Acne

 

“Acne is a common skin disease, characterized by blackheads/ whiteheads (comedones, pustules, papules) on the face, chest and neck due to clogged pores on the skin with oil, dead skin cells and bacteria.”

 

Acne (also known as pimples or zits) is a common skin problem that usually presents as skin eruptions that occur due to clogging of skin pores with dirt, bacteria, and dead skin cells. Acne may even contain pus at times.   

 

Pores are tiny holes on the surface of your skin that are connected to oil glands (sebaceous glands) hidden beneath the skin. In acne, either the pilosebaceous glands (oil glands of the skin) or the pores get clogged with excess oil, bacteria (Propionibacterium acnes or P. acnes) and dead skin particles which in turn causes inflammation. 

 

To keep your skin soft and healthy, your glands produce an oily substance called sebum. The sebaceous lipids in the sebum are crucial for waterproofing and lubricating the outer skin and hair. The overproduction of this substance can lead to a host of skin conditions including acne.

 

Scientific synonyms:  Acne Vulgaris, Acne

 

• Pimples
• Zits
• Cystic Acne
• Pustules 
• Papules 

 

• Acute
• Non-communicable 

 

• Early Adolescence
• Late Adolescence 
• Young Adults

 

Almost everyone suffers from acne at some point of their life although it is most common in teens and young adults. According to National Institute of Arthritis and Musculoskeletal and Skin Diseases, an estimate of 80% people aged between 11 and 30 years suffer from acne at some point. Acne commonly starts at the beginning of puberty. In most of the people acne disappears at the age of 25, but it can continue even during adulthood due to different reasons. Often, acne arises in adulthood as adult-onset acne.[1]

 

 

Organ System: Skin

 

 

According to American Academy of Dermatology, women experience acne at higher rates than males across all age groups 20 years and older.[2,3]

 

Four main factors that are responsible for acne outbreak are:

• Excess oil production
• Hair follicles clogged by oil and dead skin cells 
• Bacteria
• Hormonal imbalance

 

 

There are few common and scientifically proven risk factors that can trigger acne:

 

1. Age (Non-modifiable): Teenage and young adults aged between 11 years and 30 years are at very high risk of developing acne. 

 

2. Gender (Non-modifiable): Women are more prone to have acne due to changes in hormonal levels during menses. During or before periods, women are more likely to have pimples as at that time there is a change in hormones. 

 

3. Family history (Non-modifiable): Acne can run in families. If your parents had acne, it is likely that you will also develop it. According to a study, if both your parents had acne, you are likely to develop a severe acne at an early age. The study also found that if one or both of your parents had adult acne, you are more likely to get adult acne too.

 

4. Greasy makeup (Modifiable): Oil-based makeup and cosmetics can worsen the pimples that are already present. Moreover, this form of make-up can increase your risk of developing acne.

5. Medications (Modifiable): Certain medications such as steroid-containing medicines (sometimes given to body-builders for muscle growth), lithium (used to treat depression and bipolar disorders) and some anti-epileptic drugs (used to treat epilepsy) can flare up acne.

 

 

Acne commonly appears on the face and shoulders. It may also occur on the trunk, arms, legs, and buttocks. Skin changes include:

• Whiteheads
• Blackheads
• Papules (small red bumps)
• Pustules (small red bumps containing white or yellow pus) 
• Cysts
• Nodules
• Scarring of the skin

 

Your healthcare provider may diagnose acne by looking at your skin. Severity of acne is often characterized as mild, moderate and severe.

