Deal with Acne

Reviewed By:
Rana Rofagha Sajjadian, M.D., AAD
Kimberly Bazar, M.D., AAD

About acne

Acne is a very common skin disorder of the pilosebaceous units (PSUs). PSUs consist of sebaceous glands that connect to hair follicles (canals) lined with keratinocytes. The sebaceous glands produce sebum (skin oil). Acne is often inflammatory and is characterized by comedones (clogged pores) and pimples (papules and pustules), due in part to the excessive production of sebum. Acne is not a serious medical condition, and can usually be kept under control with treatment. Although scarring is common, treatment during and after an outbreak can help. When excessive amounts of sebum and dead keratinocytes accumulate in the hair follicle, they often solidify as a soft plug. The plug may be complete and form a whitehead (closed comedone) or may be incomplete and form a blackhead (open comedone). These plugged, sebum–filled follicles allow overgrowth of Propionibacterium acnes (P. acnes), which are skin bacteria that are normally present in hair follicles. P. acnes break the sebum down into substances that irritate the skin and cause inflammation. This inflammation may lead to pimples, cysts or nodules. Although acne is not a serious medical condition, it often causes great emotional distress. It may have a significant impact on social relationships, self–esteem or a person’s outlook on life. Many acne sufferers demonstrate social withdrawal, poor body image and feelings of depression, anger and frustration. Acne sufferers may also experience a higher rate of unemployment. Acne myths, such as the belief that acne is linked to poor hygiene, may contribute to this poor social regard. Acne is the most common skin condition affecting people worldwide. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), nearly 85 percent of all people between the ages of 12 and 24 develop acne and nearly 17 million people in the United States have acne. Acne is most common in teenagers and usually occurs in puberty (typically between the ages of 10 and 13), when androgens (male sex hormones) increase in both males and females. This increase in androgens causes the sebaceous glands to become bigger and more active. Although most commonly seen in teenagers, acne can affect people of all ages – even infants. Onset may occur in adulthood or breakouts that began during adolescence may continue into adulthood. Most cases of acne last between five to 10 years. Typically, the severity of acne decreases by the age of 30, but this is not always the case. It is not uncommon for people in their 20s or 30s to have the condition, and it may continue to affect people in their 40s and 50s. During adolescence, acne is more common in males than in females. In adulthood, it affects women more often than men. Types and differences of acne There are many different types of acne. “Common” acne (acne vulgaris) can be divided into four categories according to severity: Type 1. Predominantly comedones (whiteheads and blackheads) with an occasional small pimple (papule or pustule). Type 1 does not involve scarring. Type 2. Comedones and more numerous pimples, mainly facial. Type 2 involves mild scarring. Type 3. Numerous comedones and pimples, spreading to the back, chest and shoulders. Type 3 involves an occasional cyst or nodule and moderate scarring. Type 4. Numerous large cysts and nodules on face, neck and upper trunk. Type 4 involves severe scarring. Another common form of acne is acne rosacea (rosacea), which includes facial discoloration (reddening). Other types of less common acne may be characterized by severity and symptoms or by causes. Types of acne categorized by severity and symptoms include: Acne indurate. Common acne with chronic, discolored, hardened surfaces. Acne keratosa. Acne that occurs at the corners of the mouth where nodules crust over to form horny plugs. Acne ciliaris. Acne that occurs at the edges of the eyelids. Acne papulosa. Acne with papule formation and very little inflammation. Acne varioliformis. Acne with pustules occurring mostly on the temples and front of the scalp and lesser occurrence on the chest, back or nose. Acne atrophica. Acne with residual pitting and scarring. Acne pustulosa. Acne with pustule formation and subsequent deep scars. Acne urticaria. Acne with itching hives (small swellings on the skin). Acne conglobata. Acne with abscesses (pus pockets), cysts and depressions that leave scars. Cystic acne. Acne with cysts. Acne fulminans. Rare type of acne marked by inflamed, tender, crusting lesions on the upper trunk and face. Acne fulminans occurs suddenly and typically affects adolescent