Acne Treatment: General Advices from Dermatologist

 

Before discussing how to manage the different types of acne in detail, it will only be proper to dwell upon the general measures to be observed while managing acne.

Here are the general advices from dermatologist to manage your acne:

  1. Boost confidence: Having the first outbreak of acne and severe acne lesions on the face is potentially threatening to a teenager. The resulting anxiety built up and low confidence levels can affect your performance both at home and at your school/ work place. Sympathetic counseling and support are required at this stage. Take time to talk to your acne skin physician or dermatologist about your fears and doubts .
  2. Dietary and food restrictions are important in most cases. Low fat, low calorie diet, avoidance of high 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. For details on the effect of food on acne, see the links below.
  3. Stress Management: If there are frequent flare ups during stress periods, a stress management program should be charted out. Learn how to manage your stress to reduce acne outbreaks following stressful periods.

    Acne: Avoid Compulsive Face Wash
    Acne: Avoid Compulsive Face Wash
  4. Avoid compulsive washing: Excessive washing will further irritate the skin and 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 the acne medication.
  5. Avoid constant picking on the acne lesions. This will irritate the lesions. I always remind my acne patients that they are actually ‘feeding’ the pimples when they touch them too often!
  6. Avoid acne inducing cosmetics: If you have an acne prone face, avoid oil 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.
    Topical Applications causing Acne
    Avoid Topical Applications causing Acne

    This is essential to avoid recurrent flare ups. See this useful tip to find out the grease or oil content of  make up cream.

  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 you may be taking (for other illnesses) that you suspect is worsening your acne. Request for alternate prescriptions from your physician.



Published by Dr Hanish Babu, MD on 26th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

Acne Treatment Guidelines

Guidelines on How to Get Rid of Your Pimples
Acne-Skin Care Tips From Dermatologist
Acne-Treatment Guidelines

Having an understanding of the basic principles of Acne treatment and available guidelines will help the acne sufferers effectively keep their pimple problem under control.

Control of acne becomes easier and more effective if the basic pathogenesis and type and extent of the pimples are understood well. Most teenagers who suffer from acne take it lightly, at least in the early stages, and resort to self treatment with acne home remedies and OTC acne medications.

Several acne treatment aspects have been evolving since the last decade; like the combination therapies, the role of lasers and light based therapies and the various modalities of treatments for acne scars.

Acne Treatment Principles

Most people tend to believe that acne is a natural phenomenon and a minor irritation during adolescence and teenage. The latest updates from the global alliance to improve outcomes in acne recommend early and aggressive treatment of acne to reduce the chances of permanent scar formation in acne sufferers.

Following are some important guidelines regarding the management of acne:

  1. There is no cure for acne. It is impossible to get rid of acne in 3 or 10 days as is being claimed by some commercial websites.
  2. The goal of treating pimples is to control the disease activity and limit inflammatory response within the dermal layer of skin before it damages the skin structures. This will help prevent formation of acne scars and blemishes.
  3. There is no single effective treatment for all types of acne. Treatment of zits varies according to the type, severity and extent of acne eruptions. The age and sex are also deciding factors while planning a treatment schedule for the acne.
  4. It could take anywhere between 2 weeks to 16 weeks for the acne eruption to get under control.
  5. Required duration of treatment for pimples varies from individual to individual.
  6. Normally combinations of systemic and topical anti-acne medications are instituted to initiate the treatment of acne. Once new acne eruptions stop, the oral medications are gradually tapered. The topical medications, usually a combination of tretinoin/ adapalene/ tazarotene or benzoyl peroxide with topical antibiotics clindamycin or erythromycin are continued as maintenance therapy. Later, topical antibiotics are also stopped as new eruption of acne is not evident for a few weeks.
  7. Topical medications, especially the retinoids, may cause flare up of the pimples during the initial stages of treatment. There is no need to stop or change the treatment in such cases. If irritation is continues, the frequency and strength of application may be reduced till the skin tolerance is regained.
  8. Never rely on OTC acne products or acne home remedies if you have inflammatory acne (red, painful eruptions). Any delay in proper treatment of inflammatory acne could lead to permanent scarring.
  9. The topical retinoids and benzoyl peroxide applications should be used only at night; never during daytime. When you are using these creams, it is advisable to avoid prolonged sun exposure. A sun screen with sun protection factor (SPF) 30 or above should be worn while outdoors.
  10. In those with a family history of acne scarring and severe eruption of comedonal or inflammatory acne, initiation of treatment with oral isotretinoin is advised by most dermatologists.
  11. Oral retinoids are absolutely contraindicated in pregnancy. If you are a female of child bearing age group, you should practice double contraception (pills with barrier) throughout the period of treatment and at least two months after the cessation of therapy with oral retinoids.
  12. If you have an acne prone facial skin, avoid using oil based make up and creams on the face.
  13. Constant picking at the pimples is an often ignored cause of scarring and pigmentation in acne. Avoid manipulating the acne bumps at all times.
  14. Do not use topical steroids on the face unless under the supervision of a dermatologist, that too for specific indications only.
  15. Most acne treatments, in addition to their medicinal properties, have a peeling effect on the skin. In those with sensitive skin, the skin may turn red and irritated in the initial stages or during the therapy. If the dryness and irritation is severe, discontinue the treatment for a few days, apply non-comedogenic moisturizers, and then restart the treatment when the skin returns to normal.
  16. Though controversy still exists regarding the role of diet in acne formation, most acne patients do experience flare ups with certain food items. Low fat, low calorie food, avoidance of milk and milk products, high iodine containing food items, chocolates, fizzy drinks and fast foods are best avoided by acne sufferers. Excess alcohol and caffeine intake is also discouraged in acne.

