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Part-II: Understanding Acne

2. What is Acne?

Pimples! We have all experienced those nasty, painful blots on our faces as teenagers, varying in size from the ultra-small and almost unnoticeable, to the big, attention-grabbing ones!

Pimples appear at all the wrong places, at equally wrong times. They invariably appear at the tip of our nose the night of the first date or the school prom. However, the outbreak of pimples is episodic, not continual. They merely require a few years of endurance and a lot of patience before disappearing altogether from our lives, remaining just an interesting part of the memories of our adolescent years.

However, there is another skin condition which is similar in some ways to that disorder, but more severe in its appearance. It occurs on various parts of the body besides the face, and is much more difficult to cure. It can appear at any time during a person’s life, although the disorder most often begins in adolescence. This dermatological condition is called Acne.

This book will, hopefully, give you the answers to all your questions, including:

• What is acne?

• What are the various forms of acne?

• How can you treat each of these disorders?

• What causes acne?

It will focus especially on the most severe forms of acne and the symptoms, and provide a comprehensive guide to the various treatment options available.

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Whether you are an anxious teenager, a forty-year old patient or a worried parent, the in-depth information on the condition will reduce your fears and help you negotiate your way through the worries that come with acne.

Definition of Acne

Acne is one of the most common skin disorders worldwide. It occurs on almost 45% teenagers and adults, and is seen in a smaller percentage of young children. Pimples, blackheads, whiteheads and lesions appear in the various oil-producing areas of the body; the face, back, chest, neck, shoulders and upper arms.

The main reason for this is an over-production of oil by the sebaceous glands in the skin. This causes the oil to combine with dead skin cells, which clogs the pores in that area. Scientists are focusing on the roles played by hormones, bacteria and genes that can increase the risk of developing acne.

Acne exists in several forms, including acne vulgaris, acne fulminans and acne conglobata. Each differs in its cause, severity and prognosis. Some forms cannot be successfully treated but most acne is completely curable.

With the wide range of treatment options available today, ranging from topical ointments to surgical procedures, the best treatment depends upon the type and severity of the condition. Nonprescription drugs, such as topical medications, may cure some forms but oral medications or even surgery may be required for others.

Patients with moderate to severe acne must consult with a qualified doctor or a dermatologist who will help them to decide the most suitable treatment combinations for them.

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3. Who Develops Acne?

Acne affects millions of people all over the world. The statistical distribution of the condition, by age and gender is:

1 85% of adolescents and pre-adolescents are affected by acne.

2 The condition occurs on some children under 10 years of age.

3 Boys are more likely to have a severe form of the disease than teenage girls.

4 About 12% of women between 22 and 45 years of age are affected by acne.

5 About 3% of all men are affected during their adult life.

6 Women are more prone to acne during adulthood because of premenstrual hormonal changes as well as consistent use of cosmetics.

7 The incidences of acne reduce sharply after the age of 45.

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4. What is the Real Cause of Acne?

For most people, acne begins during adolescence. One of the main reasons is the excessive production of sebum due to the higher levels of sex hormones in the body during puberty.

To understand the various factors which cause acne, we need a brief insight into the anatomy of the skin surface; the hair follicles, as well as the production and role of sebum.

Here is some background before we get to the actual causes.

The Hair Follicle and the Sebaceous Glands

There are many hair follicles on our skin. The sebaceous glands (oil glands) exist near the surface of the skin and open into the hair follicles. The oil, or sebum, which they produce constantly, enters the follicle. This helps in protecting the skin from drying out.

Overproduction of sebum is a major factor in the development of acne. Before covering the various causes of acne, here is information about the production, role and regulation of sebum.

Sebum

Sebum, an oily and complex mixture of lipids (a group of fats and similar compounds including waxes, oils, sterols, triglycerides, phosphatides and phospholipids), is produced by the sebaceous glands.

Sebaceous glands exist over almost all of the body, but especially on the forehead, chin and back.

Cells in these glands disintegrate in about a week and produce sebum. The rate of production depends on age and gender:

1 Adult females produce less sebum than adult males

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3 Sebum production declines significantly with age

4 Production of sebum also falls steeply in women after menopause

Hormonal control of sebum

The sex hormones, or androgens, stimulate the cells in the sebaceous glands to produce sebum.

The testis in males, the ovaries in females and the adrenal glands produce these hormones.

The androgens that influence the production of sebum the most are:

1 5-testosterone (DHT)

2 5-androstene-317diol

Role of Sebum

Some of the functions of sebum are:

1 It acts as a protective barrier against bacteria and fungi.

2 It helps to reduce excessive water loss from the surface of the skin.

It is an environment that supports the bacteria Proprionibacterium acnes, which researchers believe may play an important role in the regulation of the immune system.

