ACNE VULGARIS DEFINITION
Acne is a skin condition that occurs when your hair follicles become plugged with oil and dead skin cells. Acne usually appears on your face, neck, chest, back and shoulders. Effective treatments are available, but acne can be persistent. The pimples and bumps heal slowly, and when one begins to go away, others seem to crop up.
Acne is most common among teenagers, with a reported prevalence of 70 to 87 percent. Increasingly, younger children are getting acne as well.
Depending on its severity, acne can cause emotional distress and scar the skin. The earlier you start treatment, the lower your risk of lasting physical and emotional damage.
ACNE VULGARIS CAUSES
Nobody is completely sure what causes acne. Experts believe the primary cause is a rise in androgen levels – androgen is a type of hormone. Androgen levels rise when a human becomes an adolescent. Rising androgen levels make the oil glands under your skin grow; the enlarged gland produces more oil. Excessive sebum can break down cellular walls in your pores, causing bacteria to grow.
Some studies indicate that a susceptibility to acne could also be genetic. Some medications that contain androgen and lithium may cause acne. Greasy cosmetics may cause acne in some susceptible people. Hormone changes during pregnancy may cause acne either to develop for the first time, or to recur.
ACNE VULGARIS PATHOPHYSIOLOGY
The pathogenesis of acne vulgaris is multifactorial. The key factor is genetics. Acne develops as a result of an interplay of the following four factors:
- Release of inflammatory mediators into the skin
- Follicular hyperkeratinization with subsequent plugging of the follicle
- Propionibacterium acnes follicular colonization
Excess sebum production
Research has shown that inflammatory responses actually occur before hyperkeratinization. Cytokines produced by CD4+ T cells and macrophages activate local endothelial cells to up-regulate inflammatory mediators such as vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), and human leukocyte antigen (HLA)–DR in the vessels around the pilosebaceous follicle.
Follicular hyperkeratinisation involves increased keratinocyte proliferation and decreased desquamation, leading to sebum- and keratin-filled microcomedones.
P acnes is an anaerobic organism present in acne lesions. The presence of P acnes promotes inflammation through a variety of mechanisms. P acnes stimulates inflammation by producing proinflammatory mediators that diffuse through the follicle wall. Studies have shown that P acnes activates the toll-like receptor 2 on monocytes and neutrophils. Activation of the toll-like receptor 2 then leads to the production of multiple proinflammatory cytokines, including interleukins 12 and 8 and tumor necrosis factor. Hypersensitivity to P acnes may also explain why some individuals develop inflammatory acne vulgaris while others do not.
Excess sebum is another key factor in the development of acne vulgaris. Sebum production and excretion are regulated by a number of different hormones and mediators. In particular, androgen hormones promote sebum production and release. The degree of comedonal acne in prepubertal girls correlates with circulating levels of the adrenal androgen dehydroepiandrosterone sulfate (DHEA-S).
Numerous other mediators and receptors, including growth hormone and insulinlike growth factor, as well as peroxisome proliferator-activated receptors also regulate the sebaceous gland and may contribute to the development of acne. Furthermore, the sebaceous gland acts a neuroendocrine-inflammatory organ that is activated via corticotrophin-releasing hormones in response to stress and normal functions.
ACNE VULGARIS SYMPTOMS
Acne signs and symptoms vary depending on the severity of your condition:
- Whiteheads (closed plugged pores)
- Blackheads (open plugged pores — the oil turns brown when it is exposed to air)
- Small red, tender bumps (papules)
- Pimples (pustules), which are papules with pus at their tips
- Large, solid, painful lumps beneath the surface of the skin (nodules)
- Painful, pus-filled lumps beneath the surface of the skin (cystic lesions)
ACNE VULGARIS DIAGNOSIS
When you see a doctor about acne, you’ll have a physical exam, and your doctor will ask about your medical history. Women may be asked questions about their menstrual cycles. This information can help your doctor find out if hormones are playing a role in acne flare-ups. Most often, you won’t have any special tests to diagnose acne.
You may need other tests if your doctor suspects that acne is a symptom of another medical problem (such as higher-than-normal amounts of testosterone in a woman).
ACNE VULGARIS TREATMENT
If over-the-counter (nonprescription) products haven’t cleared up your acne, your doctor can prescribe stronger medications or other therapies. A dermatologist can help you:
- Control your acne
- Avoid scarring or other damage to your skin
- Make scars less noticeable
Acne medications work by reducing oil production, speeding up skin cell turnover, fighting bacterial infection or reducing inflammation — which helps prevent scarring. With most prescription acne drugs, you may not see results for four to eight weeks, and your skin may get worse before it gets better. It can take many months or years for your acne to clear up completely.
The drug your doctor recommends depends on the type and severity of your acne. It might be something you apply to your skin (topical medication) or take by mouth (oral medication). Often, drugs are used in combination. Pregnant women will not be able to use oral prescription medications for acne.
Talk with your doctor about the risks and benefits of medications and other treatments you are considering.
These products work best when applied to clean, dry skin about 15 minutes after washing. You may not see the benefit of this treatment for a few weeks. And you may notice skin irritation at first, such as redness, dryness and peeling.
Your doctor may recommend steps to minimize these side effects, including using a gradually increased dose, washing off the medication after a short application or switching to another medication.
The most common topical prescription medications for acne are:
- Retinoids. These come as creams, gels and lotions. Retinoid drugs are derived from vitamin A and include tretinoin (Avita, Retin-A, others), adapalene (Differin) and tazarotene (Tazorac, Avage). You apply this medication in the evening, beginning with three times a week, then daily as your skin becomes used to it. It works by preventing plugging of the hair follicles.
