Acne

Definition

Acne is a common inflammatory skin disease characterized by pimples on the face, chest, and back. It occurs when the pores of the skin become clogged with oil, dead skin cells, and/or bacteria.

Description

Acne vulgaris, the medical term for common acne, is the most common skin disease. It affects nearly 17 million people in the United States. While acne can arise at any age, it usually begins at puberty and worsens during adolescence. Nearly 85% of people develop acne some time between the ages of 12 and 25 years old. Up to 20% of women develop mild acne. It is also found in some newborns.

The sebaceous glands lie just beneath the skin's surface. They produce sebum, an oily secretion that helps to preserve the flexibility of the hair and moisturizes the skin. These glands and the hair follicles within which they are found are called sebaceous follicles. These follicles open onto the skin through pores that allow the sebum to reach the hair shaft and the skin. In certain situations, the glands excrete excess sebum and it cannot be cleared from the pores efficiently. This happens, for instance, at puberty when increased levels of the androgen hormones cause overproduction of sebum. In addition, cells lining the follicle are shed too quickly and begin to clump together. The excess sebum combines with the dead cells and forms a plug, or comedo (also called comedones), that blocks the pore, which is not usually seen. When the follicle begins to bulge and show up as a small whitish bump mostly under the skin, it is called a whitehead. If the comedo opens up, the top surface of the plug darkens, and it is referred to as a blackhead.

Infection results when a plugged follicle is invaded by Propionibacterium acnes, a bacteria that normally lives on the skin, and possibly other microorganisms. The bacteria produce chemicals and enzymes that bring on inflammation. Pimples are the result of infected blackheads or whiteheads that rupture, releasing sebum, bacteria, dead skin, and white blood cells onto the surrounding tissues. Inflamed pimples near the skin's surface are called papules; they are red and raised, and may be quite tender to the touch. The papules may become filled with pus, and are then called pustules. If the follicle continues to enlarge rather than rupture, it forms a closed sac, called a cyst, which can be felt as a lump under the skin. Large hard swellings deep within the skin

are called nodules. Both nodules and cysts may cause pain and scarring.

Causes & symptoms

The exact cause of acne is mostly unknown. Sometimes when acne in women is due to excess male hormone production, it is diagnosed by an onset of the condition in adulthood; excessive growth of hair, especially in places not usual on a female, called hirsuitism; irregular menstrual cycles; and premenstrual flare-ups of acne. A 2001 study demonstrated that menstrual cycle does affect acne. Surprisingly, the study revealed that 53% of women over age 33 experienced a higher premenstrual acne rate than women under age 20.

Many alternative practitioners assert that acne is often related to a condition of toxicity in the intestines or liver. This may be due to the presence of bacteria such as Clostridia spp. and Yersinia enterocolitica, a low-fiber diet; a lack of friendly gut flora such as Lactobacillus spp.; an intestinal overgrowth of Candida albicans; and food allergies .

The interaction between the body's hormones, skin protein, skin secretions, and bacteria determines the course of acne. Several other factors have also been shown to affect the condition:

• Age. Teenagers are more likely than anyone to develop acne.
• Gender. Boys have more severe acne and develop it more often than girls.
• Disease. Hormonal disorders can complicate acne in girls.
• Heredity. Individuals with a family history of acne have greater susceptibility to the condition.
• Hormonal changes. Acne can flare up before menstruation , during pregnancy , and menopause.
• Diet. Although they are not the primary cause of acne, certain foods may bring on flare-ups or make the condition worse.
• Drugs. Acne can be a side effect of antibiotics, oral contraceptives, and anabolic steroids.
• Personal hygiene. Use of abrasive soaps, hard scrubbing of the face, or handling pimples will often make them worse.
• Cosmetics. Oil-based makeup and hair sprays worsen acne.
• Environment. Exposure to oils and greases, polluted air, and sweating in hot weather can all aggravate acne.
• Stress . Emotional stress may contribute to acne.
• Friction. Continual pressure or rubbing on the skin by such things as bicycle helmets, backpacks, or tight clothing, as well as hard scrubbing of the skin, can worsen acne.

The most common sites of acne are the face, chest, shoulders, and back, since these are the parts of the body where the most sebaceous follicles are found. In teenagers, acne is often found on the forehead, nose, and chin. As people get older, it tends to appear towards the outer part of the face. Adult women may have acne on their chins and around their mouths. The elderly often develop whiteheads and blackheads on the upper cheeks and skin around the eyes. Inflamed lesions may cause redness, pain, tenderness, itching , or swelling in affected areas.

Diagnosis

Acne has a characteristic appearance and is, therefore, not difficult to diagnose. A complete medical history should be taken, including questions about skin care, diet, factors that improve or worsen the condition, medication use, and prior treatment. Physical examination includes the face, upper neck, chest, shoulders, back, and other affected areas. Under good lighting, the doctor can determine what types and how many blemishes are present, whether they are inflamed, whether they are deep or superficial, and whether there is scarring or skin discoloration. Blood tests are done when the patient appears to have hormonal or other medical problems. Stool tests can be helpful in determining whether there is a bacterial or yeast overgrowth contributing to the condition. Food allergy testing should also be considered.

Treatment

Alternative treatments for acne focus on proper cleansing to keep the skin oil-free; intermittent fasting ; eating a good diet; an elimination diet where the individual avoids alcohol, dairy products, smoking, caffeine , sugar, processed foods, and foods high in iodine , a mineral which appears to contribute to acne.

Supplementation with herbs that are blood cleansers or blood purifiers is recommended. These herbs strengthen the action of the liver and the kidneys, helping with detoxification and excretion. Dandelion root tincture (Taraxacum officinale ) is recommended. Others include burdock root (Arctium lappa ), also known as gobo, and can be purchased fresh at health food grocers or in Asian markets. It can be used either raw or cooked in salads, stir-fries, or other vegetable dishes. Burdock root tincture can also be used. Red clover (Trifolium pratense ) makes a pleasant tea that can be consumed throughout the day. Milk thistle seed (Silybum marianum ) can either be taken in tincture form or the seeds can be ground up and eaten in combination with hot cereal, granola, or other foods.

Other herbs useful in the treatment of acne include Echinacea spp. and goldenseal (Hydrastis canadensis ). Goldenseal is particularly helpful in clearing up underlying conditions of intestinal toxicity. Herbal remedies used in traditional Chinese medicine (TCM) for acne include cnidium seed, (Cnidium monnieri), and honeysuckle flower (Lonicera japonica ). Supplementation nutrients, such as essential fatty acids (EFAs), vitamin B complex, zinc, vitamin A or beta-carotene, and chromium are also recommended.

Bowel toxicity may contribute to acne flare-ups, and should be addressed. Lactobacillus acidophilus and Lactobacillus bulgaricus should be taken in yogurt or in capsules to maintain a healthy balance of intestinal flora. Goldenseal can be used to kill toxic bacteria. Allergic foods should be identified and removed from the diet. Dietary fiber, such as oats and wheat bran, beans, fruits and vegetables and their skins, and psyllium seed, should be increased in the diet. The fiber will absorb toxins and carry them through the colon to be excreted.

In addition, those with acne may want to participate in movement therapy , such as yoga or t'ai chi , or begin an exercise regimen. The person may also consider stress reduction or meditation .

