Acne

Acne

Fig.1.5.

Definition

Acne is a common skin condition characterized by pimples on the face, chest, and back. It occurs when the pores of the skin become clogged with oil, dead skin cells, and bacteria.

(Fig.1.5.) Acne vulgaris affecting a woman's face. Acne is the general name given to a skin disorder in which the sebaceous glands become inflamed.


Description

Acne originates in the oil or sebaceous glands that lie just beneath the surface of the skin, within the hair follicles. These glands produce an oil called sebum-the skin's natural moisturizer-which also helps preserve the flexibility of the hair. These sebaceous follicles open onto the skin through pores, allowing the sebum to reach the hair and skin surface. The most common sites of acne are the face, chest, shoulders, and back since these have the most sebaceous follicles.

At puberty increased levels of androgens (male hormones) cause the sebaceous glands to overproduce sebum. The excess sebum cannot be cleared from the pores efficiently. In addition, cells lining the follicle are shed too quickly and the dead cells clump together. When the excess sebumcombines with the dead, sticky skin cells, a hard plug-called a comedo-forms and blocks the pore. There are two types of comedones in mild noninflammatory acne: whiteheads and blackheads. When the plugged follicle begins to bulge as a small whitish bump mostly under the skin, it is called a whitehead. If the comedo opens up, the top surface of the plug darkens as it is exposed to the air and it is referred to as a blackhead.

Moderate and severe inflammatory acnes result from infection of plugged follicles with Propionibacterium acnes, bacteria that normally live on the skin. Other microorganisms can also be involved. The bacteria produce chemicals and enzymes that cause inflammation. Pimples form when infected whiteheads or blackheads weaken and burst, releasing sebum, bacteria, and skin and white blood cells into the surrounding tissues. Inflamed pimples near the skin surface are called papules. Deeper pimples that fill with pus are called pustules. The most severe type of acne occurs when the infected follicles continue to enlarge without rupturing, forming nodules and cysts. Cysts are closed sacs that form lumps under the skin. Nodules are large hard swellings deep within the skin. Cysts and nodules can be painful and scarring can occur when new skin cells are laid down to replace damaged cells.

Acne is not a serious health threat. However, it can negatively affect appearance and has the potential of causing permanent scarring. Some people, especially teenagers, become quite upset about their acne and this distress can contribute to social or psychological problems.



Risk factors

Risk factors for acne include:

  • Age. Teenagers are most susceptible to acne because of hormonal changes.
  • Gender. Acne is more common in boys than in girls and boys tend to have more severe cases.
  • Heredity. Acne runs in families.
  • Hormonal changes in females. Acne can flare up right before menstruation, when levels of estrogen (female hormones that reduce oil production) drop, and during pregnancy and menopause.
  • Disease. Hormonal disorders can complicate acne in girls.
  • Personal hygiene. Abrasive soaps, hard scrubbing, or picking at pimples will worsen acne.
  • Cosmetics. Oil-based makeup and sunscreen-which clog pores-and hairsprays can aggravate acne.
  • Environment. Exposure to oils and grease, polluted air, and sweating in hot weather aggravate acne.
  • Diet. Although foods do not cause acne, certain foods may cause flare-ups or worsen the condition.
  • Drugs. Acne can be a side effect of drugs including tranquilizers, antidepressants, antibiotics, oral contraceptives, and steroid drugs, including anabolic steroids, which are chemically similar to the male hormone testosterone.
  • Stress. Emotional stress may contribute to acne.
  • Friction. Continual pressure or rubbing of the skin-for example by bicycle helmets, backpacks, or tight clothing-can worsen acne.

Causes and symptoms

The exact cause of most cases of acne is unknown. Contrary to popular myth, acne is not caused or aggravated by dirt, by eating greasy foods or chocolate, or by sexual activity. Many factors, including heredity, can contribute to the development of acne. The interactions between the body's hormones, skin proteins and secretions, and bacteria determine the course of acne.

Excess male hormone production in women can cause acne. Flare-ups of acne are also influenced by a woman's menstrual cycle. One study found that women over age 33 actually had a higher incidence of premenstrual acne than teenage girls.

Some alternative medical practitioners assert that acne is often related to toxicity in the intestines or liver due to:

  • the presence of bacteria such as Clostridia spp. and Yersinia enterocolitica
  • a low-fiber diet
  • a deficiency in healthy gut flora such as Lactobacillus spp.
  • an intestinal overgrowth of the yeast Candida albicans
  • food allergies
In teenagers acne often occurs on the forehead, nose, and chin. As people age the condition tends to appear towards the outer part of the face. Adult women may have acne on their chins and around their mouths. The elderly often develop whiteheads and blackheads on the upper cheeks and skin around the eyes.
Although acne is usually a superficial condition, inflamed lesions may cause tenderness, itching, pain, or swelling. The most troubling aspects of these lesions are their negative effect on appearance and the potential for scarring. Some people, especially teenagers who may be particularly self-conscious, are emotionally distressed by their acne, leading to difficulties with school, employment, or relationships.

