ACNE VULGARIS: CAUSE, TRIGGERS, TYPES, TREATMENT, PREVENTION AND MANAGEMENT

OVERVIEW

 Acne is a human skin disease that is caused when the hair follicles of the skin becomes blocked with excess sebum/oil and dead skin cells. It is also known as Acne vulgaris or Common acne. The disease tends to occur in skin areas with more amount of oil such as the face, neck, upper part of the chest, back and shoulders. It is not life-threatening but can leave skin scars behind. Acne spots include whitehead, blackheads, papules, pustules, nodules and cysts. Factors that trigger a case of acne include: Hormonal activities, genetic make-up, bacterial infection, stress, certain medications, cosmetics (known as comedogenic cosmetics) and diet. Treatment of acne involves using lotions or drugs that aims at normalizing the sebum production, killing the bacteria, hormonal manipulation and exhibiting anti-inflammatory effects

Blackheads: They are black, very visible and occur when the blockage opens to the surface of the skin (exposed to air) causing the sebum to become oxidized

For better understanding, it is important for us to take a brief look at the structure of the skin.

The skin is composed of 3 primary layers:
- Epidermis: this is the outermost layer and further consists of 3 layers called the Cornified layer (outermost or surface layer), the Granular layer (middle layer) and the Malpighian layer (the innermost layer)
- Dermis: found just after the epidermis
- Hypodermis (the innermost layer)

Deep in the Dermis layer are 2 organs known as
- Sebaceous or Oil gland: This secrets an oil known as Sebum which lubricates the hair and skin
- Hair follicle: This is formed by the infolding of the Malpighian layer. It is closely associate with the sebaceous gland and is, in fact, the only linkage the sebaceous gland has with the tiny pores on the skin surface. Hair arises from it.

The sebum/oil secreted by the sebaceous gland carries dead skin cells (this is known as Desquamation) and travels up through the hair follicles onto the skin surface.

Structure of the skin

Acne is specifically and medically caused when there is an excessive production of sebum which then, together with the dead skins, builds up and blocks the hair follicle creating an environment where bacteria can grow.

This disease tends to occur in skin areas that has more population of the sebaceous gland or secretes more amount of the sebum. These areas include the face, neck, upper part of the chest, back and shoulders

For most people, acne reduces over time and tends to disappear by the age of 25. However, for some other people, the disease may persist even into their thirties, forties and beyond

Acne is neither dangerous nor life-threatening, but it can leave skin scars behind. Apart from the scarring, its main effects are psychological such as reduced self-esteem, depression and, in extreme cases, a tendency to commit suicide.

Acne spots (generally referred to as pimples) are divided into 6 classes

1. Whiteheads: In this type, the blockage remains under the skin (closed off to the air) and are usually small with white tips

The blockage remains under the skin. Whiteheads are small with white tips

2. Blackheads: These are clearly visible. They are black and occur when the blockage opens to the surface of the skin (exposed to air) causing the sebum to become oxidized. [the opening picture is a typical view of Blackhead]


Note: Whiteheads and Blackheads are also known as Comedones (singular: Comedo)

3. Papules: These are caused when the hair follicles get so blocked that they get irritated and their walls break out. Papules are hard when you touch them and a bunch of papules that are near each other can make the skin feel like sandpaper

The blocked follicles get irritated and their walls break out. Papules are hard and makes the skin feel rough

4. Pustules: These are caused just like papules but are usually larger and filled up with pus

Pustules are similar to Papules but are usually filled with pus

5. Nodules: These occur when the blocked hair follicle gets even more irritated, causing a significant breakage of the wall. They are embedded deep in the skin and are bigger in size. Nodules are hard, do not have pus in them and can really hurt

Nodules are bigger in size, embedded deep in the skin, hard and do not have pus in them.

6. Cysts: These are similar to nodules except that they are soft and filled with pus. They can cause scars

These are similar to Nodules but are soft and filled with pus

Acne skin structure. (A): normal skin structure. (B): Blackheads. The blockage opens to the skin surface causing the sebum to become oxidized and turn black. (C): Whiteheads. The blockage is still within the skin surface. (D): Papules and Pustules. Notice that the wall of the hair follicle has broken. (E): Nodules and Cysts. There is significant breakage of the walls

Causes of Acne

The following factors can trigger or escalate an existing case of Acne

1. Hormones: Hormonal activities, such as that experienced during puberty, menstrual cycle and pregnancy can cause Acne. During puberty/adolescence, there is a significant increase in the production of male sex hormones called Androgens (testosterone, dihydrotestosterone and androstenedione). These hormones causes the sebaceous gland to enlarge and secrete more sebum. This is the major reason why Acne has a high occurrence among adolescence. Also, the use of anabolic steroids could cause a similar effect

2. Genetics: Genetic make-up can make some individuals more predisposed to Acne than others

3. Bacterial infection: Propionibacterium acnes is an anaerobic (Oxygen-hating) bacterium normally and commonly found in the skin. When the hair follicles in the skin become blocked, an anoxic (Oxygen-absent) environment is created enabling this bacterium to proliferate. Presence of this bacterium in large numbers can cause acne.

