CLINICAL DERMATOLOGY > ACNE
What is acne?
Acne is an inflammatory disease that affects the hair follicle, specifically, the hair follicle channel and the associated sebaceous glands that produce sebum or oil. It is a disease that affects people of all ages, although it is mostly found in adolescents (80%) and young adults (20-30 years old).
How does acne affect the skin?
There are different types of lesions. The most common are comedones (blackheads), papules and pustules (impurities filled with pus), and more rarely, cysts and abscesses. These lesions are located on the face or sometimes on the back, chest, shoulders, and neck. Acne lesions cause an aesthetic change that often brings emotional or social problems. On the other hand, acne may cause permanent scars on the face that can change someone’s image or self-esteem.
Fortunately, acne is curable. With the right treatment, it is possible to prevent unwanted scars from developing and improve the skin and the physical appearance in general.
Causes of acne
Three main factors play a part: a process of excessive abnormal keratinization within the follicle, an excess sebum (a secretion of the sebaceous glands composed of oil, keratin, and cellular debris), and a bacteria called Propionibacterium acnes.
The first problem is an abnormal keratinization (excess of flakes) in the lowest part of the follicle. This causes sebum to be trapped, and a barrier is created in the glands’ excretory ducts. The second factor is an increase in the secretion of sebum which flows through the excretory ducts of the sebaceous glands. This increase is stimulated by hormonal changes (secretion of testosterone or male hormones) that happen during adolescence. The retention or obstruction of sebum leads to the development of pimples or blackheads – a collection of sebaceous material and keratin trapped in the hair follicle and in the excretory ducts of the sebaceous gland. The comedones may be open (blackheads) or closed (whiteheads). The black colour is caused by the exposure of sebum to the air.
In time, the excess of sebum produced in the ducts then causes the inflammation of the walls. Subsequently the follicle breaks and releases the oils into the surrounding skin. This causes the skin to be lifted, also known as bumps (nodules) as well as abscesses and cysts (a closed area inside the skin filled with fluids or other substances).
And lastly, the bacteria in the skin colonise sebum through the Propionibacteriumacné. It acts on the sebum to degrade it and to produce free fatty acids and other substances which cause irritation and inflammation. This is seen on the skin as red bumps, nodules, and pustules (small skin bumps filled with pus, a liquid made up of bacteria and cellular debris).
There is often a family history of acne in people who suffer from it. Hormones are an important influential factor in the development of acne. Some patients have acne outbreaks before menstruation and also suffer other physical conditions such as an increase in facial hair growth (hirsutism) and hair loss (alopecia).
Contrary to popular belief, the diet is not a determining factor. However, some foods seem to be connected to the formation of acne lesions. The most important is skimmed milk intake. Other foods are chocolate, dried fruit, fried foods (especially those fried in butter or fat), foods cooked with large quantities of oil or butter, pizzas, beer, alcohol, coffee, tea, spices, heavily iodised salt, pork, sea-food (shrimps, oysters) and an excess of citrus fruits. Today, dermatologists only recommend avoiding foods that are connected to the worsening of the condition. It is advisable to eat fresh fruit and vegetables and to drink a lot of water and fruit juice.
Other negative factors include nervous tension, lack of sleep, seasonal factors (acne improves in the summer and worsens in the winter), oily cosmetics (they produce pimples) and the intake of certain medication (such as steroids, lithium, anti-epileptic and ionised drugs).
Acne is a disease that can be treated very effectively. Most people improve just with simple hygiene measures or local treatments. Some cases of severe acne, such as those that are inflammatory, tend to produce scars or result in psychological stress, may be treated with medication.
- Facial hygiene is very important. It is advisable to wash the face twice a day with an appropriate soap in order to reduce the excess of sebaceous secretion (Hidraven, Salises). This simple act often avoids the follicle getting obstructed and the appearance of lesions.
- Furthermore, it is advisable to wash body and hair frequently. If the scalp is oily, the hair should be kept away from the face as this may contribute to obstructing the pores. Oily products, such as hair conditioners should not be used. If there is dandruff, some special treatments are available and washing the hair frequently is recommended.