Learning the basic principles on which the treatment of acne is based will be beneficial for those suffering from this most common skin disease with far reaching physical and psychological consequences.

Published by Dr Hanish Babu, MD on 26th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

 

Best Acne Treatment Practices

 

Why Acne Should be Treated without Delay
Acne:  Education, Goals and Choice of Therapy

Managing the acne patients involve proper education to dispel the acne myths, defining the goals of therapy and instituting evidence based therapeutic measures.

Education of Acne Patients

Most adolescents and teens affected by acne bumps are anxious and worried about the after effects of acne bumps, the acne scars and blemishes. Proper education is necessary to reassure the patients about the natural course of acne. But care should be exercised not to trivialize the condition, so that proper treatment is delayed or ignored.

Education is based on various aspects of acne and its management.

  • The prevalence of acne. Acne is a common disorder of the adolescents and teens, affecting almost everyone at least once during their life time.
  • The natural course of the pimples. There are different types of acne and most cases of mild acne improve without causing scars. Moderate to severe types of acne require therapy for longer duration to avoid the scarring.

    Acne Treatment Best Principles
    Acne Education: Acne Myths have to be expelled
  • The common acne myths. There are many prevailing; should be clarified during the first visit.
  • Treatment options for acne. Treatment differs according to the types of acne.
  • Life style adjustments required to reduce the chances of recurrences.
  • Follow up and maintenance therapy. Regular follow up and maintenance therapy with topical retinoids is necessary to keep the acne eruptions under control.

Goals of Acne Treatment

Treatment will not cure acne. The following are the goals of acne treatment:

  • To get rid of acne bumps.
  • To prevent the inflammation from becoming deep and extensive.
  • To prevent acne scars.
  • To improve the compliance of patients.
  • To reduce anxiety and stress associated with pimples.
  • To improve self esteem in affected teens.

Choice of Acne Medications

Choice of acne medications depends on the type and extent of the acne eruptions.

  • Mild comedonal acne: Topical retinoids alone or in combination with topical clindamycin or benzoyl peroxide. Acne topical medications alone will suffice in this type of acne.
  • Moderate papular and pustular acne: Combination of topical antibiotics and benzoyl peroxide. If inflammation extensive: add systemic antibiotics.
  • Severe pustular and nodular acne: Systemic retinoids alone or a combination of systemic and/or topical antibiotics and/or benzoyl peroxide. Laser and blue light therapy may be useful in this type of acne.
  • Very severe nodulo-cystic acne:  Systemic isotretinoin for the first 12-16 weeks, then shift to combination of systemic antibiotics and topical retinoids if necessary. Surgical intervention and intralesional steroids if necessary.
  • Acne Scars need to be dealt with according to the individual characteristics and types of scarring.

Maintenance of Acne Therapy

Most acne sufferers are free of the disease by the age of 25 years. About 3% males and 12% females may still get periodic acne eruptions beyond 25 years.

Maintenance therapy, usually with topical retinoids, is necessary to prevent acne recurrences.

Adherence to these best acne treatment practices will not only help get rid acne, prevent scarring, but also ensure better patient compliance.

 Published by Dr Hanish Babu, MD on 26th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

What are Different Types of Acne?

 

Skin Care Tips From Dermatologist
Different Types of Acne
Acne Types

Acne treatment depends upon the clinical type and severity of the pimples. There are many different types of acne classifications available, depending upon the morphology, severity and pathophysiology of the acne.

Why Learn about Different Types of Acne?

