Acne

What is Acne?

Acne vulgaris (pimples) is one of the common skin conditions that causes spots.  Acne is commonly seen on the face, neck, chest, shoulders and back.

Acne can occur at any age, but is more commonly seen in teenagers and young adults. A study conducted at a dermatology clinic in India reported that around 50.6% of boys and 38.13% of girls in the age group of 12-17 years had acne. Another study from India reported that around 60% of acne cases were seen in the age group of 16-20 years.

acne

Causes and risk factors

What causes acne?

The skin has oil glands (sebaceous glands) that produce oil (sebum), which lubricates and prevents our skin from becoming dry. Excess quantity of sebum and dead skin cells can cause blocking the openings (pores) of the oil glands.

A comedone can form when skin debris and oil collect in the pore. The plug may be open to the exterior and may become dark causing a blackhead. The pore may be blocked from the surface and bulge the walls of the hair follicle to produce a whitehead. The blocked pore may become infected with bacteria causing inflammation and pus formation.

In mild acne, there may be a few red spots. In severe cases, there can be multiple spots or cysts which are the big, red bumps seen on the skin.

What are the factors that make acne worse?

  • Hormones: The hormonal changes during puberty can cause oil glands to produce more sebum and can cause acne. In women, around the time of their monthly periods, hormonal changes can cause aggravation of acne. Some types of oral contraceptive pills can worsen acne.
  • Cosmetics: Most of the available make-up materials may not affect acne. However, thick, oily make-up can increase acne.
  • Environment: Hot, humid weather is associated with excessive sweating and may make acne worse.
  • Medications: Some medicines such as anabolic steroids, corticosteroids, anti-epilepsy drugs, lithium, androgens, iodides, bromides, etc. can cause a flare-up of acne.
  • Squeezing acne: Pinching or squeezing acne or comedones can aggravate the inflammation and make the acne bigger. 
  • Food: Some food items (chocolate, dairy products, high-sugar foods) are thought to increase the likelihood of acne, but this has not been conclusively proven.

Symptoms and signs

What are the symptoms and signs of acne?

Most frequently, acne is seen on the face, but it can also affect the neck, chest, back and in few cases can involve a wide area of the body.

The different type of acne spots that can be seen in the skin include:

  • Open comedones – blackheads
  • Closed comedones – whiteheads.
  • Papules (tiny red raised spots).
  • Pustules (whitish or yellowish pus filled spots).
  • Nodules (large, solid, painful bumps on the skin)
  • Cystic lesions (large, oil or pus-filled bumps on the skin)
  • Acne scars (scar formation on the skin after the acne has healed)

Diagnosis

Your doctor will diagnose acne by examining your skin for presence of any acne lesions such as blackheads, papules, pustules and nodules in different areas of the body such as face, neck, chest, back. Based on the presence of these spots and their level of inflammation, your acne may be graded to decide a treatment plan for you.

Treatment and prevention

How is acne treated?

 The treatments used in acne may act by different mechanisms such as: decreasing the oil production, reducing the multiplication of skin cells, killing the bacteria, reducing the inflammation, etc.

 A. Topical agents: These agents are used on the surface on the skin in the form of ointments, creams, lotions, etc.

  • Benzoyl peroxide: acts by its anti-bacterial effects and killing the acne-producing bacteria. It also shows some of its action by reducing the keratin and decreasing the skin debris that causes plugging of pores. Your doctor may prescribe this medication either alone or in combination with other acne medicines.
  • Retinoids: They act by decreasing the fast growth of skin cells and help in unplugging the pores. They also have anti-inflammatory action. These drugs include adapalene, tretinoin and isotretinoin.
  • Azelaic acid: Normalizes the growth of the surface keratin skin cells and reduces comedone formation, unblocks the pores and oil glands. It also has anti-inflammatory effects.
  • Antibiotics: They function by killing the bacteria and reducing inflammation. Examples include erythromycin, clindamycin, etc

B. Oral medications

  • Oral Antibiotics: Your doctor may prescribe oral antibiotics in moderate to severe acne. They help by clearing bacteria and reducing inflammation. Examples or oral antibiotics used in acne include tetracycline antibiotics like doxycycline and minocycline.
  • Isotretinoin: is prescribed by doctors for the treatment of severe acne when acne is not responding to other treatment. It acts by causing a significant reduction in sebum production, lowering comedone formation, decreasing bacteria known to cause acne and through its anti-inflammatory effect. It is a powerful medicine with many side effects and has to be taken under the guidance of your doctor.
  • Anti-androgen agents: Blocking the effect of androgens on oil glands using anti-androgen drugs such as spironolactone may be needed to reduce acne in some adolescent girls and women who have acne.
  • Combined oral contraceptive pills: In some adolescent girls and women, acne can be a result of hormonal imbalances and excess androgens. Combined oral contraceptives may be used to treat acne in such cases.