Allopathic treatment

Acne treatment consists of reducing sebum and keratin production, encouraging the shedding of dead skin cells to help unclog the pores, and killing or limiting bacteria. Treatment choice depends upon whether the acne is mild, moderate, or severe. Complicated cases are referred to a dermatologist, or an endocrinologist, who treats diseases of the glands and the hormones. Counseling may be necessary to clear up misconceptions about the condition and to offer support regarding the negative effect of acne on the physical appearance.

Topical drugs

Treatment for mild acne consists of reducing the formation of new comedones with over-the-counter acne medications containing benzoyl peroxide (e.g., Clearasil, Fostex), salicylic acid (Stridex), sulfur (Therac lotion), resorcinol (Acnomel cream). Treatment with stronger medications requires a doctor's supervision. Such medications include comedolytics, which are agents that loosen hard plugs and open pores. Adapalene (Differin), the vitamin A acid tretinoin (Retin-A), and concentrated versions of salicylic acid, resorcinol, and sulfur are in this group. Topical antibiotics, such as erythromycin, clindamycin (Cleocin-T), and meclocycline (Meclan), may be added to the treatment regimen. Drugs that act as both comedolytics and antibiotics, such as benzoyl peroxide, azelaic acid (Azelex), or benzoyl peroxide plus erythromycin (Benzamycin), are also used.

After washing with a mild soap, the acne medications are applied alone or in combination, once or twice a day over the entire affected area of skin. It may take many months to years to control the condition with these medications. Possible side effects include mild redness, peeling, irritation, dryness, and an increased sensitivity to sunlight that requires use of a sunscreen.

Oral drugs

When acne is severe and the lesions are deep, oral antibiotics may be taken daily to reduce the spread of bacteria. Tetracycline is the medication most often used. Minocycline, however, may be more preferable because it has fewer side effects. Erythromycin and doxycycline are also used, and they also have side effects, including dizziness , photosensitivity, gastrointestinal problems, and darkening of the skin. Other possible side effects include allergic reactions, yeast infections , dizziness, tooth discoloration, and folliculitis. It is necessary for antibiotics to be used for up to three months to clear up the condition.

Isotretinoin (Accutane) can be used in cases of very severe acne, or if antibiotic therapy proves unsuccessful. It may clear up resistant cysts and nodules in up to 90% of people and prevent scarring. Some do require a second course of treatment before this happens, however. Although the medication can be quite helpful, women who might become pregnant should use it with care. Isotretinoin can cause birth defects up to a month after it has stopped being used. Therefore, strict attention is paid to pregnancy tests and contraceptive requirements for women of child-bearing age who take this medication.

The course of treatment with isotretinoin lasts about four to five months. If dosage is kept low, a longer course of therapy is needed. Isotretinoin is a strong medication. Side effects are very common, mostly dryness of the eyes, genital mucosa, and lips. Other effects may include increases in cholesterol , tryglicerides, and abnormal liver enzymes. Blood tests taken each month should be monitored during the course of treatment to ensure that the medication is not causing serious harm.

Anti-androgens, drugs that inhibit androgen production, are used to treat women who are unresponsive to other therapies. Oral contraceptives such as norgestimate/ethinyl estradiol (Ortho-Tri-Cyclen) have been shown to improve acne. In late 2001, a clinical trial demonstrated that ultra low-dose birth control pills (Alesse) prove as effective in treating acne as do pills with higher doses of estrogen. Improvement may take up to four months.

Other drugs, such as spironolactone and corticosteroids, may be used to reduce hormone activity in the adrenal glands, reducing production of sebum. This is the treatment of choice for an extremely severe, but rare type of acne called acne fulminans, found mostly in adolescent males. Acne conglobata, a more common form of severe inflammation, is characterized by numerous, deep, inflammatory nodules that heal with scarring. It is treated with oral isotretinoin and corticosteroids.

Other types of treatment

Several surgical or medical treatments are available to alleviate acne or the resulting scars:

• Comedone extraction. The comedo is removed from the pore with a special tool.
• Chemical peels. Glycolic acid is applied to peel off the top layer of skin to reduce scarring.
• Dermabrasion. The affected skin is frozen with a chemical spray, and removed by brushing or planing.
• Punch grafting. Deep scars are excised and the area repaired with small skin grafts.
• Intralesional injection. Corticosteroids are injected directly into inflamed pimples.
• Collagen injection. Shallow scars are elevated by collagen protein injections.
• Laser treatments. Two types of laser treatments are proving effective in treating acne scars. Laser-treated skin heals in three to 10 days, depending on the treatment chosen.

Expected results

Most dermatologists now use a combination of therapies to treat acne, depending on the individual. Results of specific treatments will vary. Acne is not a serious health threat. The most troubling aspects of this condition are the negative cosmetic effects and potential for permanent scarring. Some people, especially teenagers, become emotionally upset about their condition, and this may contribute to social or emotional problems.

Acne is not considered curable, although it can be controlled by proper treatment, with improvement possibly taking many months. Acne tends to reappear when treatment stops, but it often spontaneously improves over time. Inflammatory acne may leave scars that require further treatment.

KEY TERMS

Follicles

—Structures where pimples form. They are found within the skin and house the oil glands and hair.

Prevention

There are no sure ways to prevent acne, but the following steps may be taken to minimize flare-ups:

• Gentle washing of affected areas once or twice every day.
• Avoidance of abrasive cleansers.
• Limited use of makeup and moisturizers; with avoidance of oil-based brands altogether.
• Oily hair should be shampooed often and worn up, away from the face.
• A healthy, well-balanced diet should be eaten. Fresh fruits and vegetables should be stressed, and foods that seem to trigger flare-ups should be avoided.
• The face can be washed gently, twice daily with a soap compounded of sulfur, Calendula officinalis, or other substances that are useful against acne.
• Affected areas should not be handled excessively. Pimples should not be squeezed or prodded, as this may contribute to scarring, as well as spreading the acne lesions.
• Emotional stress should be kept in check.

Resources

BOOKS

Murray, Michael, and Joseph Pizzorno. Encyclopedia of Natural Medicine. 2nd ed. California: Prima Publishing, 1998.

Tierney Jr., Lawrence M., et al, eds. Current Medical Diagnosis and Treatment 2003. 42nd ed. Connecticut: Appleton & Lange, 2002.

PERIODICALS

"Combination Therapies Offer New Management Options for Acne." Medical Devices and Surgical Technology Week (December 9, 2001): 13.

"Monthly Hormonal Changes in Menstrual Cyclel Affect Flare-ups." Health and Medicine Week (December 31, 2001): 4.

"Ultra Low-Dose Estrogen Birth Control Pill is Effective Treatment." Women's Health Weekly (October 4, 2001).

OTHER

Merck & Co., Inc. The Merck Manual Online. December 28, 2000 [cited October 2002]. <http://www.merck.com>.

Patience Paradox

Acne

Definition

Acne is a common skin disease characterized by pimples on the face, chest, and back. It occurs when the pores of the skin become clogged with oil, dead skin cells, and bacteria.