With your new insight into the working of sebaceous glands and the production of sebum, you will understand the factors that cause acne more easily.

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Why Do We Get Acne?

Acne develops when the sebaceous glands in a person's skin start producing excessive levels of sebum. This oil combines with the cells lining the walls of the glands and clog the skin's pores, plugging them. This plug can enlarge and rupture the hair follicle, so that the follicle spills the oil and debris on to the skin. This causes inflammation and swelling.

Various factors can cause an increase in the production of sebum, including:

Hormones: There is a sudden surge in the level of hormones at puberty. These hormones react with the skin to form dihydrotestosterone, or DHT, which makes the sebaceous glands increase in size. It also stimulates these glands to increase the production of sebum. The increase in sebum leads to the plugging of hair follicles, which eventually leads to the development of acne.

Hormones in Women: At puberty, an increase in the production of estrogen results in menses.

The menstrual cycle results from changes in the levels of estrogen. The severity of acne differs as she goes through her monthly cycle.

Bacteria in acne: Propionibacterium acnes are bacteria found commonly on the surface of the skin, as well as in pimples. With the onset of puberty, the bacteria increase. Other types of bacteria, such as Proprionibacterium granulosum and Staphylococcus epidermidis can also be found at this time. It has been found that people with an excessive production of sebum have more bacteria on their skin, but the link between bacteria and acne has not been discovered yet.

Medications: Acne can sometimes occur as a reaction to a particular drug. This type of acne typically clears up as soon as the medication is discontinued.

Pregnancy: Pregnant women usually develop acne, due to a rise in the levels of hormones in their body. However, their acne clears up soon after the birth of the baby. Newborn babies have acne at times as well. This can be due to the stress of birth or because some hormones from the mother may have permeated the umbilical cord and passed to the baby.

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Endocrine disorders: Less frequently, acne is found in young children and old people. This could be due to a rare disorder of their endocrine system.

Genes: Researchers have found evidence that genes may play a vital role in causing acne. It has been found that children whose parents had acne in their childhood are much more likely to develop acne. In addition, the severity of their acne was similar to the severity of their parents'

acne.

Hypersensitivity to P. acnes: Acne fulminans, an extremely severe form of acne, can be caused due to a body’s hypersensitivity to the bacteria P. acnes.

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5. Types of Acne Lesions

We often get confused with the terminology when we read about acne. For example, the different types of lesions like papules, cysts and comedones or the meaning of the word lesion itself. These definitions should help you in learning about your specific need for treatment.

Lesions- Any physical change in the body tissues caused by a disease or an injury is called a lesion. This may be either external (like acne, skin cancer, or even a knife cut) or internal (like lung cancer or liver cirrhosis). An acne lesion is a physical change caused by a diseased process in the sebaceous follicle.

Comedo lesions- Comedones (plural of comedo) are skin-colored, small bumps that are most commonly found on the chin and forehead of those who suffer with acne. A comedo is a sebaceous follicle. Dead cells from this follicle, sebum, tiny hairs and even small bacteria sometimes plug the sebaceous follicle. The cells lining the sebaceous duct proliferate in acne (this is called cornification) and the result is formation of a comedo.

Some are so small that they may not be visible to the naked eye; these are called

‘microcomedones.’ An open comedo is called a blackhead because the surface of the plug appears black due to exposure to air. A closed comedo that appears as a bump in the skin is called a whitehead. Whiteheads and blackheads should only be extracted under sterile conditions by a qualified dermatologist. If whiteheads and blackheads are squeezed or picked, staphylococci, streptococci and other skin bacteria could infect the area.

Papule- A localized cellular reaction to acne produces a papule. It is a small, solid lesion elevated above the surface of the skin. Although a group of papules and microcomedomes may be invisible to the naked eye, they may give a ‘sandpaper’ feel to the touch.

Macule- A macule is a temporary red, or red-pink, spot that is left after the acne has healed. This has a well-defined border and may stay for many days before disappearing.

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Pustule- A pustule is a fragile, dome-shaped lesion that contains pus (white blood cells, bacteria and dead cells). If a pustule does not worsen into a cyst, it does not leave a scar.

Cyst- A cyst is a severe form of acne, a sac-like lesion containing white blood cells, bacteria and dead cells in a liquid or a semi-liquid form. This is inflammatory and may damage the deeper layers of the skin and cause scarring. Treatments for this lesion are usually not very effective. It is usually very painful.