 Most people think that all types of acne require same treatment. Nothing can be far from the truth. Each type of acne has to be managed according to its own merit. Most acne natural or home remedies are not effective because they do not pay attention to this important factor.

Your dermatologist will take into account a number of factors while deciding on the best pimple treatment suitable for you; like the type and severity of acne, your age, gender, profession, and; if you are a female, whether you are expecting or breast feeding or have chances of getting pregnant.

Knowing your acne type will also help you decide when to get expert help so as to avoid complications like acne scars and acne skin blemishes.

The most useful and common classifications of acne are as follows:

Morphological Types of Acne

Morphological Types of Acne include

  1. Acne Comedones: Primary lesions during the development of acne; non inflammatory type of acne. Two types: Closed comedone (whitehead) and open comedone (blackhead).
  2. Acne Papules: Papular acne shows minimal inflammation with skin colored or red bumps.
  3. Acne Pustules: Moderate to severe inflammation and pus filled bumps are seen in pustular acne.
  4. Acne Nodules: Deep seated, red, severely inflamed nodules characterise nodular acne. Acne nodules are the result of repeated inflammatory rupture and encapsulation of the hair follicle and sebaceous gland with abscess formation and foreign body reaction.
  5. Acne Cysts: Fluctuant cystic acne lesions are abscesses formed by the breakdown and necrosis of the nodules and contain the debris from infected sebaceous gland, hair duct, inflammatory cells and surrounding dermal tissue.
  6. Acne Conglobata: In very severe acne, the nodules and cysts connect together to form deep, painful sinus like tracts. These are prone for deep scars.

Types of Acne Depending Upon the Severity

The following classification, a very useful one for the patients as well as the treating dermatologist, is modified from “Acne therapy: A methodological review” by Lehmann HP et al. in the August 2002 issue of the Journal of American Academy of Dermatology.

  1. Mild Acne: Up to 20 comedones and less than 15 papules, total acne lesions less than 30 in number.
  2. Moderate Acne: 20-100 comedones and/or 15-50 inflamed papules or pustules, total count of 30-125 acne bumps.
  3. Severe Acne: More than 5 cysts/nodules, more than 100 comedones or inflammatory acne lesions more than 50 with a total acne bumps’ count more than 125
  4. Very Severe Acne: Disfiguring severe nodulocystic acne, covering the major portion of the face, chest and back.

Acne Types Based on the Pathophysiology of Pimples

  1. Inflammatory Acne: Includes acne with papules, pustules, nodules and cysts.
  2. Non-inflammatory acne: Includes comedonal acne.

Acne Grading System

 This grading of acne includes a combination of above classifications.

  1. Grade 1. Mild, comedonal acne; non inflammatory type.
  2. Grade 2: Moderate, papular acne; inflammation is minimal
  3. Grade 3: Severe, pustular acne with moderate to severe inflammation. Chances of acne scar formation present.
  4. Grade 4: Very severe, nodulocystic acne. Deep acne scars possible if not treated promptly.

These different classifications of acne are useful not only in choosing the appropriate treatment modalities for the pimples, but also for conducting acne clinical research and disease surveys. The mild acne is the only type of acne where OTC products and acne home remedy may be tried without much risk of acne complications.

Published by Dr Hanish Babu, MD on 25th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

Dr Hanish Babu, MD as a Speaker

 

Dr Hanish Babu, MD is much sought after as a speaker during the Continuing Medical Education programmes in UAE and abroad. Here are some of the certificates of his talks:

