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All About Acne: Causes, Treatment and Prevention

Acne (vulgaris) is the most common skin disorder. Nearly all teenagers will have some pimples at some stage, and about 15% will have acne that causes them to seek medical advice. Acne mostly affects the face, but can also occur on the hairline, neck, back, chest and shoulders. The condition usually begins with puberty and reaches its peak by 16 to 28 years of age. In most people it then improves, but it can persist for much longer.

Acne is caused by an excessive response of the oil-producing glands to sex hormones. Acne sufferers usually have normal levels of hormones, but the glands in their skin are more sensitive to them than in people who do not this problem.

Acne is not a serious medical condition, but the impact it has on a person’s appearance can lead to embarrassment and shyness. Acne may sometimes also cause physical discomfort, as bigger acne lesions can be tender or itchy. Additionally, if moderate to severe acne is left untreated, permanent scars can result. They will fade with time but will never disappear completely.

Fast Facts About Acne

  • Although there are many types of acne, the most common form is acne vulgaris, which is classified according to its severity and risk of scarring.
  • Acne is by far the most widespread skin condition. 80% of teenagers and 15% of adults develop acne or adult acne in the countries of the Western world.
  • This condition affects the glands that produce sebum (skin oil) and results in clogging the pores and building up sebum. Acne is often inflammatory. This is when bacteria called Propionibacterium acnes get inside the clogged pore, causing inflammation. Hence, pimples usually contain pus.
  • Acne is most common in teenagers. It typically goes away by age 30, though it also affects adults in their 40s and 50s. This condition is called adult acne and it can begin years after adolescence even though the person never had acne as a teenager.
  • Although acne is more common in teenage boys than teenage girls, in adulthood it more often affects women.
  • The cause of acne and its contributors are not exactly known. However, genetics are estimated to cause 80% of cases of acne.
  • The overproduction of sebum, irregular shedding of dead skin cells, build-up of bacteria Propionibacterium acnes in the clogged pores and resulting inflammation or infection may all contribute to the development of acne.
  • Besides family history, the factors such as hormonal changes, allergies, stress, smoking, stimulants and certain medications are also involved in acne development.
  • Acne lesions include pustules, whiteheads, blackheads, cysts and nodules.
  • These lesions may leave a variety of different scars, from tiny, deep holes to large, irregular indentations.
  • Pimples may occur anywhere on the body but they are most common on the face, neck, shoulders, chest and upper back.
  • The aim of acne treatment is to prevent further blemishes, improve those already present and minimize scarring.
  • Treatment for acne may be topical, applied directly to the skin, or systemic, such as oral pills or injections.
  • If common over-the-counter products like cleansers, lotions and creams, as the first line of treatment, are not effective, the dermatologist may prescribe stronger topical treatments (see also Treatments for Adult Acne in Women).
  • In cases of moderate to severe acne oral antibiotics may be used. For stubborn adult acne in women, birth control pills and hormonal medications may also be prescribed.
  • The latest technologies for treating acne include photodynamic therapy and photopneumatic therapy.
  • Acne scars may be treated by procedures that remove layers of damaged skin and promote growth of new, smoother skin. These procedures include dermabrasion and laser resurfacing.
  • In order to get rid of acne scars it may be sometimes necessary to loosen or fill the skin beneath the scar or surgically remove the scar.
  • Gently washing the problem area twice a day (but no more than twice a day), not resting hands and objects on the face, refraining from squeezing current blemishes, avoiding stimulants such as nicotine, alcohol and caffeine, minimizing stress and reducing intake of sugar are common measures that can help to reduce acne outbreaks and prevent worsening of current acne.

Acne Symptoms

The symptoms of acne depend on the severity of the condition and they can fluctuate from day to day. There are different types of acne lesions including whiteheads, blackheads, papules (small red lumps), pustules (pus spots), nodules (large lumps) and cysts, while scars can also occur. Persistent larger spots can be sometimes tender and occasionally itchy. Acne vulgaris is easy to diagnose.