Description

Acne vulgaris, the medical term for common acne, is the most common skin disease. It affects nearly 17 million people in the United States. While acne can arise at any age, it usually begins at puberty and worsens during adolescence. Nearly 85% of people develop acne at some time between the ages of 12-25 years. Up to 20% of women develop mild acne. It is also found in some newborns.

The sebaceous glands lie just beneath the skin's surface. They produce an oil called sebum, the skin's natural moisturizer. These glands and the hair follicles within which they are found are called sebaceous follicles. These follicles open onto the skin through pores. At puberty, increased levels of androgens (male hormones) cause the glands to produce too much sebum. When excess sebum combines with dead, sticky skin cells, a hard plug, or comedo, forms that blocks the pore. Mild noninflammatory acne consists of the two types of comedones, whiteheads and blackheads.

Moderate and severe inflammatory types of acne result after the plugged follicle is invaded by Propionibacterium acnes, a bacteria that normally lives on the skin. A pimple forms when the damaged follicle weakens and bursts open, releasing sebum, bacteria, and skin and white blood cells into the surrounding tissues. Inflamed pimples near the skin's surface are called papules; when deeper, they are called pustules. The most severe type of acne consists of cysts (closed sacs) and nodules (hard swellings). Scarring occurs when new skin cells are laid down to replace damaged cells.

The most common sites of acne are the face, chest, shoulders, and back since these are the parts of the body where the most sebaceous follicles are found.

Causes and symptoms

The exact cause of acne is unknown. Several risk factors have been identified:

• Age. Due to the hormonal changes they experience, teenagers are more likely to develop acne.
• Gender. Boys have more severe acne and develop it more often than girls.
• Disease. Hormonal disorders can complicate acne in girls.
• Heredity. Individuals with a family history of acne have greater susceptibility to the disease.
• Hormonal changes. Acne can flare up before menstruation, during pregnancy, and menopause.

• Diet. No foods cause acne, but certain foods may cause flare-ups.
• Drugs. Acne can be a side effect of drugs including tranquilizers, antidepressants, antibiotics, oral contraceptives, and anabolic steroids.
• Personal hygiene. Abrasive soaps, hard scrubbing, or picking at pimples will make them worse.
• Cosmetics. Oil-based makeup and hair sprays worsen acne.
• Environment. Exposure to oils and greases, polluted air, and sweating in hot weather aggravate acne.
• Stress. Emotional stress may contribute to acne.

Acne is usually not conspicuous, although inflamed lesions may cause pain, tenderness, itching, or swelling. The most troubling aspects of these lesions are the negative cosmetic effects and potential for scarring. Some people, especially teenagers, become emotionally upset about their condition, and have problems forming relationships or keeping jobs.

Diagnosis

Acne patients are often treated by family doctors. Complicated cases are referred to a dermatologist, a skin disease specialist, or an endocrinologist, a specialist who treats diseases of the body's endocrine (hormones and glands) system.

KEY TERMS

Androgens— Male sex hormones that are linked with the development of acne.

Antiandrogens— Drugs that inhibit the production of androgens.

Antibiotics— Medicines that kill bacteria.

Comedo— A hard plug composed of sebum and dead skin cells. The mildest type of acne.

Comedolytic— Drugs that break up comedones and open clogged pores.

Corticosteroids— A group of hormones produced by the adrenal glands with different functions, including regulation of fluid balance, androgen activity, and reaction to inflammation.

Estrogens— Hormones produced by the ovaries, the female sex glands.

Isotretinoin— A drug that decreases sebum production and dries up acne pimples.

Sebaceous follicles— A structure found within the skin that houses the oil-producing glands and hair follicles, where pimples form.

Sebum— An oily skin moisturizer produced by sebaceous glands.

Tretinoin— A drug that works by increasing the turnover (death and replacement) of skin cells.

Acne has a characteristic appearance and is not difficult to diagnose. The doctor takes a complete medical history, including questions about skin care, diet, factors causing flare-ups, medication use, and prior treatment. Physical examination includes the face, upper neck, chest, shoulders, back, and other affected areas. Under good lighting, the doctor determines what types and how many blemishes are present, whether they are inflamed, whether they are deep or superficial, and whether there is scarring or skin discoloration.

In teenagers, acne is often found on the forehead, nose, and chin. As people get older, acne tends to appear towards the outer part of the face. Adult women may have acne on their chins and around their mouths. The elderly may develop whiteheads and blackheads on the upper cheeks and skin around the eyes.

Laboratory tests are not done unless the patient appears to have a hormonal disorder or other medical problem. In this case, blood analyses or other tests may be ordered. Most insurance plans cover the costs of diagnosing and treating acne.

Treatment

Acne treatment consists of reducing sebum production, removing dead skin cells, and killing bacteria with topical drugs and oral medications. Treatment choice depends upon whether the acne is mild, moderate, or severe.

Drugs

TOPICAL DRUGS. Treatment for mild noninflammatory acne consists of reducing the formation of new comedones with topical tretinoin, benzoyl peroxide, adapalene, or salicylic acid. Tretinoin is especially effective because it increases turnover (death and replacement) of skin cells. When complicated by inflammation, topical antibiotics may be added to the treatment regimen. Improvement is usually seen in two to four weeks.

Topical medications are available as cream, gel, lotion, or pad preparations of varying strengths. They include antibiotics (agents that kill bacteria), such as erythromycin, clindamycin (Cleocin-T), and meclocycline (Meclan); comedolytics (agents that loosen hard plugs and open pores) such as the vitamin A acid tretinoin (Retin-A), salicylic acid, adapalene (Differin), resorcinol, and sulfur. Drugs that act as both comedolytics and antibiotics, such as benzoyl peroxide, azelaic acid (Azelex), or benzoyl peroxide plus erythromycin (Benzamycin), are also used. These drugs may be used for months to years to achieve disease control.

After washing with mild soap, the drugs are applied alone or in combination, once or twice a day over the entire affected area of skin. Possible side effects include mild redness, peeling, irritation, dryness, and an increased sensitivity to sunlight that requires use of a sunscreen.

ORAL DRUGS. Oral antibiotics are taken daily for two to four months. The drugs used include tetracycline, erythromycin, minocycline (Minocin), doxycycline, clindamycin (Cleocin), and trimethoprim-sulfamethoxazole (Bactrim, Septra). Possible side effects include allergic reactions, stomach upset, vaginal yeast infections, dizziness, and tooth discoloration.

The goal of treating moderate acne is to decrease inflammation and prevent new comedone formation. One effective treatment is topical tretinoin along with a topical or oral antibiotic. A combination of topical benzoyl peroxide and erythromycin is also very effective. Improvement is normally seen within four to six weeks, but treatment is maintained for at least two to four months.

A drug reserved for the treatment of severe acne, oral isotretinoin (Accutane), reduces sebum production and cell stickiness. It is the treatment of choice for severe acne with cysts and nodules, and is used with or without topical or oral antibiotics. Taken for four to five months, it provides long-term disease control in up to 60% of patients. If the acne reappears, another course of isotretinoin may be needed by about 20% of patients, while another 20% may do well with topical drugs or oral antibiotics. Side effects include temporary worsening of the acne, dry skin, nosebleeds, vision disorders, and elevated liver enzymes, blood fats and cholesterol. This drug must not be taken during pregnancy since it causes birth defects.

