Epidemiology; how common is acne?

Acne is a common skin condition and virtually every adolescentwill have a small number of acne spots at some stage, and others will havemore. Although acne is most common in adolescents, and specifically is most frequentin the late teenage years, the condition may appear for the first time in themid-twenties or even later; in fact, acne persists in a large number of peopleinto their 40s or even their 50s!

Clinical manifestations; what isacne?

Acne is a disease of the grease (sebaceous) glands and ischaracterized by blackheads, whiteheads, red spots, and sometimes deeperboil-like lesions that dermatologists call nodules or cysts. 

There are several types of acne lesions, including blackheads andwhiteheads (collectively termed comedones), larger pimples (papules) andeventually, pustules and large cysts. Scars occur after papules, pustules andcysts. They are often permanent.

The exact cause of acne is not known. It develops in theoil-producing structures of the skin called pilosebaceous follicles, which arepresent in large quantities on the face, chest, upper back and shoulders. Onetheory is that acne develops when hormone levels increase during puberty,causing the skin of the acne prone persons to react by producing excess sebum .The bacteria on the skin alters sebum to produce substances that cause acne.Dead skin cells, bacteria, hormones and altered sebum plug the hair follicle,the site where acne begins. This obstruction results in swelling and the developmentof lesions that dermatologists call "comedones," but that most peoplecommonly refer to as simply whiteheads and blackheads. Emotional stress,fatigue and cosmetics can aggravate acne.

The importance of acne should not be underestimated because thedisease can have important negative psychosocial consequences for the affectedindividual, including diminished self-esteem, social withdrawal due toembarrassment, depression, and unemployment. Provision of adequate therapy istherefore important, especially because satisfactory results from treatment canbe achieved in most cases.

Triggering factors; what makesacne worse?

  • Diet: Many people believe that there is a relationship between their diet and acne. However, there is no medical evidence proving that food causes acne and following the strictest diet will not usually clear acne. On the other hand, some people believe that their acne seems to worsen when they eat certain foods, particularly chocolate, fried food, and hot peppers. In general, people should avoid foods that clearly aggravate their acne. 
  • Cosmetics: Some cosmetics, sunscreens and moisturizers may worsen acne. But, use of "Non-comedogenic", water-based, oil-free cosmetics is unlikely to cause of exacerbate acne. You can use eyeliners, eye shadows and lipsticks without any risk of making acne worse. However, do ensure that  all cosmetics are washed off thoroughly before going to bed. 
  • Hygiene: The idea that acne is due to poor personal hygiene is certainly a myth. Blackheads are due to oxidization of sebum in the blocked pore and not to dirt, as is often believed. Do not wash with harsh or high pH soaps. Acne is not caused by dirt or poor hygiene, so don't be concerned about being "unclean." 

Psychologicalaspects of acne:

Some patients with acne will develop psychologic problems as aconsequence of their condition. Even mild to moderate disease can be associatedwith significant depression and suicidal ideation and psychologic change doesnot necessarily correlate with disease severity. Acne scars themselves havebeen shown to produce significant psychopathology.Recent works confirmed thatfemale acne patients can suffer from hypochondriasis, depression and schizoidproblems, whereas in male patients with acne, paranoia and anxiety are morecommon.76% of acne patients considered that their skin changes wereunattractive and this had an adverse effect on their sexual life.

Management; how to treat?

When initiating treatment it is important to consider the aims oftherapy. Treatment should be aimed at achieving clearance of acne, preventionof scarring and, where necessary, relief from any psychologic stress resultingfrom the acne. Therapy should be commenced early in the disease process inorder to prevent scarring and it is important to select appropriate therapiesaccording to the clinical signs and psychologic disability. Waiting to outgrowacne can be a serious mistake, since early treatment can immediately improveyour appearance and prevent the formation of scars. It is also important toensure that the patient is able to comply with therapy and clear guidelinesregarding treatment, possible adverse effects and realistic expectations shouldbe provided. To reduce the possibility of formation of scars, never pick,squeeze or scratch lesions. Although it is much easier said than done, adermatologist will advise a person with acne to keep their hands off of theirthe face.

Three broad categories of therapy are useful in the treatment ofacne:

  • Creams and lotions that are applied to the face to break up blackheads and whitehead -- called comedolytic agents.
  • Antibiotics that may be either applied directly to the face in the form of a cream or lotion, or taken internally in pill form.
  • Topical or systemic retinoids -- these are drugs like Retin-A, which is applied to the face as a cream, and Accutane, which is systemic medicine that is taken as a capsule. This drug s approval in 1982 revolutionized therapy, since it was the first oral acne-specific drug, and it provided prolonged remissions. In addition, it may prevent the emergence of resistant bacteria, a problem linked to the traditional use of antibiotics for acne

Topical therapy is the mainstay for the management of all but themost severe forms of acne. 

Comedolytic therapies (retinoids, including tretinoin,isotretinoin, adapalene and tazarotene; salicylic acid;and possibly,alfa-hydroxy acids) reduce the number of microcomedones, while antibacterialtherapies ( benzoil peroxide and antibiotics such as erythromycin andclindamycin) reduce the intrafollicular population of P.acne.Miscellaneous compounds such as sulphur and resorcinol have also been used.A"comedolytic agent" helps acne breaking up comedones, or blackheads,and is often one of the first medicines that a dermatologist will prescribe fora person with acne.  Azelaic acid is a recently introduced comedolyticagent that also has some antibiotic properties. Clinical studies haveshown the following properties contribute to the efficacy of azelaic acid intreating mild to moderate acne:

* demonstrates antimicrobial activity against Propionibacteriumacnes (P. acnes) and Staphylococcus epidermidis (Staph.epidermidis)
* normalizes the follicular hyperkeratosis associated with acne possessesanti-inflammatory effects.
* The mechanism of action of Azelaic acid, while not completely understood,leads to the reduction of acne lesions

Systemic antibiotics are often prescribed quickly bydermatologists for persons with acne that is causing scars or has the potentialto cause scars. Tetracycline, doxycycline , and minocycline  are often theantibiotics of choice because they are generally effective and have fewside-effects in most people. 

The female hormone estrogen, at high levels, can help improveacne. Many women notice a worsening of acne just before their periods, which isdue to changes in their hormone levels at this time. Pills that containestrogen can help acne, however, progesterone-only pills (such as the so-called"mini pill") can make acne worse.

Oral treatment with 13-cis-retinoic acid in severe acne isnormally successful, lasting for a number of years, and has improved thequality of life for many adolescents. It reduces the sebum excretion rate,restores desqumation and normalises the keratinisation process. However, theside effects of 13cRA include epistaxis, pruritus and effects on mucousmembranes, leading to a lack of adherence by patients, as well asteratogenicity. In fact, the first few weeks of treatment may actually make thecondition worse.

Therapeutic guidelines andnotes:

  1. Use repeat courses of benzoil peroxide, as this is known to reduce P.acnes resistance. However, no one agent is able to eradicate resistant strains completely and as resistant strains correlate to poor clinical response to therapy, prescribing strategies are required to minimize the occurrence of resistance to P. acnes.
  2. Do not prescribe antibiotics unless absolutely necessary.
  3. Use oral antibiotics for a short period of time, say 6 months.
  4. Avoid simultaneous topical and oral use of different antibiotics.
  5. Not all patients respond to isotretinoin.
  6. Stress the importance of good compliance.

Support Groups

If you suffer from severe acne, or you know someone who is, andyou would like to meet other persons similarly affected, I invite you to visit thesewebsites; 

Acne Support Group