Hormones and acne

My doctor told me I would grow out of my acne but I am now 15. If it is true that I will grow out of it, please can you tell me when?

Your acne will get better with time but no one can tell you when
that will be and it is certainly not a reason to stop you getting
treatment. Acne starts when hormone changes occur around and
after puberty. These new levels of hormones stay the same for
many years – until the menopause in women and longer for men.
It is surprising that people do grow out of it but many more people
seem to carry on having problems well into adult life. You
need to deal with your acne as a ‘now’ thing so that when it does
stop happening you won’t be left with scars to remember it by.

Help! Every month, just before my period, I get spots around my chin. They don’t even come to a head; they just sit there and hurt. Do I have acne?
Yes, you probably have. Acne is triggered by the skin’s abnormal
reaction to hormones, so the changing levels of hormones at the
time of your period cause acne even though your skin doesn’t
react to different levels at other times of your cycle. This is a
good example of needing to see your doctor when the spots
appear, as there will be nothing to show if you have to wait a
week for an appointment. It also illustrates how important it is
for people with acne to be able to tell their own story about the
pattern of spots and when they get them, rather than just being
looked at quickly. Your history of getting spots at the times of
your periods will suggest a different approach to treatment than
if you had spots all the time. You could also think about taking a
photo of yourself with spots to show the doctor how bad it can
be.
I have heard that there might be a problem with my ovaries which is why I get acne. If that is the case, what is it and why do boys get acne?
You might have a condition called polycystic ovaries. This means
that your ovaries have lots of fluid-filled lumps (cysts) on them. If
this is the case, your ovaries won’t be producing the right balance
of hormones and, in particular, too much of the male hormone
testosterone. You are then likely to have very bad acne, grow
extra hair on your body and have light or no periods. In later life
you could find it hard to get pregnant. It is very important to have
tests for this condition; they include blood tests for the hormone
levels and ultrasound scans of your ovaries.
This is one of the few times when tests are needed in acne.
Your acne will need different and stronger treatment, and you
might also be offered treatment for your ovaries. They are a lot
bigger with all the cysts, so an operation to remove some of the
cysts can lead to more normal levels of hormones.
Although girls also have some testosterone, boys’ testes – the
male equivalent of ovaries – normally produce high levels of this
hormone, which is why they are often more affected.

‘Grading’ your acne

My doctor talked about my acne being ‘moderate’. What
does this mean?
To assess the severity of acne, it is graded into different levels.
There are many different ways of grading acne, some very complex
ones being designed for carefully assessed research into
treatment. It is easiest to look at three or, perhaps, four degrees
of acne:
• mild – mainly comedones with perhaps a few papules and
pustules,
• moderate – papules and pustules,
• severe – deeper lesions, nodules and some cysts,
• very severe – many nodules and cysts with scarring.
These four grades take into account the numbers and types of
lesions (‘spots’) as well as looking at scarring or pigmentation
changes seen in darker skins. Each area of the body should be
graded separately, and consideration should also be given to the
degree of psychological impact. For example, if you have only
mild acne but feel very upset by it, you should be considered as
‘moderate’ because this will affect which treatment is chosen for
you.
An exception to the grading rule is in people with pigmented
skin. Acne is one of the most common skin diseases in black people
and can cause a lot of damage. There is always much more
inflammation going on under the skin than would seem likely, so
mild-looking acne in someone of Asian or African-Caribbean origin
should be treated as if it were moderate.
Your doctor or nurse might also talk to you about grading so
that you can check or compare how different treatments are
working and how good (or otherwise) they are for you.
I hate my spots and have to cover them up when I go out.
My doctor is no use as he says I only have mild acne. What
can I do?
It can be very difficult to get doctors to understand how bad you
feel your acne is but, if you always cover it up, there may not be
much for the doctor to look at. It is worth following a few simple
guidelines whenever you go to your doctor:
• Keep your hair away from your forehead so that any comedones
and other acne lesions there are clearly seen. You
could take some hairgrips with you and pin your hair back or
up once you get to the surgery.
• If you are male and shaving, don’t forget to shave on the day
you see your doctor. Stubble can cover spots and make them
difficult to see.
• Why not ask for the first appointment for the day? That way,
you won’t have to sit in a crowded waiting room, feeling selfconscious.
• If you really can’t bear the thought of going without makeup,
you must be prepared to remove it before consulting
your doctor. In order to make a clear diagnosis, he will need
to look closely at your skin. That is his job and he will have
to look at far worse things than your skin, even if you can’t
imagine this! So take make-up remover with you and gently
remove it just before going in to see your doctor.

