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About Acne and its Treatment
Acne vulgaris, commonly referred to as acne, is an extremely common skin condition often resulting in unsightly blemishes, inflammation or scarring around an affected person’s face, upper-chest or back. With serious variants such as cystic acne, the disease affects billions of people around the world to varying degrees. The manifested physical and psychological effects of acne can be severe; in response to this, around $2 Billion is spent on treating acne (including prescriptions, medications and other treatments) each year in the USA alone. [1] Despite the prevalence of acne and the potentially huge market for a guaranteed cure, the disease remains relatively hard to combat; this is especially true for certain types of the disease.
Acne is extremely common. Almost 90% of people worldwide will experience acne at a particular point in their lives [1], while the fraction of a specific population affected at any one time can be approaching 20%, such as is in the USA where nearly 50 million people currently experience the condition. [1] Adolescents are particularly badly affected, with the percentage of those afflicted by the disease peaking as high as 85%. Clinical reviews also suggest acne rates are independent of sex between the ages of 12 and 25 years [2], an interesting statistic as the prevalence of acne among adult females is generally considered to be more prolific than for males (it is suggested that 25% of adult males and 50% of adult females are affected by acne at some point in their lives [3]). Being especially prevalent during puberty, it is interesting to note the earlier development of girls gives rise to most acne cases occurring between the ages of 14 to 17, while in boys the condition is most prevalent between the ages of 16 and 19 years. [19] Noting the data, it should be clear the effects of acne are likely readily observable throughout daily life, making understanding, treatment and education relating to the disease of significant importance.
While it may be common to associate acne with ‘uncleanliness’ or ‘unhygienic’ practices, this association has been proven to be inaccurate. While proper hygiene practices such as regular washing, clean bedsheets and avoidance of excessive facial touching should be adhered to, in order to minimise the appearance of new lesions – external factors do not usually give rise to acne.
The causes of acne vulgaris are reasonably well understood. There are a variety of reasons acne can arise, with a broad overview being that it is due to a disorder within the pilosebaceuos unit. This ‘unit’ incorporates the hair shaft, hair follicle and importantly, the sebaceous glands which produce sebum (it also contains the erector pili muscle to stiffen the hair). A pore is the opening of a follicle on the skin’s surface, with all these terms ultimately belonging to the pilosebaceuos unit. This is in fact the reason the disease is limited to the upper half of the torso and entire face – the sebaceuos glands in these regions are the most active. [6] During puberty, androgen (of which the most commonly know is testosterone) production levels increase in both men and women, which in turn stimulates the production and release of sebum, as well as the enlargement of the sebaceous glands. This is a completely natural product that is oily in texture and whose original function is the lubrication of hair follicles. [8] However, an excess of sebum is among the contributing factors to outbreaks of acne.
Further, a disorder of the follicle lining cells, termed hyperkeratinization, is an exacerbating factor to acne. The cells lining the follicle are designed to be ejected by the growing hair (humans have very fine hairs covering most of their bodies). However, in some people, an excess of keratin (a fibrous structural protein) causes dead cells to effectively bond together, creating a block in the opening of the hair follicle (the pore). Excess oils, sebum and bacteria are free to accumulate within this enclosed space – prompting infection and inflammation of the tissue – acne. It should be noted that elevated keratin levels are a genetic trait, demonstrating people are predisposed to acne and that it should not simply be associated with poor hygiene.
A common effect of the above processes is the primary lesion of acne, the comedo (plural comedones). They may be open (usually know as a ‘blackhead’) or closed (‘pimple’ or ‘whitehead’). In the open case, the excess sebum produced by the sebaceuos glands is oxidised and forms the black tip of a comedo, leading to a ‘blackhead’. [6] In the closed case, sebum collects in a follicle that is not exposed to oxidization by the air, leaving the white or yellow colored deposit in the duct. [11] Other lesions experienced by a sufferer may include varying sizes of papules, which are raised areas of skin varying in color from brown to red and are not seen to harbor or secrete fluid.
