Acne

Description

If acne is severe, large pimples – called cysts, nodules or cystic lesions – form firm swellings deep under the skin. They become inflamed and may develop into painful lumps; leading to scarring.

Acne is not limited to teenagers. Rarely, babies are born with acne and some people get acne for the first time after they’ve reached adulthood. Most people outgrow acne; but in women it may last until the menopause. 5% of women of 40 years of age have acne; but only 1% of men in that age group.

Acne can develop on your face, neck, chest, shoulders or back. The severity may differ from person to person and may fluctuate over time. Acne often has an adverse emotional effect on sufferers.

There is no cure for acne, but it can be treated. Severe acne requires medical treatment.

Cause

When whiteheads rupture the hair follicle wall, pimples are formed. Solidified sebum, dead cells from the pore and bacteria are released into the skin, creating a pimple (pustule). This stage is called inflammatory acne. If pustules become infected, the infection may penetrate deep into the skin and form cysts (cystic acne). The cysts may rupture and leave temporary or permanent scars.

The bacteria propionibacterium acnes and staphylococcus epidermis occur naturally in hair follicles. If there are too many bacteria, they may secrete enzymes that break down sebum, promoting inflammation in the follicle. Some people may be more sensitive to this reaction than others, making their acne more severe.

Hormonal changes can stimulate sebaceous glands to produce more sebum. Therefore, anything that raises hormone levels (for example pregnancy, stress, menstrual periods and certain medicines, such as corticosteroids) could aggravate acne. The male sex hormone testosterone, which is present in both men and women, is mainly responsible, but the female sex hormone progesterone also contributes to acne in women.

Some babies are born with acne because their mothers pass certain hormones on to them just before birth or because the stress of birth makes the baby’s body release hormones. This is rare and self-limiting.

Genes and skin type may predispose a person to acne.

Stress can aggravate acne, but cannot cause it.

Symptoms

• Persistent, recurrent red spots or swellings (pimples), which may be inflamed or filled with pus – on the face, chest, shoulders, neck and/or upper back
• Dark spots with open pores at the centre (blackheads)
• Spots that bulge under the skin and do not have openings (whiteheads)
• Red swellings or lumps (pustules) that are visibly filled with pus
• Inflamed, fluid-filled lumps (cysts or nodules) under the skin that may become as large as 2,5 cm across.

Prevalence

Course

Risk factors

• Acne and its severity often run in families.
• People with oily skin tend to get more acne.
• Teenage boys tend to have more severe acne than teenage girls.

When to see a Doctor

• If acne gets worse or does not respond to home treatment within two to three months
• If you develop emotional problems as a result of your acne
• If you develop scars or marks on your skin after a pimple has healed
• If your pimples become large and hard or filled with fluid
• If you notice other symptoms, such as hair growth on the chin (if you’re a women) or bone and muscle pain (both sexes)
• If you suspect new prescription medication causes your acne
• If you suspect exposure to chemicals, oils or other substances caused your acne
• If your acne is severe

Diagnosis

Treatment

No treatment is needed for the occasional pimple or two, but if acne causes you distress, something should be done about it. Many different treatments are available, but they are not all equally appropriate for everyone. It is therefore important to keep appointments with your health care provider so that, together, you can determine the right treatment for you. Treatment usually shows an effect only after six to eight weeks.

Home

To prevent acne from getting worse:

• Wash the face twice a day with a gentle soap. Washing your face more often than that may irritate and dry your skin. Avoid hot water. Using hot water can make your acne worse.
• Do not use facial scrubs, astringents and masks unless your doctor has recommended them, because these generally irritate the skin and aggravate acne.
• Do not squeeze, pick, scratch or rub your skin. Squeezing pimples often leads to infections, worse acne and scars.
• Avoid extreme stress – if necessary, seek counselling and follow a stress management programme.
• Exercise regularly.
• Follow a healthy balanced diet with plenty of raw fruit and vegetables - yellow and green.

Medication

There are many over-the-counter medications (creams, lotions, and gels) available. Many of them contain benzoyl peroxide, alpha-hydroxy acids or salicylic acid. These medications should be water-based and hypoallergenic.

Your doctor may prescribe an ointment containing tretinoin (retinoic acid), a vitamin A derivative. This medication may make the skin red, dry and sensitive to sunlight. They should never be applied with over-the-counter medication, such as benzoyl peroxide.

Other drugs that can be used are salicylic acid, adapalene, tazarotene, and topical antibiotics.

For moderate to severe cases, tetracycline, an oral antibiotic, is used either alone or in conjunction with tretinoin to combat inflammation. Be aware though that antibiotics may make women susceptible to yeast infections. For resistant cases, oral minocycline may be prescribed. The tetracycline group of drugs causes yellow teeth of the foetus if taken after the third month of pregnancy. These drugs should be stopped if you become pregnant and only started again after breast-feeding is finished.

Tetracyclines must not be given to children before the permanent teeth have erupted because these drugs can cause yellow discolouring of permanent teeth. Other antibiotic options are erythromycin and clindamycin.

For deep, chronically inflamed cysts, the drug isotretinoin may be prescribed. This drug has potentially severe side-effects during pregnancy and the treatment must be monitored. The cure rate is between 70 and 80% after five months of treatment. Triamcinolone, a type of corticosteroid, may be injected directly into cysts. This drug may darken the skin around the lesion.

Oral contraceptives and anti-androgens may alleviate acne in some women.

Surgery

Other

Prevention

Reviewed by Dr Leonore R.J. van Rensburg, MBChB (UCT), M. Med. Dermatology (US).