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Acne: An Overview

Acne is a common skin condition which affects millions of teenagers and young adults. It is a disorder of the skin that presents as an irritating red skin rash with pustules on the face. The disorder affects more than 80% of adolescents and young teenagers. Acne can occur on the face, chest, arms and back but has a high propensity for occurring on the face. Acne is most common in teenagers and young adults. In some cases acne is seen until the late 30s. Even a single acne lesion can cause a lot of social problems and for those with multiple lesions on the face, it is can cause potentially life long loss of self esteem, depression and social isolation. When the condition is not treated, the acne can lead to disfiguring of the face which is also associated with numerous residual scars. At this stage, the condition is difficult to treat. Unlike the 1980s when only topical preparations where available to treat acne; today, newer and more effective drugs are available.

Modern day misconceptions about acne - The condition is due to poor hygiene of the face - The condition is due to dirt in the environment - Acne is not genetically acquired - Foods do not affect acne - Acne can be treated with herbs and nutrients - Acne is caused by stress - Buying more expensive soaps and creams leads to better treatment

Pathology of acne -Hair follicles are present on all parts of the body, except for the soles and palms of the extremities. Inside the hair follicles are glands which also secrete sebum (oil). The sebum is secreted at a constant rate and lubricates the skin. These sebaceous gland are specially prevalent on the face, back, axilla and chest. It is believed that in acne, there are a lot of dead cells and debris inside the hair follicle which plug the pores of the skin. The pores are unable to release their oily secretions and tend to enlarge. When these pimples grow to a certain size, they become conspicuous on the face and may even rupture. Once the pores are plugged, the bacteria that normally live on the skin start to grow in the pores and are responsible for the acne. The bacteria cause the redness and skin irritation. When the bacteria mix with the oils from the hair follicles, it secretes substance which can cause skin irritation. Acne is always worsened in the presence of the male hormones. These hormones are present in both males and females, but in a much higher concentration in males. These male hormones can cause enlargement of the sweat glands on the skin and cause these same glands to increase the production of oil. This increased oil secretion then causes the pores to plug up and lead to acne. In all males, there is a surge of the male hormones at puberty and this is the time when most males show the development of facial acne. In some men, the condition progresses leading to severe acne on the face and back. Estrogen, the female sex hormone, on the other hand helps to improve the acne. This is the major reason why during the menstrual cycle the acne is variable. This is one of the reasons why most women who take the birth control pill, almost never develop acne. In fact, some dermatologist will even prescribe oral contraceptives for a short period for the treatment of acne.

Causes and Risk Factors  - There is a genetic predisposition for acne but the actual gene responsible has not been identified. Acne is often worsened by periods of stress and diet. Foods high in chocolate content, certain spices and hot foods are known to affect and worsen acne. Propionibacteria acnes is the common bacterial cause of skin infection that accompanies acne. These bacteria are always present on the skin and play a major role in the causation of pustules.

Signs and Symptoms - Acne usually presents as small pimples (comedones). These can appear anywhere on the body but are commonly seen on the face, chest, back, and shoulders. Bacteria thrive in conditions where there is warmth, moisture and oil. When the bacteria grow into the comedone, the pimple and surrounding skin becomes red and swells up. Frequently the comedone ruptures and pus can be extruded from it. After rupture of the comedone, it leaves a skin depression (pit) or a scar.

Who should seek medical help for Acne - In some individual the acne just does not go away, keeps on recurring and is severe. In some individuals the pustules are large and are a major cosmetic problem. In others the acne has failed to respond to all over the counter medications. Anyone who has acne which is moderate to severe and of a cosmetic concern should see a doctor because there are medications to treat this condition.

Diagnosis - The diagnosis of acne is straightforward. There are no x rays or blood work required. The diagnosis is easily made by inspecting the skin.

TREATMENT Basic Skin care at home - All individuals with acne should consider performing some basic skin hygiene at home. The major goal of all acne treatment is to prevent scarring and disfiguring of the face. When acne is left treated, severe scarring can result. It is recommended that one wash the face at least 2-3 times a day to remove the excess oil from the skin. There are numerous acne cleansing products available but a simple bland soap will do just as well. One should not scrub the skin too hard as this may lead to further irritation. One should avoid all fragrances and perfumes on the face to limit the extent of skin irritation.

Medical Treatment -The major treatment of acne is medications. There are 100s of medications available for the treatment of acne- this fact alone should immediately lead one to suspect that no one really knows what the best medication is. Every single day, there is a new agent advertised which is claimed to be the best drug for acne. There are many herbs, oils, soaps, and nutrients which are supposed to treat acne, but they all lack any scientific data or clinical proof of their efficacy. The majority of these agents are a waste of money and do not cure acne. Despite these numerous options available, only a few drugs are actually helpful in the treatment of acne. There are both over the counter and prescription drugs available in the treatment of acne.