- Cosmetics to be applied to the face may be recommended by the dermatologist, but they must be oil-free.
- Men with acne in the beard area must try razor blades or an electric razor to determine the most effective shaving method for them. Shaving must be done with as much care as possible so as to avoid lesions and the razor must be very sharp.
- Blackheads and inflammatory lesions must not be touched, as any trauma to the skin could infect or scratch the lesions, which will later become scars. Sometimes, dermatologists perform pimple extractions. Some patients with acne may have many inflammatory lesions (hard or internal lumps). In these cases, the lesions are injected with anti-inflammatory medications using needles designed for this purpose.
Topical acne treatments
Topical preparations prescribed by the doctor must be applied carefully. Some of them are applied in the morning and others at night. A very effective product is topical tretinoin, a medication that acts by regulating the excess of flakes inside the hair follicle ducts, promoting peeling and improving the removal of the comedone.
These creams often cause skin dryness and redness. They must be applied at night as tretinoin produces photo-sensitivity in the skin.
Products with glycolic and mandelic acid are also very useful in the treatment phase, as also in the maintenance phase. Glycolic acid eliminates the obstruction of sebum inside the pores and avoids re-obstruction.
This acid also moisturises the skin and produces a gentle peeling effect. Furthermore, glycolic acid has a synergistic effect on tretinoin, emphasising its action and thus greatly increasing its effectiveness. And lastly, products with salicylic acid and astringent masks are recommended.
Other treatments for acne
Topical and systemic antibiotics (tetracycline) may be used to reduce bacteria in the acne, but they are usually avoided as they may generate resistance to antibiotics. In other cases, birth control pills are recommended to reduce the secretion of sebum.
Currently, 13-cis-retinoic acid is the most effective medication to fight acne. This medication reduces the production of sebum, normalises the process of follicular keratinisation and acts as a bactericide against P. acnes. It starts to act after 6-8 weeks.
The treatment duration is 15-20 weeks and the administration of the drug must not be stopped until this time has elapsed. If the treatment is not completed, or the dose is insufficient, the risk of recurrence will increase. This medication is expensive, it may cause skin dryness (especially of the lips), and is contraindicated during pregnancy.
It is recommended that women of child-bearing age who are on this medication take birth-control pills during the treatment and for a month after coming off the medication.
This medication may produce foetal deformities if taken during pregnancy. This drug does not have any consequences for future pregnancies, as it is completely eliminated from the body in a very short time (15-30 days). It is also advisable to perform blood tests that include liver enzymes, cholesterol, and triglycerides as changes may occur in these parameters.
Patients who are being treated with 13-cis-retinoic acid should not sunbathe or be in very hot places as the skin easily becomes reddened. The improvements achieved with this medication tend to be long-lasting. Patients must not wet their lips using their own saliva as this causes further dryness. It is also advisable to use specific lip balms with mandelic acid (Hidraderm lip balm, Silk lip ointment) to avoid the problem.
- Wash the face twice a day with a soap-free foamy cream or with a dermatological soap (Salises, Hididraven). If preferred, a cleansing milk may be used (Hidraderm).
- Use a tonic twice a day after washing the face (Sensyses lotion). If there is excess oil, astringent wipes may be used once or twice a day.
- Apply a moisturising cream with salicylic acid or glycolic acid in the morning and evening (Salises gel, Agilcolic gel).
- If you are taking 13-cis-retinoic acid, apply a lip balm as often as necessary to help with lips dryness (Hidraderm lip balm).
- Products with glycolic acid or salicylic acid may be used together with tretinoin creams, which should only be applied at night.
- Apply an astringent mask twice a week (Acnises Mask).
Some patients with acne have small scars (dimples, red blemishes) particularly on the face or back. The appearance of these scars may be improved considerably by using various medical procedures such as: chemical peels, micro-dermabrasion, the use of dermo-rollers, fractional lasers etc.
More information: Acne Salises
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