Acne is a common inflammatory 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/or bacteria.
Description
Acne vulgaris, the medical term for common acne,
is the most common skin disease. It affects nearly 17
million people in the United States. While acne can arise
at any age, it usually begins at puberty and worsens during
adolescence. Nearly 85% of people develop acne
some time between the ages of 12 and 25 years old. Up
to 20% of women develop mild acne. It is also found in
some newborns.
The sebaceous glands lie just beneath the skin’s
surface. They produce sebum, an oily secretion that
helps to preserve the flexibility of the hair and moisturizes
the skin. These glands and the hair follicles within
which they are found are called sebaceous follicles.
These follicles open onto the skin through pores that
allow the sebum to reach the hair shaft and the skin. In
certain situations, the glands excrete excess sebum and
it cannot be cleared from the pores efficiently. This
happens, for instance, at puberty when increased levels
of the androgen hormones cause overproduction of
sebum. In addition, cells lining the follicle are shed too
quickly and begin to clump together. The excess sebum
combines with the dead cells and forms a plug, or
comedo (also called comedones), that blocks the pore,
which is not usually seen. When the follicle begins to
bulge and show up as a small whitish bump mostly
under the skin, it is called a whitehead. If the comedo
opens up, the top surface of the plug darkens, and it is
referred to as a blackhead.
Infection results when a plugged follicle is invaded
by Propionibacterium acnes, a bacteria that normally
lives on the skin, and possibly other microorganisms.
The bacteria produce chemicals and enzymes that bring
on inflammation. Pimples are the result of infected
blackheads or whiteheads that rupture, releasing sebum,
bacteria, dead skin, and white blood cells onto the surrounding
tissues. Inflamed pimples near the skin’s surface
are called papules; they are red and raised, and may
be quite tender to the touch. The papules may become
filled with pus, and are then called pustules. If the follicle
continues to enlarge rather than rupture, it forms a
closed sac, called a cyst, which can be felt as a lump
under the skin. Large hard swellings deep within the skin
are called nodules. Both nodules and cysts may cause
pain and scarring.
Causes & symptoms
The exact cause of acne is mostly unknown. Sometimes
when acne in women is due to excess male hormone
production, it is diagnosed by an onset of the condition
in adulthood; excessive growth of hair, especially
in places not usual on a female, called hirsuitism; irregular
menstrual cycles; and premenstrual flare-ups of acne.
A 2001 study demonstrated that menstrual cycle does affect
acne. Surprisingly, the study revealed that 53% of
women over age 33 experienced a higher premenstrual
acne rate than women under age 20.
Many alternative practitioners assert that acne is
often related to a condition of toxicity in the intestines or
liver. This may be due to the presence of bacteria such as
Clostridia spp. and Yersinia enterocolitica, a low-fiber
diet; a lack of friendly gut flora such as Lactobacillus
spp.; an intestinal overgrowth of Candida albicans; and
food allergies.
The interaction between the body’s hormones, skin
protein, skin secretions, and bacteria determines the
course of acne. Several other factors have also been
shown to affect the condition:
• Age. Teenagers are more likely than anyone to develop
acne.
• Gender. Boys have more severe acne and develop it
more often than girls.
• Disease. Hormonal disorders can complicate acne in
girls.
• Heredity. Individuals with a family history of acne have
greater susceptibility to the condition.
• Hormonal changes. Acne can flare up before menstruation,
during pregnancy, and menopause.
• Diet. Although they are not the primary cause of acne,
certain foods may bring on flare-ups or make the condition
worse.
• Drugs. Acne can be a side effect of antibiotics, oral
contraceptives, and anabolic steroids.
• Personal hygiene. Use of abrasive soaps, hard scrubbing
of the face, or handling pimples will often make
them worse.
• Cosmetics. Oil-based makeup and hair sprays worsen
acne.
• Environment. Exposure to oils and greases, polluted
air, and sweating in hot weather can all aggravate acne.
• Stress. Emotional stress may contribute to acne.
• Friction. Continual pressure or rubbing on the skin by
such things as bicycle helmets, backpacks, or tight
clothing, as well as hard scrubbing of the skin, can
worsen acne.
The most common sites of acne are the face, chest,
shoulders, and back, since these are the parts of the body
where the most sebaceous follicles are found. In
teenagers, acne is often found on the forehead, nose, and
chin. As people get older, it tends to appear towards the
outer part of the face. Adult women may have acne on
their chins and around their mouths. The elderly often develop
whiteheads and blackheads on the upper cheeks and
skin around the eyes. Inflamed lesions may cause redness,
pain, tenderness, itching, or swelling in affected areas.
