What Is Acne?
Acne is a disorder resulting from the action of hormones
on the skin's oil glands (sebaceous glands), which leads to plugged
pores and outbreaks of lesions commonly called pimples or zits. Acne
lesions usually occur on the face, neck, back, chest, and shoulders.
Nearly 17 million people in the United States have acne, making it the
most common skin disease. Although acne is not a serious health threat,
severe acne can lead to disfiguring, permanent scarring, which can be
upsetting to people who are affected by the disorder.
How Does Acne Develop?
Doctors describe acne as a disease of the pilosebaceous
units (PSUs). Found over most of the body, PSUs consist of a sebaceous
gland connected to a canal, called a follicle, that contains a fine hair
(see "Normal Pilosebaceous Unit" diagram, below). These units are most
numerous on the face, upper back, and chest. The sebaceous glands make
an oily substance called sebum that normally empties onto the skin
surface through the opening of the follicle, commonly called a pore.
Cells called keratinocytes line the follicle.
| Normal Pilosebaceous Unit |
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The hair, sebum, and keratinocytes that fill the narrow
follicle may produce a plug, which is an early sign of acne. The plug
prevents sebum from reaching the surface of the skin through a pore. The
mixture of oil and cells allows bacteria Propionibacterium acnes (P.
acnes) that normally live on the skin to grow in the plugged
follicles. These bacteria produce chemicals and enzymes and attract
white blood cells that cause inflammation. (Inflammation is a
characteristic reaction of tissues to disease or injury and is marked by
four signs: swelling, redness, heat, and pain.) When the wall of the
plugged follicle breaks down, it spills everything into the nearby
skin--sebum, shed skin cells, and bacteria--leading to lesions or
pimples.
People with acne frequently have a variety of lesions,
some of which are shown in the diagrams below. The basic acne lesion,
called the comedo (KOM-e-do), is simply an enlarged and plugged hair
follicle. If the plugged follicle, or comedo, stays beneath the skin, it
is called a closed comedo and produces a white bump called a whitehead.
A comedo that reaches the surface of the skin and opens up is called a
blackhead because it looks black on the skin's surface. This black
discoloration is not due to dirt. Both whiteheads and blackheads may
stay in the skin for a long time.
Other troublesome acne lesions can develop, including the
following:
- Papules--inflamed lesions that usually appear as small,
pink bumps on the skin and can be tender to the touch
- Pustules (pimples)--papules topped by pus-filled lesions
that may be red at the base
- Nodules--large, painful, solid lesions that are lodged deep
within the skin
- Cysts--deep, painful, pus-filled lesions that can cause
scarring.
What Causes Acne?
The exact cause of acne is unknown, but doctors believe it
results from several related factors. One important factor is an
increase in hormones called androgens (male sex hormones). These
increase in both boys and girls during puberty and cause the sebaceous
glands to enlarge and make more sebum. Hormonal changes related to
pregnancy or starting or stopping birth control pills can also cause
acne.
Another factor is heredity or genetics. Researchers
believe that the tendency to develop acne can be inherited from parents.
For example, studies have shown that many school-age boys with acne have
a family history of the disorder. Certain drugs, including androgens and
lithium, are known to cause acne. Greasy cosmetics may alter the cells
of the follicles and make them stick together, producing a plug.
Factors That Can Make Acne Worse
Factors that can cause an acne flare include:
- Changing hormone levels in adolescent girls and adult women 2 to 7
days before their menstrual period starts
- Friction caused by leaning on or rubbing the skin
- Pressure from bike helmets, backpacks, or tight collars
- Environmental irritants, such as pollution and high humidity
- Squeezing or picking at blemishes
- Hard scrubbing of the skin.
Myths About the Causes of Acne
There are many myths about what causes acne. Chocolate and
greasy foods are often blamed, but foods seem to have little effect on
the development and course of acne in most people. Another common myth
is that dirty skin causes acne; however, blackheads and other acne
lesions are not caused by dirt. Finally, stress does not cause acne.
