WHAT IS IT?
Acne is the most commonly seen skin disorder which often occurs in teenagers and is more common and severe in males. Although it can affect adults at different ages it is more common in women due to hormonal fluctuations. There are many different forms of acne with the most common being acne vulgaris.
Acne is a chronic inflammatory genetic disorder of the sebaceous glands and it is mostly due to a hereditary factor known as retention hyperkeratosis (dead cells do not shed off the surface of the skin and out of the follicles as they do on normal skin) that determines who will suffer from it. Heavy sebum production is also hereditary. Acne occurs when hair follicles become plugged with sebum, dead skin cells and bacteria called propionibacterium, acnes or P. acnes bacteria. This bacteria at the base of the follicle thrives and multiplies in the absence of oxygen and from feeding off the sebum. The P. acnes bacteria irritates and inflames the hair follicle and blocks the sebaceous gland whilst sebum production continues and is trapped with bacteria under the skin. This pressure eventually leads to a rupture in the follicle wall, which then attracts white blood cells to fight off the bacteria resulting in an inflammatory acne lesion (papule). In acne lesions, pus (dead white blood cells) forms and rises to the surface, these are known as pustules.
Characteristics
Acne can be disfiguring, causing open and closed comedones, inflammatory papules, pustules, and in severe cases, nodules, cysts and lifelong scarring. This can take 6-12 months to develop. These lesions usually occur on the face, neck, shoulders, chest, back and sometimes arms. Comedonal acne is the most common form likely to occur in teenagers. Another form is inflammatory acne (papules) prevalent in young women with hormonal flares causing inflammation to the follicle from surges of sebum. Acnegenic products can also cause papules from inflammation of the follicle.
There is a tendency for remission in summer and pre-menstrual flares can occur. The skin is oily which is prominent on the T-zone and in abnormally oily skin all areas of the face (seborrhoea). Enlarged pores are indicative of oily areas. Acne can cause severe emotional, psychological or physical (scarring or excoriation) problems due to visible facial deterioration.
Grades of Acne
Grade 1 Acne
Mild acne consisting of mostly open comedones, some closed comedones and few papules and pustules
Grade 2 Acne
Moderate acne with many more open and closed comedones, papules and pustules. Skin appears bumpy due to closed comedones.
Grade 3 Acne
Moderately severe acne where the skin is very red and inflamed with many open and closed comedones, papules and pustules. Refer to a dermatologist for prescription medical treatment.
Grade 4 Acne (Nodular Cystic Acne)
Severe acne consisting of open and closed comedones, papules, pustules, severe inflammation, deep nodules (deep seated dome shaped palpable lesion), cysts (very deep pocket of infection holding large amount of pus) and scarring. Nodules can persist for weeks or longer. Cysts may be several centimetres in diameter. It is important to note that if left untreated these nodules and cysts can cause damage to the dermal layer leaving deep permanent pitting and scars. Refer to a dermatologist for prescription medical treatment.
Other Types of Acne
Acne Conglobata
Severe acne with many cysts present. Leaves severe scarring.
Acne Fulminians
A type of Acne Conglobata accompanied by fever and joint pains.
Acne Papulosa
A condition where lesions are often seen on the foreheads of young adults
Agminata (Acnitis)
Small reddish papules common on chest and shoulders which develop into pustules and leave scars when healed.
Infantile Acne
Very rare. Due to the placental stimulation of the infants adrenals. It may last up to 3 years and can be a forerunner of adolescent acne.
Occupational Acne
May affect engineers, mechanics, factory workers who come into contact with lubricating and cutting oils. Acne occurs on the front of the thighs and forearms. Fast food kitchen workers who are constantly exposed to greasy hot air.
Cosmetic Acne
Caused by some acnegenic and comedogenic skin care and cosmetics which aggravate and assist in clogging the follicles. May be due to comedo-inducing ingredients such as cocoa butter, some mineral oils and coal tar dyes (also known as D&C red dyes).
Acne Detergicans
Acne caused by over cleansing and the overuse of peeling agents and masks which may results in inflammation than can also contribute to more acne flares.
Excoriated Acne
A disorder where all the acne lesions are purposefully scraped, scratched, squeezed and/or picked resulting in scraped-looking flat lesions. These may be red because the epidermis has been scraped off or brown because pigment has formed to protect the injured skin.
Causes / Contributing factors
Although most acne is caused by excess androgen there are other contributing factors and triggers.