Nodule- A nodule is the most severe form of acne and sufferers should seek therapies like isotretitnoin. A nodule is a solid, irregularly shaped lesion. It is inflammatory and may penetrate the deeper layers of the skin, causing tissue destruction and scarring. A nodule is generally very painful.

A nodule and a cyst often occur together. That form of acne is called nodulocystic acne.

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6. Scars and Stripes - Scarring in Acne

In teenagers, as well as adults, severe acne can lead to atrophic, or pit-like, scars in the affected area. This can be the source of a huge inferiority complex and leads to depression in many people.

This section describes:

• How to define scarring

• The various types of scars that result from the different kinds of acne … and

• Are they treatable?

Definition

The human body is tuned to respond to any foreign body or abnormal change, whether in it or outside, in a similar way to how an animal would attack an intruder encroaching upon its territory. The body automatically acts to ‘normalize’, or heal the change that took place in it.

For example, if the body receives an external injury, it immediately initiates production of clotting to heal the wound. The body instigates a similar healing process when scarring occurs.

In biological terms, ‘scarring’ is the fibrous process that initiates production of collagen to heal the acne-induced changes in the body.

People suffering from either moderate or severe forms of acne vulgaris (e.g. acne fulminans, acne conglobata) are particularly prone to scarring or pigmentation. Hence, it is advisable for patients suffering from severe acne to seek immediate treatment that will reduce their chances of developing deep, or untreatable, scars.

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Types of Scars

I. Color changes due to inflammatory lesions

The healing of inflammatory acne lesions can lead to the emergence of patches of pigmentation in the affected area. These changes in skin color are temporary and curable. With the right treatment, the patches disappear after a few months and do not recur.

The color changes are classified into three types:

(1) Post- inflammatory pigmentation: Results in brown pigmentation

(2) Post- inflammatory hypopigmentation: White marks appear on the skin (3) Post- inflammatory erythema: Purple, or pink, patches are seen.

Treatment for post- inflammatory pigmentation

Treatment options for post-inflammatory pigmentation include:

Chemical peel-offs: These are face packs with glycolic acid or Jessner’s solution added to them.

Azelaic acid cream: This cream, also prescribed for treating moderate acne, is successful in treating pigmentation.

Protection from the sun: Brown marks darken under moderate to excessive exposure to the sun.

Always apply an oil-free sunscreen with an SPF of 15 or more before going out of the house.

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II. Physical disfigurations in the form of pits or lumps

Severe acne causes three kinds of scarring. These are -

1. Ice Pick scars: Appear as a series of small pits.

2. Hypertrophic/ Keloid scars: Extremely thick, lumpy scars that protrude from the skin.

3. Atrophic scars: In contrast to keloid scars, atrophic scars are thin, flat scars.

Treatment Options

There are various treatment options for each type of scar. Most scars heal completely with the right treatment, though it may take many months for this to occur. However, in a few cases, the scar recurs, even after being successfully treated.

Here are the different ways in which the three kinds of scars can be treated. For details on the procedures, please refer to the Section on Treatment.

1. Ice pick scars can be treated by:

1 Dermabrasion

2 Cutting out larger scars

3 Laser resurfacing

2. Atrophic scars:

1 Dermabrasion

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2 Increasing the soft tissue through fat or collagen implants

3. Hypertrophic, or keloid scars, are the most difficult of the three to treat successfully. Despite apparently effective treatment, the scars are liable to recur within a short time.

Treatments that can be used are -

1 Dressing of scars with silicone gel

2 Application of strong topical steroids

3 Steroidal injections in the lesions

4 Cryotherapy (Cold therapy)

5 Surgery

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7. Seborrhea Due to Hormonal Changes

Seborrhea refers to a condition where the sebaceous glands produce high quantities of oil (or sebum) and the skin becomes excessively oily. The ailment is common in both men and women.

The person suffering from seborrhea complains of unpleasant and excessively oily skin. This may lead to acne or seborrheic dermatitis. It may, rarely, also lead to Parkinson’s disease and acromegaly. A doctor should be consulted at the first sign of the condition and treatment begun immediately.

Causes of High Levels of Androgens in Women

Statistics reveal that about half of the women who suffer from acne have a hormonal imbalance.