Anti-androgens, drugs that inhibit androgen production, are used to treat women who are unresponsive to other therapies. Certain types of oral contraceptives (for example, Ortho-Tri-Cyclen) and female sex hormones (estrogens) reduce hormone activity in the ovaries. Other drugs, for example, spironolactone and corticosteroids, reduce hormone activity in the adrenal glands. Improvement may take up to four months.

Oral corticosteroids, or anti-inflammatory drugs, are the treatment of choice for an extremely severe, but rare type of destructive inflammatory acne called acne fulminans, found mostly in adolescent males. Acne conglobata, a more common form of severe inflammation, is characterized by numerous, deep, inflammatory nodules that heal with scarring. It is treated with oral isotretinoin and corticosteroids.

Other treatments

Several surgical or medical treatments are available to alleviate acne or the resulting scars:

• Comedone extraction. The comedo is removed from the pore with a special tool.

• Chemical peels. Glycolic acid is applied to peel off the top layer of skin to reduce scarring.
• Dermabrasion. The affected skin is frozen with a chemical spray, and removed by brushing or planing.
• Punch grafting. Deep scars are excised and the area repaired with small skin grafts.
• Intralesional injection. Corticosteroids are injected directly into inflamed pimples.
• Collagen injection. Shallow scars are elevated by collagen (protein) injections.

Alternative treatment

Alternative treatments for acne focus on proper cleansing to keep the skin oil-free; eating a well-balanced diet high in fiber, zinc, and raw foods; and avoiding alcohol, dairy products, smoking, caffeine, sugar, processed foods, and foods high in iodine, such as salt. Supplementation with herbs such as burdock root (Arctium lappa ), red clover (Trifolium pratense ), and milk thistle (Silybum marianum ), and with nutrients such as essential fatty acids, vitamin B complex, zinc, vitamin A, and chromium is also recommended. Chinese herbal remedies used for acne include cnidium seed (Cnidium monnieri ) and honeysuckle flower (Lonicera japonica ). Wholistic physicians or nutritionists can recommend the proper amounts of these herbs.

Prognosis

Acne is not curable, although long-term control is achieved in up to 60% of patients treated with isotretinoin. It can be controlled by proper treatment, with improvement taking two or more months. Acne tends to reappear when treatment stops, but spontaneously improves over time. Inflammatory acne may leave scars that require further treatment.

Prevention

There are no sure ways to prevent acne, but the following steps may be taken to minimize flare-ups:

• gentle washing of affected areas once or twice every day
• avoid abrasive cleansers
• use noncomedogenic makeup and moisturizers
• shampoo often and wear hair off face
• eat a well-balanced diet, avoiding foods that trigger flare-ups
• unless told otherwise, give dry pimples a limited amount of sun exposure
• do not pick or squeeze blemishes
• reduce stress

Resources

PERIODICALS

Billings, Laura. "Getting Clear." Health Magazine (April 1997): 48-52.

ORGANIZATIONS

American Academy of Dermatology. 930 N. Meacham Road, P.O. Box 4014, Schaumburg, IL 60168-4014. (847) 330-0230. Fax: (847) 330-0050. 〈http://www.aad.org〉.

Acne

Definition

Acne is a skin disorder that leads to an outbreak of lesions called pimples or "zits." The most common form of the disease is called acne vulgaris—the rash that affects many adolescents. Acne vulgaris is triggered by the hormonal changes that occur in puberty .

Description

Acne is a condition in which pimples appear on the face, chest, and back. In teenagers, acne usually appears on the forehead, nose, and chin. It is caused by the overproduction of sebum. Sebum is an oily substance that forms in glands just under the surface of the skin called sebaceous glands. Sebum normally flows out hair follicles onto the skin to act as a natural skin moisturizer. The glands are connected to hair follicles that allow the sebum, or oil, to empty onto the skin through a pore.

If hair follicles become blocked by sebum, dead skin cells, and bacteria, acne is the result. The sebaceous gland units are most commonly found on the face, neck, and back.

During puberty, there are increased levels of the male hormone androgen. High levels of androgen cause excess sebum to form. Sometimes the sebum combines with dead, sticky skin cells and bacteria called Propioni-bacterium acnes (P. acnes) that normally live on the skin. The mixture of oil and cells allows the bacteria to grow in the plugged follicles. When this happens, a hard plug called a comedo can form. A comedo is an enlarged hair follicle. It can take the following forms:

• a blackhead, which is a comedo that reaches the skin's surface and looks black
• a whitehead, which is a comedo that is sealed by keratin, the fibrous protein produced by the skin cells and looks like a white bump.

In addition, pimples can form on the skin. Types of pimples include:

• papules, which are small, red bumps that may be tender to the touch
• pustules, which are pus-filled lesions that are often red at the base
• nodules, which are large, painful lesions deep in the skin
• cysts, which are painful pus-filled lesions deep in the skin that can cause scarring

Pimples form when the follicle is invaded by the P. acnes bacteria. The damaged follicle weakens and bursts open, releasing sebum, bacteria, skin cells, and white blood cells into surrounding tissues. Scarring happens when new skin cells are created to replace the damaged cells. The most severe type of acne includes both nodules and cysts.

Demographics

Acne affects as many as 17 million people in the United States, making it the most common skin disease. Acne usually begins at puberty and worsens during adolescence . Nearly 85 percent of people develop acne at some point between ages 12 to 25. As many as 20 million teens have the condition. Acne may appear as early as age 10, and even may be found in some newborns. Some people may continue to be affected by acne after age 30.

Causes and symptoms

The exact cause of acne is as of 2004 not known. There are several risk factors that make acne more likely to occur:

• Age. Adolescents are more likely to have acne.
• Disease. Certain hormonal disorders such as polycystic ovarian syndrome make acne more likely.
• Hormonal changes. Acne can flare up before menstruation . An increase in the male hormone androgen during puberty (seen in both males and females) causes the sebaceous glands to overproduce androgen. Boys have more severe acne than girls.
• Heredity. Some individual are genetically more susceptible to acne.
• Drugs. Steroids and performance enhancing drugs, oral contraceptives, antibiotics, antidepressants , and tranquillizers such as lithium are known to cause acne.
• Cosmetics. Oily cosmetics can plug up hair follicles.

Other factors can worsen acne or cause it to flare up:

• Environmental irritants. Air pollution and high humidity can worsen acne, as can exposure to greasy environments such as working in a fast food restaurant.
• Friction. Rubbing the skin vigorously or exposure to constant friction from backpacks or tight collars can worsen acne.
• Personal hygiene. Picking at pimples or scrubbing the skin too hard can result in worsened acne.

Factors that do not cause acne include:

• chocolate and greasy foods
• stress

When to call the doctor

A healthcare provider should be contacted under the following circumstances:

• Painful nodules and cysts are present.
• Over-the-counter medications have not been effective.
• Acne lesions are causing scarring.
• Acne is causing dark skin to have darker patches when lesions heal.
• Acne is causing embarrassment or self-consciousness.
• Acne is creating emotional upset.

Acne may be treated by the family doctor. More severe cases may be referred to a dermatologist (skin doctor) or an endocrinologist (doctor who treats hormonal/glandular disorders).

