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There are certain periods of our lives we rather forget. And acne is one of them. It can be an embarrassing phase which affects not only our skin but also affect our self confidence. Acne is a common non-contagious skin condition relating to blocked skin pores that results in skin lesions. It affects most of us at sometime during our lifetime, more commonly during our teenage years. It can be grouped broadly into two main categories: 1) Non-inflammatory acne: Here acne lesions appear as whiteheads (closed comedones) or blackheads (open comedones). When bacteria and sebum are trapped in the pores below the skins surface, they appear as white spots and are known as 'whiteheads'. When the pore opens up to the surface of the skin and the contents gets oxidized and turns black, the lesions are then known as 'blackheads'. 2) Inflammatory acne: Here the acne lesions are inflamed and may appear as papules, pustules, cysts, nodules. With nodules being the most severe. Incidence: o Majority of acne cases occur between 10-17 years in females, and 14-19 years in males. o But late onset acne can sometimes occur in persons 25 years old or older. Some women develop acne in their 30 & 40's often with pre-menstrual exacerbations. o The incidence of acne is actually lower in Asians and blacks, and even rarer in China. o It can occur on the face, neck, chest, back, shoulders. Myths about Acne: 1. Acne is NOT caused by chocolate or fatty foods. 2. Acne is NOT caused by poor personal hygiene (otherwise we would have acne between our toes too) 3. Acne is NOT caused by diet. Foods do not cause acne. 4. Acne is NOT caused by masturbation 5. Acne is NOT improved by sun exposure. The Pathogenesis of Acne: By pathogenesis we mean how does a condition develop? Acne is caused by a complex interaction between the sex hormones known as androgens and bacteria (Propionibacterium acnes), along with abnormal keratinisation in the hair follicles of individuals ( usually on the face, neck, chest and back). The androgens (usually in normal amounts) stimulate the sebaceous glands of the hair follicles to produce increased amount of sebum. Normally the sebum journeys along the hair follicle to the
surface of the skin keeping it soft and supple. However in the development of acne, the combination of the increased amount of sebum, with the abnormal hyperkeratinisation of the lining of the follicle results in the plugging of the pore opening. This is known as a closed comedo (whitehead). If the plug gets exposed to the skin surface and is oxidised, it is called an open comedone (blackhead). The bacteria in these follicles act on the sebum which leads to a sterile inflammatory response. Within the follicle the bacteria continue to multiply and act on the sebum, releasing large amounts of inflammatory chemicals. The follicle walls continue to distend and may break, leading to the release of the contents into the surrounding dermis. The body mounts an intense inflammatory reaction that may result in papules, pustules or nodules which we commonly recognise as the lesions of acne. Factors that may cause or aggravate adult acne: 1. Drugs such as: Lithium, topical or systemic corticosteroids, anabolic steroids, certain types of oral contraceptive pills (oestrogen-dominant oral contraceptive pills may improve acne, while Oral contraceptive pills which contains a progestin with significant androgenic activity may aggravate acne). 2. Occupation: exposure to acnegenic mineral oils, halogenated hydrocarbons, dioxin, others. 3. Genetic Factors: Severe acne may be associated with XYY syndrome. 4. Cosmetic Induced: Certain cosmetics have ingredients that are comedogenic and may block the hair follicle openings (pore) on the skin, leading to bacterial proliferation and resultant inflammatory process with the follicle. 5. Occlusion or pressure acne: Any impermeable material worn on the skin for prolonged period of time can cause acne. Also materials that are in constant contact with the skin and cause friction or maceration can lead to acne. Occupational acne is most commonly seen in soldiers who develop acne where their bare flesh is in constant contact with their rucksacks and other equipment which they carry for prolonged periods of time. It may also be seen in person involved in regular bondage or fetish activities which involves the use outfits made of leather, rubber or PVC. 6. Emotional stress can exacerbate acne. Severity of Acne: Mild to Moderate Acne: It is the most common from of acne. Mild to moderate acne may have a combination of acne spots, such as whiteheads, blackheads, papules (red spots) and even pustules (a white or yellow pus filled centre surrounded by an inflamed red circle. Severe Acne: Nodules and Cysts are the main lesions. Nodules appear has hard painful bumps beneath the skin and can take months to heal, and scarring is common. Cysts, like nodules are painful, but are pus filled and larger (more than 5mm in diameter) in size. They too commonly heal with scarring.
Treatment of Acne: Whether acne occurs in teenagers or adults, the treatment is dependent upon the severity of the lesions and psychological impact it has on the individual. Acne can very broadly be classified as mild acne, moderate acne or severe acne. For mild acne topical treatments are the first line of therapy. In moderate cases along with the topical treatment, oral antibiotics may be added. In severe cases oral retinoid may be prescribed after blood test and close supervision by the treating dermatologist (as side effects with such a treatment can be serious). Over the counter products for acne treatment: 1. Benzoyl peroxide gels or creams are the most popular over the counter topical treatment for acne. They are effective in treating comedonal and papulopustular acne. Improvements occur over a period of months. 2. Topical preparations containing Salicylic acid helps to correct abnormal shedding of skin cells and unclog pores. Like benzoyl peroxide it needs to be used regularly otherwise pores may become blocked when treatment is stopped. It is found in many over the counter products such as lotions, creams and gels. It may be irritating to the skin. 3. Topical preparations containing nicotinamide has been shown to help to treat acne. 4. Natural remedy: Tea tree oil has been shown to have anti-microbial activity and that is probably why it is popular among those who want a 'natural' treatment. Unfortunately only a few studies have been done, so its actual effect on acne is still unclear. But one study that compared tea tree oil to benzoyl peroxide found it to improve acne but was not as effective as benzoyl peroxide. 5. Turmeric creams have been used in Ayurvedic medicine to treat acne. Avoid: Avoid products that contain ingredients that are may irritate your skin (e.g. Acetone, Algin, Laureth 4, Octyl stearate, etc), or contain comedogenic ingredients (e.g. Acetylated Lanolin, cocoa butter, Potassium chloride, Sodium Lauryl sulphate, etc). The presence of a comedogenic ingredient does not mean it will cause comedone because it also depends on the formula and what is its intended use. For instance a cleanser will remain on the face for a short time compared to a moisturiser. The list is extensive but only a few have been mentioned here. What would a dermatologist prescribe? If the topical over the counter remedies do not work, then a dermatologist after evaluating the severity of the acne lesions and the psychological condition of the patient may prescribe: 1. Mild Acne: Topical antibiotic or topical retinoid creams. 2. Moderate Acne: In addition to a topical treatment, an oral antibiotic may be added. 3. Severe Acne: Isotretinoin is a powerful retinoid drug that is usually reserved for severe acne,
which has failed to respond to all other treatments. It inhibits sebaceous gland function and inhibits keratinisation and has proved to be very effective for severe acne. But it does have serious side effects and thus must be closely monitored by your dermatologist. Pregnancy must be avoided at all costs while on this treatment. In conclusion I want to say that Acne is one of the most common skin conditions that affects almost everyone of us at some in our lives. Most of us experience it during our teenage years while a few of us experience it during our adult life. But at whatever age it decides to pay us a visit, it affects us in more ways than one.
Dr Tuhin Dev is a skincare expert, entrepreneur and founder of Dr Tuhin Dev Skin Care Ltd, which is based in the United Kingdom. To learn more about him and what he does please visit http://www.drtuhindev.co.uk. If you enjoyed this article, you can find other articles written by him at http://blog.drtuhindev.co.uk.
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