Classification of acne scars: A review with clinical and ultrasound correlation

introduction
Scar is defined as ‘‘the fibrous tissue that replaces normal
tissue destroyed by injury or disease’’.(1) Causes of acne scar
formation can be broadly categorized as either the result
of increased tissue formation or, more commonly, loss or
damage of local tissue.(2)
Clinical manifestations of acne scars as well as severity of
scarring are generally related to the degree of inflammatory
reaction, to tissue damage, and to time lapsed since the onset
of tissue inflammation.(3, 4) There have been attempts to
classify acne scars in order to standardize severity assessments
and treatment modalities.(3, 4) However, consensus
concerning acne scar nomenclature and classification is still
lacking.(3)
clinical classifications
In 1987 Ellis et al. proposed an acne scar classification system
and utilized the descriptive terms ice pick, crater, undulation,
tunnel, shallow-type, and hypertrophic scars.(5) Langdon, in
1999, distinguished three types of acne scars: Type 1, shallow
scars that are small in diameter; Type 2, ice pick scars; and Type
3, distensible scars.(6) Lately, Goodman et al. proposed that
atrophic acne scars may be divided into superficial macular,
deeper dermal, perifollicular scarring, and fat atrophy based on
pathophysiologic features.(7)
One classification system frequently used in clinical practice
for acne scars is based on both clinical and histological
features.(8) Acne scars are classified into three basic types
depending on width, depth, and 3-dimensional architecture:
Icepick scar•• s: narrow (diameter < 2 mm), deep, sharply
marginated and depressed tracks that extend vertically to
the deep dermis or subcutaneous tissue.
•• Boxcar scars: round to oval depressions with sharply
demarcated vertical edges. They are wider at the surface
than icepick scars and do not taper to a point at
the base. These scars may be shallow (0.1–0.5 mm) or
deep (≥ 0.5 mm) and the diameter may vary from 1.5
to 4.0 mm.
•• Rolling scars: occur from dermal tethering of otherwise
relatively normal-appearing skin and are usually
wider than 4 to 5 mm in diameter. An abnormal fibrous
anchoring of the dermis to the subcutis leads to superficial
shadowing and to a rolling or undulating appearance
of the overlying skin.
Other clinical entities included in this classification are hypertrophic
scars, keloidal scars, and sinus tracts.(8) Both hypertrophic
and keloidal scars result from an abnormal excessive tissue
repair: clinically, hypertrophic scars are raised within the limits
of primary excision, whereas keloidal scars transgress this
boundary and may show prolonged and continuous growth.
(9) Sinus tracts may appear as grouped open comedones histologically
showing a number of interconnecting keratinized
channels.(7)
Another classification is that proposed by Kadunc et al.(3)
Based on clinical appearance and relationship to surrounding
skin, acne scars are classified in this system as elevated, dystrophic,
or depressed. Other parameters include shape, consistency,
colour, and distensibility. This classification system may
also serve to assess the efficacy of various therapeutic options
based on acne scars types.(3) Kadunc’s classification is summarized
in Table 1.1.
Goodman et al. proposed a qualitative grading system that
differentiates four grades according to scar severity (Table
1.2): Grade I corresponds to macular involvement (including
erythematous, hyperpigmented, or hypopigmented scars),
whereas Grades II, III, and IV correspond to mild, moderate,
and severe atrophic and hypertrophic lesions, respectively. (10)
Interestingly, the authors consider lesion severity also according
to visibility at a social distance (> 50 cm). Moreover, since
patients may present various types of acne scars at numerous
anatomic sites (i.e., one cheek, the neck, the chest, and so
on; these single areas are defined by the authors as “cosmetic
units”), scars are further subdivided into four grades of severity
by anatomic sites involved, and the localized disease (up to
three involved areas) is classified as A (focal, 1 cosmetic unit
involvement) or B (discrete, 2–3 cosmetic units), whereas the
involvement of more cosmetic units is classified as generalized
disease, previously described in Table 1.2.
The same authors subsequently, suggested a quantitative
numeric grading system based on lesion counting (1–10,
11–20, >20), scar type (atrophic, macular, boxcar, hypertrophic,
keloidal), and severity (mild, moderate, severe). Final scoring
depends on the addition of points assigned to each respective
category and reflects disease severity, ranging from a minimum
of 0 to a maximum of 84 (Table 1.3).(11)
Finally, Dreno et al. first proposed the ECLA scale (echelle
d’evaluation clinique des lesions d’acne) (12), followed by
the ECCA grading scale (echelle d’evaluation clinique des
cicatrices d’acne) (4). According to this scoring system,
morphological aspects of lesions define the type of scars as
follows: atrophic scars (V-shaped, U-shaped and M-shaped),
superficial elastolysis, hypertrophic inflammatory scars (<2
years since onset), and keloid-hypertrophic scars (>2 years
since onset). Each scar type is associated with a quantitative
score (0, 1, 2, 3 depending on the number of lesions) multiplied
by a weighting factor that varies according to severity,
evolution, and morphological aspect. The final global score
is directly correlated with clinical severity and ranges from
0 to 540 depending on the type and number of acne scars
clinical and ultrasound correlations
Methods
Ultrasound imaging is a noninvasive technique that uses
various acoustic properties of biologic tissues. Typically, echo
signals are represented in one-dimensional diagrams (A-mode)
or two-dimensional images (B-mode).
Ultrasound of the skin is best performed by equipment
using frequencies of > 20 MHz. Using B-mode imaging,
normal skin typically shows an epidermal entrance echo, the dermal layer, and the subcutaneous layer. This technique offers
a wide range of possibilities in clinical and experimental dermatology.
It is used for the evaluation of skin tumour thickness
(e.g., basal-cell carcinoma, melanoma). Areas of research
may include scleroderma, psoriasis, and aged and photoaged
skin. Moreover, it provides an objective measurement of skin
thickness and has been utilized to assess thickness of hypertrophic
scars before and after treatment.(13)
A preliminary study was preformed in a series of
patients (N = 20) affected by various types of acne scars
in order to determine whether a correlation exists between
clinical appearance of selected scar parameters (thickness,
width, depth) with ultrasound examination. Cross-sectional
B-mode scans were obtained using a 22-MHz ultrasound
system (EasyScan Echo®, Business Enterprise, Trapani, Italy)
that allowed examination of skin sections of 12 mm in width
and 8 mm in depth.
Results
Atrophic scar•• s appear as invaginations of the skin in
which all skin layers are normally represented:
a) Icepick scars (n = 5) uniformly have a sharp, demarcated
V-shaped appearance and are characterized by a
narrow diameter at the surface (usually < 2 mm) and