Examination

Acne has a characteristic appearance and is not difficult to diagnose. The doctor takes a complete medical history, including questions about skin care, diet, factors that seem to improve or exacerbate the condition, medication use, and prior treatment. A physical examination includes the face, upper neck, chest, shoulders, back, and other affected areas. Under good lighting the doctor determines the number and types of blemishes, whether they are inflamed, whether they are deep or superficial, and whether there is skin discoloration or scarring.

Tests

Laboratory tests are not performed unless the acne appears to be caused by a hormonal disorder or other underlying medical problem. In these cases, blood analyses or other tests may be ordered. Stool tests can be helpful in determining whether there is a bacterial or yeast overgrowth contributing to the condition. Food-allergy testing may also be considered. Most insurance plans cover the costs of diagnosing and treating acne.


Traditional

Acne cannot be cured, but it can be controlled. The goal of acne treatment is to reduce sebum and keratin production, remove dead skin cells to help unclog the pores, and kill bacteria with topical drugs and oral medications. Treatment choice depends upon whether the acne is mild, moderate, or severe. Severe cases are referred to a dermatologist or an endocrinologist who treats diseases of the glands and the hormones. Most dermatologists use a combination of treatments, depending on the individual. Counseling may be necessary to clear up misconceptions about the condition and to offer support regarding the negative effect of acne on physical appearance.
In addition to medications, treatments for severe acne or the resulting scars include:

  • Comedone extraction. The comedo is removed from the pore with a special tool.
  • Chemical peels. Glycolic acid is applied to peel off the top layer of skin to reduce scarring.
  • Dermabrasion. The affected skin is frozen with a chemical spray and removed by brushing or planing.
  • Punch grafting. Deep scars are excised and the area repaired with small skin grafts.
  • Intralesional injection. Corticosteroids are injected directly into inflamed cysts.
  • Collagen injection. Shallow scars are elevated by collagen protein injections.
  • Laser treatments. There are two types of laser treatments for removing acne scars.

Drugs

Mild non-inflammatory acne is usually treated with topical over-the-counter acne medications that reduce the formation of new comedones. These may contain:

  • benzoyl peroxide (Clearasil, Fostex)
  • salicylic acid (Stridex)
  • sulfur (Therac lotion)
  • resorcinol (Acnomel cream)

Treatment with stronger topical medications requires a doctor's prescription. Such medications include comedolytics, which are agents that loosen hard plugs and open pores. These include concentrated formulas of salicylic acid, resorcinol, and sulfur. They also include topical retinoids-natural or synthetic vitamin A derivatives-which increase turnover (death and replacement) of skin cells. Topical retinoids are considered a cornerstone of acne treatment:

  • adapalene (Differin)
  • tretinoin (Retin-A, Avita, Renova Emollient)
  • tazarotene (Tazorac)

Topical antibiotics to kill bacteria may be added to the treatment regimen if inflammation is present. These include:

  • erythromycin
  • clindamycin (Cleocin-T)
  • meclocycline (Meclan)
  • sodium sulfacetamide

Topical medications are available as creams, gels, lotions, soaps, or pads of varying strengths. The medications are applied to the entire affected skin area once or twice per day after washing with mild soap. Possible side effects include mild redness, peeling, irritation, dryness, and an increased sensitivity to sunlight that requires the use of a sunscreen. Medications may be used for months or years to control acne. The goal of treating moderate acne is to decrease inflammation as well as prevent new comedone formation. Common treatments are topical tretinoin combined with a topical or oral antibiotic or topical benzoyl peroxide and erythromycin. The treatment is maintained for at least two to four months. When acne is severe and the lesions are deep, oral antibiotics may be taken daily to reduce the spread of bacteria:

  • tetracycline, which is the most common antibiotic for treating acne but which should not be taken while pregnant or breastfeeding
  • erythromycin
  • minocycline, which may have fewer side effects than other antibiotics
  • doxycycline for inflammatory acne

Antibiotics must be used for up to three months to affect severe acne. They can cause side effects including:

  • dizziness
  • photosensitivity
  • gastrointestinal upset
  • skin darkening
  • allergic reactions
  • yeast infections
  • tooth discoloration
  • folliculitis

Oral isotretinoin (Accutane) reduces sebum production and cell stickiness. It is reserved for the treatment of very severe acne with cysts and nodules or if antibiotic therapy is unsuccessful. Isotretinoin is sometimes used in combination with topical or oral antibiotics. Treatment may continue for four to five months and may be repeated or replaced with topical drugs or oral antibiotics if the acne returns. Lower dosages require a longer course of therapy.