 

For mild acne, normal clinical manifestation can be useful. But for severe cases few tests need to be done. These tests can be: 

Some women are advised to take blood tests to check the hormone levels. These tests may include:

1. Testosterone 
2. Sex hormone binding globulin
3. Free androgen index
4. Dehydroepiandrosterone sulfate 
5. 17-hydroxyprogesterone
6. Synacthen test of adrenal stimulation
7. LH and FSH test
8. Prolactin test
9. Cortisol
10. Dexamethasone suppression test

A pelvic ultrasound test and a CT Scan can be done to detect PCOS in severe cases of adult acne in women.[5]

 

 

Nowadays, with a better understanding of the factors that lead to the development of acne, it has become easier to decide the most suitable treatment procedure. Treatment of acne is directed towards known pathogenic factors such as follicular keratinization, increased production of sebum because of high androgen secretion, proliferation of P. acnes and inflammation.[6] 

 

The grade and severity of acne plays a major role in determining which of the following treatment alone or in combination is appropriate. Following treatment methods are currently available: 

 

1. Topical Therapy 
2. Systemic Therapy 
3. Physical Treatment

 

1. Topical Therapy: Topical therapy is generally given in the treatment of mild to moderate acne. It can be used as monotherapy, in combination and also as maintenance therapy.

 

• Topical retinoids: Topical retinoids are comedolytic and anti-inflammatory medicines. They normalize follicular hyperproliferation and hyperkeratinization. Topical retinoids reduce the number of papules and pustules, and reduce the risk of worsening of acne. Topical retinoids should be initiated as first-line therapy for both papules, pustules and inflammatory acne lesions and should be continued as maintenance therapy to prevent further microcomedone formation.[7]

 

 

The most commonly prescribed topical retinoids for acne vulgaris include: 

Adapalene

Tazarotene 

Tretinoin

These retinoids should be applied to clean and dry skin once at night daily. The frequency of using these retinoids may need to be decreased if irritation occurs. Skin irritation accompanied with peeling and redness may be because of the early use of topical retinoids. This typically resolves within the first few weeks of use. The use of mild non-irritating cleansers and non-comedogenic moisturizers may help reduce this irritation. Alternate day dosing may be used if irritation persists.

Topical retinoids make the stratum corneum (outermost layer of skin, consisting of keratinized cells) thin and have been associated with sun sensitivity. Therefore, the patients are instructed to protect themselves from the sun.

 

• Topical antimicrobials: Use of topical antimicrobials is an effective way of treating acne. These work against P. acnes.[8]  

 

Topical antimicrobials include: 

 

Benzoyl peroxide:  Benzoyl peroxide is an oxidizing agent that possesses antibacterial properties and is comedolytic. Benzoyl peroxide products are also effective against C acnes (formerly P acnes). Bacterial resistance to benzoyl peroxide has not been reported. Benzoyl peroxide products are available over the counter and by prescription in a variety of topical forms, including soaps, washes, lotions, creams and gels. Benzoyl peroxide products may be used once or twice a day. These medicines may occasionally cause true allergic contact dermatitis. More often, an irritant contact dermatitis develops, especially if Benzoyl peroxide is used with tretinoin or when accompanied by aggressive washing methods. If intensive erythema and pruritus develop, a patch test with Benzoyl peroxide is indicated to rule out allergic contact dermatitis.

 

• Topical Antibiotics: Topical antibiotics are mainly used for their role against P. acnes. They may also have anti-inflammatory properties. Commonly prescribed topical antibiotics for acne vulgaris include:

Clindamycin

Erythromycin

Dapsone (most recent)

 

Topical dapsone is a sulfone antibiotic with anti-inflammatory properties that has been shown to be effective for mild to moderate acne. It has a convenient once daily and twice daily application schedule. The major drawback of topical antibiotics is that the body can develop bacterial resistance against antibiotics. Therefore, it is mostly used in combination with other medicines to support the treatment.

 

Topical clarithromycin, azithromycin and nadifloxacin are available in India but trials for their efficacy and safety are lacking.[6]

 

Antimicrobials should be combined with topical retinoids for better treatment and greater clearing of lesions.

 

Combination Therapies: The efficacy of benzoyl peroxide increases when it is used with topical antibiotics, namely, clindamycin and erythromycin.