 a vertical extension that reaches a depth corresponding
to the deep dermis (Figure 1.1a–1.1b).
b) Boxcar scars (n = 5) uniformly present with a sharp
demarcated U-shaped appearance and are characterized
by a superficial diameter usually ranging from 2 to 4 mm
and a vertical extension that reaches a depth corresponding
to the superficial or deep dermis (Figure 1.2a–1.2b).
c) Rolling scars (n = 5) uniformly appear as large (up to 5
mm) poorly demarcated depressions of the skin; these
scars are very superficial, sometimes hardly visible, with
a vertical extension that is limited to a depth corresponding
to the epidermal thickness (Figure 1.3a–1.3b).
•• Hypertrophic and keloidal scars (n = 5) uniformly
appear as dome-shaped, localized increase of skin thickness
(Figure 4a–4b; 5a–5b); the dermis usually is less
echogenic than normal skin; in most cases, with the 22
MHz probe, keloidal scars may not be entirely visualized
because of their large size.

Getting acne....Q&A............(part 3 of 5)

I’ve started getting acne spots. How long do they last?
This depends on what type of spots they are and, even then, it can
be very difficult to predict what will happen. Some spots will
appear and then disappear during the course of a day but others
will evolve more gradually through the various stages. Comedones
can be very persistent if they don’t get inflamed. Mildly inflamed
spots will last 5–10 days before settling down, but can leave a flat
red mark (macule) for several weeks. Nodules and cysts may last
for weeks or months unless you get some treatment.

What is the difference between a whitehead and a yellow-
head spot?
These two common terms describe quite different types of spot.
A whitehead is a closed comedone where the pore is blocked and
not open to the air. There is no inflammation (redness). A yellow-
head suggests a spot with pus in it. The medical term is a ‘pustule’.
Whiteheads may become yellowheads if the blocked pore becomes
infected.

My daughter is only 9 but she seems to have developed some
blackheads around her nose. Can this be acne – like I had?

Girls seem to be starting puberty earlier and earlier, and many
9-year-olds have started to develop some hormone changes.
Blackheads are one of the types of spots that occur in acne so,
yes, this could well be the start of it. Almost all children will get
some blackheads and other spots as they start and go through
puberty, so your daughter will not necessarily get worse but this
might depend on how bad your own acne was. We don’t fully
understand the role of genes in acne but there is some inherited
factor that makes acne more likely in some families. If you had
severe acne, it is worth starting a simple treatment approach to
reduce the number of blackheads on your daughter’s nose.

I am an identical twin and I have acne but my sister
doesn’t – weird or what? Can you explain why?
Answering questions like this is always difficult. We can’t give you a
reason why your twin doesn’t have acne, because the precise cause
and triggers are not fully understood. However, studies of twins
have helped to work out that some genetic inheritance is involved,
as identical twins tend to produce similar amounts of the skin
grease called sebum. This is not the case for non-identical twins.
You don’t say how old you are – it may be that your sister will
go on to develop acne. She is certainly more likely to have acne
than if she were not your twin.