Who Gets Acne?
People of all races and ages get acne. It is most common
in adolescents and young adults. Nearly 85 percent of people between the
ages of 12 and 24 develop the disorder. For most people, acne tends to
go away by the time they reach their thirties; however, some people in
their forties and fifties continue to have this skin problem.
Methods of Acne Treatment?
Acne is often treated by dermatologists (doctors who
specialize in skin problems). These doctors treat all kinds of acne,
particularly severe cases. Doctors who are general or family
practitioners, pediatricians, or internists may treat patients with
milder cases of acne.
The goals of treatment are to heal existing lesions, stop
new lesions from forming, prevent scarring, and minimize the
psychological stress and embarrassment caused by this disease. Drug
treatment is aimed at reducing several problems that play a part in
causing acne: abnormal clumping of cells in the follicles, increased oil
production, bacteria, and inflammation. Depending on the extent of the
person's acne, the doctor will recommend one of several over-the-counter
(OTC) medicines or prescription medicines that are topical (applied to
the skin) or systemic (taken by mouth). The doctor may suggest using
more than one topical medicine or combining oral and topical
medicines.
Blackheads,
Whiteheads, and Mild Inflammatory Acne Treatment
Doctors usually recommend an OTC or prescription topical
medication for people with mild signs of acne. Topical medicine is
applied directly to the acne lesions or to the entire area of affected
skin.
Benzoyl peroxide, resorcinol, salicylic acid, and sulfur
are the most common topical OTC medicines used to treat acne. Each works
a little differently. Benzoyl peroxide is best at killing P.
acnes and may reduce oil production. Resorcinol, salicylic acid, and
sulfur help break down blackheads and whiteheads. Salicylic acid also
helps cut down the shedding of cells lining the follicles of the oil
glands. Topical OTC medications are available in many forms, such as
gel, lotion, cream, soap, or pad.
In some patients, OTC acne medicines may cause side
effects such as skin irritation, burning, or redness. Some people find
that the side effects lessen or go away with continued use of the
medicine. Severe or prolonged side effects should be reported to the
doctor.
OTC topical medicines are somewhat effective in treating
acne when used regularly. Patients must keep in mind that it can take 8
weeks or more before they notice their skin looks and feels better.
Moderate to Severe
Inflammatory Acne Treatment
Patients with moderate to severe inflammatory acne may be
treated with prescription topical or oral medicines, alone or in
combination.
Prescription Topical Medicines
Several types of prescription topical medicines are used
to treat acne, including antibiotics, benzoyl peroxide, tretinoin,
adapalene, and azelaic acid. Antibiotics and azelaic acid help stop or
slow the growth of bacteria and reduce inflammation. Tretinoin, a type
of drug called a retinoid that contains an altered form of vitamin A, is
an effective topical medicine for stopping the development of new
comedones. It works by unplugging existing comedones, thereby allowing
other topical medicines, such as antibiotics, to enter the follicles.
The doctor may also prescribe newer retinoids or retinoid-like drugs,
such as tazarotene or adapalene, that help decrease comedo
formation.
Like OTC topical medicines, prescription topical medicines
come as creams, lotions, solutions, or gels. The doctor will consider
the patient's skin type when prescribing a product. Creams and lotions
provide moisture and tend to be good for people with sensitive skin.
Gels and solutions are generally alcohol based and tend to dry the skin.
Therefore, patients with very oily skin or those who live in hot, humid
climates may prefer them. The doctor will tell the patient how to apply
the medicine and how often to use it.
Some people develop side effects from using prescription
topical medicines. Initially, the skin may look worse before improving.
Common side effects include stinging, burning, redness, peeling,
scaling, or discoloration of the skin. With some medicines, like
retinoids, these side effects usually decrease or go away after the
medicine is used for a period of time. Patients should report prolonged
or severe side effects to their doctor. Between 4 and 8 weeks will most
likely pass before patients see their skin improve.