Erythromycin and benzoyl peroxide 

Clindamycin and tretinoin

Clindamycin and benzoyl peroxide

Azelaic acid 

 

Azelaic acid has been shown to help reduce inflammation and may aid in the treatment of post-inflammatory hyperpigmentation. It is present in 10-20% topical creams which have been shown effective in inflammatory and comedonal acne.

 

2. Systemic Therapy: Patients with mild acne can be treated with topical treatment methods. However, those with moderate to severe acne require systemic treatment. The mainstay systemic therapies for acne are: 

Oral Antibiotics: Oral antibiotics are the mainstay of systemic treatment of moderate to severe acne. Following oral antibiotics are used:

Tetracycline 

Minocycline 

Doxycycline

Sarecycline

Trimethoprim/Sulfamethoxazole

Clindamycin

Daptomycin 

 

Long-term use of oral antibiotics should be avoided as it may lead to resistance as well as some other infections such as vaginal candidiasis.[9]

 

3. Hormonal Therapy: Hormonal agents provide effective second-line treatment in women with acne regardless of underlying hormonal abnormalities. A number of clinical studies illustrate that hormonal therapy is mainly effective for deep nodules on lower face or back. Estrogen can be used to decrease sebum production. Additionally, it reduces the production of ovarian androgens by suppressing the release of gonadotropins. Oral contraceptives also increase hepatic synthesis of sex hormone-binding globulin, resulting in an overall decrease in circulating free testosterone. Combination birth control pills have shown efficacy in the treatment of acne vulgaris.

 

Isotretinoin is a systemic retinoid that is highly effective in the treatment of severe, recalcitrant acne vulgaris. Isotretinoin causes normalization of epidermal differentiation, depresses sebum excretion by 70%, is anti-inflammatory, and even reduces the presence of C acnes (formerly P acnes). 

 

1. Comedone extraction
2. Chemical peels and microdermabrasion
3. Intra-lesion corticosteroid injection for acne cysts
4. High intensity, narrow-band blue light photodynamic therapy
5. Injectable filters 
6. Laser resurfacing 
7. Derma roller
8. Subcision
9. Platelet-rich plasma (PRP)[10]

 

1. Diet related changes

 

Healthy diet is always in! Food rich in zinc may reduce your chances of getting acne. [13]

Dairy products and foods with high sugar content (high GI food) may worsen your condition of acne.[11]

High GI foods increases the blood sugar which in turn rises the insulin levels. This can stimulate the oil glands and lead to acne outbreak. People eating low GI food have a lesser chance of getting acne in comparison to those who are taking high GI diet. Several observation studies suggest that few dairy products such as skimmed milk may aggravate acne. Dairy products may make small hormonal imbalance which leads to acne.[12]

 

There are very few evidences of any link between diet and acne.

As per our dermatologists, healthy diet and lifestyle is always good to reduce the chances of acne. 

 

If you already have acne, then to prevent its worsening you must avoid the following food items:

• Dairy products such as skimmed milk
• Sugar
• White bread
• White rice 

 

2. Skin-related tips: 

• Try not to pick or squeeze your spots. Doing this aggravates the acne and may cause scarring.
• Some topical treatments may dry or irritate the skin when you start using them. If your face goes red and is irritated by a lotion or cream, stop the treatment for a few days and try using the treatment less often and then resume gradually.
• Makeup may help you gain your confidence. Use products that are oil-free or water based. Choose products that are labelled as being ‘non-comedogenic’ (will not cause blackheads or whiteheads) or non-acnegenic (will not cause acne). 
• Cleanse your skin and remove makeup with a mild soap or a gentle cleanser and water or an oil-free soap substitute. Scrubbing too hard can irritate the skin and make your acne worse. Remember blackheads are not due to poor washing.[14]
• Stress: One should try staying relaxed as excessive stress can lead to fluctuation in hormones. These fluctuating hormones may lead to acne breakout. 

