What is acne?

Acne is a disorder of pilosebaceous unit associated with hair follicles and sebaceous glands; characterized by eruptions which can be comedones, pustules, papules, cysts or scars. The sebaceous glands secrete an oily substance that consists of triglycerides, fatty acids, wax esters, and sterols as “sebum”.

• Who all are affected?

  Nearly all teenagers have some acne. Acne affects the sexes equally, starting usually between the ages of 12 and 14 years, tends to be earlier in females. Peak age- 16-17 years in females and 17-19 in males. 90% of acne gets resolved by the age of 30years. A few percentages of people continue to have acne even after age of 30 years. A small percentage of people especially women have acne in their 30’s, 40’s, 50’s and beyond.

• Does acne only occur on face?

  Acne usually occurs on the face but it can appear on other parts of the body. It can occur on external auditory meatus, back, chest, shoulders and anogenital area.

What causes acne?

There are various underlying causes which can be physical, physiological, hormonal and emotional or drug induced.

1. Sebum: Increased sebum excretion from the glands can increase incidence of acne.
2. Hormones: The hormonal imbalance is the basic cause of all troubles. There are a lot of hormonal changes that occur in developing teenagers. And hence the reason for acne being most common in teenagers. Different hormones have different effects. Androgens which are secreted from testes, ovaries and adrenals, increase the size of sebaceous glands and increase sebum secretion. Androgenic adrenocorticosteroids also have the same effect. Oestrogens have the opposite effect in prepubertal boys and girls. Fifty per cent of females with acne have slightly raised free testosterone levels. Oral contraceptives can induce acne.
3. Fluid retention: The premenstrual exacerbation of acne is thought to be due to fluid retention leading to increased hydration of and swelling of the duct. Sweating also makes acne worse, possibly by the same mechanism.
4. Diet: In some patients acne is made worse by chocolate, nuts and coffee or fizzy drinks.
5. Season: Acne often improves with natural sunlight and is worse in winter.
6. Bacterial: Propionibacterium on normal skin commensally plays a pathogenic role. It colonizes the pilosebaceous ducts, breaks down triglycerides releasing free fatty acids, produces substances chemotactic for inflammatory cells and induces the ductal epithelium to secrete pro-inflammatory cytokines. The inflammatory reaction is kept going by a type IV immune reaction to one or more antigens in the follicle.
7. Steroids: Oral as well as topical steroids tend to cause and aggravate the preexisting acne lesions.
8. Genetic: The condition is familial in about half of those with acne. There is a high concordance of the sebum excretion rate and acne in monozygotic, but not dizygotic, twins.
9. External factors: Oils can cause acne like lesions. Other acne causing substances include coal tar, dicophane (DDT), cutting oils, and halogenated hydrocarbons (polychlorinated biphenyls and related chemicals). Cosmetic acne-women using cosmetics containing comedogenic oils.
10. Psychological: Increased acne severity is strongly associated with increased stress levels.

What are different types of acne?

Acne is not just an aberrant eruption on the skin but there are well demarcated features which differentiate one form of acne from other. Different types of acne are as follows:

1. Acne vulgaris
2. Infantile acne
3. Acne conglobata
4. Occupational
5. Drug induced

Acne vulgaris

It is the most common type of acne, occurs during puberty and affects the comedogenic areas of face, back and chest. Acne vulgaris is slightly more common in boys of which 30-40% has acne between 18-19 years. In girls peak incidence is between 16-18 years. Adult acne is a variant affecting 1% of men and 5% of women aged 40.

Signs and symptoms

Acne vulgaris is usually asymptomatic, although the large nodular lesions can be tender. Many people think that acne is just pimples but a person who has acne can have any of these blemishes:

1. Blackheads(open comedones)
2. Whiteheads(closed comedones)
3. Papules
4. Pustules
5. Cysts
6. Nodules

Patients with acne often complaint of excessive greasiness of the skin and developing blackheads or pimples. The nodules are deeper, erythematous lesions ranging from 6 to 20 mm in diameter and occur on the face, neck, back, and chest. Resolving lesions leave inflammatory macules and scarring. Scars may be:

1. Ice pick scars: Deep pits, that are most common and a classic sign of acne scarring.
2. Box car scars: Angular scars that usually occur on the temple and cheeks, and can be either superficial or deep, these are similar to chickenpox scars.
3. Rolling scars: Scars that give the skin a wave like appearance.
4. Hypertrophic scars: Thickened or keloid scars.

Infantile acne

Localised acne lesions occur on the face in the first few months of life. They clear spontaneously but may last for some years. There is said to be an associated increased tendency to severe adolescent acne.

Acne conglobata

Severe form of acne and more common in boys and in tropical climate, it is extensive, affecting the trunk, face and limbs. In “acne fulminans” there is associated systemic illness with malaise, fever, and joint pains. It appears to be associated with a hypersensitivity to P. acnes. Another variant is pyoderma faciale, which produces erythematous and necrotic lesions and occur mainly in adult women.

Occupational acne

Acne-like lesions occur as a result of long term contact with oils or tar. This usually results from lubricating, cutting, or crude oil soaking through clothing. In chloracne there are prominent comedones on the face and neck. It is caused by exposure to polychloro biphenyl and related compounds and also to weed killer and dicophane.

Drug induced acne

Corticosteroids, androgenic and anabolic steroids, gonadotrophins, oral contraceptives, lithium, iodides, bromides, antituberculosis and anticonvulsant therapy can all cause an acneiform rash.

Treatment

The easy availability of the potent topical steroids applications over the counters and the indiscriminate prescription of steroids by RMP’s have made the treatment of acne a troublesome entity for dermatologists. The easy availability and indiscriminate usage of steroids should be strictly discouraged and patients with acne should consult a dermatologist for the proper management of the acne. In most adolescents acne clears spontaneously with minimal scarring. Reassurance and explanation along the following lines helps greatly:

• The lesions can be expected to clear in time.
• It is not infectious.
• The lesser patients are self-conscious and worry about their appearance the less other people will take any notice of their acne.
• The first line of treatment includes - Encouraging a positive attitude, avoiding environmental and occupational factors, topical treatment with benzoyl peroxide and salicylic acid. It also includes oral antibiotics for months.
• The second line of treatment includes - Topical vitamin A acid, topical antibiotics, ultraviolet light and administration of antiandrogens.
• The third line of treatment - In this oral retinoids are administered in hospitals.

Prognosis

Acne usually improves around the age of 25-30 years but may persist into adulthood. Permanent scarring may occur. Most patients with adolescent acne improve spontaneously. Nonetheless, there may be severe and lifelong psychological effects. Patients with adult acne can continue to have episodic or persistent involvement for many years.

Tips for managing

• Wash your skin minimum twice a day and especially after sweating.
• Use your fingertips to apply a non-abrasive cleanser.
• Be gentle with your skin. Use gentle products such as those which are alcohol free.
• Scrubbing your skin can make acne worse.
• Rinse with lukewarm water.
• Shampoo regularly.
• Let your skin heal naturally. Don’t pick, pop or squeeze your acne.
• Keep your hands off your face.
• Stay out of the sun and tanning beds.
• A dermatologist consultation should always be taken.

References

1. American academy of dermatology
2. Clinical dermatology (Hunter,Savin J,DAHL M)
3. ABC of dermatology
4. Field Guide to Clinical Dermatology, 2nd Edition(Frankel, David H.)
5. Dawson, A. L.; Dellavalle, R. P. (2013). "Acne vulgaris
6. Treatment of acne vulgaris during pregnancy and lactation". Kong YL, Tey HL (June 2013)