Prescription Oral Medicines
For patients with moderate to severe acne, the doctor
often prescribes oral antibiotics (taken by mouth). Oral antibiotics are
thought to help control acne by curbing the growth of bacteria and
reducing inflammation. Prescription oral and topical medicines may be
combined. For example, benzoyl peroxide may be combined with
clindamycin, erythromycin, or sulfur. Other common antibiotics used to
treat acne are tetracycline, minocycline, and doxycycline. Some people
have side effects when taking these antibiotics, such as an increased
tendency to sunburn, upset stomach, dizziness or lightheadedness, and
changes in skin color. Tetracycline is not given to pregnant women, nor
is it given to children under 8 years of age because it might discolor
developing teeth. Tetracycline and minocycline may also decrease the
effectiveness of birth control pills. Therefore, a backup or another
form of birth control may be needed. Prolonged treatment with oral
antibiotics may be necessary to achieve the desired results.
Severe Nodular or
Cystic Acne Treatment
Acne where infections are deep under the skin and
do not raise to the surface of skin is called severe nodular acne or
cystic acne. Cystic acne heals very slowly as infection waste material
is not discharged. People with nodules or cysts should be treated by a
dermatologist. For patients with severe inflammatory acne that does not
improve with medicines such as severe nodular or cystic acne, a doctor may
prescribe isotretinoin (Accutane*), a retinoid. Isotretinoin is an oral
drug that is usually taken once or twice a day with food for 15 to 20
weeks. It markedly reduces the size of the oil glands so that much less
oil is produced. As a result, the growth of bacteria is decreased.
* Brand names included in this booklet are
provided as examples only, and their inclusion does not mean that these
products are endorsed by HealthNewsflash. Also, if a particular
brand name is not mentioned, this does not mean or imply that the product is
unsatisfactory.
Advantages of Isotretinoin (Accutane)
Isotretinoin is a very effective medicine that can help
prevent scarring. After 15 to 20 weeks of treatment with isotretinoin,
acne completely or almost completely goes away in up to 90 percent of
patients. In those patients where acne recurs after a course of
isotretinoin, the doctor may institute another course of the same
treatment or prescribe other medicines.
Disadvantages of Isotretinoin (Accutane)
Isotretinoin can cause birth defects in the developing
fetus of a pregnant woman. It is important that women of childbearing
age are not pregnant and do not get pregnant while taking this
medicine. Women must use two separate effective forms of birth
control at the same time for 1 month before treatment begins, during the
entire course of treatment, and for 1 full month after stopping the
drug. They should ask their doctor when it is safe to get pregnant after
they have stopped taking Accutane.
Some people with acne become depressed by the changes in
the appearance of their skin. Changes in mental health may be
intensified during treatment or soon after completing a course of
medicines like Accutane. A doctor should be consulted if a person feels
unusually sad or has other symptoms of depression, such as loss of
appetite or trouble concentrating.
Other possible side effects include dry eyes, mouth, lips,
nose, or skin; itching; nosebleeds; muscle aches; sensitivity to the
sun; and, sometimes, poor night vision. More serious side effects
include changes in the blood, such as an increase in triglycerides and
cholesterol, or a change in liver function. To make sure Accutane is
stopped if side effects occur, the doctor monitors blood studies that
are done before treatment is started and periodically during treatment.
Side effects usually go away after the medicine is stopped.
Hormonally
Influenced Acne Treatment in Women
Clues that help the doctor determine whether acne in an
adult woman is due to an excess of androgen hormones are hirsutism
(excessive growth of hair in unusual places), premenstrual acne flares,
irregular menstrual cycles, and elevated blood levels of certain
androgens. The doctor may prescribe one of several drugs to treat women
with this type of acne. Low-dose estrogen birth control pills help
suppress the androgen produced by the ovaries. Low-dose corticosteroid
drugs, such as prednisone or dexamethasone, may suppress the androgen
produced by the adrenal glands. Finally, the doctor may prescribe an
antiandrogen drug, such as spironolactone (Aldactone). This medicine
reduces excessive oil production. Side effects of antiandrogen drugs may
include irregular menstruation, tender breasts, headache, and
fatigue.