Selecting a Treatment Regimen - The physician treating acne should consider some skin factors when managing acne. Patients with dry skin benefit best most from creams, whereas patients with oily skin do best with solutions which may contain an alcohol. Using the appropriate vehicle can lead to better compliance by limiting side effects.

Over the counter medications- There are numerous over the counter medications available to treat acne. These non prescription chemicals include everything from baby oil, shampoos, soaps, creams, ointments, herbs, minerals, emollients etc. No one knows if these work and judging from the number of chemicals available, it is a sure bet that the majority do not work.

Benzyl peroxide - Benzyl peroxide is available over the counter and has been used to treat acne for at least 50 years. This agent can kill the bacteria and also acts as an abrasive agent. It is the only topical agent that is most effective against the bacteria which is commonly found in acne pustules. Benzyl peroxide is available in various concentrations (2.5 to 10 percent), although there is no evidence that using higher concentrations result in better treatment. The water-based formulations cause less drying of the skin than the alcohol-based preparations. Benzyl peroxide gels are applied once or twice daily. The most common side effect of the agent is skin irritation. This effect occurs more often at higher concentrations and tends to decrease with continued use. Some individuals develop contact allergy. All patients using benzyl peroxide formulations should test the skin to make sure they do not have contact allergy. The drug is a strong oxidizing agent and can irreversibly stain clothing and linen. The drug is best applied in the morning so it will be dry by night time and so the risk of staining is avoided.

Acidic solutions- Mild acidic solutions are available in most pharmacies and health care stores. Theses acidic solutions like salicylic and glycolic acids can be effective in some cases. The mild acids peel of the old skin and open up the pores, thus removing the accumulated oil inside the skin pores. However, the effectiveness of these acids is variable and they do not work for the moderate to severe cases of acne. Drying up of the skin is a common problem with these peeling acids.

Salicylic Acid- Salicylic acid is a chemical available in various concentrations as an over the counter medication. This agent inhibits the formation of black heads by acting as peeling agent. It has been shown to be as effective as benzyl peroxide in the treatment of acne. Salicylic acid is well tolerated and should be applied once or twice daily.

Sulfur Preparations -Sulfur preparations have been used to treat acne for centuries. Sulfur is combined with other over the counter acne medications. This agent has been shown to be effective in the treatment of acute acne lesions and acts as a keratolytic agent. It has a few unpleasant side effects including an unpleasant odor and skin discoloration. Today, sulfur medications are rarely used in the treatment of acne because of the availability of better and effective agents.

Azelaic Acid-Azelaic acid is a decarboxylic acid is sometimes used to treat mild acne. How it works remains unknown but it appears to be as effective as salicylic acid and tretinoin in the treatment of mild to moderate acne. Azelaic acid is a cream which is applied twice a day. Most individuals have no complaints but some may develop skin irritation and redness at the site of application. Because the agent also has the ability to decrease skin pigmentation, it should be used with caution in dark skinned individuals.

Prescription medications- Various prescription medications are available for the treatment of acne. These include the antibiotics and retinoids. These prescribed medications are generally administered for moderate to severe long standing acne which has failed to respond to all other measures. Antibiotics have been used for a long time in the treatment of acne. They are most effective in the treatment of acne which is red and tender. The antibiotics kill the bacteria and cause decrease in redness and swelling. However, these antibiotics do not work in all individuals and the results are not always predictable. The antibiotics can be applied topically or be taken as a pill. In general, most individuals show a poor response to antibiotic. Judging from the number of antibiotics prescribed to treat acne, should indicate that one antibiotic alone does not always work for all individuals.

Topical antibiotics- Topical antibiotics can help reduce acne. Types of topical antibiotics include erythromycin, clindamycin, and sulfa drugs. The topical approach is sometimes effective because the medication is applied directly to the skin lesions. In addition, because the drug is not swallowed, there are fewer side effects. A disadvantage of all antibiotic treatment is that bacteria often develop tolerance and resistance to the medication over time, and thus become difficult to eradicate. Almost all topical antibiotics are associated with some minor skin irritation which may be due to the solution in which the antibiotic is dissolved.

Oral Antibiotics- Tetracyclines are the most frequently prescribed oral antibiotics for the treatment of acne. These antibiotics are taken for short term duration only. There are a number of tetracycline drugs (minocyline, doxycycline) which are used to treat acne. However, the majority of acne sufferers fail to respond to these drugs and the drugs also have a few side effects. Most users of tetracycline type drugs for acne reveal a great disappointment with this therapy.