Causes of Acne

Acne is a disease of the oil-producing (sebaceous) glands. At puberty both males and females experience an increase in the production of sex hormones called androgens. At the same time their sebaceous glands can become oversensitive to these sex hormones, which causes them to produce excessive amounts of the natural oil of the skin called sebum.

Furthermore, the outflow ducts of some sebaceous glands can become narrower and get blocked by dead cells. This can provide favorable environment for certain harmless bacteria to multiply. The combination of these factors causes acne. As a result, the areas of skin most usually affected are those with the greatest density of sebaceous glands, i.e., the face, neck, back and chest.

A bacterium called Propionibacterium acnes within the hair follicle duct contributes to the inflammation, particularly affecting whiteheads. This is because whiteheads have a smaller opening than blackheads, so it is more difficult for their contents to get out. For this reason, whiteheads are more likely to become inflamed than blackheads. Inflammation then results in red spots, pus bumps and cysts.

Although there appears to be a hereditary tendency towards acne, the condition is independent of environmental factors. However, high air humidity (e.g., in saunas, humid climates) or sweating (e.g., caused by tight clothes) can make acne worse. Natural sunlight usually improves acne a little, but sunbeds may make it worse. Stress in itself is unlikely to cause more acne spots to develop, but people might be more likely to pick at or scratch their acne lesions when stressed and thus increase the risk of scarring.

Factors that Can Worsen Acne

Cosmetics. Greasy preparations used to style or de-frizz hair can trigger acne along the hairline. Oily sunscreens may also contribute to acne.

Medications. Certain medications can trigger acne or make existing acne worse. These include steroids, some contraceptives, epilepsy drugs such as phenytoin and phenobarbitone and the anti-tuberculosis drugs isoniazid and rifampicin.

Menstrual cycle. About 70% of women with acne report pre-menstrual flare-ups in the condition. This is most likely related to changes in hormone levels.

Pregnancy. During pregnancy, acne can either improve or worsen.

Medicinal Treatments for Acne

The vast majority of cases of acne can be effectively controlled, but treatment may be needed for a number of years. Whiteheads can be more difficult to treat than other types of acne.

Topical treatments

Topical treatments should be applied to the whole area affected by acne, not just the individual spots. They include:

  • Benzoyl peroxide – is usually the first-line treatment for mild acne and it is available over the counter as a cream, lotion, gel or wash. Benzoyl peroxide works by reducing the presence of bacteria on the skin. Skin irritation is the main side effect of this treatment.
  • Azelaic acid – is preferred by some patients because it is usually less irritating than benzoyl peroxide.
  • Retinoids – (derivatives of vitamin A) are available on prescription as a cream, gel or lotion and are effective for whiteheads and blackheads. The main side effects are skin irritation and redness. Retinoids can make a person more sensitive to the sun and should be avoided during pregnancy. Combinations of retinoids and antibiotics are commonly prescribed for acne treatment.
  • Topical antibiotics – such as clindamycin and erythromycin are available on prescription to treat mild to moderate acne. They can be combined with benzoyl peroxide.
  • Nicotinamide – (e.g., Papulex gel) is an older treatment for acne that is probably as effective as topical antibiotics for mild to moderate acne. It works by reducing inflammation.

Oral treatments

  • Oral antibiotics – such as doxycycline, minocycline and tetracycline are prescribed for moderate to severe acne. To see their full benefit, they should be used for at least six months. Oral antibiotics work by decreasing both skin bacteria and inflammation.
  • Isotretinoin (Roaccutane) – is used for severe acne or acne that has not responded to other treatments. Isotretonoin acts by reducing sebum excretion and by unblocking the opening of follicles, thus reducing the occurrence of whiteheads and blackheads. Usually, four months of treatment are required. Isotretinoin should not be taken by women who may get pregnant while on it. Common side effects include dry lips, redness and dryness of the face, nosebleeds, muscle aches and increased sensitivity to the sun.
  • Hormone treatment – can only be prescribed to women. An oral contraceptive pill (Dianette or Diane-35), which contains ethinyloestradiol (an estrogen) with cyproterone acetate (an anti-androgen), can cause a decrease in oil production in the skin and thus reduce acne. Spironolactone (Aldactone) is another hormonal treatment that can be prescribed off-label for adult acne in women. For many women it is the ultimate treatment for acne when nothing else works.

