A pharmacist from a century ago can help your cooking. Wilbur Scoville's Scoville Heat Units range from 0 for a bell pepper to 16 million for pure capsaicin. Typical peppers you might find in your kitchen are jalapeno's at 10,000 SHU's to habanero's at 100,000 SHU's. Recently the ghost pepper was the world champ at around 1 million SHU's. If you like to watch YouTube while your chili is simmering, look up people being dared to eat a ghost pepper. These poor souls will warm your heart as well. It seems now the ghost pepper has been knocked off its perch by the Carolina Reaper at a reported 2 million SHU's! I don't know if that much heat makes me excited or scared, but just thinking about the Carolina Reaper gives me a burning ring of fire.

As always if you have any questions or concerns about these or other products, ask your pharmacist

New Canadian Acne guidelines:

Wilbur and his Scoville Heat Units -

Mr Johnny Cash-

The information in this article is intended as a helpful guide only. It is not intended to be used as a substitute for professional advice. If you have any questions about your medications and what is right for you see your doctor, pharmacist or other health care professional.

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