I have been having problems with my skin for about two years. Can you tell me what the difference is between spots and acne? I think that to have acne you must have at least 20 spots but my mum thinks otherwise.
There is no real difference between spots and acne, assuming
that the type of spots fits into the pattern we have described withblackheads, whiteheads, papules and pustules. What is most
important is the effect the spots have on you and whether you
have any of the more serious types of spot that might cause long-
term scars. If you are upset by the appearance of your skin, it
doesn’t really matter how many spots you have – you have a
problem that is worth seeking some treatment for.

Why am I the only one in my class who has spots? I heard
it was very common but I don’t think it is really.
The most important spots are the ones that you have, and you
will be much more aware of them than anyone else. Other
students might have spots that you can’t see – on their back or
chest – or they might be using some treatment or camouflaging
make-up. Don’t worry about them; just talk to your pharmacist or
doctor if you are not already using some creams.DBE6SCXAA5WF

What is acne?.....................(part 2 of 5 )

Below we outline the types of spots you can get, so you can tell whether you have a mild, moderate or severe problem. They do not all have to be present for you to have acne. Just one type will still mean you have this condition, and there are effective treatments no matter how bad your problem is.

Comedones

These are the starting point of all acne. They begin as very small blockages in the pores. At this stage a blockage is referred to as a microcomedone – the comedone is too small to be seen. Microcomedones can progress to become larger comedones, or they can burst (rupture) internally, causing different types of spots.They burst because of the build-up of pressure and the damage that the inflammatory process does to the wall of the duct.

Whiteheads (closed comedones)

Some people think of whiteheads as a type of pus-like spots, but they are not. As the microcomedone gets larger, because swelling is building up behind the blockage, it becomes visible. If the initial blockage is quite deep in the pore, the opening onto the skin will remain closed; this causes the typical whitish lump that can be seen and felt on the surface.
Blackheads (open comedones)

These are clearly visible and very annoying because they look so dark and obvious. The blockage has occurred further up the duct, so its opening is widened and the contents are visible. If you were to dissect your skin, you would see the curly sebaceous gland –which is the escape route for oil – blocked full of a hard, yellow plug. This plug is a mixture of the sebum that has solidified and
the dead lining cells that have been shed. Because these are like skin cells, they contain some of the pigment (melanin) that gives skin its colour. This pigment turns dark when it is exposed to air,so the ‘black’ in ‘blackhead’ is notdirt.

Inflamed spots

Comedones can stay quite happily in your skin for months, or even years, without changing. If they progress or burst (rupture), though, different kinds of spots result: papules, pustules, nodules and cysts.

Papules

If the comedones start to leak sebum into the surrounding tissue, this produces inflammation and a red spot results. Papules are less than 5mm across and have no pus visible. They could be
called ‘redheads’, as they are otherwise like the whiteheads. If your microcomedones rupture, you will produce papules without going through the whitehead and blackhead stage.

Pustules

A pustule is the typical pus spot or yellowhead. These occur when the bacteria present on the skin and in the duct start to multiply. These bacteria are called Propionibacterium acnes
(usually shortened to P. acnes). They prefer dark places with no air to breed. A blocked pore is ideal and soon there will be lots of bacteria producing more inflammation; this triggers the body’s
own defences as mentioned above, leading to a head of pus on a red swelling.

Nodules and cysts

Comedones, papules and pustules are nasty to look at and caus pain associated with the swelling and inflammation but will clea up without causing much scarring except in people wit
pigmented skin. (This is discussed further in Chapter 6, The physical scars.) The next two types of spot mentioned, howeve – nodules and cysts – can cause real and lasting damage.

Nodules

Nodules are solid spots; they are much bigger than papules and extend deeper into the skin. They are caused when a large comedone has ruptured, releasing lots of inflammatory contents
(white cells and bacteria) into the surrounding skin. More inflammation and pus result, leading to more pain and swelling.The nodule extends deeper into the area that contains the skin’s
structural support. Damage here leads to the scarring.

Cysts

Unlike nodules, cysts are bags of liquid that is a mixture of pus and bacteria. Cysts usually occur only with nodules, often when two or three are close together. They are even more destructive
than nodules to the structure of the skin but, luckily, are quite rare.

What is acne? ......................(part 1 of 5)

‘Acne is just when you get a load of spots all over your face. You
probably need to have about 20 for it to be bad.’
‘I think it is when you don’t wash and your face gets all spotty
and horrible.’

Acne is, in fact, the world’s most common skin disease. You know you have it when your skin develops blackheads, whiteheads, or red or yellow spots and becomes greasy. These are the classic signs and it doesn’t matter how many you have for your doctor to confirm it as acne. Acne doesn’t care who you are, what colour your skin is or how old you are. However, it is far more
likely that, as you approach puberty, your skin will start to change enough to kick-start the ‘acne process’. What most people don’t know is that you don’t always grow out of it: 15 per cent of
women in their 40s are still troubled by acne, although for men is it less likely to carry on for so long.

