ACNE (PIMPLES)

Answers and Questions

What is it?

Acne is a disease of the pilosebaceous follicles that occurs when oil and dead skin cells clog the skin’s pores.

Where does acne usually occur?

Acne usually occurs on areas where there are large numbers of sebaceous (oil) glands such as face, neck, chest, upper back and shoulders.

What causes acne?

Acne is caused by the overactivity of the sebaceous glands (so they produce an excess of sebum onto the skin), especially sensitive, in people prone to acne, to normal blood levels of a hormone called testosterone, normally present in both men and women.

At the same time, the dead skin cells lining the openings of the hair follicles (the tubes that hold the hair) are abnormally cohesive and are not shed properly and block the follicles. These two effects combined cause a build-up oil in the hair follicles that become visible at the skin surface as whiteheads or blackheads.

On some people, acne does not progress beyond this stage; in other people, the build-up of oil in the hair follicles creates an ideal environment for a bacterium called Propionibacterium acnes (normally live harmlessly on the skin) to grow and to produce some enzymes which stimulates the inflammation. In more severe inflammatory acne, cysts develop and their rupture can spread the infection into nearby skin tissue, resulting in scars.

Which kind of lesions does acne cause?

Acne tipically causes one or more of the following:

• Whitehead: the first visible acne lesion. It appears as a white dot ranging from 0.1 to 3.0 mm in diameter.

• Blackhead (comedone): it looks like a black dot. Its diameter is similar to whitehead.

• Papule: it is a pink to red, raised, palpable lesion with no visible accumulation of fluid, which can range from 1 to 4 mm in diameter.

• Pustule: it is a raised accumulation of purulent material on the skin’s surface and is similar in size to the papule.

• Nodule: it is a tender, firm lesion that may persist for weeks.

• Cyst: it is a lesion as large as several centimeters in diameter and may drain a creamy, yellowish material.

• Hyperpigmented macule: It is a postinflammatory lesion, common especially in darkly pigmented skin. It usually fades in 3-18 months.

• Scar: it is the possible sequelae of acne lesion. It can be atrophic or hypertrophic. Atrophic scar include ice-pick scars, multichanneled tracks or sinuses and dermal troughs. Hypertrophic scars include keloids.

How does acne begin?

Acne begins as a blockage to a sebaceous (oil) gland conduct. Certain hormones (androgens), released at puberty, cause the sebaceous glands to overproduce sebum (oil). Sebum combines with dead cells to form a plug in the hair follicles resulting in a comedone.

Who gets acne?

Both boys and girls. Acne usually develops at puberty when the hormones (testosterone and progesterone) which stimulate oil glands are first produced. Acne usually appears earlier in females than males, because females tend to start puberty earlier but males often have more severe and long lasting acne, because of much higher levels of testosterone. But women tend to have intermittent acne due to hormonal changes with their menstrual cycle and acne caused by cosmetics.

While most people outgrow their acne by their 20’s, some, especially women, have acne well into adulthood.

Can acne be hereditary?

If the mother and father had had acne, the son may too.

Does acne cause scars?

Acne, especially cystic acne, can cause scars in some people. To reduce scarring not squeeze or peek at blemishes, and also, avoid to scrub the skin.

Not true about acne

• Acne is related to fatty food.

• Eating french fries causes acne.

• Acne is contagious. Acne is not a infection and so it can not be spread from one person to another.

• Eating chocolate causes acne.

• Acne is an allergic reaction to something.

• Squeezing pimples will make them spread.

• Acne is due to lack of cleanliness.

• Blackheads get their colour to dirt.

• Lying in the sun or using a sun lamp will clear acne.

• Acne is caused by oily hair.

• Masturbation cause acne.

What does it cause the dark color of blackhead?

Dirt-blackhead get their dark colour through excess skin pigment – not dirt.

Can certain foods cause acne?

There is no evidence that certain foods cause acne. Food seems to have little effect on the severity of acne in most individuals. However if  you notice a relationship between certain foods such as chocolate, fatty foods, excessive amounts of milk or sweets, fried food and acne, it is best to avoid them. A balanced diet, is important not only to maintain healthy, but also to have a clear skin.

Does people with acne follow a particular diet?

NO. Scientifically there is no proof that some foods make acne worse. Eating occasional chocolate or sweet does not seem to make any difference to acne.

Why is acne caused during puberty?

Because in puberty there is the appearance of hormones (testosterone and progesterone) which stimulates oil glands.

What else causes or worsens acne?

• Stress can worse acne.

• Oily cosmetics (makeup, suntan oil, sunscreens, hair gels and spray) may form comedones.

• Certain medications can cause or worsen acne: progestin-dominant birth controll pills (this is due to the type of progesterone hormone in some pills whereas some other types of contraceptive pills can improve acne), Depo-Provera, androgens, Lithium, ACTH, INH, bromides, iodine, barbiturates, steroids, Dilantin. If you have concerns that a medication may be worsening your acne, do not stop taking it before talking with your doctor. An alternative may be an option.

• Women may also have flares prior to their menstrual periods.

• Hard scrubbing of the skin.

Things you should avoid to do when having acne.

• Picking or squeezing on acne lesions, as this can delay healing and can cause further inflammation with possible scarring.

• Self-treatment.

• Using hot water to wash yourself. The colder the water, the better.

• Using diving masks. Use goggles instead. Pressure on your face could help to grow a very unusual amount of new pimples.

• Shaving with a bad razor and/or without shaving cream.