The role of bacterial infection in the root cause of acne is still the subject of much investigation. There are theories suggesting microbes simply benefit from the conditions created by hyperkeratinization influenced blockades, infecting follicles rather than being the fundamental reason behind the acne. It is possible strains of bacteria effect oil production and the effective ejection of dead follicle lining cells, worsening the acne. [23] Propionibacterium acnes is generally considered to be the main microbe responsible for flaring acne incidents. [10] As the bacteria naturally reside in the follicles, it becomes an ideal breeding ground for the species, with the organism consuming sebaceous triglycerides and producing fatty acids. While normal pores appear only colonised by Propionibacterium acnes, another species, Staphylococcus epidermis is widely recognised to play a role in enfacing blocked follicles. However, is not yet understood whether there is a root pathogen cause behind certain types of acne outbreaks, or whether Staphylococcus epidermis is introduced from an external source once the follicle has been comprised via the mechanisms already discussed. [22] In general though, it is these bacterial strains that cause inflammatory acne due to their reaction with the bodies immune system, with raised lesions (papules, pustules and nodules) occurring around the original comedone in the skin’s dermis layer. [15]
External causes of acne are subject to much debate. It has been suggested a diet high in sugar (as is often found in western countries) is linked with worsening acne [16], while dairy product consumption has been scrutinized and found to be linked to the severity of acne experienced.[17] Often, supplements such as cider vinegar are suggested to alleviate the symptoms of acne, with the main catalyst being a high volume of positive anecdotal evidence. Some researchers deny any major link between diet and acne at all [5],leaving the main cause firmly in the area of excess sebum production, hyperkeratinization and bacterial infection.
We can now see that acne cases can be broadly divided into inflammatory and non-inflammatory. As eluded to previously, there are four main classifications of acne which are: purely comedonal (non-inflammatory acne), mild papular, scarring papular, and nodular (acne that leaves permanent scaring), with the last three being varying degrees of inflammatory acne. Classification of the physical acne effects are important for ensuring the correct treatment plan is followed. It is worth noting, the actual number count of blemishes, spots or pimples is not usually taken into account during diagnosis as it is the most severe lesions that should be noted when considering treatments. [5] This ensures severe scaring from the worst pimples is minimised, as well as treating the less seriously affected areas.
While the physical manifestation of acne is damaging to the skin, it is often psychological damage to the sufferer that is more dangerous and longer lasting. Especially damaging to growing adolescents, acne can drastically alter a psyche to the point one may avoid eye contact, find it hard to form new relationships and generally suffer from reduced confidence in all aspects of life [18]. These effects all stem from acne significantly impairing a multitude of factors in individuals including their self-esteem [20] and general psychological well being. [21] In addition, not only is acne likely exacerbated by stress [24], it may be that stress is an indirect cause of the condition, leading to acne perpetuating itself.
Due to the multitude of causes, varying degree of symptom seriousness and multi-billion dollar pharmaceutical backing of treatments (including prescription drugs), the methods for combating acne are wide ranging. The reduction of comedones and Propionibacterium acnes is usually the main target of treatment plans – with the most effective plans treating inflammatory and comedonal outbreaks with retinoids (chemicals related to vitamin A) and antibacterial drugs [5].
Non-inflamed acne, while being the least severe form, can be the most difficult to treat because blockages occur deeply within the follicle. There are various retinoids such as tretinoin, adapalene and isotretinion which work to prevent comodones by altering the life-cycle of the lining cells in the follicles. Even severe cases of non-inflamed acne can be cleared within months with daily application. [25] As a drawback, patients usually have to be diligent in moisturising treated areas as these chemicals cause significant dryness of the skin. It is also usually recommended to treat even unaffected areas as the method is that of prevention, rather than cure.
Inflammatory acne often requires more intense methods of treatment. In the case of mild papular acne, it usually responds well to aggressive topical treatment including the use of prescription antibiotics (applied topically). The most common topical applicant is benzoyl peroxide solution (between 2% and 10% concentration), which attacks the Propionibacterium acnes bacteria and does not build resistant strains, as antibiotics are found to do very regularly. [26] Comedolytic drugs are also prescribed to directly break up comedones.
Most severe cases of acne require oral antibiotics to combat the scaring that often occurs. These drugs also usually prescribe some anti-inflammatory effects themselves, which can be as important as attacking the bacterial infection. A whole range of products are used including doxycycline, minocycline and tetracycline. [27] Powerful oral retinoids such as isotretinoin (commonly know as one of its market names – accutane) can be a complete cure for acne, having revolutionized the acne treatment market nearly 30 years ago. They work by ‘drying up’ the sebaceous glands, reducing the amount of sebum they produce and so making follicle blockages far less likely. It has been estimated that isotretinion can completely clear acne from up to 80% of patients and even though the effect on sebum production is temporary, results are often very prolonged or even permanent. [28] Side affects of the drug can be serious – depression [29] and liver damage have been reported, although less serious effects such as initial acne flare up and dry skin are more likely.
