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Acne Vulgaris

Acne Vulgaris or common acne or pimples: its causes, treatment and prevention by Dr.Hanish Babu, MD

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Acne is actually a disease of the pilo(hair)-sebaceous unit of the skin.

What is the cause of Acne?

The sebum secreting sebaceous glands are small in size and activity during infancy and childhood. Sebaceous glands secrete the oily sebum through the hair pores due to the activity of circulating androgen hormones, which are testosterone and di-hydro-testosterone. 

  During puberty, there  is increase in the  secretion of these hormones and subsequnetly, the sebaceous glands enlarge in size, become active and start secreting oil rich sebum. A small germ, propionibacterium acnes, which is also a normal resident of skin, also increases in number when its favourite food, the sebum is abundant in supply.  

The action of this germ is mainly two fold: it generates enzymes like lipases which digest the triglycerides in the sebum into free fatty acids which irritate the area and release certain chemicals which attract the inflammatory cells like neutrophils  to arrive at the site. This further results in the keratin structure of the hair follicle which become plugged and blocked. 

The degree of plugging and inflammation decides the severity of acne (See below for the grading)

When this keratin plug blocks the hair follicle opening on the surface, it is known as a closed comedone (white head). 

An open comedone (blackhead) occurs when the orifice is open and the sebum comes in contact with the atmospehere and changes its color into a black plug.

                  When the inflammation and infection is severe, the follicular wall ruptures, releasing part of the comedone into the dermis, thus causing intenese foreign body reaction and inflammation in the dermis. This results in pustules, cysts and nodes.

Acne Risk Factors

Predominant Age

          Acne is a disease of early to late puberty, majority of individuals stop getting acne lesions by the age of 25. Some, particularly women, tend to have occasional attacks well into middle age.

Gender Difference

            Male androgen hormones being the perpetrator of acne and its lower levels in female makes the females less susceptible to acne than males, but this is contested in many studies. At present, most dermatologists agree that the genders are equally affected. Males are more prone for severe nodulo-cystic variety of acne; while females, the aesthetically literate gender, tend to approach dermatologists for treatment than their counterparts.

Cosmetics

Oil based cosmetics including cold creams, moisturizers and oil based foundations can cause acne outbreaks. Cosmetic products that contain lanolins, isopropyl myristate, sodium lauryl sulfate, laureth-4, and D & C red dyes should also have to  be avoided. Rubbing or occlusive wraps (Veils) also may be the culprits in acne eruptions.

Constant 'Picking'

Picking on the acne lesions will increase the inflammatory response and cause ugly scars on the face(acne excorie) and should be avoided. I always tell my patients who come with tell tale abrasions and scars, that when they take their fingers to the pimples, actually they are stimulating them to grow faster and deeper! So Hands OFF!

Wrong Applications

Many patients try a variety of OTC products including steroids on the acne. Most steroids temporarily suppress the inflammation, but cause aggravation of the disease, the well know entity of Steroid Acne. Hence, under no circumstances should steroid creams be applied to acne lesions or acne prone skin, unless prescribed by the dermatologist for some other reasons. Likewise, oils and so called"natural" herbal remedies, most of which contain sulphur and resorcinol( the more irritant old age therapies!), will only help to aggravate acne

 

CLINICAL  ALERT

Acne can be serious!

Most people tend to ignore acne as a nature phenomenon connected with pubertal hormonal activities. If the acne is severe , left untreated, it can cause severe scarring for life.

Acne is classified in four grades:

Grade 1: Comedonal Acne: Mild, a few few whiteheads and blackheads. 

Grade 2: Papular Acne: A few non inflammatory papules and comedones.

Grade 3: Pustular Acne: Inflammatory papules and pustules.

Grade 4: Severe acne with nodules, cysts and inflammatory lesions.

Grades 3 & 4 can cause scarring and should be treated without delay. Severe inflammatory acne if left untreated, can cause disfiguring for life. This can have serious psychological repercussions. Hence a dermatologists should be consulted at the earliest sign of worsening of the condition despite OTC trials.

Grade 1 & 2 Acne can be treated with OTC products.