males. It is often accompanied by fever, high levels of white blood cells and an elevated sedimentation rate. It is occasionally accompanied by inflammation in several joints. Acne keloidalis nuchae. Also called keloid acne. Acne keloidalis involves infection of the hair follicles at the back of the neck. This type of acne causes scars and thickening of the skin, and almost exclusively affects African American men. Types of acne categorized according to cause include: Halogen acne. Acne that occurs after exposure to halogens (e.g., bromides, iodine, chlorine). Chloracne. Type of halogen acne that occurs after exposure to chlorinated chemicals, such as the chlorine used to treat pool water. Petroleum acne. Acne that occurs in individuals who work with petroleum and oils. Steroid acne. Acne that results after the systemic or topical use of steroids, including corticosteroids and anabolic steroids. Often occurs predominantly on the upper back and shoulders. Summer acne. Also called tropical acne. Summer acne occurs in hot, humid weather or is made worse by such weather. It predominantly affects the neck, chest, back and legs, and often occurs in individuals unaccustomed to such climates. In addition, acne occurring among newborns and infants is known as acne neonatorum. Risk factors and causes of acne The actual cause of acne is not known. Contributing factors include: Overproduction of sebum (skin oil) Irregular shedding of dead skin cells Buildup of bacteria Inflammation or infection There are many factors that influence these contributing factors and outbreaks after onset, including: Hormonal changes. These may include changes due to: Puberty. Involves increased secretion of androgens (male sex hormones) in both males and females, resulting in increased size and activity of sebaceous glands. Menstruation. Women and girls may experience acne outbreaks two to seven days prior to their periods. Pregnancy. May improve or worsen acne. Oral contraceptives. Women starting or stopping birth control pills may experience an improvement or worsening of acne. Stress. Stress may have an affect on hormones, causing individuals undergoing high levels of stress to experience an outbreak or worsening of acne. Certain medications. Medications such as corticosteroids, anabolic steroids (such as those used by athletes) and barbiturates may lead to acne outbreaks. Heredity. Severe acne may have a genetic component. Allergies and sensitivities. In some people, food and other allergies or intolerances may cause an outbreak of acne. Also, some individuals are more sensitive to the bacteria that cause acne. Certain chemicals and other substances. Exposure to halogens (e.g., chlorine, fluorine, iodine, bromine) and tar may lead to acne outbreaks. Direct skin exposure to greasy or oily substances (e.g., from scalp or hair, mineral or cooking oils) and certain cosmetics may cause acne. Friction or pressure on skin. Friction and pressure, such as that caused by telephones, helmets, tight collars and backpacks, may lead to acne outbreaks. Irritation from picking or squeezing acne blemishes, scrubbing the skin too hard or using harsh soaps or chemicals may also cause or worsen acne. Environmental factors. Humidity, pollution, changes in the season and other environmental factors may lead to an outbreak of acne. Many factors are widely believed to cause or worsen acne when they actually do not. These include: Particular foods. Chocolate and greasy foods (e.g., French fries, pizza) are often blamed for acne. In reality, they have no influence on the condition unless an individual has an allergy or intolerance to these items. Poor hygiene. Acne is caused by a build-up of excessive amounts of sebum. Dirt and sweat are not involved. The belief that poor hygiene is related to acne has led many individuals to harshly scrub their skin to get rid of or to prevent acne. This practice can cause irritation and actually make acne worse. Signs and symptoms of acne Acne is characterized by an outbreak of lesions on the skin. These lesions include: Whiteheads (closed comedones). The openings of the hair follicles become clogged and completely blocked. The soft plug is a white color. These are noninflammatory. Blackheads (open comedones). The openings of the hair follicles become clogged and partially blocked. The plug darkens and is open to the surface of the skin. These are noninflammatory. Pimples (papules and pustules). Raised, reddish spots with white centers that signal inflammation or infection in the follicle. These may be without pus (papules) or may contain pus (pustules). They may be tender or painful. Nodules. Solid, raised