Some causes of high levels of male sex hormones in women are:

Disease of the Pituitary Gland -

Acromegaly (gigantism)

Problems in lactation (galactorrhoea) due to tumor-producing prolactin

'Moon face’, stretch marks, tiredness and/or easy bruising due to excessive ACTH

(adrenocorticotrophic hormone)

Disease of the Adrenal Gland -

Benign, or malignant, adrenal tumors

Partial deficiency of enzyme 21- hydroxylase

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Disease of the ovaries -

Benign, or malignant, ovarian tumors

Infertility, irregular menstruation and hirsutism (abnormal growth of hair) caused by Polycystic ovarian syndrome

Obesity- Body fat also results in the synthesis of more androgens.

Any of the conditions listed above can stimulate the sebaceous glands and lead to seborrhea.

While diagnosing acne, doctors must check for signs of any of these disorders as the underlying cause of the acne and even perform a laboratory analysis to rule them out.

If any of the above conditions is the cause of acne, it should be tackled first.

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8. Factors Which Aggravate Acne

Some of the factors that can aggravate acne are -

Genetic Factors - If a person’s parents had severe acne, they may also suffer bad acne.

Stress- Like a lot of other health problems, acne also may be caused by severe stress.

Hormonal Factors - If a person has a high level of androgenic hormones, due to any of the following reasons, it may lead to acne.

- Enzyme deficiency

- Polycystic ovaries

- Excessive corticosteroids

- Certain medicines

Clothes or other equipment rubbing against the body - Wearing tight straps, headbands, chinstraps, turtleneck sweaters or bra straps may make acne worse. Wearing equipment like helmets, shoulder pads, or holding a violin between your chin and neck may also make the acne get worse.

- Using harsh soap or very hot water may also aggravate acne.

- Rubbing your face too often or too hard can make the acne get worse.

- Sweating too much may also be an aggravating factor.

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Acne Lesions

The two types of acne are inflammatory and non-inflammatory. Blackheads, or open comedones, and whiteheads, or closed comedones, are examples of non-inflammatory acne.

Nodular acne is an example of inflammatory acne.

Inflammatory acne

Inflammatory acne includes pimples (or ‘zits’), red blemishes and deeper, swollen lesions called nodules.

1 Pustules are closed comedones that become inflamed and then begin to rupture into the skin. Then, they form pustular heads of different sizes.

2 Papules are closed comedones that become swollen, red and then inflamed.

3 Nodules are the most severe form of acne and can produce scarring if they are not treated in time. These are large, swollen and tender acne lesions. They become intensely inflamed and rupture under the skin. Proper treatment should be sought quickly for them.

Non-Inflammatory acne

Non-Inflammatory acne is of two types; blackheads and whiteheads.

1 Open comedones are enlargement of the plug formed by oil and flakes of skin inside the hair follicle.

2 A closed comedo is formed if the hair follicle plug is not exposed to outside air and, thus, no black color develops. It appears as a tiny, pink bump on the skin.

3 If, however, the plug is exposed to outside air, the oil inside the plug turns black (the black color is not due to dust) and is known as a blackhead.

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9. Acne Vulgaris

A cne vulgaris is the most commonly-occurring type of acne in adolescents and young adults worldwide. Affecting almost 90% of people at some point in their lives, the condition usually starts at puberty and may become more severe in adulthood. It mostly affects the face, the back and the upper chest. This dermatological condition is characterized by the following kinds of lesions –

1 Non-inflammatory nodules (cysts), open comedones (blackheads) and closed comedones (whiteheads) in its mild to moderate forms

2 Inflammatory papules, nodules and pustules in its severe forms

3 Macules (dark scars seen on dark skin)

4 Erythematous macules (reddish-colored scars from recently healed blemishes, seen mostly in fair-skinned people)

These lesions may disappear without any treatment after a few weeks. However, more severe forms of acne require extensive treatment and may take a few months to a few years to heal.

Pathophysiology of Acne vulgaris

Acne lesions develop in the following four stages –

1 Follicular epidermal hyperproliferation (rapid multiplying of cells) and

hyperkeratinization (cells convert to keratin, a natural part of the hair, too fast and clump wrongly, causing acne or keratosis pilaris).

2 Excess sebum

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3 Propionibacterium acnes

4 Inflammation

Frequency: Acne vulgaris affects 85-95% of people worldwide at some point in their lives. It is one of the most commonly occurring dermatological disorders in the world. Acne vulgaris seems to strike people of all races in equal ratios.

Gender: Acne develops in girls between the ages of 10 to 18 years. In boys, acne usually develops between the ages of 14 to 20 years.

1 Acne vulgaris affects a larger number of boys than girls during adolescence.

2 There is a reversal after adolescence; a greater number of women than men have acne during adulthood.

Causes: Acne vu

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