Diagnosis

Acne can be diagnosed by physical examination and a medical history of acne. The physician will take a medical history, including information about skin care, diet, medications, factors that can cause flare-ups, and prior treatment. Blood tests are not usually necessary unless a hormonal disorder is suspected.

Physical examination will include the face, neck, shoulders, back, and other affected areas. Using specialized lighting, the physician will examine the affected areas to see the following:

• what type and how many lesions are present
• how deep the lesions are
• whether they are inflamed
• whether scarring or skin discoloration is present

Treatment

Acne treatment consists of reducing the sebum production, removing dead skin cells, and killing bacteria with oral medication and drugs used on the skin (topical). The treatment depends on the severity of the condition.

Drugs

TOPICAL (SKIN) MEDICATION Treatment for mild noninflammatory acne consists of reducing the formation of new comedones with medications including topical tretinoin, benzoyl peroxide, adapalene, or salicylic acid. Tretinoin is especially effective because it increases turnover and replacement of skin cells. If lesions are inflamed, topical antibiotics may be added to the treatment regimen. Improvement is usually seen in two to four weeks.

Topical medications are available as cream, gel, lotion, or pad preparations of varying strengths. They include antibiotics (to kill bacteria) such as erythromycin, clindamycin (Cleocin-T), and meclocycline (Meclan); and comedolytics (agents that loosen hard plugs and open pores) such as the vitamin A acid tretinoin (Retin-A), salicylic acid, adapalene (Differin), resorcinol, and sulfur. Drugs that act as both comedolytics and antibiotics, such as benzoyl peroxide, azelaic acid (Azelex), or benzoyl peroxide plus erythromycin (Benzamycin), are also used. These drugs may be used for months to years to achieve disease control.

After the person washes with mild soap, the drugs are applied alone or in combination, once or twice a day over the entire affected area of skin. Possible side effects include mild redness, peeling, irritation, dryness, and an increased sensitivity to sunlight that requires use of a sunscreen.

ORAL DRUGS Oral antibiotics are taken daily for two to four months. The drugs used include tetracycline, erythromycin, minocycline (Minocin), doxycycline, clindamycin (Cleocin), and trimethoprim-sulfamethoxazole (Bactrim, Septra). Possible side effects include allergic reactions, stomach upset, vaginal yeast infections, dizziness , and tooth discoloration.

The goal of treating moderate acne is to decrease inflammation and prevent new comedones from forming. One effective treatment is topical tretinoin, used along with a topical or oral antibiotic. A combination of topical benzoyl peroxide and erythromycin is also very effective. Improvement is normally seen within four to six weeks, but treatment is maintained for at least two to four months.

A drug reserved for the treatment of severe acne, oral isotretinoin (Accutane), reduces sebum production and cell stickiness. It is the treatment of choice for severe acne with cysts and nodules and is used with or without topical or oral antibiotics. Taken for four to five months, it provides long-term disease control in up to 60 percent of patients. If the acne reappears, another course of isotretinoin may be needed by about 20 percent of patients, while another 20 percent may do well with topical drugs or oral antibiotics. However there are significant side effects, including temporary worsening of the acne; dry skin; nosebleeds; vision disorders; and elevated liver enzymes, blood fats, and cholesterol. The drug also causes benign intracranial hypertension (pseudotumor cerebri) and mood changes. This drug must not be taken during pregnancy since it causes birth defects. Sexually active young women being treated with isotretinoin must use a reliable contractive, and they need to use contraception for up to one month after stopping use of the drug.

Anti-androgens, drugs that inhibit androgen production, are used to treat women who are unresponsive to other therapies. Certain types of oral contraceptives (for example, Ortho-Tri-Cyclen) and female sex hormones (estrogens) reduce hormone activity in the ovaries. Other drugs (for example, spironolactone and corticosteroids) reduce hormone activity in the adrenal glands. Improvement may take up to four months.

Oral corticosteroids, or anti-inflammatory drugs, are the treatment of choice for an extremely severe, but rare type of destructive inflammatory acne called acne fulminans, found mostly in adolescent males. Acne conglobata, a more common form of severe inflammation, includes numerous, deep, inflammatory nodules that heal with scarring. It is treated with oral isotretinoin and corticosteroids.

Other treatments

Several surgical or medical treatments are available to alleviate acne or the resulting scars:

• Comedone extraction. The comedo is removed from the pore with a special tool.
• Chemical peels. Glycolic acid is applied to peel off the top layer of skin to reduce scarring.
• Dermabrasion. The affected skin is frozen with a chemical spray and removed by brushing or planing.
• Punch grafting. Deep scars are excised and the area repaired with small skin grafts.
• Intralesional injection. Corticosteroids are injected directly into inflamed pimples.
• Collagen injection. Shallow scars are elevated by collagen (protein) injections.

Alternative treatment

Alternative treatments for acne focus on self care: proper cleansing to keep the skin oil-free; eating a well-balanced diet high in fiber, zinc, and raw foods; and avoiding alcohol, dairy products, tobacco, caffeine , sugar, processed foods, and foods high in iodine, such as salt.

Supplementation with herbs such as burdock root (Arctium lappa ), red clover (Trifolium pratense ), and milk thistle (Silybum marianum ), and with nutrients such as essential fatty acids, vitamin B complex, zinc, vitamin A, and chromium is also recommended. Chinese herbal remedies used for acne include cnidium seed (Cnidium monnieri ) and honeysuckle flower (Lonicera japonica ). Holistic physicians or nutritionists can recommend the proper amounts of these herbs.

Nutritional concerns

Acne is not caused or worsened by eating chocolate or oily foods.

Prognosis

Acne is not curable, although it can be controlled by proper treatment. Improvement can take two or more months. Long-term control is achieved in up to 60 percent of patients with severe acne who are treated with the drug isotretinoin. Acne tends to reappear when treatment stops, but spontaneously improves over time. Acne usually improves after adolescence, although some individuals continue to have lesions after age 30. Inflammatory acne may leave scars that require further treatment.

Prevention

There are no sure ways to prevent acne, but the following steps may be taken to minimize flare-ups:

• gentle washing of affected areas once or twice every day
• avoiding abrasive cleansers
• using noncomedogenic (does not clog pores) makeup and moisturizers
• shampooing often and wearing hair off the face
• eating a well-balanced diet, avoiding foods that trigger flare-ups
• unless told otherwise by the healthcare provider, giving dry pimples a limited amount of sun exposure
• not picking or squeezing blemishes

Parental concerns

Acne comes at a difficult time, during the adolescent years. While mild acne can be treated with over-the-counter medications, more severe acne needs medical attention. Experts advise against a wait-and-see attitude. Treatment options can help control acne and avoid scarring.

KEY TERMS

Androgens —Hormones (specifically testosterone) responsible for male sex characteristics.

Antiandrogen —A substance that blocks the action of androgens, the hormones responsible for male characteristics.

Antibiotics —Drugs that are designed to kill or inhibit the growth of the bacteria that cause infections.

Comedo —A hard plug composed of sebum and dead skin cells, also called a blackhead. The mildest type of acne.

Comedolytic drugs —Medications that break up comedones and open clogged pores.

Corticosteroids —A group of hormones produced naturally by the adrenal gland or manufactured synthetically. They are often used to treat inflammation. Examples include cortisone and prednisone.

