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Surgery and Cosmetics

Treatment Options for Oily Skin

Mariana Soirefmann, Taciana Dal'Forno

Wednesday, April 16, 2008

Oily skin results from large quantities of sebum, filling the follicular reservoir and leaking onto the body surface.1 Although the presence of excessive sebum on the face is the subjective impression of the patient, it is generally considered unaesthetic and cosmetically undesirable, contributing to facial shine and imparting an unclean, greasy feel to the skin.2,3

Sebum is secreted by the sebaceous glands, which are most numerous on the face, particularly on the T-zone. Sebaceous glands are present at birth, with sebum production being relatively high during the first 6 months of life. After this period, sebum production declines and remains low until puberty, when sebaceous gland activity increases dramatically, as a result of increasing androgen output, and remains stable through adulthood. The number, size, and activity of sebaceous glands are thought to be inherited. Throughout life, their number remains stable, their size increases, and the sebum secretion rate declines with age.4

Clinically, the presence of sebum on the face is associated with facial shine, formation of comedonal and inflammatory acne lesion, and large pore size.2

The Sebumeter® and Sebutape® methods are photometric devices universally used to measure sebum secretion.3

Most of the therapies used for oily skin have been studied in acne, and the same treatment principles hold for oily skin.

Topical Treatments

Some topical treatments have been published as being useful for oily skin. The cleansers recommended for oily skin must be simple solutions of surfactant containing no oils, waxes, or any fatty agents that could aggravate the oily condition. Moisturizers, sunscreens, and other topical products must have the formulations with nonocclusive, noncomedogenic, and oil-free agents.5 We recommend gel-cream and powder presentations as topical products for oily skin.

Astringent agents such as alcohol, witch hazel, and acetone may cut through oils on the skin surface, but this is strictly a function of temporary removal and these agents do not tend to have long lasting effects. However, skin cleansers and astringents should be considered a first-line approach in the treatment of oily skin.

Draelos et al. conducted a randomized, double-blind, clinical trial, evaluating the effect of 2% niacinamide on facial sebum production. They concluded 2% niacinamide might aid in an improved cosmetic appearance for facial shine reduction, but further studies are necessary to characterize its mechanism of action.2

Dobrev reported the successful use of a cream containing polyphenol-rich extract from saw palmetto, sesame seeds, and argan oil in reducing the greasiness and improving the appearance of oily facial skin.6

Grimes reported that superficial salicylic acid peels are safe and efficacious for the treatment of acne and oily skin in patients with skin types V and VI.7

Oral Therapies

Isotretinoin is an extremely effective drug if given systemically for severe forms of oily skin and acne. It's the only retinoid with potent sebostatic properties. Systemic isotretinoin is the regimen of choice today in severe oily skin, since it reduces sebocyte lipid synthesis by 75% with daily doses as low as 0.1 mg/kg after 4 weeks.8 In a study with a small number of patients, the influence on oily skin was measured during oral isotretinoin treatment with 5 mg/d, 2.5 mg/d, or 2.5 mg 3x weekly. The authors showed that the sebum production was reduced by up to 64%, and the biopsies revealed a 51% reduction in sebaceous gland size. Good results were achieved in all patients, but there was a tendency toward better results with the 2 higher doses9. Multiple mucocutaneous and systemic side effects have been described with isotretinoin use and the observed side effects are usually dose dependent and reversible.4 Isotretinoin crosses the placenta and is recognized as a strong teratogenic compound.8 It should be used with a secure contraception in women of childbearing age. Oral isotretinoin is the only remedy for men. In women, oral isotretinoin is the most effective remedy, followed by antiandrogens.9

Oral antiandrogens also proved to affect the sebaceous glands. Spironolactone is an aldosterone antagonist used as a diuretic and as an antihypertensive drug. It also acts as an androgen receptor blocker and has been used for over 20 years for the treatment of acne and hirsutism. The antiandrogen effects of spironolactone result in a 30% to 50% decrease in sebum excretion rate. The usual dosage for the treatment of acne is 50 to 200 mg daily. However, lower daily doses may be effective in controlling acne with the advantage of having a reduced side-effect profile.4 There are no studies evaluating the effect of spironolactone only for oily skin.

Another antiandrogen, cyproterone acetate (CPA) is a progestin that acts as an androgen receptor blocker and inhibits ovulation. It can be used as a sole agent or in a combination with an oral contraceptive. It is used in doses ranging from 2 to 100 mg/day and is most commonly used in the form of an oral contraceptive with 35 micrograms of ethinyl estradiol (EE) and 2 mg of CPA. Its effect on oily skin is seen after 2 to 3 cycles.10

Flutamide is a potent nonsteroidal inhibitor of androgen receptors. It was introduced for the treatment of prostatic cancer but is also used in the therapy of hirsutism, androgenic alopecia and acne. Its main problem has been the possible appearance of hepatic toxicity, which seems to be dose-dependent.10 There are no studies evaluating the effect of flutamide only for oily skin.

