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Acne is a chronic skin disease affecting over 70% of the adolescent and young adult population in the West. Although acne is not a life threatening condition, it has the potential to cause scars and significant disfigurement. This can lead to psychological issues aggravating the common psychosocial problems associated with growth in that period of a young individual’s life. Inadequate research on a disease as old and common as acne has created myths leading to home spun remedies, some fraught with danger. Acne therefore merits serious attention.

Acne presents itself as lesions mainly on the face, neck, back and shoulder. The primary lesions in acne are called comedones, which are non-inflammatory. When these comedones burst the follicular walls they get converted into inflammatory lesions called papules and pustules. It is these inflammatory lesions which have the potential to produce scars.

Acne types

Acne classification is important for appropriate treatment. Acne is classified as mild, moderate and severe based on the number and distribution of various types of acne spots. To give a rough idea, mild acne would consist of mostly non-inflammatory comedones, moderate acne would have comedones, pustules and papules, and severe acne would consist entirely of inflamed lesions.

Causes

The causes of acne are not well known. However, it is certain that at least two agents play leading roles in acne development. The first one, sebum, is a fluid secreted by sebaceous glands present in the skin. The second agent is androgen, which is a body hormone.

It is believed that acne is caused by excess sebum secretion resulting from stimulation by excess androgen. Several studies have shown that androgens are the main cause for acne. Treatments therefore are designed to reduce the influence of androgens in various ways. While there is no dispute regarding the role of androgens in acne, not much is known about factors leading to excess androgen production. To that extent acne therapy today remains underdeveloped.

Treatment

Most treatments today use drug formulations including; retinoids, antibiotics, anti microbials and sulfur or it’s compounds, in oral as well as topical forms.

Retinoids: Topical retinoid is preferred for mild acne. Since they have anti-inflammatory action, retinoids can also be used for inflamed lesions. The commonly used drugs are tretinoin, adapalene and isotreinoin. They come in both cream and gel form. Oral isotretinoin is the most effective drug for treating the more severe types of acne, but retinoids can also be used to treat the milder types of acne.

Antibiotics: Topical antibiotics like clindamycin and erythromycin are effective in reducing mild and inflamed acne. Oral antibiotics like tetracycline, doxyline and minocycline are prescribed as systemic treatments recommended in cases where scarring or hyperpigmentation of the skin is expected. Antibiotics use is now restricted due to a significant increase in bacterial resistance. Now they are used in combination with antimicrobials to combat bacteria and antibiotics are withdrawn once the inflammation is cleared.

Antimicrobials: Benzoyl peroxide and azelaic acid are the most common anti microbials utilized. These drugs also have anti inflammatory action and they are anti-comedogenic, making them useful against mild and moderate acne. Combined with antibiotics, they are more effective and better tolerated. Side effects are mild and include skin irritation and erythema.

Sulfur: Sulfur compounds have long been a traditional treatment for acne. But unfortunately due to the emergence of other formulations, their use has declined. Sulfur is well absorbed and has few, mild and short lived side effects. It still remains a viable treatment option.

Conclusions

While much is now known about acne, much still remains to be understood, especially about its pathogenesis. Today, with the kind of treatments available, scars and disfigurement due to acne should be things of the past. With more knowledge available, the future points to more targeted and effective therapies.

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