Retinoids- Retinoids, which are derivatives of vitamin A, act by decreasing comedomes and decreasing oil production. Retinoids are the most effective agents for acne. They have been a mainstay of acne treatment for the past 25 years. Until recently, tretinoin was the only available topical retinoid. This agent is used as a single agent and quite effective for mild to moderate acne. Tretinoin is available as a cream, gel or liquid. The cream has the lowest potency, and the liquid has the highest potency. All tretinoin formulations can cause some skin irritation and this is related to the strength of the formulation. Tretinoin is applied to clean dry skin. Because the drug can cause light sensitivity, sun exposure should be avoided when applying the treatment. Or the treatment can be applied at night time. To minimize irritation, tretinoin should be started at a low concentration, which can then be gradually increased as needed. Skin irritation usually decreases with continued therapy. All users of tretinoin should be aware that when initially using the agent, a flare up may occur. This is common during induction therapy and not a sign of an adverse reaction. The skin flares up declines over the next few days.

Caution with Retinoids - Because of the known teratogenic (birth defects) effects of oral vitamin A products, the use of tretinoin in pregnancy is a major concern. When a female of child bearing age is prescribed tretinoin, the adverse effect on this drug on the fetus must always be explained to the individual. Numerous litigation cases have occurred with the use of these drugs in young females. A signed consent from the individual acknowledging the use of this drug must be placed in the chart. Occasionally the retinoids may also cause an increase in the blood levels of fatty acids. Still in other individuals, the drugs have been associated with depression and suicidal thoughts. Sun sensitivity may occur in some individuals who do take retinoids. Therefore it is recommended that the individual wear a sun screen or cover the skin while taking this medication

Topical Vitamin A products - Adapalene (Differin) and Tazarotene are two topical retinoids that have been approved for the use of Acne. These topical medications are applied once a day and are less irritating then benzyl peroxide and other antibiotics. Like the oral retinoids, the use of these drugs in pregnant females should be used with caution. These vitamin A related products can treat several types of acne lesions. The retinoids may be applied topically or even be taken orally as a pill. When applied topically, they help to cleanse the pores and remove the skin oils. The oral retinoids are excellent for severe acne and lead to rapid clearance of the condition. They have a peeling action on the skin. Within a few weeks, the majority of individuals show a response and the drug also leads to a reduction in wrinkles on the face.

Miscellaneous medications- With a large lucrative market and millions of individuals seeking to look younger and more beautiful, there are daily reports of newer products, herbs, spices, mineral and nutrients claming to cure acne. The majority of these substances are worthless. A few chemicals that may have the potential to treat acne include zinc and use of lasers. However, there are no scientific data to back the claims made by these individuals who sell or offer these products.

Surgery- Surgery for acne is a last resort treatment. When all therapies have failed and the comedomes are large, surgery may be of some benefit. The surgery is a very minor procedure and involves extraction of the blackheads with a special instrument (comedo extractor). In rare cases, corticosteroids may be injected into the lesion to help reduce the redness and soften up the comedone. Steroids may also help to reduce the scarring. Surgery may cause skin scarring and dermabrasion may be required in future.

Patient Education- To avoid the disfiguring effects of acne, it is essential to educate the patient about acne. Patients need to know the facts and dispel the myths about the disorder. The acne is not related to hygiene and extensive scrubbing and use of strong alcohol based acids only worsen the disorder. Patients should know that simple washing with warm water and soap is sufficient. Individuals with acne have to know that acne is not caused by stress but infact acne can worsen the stress. The role of cosmetic products in the etiology of acne is overstated. Cosmetics do not cause acne but may worsen the redness and skin irritation. Oil based cosmetics generally worsen the acne.

 Prognosis-Most teenagers and young adults with acne grow out of this stage by the mid to late 20s. The best treatment for acne is the combination of drugs in which a retinoid is a part of the treatment regimen. Depending on the physician and his/her experience, the combination therapy may be variable. One needs to go to a dermatologist who has experience in treating acne. All patients with acne should be given realistic expectations about their treatment plan, along with good follow-up. These measures can contribute to the ultimate success of treatment. The majority of individuals who get treated early for acne have excellent results. For those who have delayed their treatment, some scarring and facial disfiguring may be evident. In such cases, a visit to a cosmetic or plastic surgeon may be necessary. Today, advances in lasers can help smooth the skin and remove the facial scars. Before going to any plastic surgeon for scar removal, be informed about the various skin peeling procedures. They are not only expensive and the results are not always guaranteed.