What is acne

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What Is Acne

Acne is a common inflammatory skin condition affecting about 70-80% adolescents. It commonly occurs in the face neck, chest and back. The initial lesion is a non-inflammatory lesion called comedons, that essentially are plugs of dead skin and oil mixed together, filling up the hair follicle openings. They are commonly called blackheads. When the comedones rupture, the follicular wall undergoes an inflammatory reaction secondary to an immune response, which results in papules and pustules. These inflammatory lesions are capable of producing scars when they heal.

These facial scars are permanent and can cause a loss in self-esteem resulting in depression and anxiety. Since adolescents are commonly afflicted, acne tends to escalate body-image, peer-pressure and other common psychosocial problems associated with teenagers. Thus although acne is not life threatening, it can adversely affect the quality of life of those affected. Appropriate treatment can help prevent or clear this condition and improve the lives of these persons.

Pathophysiology: What causes acne ?

Despite its wide prevailence, the pathophysiology of acne is poorly understood. Four facts are proven to occur in all cases of acne, i.e. sebum overproduction by sebaceous glands; colonization of hair follicles by propionibacterium acnes; release of inflammatory mediators into skin and familial and genetic predisposition. Of these sebum overproduction happens to be the main component of the pathogenesis of acne. Thus, any therapy must aim at reducing sebum production.

Another well-recognized fact is that certain hormones such as androgens increase the incidence of acne by increasing sebum production. This may in turn increase the size of the sebaceous glands, possibly through follicular hyperkeratinzation.

The density of sebaceous glands is another factor that increases the likelihood of developing acne. For example, their density is 400-900 glands/sq cm on the face, neck, chest and back – areas that are prone to acne formation. Where as their density is around 100 glands/ sq cm in areas that do not develop acne.


Acne is normally graded as mild, moderate and severe. Grading is based on the presence and distribution of the comedones, papules, pustules and nodules, and is important for selecting the right treatment. Mild comedonal acne can be purely non-inflammatory (only blackheads are present), while severe acne can involve papules, pustules and nodules. In its worst presentation, acne involves heavy inflammation and scarring.

During evaluation of acne severity by a doctor, the focus should be on more severe lesions; their location, number, and size. Then, the family medical history must be obtained. In some families, sever acne is common. A family history of severe acne typically suggests are more treatment resistant form of acne that requires a longer treatment protocol. Also, the doctor must consider what other medical conditions an individual with acne has. For example, if a woman develops acne and hirsutism (excess facial and body hair growth) together, it might suggest an underlying hormonal problem such as Polycystic ovary syndrome which needs to be treated. Finally, the doctor must consider what drug treatments a patient may be taking. Some medicines may aggravate acne and adversely interact with the drugs prescribed to treat acne.

Mild acne: For mild, purely comedonal acne, topical retinoid drug therapy is often recommended. Commonly prescribed drugs are tretninoin, isotretinoin and adapalene among others. The disadvantage with these drugs is the irritation they can cause. Antibiotics like erythromycin are mildly anti-inflammatory but increasing bacterial resistance has limited their use.

Moderate acne: Systemic drug therapy may be best for moderate acne. This therapy is always advised whenever there is a possibility of scarring or hyperpigmentaion and the acne is widespread. Treatment options include oral antibiotics like tetracycline, hormonal therapy and oral retinoids.

Care must be taken in prescribing tetracycline to women; since the drug interacts with oral contraceptives and is teratogenic i.e. can cause birth defects if the woman becomes pregnant whilst on the drug.

Hormonal therapy is suitable for women with hirsutism, androgenetic alopecia and severe sebum secretion. The anti-androgenic oral contraceptive ethinyl estradiol is commonly used for hormonal treatment.

Severe acne: Isotretinoin is the best drug in severe acne cases and in patients with severe scarring. The drug, however, can have serious opthamalogic, neurologic and gastro-intestinal side effects. The most important issue is that it is teratogenic. A dermatologist should ensure that a woman patient is on effective contraception 1 month before the start of isotretinoin use, and that contraceptive use is continued throughout acne treatment and up to 6 weeks after discontinuation of isotretinoin treatment.

A third of patients relapse after successful isotretinoin treatment i.e. the acne can recur once treatment has been stopped. In these cases, another round of isotretinoin, or any other suitable treatment, may be administered. Experience shows that combination therapies generally work better than just using one treatment alone.

Physical treatment of lesions

For maximum therapeutic effect, physical treatment, where lesions are removed using a fine needle, is recommended along with other treatments. Though temporary, such treatments avoid excessive inflammation where the patient has numerous lesions. It might also help reduce scarring.

Maintenance therapy

This is mandatory after every successful treatment. Topical retinoids are usually recommended as are cosmetics to improve the skin appearance. Isoretinoin requires moisturizing agents to offset the drying effects of the drug.

Future therapies

Laser and photo therapy for acne are still at an experimental stage. Future treatment will become more targeted and most likely include agents like leukotriene inhibitors which reduce inflammation.

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