Estrogen —Female hormone produced mainly by the ovaries and released by the follicles as they mature. Responsible for female sexual characteristics, estrogen stimulates and triggers a response from at least 300 tissues. After menopause, the production of the hormone gradually stops.

Isotretinoin —A powerful vitamin A derivative used in the treatment of acne.

Noncomedogenic —A substance that does not contribute to the formation of blackheads or pimples on the skin.

Sebaceous follicle —A structure found within the skin where a sebaceous gland opens into a hair follicle.

Sebum —An oily skin moisturizer produced by sebaceous glands.

Tretinoin —A drug, used in the treatment of acne, that works by increasing the turnover (death and replacement) of skin cells.

See also Antiacne drugs.

Resources

BOOKS

Ceaser, Jennifer. Everything You Need to Know about Acne. New York: Rosen Publishing Group, 2003.

Papadopoulos, Linda, et al. Understanding Skin Problems: Acne, Eczema, Psoriasis, and Related Conditions. New York: John Wiley and Sons, 2003.

Preston, Lydia, et al. Breaking Out: A Woman's Guide to Coping with Acne. New York: Simon & Schuster, 2004.

ORGANIZATIONS

American Academy of Dermatology. 930 E. Woodfield Rd., Schaumburg, IL 60168. Web site: <www.aad.org/>.

WEB SITES

"Questions and Answers about Acne." National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) Information Clearinghouse, October 2001. Available online at <www.niams.nih.gov/hi/topics/acne/acne.htm> (accessed October 15, 2004).

"Treating Acne in Skin of Color." AcneNet 2002. Available online at <www.skincarephysicians.com/acnenet/update.htm> (accessed October 15, 2004).

"What Can I Do About Pimples?" American Family Physician, Information from Your Family Doctor Handout, January 15, 2000. Available online at <www.aafp.org/afp/20000115/20000115a.html> (accessed October 15, 2004).

Christine Kuehn Kelly

ACNE

DEFINITION

Acne is a common skin disease characterized by pimples on the face, chest, and back. It occurs when the pores of the skin become clogged with oil, dead skin cells, and bacteria.

DESCRIPTION

The medical term for acne is acne vulgaris. It is the most common of all skin diseases, affecting about seventeen million Americans. Acne can occur at any age, but it is most common among adolescents. Nearly 85 percent of people between the ages of twelve and twenty-five develop acne. Up to 20 percent of women over twenty-five develop mild acne. The disease is also sometimes found in newborns.

Acne is a disease of the sebaceous (pronounced see-BAY-shus) glands. These glands lie just beneath the surface of the skin. They produce an oil called sebum, which keeps the skin moist. At puberty, a person's body may begin to produce an excess of sebum. Puberty is the period of life when a person's sex hormones become active. The male sex hormone called androgen causes an over-production of sebum.

When excess sebum combines with dead skin, a hard plug, or comedo (pronounced KO-mee-do), is formed. The comedo can block skin pores. Two types of comedos can occur. They are known as whiteheads and blackheads.

More serious forms of acne develop when bacteria invade blocked pores. A pimple forms when sebum, bacteria, skin cells, and white blood cells are released into tissue around the pore. The pimple may then become inflamed. Inflamed pimples near the skin are called papules. Those that form deeper in the skin are called pustules. The most severe type of acne occurs when cysts (closed sacs) or nodules (hard swellings) form.

Acne often causes scarring of the skin. This occurs when new skin cells form to replace damaged cells. The new skin is usually not formed very easily, causing an unevenness that produces scars. Acne occurs most commonly on the face, chest, shoulders, and back because those are the places that sebaceous cells occur.

Acne: Words to Know

Androgen:

A male sex hormone found in both males and females.

Anti-androgen:

A drug that slows down the production of androgens.

Antibiotic:

A drug that kills bacteria.

Comedo:

A hard plug that develops in the pores of the skin composed of sebum and dead skin cells. The mildest form of acne.

Comedolytic:

Drugs that break up comedos and open clogged pores.

Isotretinoin:

A drug that decreases sebum production and dries up acne pimples.

Sebum:

An oily material produced by sebaceous glands that keeps the skin moist.

Tretinoin:

A drug that increases the rate at which skin cells are formed and die.

CAUSES

The exact cause of acne is not known, however, several risk factors have been identified.

• Age. Because of the effect of sex hormones, teenagers are quite likely to develop acne.
• Cosmetics. Make-up and hair sprays that contain oils can make acne worse.
• Diet. Acne is not caused by diet, but some foods can make the disease more serious.
• Disease. Hormonal disorders can increase the severity of acne problems in girls.
• Drugs. Acne can develop as a result of using certain drugs, such as tranquilizers, antibiotics, oral contraceptives, and anabolic steroids. Steroids are synthetic hormones that may sometimes be abused by athletes to increase the size of their muscles.
• Environment. Acne can become worse as a result of exposure to oils, greases, and polluted air. Sweating in hot weather can also make the condition worse.
• Gender. Boys are more likely to develop acne and tend to have more serious cases than girls.
• Heredity. Acne is more common in some families than in others.
• Hormonal changes. Acne can flare up during menstruation, pregnancy, and menopause. Menopause is the period in a woman's life when her body stops producing certain hormones.
• Personal hygiene. Strong soaps, hard scrubbing, and picking at pimples can make acne worse.
• Stress. Emotional stress can contribute to acne.

SYMPTOMS

Acne is often not apparent to an observer. Inflamed pores, however, can cause pain or itching. The most troubling aspect of acne for many people is the scarring that can occur. And, while acne may not be very noticeable, individuals tend to be sensitive about their appearance. Teenagers especially may become concerned about the way other people react to them.

DIAGNOSIS

People with acne are often treated by family doctors. More serious cases are referred to a dermatologist (a specialist in skin disorders) or an endocrinologist (a specialist in hormonal disorders).

Because of its appearance, acne is not difficult to diagnose. A doctor takes a complete medical history, which includes questions about skin, diet, medication use, and other factors associated with risk for acne. He or she conducts a physical examination of the face, upper neck, chest, shoulders, back, and other affected areas. The doctor determines the number and type of blemishes, whether they are inflamed or not, whether they are deep or near the surface of the skin, and whether there is scarring or skin discoloration.

Laboratory tests are not done unless the patient appears to have a hormonal disorder. In that case, blood tests and other tests may be ordered. Most insurance plans cover the cost of diagnosing and treating acne.

TREATMENT

Acne treatment consists of reducing sebum production, removing dead skin cells, and killing bacteria. Treatment methods differ depending on how serious the acne is.

Topical Drugs

Topical drugs are applied directly to the affected areas of the skin. They are available in the form of creams, gels, lotions, or pads. They are used primarily to treat mild forms of acne in which there is little or no inflammation.

One group of topical drugs used for acne includes antibiotics. These drugs kill the bacteria that contribute to the disease. Another group of drugs is called comedolytics (pronounced KO-mee-do-LIE-tiks). These drugs loosen hard plugs and open pores. Still another group of drugs works by increasing the rate at which new skin cells form. These drugs prevent the formation of new comedos.