Drugs: The following drugs can either cause or exacerbate acne:

  1. Corticosteroids (both systemic and local)
  2. Iodides/bromides
  3. Phenytoin (antiepileptic)
  4. Lithium (antipsychotic)
  5. Isoniazid (antituberculous)
  6. Surprise! B Complex vitamins causes eruption of acne in some individuals!

  7. Some oral contraceptive pills like Ovral, Loestrin, Norlestrin, and Norinyl etc increase acne formation, while some, like Diane 35 are used to treat certain types of hormone induced acne!

Diseases

  1. Virilization diseases which increase the male hormones in females like hirsuitism  or Klinefelter's disease can cause acne
  2. Females with polycystic ovarian disease may have increased acne lesions and increased hair growth
  3. Other hormone related diseases and genetic disorders may also induce abnormal acneiform  eruptions.

Pregnancy

Most females with acne get relief during pregnancy, while paradoxically some get new lesions when they are pregnant!

Stress

Stress by increasing the secretion of sebum and reducing the immune status can aggravate acne

Climate

Exposure to hot, humid climate is a stimulant for acne.

 

 

Does food aggravate acne?

The role of food ingestion in the causation of acne is a controversial one. Most dermatology text books swear that there is no role and most dermatologists toe the line. But personally I would say that food habits definitely do affect the pathophysiology of acne and acneiform eruptions. I would cite the following reasons on which I base this observation:

  1. Many of my patients who have been on remission(without clinical acne after treatment) and on a "no chocolate, no ice cream, no cola, no fried fast food' regimen have come back experiencing severe outbreaks after they restart their junk food habits! More than two decades of such solid observations cannot be discounted or discarded! Chocolates and fatty food are best avoided if you are a person with acne prone skin!
  2. Iodides have been proven to cause acne, and hence it follows that iodide containing drugs, and foods will cause the same! 

Just look at the list of iodide containing food items with the amount of iodide in each, then you will understand why I stand solidly by the food aggravation theory of acne:

Food/Beverage Iodides (ppm*)
Seafood
Clams 20
Crab 33
Kelp 1,020
Lobster 9
Oysters 8
Shrimp 17
Sole 24
Squid 39
Meat and Poultry
Beef liver 325
Chicken 67
Hamburger 44
Turkey 132
Vegetables
Asparagus 169
Broccoli 90
Brussels sprouts 23
Corn 45
Green beans 7
Onions (white) 82
Potato 9
Dairy Products
Butter 26
Cheddar cheese  27
Cottage cheese  5
Homogenized Milk 11
Sour cream 7
Yogurt 3
Drinking water 8
Miscellaneous
Coca-Cola 3
Iodized Salt 54
Potato chips 40
Seasoned 40
Sugar 2
Tortilla chips 80
Wheat germ 46
White bread 8
* ppm: parts per million

 Now, with a list like that, who would dare say food is not an aggravating factor for acne?!

  1. Now, here is an additional proof from my household itself, my second daughter, Anju, had been recurrent acne eruptions which were kept in control by my medications. Despite my advice, on the sly,  she had been consuming her favourite Ferrorocher chocolates.(Children, they never listen to their parents, even when they are dermatologists!). She went back to India for three months' vacation last May. Ferrorocher was not available  there, and she did not like any other chocolates. She never had a single acne on her face during the last 10 weeks of her stay back home! As soon as she came back, she started on her favourite chocolate again, and again the tell tale small bumps re-appeared! My wife vouches that the chocolate was her only change in dietary intake here.Though this is only a circumstantial evidence, added along with what my other young patients have also experienced, yes, I would definitely say certain food does affect acne.

More on Food and Acne

Treatment of Acne

Acne Best Treatment Principles:

  1. Boost confidence: Having the first outbreak of acne and severe acne lesions on the face can be potentially threatening to a teenager. The resulting anxiety built up and low confidence levels have to be coped properly. Sympathetic counseling and support are required.