It’s a cruel fact that acne feels most at home on your face, butt can also crop up on your neck, back, chest or shoulders. This is because the oil-producing glands (the sebaceous glands) on your
skin are most concentrated here.

There has been extensive research into acne, and dermatologists blame four main factors in the skin:

• Firstly, the body seems to become extremely sensitive to the male hormones (the androgens) in the body. Women as well as men have male hormones but, because men have higher levels, they are often more affected. However, there do not have to be large amounts of these male hormones to get the oil-producing glands over-working, which makes them pump out more oil – called sebum.
• Secondly, these oil-producing glands have an opening into pores in the skin – small holes at the top of a tube or duct. At the bottom of the duct lies a hair follicle – specialised cells that are capable of producing a hair. The gland opens about half-way up the duct, which is lined by cells just like the ones on the surface of the skin. If you are affected by acne, these cells tend to clump together when they die and are shed, and cause the duct to narrow.
• Thirdly, the combination of this narrowing and the excess sebum results in the blockage – the starting point for all types of acne. This creates a wonderful environment for the acne bacteria that normally live on the skin: they start to multiply, which can lead to infection and inflammation.
• Fourthly, this inflammation then wakes up the body’s defence system, which sends white blood cells to fight the bacteria and repair the damage caused. These white blood
  cells make up the bulk of what we see as pus – yellow or greenish fluid produced by the body in response to inflammation; it contains lots of white cells that come out of the blood stream to attack the cause of the inflammation. But, if the blockage doesn’t become infected, it will remain as a solid plug – or what we know as a blackhead.

How Is Acne Treated?

By the time many people consult a doctor for their acne, they usually have
tried a drawerful of over-the-counter (OTC) medications. Acne is often
treated by a dermatologist, a doctor who specializes in diseases and
disorders of the skin. Dermatologists treat all kinds of acne, particularly
severe cases. Doctors who are general or family practitioners, pediatricians,
or internists may treat patients with milder cases of acne.
The main goal of acne treatment is to prevent scarring. Additional goals are
to reduce the number of painful lesions and to minimize the psychological
stress and embarrassment caused by this disease. Doctors often use drug
therapy as the first choice for treating acne. Drug therapy is aimed at
reducing several problems that play a part in causing acne: abnormal
clumping of cells in the follicles, increased oil production, the bacterium P.
acnes, and inflammation. Depending on the severity of the person’s acne, the
doctor will recommend one of several OTC or prescription topical
medications (medication applied to the skin) or a prescription systemic
medication (medication taken by mouth). The doctor may suggest using
more than one topical medication or using both an oral medication and a
topical medication at the same time.
Common Over-the-Counter Topical Medications Used to Treat
Acne
Benzoyl peroxide cream, gel, lotion, or soap:
Clearasil
Fostex
PanOxyl
Dryox
Persa-Gel
Salicylic acid:
PROPApH, Stridex
Oxy Night Watch
Clearasil Clearstick Maximum Strength
Sulfur:
Sulpho-Lac Acne Medication
Liquimat
Therac Lotion
Sulmasque
Benzoyl peroxide and sulfur:
Dryox 10S
Dryox 20S 10
Sulfoxyl
Sulfur and resorcinol:
Sulforcin Lotion
Rezamid Lotion
Acnomel Cream
Treatment for Blackheads, Whiteheads, and Mild Inflammatory
Acne
Doctors usually recommend an OTC or prescription topical medication for
people with blackheads, whiteheads, and mild inflammatory acne.
Depending on the type of medication, a topical drug is applied directly to
the acne lesions or to the entire area of skin affected. The medication helps
limit the formation of new blackheads and whiteheads and decrease
inflammation.