Topical drugs are applied once or twice a day after washing with mild soap. Treatment may have to continue anywhere from a few weeks to a few months to a few years. Side effects such as mild redness, peeling, irritation, dryness, and an increased sensitivity to sunlight may occur.

Oral Drugs

Oral drugs are taken by mouth. Doctors sometimes prescribe oral antibiotics for moderate cases of acne. These antibiotics prevent the formation of new comedos and reduce inflammation. They are usually taken once a day

for two to four months. Side effects may include allergic reactions, stomach upset, vaginal yeast infections, dizziness, and tooth discoloration.

A drug that is used for severe cases of acne is isotretinoin (pronounced i-so-TRET-uh-no-un, trade name Accutane). This drug reduces the production of sebum and the stickiness of skin cells. It is used when cysts and nodules are present. The drug may be used alone or with other topical or oral antibiotics.

Isotretinoin treatment usually lasts for four or five months. It is effective in about 60 percent of all patients. If the acne reappears, another course of treatments may be necessary. Some side effects that may accompany the use of isotretinoin include nosebleeds, dry skin, a temporary worsening of the acne, vision disorders, and increased production of liver enzymes, blood fats, and cholesterol. It may also cause birth defects and cannot, therefore, be used by pregnant women.

Women who do not respond to any of these treatments may be given another type of oral drug, an anti-androgen. Anti-androgens reduce the production of androgen and therefore reduce the formation of comedos. Certain types of oral contraceptives are also effective as anti-androgens.

The most serious forms of acne require other types of drugs, including oral corticosteroids, or anti-inflammatory drugs. These drugs are often used for the treatment of a form of acne known as acne fulminans, which occurs mostly among adolescent males. They are also used with acne that produces numerous deep, inflamed nodules that heal with scarring.

Other Treatments

Several surgical or medical treatments may be used to reduce acne or the scars caused by the disease.

• Chemical peel. A chemical known as glycolic acid is first applied to the skin. When it dries, it is peeled off, taking the top layer of skin with it. This treatment helps reduce scarring.
• Collagen injection. Shallow scars are filled in by injecting collagen, a skin protein, beneath the scars.
• Comedo extraction. A special tool is used to remove a comedo from a pore.
• Dermabrasion. The affected skin is first frozen with a chemical spray. Then it is removed with a brush or sandpaper-like instrument.
• Intralesional injection. Anti-inflammatory drugs are injected directly into inflamed pimples.
• Punch grafting. Deep scars are removed and the area repaired with small skin grafts.

Alternative Treatment

Alternative treatments for acne focus on proper hygiene and diet. Patients are advised to keep their skin clean and oil-free. They are also encouraged to eat a well-balanced diet high in fiber, zinc, and raw fruits and vegetables. They should also avoid alcohol, dairy products, caffeine, sugar, smoking, processed foods, and foods high in iodine, such as table salt.

Some doctors recommend the use of herbs to supplement the diet. Some herbs that have been used in the treatment of acne include burdock root, red clover, and milk thistle. Additional nutrients that may help to control acne include B-complex vitamins and chromium. Chinese herbal treatments that are recommended include cnidium seed and honeysuckle flower. Another herbal treatment is tea tree oil. The proper dose of these substances can be recommended by physicians or nutritionists.

PROGNOSIS

Acne cannot be cured. However, it can be controlled in about 60 percent of patients with the drug isotretinoin. Improvement usually takes at least two months, and the problem may recur after treatment has been stopped. Inflammatory acne that results in the formation of scars may require one of the more aggressive treatments already described.

PREVENTION

There are no sure ways to prevent acne. However, the following steps tend to reduce flare-ups of the condition:

• Gently wash—do not scrub—the affected areas once or twice every day.
• Avoid rough cleansers.
• Use makeup and skin moisturizers that do not produce comedos.
• Shampoo often and wear hair away from the face.
• Eat a well-balanced diet and avoid foods that trigger flare-ups.
• Give dry pimples a limited amount of sun exposure unless otherwise directed by your doctor.
• Do not pick or squeeze pimples.
• Reduce stress.

FOR MORE INFORMATION

Books

Balch, James F., and Phyllis A. Balch. "The Disorders: Acne." in Prescription for Nutritional Healing, edited by Amy C. Tecklenburg, et al. Garden City, NY: Avery Publishing Group, 1997.

Bark, Joseph P. Your Skin: An Owner's Guide. Englewood Cliffs, NJ: Prentice Hall, 1995.

Chu, Tony, and Anne Lovell. The Good Skin Doctor: A Leading Dermatologist's Guide to Beating Acne. London: Thorson's, 1999.

Silverstein, Alvin, Robert Silverstein, and Virginia Silverstein. Overcoming Acne: The How and Why of Healthy Skin Care. New York: William Morrow & Company, 1992.

Periodicals

Billings, Laura. "Getting Clear." Health Magazine (April 1997): pp. 48–52.

Christiano, Donna. "Acne Treatment Meant for Grown-Ups." American Health (October 1994): pp. 23–24.

"Clearly Better New Treatments Help Adult Acne." Prevention Magazine (August 1997): pp. 50–51.

"Pimple Control Pill?" Prevention Magazine (May 1997): p. 132.

Organizations

American Academy of Dermatology. 930 N. Meacham Road., Schaumburg, IL 60173–6016. (847) 330–0230. http://www.aad.org.

Acne

Johnny’s Story

What Is Acne?

What Kinds of Acne Are There?

Who Gets Acne?

What Else Causes Acne?

What Does Acne Look Like?

How Is Acne Treated?

What Doesn’t Cause Acne?

Resources

Acne (AK-nee) is a condition in which there are pimples, black-headsy whiteheads, and sometimes deeper lumps on the skin.

KEYWORDS

for searching the Internet and other reference sources

Acne vulgaris

Comedones

Dermatology

Inflammation

Johnny’s Story

Until he turned 13, Johnny’s skin had always been clear. Soon after the start of eighth grade, though, Johnny noticed the first few pimples on his face. Before long, the problem had gotten much worse. Johnny’s face was always broken out, and the pimples had spread to his neck, back, and chest.

Johnny was willing to try almost anything to get rid of the problem. He had heard that acne was caused by dirt or by eating certain foods, so he washed his face several times a day and gave up chocolate, nuts, and french fries. He also tried several acne medicines sold without a prescription. Nothing did the trick. Finally, Johnny went to see the doctor, who prescribed a medicine. Within a few weeks, the acne started to go away. Although Johnny had to keep using medicine and seeing the doctor for a while, he felt that his new and improved appearance was well worth the trouble.

What Is Acne?

Acne is the name for pimples or comedones*: blackheads, whiteheads, and sometimes deeper lumps that occur on the skin, especially on the face, neck, chest, back, shoulders, and upper arms and legs. Almost all teenagers have at least a little acne, and some adults have the problem as well. Although acne is not a serious health threat, it can affect how people look, which in turn can affect how they feel about themselves. When the acne is severe, it can leave permanent scars on the skin.

* comedo

(KOM-e-do) is an acne pimple. A blackhead is an open comedo. A whitehead is a closed comedo. Cosmetics that are labeled “non-comedogenic” (non-kom-e-do-JEN-ik) are less likely to cause pimples.