  2. Dietary and food restrictions are called for, as the preceding discussion shows. Low fat, low calory diet, avoidance of too much iodine containing food, chocolates, fizzy drinks and fried food is advisable. Intake of lots of vegetables and fruits and salads should be encouraged. Avoidance of alcohol and caffeine are mandatory.(Remember, cola drinks and tea also contain caffeine.)

  3. Stress Management: If there are frequent flare ups during stress periods, a stress management program should be charted out.   Click here for an appropriate program.

  4. Avoid compulsive washing: Excessive washing will further irritate the skin and also interfere with the treatment regimens. Wash the face with mild soap 2-3 times daily, not more than that. Take care to wash off all specks of cosmetics that you have applied before going to bed and applying acne medication.

  5. Avoid constant picking on the acne lesions. See above.

  6. Avoid cosmetics: If you have an acne prone face, avoid cream based cleansers and moisturizers on the face. Moderate use of non greasy lubricants and water based make ups are allowed. A gradual decrease in cosmetic usage is encouraged as acne improves. This is essential to avoid recurrent flare ups.

    How to test for grease content in your make up?

    The oiliness in your cosmetic face cream can be found out very easily.

    Apply a little make up cream to a normal bond typing paper. Keep it in a safe place. After 24 hours, take it out and check the surface. The size of the oil ring around the cream will tell you the oil content of your make up cream.

    Avoid using make up creams with large oil rings. These make ups are potential acne inducers!

  7. No OTC medication without consulting your dermatologist! Many OTC applications, whether they are herbal or chemical are potentially harmful to the skin on prolonged usage. Take expert advice before you experiment! It is your face. You cannot afford to make it an experimental field for the cosmetic industry.

  8. Avoid any suspicious medication that may be causing flare ups. Ask your doctor for alternate prescriptions.

More Acne Best Treatment Principles

Medical Treatment

Points to Consider

  1. The aim of medical therapy of acne is not to achieve cure of the disease (which is practically impossible), but to get rid of the acne before it causes scarring and pigmentation and achieve long lasting remissions. Hence no higher expectations should be maintained about therapy.
  2. Treatment of acne has to be individualised according to the grade of acne, severity, extend of involvement, age and sex of the patient
  3. The effect of treatment will be visible only after about 3-5 weeks of starting treatment. 
  4. Duration of treatment also differs from person to person. No medication should be stopped abruptly unless directed  by the dermatologist.
  5. Some topical medications can cause flare up during the first 1-3 weeks, this does not warrant discontinuation of treatment, only the periods between applications should be prolonged.
  6. Minimize   sun exposure while using medications such as retinoids.

  7. Topical Medications that your dermatologist may prescribe:

    1. Tretinoin 0.025% or 0.05 % concentrations
    2. Benzoyl Peroxide 2.5 - 10%
    3. Adapeline
    4. Topical Clindamycine
    5. Topical Erythromycine

    Systemic Medications used in Inflammatory and nodulo-cystic acne:

    1. Antibiotics.
    2. Isotretinoin

    More on the Best Treatment for Acne...

Clinical Alert!

All Facial Eruptions Are Not Acne: The Acne Mimics!

Do not reach for OTC anti-acne preparations at the first sign of facial eruptions! Many other diseases can cause acne like lesions on the face. Here are some of the important ones:

  1. Folliculitis: This is inflammation of the hair follicles. Usually superficial pustules, appear after facials, shaving or waxing. Respond well to systemic and topical antibiotics.

  2. Acne Rosacea: Usually in middle aged females. Reddish bumps on the central area of face. See details here

  3. Peri-oral dermatitis: Usually the after effect of topical steroids or irritant, spicy  food. This needs soothing applications.

  4. Milia: Small epidermal cysts, resemble whiteheads.

  5. Steroid acne: Inflammatory and papular eruptions following application of fluorinated steroids

  6. Senile comedones: Associated with toughened, wrinkled, weather beaten skin

  7. Epidermal and dermal tumors, seen in diseases like tuberous sclerosis, milia rubra facei, neurofibromatosis, syringoma etc.

A dermatologist can differentiate between these types and suggest an appropriate treatment regimen for each.                                        More on facial eruptions that mimic acne.