 C. Other therapies

  • Chemical peels: A chemical solution (e.g., Salicylic acid) is used on the face to peel off the surface layer and unblock the pores. It is used in combination with other acne treatment, except in those patients on oral retinoids where they will cause severe irritation of the skin.
  • Light-based therapies: A blue-light or blue+red light is applied to the skin to kill the bacteria. These therapies have only limited evidence in their favour.
  • Manual removal of blackheads and whiteheads: Special instruments may be used to manually extract the blackheads and whiteheads. These are cosmetic procedures used to provide temporary relief.

 D. Acne scar treatment

 Acne scars can be treated by certain techniques such as:

  • Soft tissue fillers: Some filler items such as fat or collagen is injected in the pits caused by scars, which will make them less prominent.
  • Chemical peels:  Chemical peeling agents are used to remove the top layer of skin and decrease the deep scars.
  • Dermabrasion: In this procedure a wire brush or a diamond wheel with rough edges is used to remove the surface layers of skin. This makes the scars blend with the surrounding skin and skin appears smoother.
  • Laser resurfacing: Laser beam is used to smoothen out irregular skin and improve the appearance of skin.
  • Skin surgery: This is a minor surgical procedure in which the pits of individual acne scars are repaired by cutting and then stitching or skin grafting.

How can acne be prevented?

  1. Keeping the face clean: Wash your face twice daily with a gentle cleanser. Use only gentle soaps on the face. Use a soft cloth on the face and do not scrub the face roughly with any hard cloth or loofah.
  2. Use gentle cosmetics: Use cosmetic products that are gentle and preferably alcohol-free. Avoid products that irritate skins such as exfoliating agents, astringents, toners, etc.
  3. Take proper care of hair: If you have oily hair, shampoo it regularly. Do not use too much oils or gels on the hair, which can cause them to trickle down to face and block your pores.
  4. Do not touch face too much: Touching the face with hands frequently can aid in the spread of bacteria and also irritate the skin.
  5. Do not pinch or squeeze acne: Pinching acne may cause the comedones to burst into the skin and cause inflammation, spread inflamed acne lesions and cause scars.
  6. Limit exposure to sunlight: Ultraviolet rays can increase the inflammation and redness.
  7. Eat healthily and avoid stress: Although the relationship between food and acne is not firmly established, it may help if you avoid junk foods and chocolate. Reduce stress as it can flare up acne.

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Complications

Scarring is the most significant complication of acne. Mostly, the deeper acne lesions such as nodules and cysts burst and cause scars when the skin heals. Squeezing or picking the acne lesion can also lead to scars.

Next Steps

Acne is effectively treatable in most cases. Consult a dermatologist:

  • If you have severe acne, nodular or cystic acne
  • If your acne is leaving scars and marks on face
  • If your acne is causing you embarrassment and making you socially withdrawn

Red Flags

Some of the causes of concerns with acne include:

  • If you are suffering from a nodulocystic type of acne, it is unlikely to resolve on its own and you probably need a dermatologist consultation.
  • A nodule arising within a mole (This may need a biopsy to rule out cancer)
  • Lesion in a sun-exposed area in an elderly patient may be a cancer.
  • If you develop multiple skin nodules in a few weeks interval with loss of weight and general weakness, consult your doctor.

 

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References

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  • Adityan B, Thappa DM. Profile of acne vulgaris-a hospital-based study from South India. Indian J Dermatol Venereol Leprol. 2009 May-Jun;75(3):272-8.
  • Kubba R, et al. Acne in India: guidelines for management – IAA consensus document. Indian J Dermatol Venereol Leprol. 2009 Jan;75 Suppl 1:1-62.
  • American Academy of Dermatology. Diseases and conditions – Acne. Accessed at https://www.aad.org/public/diseases/acne-and-rosacea/acne
  • Mayo Clinic. Diseases and conditions –Acne. Accessed at http://www.mayoclinic.org/diseases-conditions/acne/basics/definition/con-20020580
  • Nast A, et al. European evidence-based (S3) guidelines for the treatment of acne. J Eur Acad Dermatol Venereol. 2012 Feb;26 Suppl 1:1-29.

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