Treatment for Moderate to Severe Inflammatory Acne
Patients with moderate to severe inflammatory acne may be treated with an
OTC or prescription topical medication, a prescription oral medication, or a
combination of these.
Topical OTC Medications
Benzoyl peroxide, resorcinol, salicylic acid, and sulfur are the most common
topical OTC medications used to treat acne. Each works a little differently.
Benzoyl peroxide is best at killing P. acnes and may reduce oil production.
Resorcinol, salicylic acid, and sulfur help break down blackheads and
whiteheads. Salicylic acid also helps cut down the shedding of cells lining
the follicles of the oil glands. Topical OTC medications are available in many
forms, such as gel, lotion, cream, soap, or pad.
In some patients, OTC acne medications may cause side effects such as skin
irritation, burning, or redness. Some people find that the side effects lessen
or go away with continued use of the medication. Severe or prolonged side
effects should be reported to the doctor.
OTC topical medications are usually moderately effective in treating acne
when used regularly. Patients must keep in mind that it can take between 4
and 8 weeks before they notice an improvement in their skin.
Prescription Topical Medications
Several types of prescription topical medications are used to treat acne,
including benzoyl peroxide, antibiotics, tretinoin, adapalene, and azelaic
acid. Prescription and OTC benzoyl peroxide work in the same way. Many
doctors prescribe benzoyl peroxide instead of recommending OTC versions
to make sure patients get the most desirable formulation (cream, gel, or
lotion).
Common prescription topical medications used to treat acne:
Benzoyl peroxide
Adapalene gel (Differin)
Clindamycin phosphate (Cleocin T)
Azelic acid (Azelex)
Erythromycin
Benzoyl peroxide and sulfur
Tetracycline HCL
Erythromycin and benzoyl peroxide
Tretinoin (Retin-A, Avita)
Sulfur and resorcinol
Antibiotics and azelaic acid help stop or slow the growth of P. acnes and
reduce inflammation. Tretinoin, a type of drug called a retinoid that contains
vitamin A, is the most effective topical medication for stopping the
development of new comedones. It also fights acne by increasing cell
turnover, which helps unplug existing comedones, and thereby allows other
topical medications, such as antibiotics, to penetrate the follicles better. The
doctor may also prescribe a newer drug called adapalene gel, a retinoidlike
compound that helps decrease microcomedone formation.
Prescription topical medications come in a variety of products. The doctor
will consider the patient’s skin type when prescribing a product. Creams and
lotions are moisturizing and tend to be good for people with dry skin. Gels
and solutions are generally alcohol based and tend to dry the skin, so
patients with excessively oily skin or those who live in hot, humid climates
may prefer a gel. The doctor will tell the patient how to apply the medication
and how often to use it.
Some people develop side effects from using prescription topical
medications. Common side effects include stinging, burning, redness,
peeling, scaling, or discoloration of the skin. With retinoids, these side effects
usually decrease or go away after the medication is used for a period of time.
Patients should report prolonged or severe side effects to their doctor.
Between 4 and 8 weeks will most likely pass before patients see
improvement in their skin.
Prescription Oral Medications
For patients with moderate to severe acne, the doctor often prescribes oral
antibiotics (taken by mouth) in addition to topical medication. Oral
antibiotics are thought to help control acne by curbing the growth of P. acnes
and decreasing inflammation. Common antibiotics used to treat acne are
tetracycline, minocycline, doxycycline, and erythromycin. Some people have
side effects when taking these antibiotics, such as photosensitivity (higher
risk of sunburn), upset stomach, dizziness or lightheadedness, and skin
discoloration. Tetracycline is not given to pregnant women or children under
12 years of age because it can discolor developing teeth. Tetracycline and
minocycline also decrease the effectiveness of birth control pills, so a backup
or alternative form of birth control must be used. Patients usually must take
oral antibiotics for as long as 4 to 6 months to effectively treat acne.
Treatment for Severe Nodular or Cystic Acne
People with severe nodular or cystic acne should be treated by a
dermatologist. For patients with severe inflammatory acne that does not
improve with other medications, such as those described above, isotretinoin
(Accutane), a retinoid, may be needed. Isotretinoin is an oral drug and is
usually taken once or twice a day for 16 to 20 weeks. It is believed to
markedly reduce the size of the oil glands so that much less oil is produced.
As a result, the growth of P. acnes is decreased. Isotretinoin also reduces cell
shedding and the stickiness of cells in the follicles, which helps prevent the
development of comedones.
Advantages of Isotretinoin
Isotretinoin is a very effective medication that can help prevent extensive
scarring in patients. After 16 to 20 weeks of treatment with isotretinoin, acne
completely or almost completely goes away in most patients (up to 90
percent). For some people, however, the acne will come back, and they will
need additional treatment with isotretinoin.
Disadvantages of Isotretinoin
Patients should carefully consider the several disadvantages of isotretinoin.
The drug is not only expensive but is also linked to some adverse effects that
can be severe. Possible side effects include inflammation of the lip and
mucous membrane of the eye; dry mouth, nose, or skin; itching; nosebleeds;