 

How I manage the Acne according to severity & grades*

 

Mild Acne

Open & Closed Comedones

  •  Initiate treatment with Tretinoin 0.025% increasing the strength, if required, after 3- 4 weeks to .05%.

  • I may also consider adding 2.5% to 5% Benzoyl Peroxide or topical clindamycin after 4-6 weeks to alternate with Tretinoin.

  • Oral antibiotics may be considered if comedones tend to become inflamed

  • Dietary advice : Not very stringent

More on Mild Acne Best Treatment

 

Moderate Acne

Papular & Pustular

  • Initiate treatment with 5% Benzoyl Peroxide in the evening and topical clindamycin/erythromycin

  • Once stabilized, reduce strength of BP to 2.5%

  • Systemic antibiotics will be added if lesion are numerous

  • Review every 4 weeks

  • Taper antibiotics over 3-4 months depending upon response

  • Dietary advice: moderately strict!

More on Best Treatment for Moderate Acne

Severe Pustular Acne

  • Initiate treatment with oral antibiotics with full dosage till new lesions stop appearing

  • Gradual tapering every month till no recurrence over 4-6 months

  • Topical therapy as in second group.Tretinoin may be substituted for BP when the new lesions disappear.

  • In unresponsive males, Systemic Isotretinoin may be considered

  • Female patients in the child bearing age will be treated with antibiotics for lonegr period before considering isotretinoin.

More on Best Treatment for Severe Acne

 

Very Severe Nodulocystic Acne

  • A trial with Minocycline for 2-4 weeks with topical BP or Tretinoin

  • May drain deep seated abscesses followed by 

  • Intralesional Triamcoinolone acetonide under antibiotic cover

  • Consider Isotretinoin

More on Best Treatment for Very Severe Acne

* All these medications should be taken under the guidance of a dermatologist only. This is only for information, and does not replace personal consultation! (See disclaimer below)

Clinical Red Alert

  • Oral retinoids can cause severe deformities in babies. Hence females in child bearing age group should use this drug only if absolutely necessary under the supervision of a qualified dermatologist. Ensure absolute and 100% effective contraceptive methods during and after 2-6 months of treatment with oral retinoids. Refer to the manufacturers literature and sign a consent form before you use this drug.

  • Oral retinoids can also cause excessive skin dryness

  • Liver toxicity is uncommon, still regular Liver function tests should be performed during therapy

  • Isotretinoin can cause significant elevation of serum triglycerides and so these also should be tested regularly

  • Oral Tetracycline should be avoided in pregnancy and children below the age of 12.

 

 

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About Your Online Dermatologist

 

Dr.Hanish Babu, MD is a non resident Indian Dermatologist & Venereologist  practicing in Ajman, UAE. He is the  author of the well known stress management package  10 Days to Stress Free Life and a net-entrepreneur. He is also a certified hypnotist, stress management trainer and personality development trainer. He is the web editor of half a dozen web sites on the above subjects.

 

Click Here to Subscribe to his Stress Tips Newsletter.

 

 

Disclaimer

Information on this site is provided for informational purposes and is not meant to substitute for the advice provided by your own dermatologist or other medical professional. You should not use the information contained herein for diagnosing or treating a health problem or disease, or prescribing any medication. Many skin diseases have similar morphology and may resemble one another. But their treatment varies. Hence, self diagnosis and treatment are not advised. In case of doubt always be on the safer side and consult your dermatologist. Your online dermatologist will give you special tips to deal with specific skin and cosmetic problems.

Information about each product is taken from the labels of the products or from the manufacturer's advertising material. Skin Care Tips From Dermatologist.com or Dr.Hanish Babu are not responsible for any statements or claims that various manufacturers make about their products. We cannot be held responsible for typographical errors or product formulation changes. You should read carefully all product packaging. If you have or suspect that you have a medical problem, promptly contact your health care provider. Information and statements regarding dietary supplements have not been evaluated by the Food and Drug Administration and are not intended to diagnose, treat, cure, or prevent any disease. 

Copyright © 2006 Dr.Hanish Babu, MD. All rights reserved