The beneficial effect of oral contraceptives is related to a decrease in ovarian and adrenal androgen precursors; to an increase in sex hormone-binding globulin (SHBG), which limits free testosterone; and to a decrease in 3a-androstenediol glucuronide conjugate, the catabolite of dihydrotestosterone (DHT) formed in peripheral tissues. The oral contraceptive 35 microg EE/2 mg CPA is used worldwide as a hormone treatment for acne and oily skin. A new oral contraceptive that contains a unique progestogen, drospirenone, and that has both antiandrogenic and antimineralocorticoid activity has results on acne comparable to 35 microg EE/2 mg CPA. The combined oral contraceptive containing EE and the selective progestogen, desogestrel, has been shown to reduce facial oiliness.11 The use of this contraceptive appears to improve oily skin after just 1 cycle of treatment.12

New Treatments

Recently, new modalities targeting the sebaceous glands have been developed for the treatment of acne and have been shown the selective necrosis of the sebaceous glands. These are photodynamic therapies,13 diode laser devices,14 and nonablative radio frequency devices.15

A study evaluated the sebum excretion by sebum-absorvent tape method after 31,450 diode laser treatments. The maximal observed effect was a reduction by 18% in number of sebum producing follicles at 6 weeks.16 The same method was used in another study to evaluated the effect of topical aminolevulinic acid-photodynamic therapy (PDT) on sebaceous glands. Multiple PDT caused far lower sebum excretion than single PDT at the longest follow-up time (20 weeks). On histology, sebaceous glands showed acute damage and were smaller 20 weeks after PDT.17 This study obtained a prolonged suppression of sebaceous gland function.

A recent uncontrolled clinical assessment study evaluated the efficacy of selective electrothermolysis of the sebaceous glands to the treatment of facial oily skin and showed a mean reduction rate of skin surface lipids of 31.5%.18

Therapeutic options for oily skin should target the sebaceous glands. As more knowledge is gained about the complex function of the sebaceous gland, novel therapies will hopefully be developed to more effectively treat oily skin and reduce side effects.

References

  1. Roh M, Han M, Kim D, et al. Sebum output as a factor contributing to the size of facial pores. Br J Dermatol. 2006;155:890-4.
  2. Draelos ZD, Matsubara A, Smiles K. The effect of 2% niacinamide on facial sebum production. J Cosmet Laser Ther. 2006;8:96-101.
  3. Youn SW, Na JI, Choi SY, et al. Regional and seasonal variations in facial sebum secretions: a proposal for the definition of combination skin type. Skin Res Technol. 2005;11(3):189-95.
  4. Clarke SB, Nelson AM, George RE, et al. Pharmacologic modulation of sebaceous gland activity: mechanisms and clinical applications. Dermatol Clin. 2007;25:137-46.
  5. Baran R, Maibach HI, eds. Textbook of Cosmetic Dermatology. 3rd ed. Spain: Taylor & Francis 2005.
  6. Dobrev H. Clinical and instrumental study of the efficacy of a new sebum control cream. J Cosmet Dermatol. 2007;6:113-8.
  7. Grimes PE. The safety and efficacy of salicylic acid chemical peels in darker racial-ethnic groups. Dermatol Surg. 1999;25:18-22.
  8. Orfanos CE, Zouboulis CC. Oral retinoids in the treatment of seborrhoea and acne.Dermatology. 1998;196:140-7.
  9. Geissler SF, Michelsen S, Plewig G. Very low dose isotretinoin effective in controlling seborrhea. J Dtsch Dermatol Ges. 2003;1:952-8.
  10. Haroun M. Hormonal therapy of acne. J Cutan Med Surg. 2004;8:6-10.
  11. Katz HI, Kempers S, Akin MD, et al. Effect of a desogestrel-containing oral contraceptive on the skin. Eur J Contracept Reprod Health Care. 2000;5:248-55.
  12. Prilepskaya VN, Serov VN, Zharov EV, et al. Effects of a phasic oral contraceptive containing desogestrel on facial seborrhea and acne. Contraception. 2003;68:239-45.
  13. Horfelt C, Funk J, Frohm-Nilsson M, et al. Topical methyl aminolaevulinate photodynamic therapy for treatment of facial acne vulgaris: results of a randomized, controlled study. Br J Dermatol. 2006;155:608-13.
  14. Lloyd JR, Mirkov M. Selective photothermolysis of the sebaceous glands for acne treatment.Lasers Surg Med. 2002;31:115-20.
  15. Ruiz-Esparza J, Gomez JB. Nonablative radiofrequency for active acne vulgaris: the use of deep dermal heat in the treatment of moderate to severe active acne vulgaris (thermotherapy): a report of 22 patients. Dermatol Surg. 2003;29:333-9.
  16. Perez-Maldonado A, Runger TM, Krejci-Papa N. The 1,450-nm diode laser reduces sebum production in facial skin: a possible mode of action of its effectiveness for the treatment of acne vulgaris. Lasers Surg Med. 2007;39:189-92.
  17. Hongcharu W, Taylor CR, Chang Y, et al. Topical ALA-photodynamic therapy for the treatment of acne vulgaris. J Invest Dermatol. 2000;115:183-92.
  18. Kobayashi T, Tamada S. Selective electrothermolysis of the sebaceous glands: treatment of facial seborrhea. Dermatol Surg. 2007;33:169-77.

 

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