• Having a wet face after going to swim/exercise. Always have a ready towel to clean your face after exercise and take a good bath after swimming.

As soon as possible contact a dermatologist: before you start to treat properly your acne, before you heal from it.

Is there a grading system for acne?

Usually acne may be classified as:

• mild (comedones and few to several papules and pustules),

• moderate (comedones, several to many papules and pustules, and a few nodules),

• severe (numerous papules and pustules and many nodules). Severe may be an acne that produces serious scarring or psychological problems, even if the lesions type and the number don’t reflect traditional categories of severe disease.

Another method to classify the disease is identifying the most severe predominant lesions:

• comedonal acne (comedones)

• papulopustular acne (papules/pustules)

• nodulocystic acne (nodules/cysts)

What is acne cosmetica?

Acne cosmetica is a low-grade crops of closed comedones on the cheeks of women aged 20-25 that were triggered by comedogenic substances in cosmetics.

What is adult acne?

Adult acne is defined as acne after the age of 25 years and appears to be more common in women than in men.

Two are the main forms of adult acne:

• persistent acne, in which adolescent acne persists into adulthood.

• late-onset acne, in which the disease erupts for the first time in adulthood.

Is it important to keep spot-prone areas clean?

Yes, it is. It’s better to wash the affected area once or twice a day with a gentle cleanser. The skin needs a certain amount of oil to maintain its natural condition, so it is important to avoid aggressive washing with strong soaps, facial scrub, toners, or masks because they may dry your skin. Washing more doesn’t help as not washing at all.

What doesn’t acne worse?

• Dirt. Acne is not due to a lack of cleanliness.

• Food such as chocolate, fatty o fried foods (French fries), dairy products, cakes or sweets. Acne is not caused by eating them.

• Sexual activity

• Masturbation

What about acne and cosmetics?

This is  an usual question of women with acne.  “Noncomedogenic” designation for skin care products is a useful guide for patients when selecting cosmetics. There are some general guidelines for acne-patients:

• powder blushers are usually preferred over creams

• cream/powder foundations are usually preferred over then liquid type.

• If a liquid foundation is chosen, it should be silicone-based (cyclomethicone, dimethicone).

• It should be also vigilant about discarding old cosmetics and purchasing fresh replacements.

How can acne be treated?

Acne can be treated in different ways: it depends on the type of acne, upon its severity and it varies between individuals.  Can be treated by applying topical preparations; if it does not respond to topical treatment may require systemic treatment.

Which is the goal of treatment?

• To prevent new spots forming

• To improve those already present, reducing and eliminating outbreaks.

• To prevent scarring

How should topical antiacneic medicines to be used?

Topical preparations should be applied on all areas of the skin which are acne prone, not just on the inflamed spots present today. Sometimes topical treatments can cause redness and peeling, especially to start with. This tends to settle down reducing the number of times you use it. You can then build up your use gradually. But generally, to decrease the chance of skin irritation, it would be better to apply to dry skin after 20-30 minutes after washing the face, and apply every other day for the first two weeks. They have not to get near the eyes, the mouth and the area under the nose.

How should topical treatment work?

There are a number of topical remedies to treat acne (es. benzoyl peroxide, retinoids, azelaic acid, isotretinoin, topical antibiotics). Some work for their antibacterial effects, other can dry the skin and encourage the outer layer of skin to flake off, some with both effects.

Will home treatments work immediately?

No. It can takes weeks, if not months, for significant effects to be noticeable. Patients should have a realistic sense of timeline of acne treatment, so that they don’t become frustrated and discontinue therapy when they don’t see immediate improvement.

Are there systemic treatments for acne?

Yes, There are several oral treatments:

• Antibiotics, such as tetracycline, doxycicline, erythromycin and other macrolides, minocycline. They are prescribed for inflammatory acne. They work to reduce bacteria, thereby reducing inflammation. They should be taken for several weeks. Sometimes some strains of bacteria are resistant to these antibiotics resulting in a limited success for this kind of treatment. Antibiotic do not prevent pores from coming locked.

• Some types of oral contraceptive tablets help women and adolescent girls who have acne decreasing male hormone activity, thereby decreasing sebum production.

• Isotretinoin (eg. Roaccutan) is a potent medicine. It also exists in a topical form. Isotretinoin is the only available therapy that targets all 4 pathogenic  factors in acne: it decrease the size of the sebaceous glands and reduces conseguent sebum secretion; normalizes follicular keratinization; inhibits P. acnes proliferation; has anti-inflammatory effects. It is indicated for the treatment of severe, recalcitrant nodular acne that has failed to respond to conventional therapy, including sistemic antibiotics. There a number of potentially serious side effects of this drug. In girls, it should not be taken during pregnancy or even 1 month before pregnancy because isotretinoin can cause birth defects and miscarriages. Girls must to use two methods of birth control (and have monthly pregnancy tests) or not have sex during therapy, as well 1 month before they start the drug and 1 month after they stop taking it. For safety reasons, isotretinoin is only prescribed under the supervision of dermatology specialists.

Will acne go away?

Yes. The goal of treatment is to keep acne under control until clears with time. Sometimes acne worsens for the first several weeks after treatment is initiated and then gradually improves. Once acne significantly improves, continued treatment is need to keep acne from appearing. The care of acne may require teamwork between the patient and the dermatologist. In fact medications may be added or deleted based on how the skin responds to treatment.

Suggested links: Sebaceous hyperplasia | Herpes genitalis | Perianal streptococcal dermatitis | The skin and the sun| Mycotic infections |