Acne – Risk factors, Diagnosis and Treatment

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Acne – Risk factors, Diagnosis and Treatment

Acne is a skin condition that many people experience during their lifetime. It is commonly known as “acne vulgaris.” It is often seen in teenagers and younger adults due to hormonal imbalance. About 70 – 85% of the people affected by acne fall under the age group of 10-32 years. It affects girls (during 13 to 17 years of age) more than boys ( during 15-20 years of age). It usually disappears in the mid-twenties and may be present on and off for several years.

It occurs when hair follicles in your skin get clogged with dead skin cells, oil, and dust. It causes oily skin, spots and sometimes sore skin that is painful to touch and hot skin. It usually develops in different areas of the body such as:

  • Face (cheeks, nose, and forehead) – Majority of the people have acne on face.
  • Back – More than half the people with acne have acne on the back,
  • Chest – 10 -15% of people have acne on the chest
  • Shoulders

Acne typically appears on your face, shoulders and upper back because these areas have sebaceous glands that produce excessive oil. It can be persistent and troubling. The acne can be of various types such as blackheads, whiteheads, pimples, papules, pustules, nodules, and cystic lesions.

Acne appears on the skin as

  • Blackheads or whiteheads: Commonly known as comedones.
  • Pimples: Small or big tender red bumps on the skin
  • Pustules: Bumps that contain pus
  • Cysts: They are boils or deep pimples.

Certain conditions can aggravate acne such as

  • Manipulation (poking/pricking/squeezing) of acne lesions unnecessarily,
  • Hormonal imbalance and fluctuation during menstruation,
  • Blocking the pores of the skin by wearing hats, sports helmet and hats,
  • Air pollution
  • Extreme weather conditions especially high humidity.

Acne can vary from mild to severe forms. It can be divided into the following categories depending on its severity.

Mild Acne: People with this acne have comedones (whiteheads or blackheads). They are caused due to clogging of pores in the skin. Blackheads have skin pigment melanin that reacts with oxygen present in the air and hence looks black (it does not contain dirt).  Whiteheads have a white or yellowish head and are closed pores. The acne will increase when more oil or sebum is produced in the skin and bacteria will multiply and lead to the inflammatory type of acne.  If someone only has a few pimples, then it is considered as “mild acne.”

Moderate Acne: People with this type of acne have noticeably more pimples on their skin. When these pimples inflame, they are called papules or pustules. Papules are small bumps, and pustules are pimples filled with yellow pus.

Severe Acne: People with this type of acne has a lot of pustules or papules on the skin along with nodules and scars on their skin. These nodules are often painful and reddish.

Many effective treatments are available for acne. The bumps and pimples on skin heal slowly and may or may not leave a scar behind. Recurrence of acne is a major problem. The risk of problems caused by acne can be lowered by starting an early treatment. Severe cases of acne can cause emotional distress and depression in few patients.

Four main factors cause acne are
  • Excessive oil and sebum production,
  • Hair follicles clogged with oil, dead skin cells, and bacteria,
  • Excessive activity of androgens (hormones).