muscle aches; photosensitivity; and, rarely, decreased night vision. Other
more serious side effects include increased blood cholesterol, lipid, and
triglyceride levels and abnormal liver enzymes. To make sure isotretinoin is
stopped if these side effects occur, the doctor usually monitors a patient’s
complete blood count, blood chemistries, cholesterol, triglycerides, and liver
enzymes before therapy is started and periodically during treatment. All of
these side effects usually go away after the medication is stopped. Patients
who experience side effects while using isotretinoin should tell their doctor.
The doctor may be able to reduce the dose of the drug so that the side effects
are decreased or stopped.
The most serious potential adverse effect of isotretinoin is that it is
teratogenic: it can cause birth defects in the developing fetus of pregnant
women who take the drug. Therefore, it is crucial that women of
childbearing age are not pregnant and do not get pregnant while taking
isotretinoin. Women must use an appropriate birth control method for 1
month before therapy begins, during the entire course of therapy, and for 1
full month after therapy stops. Women should talk to their doctor about
when it is safe to get pregnant after therapy with isotretinoin has stopped.
Treatments for Hormonally Influenced Acne
For some female patients, treatment-resistant acne is caused by excessive
production of hormones called androgens. Clues that help the doctor
diagnose hormonally influenced acne are adult-onset acne, hirsutism
(excessive growth of hair or hair in unusual places), premenstrual acne
flares, irregular menstrual cycles, and elevated blood levels of certain
androgens.
The doctor may prescribe one of several drugs to treat women with this type
of acne. Low-dose estrogen birth control pills help suppress the androgen
produced by the ovaries. Low-dose corticosteroid drugs, such as prednisone
or dexamethasone, may have an anti-inflammatory effect and suppress the
androgen produced by the adrenal glands. Finally, the doctor may prescribe
an antiandrogen drug, such as spironolactone, which helps prevent
androgens from causing excessive oil production. Spironolactone also stops
androgen production in the ovaries and adrenal glands. Side effects of
antiandrogen drugs may include menstrual irregularities, breast tenderness,
headache, and fatigue.
Other Treatments for Acne
Doctors may use other types of procedures in addition to drug therapy to
treat patients with acne. The doctor may remove the patient’s comedones
during office visits. Sometimes the doctor will inject a corticosteroid drug
directly into lesions to help reduce the size and symptoms of tender and
inflamed cysts and nodules. Other patients may benefit from light skinpeeling
agents that are prescribed by a doctor or applied in the doctor’s
office. For some patients, the doctor may suggest a minor surgical or medical
procedure to help reduce scarring caused by acne.
How Should People with Acne Care for Their Skin?
Clean Skin Gently
People with acne may try to stop outbreaks and oil production by scrubbing
their skin and using strong detergent soaps. However, scrubbing will not
improve acne; in fact, it can make the problem worse. Most doctors
recommend that people with acne gently wash their skin with a mild
cleanser, once in the morning and once in the evening. Patients should ask
their doctor or another health professional for advice on the best type of
cleanser to use. The skin should also be washed after heavy exercise. Patients
should wash their face from under the jaw to the hairline; rough scrubs or
pads should not be used. It is important that patients thoroughly rinse their
skin after washing it. Astringents are not recommended unless the skin is
very oily, and then they should be used only on oily spots. Doctors also
recommend that patients regularly shampoo their hair. Those with oily hair
may want to shampoo it every day.
Avoid Frequent Handling of the Skin
People who squeeze, pinch, or pick their blemishes risk developing scars.
Acne lesions can form in areas where pressure is frequently applied to the
skin. Frequent rubbing and touching of skin lesions should be avoided.
Shave Carefully
Men who shave and who have acne can try electric and safety razors to see
which is more comfortable. Men who use a safety razor should use a sharp
blade and soften their beard thoroughly with soap and water before
applying shaving cream. Nicking blemishes can be avoided by shaving
lightly and only when necessary.
Avoid Suntanning
A suntan or sunburn that reddens the skin can make blemishes less visible
and make the skin feel drier for a little while. But the benefits are only
temporary. The sun can seriously damage skin, promote aging of skin, and
cause skin cancer. Furthermore, many of the medications used to treat acne
make a person more prone to sunburn.
Choose Cosmetics Carefully
People being treated for acne often need to change some of the cosmetics
they use. All cosmetics, such as foundation, blush, eye shadow, and
moisturizers, should be oil free. Patients may find it difficult to apply
foundation evenly during the first few weeks of treatment because skin may
be red or scaly, particularly with the use of topical tretinoin or benzoyl
peroxide. Lip products that contain moisturizers may cause small, open and
closed comedones to form. Hairstyling products that come in contact with
the skin along the hairline can cause burning or stinging in people with acne.
Products that are labeled as noncomedogenic (do not promote the formation
of blemishes) should be used; in some people, however, even these products
may cause acne.