reddish bumps. Cysts. Thick lumps beneath the skin formed by the build–up of secretions deep in the hair follicle. Acne can occur anywhere on the body, but it is most common in areas with high concentrations of sebaceous glands (e.g., face, neck, chest, shoulders, upper back). Mild (superficial) acne is characterized by whiteheads or blackheads and a few small, mildly irritated pimples and usually do not leave scars. Severe (deep, cystic) acne is characterized by many large, painful nodules and cysts that may join together under the skin into even larger abscesses (pus pockets). Severe acne often leaves scars. Acne scars may last a lifetime or fade over time. They may appear in many forms, including: Tiny, deep holes (ice pick scars) Wide pits of varying depth Large, irregular indentations Raised thickened tissue (hypertrophic scars or keloids) Although over-the-counter acne medications can help treat minor cases of acne, more serious forms of acne require a physician’s attention. Patients should consult with a dermatologist under the following circumstances: Acne affects the patient emotionally. Over-the-counter products fail to improve symptoms. Scars form after lesions clear. Nodules are present, in addition to whiteheads, blackheads, and reddened spots on the skin. Darker patches appear on the skin where acne lesions have cleared (in people with dark skin). People concerned about their acne should contact a dermatologist as early as possible. Early treatment often leads to the best results and helps prevent scarring. Diagnosis and treatment of acne Acne is typically treated by a dermatologist (skin specialist). The diagnosis of acne relies upon the patient’s medical history and a physical examination. In most cases, acne is obvious and does not require any additional testing. However, in rare cases the sudden onset of severe acne in older adults may be a sign of a more serious underlying condition, such as polycystic ovarian syndrome (an endocrine and hormonal disorder). In some cases, an acne-like rash can develop as the result of make-up, lotions or medications. Therefore, it is important for patients to provide their physician with an accurate history of all products used on the skin and any medications taken. The goal of acne treatment is to minimize scarring, prevent further eruptions of blemishes and improve those that are already present. Treatments that work for one patient may not work for another. As a result, certain considerations need to be made when deciding upon treatment. These include: Acne severity Types of lesions present Patient's age Patient's skin type Patient’s overall health and medical history Patient’s tolerance for specific medications, procedures or therapies Patient and physician’s expectations for the course of the condition Patient’s opinion or preference Acne treatments may be local or systemic and generally work by reducing the inflammation in the skin, speeding up skin cell turnover, fighting bacterial infection or a combination of these methods. It is normal to see little or no improvement in the acne for six to eight weeks after starting a medication, and in many cases the acne gets worse before it gets better. When a patient’s acne fails to improve after several weeks of treatment, their physician may change treatment methods Patients should continue using their acne medication until instructed otherwise, regardless of whether the skin has cleared. Sudden discontinuation of acne medication can lead to a recurrence of acne several weeks later. In some cases, acne may improve with exposure to a small amount of sun. However, many treatments make the skin more susceptible to sun damage, so patients on these therapies are typically advised to avoid sun exposure. Acne treatments are numerous and varied. Mild acne requires less extensive treatment and often clears up quickly and with no ill effects. Severe acne may require more powerful treatments that may have serious side effects. Most patients will benefit from a combination of two or more therapies. Topical treatments are widely available both over-the-counter and in prescription form. Acne lotions, gels and washes may dry up sebum, kill the acne bacteria or promote the proper sloughing of dead skin cells. Over–the–counter topical treatments are generally mild. Their active ingredients may include benzoyl peroxide, one of the most commonly used topical treatments. Other ingredients include alcohol and acetone, which are used together to reduce oil concentrations and help kill bacteria. Stronger prescription lotions may be prescribed for moderate to severe acne. These are typically