Other causes are

  • P. acnes: Acne is usually caused by a harmless skin bacterium known as P. acnes. Abnormal sebum is produced in large amounts by some glands present on the skin due to hormonal changes. When this sebum is in large amounts, the harmless skin bacteria become aggressive and cause inflammation of the skin and pus. The blockage of the pores is seen at the opening of the hair follicles as these hormones also cause the thickening of the inner lining of the hair follicle.
  • Familial Tendency: Acne is also known to have a familial tendency (runs in the families). You can have acne if your parents have acne now or when they were young.
  • Hormonal Imbalance: It is usually seen during menstrual cycle and pregnancy in women. Episodes of acne are often observed in women. Androgens are hormones that are present more in boys. They produce excessive sebum due to the enlargement of the sebaceous gland. Use of oral contraceptives also can affect the production of sebum.
  • Diet: Some studies have indicated that certain dietary foods such as chips, bagels, chocolate, and bread can aggravate and worsen acne.
  • Medications: Certain drugs such as testosterone, corticosteroids, and lithium may also aggravate acne.
  • Stress: Stress can worsen acne in many people.
  • Hygiene: Poor hygiene or dirty skin does not cause acne. In fact, cleansing the skin with harsh soaps, scrubbing the skin too hard or applying chemicals that irritates the skin may cause acne to worsen.
  • Greasy Foods: Eating greasy or fatty foods do not cause acne. Exposure of skin to oil particles in the air such as working in kitchens can cause the clogging of the pores of the skin and worsen acne.
  • Cosmetics: Not all cosmetics cause acne or worsen it. Non-comedogenic cosmetics that are oil and fragrance-free can be used to prevent the clogging of pores that causes acne. Make-up must be removed on a regular basis and daily before going to sleep.
Acne can present itself as six main types of spots:
  • Blackheads – The pores on the skin are plugged with bacteria and oil. These clog the pores and turn brown when exposed to air. Small yellowish or black bumps develop on the skin.
  • Whiteheads – The pores on the skin are closed and plugged. They appear similar to blackheads, and when squeezed, they do not empty.
  • Pimples – They are usually pustules with pus at their tips.
  • Papules – Small, red and tender bumps are seen on the skin. They have a white tip in the center.
  • Nodules – Solid, large and painful bumps or lumps present beneath the surface of the skin.
  • Cystic Lesions – They are pus-filled lumps present beneath the surface of the skin and are painful. They cause permanent scarring and look similar to boils.

You can take the advice of your doctor if you have any of the following symptoms:

  • If you are feeling unhappy or feeling depressed due to your acne,
  • If you cannot control the acne (pimples, spots, and scars) with over the counter medications available,
  • If you develop cysts or nodules that are visible and painful,
  • If your skin is red, inflamed and hot to touch.
  • If your skin is excessively dry or skin peeling is seen.

Scarring can be seen in acne if it is severe. The wounds caused by acne are commonly found in the deeper layers of the skin. Some people have apparently visible indented scars (pockmarks) on their face while others only have small, flat scars that are hardly noticeable on their face.

Acne scars can be divided as follows:

  1. Hypertrophic Scars: This type of acne scar is less commonly seen. They are usually found in people with severe acne. These scars can be seen on your back, chest, and shoulders. During the process of healing of the wound production of excessive connective tissue causes hypertrophic scars.
  2. Atrophic Scars: It is found in people who do not squeeze their pimples, and they are less likely to get scars. During the process of healing of the wound, when it does not heal properly, the connective tissue is not produced in sufficient amounts. Hence a scar forms beneath the surrounding skin, creating a dent in the skin.
  3. Keloid scars: It is a very rare type of acne scarring. They are bigger than the original inflamed area unlike in the hypertrophic scars. These scars also occur when excessive connective tissue is produced.

Some other skin conditions that may mimic acne are

  • Rosacea: It affects people in their thirties and forties. It occurs in the middle third of the face, along with redness. Flushing and superficial blood vessels are also seen in few cases. Pimples characterize this condition in the middle third of the face, but they do not have comedones.
  • Folliculitis: They are inflamed follicles and not acne. Doctors may prescribe oral antibiotics, generally not the same ones used for the treatment of acne.
  • Pseudofolliculitis: When the hair on the skin is shaved they may produce small tender bumps known as “razor rash or bumps.” In such cases, treatment involves growing beard, shaving less often and laser hair removal.
  • Gram-negative folliculitis: Some people develop pustules filled with bacteria on their skin that are resistant to antibiotics. It is commonly seen in patients who are treated with oral antibiotics for long periods of time. Bacterial cultures are helpful in such kind of cases.
Risk factors
  • Age: Young adults and teenagers are more prone to acne. But it can affect people of all age groups.
  • Hormonal Changes: Hormonal imbalance is often seen in girls and women during the menstrual cycle and pregnancy.
  • Medications: Certain drugs that contain corticosteroids, lithium and androgens are high-risk factors for acne.
  • Family History: Genetics often play a role in acne. If your parents have acne, then you have the risk of developing acne too.
  • The Friction of your Skin: This friction on the skin is usually caused by cellphones, telephones, helmets, backpacks and tight collars.