Dr Hanish Babu MD CME Talks
Dr Hanish Babu, CME Speaker, Alaska, US
2006 Ras al Khaima talk Dr Hanish Babu, MD Stress Management
2017 Sharjah Infectious Skin Diseases Dr Hanish Babu, MD
2017 Sharjah Infectious Skin Diseases Dr Hanish Babu, MD
2011 Chairperson CME Dr Hanish Babu MD
2011 Chairperson CME Dr Hanish Babu MD
2011 CME Talk Dr Hanish Babu MD
2011 CME Talk Dr Hanish Babu MD
2011 Skin in Diabetes CME Talk in US by Dr Hanish Babu MD
2011 Skin in Diabetes CME Talk in US by Dr Hanish Babu MD
2012 RAK Herpes Zoster and Post Herpetic Neuralgia Talk Dr Hanish Babu MD
2012 RAK Herpes Zoster and Post Herpetic Neuralgia Talk Dr Hanish Babu MD
2012 RAK Talk Dr Hanish Babu, MD Occupational Skin Diseases
2012 RAK Talk Dr Hanish Babu, MD Occupational Skin Diseases
2015 Emergencies in Dermatology Talk by Dr Hanish Babu MD
2015 Emergencies in Dermatology Talk by Dr Hanish Babu MD
2015 Evidence Based Dermatology Dr Hanish Babu MD CME Talk
2015 Evidence Based Dermatology Dr Hanish Babu MD CME Talk
2015 Skin and Thyroid CME Talk by Dr Hanish Babu MD
2015 Skin and Thyroid CME Talk by Dr Hanish Babu MD
2016 Lifestyle Skin Diseases CME Talk by DR Hanish Babu MD
2016 Lifestyle Skin Diseases CME Talk by DR Hanish Babu MD
2016 Skin in Rheumatic Diseases Talk Dr Hanish Babu MD
2016 Skin in Rheumatic Diseases Talk Dr Hanish Babu MD
2017 Sharjah Infectious Skin Diseases Dr Hanish Babu, MD
2017 Sharjah Infectious Skin Diseases Dr Hanish Babu, MD
2006 Diploma in Advanced Stress Management Dr Hanish Babu MD
2011 Sharjah Endocrines and Skin Talk Dr Hanish Babu MD
2011 Sharjah Endocrines and Skin Talk Dr Hanish Babu MD
1990 IADVL National Conference Talk DR Hanish Babu MD
1990 IADVL National Conference Talk DR Hanish Babu MD

Who is at Risk of Developing Pimples?

Acne Risk Factors: What are they?

Some individuals are more acne prone than others. Is it just heredity or are there some other factors responsible for the pimple eruptions?

Though there is a hereditary tendency for acne eruptions, there are many factors that might contribute to the development of acne in normal individuals.

Who is at Risk of Developing Pimples?

 Common acne risk factors include age, sex, occupation, hormonal imbalance, food habits, medications, outdoor activities and stress.

Acne and Food: Choice is yours!
                                   Acne and Food: Choice is yours!

 

Age and Acne

 Adolescence is of course the most common age for acne. The onset of puberty brings in hormonal changes which affects the sebaceous gland activity and other factors stimulating the acne development.

Acne and Gender

Though both sexes are equally affected, acne is more severe in males. Risk of acne complications like acne scars are consequently more in the males.

Hormone Disturbances Causing Acne

 Androgenic hormones from the testes, ovaries and the adrenal cortex are mainly responsible for the sebaceous hyperactivity in acne. Hence any diseases of these organs, medications stimulating or increasing the secretions of these hormones or drugs having similar pharmacological effects can stimulate acne production in some individuals. It is common for women to get acne eruptions, usually of mild to moderate type, just before or during their menstrual periods. In pregnancy, some women experience worsening of their acne, while, in others, acne simply disappear during pregnancy.

Many patients with polycystic ovarian disease have moderate to severe type of acne along with unwanted hair growth. Low dose oral contraceptives are beneficial in treating acne in some female patients who show high levels of testosterone or Dehydroepiandrosterone (DHEA). Some combination pills which contain androgens could induce acne eruptions as well.

Virilization disorders where the male hormone levels are increased in females due to adrenal or ovarian growths are characterized by acne eruptions, abnormal hair growth (hirsuitism), voice changes, clitoral enlargement and increased libido.

Topical Applications Causing Acne

Topical Applications causing Acne
Topical Applications causing Acne

 Acne is caused by the occlusion of the hair pores with plugs caused by thickened walls and action of the bacteria P.acnes on the oily sebum. It follows that anything irritating or further occluding the skin surface is bound to induce or aggravate acne. Oily cosmetic products like cold creams, moisturizers or oil based foundations can cause fresh acne eruptions and hence should be avoided by teens with acne prone skin.

Oil, gel or pomade applications on face could cause acne bumps to appear on the forehead, scalp or behind the neck.

Topical steroids, especially the potent fluorinated classes of topical steroids are infamous for causing acneiform eruptions even in individuals without a previous history of acne.

Occluding and Irritating Agents as Acne Risk Factors

In addition to the occluding oily creams and oils, occluding synthetic dresses(body acne), helmets (forehead, scalp and neck acne), industrial oils(chloracne on hands and forearms), shoulder pads in players also induce acne eruptions. To be qualified as acne, the individual should have the tell tale comedones in nearby skin or face. Otherwise these should be called folliculitis, the inflammation of hair follicles. Most of the acneiform eruptions that are supposedly caused by chronic rubbing are not acne lesions, but folliculitis.

Acne Inducing Medications

 Certain medications can induce acne like eruptions or exacerbate existing acne. The most common culprits are systemic and topical steroids, phenytoin, isoniazid, lithium, iodides and bromides.

