Acne

In this article:

• What Is acne?
• Symptoms
• When to see a doctor
• What are the different types of acne?
• Causes
• Acne truth and myths
• Hormonal factors
• Other possible triggers
• Complications
• Risk Factors
• How is acne diagnosed?
• What is the outlook for someone with acne?
• How can acne be prevented?
• References

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What Is acne? 

Acne is the inflammation of the skin pore that is commonly called a pimple, or a zit. It happens when the skin gland that releases fat/oil to moisturize the skin gets blocked. As a result, inflammation may start with or without bacteria, or a black head develops. The most common time to see acne is puberty. During this time, it is mostly a hormonal issue, when the quality of the fatty secretions of the skin change. As a result, thicker fatty secretions get stuck in the gland, and may get infected. 

Adult acne will continue past the puberty, and have to do with many factors influencing the skin quality. Acne becomes less of a problem with age, and are an extreme rare problem for elderly people.

Boys and girls get acne evenly. It seems to be more of a genetic problem running in the families. It is a very common health issue worldwide affecting all ethnicities and races. Some people never experience acne.

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Symptoms

The symptoms of the acne are simple to recognize:

• A zit that suddenly appears on the face (red elevated swelling with the white head in the middle)
• Small red pimples and black dots on the nose, cheeks, forehead and chin
• This rash does not itch, but may hurt
• The way pimple looks may change every day. Some black dots may disappear, while others can get inflamed and develop red bump with white head. 

When to see a doctor

Acne can range from a small esthetic inconvenience to a significant health problem and social embarrassment. If you can take some simple measures to control acne, you really do not need to see a doctor. There are couple of reasons you need to schedule an appointment with the dermatologist or esthetician:

1. Acne is a significant problem for a social life
2. Acne causes deep infection or large areas of the skin involved
3. Acne leaves scars that do not go away
4. Other systemic symptoms are present together with rash.

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What are the different types of acne?

Acne occurs on central-facial areas of the back, upper trunk, and deltoid region. Acne presents as skin rash starting with comedones.

• Grade 1 (a and b): Comedones. They are of two types, open and closed. Open comedones are due to plugging of the pilosebaceous orifice by sebum on the skin surface. Closed comedones are due to keratin and sebum plugging the pilosebaceous orifice below the skin surface.
• Grade 2 (c): Inflammatory lesions present as a small papule with erythema.
• Grade 3 (d): Pustules or pimples.
• Grade 4: Many pustules coalesce to form nodules and cysts.

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Causes

As we discussed before, the main cause of the acne is clogging of the oil pores of the skin. If the composition of the oil produced by the skin glad is soft and smooth, the oil will be squeezed out to moisturize the skin. But if the gland starts producing thick fatty content, it will get stuck in the duct and clog the pore. As the gland actually does not stop production, eventually the duct will distend and form comedones. 

During puberty, under the influence of androgens, sebum (skin oil) secretion is increased. Speaking scientifically, 5-alpha reductase converts testosterone to more potent DHT, which binds to specific receptors in the sebaceous glands increasing sebum production. This leads to an increased hyperproliferation of follicular epidermis cells, causing retention of sebum and blockage of the gland.

Distended follicles rupture and release pro-inflammatory chemicals into the dermis, stimulating inflammation. C. acnes, Staphylococcus epidermis, and Malassezia furfur induce inflammation and induce follicular epidermal proliferation.

Acne truth and myths

There is a lot of research done to figure out acne nature and cure. It is still unclear why some people get acne as teens, and others don’t. Also, there is new evidence on the importance of the bacteria that normally lives on our skin.

Acne myths. Let’s talk about true and anecdotal evidence about acne.

1. Acne rash is contagious. No, you cannot contract acne as a disease from someone. Acne is a problem with your own skin.
2. Acne are caused by infection. While bacteria is involved, it does not cause acne. First of all, the cause of comedones is blockage of the gland in the skin. Second, it is now found that an imbalance of the skin microbiome, when good bacteria is gone, can cause pathogenic bacteria to invade the glands.
3. Acne always cause scars. Not true. The most important rule is not to squeeze the zits out. That action will always cause the worsening of the condition, and if you do it often it will eventually lead to the scar.

Hormonal factors

Hormones are directly connected to the function of the oil glands, especially in the face. Why? That is just how it works. Any sex hormone changes from high to low (and the opposite) can cause more or less acne. During puberty these ups and downs of androgen and estrogen are common, so are acne. 

Most of the time acne improve and disappear when the sex maturation is complete. If they persist into adult life, levels of testosterone, LH, FSH, and DHEA should be ordered.

Other possible triggers

Factors aggravating acne include:

• Food with a high glycemic number like dairy products (which also may contain hormones), junk food, and chocolates. These cause insulin-like growth factors production in the body influencing more epidermal cells which clog pores.
• Oil-based cosmetics and facials with exfoliating rough treatments
• A premenstrual flare-up in acne is common due to jumps in progesterone-estrogen balance. This occurs in about 70% of females.
• Severe anxiety and anger may aggravate acne by stimulating stress hormones release.
• Certain medications can cause acne
• Gluten-related acne may develop in unusual places, such as hairline, back of the neck, lower chin and temples. These are not real acne and should be immediately evaluated by an allergist or dermatologist. Gluten-free diet clears this rash completely.