Your physician can diagnose acne by:

  • Examination of the skin of face, chest, the abdomen, and the back,
  • For the different types of a spot (such as blackheads or whiteheads, red nodules, pimples).
  • How many spots you have and whether they are painful or not.
  • History can be asked about conditions like PCOS. (In adult women, condition like PCOS – Polycystic Ovarian Syndrome can cause hormonal imbalance that can cause acne).
  • Four grades can be used to measure the severity of acne. This is important in planning your type of treatment. The grades are:
  • Mild – grade 1:  Acne is mostly confined to blackheads and whiteheads, with just a few pustules and papules.
  • Moderate – grade 2: There are multiple pustules and papules, which mostly occur on the face.
  • Moderately severe – grade 3: A large number of pustules and papules are seen on the back and chest, as well as the occasional inflamed nodule can be seen.
  • Severe – grade 4: A large number of painful pustules and nodules can be observed on the skin.

The treatment of acne is a slow process and may take from months to years. Topical treatments may take up to three months to start working, but they have good results after they start working. Three medications that are proven to be effective on acne are benzoyl peroxide, retinoids, and also antibiotics. These medications target the acne by acting on different factors. In most of the patients, two of the below drugs can be used as an effective treatment for acne.

1) Benzoyl peroxide: It targets surface bacteria, P. acnes that often aggravate acne. Dryness or Irritation of skin is a common side effect. If it is not used as per the instructions or excessive application on the skin can cause peeling of the skin.

It must be used in wash formulations or lower concentrations. It is available as a face wash or leave-on gel. Few products that contain benzoyl peroxide (in low concentrations) may be advised by your doctor to treat acne.

2) Retinoids: Most of the patients are suitable candidates for retinoid therapy. They are vitamin A derivatives which act by breaking up of comedones (both whiteheads and blackheads). They help in preventing the formation of first lesions of acne and thus help prevent the clogging of pores. To prevent the formation of new bumps of acne, they must be applied to the entire affected area of the skin. The common side effects of this therapy are excessive dryness of the.

Isotretinoin: It is usually prescribed as an oral retinoid. It is used in patients with severe scarring or acne. This helps in shrinking of the size of oil glands (the anatomic origin of the acne). The acne diminishes if the oil glands are inactive. The course usually is given for five to six months. The common side effects are skin dryness; patients can also have elevated liver enzymes or blood lipids. Risk of the devastating birth defect is usually seen when given to pregnant women or women of childbearing age (women planning to get pregnant).

3) Hormone Therapy: It is helpful especially for those women with acne which flare up during menstruation cycle.  The hormone therapy consists of

A medication that blocks the effect of male hormones (at the level of oil glands and hair follicle) known as spironolactone

Low-dose progesterone and estrogen (usually seen in birth control pills)

4) Antibiotics: Topical or oral antibiotics are used to treat acne. Erythromycin and clindamycin are applied on the skin or taken orally to prevent the accumulation of surface bacteria on the skin and often the inflammation of the skin is reduced. Antibiotics are most effective when used in combination with retinoids or benzoyl peroxide. It helps in preventing antibiotic resistance.

Antibiotic creams: If acne is caused by bacteria, it may be treated with stronger antibiotic creams advised by your doctor. Acne present on the back and chest is usually of bacterial origin.

Oral antibiotics: Tetracyclines are effective in treating acne. Other oral antibiotics that are useful in the treatment of acne are Amoxicillin, cefadroxil, and other sulfa drugs. Doxycycline can cause esophagitis (irritation of the esophagus) and an increased tendency to sunburn. Long-term use of tetracyclines can cause induce bacterial resistance and weaken the immune system.

5) Oral contraceptives: Low dose oral contraceptives can treat acne.

6) Spironolactone: This drug blocks hormone receptors such as androgen hormone receptors. It can cause menstrual irregularities, breast tenderness, and increased potassium levels in the bloodstream. It is generally well-tolerated in young women and in women with resistant acne.

7) Cortisone Injections:  Doctors inject a form of cortisone to make large cysts and pimples to flatten out fast.

