What is acne?
Acne is a skin disease consisting of clogged pores, pimples, pustules and cysts that occur on the face, neck, and upper body. It usually first develops around the age of twelve and lasts five to ten years, although some people never outgrow it, especially if there is a family history of acne. It affects about 80% of people at one time or another during their lives. Most teenagers develop acne; however, acne is not restricted to any age group, and adults can certainly develop acne. Both males and females develop acne, but males tend to have a more severe and longer lasting form of acne. Females may have intermittent acne due to hormonal changes. Acne can lead to serious and permanent acne scarring and can have a significant impact on people’s lives. Acne scarring can lead to decreased self-esteem, reduced self-confidence, poor body image, withdrawal from social activities, frustration, and depression.
What causes acne?
Several factors play a role in acne. Hormonal changes during puberty cause the sebaceous oil glands of the skin to produce more oil. Male hormones called androgens affect the sebaceous glands. Females have androgens as well as males, but in lower amounts. Sebaceous glands empty their sebum (oil) into a hair shaft follicle. During puberty, the skin cells that line the follicle shed more quickly. In people with acne, the shed skin cells stick together and mix with the increased amount of sebum that is produced and they plug the opening of the follicle. Because the sebaceous glands continue to produce sebum, the follicle enlarges. This process causes comedones (blackheads and whiteheads). P. acnes, bacteria that are normally found on the skin, grow in the clogged hair follicle and cause irritation that leads to inflammation. The wall of the follicle can rupture and spread inflammation to the surrounding skin. Papules, pustules, nodules and cysts can develop.
Types of acne
Comedo — A comedo (plural is comedones) is a sebaceous follicle plugged with sebum, shed cells from the lining of the follicle, and bacteria. A comedo can open to the surface of the skin and have a blackish top, or the plug is deeper in the follicle and forms a whitehead below the surface of the skin. These lesions should not be picked or squeezed since infection and acne scarring can occur.
Papule — A papule is a small bump slightly raised on the surface of the skin. This acne lesion is a more advanced lesion than a comedo.
Pustule — A pustule is a papule that contains pus consisting of shed skin cells, bacteria and white blood cells.
Nodule — A nodule is larger than a papule and is inflamed. It is usually painful and may cause acne scarring.
Cyst — A cyst is a balloon-like lesion that contains shed cells, bacteria and white blood cells and is larger than a pustule. It may be very inflamed and painful, and extend into deep layers of the skin. It is difficult to treat and usually leads to acne scarring.
It takes time for acne treatment to work effectively, so it is important to be patient. It can take two months before the effects of treatment are noticed. A treatment that helps one patient may not be the best treatment for the next patient. Since there are several factors that affect acne and various available treatments, it is important to see a dermatologist who can determine the appropriate treatment for an individual. Several factors are taken into account when choosing a treatment plan for a patient: the type and severity of acne, any co-existing conditions such as a hormonal imbalance in females, the skin type, and whether the patient is motivated to treat. It is best to treat acne early to prevent acne scarring. Acne cannot be cured, but with treatment, it can be controlled.
Patients with small lesions such as comedones and pustules, should gently wash the acne-prone area with a salicylic acid wash, if tolerated, or a mild wash twice a day. Acne is not caused by poor hygiene, so scrubbing should be avoided since it can irritate skin and worsen acne. Avoid squeezing pimples since it can cause more inflammation and acne scarring.
Combination topical medications are usually used, including salicylic acid lotions, benzoyl peroxide gels, glycolic acid lotions, and tretinoin creams. These medications address several of the causes of acne since they help to peel the skin, unplug the follicles, and treat the bacteria. Other treatments may include topical antibiotics; salicylic acid or glycolic acid peels which exfoliate and help to unclog the pores, and help the medication penetrate more effectively; microdermabrasion which causes exfoliation of the skin and smoothes the skin surface; Blu-U light treatments which destroy the bacteria; and Levulan® photodynamic therapy and laser treatments which shrink the sebaceous glands. It may take two months or so to see the improvement and treatment must be continued to prevent new lesions from developing. Red or dark brown marks (postinflammatory pigmentation) may be left after lesions have cleared, depending on the patient’s skin type. With time, the pigmentation will fade and continuing on with treatment will speed up the fading. Intense pulsed light treatments can help the redness fade more quickly and chemical peels can help fading of the pigmentation.
Adult acne usually affects women because of hormonal changes associated with aging. Birth control pills, ovarian cysts and pregnancy can cause hormonal changes that can cause acne. Occlusive make-up can clog pores and cause acne. Noncomedogenic cosmetics should be used. Some patients find that certain foods affect their acne. They should avoid those aggravating foods and eat a well-balanced diet. Treating acne before it becomes severe can prevent worsening of acne and reduce the risk of acne scarring.
Moderate to severe acne
Patients with papules, nodules, and cysts of more advanced acne require more aggressive treatment than those with mild acne. Acne conglobata involves deep abscesses that damage the skin and cause extensive acne scarring. Acne fulminans is characterized by a sudden onset of inflammation causing severe acne scarring and is associated with fever and joint pains. These severe forms of acne scarring can take years to treat. It is important for patients to have the support of family and friends and to follow their dermatologist’s advice.
In addition to the above treatments, oral medication may be prescribed
such as oral antibiotics, birth control pills in females, and Accutane.
Accutane is the strongest oral medication for acne. It can work very
well but there are potential side effects that may occur, including
liver toxicity, elevation of lipids, pancreatitis, pseudotumor cerebri,
skeletal abnormalities, hearing and visual impairment, psychiatric
disorders, and dryness. Pregnancy must be avoided because of the high
risk of fetal abnormalities. Patients must have blood work and see
their dermatologist every 4 weeks. Additional information on Accutane
may be found at: www.fda.gov/cder/drug/infopage/accutane
Acne scarring is caused by the body’s
inflammatory response to the plugged follicles. Cysts that occur
deep in the skin can cause acne scarring, but sometimes, even mild
acne can result in scarring. With time, some acne scars improve,
but others worsen with aging. It is important to treat acne early
in its course to try and prevent acne scarring. Ongoing treatment
by a dermatologist is necessary to prevent inflammation and new
acne lesions that can potentially lead to acne scarring.
Type of acne scarring
When acne scars are caused by increased tissue formation, the skin is raised and these scars are called keloids or hypertrophic scars. There is an overproduction of collagen when the cells are injured by inflammation and these acne scars are raised.
When acne scars are associated with a loss of tissue, they cause depressions in the skin. Examples of depressed acne scars are ice-pick scars, depressed fibrotic scars, soft rolling scars, and follicular atrophic scars.
Treatment of acne scarring depends on the patient’s skin type, the type of acne scarring, the time commitment involved and the cost of the treatments.
Raised acne scars can be injected with cortisone injections, or treated with laser treatments or intense pulsed light. Depressed scars can be treated by injections with filler substances such as collagen, fat or hyaluronic acid to plump up the scars. Superficial scars can be improved with chemical peels or microdermabrasion, and deeper scars benefit from dermabrasion, deeper chemical peels, and resurfacing lasers such as the Fraxel® laser. Fraxel® laser treatments have become the laser treatment of choice for acne scarring since there is very little downtime, and improvement is seen even after the first treatment.