Diagnosis
Acne has a characteristic appearance and is, therefore,
not difficult to diagnose. A complete medical history
should be taken, including questions about skin care,
diet, factors that improve or worsen the condition, medication
use, and prior treatment. Physical examination
includes the face, upper neck, chest, shoulders, back, and
other affected areas. Under good lighting, the doctor can
determine what types and how many blemishes are present,
whether they are inflamed, whether they are deep
or superficial, and whether there is scarring or skin discoloration.
Blood tests are done when the patient appears
to have hormonal or other medical problems. Stool tests
can be helpful in determining whether there is a bacterial
or yeast overgrowth contributing to the condition. Food
allergy testing should also be considered.
Treatment
Alternative treatments for acne focus on proper
cleansing to keep the skin oil-free; intermittent fasting;
eating a good diet; an elimination diet where the individual
avoids alcohol, dairy products, smoking,
caffeine, sugar, processed foods, and foods high in iodine,
a mineral which appears to contribute to acne.
Supplementation with herbs that are blood cleansers
or blood purifiers is recommended. These herbs
strengthen the action of the liver and the kidneys, helping
with detoxification and excretion. Dandelion root
tincture (Taraxacum officinale) is recommended. Others
include burdock root (Arctium lappa), also known as
gobo, and can be purchased fresh at health food grocers
or in Asian markets. It can be used either raw or cooked
in salads, stir-fries, or other vegetable dishes. Burdock
root tincture can also be used. Red clover (Trifolium
pratense) makes a pleasant tea that can be consumed
throughout the day. Milk thistle seed (Silybum marianum)
can either be taken in tincture form or the seeds
can be ground up and eaten in combination with hot cereal,
granola, or other foods.
Other herbs useful in the treatment of acne include
Echinacea spp. and goldenseal (Hydrastis canadensis).
Goldenseal is particularly helpful in clearing up underlying
conditions of intestinal toxicity. Herbal remedies
used in traditional Chinese medicine (TCM) for acne
include cnidium seed, (Cnidium monnieri), and honeysuckle
flower (Lonicera japonica). Supplementation nutrients,
such as essential fatty acids (EFAs), vitamin B
complex, zinc, vitamin A or beta-carotene, and chromium
are also recommended.
Bowel toxicity may contribute to acne flare-ups, and
should be addressed. Lactobacillus acidophilus and Lactobacillus
bulgaricus should be taken in yogurt or in
capsules to maintain a healthy balance of intestinal flora.
Goldenseal can be used to kill toxic bacteria. Allergic
foods should be identified and removed from the diet.
Dietary fiber, such as oats and wheat bran, beans, fruits
and vegetables and their skins, and psyllium seed,
should be increased in the diet. The fiber will absorb toxins
and carry them through the colon to be excreted.
In addition, those with acne may want to participate
in movement therapy, such as yoga or t’ai chi, or begin
an exercise regimen. The person may also consider
stress reduction or meditation.
Allopathic treatment
Acne treatment consists of reducing sebum and keratin
production, encouraging the shedding of dead skin
cells to help unclog the pores, and killing or limiting
bacteria. Treatment choice depends upon whether the
acne is mild, moderate, or severe. Complicated cases are
referred to a dermatologist, or an endocrinologist, who
treats diseases of the glands and the hormones. Counseling
may be necessary to clear up misconceptions about
the condition and to offer support regarding the negative
effect of acne on the physical appearance.
Topical drugs
Treatment for mild acne consists of reducing the
formation of new comedones with over-the-counter acne
medications containing benzoyl peroxide (e.g., Clearasil,
Fostex), salicylic acid (Stridex), sulfur (Therac lotion),
resorcinol (Acnomel cream). Treatment with stronger
medications requires a doctor’s supervision. Such medications
include comedolytics, which are agents that
loosen hard plugs and open pores. Adapalene (Differin),
the vitamin A acid tretinoin (Retin-A), and concentrated
versions of salicylic acid, resorcinol, and sulfur are in
this group. Topical antibiotics, such as erythromycin,
clindamycin (Cleocin-T), and meclocycline (Meclan),
may be added to the treatment regimen. Drugs that act as
both comedolytics and antibiotics, such as benzoyl peroxide,
azelaic acid (Azelex), or benzoyl peroxide plus
erythromycin (Benzamycin), are also used.
After washing with a mild soap, the acne medications
are applied alone or in combination, once or twice
a day over the entire affected area of skin. It may take
many months to years to control the condition with these
medications. Possible side effects include mild redness,
peeling, irritation, dryness, and an increased sensitivity
to sunlight that requires use of a sunscreen.
