Troubles of Acne

Many of us will be plagued with acne at some point in our lives – just when you think you’re safe, those hormonal changes kick in and – it’s blemish-central. Acne is characterised by primary lesions on the face, chest, and back, which form when the skin pores become clogged with oil, dead skin cells, and bacteria. Such lesions are either noninflammatory (open and closed comedones, also called whiteheads and blackheads) or inflammatory (papules and pustules).

Acne and Hormones

Acne is a common inflammatory disorder of the face, back, and chest that is characterised by the presence of blackheads, pustules, and potentially cysts and scars. Acne usually starts at puberty and varies in severity from a few spots, which most adolescents will have at some time, to a more serious problem that may be embarrassing, sap self-confidence and cause scarring. The sebaceous (oil-producing) glands of people who get acne are particularly sensitive to normal blood levels of a hormone called testosterone, which is present in both men and women. This causes the glands to produce an excess of oil. At the same time, the dead skin cells lining the pores are not shed properly and clog up the follicles. These two effects result in a build-up of oil producing blackheads (where a darkened plug of oil is visible) and whiteheads. During the teenage years, you make much more sebum than when you were a child. This is due to the hormonal changes of puberty which stimulate the sebaceous glands. As a rule, the more sebum that you make, the more greasy your skin feels and the worse acne is likely to be.

What is Propionibacterium Acnes?

The acne bacterium (known as Propionibacterium acnes, P.acnes) lives on everyone’s skin, usually causing no problems, but, in those prone to acne, the build-up of oil creates an ideal environment in which these bacteria can multiply. This triggers inflammation and the formation of red or pus-filled spots.

Acne Most Commonly Develops On The:

  • face – this affects almost everyone with acne
  • back – this affects more than half of people with acne
  • chest – this affects about 15% of people with acne

4 main contributing pathogenic factors of acne have been clearly identified:

  1. Androgen-induced seborrhoea(excess grease)
    • The more sebum (grease) the greater degree of acne
    • Sebum is produced by the pilosebaceous glands, which are predominantly found on the face, back and chest
    • Evidence suggests that in most patients the seborrhoea is due to increased response of the sebaceous glands to normal levels of plasma androgens
  2. Comedone formation (blackheads, whiteheads and microcomedones)
    • Is due to an abnormal proliferation and differentiation of ductal keratinocytes
    • It is controlled, in part, by androgens
    • In pre-pubertal subjects comedones are seen early and they precede the development of inflammatory lesion
  3. Colonisation of the pilosebaceous duct with P. acnes
    • Is a later stage in the development of acne lesions (especially inflammatory lesions)
    • The seborrhoea and comedone formation alter the ductal micro environment, which results in colonisation of the duct
    • P. acnes is the most important organism
  4. Production of inflammation
    • Biological changes occurring in the duct as a result of comedone formation and P. acnes colonisation of the duct
    • And the patients cellular (especially lymphocytes) response within the dermis, which responds to pro-inflammatory cytokines spreading from the duct to the dermis

Secondary factors that could trigger or exacerbate acne may include inappropriate personal hygiene (use of abrasive soaps, harsh detergents, and excessive scrubbing), use of cosmetics and emollients (pore occlusion could cause an acneiform eruption), environmental factors (exposure to dust, dirt, polluting elements, food residues, and sweat), hormonal factors and common medications.

  • Acne Scars– Scars can happen with all types of acne. Scars can be narrow ‘ice pick’ scars or broader ‘box’ scar or wavy ‘rolling’ scars.
  • Hyper/hypo-pigmentation– Leaving residual reddish brown spots after the acne heals
  • Psychological Issues– Acne can cause anxiety and depression in some people by affecting one’s confidence.

Some pores become plugged. This is due to the skin at the top of the pores becoming thicker, combined with dead skin cells that are shed into the pores. Those plugs that block the top of the pores as tiny spots known as blackheads and whiteheads (comedones).