In addition to the above, acne eruptions are worse in hot and humid conditions where sweating and increased sebum secretion can enhance the follicular occlusion and P.acnes proliferation. Acne has

 

also been found to be increased under stressful conditions, probably through the hormonal stimulation of the sebaceous glands.

Published by Dr Hanish Babu, MD on 24th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

Acne Triggers

What Causes Pimples to Appear or Worsen?

Though acne is one of the commonest diseases affecting the humanity, the triggering factors of acne have not yet been delineated conclusively.

Acne vulgaris is a common, chronic skin disease affecting almost everyone at least once in their life time.

In most people, acne appears during adolescence, though it could appear de novo at any age. In 2000, Layton AM, in an article in the Medicine titled ‘Acne vulgaris and similar eruptions’, noted that approximately 5% of women and 1% of men 25–40 years of age either continue to get acne lesions or develop acne (late-onset acne) after adolescence.

It will be interesting to analyze what triggers acne and whether the life style is also a deciding factor, in addition to the hereditary and hormonal causes.

Acne Triggering Factors: Age & Hormones

Acne is most prevalent among adolescents and young adults, affecting approximately 85% of people at some point between 11–30 years of age. Peak incidence is seen in females 14–17 years of age and males 16–19 years of age.

During puberty, androgen hormone production increases which induces an increase in the production of sebum and the development of greasy skin. This stimulates a cascade of events that cause acne formation.

In females, hormonal imbalance due to ovarian diseases (for example in polycystic ovarian disease) induces acne eruptions. There is a flare up of acne immediately before the menstrual periods in some women. Pregnancy, in some, clears acne; while in others, there is a worsening of acne during the expecting months.

Acne Trigger: Heredity

A hereditary predisposition for acne formation has been noted by most studies. It is well known that tendency to pimples and acne scar formations runs in families. These could be due to the inborn sensitivity of the sebaceous glands to hormonal actions during puberty.

Acne Triggers: Occlusive Cosmetics

In individuals with an acne prone skin, use of oil based greasy foundations and face creams may stimulate new acne eruptions by causing build up of sebum within by blocking the hair follicle pores. This is known as acne cosmetica. Such individuals are advised to use only water based, oil free cosmetics as make up.

Acne Trigger: Aggressive Washing

Acne is not caused by poor hygiene and aggressive and frequent washing with abrasive soaps can worsen the acne situation in most sufferers.

Acne Triggers: Topical and Systemic Steroids

Potent Steroids cause acne
Potent Steroids cause acne

Steroids, particularly the medium and potent strength topical halogenated steroids, can induce eruption of steroid acne, where sudden appearance of skin colored and pus filled bumps worsen the acne after an initial period of improvement for a few days. The initial period of improvement with steroids is because of their anti-inflammatory actions.

Prolonged periods of oral steroids can trigger pimples on the face and body in a majority of patients.

Acne Triggers: Medications

Many systemic drugs and topical applications may induce fresh acne eruptions, known as acne medicamentosa. In addition to the steroids, drugs like phenytoin, lithium, iodides and the anti-tuberculous medication INH are known to trigger acne. Topical agents like chlorinated hydrocarbons, coal tar derivatives, cutting oils and grease cause acne like eruptions even on body areas where normal zits usually do not appear.

Acne Triggers: Diet

Food as a cause of acne is still a controversial topic among dermatologists, despite patient’s anecdotal reports and a few studies which blame westernized dietary habits, milk and milk products, and food items containing high levels of iodine and, possibly hormones. More studies and research is required in this field, but it would suffice to state that if the patient notices exacerbation of existing pimples or new acne eruptions after certain foods, these should be eliminated from the diet.

Acne Trigger: Stress

Hormones and other neuro-endocrine mechanisms during stressful periods can trigger fresh acne eruptions. Recently many studies have proven beyond doubt that the acne condition worsens in teens during stressful periods like exams.

Acne Trigger: Sunlight?

Limited sunlight exposure has a positive effect on acne, though remaining longer duration in hot, humid daylight actually has been found to worsen acne. Those who are using retinoids and tetracycline to treat acne should avoid sun exposure, as this can cause photosensitive reactions on the skin.

Acne Trigger: Hair Products

An overlooked cause of acne eruptions, especially on the forehead is use of oils and greasy creams on the hair.

The above list is not all inclusive by any means. There would be many more unknown triggers for acne, as many individuals, even in adulthood, get sudden acne eruptions without any identifiable causes. There is certainly a need for more research in this field.

Published by Dr Hanish Babu, MD on 24th May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

Pathogenesis of Acne or How Does Acne Develop?

How Acne Occurs
How Does Acne Occur?

The pathogenesis of acne or how acne forms  includes a combination of factors affecting the integrity of the hair follicle and its oil producing gland, the sebaceous gland.