Oral drugs
When acne is severe and the lesions are deep, oral
antibiotics may be taken daily to reduce the spread of
bacteria. Tetracycline is the medication most often used.
Minocycline, however, may be more preferable because
it has fewer side effects. Erythromycin and doxycycline
are also used, and they also have side effects, including
dizziness, photosensitivity, gastrointestinal problems,
and darkening of the skin. Other possible side effects include
allergic reactions, yeast infections, dizziness,
tooth discoloration, and folliculitis. It is necessary for
antibiotics to be used for up to three months to clear up
the condition.
Isotretinoin (Accutane) can be used in cases of very
severe acne, or if antibiotic therapy proves unsuccessful.
It may clear up resistant cysts and nodules in up to 90%
of people and prevent scarring. Some do require a second
course of treatment before this happens, however.
Although the medication can be quite helpful, women
who might become pregnant should use it with care.
Isotretinoin can cause birth defects up to a month after it
has stopped being used. Therefore, strict attention is paid
to pregnancy tests and contraceptive requirements for
women of child-bearing age who take this medication.
The course of treatment with isotretinoin lasts about
four to five months. If dosage is kept low, a longer
course of therapy is needed. Isotretinoin is a strong medication.
Side effects are very common, mostly dryness of
the eyes, genital mucosa, and lips. Other effects may include
increases in cholesterol, tryglicerides, and abnormal
liver enzymes. Blood tests taken each month should
be monitored during the course of treatment to ensure
that the medication is not causing serious harm.
Anti-androgens, drugs that inhibit androgen production,
are used to treat women who are unresponsive to
other therapies. Oral contraceptives such as norgestimate/
ethinyl estradiol (Ortho-Tri-Cyclen) have been
shown to improve acne. In late 2001, a clinical trial
demonstrated that ultra low-dose birth control pills
(Alesse) prove as effective in treating acne as do pills
with higher doses of estrogen. Improvement may take up
to four months.
Other drugs, such as spironolactone and corticosteroids,
may be used to reduce hormone activity in the
adrenal glands, reducing production of sebum. This is
the treatment of choice for an extremely severe, but rare
type of acne called acne fulminans, found mostly in adolescent
males. Acne conglobata, a more common form of
severe inflammation, is characterized by numerous,
deep, inflammatory nodules that heal with scarring. It is
treated with oral isotretinoin and corticosteroids.
Other types of treatment
Several surgical or medical treatments are available
to alleviate acne or the resulting scars:
• Comedone extraction. The comedo is removed from
the pore with a special tool.
• Chemical peels. Glycolic acid is applied to peel off the
top layer of skin to reduce scarring.
• Dermabrasion. The affected skin is frozen with a chemical
spray, and removed by brushing or planing.
• Punch grafting. Deep scars are excised and the area repaired
with small skin grafts.
• Intralesional injection. Corticosteroids are injected directly
into inflamed pimples.
• Collagen injection. Shallow scars are elevated by collagen
protein injections.
• Laser treatments. Two types of laser treatments are proving
effective in treating acne scars. Laser-treated skin heals in
three to 10 days, depending on the treatment chosen.
Expected results
Most dermatologists now use a combination of therapies
to treat acne, depending on the individual. Results
of specific treatments will vary. Acne is not a serious
health threat. The most troubling aspects of this condition
are the negative cosmetic effects and potential for
permanent scarring. Some people, especially teenagers,
become emotionally upset about their condition, and this
may contribute to social or emotional problems.
Acne is not considered curable, although it can be
controlled by proper treatment, with improvement possibly
taking many months. Acne tends to reappear when
treatment stops, but it often spontaneously improves over
time. Inflammatory acne may leave scars that require
further treatment.
Prevention
There are no sure ways to prevent acne, but the following
steps may be taken to minimize flare-ups:
• Gentle washing of affected areas once or twice every day.
• Avoidance of abrasive cleansers.
• Limited use of makeup and moisturizers; with avoidance
of oil-based brands altogether.
• Oily hair should be shampooed often and worn up,
away from the face.
• A healthy, well-balanced diet should be eaten. Fresh
fruits and vegetables should be stressed, and foods that
seem to trigger flare-ups should be avoided.
• The face can be washed gently, twice daily with a soap
compounded of sulfur, Calendula officinalis, or other
substances that are useful against acne.
• Affected areas should not be handled excessively. Pimples
should not be squeezed or prodded, as this may contribute
to scarring, as well as spreading the acne lesions.
• Emotional stress should be kept in check.
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