Acne

ACNE

DEFINITION

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Acne is a common skin disease characterized by pimples on the face, chest, and back. It occurs when the pores of the skin become clogged with oil, dead skin cells, and bacteria.

DESCRIPTION

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The medical term for acne is acne vulgaris. It is the most common of all skin diseases, affecting about seventeen million Americans. Acne can occur at any age, but it is most common among adolescents. Nearly 85 percent of people between the ages of twelve and twenty-five develop acne. Up to 20 percent of women over twenty-five develop mild acne. The disease is also sometimes found in newborns.

Acne is a disease of the sebaceous (pronounced see-BAY-shus) glands. These glands lie just beneath the surface of the skin. They produce an oil called sebum, which keeps the skin moist. At puberty, a person's body may begin to produce an excess of sebum. Puberty is the period of life when a person's sex hormones become active. The male sex hormone called androgen causes an over-production of sebum.

When excess sebum combines with dead skin, a hard plug, or comedo (pronounced KO-mee-do), is formed. The comedo can block skin pores. Two types of comedos can occur. They are known as whiteheads and blackheads.

More serious forms of acne develop when bacteria invade blocked pores. A pimple forms when sebum, bacteria, skin cells, and white blood cells are released into tissue around the pore. The pimple may then become inflamed. Inflamed pimples near the skin are called papules. Those that form deeper in the skin are called pustules. The most severe type of acne occurs when cysts (closed sacs) or nodules (hard swellings) form.

Acne often causes scarring of the skin. This occurs when new skin cells form to replace damaged cells. The new skin is usually not formed very easily, causing an unevenness that produces scars. Acne occurs most commonly on the face, chest, shoulders, and back because those are the places that sebaceous cells occur.

Acne: Words to Know

Androgen:

A male sex hormone found in both males and females.

Anti-androgen:

A drug that slows down the production of androgens.

Antibiotic:

A drug that kills bacteria.

Comedo:

A hard plug that develops in the pores of the skin composed of sebum and dead skin cells. The mildest form of acne.

Comedolytic:

Drugs that break up comedos and open clogged pores.

Isotretinoin:

A drug that decreases sebum production and dries up acne pimples.

Sebum:

An oily material produced by sebaceous glands that keeps the skin moist.

Tretinoin:

A drug that increases the rate at which skin cells are formed and die.

CAUSES

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The exact cause of acne is not known, however, several risk factors have been identified.

• Age. Because of the effect of sex hormones, teenagers are quite likely to develop acne.
• Cosmetics. Make-up and hair sprays that contain oils can make acne worse.
• Diet. Acne is not caused by diet, but some foods can make the disease more serious.
• Disease. Hormonal disorders can increase the severity of acne problems in girls.
• Drugs. Acne can develop as a result of using certain drugs, such as tranquilizers, antibiotics, oral contraceptives, and anabolic steroids. Steroids are synthetic hormones that may sometimes be abused by athletes to increase the size of their muscles.
• Environment. Acne can become worse as a result of exposure to oils, greases, and polluted air. Sweating in hot weather can also make the condition worse.
• Gender. Boys are more likely to develop acne and tend to have more serious cases than girls.
• Heredity. Acne is more common in some families than in others.
• Hormonal changes. Acne can flare up during menstruation, pregnancy, and menopause. Menopause is the period in a woman's life when her body stops producing certain hormones.
• Personal hygiene. Strong soaps, hard scrubbing, and picking at pimples can make acne worse.
• Stress. Emotional stress can contribute to acne.

SYMPTOMS

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Acne is often not apparent to an observer. Inflamed pores, however, can cause pain or itching. The most troubling aspect of acne for many people is the scarring that can occur. And, while acne may not be very noticeable, individuals tend to be sensitive about their appearance. Teenagers especially may become concerned about the way other people react to them.

DIAGNOSIS

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People with acne are often treated by family doctors. More serious cases are referred to a dermatologist (a specialist in skin disorders) or an endocrinologist (a specialist in hormonal disorders).

Because of its appearance, acne is not difficult to diagnose. A doctor takes a complete medical history, which includes questions about skin, diet, medication use, and other factors associated with risk for acne. He or she conducts a physical examination of the face, upper neck, chest, shoulders, back, and other affected areas. The doctor determines the number and type of blemishes, whether they are inflamed or not, whether they are deep or near the surface of the skin, and whether there is scarring or skin discoloration.

Laboratory tests are not done unless the patient appears to have a hormonal disorder. In that case, blood tests and other tests may be ordered. Most insurance plans cover the cost of diagnosing and treating acne.

ANTI-ACNE DRUGS
Brand Name (Generic Name)	Possible Common Side Effects Include:
Accutane (isotretinoin)	Dry skin, dry mouth, conjunctivitis
Benzamycin	Dry and itchy skin
Cleocin T (clindamycin phosphate)	Dry skin
Desquam-E (benzoyl peroxide)	Itching, red and peeling skin
Erythromycin topical (A/T/S, erycette, t-stat)	Burning, dry skin, hives, red and peeling skin
Minocin (minocycline hydrochloride)	Headache, hives, diarrhea, peeling skin, vomiting
Retin-A (tretinoin)	Darkening of the skin, blistering, crusted, or puffy skin

TREATMENT

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Acne treatment consists of reducing sebum production, removing dead skin cells, and killing bacteria. Treatment methods differ depending on how serious the acne is.

Topical Drugs

Topical drugs are applied directly to the affected areas of the skin. They are available in the form of creams, gels, lotions, or pads. They are used primarily to treat mild forms of acne in which there is little or no inflammation.