The study of how acne develops is a fascinating one. There are many points to be clarified regarding the pathogenesis of acne. What is the basic cause of acne? Why does it appear only on some parts of the body? Why does acne have a course with waxing and waning? What is the role of hormones, skin oiliness and germs in the development of acne?

There are four major causes contributing to acne development –

  1. Increased sebum production
  2. Colonization of the hair follicle duct with the germ Propionibacterium acnes
  3. Thickening and plugging of the hair follicle walls and opening, resulting in comedo formation
  4. Inflammation of the pilosebaceous unit. Pilosebaceous unit includes the hair follicle and its associated sebaceous gland.
How Acne Develops
Stages of Acne Development

How Acne Develops: Increased Sebum Production or Seborrhea

Sebum is the oily secretion from the sebaceous gland lying alongside the hair follicle. Sebum is responsible for maintaining the oiliness of the skin and the hair. It keeps the skin supple and smooth. In infancy and childhood, the sebaceous glands are small and inactive. The sebaceous glands enlarge and become active during puberty under the influence of the androgen hormones secreted by the adrenal and gonadal glands.

The increased production of sebum, seborrhea, may be genetically programmed; some individuals are more acne prone than others. It is also seen that sebum secretion and sensitivity of the sebaceous glands to the action of androgens vary from follicle to follicle and area to area. This is the reason why acne severity varies between different follicles and hair bearing areas of the body.

How Acne Develops: Bacteria Colonization

 The increased sebum secretion predisposes to the overgrowth of the bacteria Propionibacterium acnes within the hair follicle and the sebaceous gland. The action of these bacteria on the sebum is thought to produce irritant products like free fatty acids within the hair follicle. These and other chemical mediators known as cytokines are thought to be responsible for the thickening of the hair follicle, plug formation and inflammatory events in acne.

How Acne Develops: Comedogenesis or Comedo Formation

 The thickening of the hair follicle walls, known as ductal hypercornification, and the keratinous plug formation is the cause for the formation of the comedo, better known as the acne whiteheads and blackheads. Comedo formation is the first stage of development of acne. When the follicular opening is closed with the keratinous plug, it is known as closed comedone or whitehead, and when it is dilated, the open comedone or blackhead. The black color seen in the blackhead is not dirt, but due to the sebum changing color when it comes in contact with the atmospheric oxygen.

How Acne Develops: Inflammation

 Inflammation of the hair follicle and the sebaceous glands and the surrounding dermis is the final event in the moderate to severe types of acne. Inflammation results in red, painful and pus filled bumps in acne. Acne gets inflamed by a combined action of P.acnes, the bye products of the action of the bacteria on the sebum, the corneocytes lining the hair follicle duct and the inflammatory mediators induced by the sebaceous glands.  

The inflammation weakens the follicular and sebaceous gland walls which rupture to discharge the sebum and part of the comedone into the dermis. This induces a severe foreign body inflammatory reaction resulting in formation of acne cysts and nodules.

Recent Advances in Acne Pathogenesis Information

 The 2009 acne update from the Global Alliance to Improve Outcomes in Acne throws some interesting insights to the pathogenesis of acne:

The inflammatory events in acne precede the hyperkeratinization (thickening of the follicular walls).

  1. acnes specifically activate special receptors on the cell membranes of inflammatory cells.

The sebaceous gland is a neuroendocrine-inflammatory organ that coordinates and executes a local response to a variety of neuro-endocrinological and stress induced stimuli.

Sebaceous gland plays an important role in hormonally induced aging of skin.

In addition to their action on sebaceous gland activity, androgens have influence on the follicular cells (corneocytes) also.

Oxidized lipids in sebum (possibly altered by P.acnes) induce the production of inflammatory mediators.

Sebum contains several matrix metalloproteinases (MMPs) which play important roles in the inflammatory process of acne. The levels of MMPs are significantly reduced in the acne lesions following treatment.

The acne information provided above is a short review of how acne develops. The degree of plugging of the comedones and the extent of inflammation decides the severity of the pimples. Different types of acne are categorized according to the severity of the acne lesions.

Reference

  1. Simpson NB & Cunliffe WJ. Disorders of the Sebaceous Glands in Rook’s Textbook of Dermatology. 2004; 7: 43.1-43.75.
  2. Diane T, Gollnick H et al. New insights into the management of acne: An update from the Global Alliance to Improve Outcomes in Acne Group. J Am Acad Dermatol, 2009;60:S1-50.

    Published by Dr Hanish Babu, MD on 24th May, 2018

    Disclaimer
    The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

    Copyright 2018 © Dr Hanish Babu, MD

What are the causes of Acne?