What Research Is Being Done on Acne?
Medical researchers are working to develop new topical antibiotics for
treating acne to replace some of those in current use. As with many other
types of bacterial infections, doctors are finding that, over time, the bacteria
that cause acne are becoming resistant to treatment with certain antibiotics.
A different type of antibiotic or a stronger one is needed to kill diseasecausing
bacteria once they become resistant to existing antibiotics.
Research is being conducted on lipophilic compounds, a class of drugs that
are potent in decreasing inflammation and killing P. acnes. Additional research is also being conducted on the potential side effects of isotretinoin
and the long-term use of medications used for treating acne.
Other researchers are attempting to determine the factors in girls during
early puberty that might predict the development of severe acne later.
Finally, some researchers are studying how acne affects certain aspects of
patients’ lives, including psychological health and quality of life.

Who Gets Acne?

People of all ages get acne, but it is most common in adolescents. Nearly 85
percent of adolescents and young adults between the ages of 12 and 24
develop the disorder. People of all races can have acne, but it is more
common among Caucasians. For most people, acne tends to go away by the
time they reach their thirties; however, some people in their forties and fifties
continue to have the disorder.

What Causes Acne?

The exact cause of acne is unknown, but doctors believe it results from
several related factors. One important factor is rising hormone levels. These
hormones, called androgens (male sex hormones), increase in both boys and
girls during puberty and can cause the sebaceous glands to enlarge and
make more sebum. Another factor is heredity or genetics. Researchers
believe that the tendency to develop acne can be inherited from parents. For
example, studies have shown that many school-age boys with acne have a
family history of the disorder.



Factors That Can Contribute to Acne or Make It Worse

Several factors can contribute to the cause of acne or make it worse.
Changing hormone levels in girls and women may cause a flare in their acne
2 to 7 days before their menstrual period starts. Hormonal changes related to
pregnancy or starting or stopping birth control pills can also cause acne.
Stress, particularly severe or prolonged emotional tension, may aggravate
the disorder.
In addition, certain drugs, including androgens, lithium, and barbiturates,
are known to cause acne. Greasy cosmetics may alter the cells of the follicles
and make them stick together. Friction caused by leaning on or rubbing the
skin or the pressure from bike helmets, backpacks, or tight collars can
contribute to or worsen acne. Also, environmental irritants (such as pollution
and high humidity), squeezing or picking at blemishes, and hard scrubbing
of the skin can make acne worse.
Myths about the Causes of Acne

There are many myths about what causes acne. Chocolate and greasy foods
are often blamed, but research has shown that foods seem to have little effect
on the development and course of acne in most people. Another common
myth is that dirty skin causes acne; however, blackheads and other acne
lesions are not caused by dirt.

How Does Acne Develop?

Doctors describe acne as a disease of the pilosebaceous units. Found over
most of the body, pilosebaceous units consist of a sebaceous (oil) gland
connected to a hair-containing canal called a follicle (see below). These units
are largest and most numerous on the face, upper back, and chest—areas
where acne tends to occur. The sebaceous glands make an oily substance
called sebum that normally empties onto the skin surface through the
opening of the follicle.
Acne is believed to result from a change in the inner lining of the follicle that
prevents the sebum from passing through. For reasons not understood, cells
from the lining of the follicle are shed too fast and clump together. The
clumped cells plug up the follicle’s opening so sebum cannot reach the
surface of the skin. The mixture of oil and cells causes bacteria that normally
live on the skin, called Propionibacterium acnes (P. acnes), to grow in the
plugged follicles. These bacteria produce chemicals and enzymes that can
cause inflammation. (Inflammation is a characteristic reaction of tissues to
disease or injury and is marked by four signs: swelling, redness, heat, and
pain.) When the plugged follicle can no longer hold its contents, it bursts and
spills everything onto the nearby skin—sebum, shed skin cells, and bacteria.
Lesions or pimples develop as a result of the skin’s being irritated.

People with acne frequently have a variety of lesions, some of which are
shown below. The basic acne lesion, called the comedo (kom´-e-do) or
comedone, is simply an enlarged hair follicle plugged with oil and bacteria.
This lesion is often referred to as a microcomedo because it cannot be seen by
the naked eye. If the plugged follicle, or comedo, stays beneath the skin, it is
called a closed comedo or whitehead. Whiteheads usually appear on the skin
surface as small, whitish bumps. A comedo that reaches the surface of the
skin and opens up is called a blackhead because it looks black on the skin’s surface. This black discoloration is not due to dirt. Both whiteheads and
blackheads may stay in the skin for a long time.
Other troublesome acne lesions can develop, including the following:
       Papules—inflamed lesions that usually appear as small, pink bumps
on the skin and can be tender to the touch.
       Pustules (pimples)—inflamed, pus-filled lesions that can be red at the
base.
       Nodules—large, painful, solid lesions that are lodged deep within the
skin.
       Cysts—deep, inflamed, pus-filled lesions that can cause pain and
scarring.

What Is Acne?

Acne is a disorder of the skin’s oil glands (sebaceous glands) that results in
plugged pores and outbreaks of lesions commonly called pimples or zits.
Acne lesions usually occur on the face, neck, back, chest, and shoulders.
Nearly 17 million people in the United States have acne, making it the most
common skin disease. Although acne is not a serious health threat, severe
acne can lead to disfiguring, permanent scarring, which can be upsetting for
people who suffer from the disorder.