Prevention 

Some preventive and daily care tips for acne are:

• Clean your skin gently with a mild, non-drying soap. If your skin is oily and prone to acne using a face wash which contains salicylic acid or benzoyl can be helpful. Remove all dirt or makeup. 
• Wash once or twice a day and also after exercising. Avoid scrubbing or repeated skin washing. 
• Shampoo your hair daily, if it is oily.
• Avoid oil-based makeup.Avoid using rubbing alcohol or toners that are very drying to the skin.

 

Organ System: Skin

 

Acne scarring can sometimes develop as a complication of acne when the most serious types of spots, nodules and cysts rupture (burst), damaging the skin surrounding it. Scarring can also occur if you pick or squeeze your spots, so it is important to avoid doing this.

 

There are three main types of acne scars:

1. Ice-pick scars: These are small, deep holes in the surface of your skin that look as if the skin has been punctured with a sharp object.

2. Rolling scars: These are formed when the scar tissues accumulate under the skin, giving the surface of the skin a rolling and uneven appearance.

3. Boxcar scars: These are round or oval depressions or craters in the skin.

 

 

Dermatologist 

 

[1]Topics H. Acne [Internet]. National Institute of Arthritis and Musculoskeletal and Skin Diseases. 2016 [cited 19 January 2019]. Available from: https://www.niams.nih.gov/health-topics/acne#tab-risk

 

[2]Women More Likely Than Men To Be Affected By Acne As Adults [Internet]. ScienceDaily. 2007 [cited 9 January 2019]. Available from: https://www.sciencedaily.com/releases/2007/10/071019155627.htm

 

[3]Skroza N, Tolino E, Mambrin, A. Adult Acne Versus Adolescent Acne. The Journal of Clinical and Aesthetic Dermatology. 2018;11(1):21-25.

 

[4]U.S.National Library of Medicine.MedlinePlus.[Online]Available from:https://medlineplus.gov/ency/article/000873.h

 

[5]Dermnet.New Zealand.Investigations-in-acne[Online].Available from:

https://www.dermnetnz.org/topics/investigations-in-acne/

 

[6]Rathi KS.ACNE VULGARIS TREATMENT:THE CURRENT SCENARIO.Indian J Dermatol.2011.56(1);7-13.

 

[7]Retinoid therapy decreases the number of comedones and inflammatory lesions by 40%-70%. Haider A.Shaw JC.Treatment of acne vulgaris.JAMA.2004;292(6):726-35.

 

[8]Strauss JS,Krowchuk DP,Leyden JJ et al.Guidelines of care for Acne vulgaris management.J Am Acad Dermatol.2007.56(4):651-63.

 

[6]Rathi KS.ACNE VULGARIS TREATMENT:THE CURRENT SCENARIO.Indian J Dermatol.2011.56(1);7-13.

 

[9]Zaenglein AL,Pathy AL,Schlosser BJ et al. Guidelines of care for the management of acne vulgaris.J Am Acad Dermatol.2016.74(5):945-73.

 

[10]Kraft J,Freiman A.Management of Acne.CMAJ.2011.183(7):430-5.

 

[11]Smith RN,Mann NJ,Braue A et al.The effect of a high-protein, low glycemic-load diet versus a conventional, high glycemic-load diet on biochemical parameters associated with acne vulgaris: a randomized, investigator-masked, controlled trial.J Am Acad Dermatol.2007.57(2).247-56.

 

[12]Adebamowo CA,Spiegelman D,Berkey CS et al.Milk consumption and acne in teenaged boys.J Am Acad Dermatol.2008.58:787-93.

 

[13]Rostami MM,Safavi AN,Maleki N et al.Correlation between the severity and type of Acne Lesions with Serum Zinc Levels in Patients with Acne Vulgaris.Biomed Res intl.2014.474108.

 

[14]British Association of Dermatologists.[Online]Available from:http://www.bad.org.uk/shared/get-file.ashx?id=65&itemtype=document