8) Light Treatments: Special lights and devices are used in the treatment of acne alone or in conjunction with photosensitizing dyes. These treatments can be effective and are safe. The best option is laser treatment of acne and is considered as an adjunct to conventional therapy.

9) Chemical Peels: Chemical peels (such as the superficial peels with glycolic acid) have supportive benefit. They do not substitute for regular therapy.

10) Treatment of Acne Scars: In some patients, acne leaves them with permanent scarring on the skin. Surgical procedures to elevate deep acne scars can be done. Smoothing out of shallow acne scars can be done by laser resurfacing.

11) Self-Care Measures: Many self-care measures can prevent acne and are helpful in having better skin.

  • Do not attempt to squeeze or prick the acne spots, this can lead to permanent damage of the skin and severe scarring is often seen.
  • Frequent washing of skin can make the symptoms worse. Do not wash the affected areas of skin many times (more than twice a day).
  • Very cold or hot water can worsen acne. The affected area can be washed with a mild cleanser or soap and lukewarm water.
  • Do not try to squeeze spots or “clean out” blackheads. This can make the acne worse and may also result in permanent scarring on the skin.
  • Several over the counter creams or lotions are available that reduce the spots.
  • Use a water-based, fragrance-free skin emollient if your skin is too dry.
  • Make-up must be removed completely before going to bed.
  • Avoid using too many cosmetics and too much make-up. Use the product that is less likely to clog the pores in your skin such as water-based, non-comedogenic cosmetics.
  • Wash your hair regularly, and this may prevent, falling of hair on your face.

12) Exercise: Regular exercise may not improve acne. But it can improve your self-esteem and boost your mood. Take a shower after the exercise as sweat can also clog the pores and worsen your acne.

Acne can be prevented by taking simple measures such as:
  • Keep your face clean: It is important to wash your face twice daily. Impurities, dead skin cells and extra oil can be removed from your skin’s surface.
  • Moisturize: Always use a moisturizer that minimizes dryness and peeling of skin as many acne products contain ingredients that may cause dryness of the skin.
  • Use makeup sparingly: During a breakout of acne, avoid wearing foundation, face powder, or blush. Non-comedogenic products can be preferred.
  • Over-the-counter acne product: Try an over-the-counter acne product such as salicylic acid, benzoyl peroxide, glycolic acid to reduce acne.
  • Avoid too much touching of your skin: Avoid touching your chin, face as you can irritate the already inflamed facial skin and spread bacteria. Do not pop the pimples.
  • Avoid Sunlight: The sun’s UV rays (ultraviolet rays) can increase redness and inflammation of the skin and can cause post-inflammatory hyperpigmentation.
  • Hair Products: Avoid using oils, fragrances, or gels on your hair that may aggravate your acne.
  • Skin Care: Eating healthy fruits and vegetables can prevent acne breakouts.
  • Exercise: Regular exercise is good for your body, including your skin.
  • Stress & Depression: Avoid stress and stress relating factors that may aggravate your acne as much as possible.

What is acne?

Acne is a disorder of the follicle. It is evolving from the buildup of bacteria, dead skin cells, and the increasing amounts of sebum or oil that blocks up the pores

What causes acne-prone skin?

Acne prone skin is caused mainly due to two factors such as heredity and hormones. The dead cells on the skin build up on the follicle wall, clogging the follicle causing the skin to be acne prone.

What role does oiliness play in the development of acne lesions on the skin?

The oil glands in the skin are “switched on” by hormones. This explains both the development of acne during puberty, as well as hormone-related acne flares associated with menstrual and pre-menstrual breakouts. Sebum or oil “coats over” the dead cells of the skin, forming plugs in the lower part of hair follicle called microcomedones.

What role does stress play in acne and acne flares?

Stress actually can cause hormone fluctuations. They can cause sudden surges of oil and inflammation of follicles that can lead to sudden breakouts of acne-causing acne flares.

Do greasy foods, pizza, and chocolate cause or make acne problems worse?

The role of food in acne is relatively minimal. It is essential to have a balanced diet. Greasy food as such does cause acne.

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