4. Certain medications: Some drugs that contain Corticosteroids, androgens or lithium are known to cause acne

5. Stress: This does not exactly cause acne, but it can worsen an existing case of acne. Cells that produce sebum have receptors for stress hormones. However, this is just a clue. The actual mechanism behind it has not been fully established.

6. Cosmetics: Some skin-care products are pore-blocking, causing Comedones. Skin products that claim not to block pores are termed "non-comedogenic" or "non-acnegic" while those that do are termed "comedogenic" or "acnegic"

7. Diet: Contrary to widespread opinion, chocolate, fatty, greasy, fried and junk food do not cause Acne. When these foods are taken in excess, they are stored in the adipose tissues - a collection of body fat cells located beneath the skin. However, studies have shown that certain dietary factors such as milk products and carbohydrate-rich foods such as bread, chips etc may trigger acne in some people.

Treatment 

The various treatments of Acne works in at least 1 of the following 4 different ways

• Normalizing sebum production and shedding of dead skin cells into the hair follicle to prevent blockage

• Killing the bacteria, Propionibacterium acnes

• Anti-inflammatory effects

• Hormonal manipulation.

Various Acne medications includes:

1. Over-the-counter (OTC) topical lotions: This is usually used if it is a mild case of acne. They can be used without a doctor's prescription. These lotions act by drying up the sebum to a reasonable level, killing the bacteria and promoting the efficient movement of dead skin cells. OTC acne lotions contain active ingredients such as Benzoyl peroxide, Salicylic acid, Sulphur, Alpha-hydroxy acids and Azelaic acid

2. Topical treatments available by prescription: This is the next step taken if OTC lotions are not effective. It involves getting a doctor or dermatologist to prescribe a stronger lotion. Certain topical products derived from vitamin A can be used. These include Adalapene, tretinoin, tazarotene etc. They act by promoting dead cell movement and preventing blockage of the hair follicles

3. Oral antibiotics: This is used for moderate to severe acne and involves the intake of prescribed oral antibiotics to fight the bacteria and reduce inflammation. However, with increasing resistance of P.acnes, antibiotics are becoming less effective. Commonly used antibiotics either applied topically or taken orally include erythromycin, clindamycin, sodium sulfacetamide and tetracycline. For optimal results, a combination of oral antibiotics and acne lotions can be used.

4. Isotretinoins: This is a very effective medication for severe acne such as cystic acne or acne that has defied the above treatment options. However, it has a lot of side-effects and should be taken under the close supervision of a doctor. Its side-effect include dry skin, eyes, mouth, lips and nose, nosebleed, muscle pains, increased liver enzymes and lipid levels in the blood and depression. It also causes severe birth defects and so shouldn't be taken during pregnancy.

5. Oral contraceptives: This involves the oral intake of birth control pills containing Oestrogen (the female sex hormone). They act by suppressing the action of Androgens and can help improve acne in women. Its side effects include headaches, breast tenderness, nausea, depression, high blood pressure and blood clots

6. Corticosterois injection: This involves injecting a diluted corticosteroid into a particularly large acne spot, usually a cyst, to relieve pain and prevent it from rupturing on its own. The cyst usually breaks down within a few days after this injection.

Prevention and management of Acne:

• Wash problem areas with mild soap at least twice daily

• Wash gently. Do not scrub, as scrubbing may irritate the skin and worsen the acne

• Use oil-free or water-based skin products. While trying to choose a skin-care product, it is essential to read the list of ingredients and choose those which have high water content than oil. Water-based products are usually best for those with acne

• Avoid bursting pimples. You may push the infection further down, causing more blocking and worse swelling and redness. Also, bursting pimples makes scarring more likely.

• Your skin needs to breathe. If your acne is on your back, shoulders or chest try wearing loose clothing. Tight garments, such as headbands, caps and scarves should be avoided - if you have to wear them make sure they are cleaned regularly.

• As much as possible, avoid the incessant touching of the face. If you must do so, then it should be with clean hands.

• Avoid going to sleep with makeup on   

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