Acne: A Summary
The term “acne rosacea” is a synonym for rosacea, however some individuals may have almost no acne comedones associated with their rosacea and therefore prefer the term rosacea. Chloracne is associated with exposure to polyhalogenated compounds.
Signs and symptoms
Typical features of acne include: seborrhea (increased oil-sebum secretion), comedones (blackheads and whiteheads), papules (pinheads), pustules (pimples), nodules (large papules) and, possibly scarring. The appearance of acne varies with skin color.
Physical acne scars are often referred to as “Icepick” scars. This is because the scars tend to cause an indentation in the skin’s surface. There are a range of treatments available. Although quite rare, the medical condition Atrophia Maculosa Varioliformis Cutis also results in “acne-like” depressed scars on the face.
- Ice pick scars: Deep pits, that are the most common and a classic sign of acne scarring.
- Box car scars: Angular scars that usually occur on the temple and cheeks, and can be either superficial or deep, these are similar to chickenpox scars.
- Rolling scars: Scars that give the skin a wave-like appearance.
- Hypertrophic scars: Thickened, or keloid scars.
Pigmented scars is a slightly misleading term, as it suggests a change in the skin’s pigmentation and that they are true scars; however, neither is true. Pigmented scars are usually the result of nodular or cystic acne (the painful ‘bumps’ lying under the skin). They often leave behind an inflamed red mark. Often, the pigmentation scars can be avoided simply by avoiding aggravation of the nodule or cyst. Pigmentation scars nearly always fade with time taking between three months to two years to do so, although can last indefinitely if untreated.
Acne develops as a result of blockages in the follicles. Hyperkeratinization and formation of a plug of keratin and sebum (a microcomedo) is the earliest change. Enlargement of sebaceous glands and an increase in sebum production occur with increased androgen (DHEA-S) production at adrenarche. The microcomedo may enlarge to form an open comedone (blackhead) or closed comedone (milia). Comedones are the direct result of sebaceous glands‘ becoming clogged with sebum, a naturally occurring oil, and dead skin cells. In these conditions, the naturally occurring largely commensal bacterium Propionibacterium acnes can cause inflammation, leading to inflammatory lesions (papules, infected pustules, or nodules) in the dermis around the microcomedo or comedone, which results in redness and may result in scarring or hyperpigmentation.
Hormonal activity, such as menstrual cycles and puberty, may contribute to the formation of acne. During puberty, an increase in male sex hormones called androgens cause the follicular glands to grow larger and make more sebum. Use of anabolic steroids may have a similar effect. Several hormones have been linked to acne: the androgens testosterone, dihydrotestosterone (DHT) and dehydroepiandrosterone sulfate (DHEAS), as well as insulin-like growth factor 1 (IGF-I).
Development of acne vulgaris in later years is uncommon, although this is the age group for estradiol fails at menopause. The lack of estradiol also causes thinning hair, hot flushes, thin skin, wrinkles, vaginal dryness, and predisposes to osteopenia and osteoporosis as well as triggering acne (known as acne climacterica in this situation).
The tendency to develop acne runs in families. For example, school aged boys with acne often have other members in their family with acne. A family history of acne is associated with an earlier occurrence of acne and an increased number of retentional acne lesions.
While the connection between acne and stress has been debated, scientific research indicates that “increased acne severity” is “significantly associated with increased stress levels.” It is also not clear whether acne causes stress and thus perpetuates itself to some extent.
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There are multiple grading scales for grading the severity of acne vulgaris, three of these being:
- Leeds acne grading technique: Counts and categorises lesions into inflammatory and non-inflammatory (ranges from 0–10.0).
- Cook’s acne grading scale: Uses photographs to grade severity from 0 to 8 (0 being the least severe and 8 being the most severe).
- Pillsbury scale: Simply classifies the severity of the acne from 1 (least severe) to 4 (most severe).
Many different treatments exist for acne including benzoyl peroxide, antibiotics, retinoids, antiseborrheic medications, anti-androgen medications, hormonal treatments, salicylic acid, alpha hydroxy acid, azelaic acid, nicotinamide, and keratolytic soaps. They are believed to work in at least 4 different ways, including: normalising shedding into the pore to prevent blockage, killing Propionibacterium acnes, anti-inflammatory effects, hormonal manipulation.
- Benzoyl peroxide
Sometimes benzoyl peroxide topical medication is combined with a salt of hydroxyquinoline, such as potassium hydroxyquinoline sulphate, which has antibacterial properties. One such topical product is available without prescription in the UK.
Antibiotics are reserved for more severe cases.minocycline.
In females, acne can be improved with spironolactone can have anti-androgenetic properties, especially in patients with polycystic ovarian syndrome.