Hormonal changes (e.g. puberty, pregnancy, menopause) - excess androgen (Dihydro-Testosterone - DHT a by-product of testosterone) which stimulates the sebaceous glands and excess sebum secretion
Increased abnormal keratinisation (retention hyperkeratosis)
Seborrhoea (severe oiliness of the skin)
Genetic factors
Bacteria
Stress
Heat and humidity
Medications (e.g. oestrogen oral contraceptives, lithium, androgens, corticosteroids)
Steroids
Skin surface friction and irritation
Acnegenic & Comedogenic cosmetics and skin care products
Poor diet and being overweight
The research team led by Associate Professor Neil Mann from RMIT University’s School of Applied Sciences, has discovered a solid link between acne and diet. The diet study was based on observations in non-industrial societies where no acne exists until the teenagers start eating western foods. “The acne of the boys on the higher protein-low GI diet improved dramatically by more than 50%, which is more than what you see with topical acne solutions,” said Associated Professor Mann. “A diet high in processed foods pushes glucose and insulin levels higher, exacerbating the problem, but low-GI foods do the opposite. The mechanism and the results are as clear as day.”[1]
Treatments
Acne can be controlled but not cured. Early treatment is best to avoid permanent scarring and worsening of the disorder. It is advisable to seek a dermatologists’ opinion for diagnosis and treatment of Grade 3 and 4 acne. Comedo-papular acne is managed by topical treatment alone. Pustular-Cystic and scarring acne require topical and oral treatment.
Depending on the severity of acne would depend on the treatments to be used which are listed below.
Eliminate contributing factors &/or known triggers (e.g. products/stress/medication/humidity)
Psychological treatment if necessary
Massage & meditation for stress reduction
Intralesional steroids, silicone sheeting or vascular lasers (hypertrophic scars)
Infrared resurfacing lasers, plasma resurfacing, fillers/implants, plastic surgery (atrophic scars)
Topical Therapies and Medications
Clearogen - New over the counter treatment that blocks DHT
Benzoyl peroxide - Used to dry and exfoliate skin.
Topical antibiotics - prescribed medications to dry skin and kill bacteria e.g. clindamycin
Retin A - useful for comedonal acne, contains Tretinoin a powerful Vitamin A derivative that dries and rapidly exfoliates skin.
Salicylic Acid - Beta hydroxy acid (BHA) that mildly dries and promotes cell turnover
Glycolic and alpha hydroxy peels - alpha hydroxy acids(AHA‘s) that remove the outer layer of skin (stratum corneum) unplugging clogged pores and promoting cell turnover.
High grade tea tree oil (mild acne)
Gentle washes containing colloidal oatmeal which has a calming anti-irritant effect.
All types of acne can benefit from fortnightly - monthly deep cleansing salon treatments that include- desincrustation under galvanic current, gentle extractions, high frequency, clay based masks containing exfoliants, antibacterial agents and are sometimes medicated. Alpha hydroxy exfoliating treatments may be used also. Proper homecare is essential.
Oral Therapies
Minimum 3 month course of antibiotics as Tetracycline, Minocycline and Erythromycin inhibit bacteria growth
Accutane/Isotretinoin is related to Retinoic Acid and can be prescribed for severe Grade 3 & 4 acne. It inhibits functioning of the sebaceous gland and keratinisation (chemical conversion of living cells into dead protein cells)..Abnormal liver function can occur which is reversible once medication has ceased. Extreme caution must be taken to avoid pregnancy as severe birth defects are a side effect.
Anti androgen/oestrogen oral contraceptive (increases risk of breast & ovarian cancer)
Sunder Vati is an Indian ayurvedic medicine that may reduce acne
Zinc (mild to moderate inflammatory acne)
Homecare
Eliminate all acnegenic and comedogenic products.
Do not irritate the skin by over use of cleansers, peels/exfoliants, masks or by scrubbing
Avoid stress and environmental factors (heat & humidity, greasy environments, excessive sun exposure.
Eat a healthy diet, drink plenty of water and get regular exercise
Control oil by using non stripping foaming type cleansers twice daily (if mild acne and skin is irritated an oatmeal wash may be used). They may contain AHA’s or exfoliating granules. Aging, sun damaged skin or if using prescription exfoliants will need a non medicated, non-exfoliating gentle cleanser
Apply toners for oily and acne-prone skin containing SD alcohol, witch hazel extract, salicylic acid or glycolic acid, sulphur, chamomile extract or aloe (for sensitive skin). Aging skin will need a mild hydrating toner instead.
Apply AHA’s (in 8-10% concentration) gels including glycolic and lactic acids combined with a small amount of salicylic acid are excellent follicle exfoliants. They are not anti-bacterial but they are less irritating than the medications and can be used to treat all areas affected by acne. This will help flush out microcomedones and prevent reformation, also helping with inflammatory acne. The more severe the acne the stronger the exfoliant needs to be. ( NOTE: exfoliating gels are not to be used for people using prescription catalytic drugs such as tretinoin, etc)
Apply non comedogenic lightweight moisturiser & SPF15+ sunscreen for daytime
Apply eye cream
Apply nightly to spot treat affected areas follicular exfoliants to remove and prevent comedones. Medicated antibacterial agents that kill p. acnes bacteria include benzol peroxide gels, sulphur and resorcinol lotions/suspensions or salicylic acid gel or liquid. If mild acne a natural alternative tea tree oil may be used.
Exfoliating clay based masks with sulphur or benzoyl peroxide can be used every other night for thicker acne skin, on thin skin less often. Once skin has started to clear masks can be used 1-2 times a week.