  • Blackheads appear on the skin as tiny black dots. The dark color of blackheads is not caused by dirt; instead, this is the colour sebum takes after being exposed to air. Blackheads also stretch the opening of a pore. Blackheads are sometimes called open comedones.
  • Whiteheads are closed, and have a white or yellowish head. Unlike blackheads, whiteheads haven’t pushed all the way through to the skin’s surface so they are considered closed off from air that turns the sebum black. Whiteheads are also known as closed comedones. They often appear on the face, especially the chin and nose.
  • Small pimples, also known as papules, are pink or red dome-shaped bumps, varying in size from a pinhead to half an inch. There is no visible fluid and they don’t contain pus. They are usually painless unless scratched or picked.

When a large number of P.acnes develop in the trapped sebum, the immune system may react and cause inflammation. When inflammation develops, it causes the surrounding skin to become red and the spots become larger and filled with pus (pustules). In some cases, the pustules become even larger and form into small nodules and cysts.

  • Pustules are like papules except that they are noticeably white or yellow in the middle and are filled with pus. When your immune system attempts to fight bacteria that has made its way into a ruptured follicle, it will set off a build-up of white blood cells, resulting in pus production. The greater the inflammation, the redder and larger the pustule will be.
  • Nodules are hard acne lesions lodged deep within the skin and are often painful. They are larger than pustules and papules, and feel solid to the touch. Unlike other, less severe forms of acne, Nodules may persist for weeks or even months, with the result of their contents hardening into deep (and stubborn) cysts. They may be dormant and rear up in occasional bouts. If squeezed or ruptured, these nodules can spread over a larger area of the skin and cause deep infections. These lesions can cause damaging and permanent scars to the skin. Over-the-counter treatments may not be powerful enough to clear them up, and a visit to the dermatologist may be required to treat such cases of acne.
  • Cysts are the most severe form of acne. They are deep, painful, pus-filled bumps that can be quite large, measuring up to an inch or more, and may result in permanent scarring. This severe form of Acne Vulgaris usually requires the help of a dermatologist in conjunction with self-care and preventative measures.

  1. Topical Treatments

Topical (applied to the skin) prescription products are the most common medical treatment for mild to moderate acne. The active ingredients often target only one cause of acne – help to control abnormal shedding of skin cells, or kill bacteria or reduce excess oil production. Newer combination treatments have been developed that include several active ingredients and target multiple factors at the same time. The main active ingredients in topicals are:

  • Retinoids
  • Antibiotics
  • Benzoyl peroxide
  1. Oral Medications

Oral medications, also called systemic medications, work internally to improve the skin. Acne medications work by reducing oil production, speeding up skin cell turnover, fighting bacterial infection or reducing inflammation — which helps prevent scarring. With most prescription acne drugs, you may not see results for four to eight weeks, and your skin may get worse before it gets better. It can take many months or years for your acne to clear up completely. The main forms of oral medications are:

  • Oral Antibiotics (e.g. Tetracycline, Doxycycline or Trimethoprim)
  • Oral Isotretinoin (e.g. Accutane)
  • Oral Contraceptives (e.g. Ortho Tri-Cyclen or Yaz)

Read more about Isotretinoin for acne in: Isotretinoin – How It Works & Its Side Effects

As much as you’d like to forget your pimpled past, your face remembers—in the form of scars. The scars acne leave behind can feel downright diabolical. The good news is that acne scars can be treated. There are many clinically proven treatment options available to help reduce the appearance of your scars, including:

  • Chemical Peels
  • Subcision
  • Laser Resurfacing
  • Light Therapies
  • Fillers
  • Radiofrequency Microneedling

It’s important to have realistic expectations about what aesthetic treatment can achieve. While treatment can certainly improve the appearance of your scars, it can’t get rid of them completely.

After treatment for acne scarring, most people notice up to 80% improvement in their appearance.