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Complications

Acne can leave various scars after healing, which may present as depressed scars or hypertrophic and keloidal scars. Depressed scars may be gentle contour (boxcar scars) or ice pick scars, which are deep pits. 

Acne is associated with seborrhoea and in the case of abnormal hormones. Hyperandrogenism (such as Polycystic Ovarian Syndrome, POS) causes acne associated with hirsutism, acanthosis nigricans, irregular menstrual period, and weight gain.

Most common complications:

• Scars
• Depression
• Anxiety
• Social withdraw
• Poor facial aesthetics
• Poor self-esteem

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Risk Factors

Factors provoking acne include the following:

• Use of medications like lithium, steroids, and anticonvulsants
• Exposure to excess sunlight
• Use of occlusive wear like shoulder pads, headbands backpacks, and underwire brassieres
• Endocrine disorders like polycystic ovarian syndrome and even pregnancy

Genetic factors affect the percentage of branched fatty acids in sebum. Heritability estimates range from 50-90% 

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How is acne diagnosed?

Acne is a clinical diagnosis and is very simple if certain criteria are met:

• Teenage years onset
• Other signs of the sexual maturation present
• Rash is located in classic areas
• No other systemic signs of disease present

There are few other conditions that need to be ruled out, such as:

• Dermatitis Herpetiformis (gluten rash)
• Atopic dermatitis
• Contact dermatitis
• Lupus rash
• Impetigo 

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What is the outlook for someone with acne?

As we discussed, acne is usually a benign annoyance. If treated correctly, and all factors making it worse are taken care of, acne are manageable and can go away fast. It is important not to cause more problems by picking and trying to squeeze pimples out.

If the scars form, this can be a life-long cosmetic issue. Thankfully, there are many cosmetic laser treatments available which may help to get rid of the scarring as well.

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How can acne be prevented?

There are many acne treatments available. But you have to be careful not to trust just any advertisement. Some commercial creams and acne treatments can actually cause more trouble, and make the skin look worse if allergic reaction develops.

We recommend a conservative approach with a maximum effort to ensure healthy lifestyle:

• Balanced diet with an abundance of the easily digestible protein, good fats and healthy carbs. If you are unsure of the dietary requirements in a teenager, it is best to consult with a nutritionist or a natural practitioner.
• Daily exercise with cardio will help skin pores to clear up. Outdoor exercise are preferred, as sunlight stimulates vit D production 
• Ensure sufficient sleep and daily routine to help balance hormones
• Organized sports may help to improve mood and prevent stress.

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References 

Yan HM, Zhao HJ, Guo DY, Zhu PQ, Zhang CL, Jiang W. Gut microbiota alterations in moderate to severe acne vulgaris patients. J Dermatol. 2018 Oct;45(10):1166-1171. [PubMed]

Juhl CR, Bergholdt HKM, Miller IM, Jemec GBE, Kanters JK, Ellervik C. Dairy Intake and Acne Vulgaris: A Systematic Review and Meta-Analysis of 78,529 Children, Adolescents, and Young Adults. Nutrients. 2018 Aug 09;10(8) [PMC free article] [PubMed]

George RM, Sridharan R. Factors Aggravating or Precipitating Acne in Indian Adults: A Hospital-Based Study of 110 Cases. Indian J Dermatol. 2018 Jul-Aug;63(4):328-331. [PMC free article] [PubMed]

Motosko CC, Zakhem GA, Pomeranz MK, Hazen A. Acne: a side-effect of masculinizing hormonal therapy in transgender patients. Br J Dermatol. 2019 Jan;180(1):26-30. [PubMed]

Özçelik S, Kulaç İ, Yazıcı M, Öcal E. Distribution of childhood skin diseases according to age and gender, a single institution experience. Turk Pediatri Ars. 2018 Jun;53(2):105-112. [PMC free article] [PubMed]

Alexeyev OA, Dekio I, Layton AM, Li H, Hughes H, Morris T, Zouboulis CC, Patrick S. Why we continue to use the name Propionibacterium acnes. Br J Dermatol. 2018 Nov;179(5):1227. [PubMed]

Eyüboglu M, Kalay I, Eyüboglu D. Evaluation of Adolescents Diagnosed with Acne Vulgaris for Quality of Life and Psychosocial Challenges. Indian J Dermatol. 2018 Mar-Apr;63(2):131-135. [PMC free article] [PubMed]

Acne Vulgaris. Sutaria AH, Masood S, Schlessinger J.2021 Aug 9. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.PMID: 29083670 Free Books & Documents. Review.

Acne Keloidalis Nuchae. Al Aboud DM, Badri T.2021 Aug 9. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan    PMID: 29083612 Free Books & Documents. Review.