Other Acne Treatments
Doctors may use other types of procedures in addition to
drug therapy to treat patients with acne. For example, the doctor may
remove the patient's comedones during office visits. Sometimes the
doctor will inject cortisone directly into lesions to help reduce the
size and pain of inflamed cysts and nodules.
Early treatment is the best way to prevent acne scars.
Once scarring has occurred, the doctor may suggest a medical or surgical
procedure to help reduce the scars. A superficial laser may be used to
treat irregular scars. Another kind of laser allows energy to go deeper
into the skin and tighten the underlying tissue and plump out depressed
scars. Dermabrasion (or microdermabrasion), which is a form of "sanding
down" scars, is sometimes combined with the subsurface laser treatment.
Another treatment option for deep scars caused by cystic acne is the
transfer of fat from one part of the body to the face.
Skin Care and Acne Treatment
Clean Skin Gently
Most doctors recommend that people with acne gently wash
their skin with a mild cleanser, once in the morning and once in the
evening and after heavy exercise. Some people with acne may try to stop
outbreaks and oil production by scrubbing their skin and using strong
detergent soaps and rough scrub pads. However, scrubbing will not
improve acne; in fact, it can make the problem worse. Patients should
ask their doctor or another health professional for advice on the best
type of cleanser to use. Patients should wash their face from under the
jaw to the hairline. It is important that patients thoroughly rinse
their skin after washing it. Astringents are not recommended unless the
skin is very oily, and then they should be used only on oily spots.
Doctors also recommend that patients regularly shampoo their hair. Those
with oily hair may want to shampoo it every day.
Avoid Frequent Handling of the Skin
People who squeeze, pinch, or pick their blemishes risk
developing scars or dark blotches. People should avoid rubbing and
touching their skin lesions.
Shave Carefully
Men who shave and who have acne can test both electric and
safety razors to see which is more comfortable. Men who use a safety
razor should use a sharp blade and soften their beard thoroughly with
soap and water before applying shaving cream. Nicking blemishes can be
avoided by shaving lightly and only when necessary.
Avoid a Sunburn or Suntan
Many of the medicines used to treat acne can make a person
more prone to sunburn. A sunburn that reddens the skin or suntan that
darkens the skin may make blemishes less visible and make the skin feel
drier. However, these benefits are only temporary, and there are known
risks of excessive sun exposure, such as more rapid skin aging and a
risk of developing skin cancer.
Choose Cosmetics Carefully
People being treated for acne often need to change some of
the cosmetics they use. All cosmetics, such as foundation, blush, eye
shadow, and moisturizers, should be oil free. Patients may find it
difficult to apply foundation evenly during the first few weeks of
treatment because the skin may be red or scaly, particularly with the
use of topical tretinoin or benzoyl peroxide. Oily hair products may
eventually spread over the forehead, causing closed comedones. Products
that are labeled as noncomedogenic (do not promote the formation of
closed pores) should be used; in some people, however, even these
products may cause acne.
What Research Is Being Done on
Acne?
Medical researchers are working on new drugs to treat
acne, particularly topical antibiotics to replace some of those in
current use. As with many other types of bacterial infections, doctors
are finding that, over time, the bacteria that are associated with acne
are becoming resistant to treatment with certain antibiotics. Research
is also being conducted by industry on the potential side effects of
isotretinoin and the long-term use of medicines used for treating
acne.
Scientists are working on other means of treating acne.
For example, researchers are studying the biology of sebaceous cells and
testing a laser in laboratory animals to treat acne by disrupting
sebaceous glands. Scientists are also studying the treatment of
androgenic disorders, including acne, in men by inhibiting an enzyme
that changes testosterone to a more potent androgen.
Keeping on top of Your Condition
Keeping in tune with your disease or condition not only makes treatment less intimidating but also increases its chance of success, and has been shown to lower a patients risk of complications. As well, as an informed patient, you are better able to discuss your condition and treatment options with your physician.
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