Patients should know that depending on the type of treatment it generally takes at least four to six weeks to see any improvement. This can obviously also differ from person to person. It is therefore better to try a treatment for at least ten weeks before deciding that it is not working and changing to another one.

Physical Treatments

  • Liquid nitrogen – is occasionally used to destroy acne cysts.
  • Photodynamic therapy – A special light-activated solution is applied to the patient’s face or other area affected by acne and then laser light is used to activate this substance to reduce the size and activity of sebaceous glands and to destroy bacteria.
  • Photopneumatic therapy – also known as Isolaz, is a combination of a vacuum and blue-light therapy. The vacuum cleans the pores, while the light kills bacteria and reduces the activity of the oil-producing sebaceous glands.

Complementary Treatment Options for Acne

Contrary to general belief, there is no scientific evidence to suggest that diet plays a role in acne. Despite that many people believe that a healthy diet with plenty of fresh fruit, vegetables and water can improve acne. Likewise, facial massage and cleaning with facial steam baths to open up the pores are often recommended, though not helpful, and should better be avoided because humidity can actually make acne worse.

Tea tree oil is probably the most effective alternative treatment for acne that in some cases might be as good as traditional drug treatments.

There are also other complementary treatments that are often recommended for acne although there is not enough scientific evidence to show their effectiveness, including:

  • Acupuncture
  • Aromatherapy – German chamomile oil, lavender oil
  • Ayurvedic medication Sunder Vati
  • Herbs such as Agnus castus, Myrtillus oligoplex, burdock, dandelion, Echinacea and nettle
  • Homeopathy
  • Propolis cream

Treating Acne Scars

Acne scars are difficult to treat and the risks of causing further scarring with dermabrasion, chemical peels or laser treatment should be weighed against any possible benefit. Injecting collagen into depressed scars can help some people, but benefit is only temporary.

Preventing Acne

It is not possible to prevent acne, but people who are prone to acne can avoid some of the factors that can make it worse such as humid environments and wearing tight clothes that rub against the skin or cause sweating which can promote acne.

Patients with acne should better avoid thick foundation and concealer as well as using oil-based cosmetics. Oil-free powder cosmetics should be chosen over creams. Also, there is no evidence that ‘hypoallergenic’ cosmetics are of any extra benefit in acne.

Excessive washing or using harsh cleansers can dry out the skin so much that it becomes red and sore. This can not only make the acne spots appear worse, but it may also make it uncomfortable to use the topical treatments that the patient might have been prescribed for acne.

Possible Complications Associated with Acne

In most cases, acne begins with blackheads, whiteheads and some small red spots. In many people the condition will never progress beyond this stage, while some will develop further lesions with pus bumps and cysts. This is more common in teenage men, as are acne lesions on areas of the body other than the face.

Very rarely, a condition called acne fulminans may develop. This is a form of very severe acne, with large spots on the trunk that often leave scars. Acne fulminans begins suddenly and is associated with fever, swelling and joint pain as well as general feeling of unwell. This form of acne almost always affects males. It usually begins without any recognisable trigger, but sometimes it can be set off by oral isotretinoin or by testosterone and anabolic steroids. Acne fulminans is treated with oral steroids, antibiotics, anti-inflammatory medications like aspirin and (surprisingly) with isotretinoin.

Acne scarring occurs in about 20% of patients, but it varies in severity. Early and effective treatment can significantly reduce this risk.

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