- Topical retinoids
Topical retinoids are medications that normalize the follicle cell life cycle. This class includes tretinoin (Retin-A), adapalene (Differin), and tazarotene (Tazorac). Like isotretinoin, they are related to vitamin A, but they are administered topically and they generally have much milder side effects. They can, however, cause significant irritation of the skin. The retinoids appear to influence the cell life cycle in the follicle lining. This helps prevent the hyperkeratinization of these cells that can create a blockage. Retinol, a form of vitamin A, has similar, but milder, effects and is used in many over-the-counter moisturizers and other topical products. Effective topical retinoids have been in use for over 30 years, but are available only on prescription, so are not as widely used as the other topical treatments. Topical retinoids often cause an initial flare-up of acne and facial flushing.
- Oral retinoids
A daily oral intake of vitamin A derivative
Mandelic acid has been noted to be an effective topical treatment for mild to moderate acne. It is considered[according to whom?] to be a gentler alternative to popular alpha hydroxy acids such as glycolic acid and lactic acid.
Dermabrasion is a cosmetic medical procedure in which the surface of the skin is removed by abrasion (sanding). It is used to remove sun-damaged skin and to remove or lessen scars and dark spots on the skin. The procedure is very painful and usually requires a general anaesthetic or “twilight anaesthesia”, in which the patient is still partly conscious. Afterward, the skin is very red and raw-looking, and it takes several months for the skin to regrow and heal. Dermabrasion is useful for scar removal when the scar is raised above the surrounding skin, but is less effective with sunken scars.
In the past, dermabrasion was done using a small, sterilized, electric sander. In the past decade, it has become more common to use laser dermabrasion using CO2, Er:YAG laser or a combination of both for the treatment of acne scars. Indications for CO2 laser treatment include previous non erythematous and non-proliferative hypertrophic scars, atrophic acne scars and burn scars.] Laser dermabrasion is much easier to control, much easier to gauge, and is practically bloodless compared to classic dermabrasion.
Blue and red light
Light exposure has long been used as a short-term treatment for acne. Recently, visible light has been successfully employed to treat mild to moderate acne (
It seems that the treatment works even better if used with a mixture of the violet light and red visible light (660 nanometer), resulting in a 76% reduction of lesions after three months of daily treatment for 80% of the patients;and overall clearance was similar or better than benzoyl peroxide. Unlike most of the other treatments, few if any negative side-effects are typically experienced, and the development of bacterial resistance to the treatment seems very unlikely. After treatment, clearance can be longer-lived than is typical with topical or oral antibiotic treatments; several months is not uncommon. The equipment or treatment, however, is relatively new and reasonably expensive to buy initially, although the total cost of ownership can be similar to many other treatment methods (such as the total cost of benzoyl peroxide, moisturizer, washes) over a couple of years of use.
In addition, basic science and clinical work by dermatologists Yoram Harth and Alan Shalita and others have produced evidence that intense blue/violet light (405–425 nanometer) can decrease the number of inflammatory acne lesion by 60–70% in four weeks of therapy, in particular, when the P. acnes is pretreated with delta-aminolevulinic acid (ALA), which increases the production of porphyrins. However this photodynamic therapy is controversial and not published in a peer-reviewed journal. A phase II trial, while it showed improvement occurred, failed to show improved response compared to the blue/violet light alone.
Laser surgery has been in use for some time to reduce the scars left behind by acne, but research has been done on lasers for prevention of acne formation itself. The laser is used to produce one of the following effects:
- to burn away the follicle sac from which the hair grows
- to burn away the sebaceous gland, which produces the oil
- to induce formation of oxygen in the bacteria, killing them
Since lasers and intense pulsed light sources cause thermal damage to the skin, there are concerns that laser or intense pulsed light treatments for acne will induce hyperpigmented macules (spots) or cause long-term dryness of the skin.
Alternative medicine for acne generally claims to cleanse the blood of toxins, increase immunity, balance hormones and sebum production.
- Egg Oil (INCI: Egg Oil) has often been used with success, since it contains antioxidant xanthophylls like Lutein and Zeaxanthin, Cholesterol and long chain polyunsaturated fatty acids (Omega-3, Omega-6) like Docosahexaenoic acid and Arachidonic acid. It has known anti-bacterial, anti-inflammatory properties in skin infections due to the presence of immunoglobulin.
Acne usually improves around the age of 20 but may persist into adulthood.
Acne affects 40 to 50 million people in the United States (16%), and approximately 3 to 5 million in Australia (23%).
A 2007 microbiology article reporting the first genome sequencing of a Propionibacterium acnes bacteriophage (PA6) said this “should greatly enhance the development of a potential bacteriophage therapy to treat acne and, therefore, overcome the significant problems associated with long-term antibiotic therapy and bacterial resistance.