- Antibiotics. These work by killing excess skin bacteria and reducing redness. For the first few months of treatment, you may use both a retinoid and an antibiotic, with the antibiotic applied in the morning and the retinoid in the evening. The antibiotics are often combined with benzoyl peroxide to reduce the likelihood of developing antibiotic resistance. Examples include clindamycin with benzoyl peroxide (Benzaclin, Duac, Acanya) and erythromycin with benzoyl peroxide (Benzamycin).
- Dapsone (Aczone). This gel is most effective when combined with a topical retinoid. Skin side effects include redness and dryness.
- Antibiotics. For moderate to severe acne, you may need oral antibiotics to reduce bacteria and fight inflammation. Choices for treating acne include tetracyclines, such as minocycline and doxycycline.
Your doctor likely will recommend tapering off these medications as soon as your symptoms begin to improve or as soon as it becomes clear the drugs aren’t helping — usually, within three to four months. Tapering helps prevent antibiotic resistance by minimizing undue exposure to these medications over a long time.
You will likely use topical medications and oral antibiotics together. Studies have found that using topical benzoyl peroxide along with oral antibiotics may reduce the risk of developing antibiotic resistance.
Antibiotics may cause side effects, such as an upset stomach and dizziness. These drugs also increase your skin’s sun sensitivity. They can cause discoloration of developing permanent teeth and reduced bone growth in children born to women who took tetracyclines while pregnant.
- Combined oral contraceptives. Combined oral contraceptives are useful in treating acne in women and adolescent girls. The Food and Drug Administration approved three products that combine estrogen and progestin (Ortho Tri-Cyclen, Estrostep and Yaz).
The most common side effects of these drugs are headache, breast tenderness, nausea, weight gain and breakthrough bleeding. A serious potential complication is a slightly increased risk of blood clots.
- Anti-androgen agent. The drug spironolactone (Aldactone) may be considered for women and adolescent girls if oral antibiotics aren’t helping. It works by blocking the effect of androgen hormones on the sebaceous glands. Possible side effects include breast tenderness, painful periods and the retention of potassium.
- Isotretinoin. This medicine is reserved for people with the most severe acne. Isotretinoin (Amnesteem, Claravis, Sotret) is a powerful drug for people whose acne doesn’t respond to other treatments.
Oral isotretinoin is very effective. But because of its potential side effects, doctors need to closely monitor anyone they treat with this drug. The most serious potential side effects include ulcerative colitis, an increased risk of depression and suicide, and severe birth defects.
In fact, isotretinoin carries such serious risk of side effects that women of reproductive age must participate in a Food and Drug Administration-approved monitoring program to receive a prescription for the drug.
These therapies may be suggested in select cases, either alone or in combination with medications.
- Light therapy. A variety of light-based therapies have been tried with success. But further study is needed to determine the ideal method, light source and dose. Light therapy targets the bacteria that cause acne inflammation. Some types of light therapy are done in a doctor’s office. Blue-light therapy can be done at home with a hand-held device.
Possible side effects of light therapy include pain, temporary redness and sensitivity to sunlight.
- Chemical peel. This procedure uses repeated applications of a chemical solution, such as salicylic acid. It is most effective when combined with other acne treatments, except oral retinoids. Chemical peels aren’t recommended for people taking oral retinoids because together these treatments can significantly irritate the skin.
Chemicals peels may cause temporary, severe redness, scaling and blistering, and long-term discoloration of the skin.
- Extraction of whiteheads and blackheads. Your dermatologist uses special tools to gently remove whiteheads and blackheads (comedos) that haven’t cleared up with topical medications. This technique may cause scarring.
- Steroid injection. Nodular and cystic lesions can be treated by injecting a steroid drug directly into them. This improves their appearance without the need for extraction. The side effects of this technique include thinning of the skin, lighter skin and the appearance of small blood vessels on the treated area.
TREATING ACNE SCARS
Procedures used to diminish scars left by acne include the following:
- Soft tissue fillers. Injecting soft tissue fillers, such as collagen or fat, under the skin and into indented scars can fill out or stretch the skin. This makes the scars less noticeable. Results are temporary, so you would need to repeat the injections periodically. Side effects include temporary swelling, redness and bruising.
- Chemical peels. High-potency acid is applied to your skin to remove the top layer and minimize deeper scars.
- Dermabrasion. This procedure is usually reserved for more severe scarring. It involves sanding (planing) the surface layer of skin with a rotating brush. This helps blend acne scars into the surrounding skin.
- Laser resurfacing. This is a skin resurfacing procedure that uses a laser to improve the appearance of your skin.
- Light therapy. Certain lasers, pulsed light sources and radiofrequency devices that don’t injure the epidermis can be used to treat scars. These treatments heat the dermis and cause new skin to form. After several treatments, acne scars may appear less noticeable. This treatment has shorter recovery times than some other methods. But you may need to repeat the procedure more often and results are subtle.
- Skin surgery. Using a minor procedure called punch excision, your doctor cuts out individual acne scars and repairs the hole at the scar site with stitches or a skin graft.
Most studies of acne drugs have involved people 12 years of age or older. Increasingly, younger children are getting acne as well. In one study of 365 girls ages 9 to 10, 78 percent of them had acne lesions. If your child has acne, you may want to consult a pediatric dermatologist. Ask about drugs to avoid in children, appropriate doses, drug interactions, side effects, and how treatment may affect a child’s growth and development.
Treatment of children with acne is often complicated by their family situation. For example, if a child moves between two homes due to divorced parents, it may help to use two sets of medications, one in each home.