Acne occurs when hair follicles (FOL-li-culs) become plugged. A follicle is a tiny shaft in the skin through which a hair grows. The follicles are connected to sebaceous (se-BAY-shus) glands, which are small structures in the skin that make an oily substance called sebum (SEE-bum). This oil helps keep the skin and hair healthy. To reach the surface of the skin, the oil drains from the glands into the follicles, then leaves the follicles through tiny openings in the top. As it leaves the follicles, the oil carries away dead skin cells shed by the follicle linings.

What Kinds of Acne Are There?

Sometimes the cells inside the follicles shed too fast and stick together, forming a white, cheesy plug at the surface of the skin. If the opening to the surface stays partly open, the top of the plug may darken, causing a blackhead. If the opening to the surface closes, the follicle may fill up and its wall may start to bulge, causing a whitehead. The mixture of oil and cells inside the follicle also aids the growth of bacteria. If the follicle wall bursts, the oil, cells, and bacteria spill into the skin. The result is redness, swelling, and pus, in other words, a pimple. Ordinary acne is made up of blackheads, whiteheads, and pimples.

At times, large, pus-filled lumps called cysts (pronounced SISTS) form deeper in the skin. This is a more severe form of acne. The lumps may be painful, and if they are not treated by a doctor, they may lead to permanent scars.

Who Gets Acne?

Nearly all teenagers have at least an occasional pimple. The problem usually starts between the ages of 10 and 13, and it typically lasts for 5 to 10 years. Acne usually goes away on its own by the early twenties. However, it can last into the twenties, thirties, and beyond. A few people get acne for the first time as adults. Acne strikes boys and girls about equally. However, boys are more likely than girls to have more severe, longer-lasting forms of the problem.

During the teen years, both boys and girls go through changes in their hormones*. One group of hormones, called androgens (AN-dro-jens), seem to play a role in acne. Among other things, androgens make the sebaceous glands work harder. The more oil the glands make, the greater the chance that the follicles will become clogged. Teenage boys

* hormones

are chemicals that are produced by different glands in the body. Hormones are like the body’s ambassadors: they are created in one place but are sent through the body to have specific regulatory effects in different places.

make ten times as much androgen as teenage girls, so it is not surprising that boys are more likely to get more severe cases of acne.

What Else Causes Acne?

Certain oily kinds of makeup and face cream can clog the openings of the skin and cause mild acne. That may mean that people who try to cover their pimples with makeup actually make the problem worse by causing new pimples. Oil-free products are labeled “non-comedogenic” (non-kom-ee-do-JEN-ik), meaning they should not cause blackheads or whiteheads, or “non-acnegenic” (non-ak-nee-JEN-ik), meaning they should not cause acne.

Several other things can cause acne or make it worse. These include certain medicines. People who work in fast food restaurants or garages may find that their acne is made worse by the constant contact with grease, motor oil, or chemical irritants. Many girls also find that their pimples get worse around the time of their periods.

What Does Acne Look Like?

Acne is typically found where the sebaceous glands are most numerous: on the face, neck, chest, back, and shoulders. Blackheads are spots with a dark top, whereas whiteheads are spots with a white center. Pimples look like small, red bumps. Some of them have a white center with a ring of redness around it. When pimples occur with no blackheads or whiteheads, they may be a sign of another skin disease or a skin reaction to medication. Cysts are large, red bumps that are often painful. They may leave deep pits and scars after healing.

It is usually easy for a doctor to recognize acne by sight. It is smart to see a doctor whenever:

• acne interferes with a person’s life
• acne spots are large, red, and painful
• acne causes dark patches to appear on a dark-skinned person
• acne scars remain when the acne spots heal
• treatment with nonprescription medication does not work

How Is Acne Treated?

Acne treatments work by stopping new pimples from forming. They do this by cutting back on the amount of oil the sebaceous glands make, the number of bacteria that are present in the skin, or the rate at which dead skin cells are shed. It is important to give an acne treatment enough time to do its job. It may take weeks for the skin to clear up, even if a treatment is working.

Retin-A and Accutane

Two drugs used to clear up severe cases of acne are Retin-A and Accutane. Both of these drugs are derivatives of vitamin A.

Retin-A (tretinoin) comes in a cream, gel, or liquid and is applied to the skin daily. Exactly how it works is unknown but it is thought to loosen and expel existing acne plugs in the skin glands and prevent new lesions from forming. Results are seen in about 2 or 3 weeks but treatment should be continued for at least 6 weeks. The most common side effect is skin irritation.

Accutane (isotretinoin) is taken orally. Accutane must be taken daily for 4 or 5 months, and results last for about one year. Accutane has some serious side effects such as chapped lips, dry, itchy skin, nosebleeds, irritation of the eyelids, joint and muscle pain, temporary hair loss, and rash. It is particularly important that Accutane not be taken by women who are pregnant or who may become pregnant during treatment as the drug can severely damage the developing fetus.

Over-the-counter medications

Milder cases of acne are often helped by lotions, creams, pads, and gels sold without a prescription. Many will dry out the skin if used too frequently, however, and it is important to follow label instructions carefully.

Prescription medications

A doctor may prescribe stronger medicines than those sold over the counter. When put on the skin in creams or lotions, such medicines may cause dryness and peeling. The doctor can offer advice on how to deal with these side effects.

Other treatments

The doctor may open pimples or remove blackheads and whiteheads in the office. A skilled doctor is the best one to do this. People who try to do it themselves may wind up making the acne worse and increasing the risk of scarring.

What Doesn’t Cause Acne?

Acne is not caused by being dirty. Even the black in a blackhead is dried oil and dead skin cells, not dirt. Washing too often may actually irritate the skin and make the acne worse. In general, the following guidelines may help to prevent acne or to reduce its symptoms:

• not popping, squeezing, or picking at acne pimples, as this can just lead to more redness, swelling, and scars.

• Choosing oil-free makeup and face creams labeled “non-comedo-genic” or “non-acnegenic.”
• Avoiding things that can irritate the skin, such as grease, oil, and rubbing from clothes and sports equipment.
• Washing the face gently twice a day with a mild soap, then patting it dry.
• Shampooing hair regularly.
• For men who shave, shaving as lightly as possible to avoid nicking any pimples.

Acne also is not caused by the foods a person eats. Studies have shown that a strict diet alone will not clear up the skin. On the other hand, some people are still convinced that certain foods such as chocolate or french fries make their acne worse. It certainly could not hurt to cut back on junk food. A healthier diet is always a plus, whether or not it has an effect on acne.

See also

Skin Conditions

Resources

Book

Silverstein, Alvin, Virginia Silverstein, and Robert Silverstein. Overcoming Acne: The How and Why of Healthy Skin Care. New York: William Morrow, 1990.

Organizations

The U.S. National Institute of Arthritis and Musculoskeletal and Skin Diseases posts a fact sheet about acne at its website. http://www.nih.gov/niams/healthinfo/acne/acne.htm

American Academy of Dermatology, P.O. Box 681069, Schaumburg, IL 60168–1069. The AAD publishes a brochure called Acne. Telephone 888–462-DERM http://www.aad.org

AcneNet is the website created by Roche Laboratories, a drug company, and the American Academy of Dermatology. http://www.derm-infonet.com/acnenet