One group of topical drugs used for acne includes antibiotics. These drugs kill the bacteria that contribute to the disease. Another group of drugs is called comedolytics (pronounced KO-mee-do-LIE-tiks). These drugs loosen hard plugs and open pores. Still another group of drugs works by increasing the rate at which new skin cells form. These drugs prevent the formation of new comedos.

Topical drugs are applied once or twice a day after washing with mild soap. Treatment may have to continue anywhere from a few weeks to a few months to a few years. Side effects such as mild redness, peeling, irritation, dryness, and an increased sensitivity to sunlight may occur.

Oral Drugs

Oral drugs are taken by mouth. Doctors sometimes prescribe oral antibiotics for moderate cases of acne. These antibiotics prevent the formation of new comedos and reduce inflammation. They are usually taken once a day

for two to four months. Side effects may include allergic reactions, stomach upset, vaginal yeast infections, dizziness, and tooth discoloration.

A drug that is used for severe cases of acne is isotretinoin (pronounced i-so-TRET-uh-no-un, trade name Accutane). This drug reduces the production of sebum and the stickiness of skin cells. It is used when cysts and nodules are present. The drug may be used alone or with other topical or oral antibiotics.

Isotretinoin treatment usually lasts for four or five months. It is effective in about 60 percent of all patients. If the acne reappears, another course of treatments may be necessary. Some side effects that may accompany the use of isotretinoin include nosebleeds, dry skin, a temporary worsening of the acne, vision disorders, and increased production of liver enzymes, blood fats, and cholesterol. It may also cause birth defects and cannot, therefore, be used by pregnant women.

Women who do not respond to any of these treatments may be given another type of oral drug, an anti-androgen. Anti-androgens reduce the production of androgen and therefore reduce the formation of comedos. Certain types of oral contraceptives are also effective as anti-androgens.

The most serious forms of acne require other types of drugs, including oral corticosteroids, or anti-inflammatory drugs. These drugs are often used for the treatment of a form of acne known as acne fulminans, which occurs mostly among adolescent males. They are also used with acne that produces numerous deep, inflamed nodules that heal with scarring.

Other Treatments

Several surgical or medical treatments may be used to reduce acne or the scars caused by the disease.

• Chemical peel. A chemical known as glycolic acid is first applied to the skin. When it dries, it is peeled off, taking the top layer of skin with it. This treatment helps reduce scarring.
• Collagen injection. Shallow scars are filled in by injecting collagen, a skin protein, beneath the scars.
• Comedo extraction. A special tool is used to remove a comedo from a pore.
• Dermabrasion. The affected skin is first frozen with a chemical spray. Then it is removed with a brush or sandpaper-like instrument.
• Intralesional injection. Anti-inflammatory drugs are injected directly into inflamed pimples.
• Punch grafting. Deep scars are removed and the area repaired with small skin grafts.

Alternative Treatment

Alternative treatments for acne focus on proper hygiene and diet. Patients are advised to keep their skin clean and oil-free. They are also encouraged to eat a well-balanced diet high in fiber, zinc, and raw fruits and vegetables. They should also avoid alcohol, dairy products, caffeine, sugar, smoking, processed foods, and foods high in iodine, such as table salt.

Some doctors recommend the use of herbs to supplement the diet. Some herbs that have been used in the treatment of acne include burdock root, red clover, and milk thistle. Additional nutrients that may help to control acne include B-complex vitamins and chromium. Chinese herbal treatments that are recommended include cnidium seed and honeysuckle flower. Another herbal treatment is tea tree oil. The proper dose of these substances can be recommended by physicians or nutritionists.

PROGNOSIS

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Acne cannot be cured. However, it can be controlled in about 60 percent of patients with the drug isotretinoin. Improvement usually takes at least two months, and the problem may recur after treatment has been stopped. Inflammatory acne that results in the formation of scars may require one of the more aggressive treatments already described.

PREVENTION

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There are no sure ways to prevent acne. However, the following steps tend to reduce flare-ups of the condition:

• Gently wash—do not scrub—the affected areas once or twice every day.
• Avoid rough cleansers.
• Use makeup and skin moisturizers that do not produce comedos.
• Shampoo often and wear hair away from the face.
• Eat a well-balanced diet and avoid foods that trigger flare-ups.
• Give dry pimples a limited amount of sun exposure unless otherwise directed by your doctor.
• Do not pick or squeeze pimples.
• Reduce stress.

FOR MORE INFORMATION

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Books

Balch, James F., and Phyllis A. Balch. "The Disorders: Acne." in Prescription for Nutritional Healing, edited by Amy C. Tecklenburg, et al. Garden City, NY: Avery Publishing Group, 1997.

Bark, Joseph P. Your Skin: An Owner's Guide. Englewood Cliffs, NJ: Prentice Hall, 1995.

Chu, Tony, and Anne Lovell. The Good Skin Doctor: A Leading Dermatologist's Guide to Beating Acne. London: Thorson's, 1999.

Silverstein, Alvin, Robert Silverstein, and Virginia Silverstein. Overcoming Acne: The How and Why of Healthy Skin Care. New York: William Morrow & Company, 1992.

Periodicals

Billings, Laura. "Getting Clear." Health Magazine (April 1997): pp. 48–52.

Christiano, Donna. "Acne Treatment Meant for Grown-Ups." American Health (October 1994): pp. 23–24.

"Clearly Better New Treatments Help Adult Acne." Prevention Magazine (August 1997): pp. 50–51.

"Pimple Control Pill?" Prevention Magazine (May 1997): p. 132.

Organizations

American Academy of Dermatology. 930 N. Meacham Road., Schaumburg, IL 60173–6016. (847) 330–0230. http://www.aad.org.