How does Acne occur?

Acne vulgaris or common acne (also known as pimple and zits) is actually a disease of the hair follicle and its associated oil producing

Acne Cause: Hair Follicle
Acne Cause: Hair Follicle

sebaceous gland, as we have already discussed. The oily liquid produced by the sebaceous gland is known as sebum.

The sebaceous glands remain relatively small during infancy and childhood. At puberty due to the action of hormones known as androgens (which include testosterone and dihydrotestosterone), increase the size and activity of the glands. As a result, there is increased sebum production from the sebaceous glands.

How Acne Occurs
How Does Acne Occur?

A bacteria known as Propionibacterium acnes(P.acnes), which is a normal resident of the hair follicle and which thrives on a fatty food, increases in number during puberty due to the increased ‘food supply’ in the form of sebum!

The combined effects of activities of the increased sebum secretion and the P.acnes is the cause for the disease we commonly recognise as acne.

Let us examine how these two conspire together to disturb the normal milieu interior of the skin and damage the clear complexion of millions of teenagers around the globe.

How Acne Develops
Stages of Acne Development

Depending upon severity, there are 4 types of acne.

Grade 1: Mild (Comedonal) Acne

We have already seen that the combined effects of activities of the increased sebum secretion and the bacteria Propionibacterium acnes(P.acnes) is the cause for acne.

Comedonal Acne
Acne Grade 1: Comedone

Certain enzymes produced by the bacteria cause chemical changes in the composition of sebum, converting the triglycerides into free fatty acids.

These free fatty acids are potentially irritating to the epidermal cells lining the inside of the hair follicle. Some chemotactic factors are also released due to the action of the P.acnes on the sebum. These in turn attract certain white blood cells known as neutrophils to the vicinity of the hair follicle. This starts another chain of chemical and physiological reactions that results in what we know as inflammation.

The net result of all those changes are these:

How Acne Develops
How Acne Develops
  • The lining of the hair follicle above the sebaceous gland become thickened.
  • Because of changes in the keratinization of the follicular cells, there is accumulation of abnormal cornified cells inside the follicular lumen.
  • This sticky cells become adherent to the top of the sebaceous gland to form a plug known as microcomedone.
  • When this plug enlarges just beneath the small hair follicle(pore) opening on the surface of the skin, it become visible to our eyes. This is nothing but the (in)famous whitehead or the closed comedone!
  • An open comedone or blackhead occurs when, because of the pressure from the plug beneath, the hair orifice enlarge to reveal the black “dirty looking” plug. This black color is not due to dirt, but due to the action of atmospheric oxygen on the free fatty acids, the after products of sebum.

This, then, is how the comedones come into existence during puberty.

Some comedones are not as innocuous as they look. For many unfortunate teens, they are time bombs ticking, with impending catastrophe in later years to break into scar forming nodules and cysts.

Grade 2: Moderate(Papular)Acne

As the sebum continues to accumulate, the hair follicular wall become stretched and larger skin colored papules become evident on the skin surface. There is minimal inflammatory reaction due to the neutrophils attracted to the area in this moderate type of papular acne.

What is Grade 2 Moderate Acne?
Grade 2 Moderate Acne

The lesions are more pronounced and more in number than in the comedonal acne.

Grade 3: Severe(Pustular) Acne
Severe Inflammed Acne
Grade 3 Pustular Acne

When the sebum secretion is increased and the chemical breakdown of the sebum occurs due to the action of the bacteria P.acnes, neutrophils are attracted to the area. Neutrophils are the white cells involved in inflammatory reaction. These release certain chemical mediators and enzymes which further weaken the follicular walls. The wall and the sheath of the sebaceous gland thins and become inflamed leading to pustule formation.

These are numerous red, tender, pus filled lesions on the affected areas.

This is the severe grade 3 acne or pustular acne.

Grade 4: Very Severe (Nodulo-cystic) Acne

Acne Cyst
Acne Cyst Formation

When the follicular walls further weaken and get inflamed gradually the walls expand and become deep seated nodules. Further action of inflammatory mediators cause rupture of the wall and sebum, part of the wall and cornified cells and bacteria are released into the dermis. This causes an intense reaction known as foreign body reaction within the dermis resulting in the formation of deep seated cysts.

Nodulocystic Acne
Very Severe Grade 4 Acne: Acne Conglobata

This is known as the very severe scarring type of nodulocystic variety of acne.

Note: The grading is only facilitatory. There may be more than one or two kinds of lesions (comedone, papule, pustule, nodule) present at any time in acne patients. The grading is done when a particular type of lesion out numbers others.