retinoids (vitamin A derivatives) that work by promoting cell turnover and preventing the clogging of hair follicles or topical antibiotics. Topical antibiotics work by killing the bacteria that lead to acne and reducing inflammation. Oral antibiotics may be prescribed for moderate to severe acne. These reduce bacteria and fight inflammation, but may take months to work. They are often used in combination with topical products. Many oral antibiotics (e.g., isotretinoin) should not be taken by women who are or may become pregnant. When acne outbreaks coincide with a woman’s monthly period, oral contraceptives may help to control the acne. Large, inflamed nodules or cysts may be treated by an injection with corticosteroids. It typically takes three to five days after the injection to clear up the treated nodule or cyst. Physical treatments for acne and the scars left by acne include: Extraction of comedones. A whitehead or blackhead is opened and extracted with a sterile, pen-sized device, fine needle or blade. Drainage and surgical extraction. Also called “acne surgery,” this is the drainage and extraction of large cysts. It reduces the pain and decreases the likelihood of scarring. Chemical peels. Chemicals (e.g., glycolic acid) are applied to the skin in a physician’s office to loosen blackheads and whiteheads and decrease acne papules. This method may eliminate superficial scars by peeling away damaged skin. Microdermabrasion. Aluminum oxide crystals pass through a vacuum tube to gently scrape away scarred tissue. Multiple treatments may be required for subtle results. Dermabrasion. A rotating wire brush or spinning diamond instrument is used to wear down the surface of the skin. As the skin heals, a smoother layer replaces the abraded skin. This healing usually takes from 10 days to three weeks. Subcision. Small cuts are made under the skin to release scar tissue. This often allows skin to resume normal contours and may cosmetically improve wide, indented scars. Excision and punch replacement graft. A depressed acne scar is surgically removed and replaced with a patch of skin from elsewhere on the patient’s body. Soft tissue fillers. Small quantities of soft tissues (e.g., collagen, polymer implants, fat) are injected under the skin to elevate depressed scars to skin level. Laser resurfacing. Short pulses of intense light are used to remove the outer, damaged layer of skin and tighten the middle layer, leaving skin smoother. This procedure can usually be performed in the dermatologist’s office and may take from a few minutes to an hour. It may take from three to 10 days to heal. Prevention methods for acne There are several steps that may be taken to prevent acne outbreaks. These may also help prevent current acne from getting worse. They include: Washing problem areas with gentle cleansers. It is important to wash the face twice daily with a gentle cleanser. It is also important to remove all makeup from the skin. However, excessive washing and scrubbing can irritate the skin. People with acne are typically advised to avoid facial scrubs, astringents, masks and skin abrasion, as these may irritate the skin and cause or worsen acne. Shampooing hair frequently. This is particularly important when acne tends to develop around the hairline. Oils from the hair and scalp may contribute to acne. Avoiding irritants. Oily or greasy substances (e.g., cosmetics, sunscreens, hair styling products, acne concealers) may contribute to the development or worsening of acne. Using products labeled “water based” or “noncomedogenic” (does not block pores), "oil-free" or "nonacnegenic" may help avoid this. Patients should also keep hair styling products, such as hairsprays and gels, away from the face. Exercising caution around problem areas. This includes: Keeping hair off the face Not resting hands or objects (e.g., telephone receivers, headphones) on the face Avoiding tight clothing and hats Not picking or squeezing blemishes. This can cause infection or scarring and most acne will clear up without this form of intervention. Shaving carefully. Razors can irritate blemishes. Therefore, patients should shave gently and only when necessary. Ongoing research regarding acne Ongoing research is currently investigating many factors in the treatment of acne, including: New medications. New drugs to treat acne, particularly new topical antibiotics, are being researched. The bacteria that causes acne is becoming resistant to some antibiotics, so other means of treating acne are being evaluated. New procedures. New laser treatments are currently under investigation. Many of these show a great deal of promise.