Women who might become pregnant should use isotretinoin with extreme caution, since it can cause birth defects and miscarriage up to a month after stopping the medication. Strict attention should be paid to pregnancy tests and contraceptive requirements for women of childbearing age who take this medication. Side effects of isotretinoin are very common and may include:

  • temporary worsening of the acne
  • dry eyes, lips, skin, and genital mucosa
  • nosebleeds
  • vision disorders
  • elevated liver enzymes, blood fats, and cholesterol

Monthly blood tests are necessary to ensure that the medication is not causing serious harm. Anti-androgens-drugs that inhibit androgen production-and estrogens (female hormones) are used to treat women whose acne is unresponsive to other therapies. Certain types of oral contraceptives, such as norgestimate/ethinyl estradiol (Ortho-Tri-Cyclen), have been shown to improve acne. Both ultra-low-dose birth-control pills (Alesse) and those with higher doses of estrogen can be effective in treating acne.
Other drugs, such as spironolactone and oral corticosteroids or anti-inflammatory drugs, may be used to reduce hormone activity in the adrenal glands, thereby reducing production of sebum. This is the treatment of choice for an extremely severe but rare type of inflammatory acne called acne fulminans, which primarily affects adolescent males. Acne conglobata is a more common form of severe inflammation characterized by numerous, deep, inflammatory nodules that heal with scarring. It is treated with oral isotretinoin and corticosteroids.

Alternative

In addition to proper cleansing to keep the skin free of oil, alternative treatments for acne include:

  • a well-balanced diet high in fiber, zinc, and raw foods
  • intermittent fasting
  • an elimination diet with the avoidance of alcohol, dairy products, caffeine, sugar, processed foods, and foods high in iodine, which appear to contribute to acne
  • avoidance of smoking

Nutritional supplements for treating acne include:

  • essential fatty acids
  • vitamin B complex
  • vitamin A or beta-carotene
  • zinc
  • chromium

Supplementation with herbs that are blood cleansers or blood purifiers, strengthen the action of the liver and the kidneys, and help with detoxification and excretion are used to treat acne. These include:

  • dandelion (Taraxacum officinale) root tincture
  • burdock root (Arctium lappa), also known as gobo, which can be purchased fresh at health-food grocers or in Asian markets and can be used raw or cooked in salads, stir fries, or other vegetable dishes or as a tincture
  • red clover (Trifolium pratense), which can be consumed as a tea throughout the day
  • milk thistle (Silybum marianum) seed which can be taken as a tincture or ground up and eaten in combination with hot cereal, granola, or other foods

Other herbs useful in the treatment of acne include:

  • Echinacea spp.
  • goldenseal (Hydrastis canadensis), which is particularly helpful for clearing up underlying intestinal toxicity and killing bacteria
  • traditional Chinese herbal remedies such as cnidium seed (Cnidium monnieri) and honeysuckle flower (Lonicera japonica) Wholistic physicians or nutritionists canrecommend the proper amounts of these herbs.

Bowel toxicity may contribute to acne flare-ups. Lactobacillus acidophilus and Lactobacillus bulgaricus can be obtained from yogurt or as capsules to maintain a healthy balance of intestinal flora. Allergic foods should be identified and removed from the diet. Dietary fiber, such as oat and wheat bran, beans, fruits and vegetables and their skins, and psyllium seed, should be increased. The fiber absorbs toxins and carries them through the colon for excretion. Individuals with acne may want to participate in a movement therapy, such as yoga or t'ai chi, or begin an exercise regimen. Stress reduction or meditation can also be helpful.

Home remedies

Washing the acne-affected area with a mild germicidal soap and an abrasive sponge can help dislodge the material plugging the gland. However manipulating or squeezing acne pustules can cause deep and permanent scarring.


Prognosis

Acne is not curable, but it can be controlled by proper treatment. Improvement takes time and the results of specific treatments vary with the individual. Over-the-counter treatments for mild non-inflammatory acne can help prevent new blemishes, although it often takes 8-10 weeks to see improvement, as old blemishes take time heal. Inflammatory acne that is treated with a topical comedolytic in combination with an antibiotic usually improves within four to six weeks. Acne tends to reappear when treatment stops, but spontaneously improves over time. Inflammatory acne can leave scars that require further treatment.

Oral isotretinoin clears up resistant cysts and nodules in up to 90% of patients and prevents scarring. Long-term control is achieved in up to 60% of patients treated for four to five months. Another 20% of patients require a second course of isotretinoin and the final 20% may require only topical drugs or oral antibiotics. Improvement with anti-androgens may take up to four months.


Prevention

There is no sure way to prevent acne, but the following steps may help minimize flare-ups:

  • washing affected areas gently with lukewarm water twice every day, using just the fingertips and a mild soap containing sulfur, Calendula officinalis, or other substances that are useful against acne
  • washing gently after sweating
  • waiting 5-15 minutes after washing to apply acne medication
  • avoiding abrasive soaps, facial scrubs, toners, astringents, and masks, which can irritate the skin and cause breakouts
  • limiting use of makeup and moisturizers; applying any medications before applying makeup
  • using only skin and hair products that are labeled "oil-free," "nonacnegenic," or "noncomedogenic," meaning that they do not clog pores
  • shampooing often and wearing hair up and away from the face
  • eating a healthy well-balanced diet of fresh fruits and vegetables
  • avoiding foods that trigger flare-ups
  • exposing the affected skin to sunlight on a limited basis, unless otherwise advised
  • avoiding the handling of affected areas or picking or squeezing pimples, as this can contribute to scarring and spread the acne
  • reducing stress