Published by Dr Hanish Babu, MD on 23rd May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis

should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

Acne 101: The Acne Basics

 

Acne 101 will discuss the acne basics in general. A basic knowledge of acne is important to learn how to effectively treat acne in its varied clinical presentations and avoid complications like acne scars.

The course of acne is punctuated with frequent flare-ups in the affected and hence acne is to be approached as a chronic disease which requires active treatment intervention and a maintenance program for optimal control of the inflammatory pimples. During the adolescent years acne can cause untold heartbreaks and psychosocial impacts, which makes it a disease to be handled with proper care and knowledge.

Is Acne a Disease or a Normal Physiological Problem of the Adolescence?

Acne is a disease of the pilo-sebaceous unit which includes the hair follicle and the associated sebaceous gland. It is not just a normal age related phenomenon, as hormone related pathological changes assisted by the bacteria propionibacterium acnes occur in acne and result in long lasting effects on the skin, like pigmentation and scars. The Global Alliance to Improve Outcomes in Acne in their report presented as a supplement to the May issue of Journal of American Academy of Dermatology advocates approaching acne as a chronic disease requiring initial aggressive therapy followed by maintenance therapy to avoid the complications and minimized the social and psychological fallouts of the acne.

When it is very mild and limited to a few numbers of comedones, acne can be considered physiological. The presence of inflamed papules, pustules or presence of nodules and acne cysts calls for active treatment of the acne.

How Common is Acne?

Acne is the commonest skin disease. It affects approximately 85% of young people. Previously thought to be a disease of the adolescents, acne is also common in adults from 20 to 35 years of age. The common acne is called acne vulgaris. There are many variants of acne like neonatal acne, drug induced acne, chloracne, acne excoriee, keloidal acne etc.

How Does Acne Occur?

Many factors play a role in the causation of acne, including a hereditary predisposition, effect of androgenic hormones and many other external and internal factors. After puberty, androgen hormones stimulate the sebaceous glands to increase their size and produce more sebum, an oily liquid intended to keep the skin smooth and supple. The sebum is a good growth media for certain bacteria, which in turn produces inflammation within the hair follicle and the surrounding dermal structures. Depending upon the severity of the inflammation, the types of acne also vary in different individuals and at different times in the same individual.

What is the Age Incidence of Acne?

Contrary to popular belief, acne can occur at any age, from neonates to old age. Mostly acne is seen in early puberty to early adulthood, i.e., the ages of 12 to 25 years. About 50% of teenage acne can continue to adulthood. Some people, especially females, tend to have an occasional flare ups into their 30s. At the age of 40, 1% of males and 5% of females still have active lesions of acne.

Does Acne Differ in Males and Females?

Males and females are affected equally in acne, though the severity of acne is more in males. Almost all boys and 90% of girls will have had an attack of acne during their teen age. Acne conglobata or nodulocystic acne is more common among males.

Moderate Acne: Type 3
Moderate Acne


What are the Common Areas of the Body Affected by Acne?

Acne can develop on any hair bearing area, though it is most common on face, as this is the area with the maximum density of sebaceous glands. In the face, the cheeks, nose, chin and forehead are mostly affected, in that order most of the time. Acne on face is most commonly known as the pimples or zits. Acne also occurs on the chest, shoulders, upper back, buttocks and thighs.

Is it True that Excess Dandruff is the Cause of Acne, especially on the Forehead?

Dandruff and acne has got some common features as their causes, like increased seborrhea, oily skin and the effect of the androgenic hormones. Hence both are complimentary; one is not cause of the other.

What are the Common Signs and Symptoms of Acne?

Whiteheads and blackheads are the earliest skin lesions in acne. Depending upon the severity acne is divided into different types of acne, the comedonal, papular, pustular and nodulocystic.

In presence of inflammation, in the pusutlar and nodulocyctic variety, the acne eruptions can be red, painful and hot and tender on touch.

The skin of acne sufferers is usually greasy and oily and most of them suffer from concomitant dandruff during the acne attack or later in their life.

Oiliness and sudden eruptions can sometimes cause an itchy feeling on the acne affected area.

Though the commonest skin disease affecting more than 85% of world’s population at least once in their life time, there are many misconceptions and myths regarding acne vulgaris.

Published by Dr Hanish Babu, MD on 23rd May, 2018

Disclaimer
The information given in this article is for educational purpose only so that patients are aware of the options available. No diagnosis

should be made or treatment undertaken without first consulting your doctor. If you do so, the author or the website will not be responsible for any consequences. The images provided are for illustration purpose only and are copyrighted.

Copyright 2018 © Dr Hanish Babu, MD

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