There are several other less conventional treatments that work effectively amongst some groups of patients. For instance, in women with masculinization, raised levels of testosterone are combatted using oral contraceptions or cyproterone acetate prescribed to rebalance hormone levels and so reduce sebum production. [31] Lasers are also beginning to play a larger role in the treatment and prevention of acne. The intense light produced is able to remove some scar tissue as a result of cystic acne. [32] In addition, research is continuing into using lasers to destroy the sebaceous glands or follicle sacs at the root of the condition.
The various causes of acne previously outlined give rise to a large variance in the severity of cases. Mild acne vulgaris causing the emergence of whiteheads, blackheads and pustules make up the least severe cases known. More seriously are the infections stemming from bacterial roles where nodules and cysts can lead to scarring of the skin tissue (often termed cystic acne). Unfortunately for some individuals, the most severe cases to manifest themselves result in irrevocable damage to the skin and disfiguring scars from infected pores and surrounding tissue, with one such type of acne termed acne congobata. Increasing in severity, acne fulminans encompasses not only the physical scaring and inflammation but additionally aches and pains with joints and feverish symptoms. [30] The determination of which patient will be subject to which type of the disease is not an exact science. Certainly, genetics will play a central role, followed by the daily topical treatment routine used and considerations of stress; possibly playing some part is the diet of the individual. Whatever the cause, treatment must be tailored to the individual case usually with strong isotrenin doses for the most severe outbreaks, possibly in conjunction with antibiotics. Although to give some indication of the complexities in prescribing treatment courses, acne fulminans does not respond well to antibiotics – with isotrenin and oral steroids being likely candidates for a treatment plan. Often, the patient is directed towards several treatments before a course is found that is suitable for the specific case. For example, one sufferer may need high doses of isotrenin, oral steroids and a topical treatment such as benzoyl peroxide while another person may find the oral steroids ineffective or that benzoyl peroxide causes excessive irritation of the skin, worsening the condition.
In summary, acne is a generally unpleasant condition to suffer from and the worst cases can have significant physical and psychological effects on the bearer. Whilst billions of dollars are spent every year globally on research, treatment development and care, the affliction is widespread and will continue to be so for the foreseeable future. At present, the best advice to offer a particular person affected by acne is to educate themselves about the condition’s causes, effects and treatments and to seek help from a qualified health professional.
References:
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[2] Kai, Dr Anneke, and Dr Sandeep Cliff. “Clinical Review – Acne Vulgaris | GPonline.com.” GP Online Primary Care News, Medical Articles and Jobs | GPonline.com. Web. 04 Nov. 2011.
[3] Knaggs HE, Wood EJ, Rizer RL, Mills OH. “Post-adolescent acne.” International Journal of Cosmetic Science. 2004 Jun;26(3):129-38.
[4] Purdy S, de Berker D. Acne. British Medical Journal 2006; 333(7575): 949-53.
[5] Webster, G. F., Clinical Review: Acne Vulgaris, BMJ 2002;325:475–9
[6] Kligman AM. An overview of acne. J Invest Derm 1974;62:268-87.
[7] Leyden JJ. The evolving role of Propionibacterium acnes in acne. Semin Cutan Med Surg 2001;20:139-43.
[8] Dellmann’s textbook of veterinary histology (405 pages), Jo Ann Coers Eurell, Brian L. Frappier, 2006, p.29
[9] Purvis D, Robinson E, Merry S, Watson P (December 2006). “Acne, anxiety, depression and suicide in teenagers: a cross-sectional survey of New Zealand secondary school students”. J Paediatr Child Health 42 (12): 793–6.
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[11] “Whitehead Definition – EMedicineHealth – Experts in Everyday Emergencies, First Aid and Health Information.” Web. 04 Nov. 2011.
[15] Simpson, Nicholas B.; Cunliffe, William J. (2004). “Disorders of the sebaceous glands”. In Burns, Tony; Breathnach, Stephen; Cox, Neil; Griffiths, Christopher.Rook’s textbook of dermatology (7th ed.). Malden, Mass.: Blackwell Science. pp. 43.1–75.
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