TYPES OF ACNE
- Acne vulgaris: Acne vulgaris is the most common type of acne, and it can range from mild to severe. Mild or moderate cases of acne vulgaris include the following types of lesions:
- Whitehead: this type of blemish is also called a “closed comedone” and occurs when a plug causes the wall of the hair follicle to swell. Because air can’t reach the material trapped inside, it doesn’t oxidize and remains white.
- Blackhead: this type of blemish is also called an “open comedone” and occurs in over sized follicles where air is able to penetrate the plug and oxidize with skin’s natural pigment, melanin, creating a black appearance.
- Papule: a small red blemish that doesn’t contain pus is called a papule. Also known as a “pimple,” a papule forms when a breakage occurs near the surface of the hair follicle.
- Pustule: these reddish lesions are often raised and contain a white or yellowish fluid that consists of pus, oil, dead skin and white blood cells. Like a papule, these inflamed pimples are the result of a breakage within the wall of the follicle.
Cases of acne vulgaris that range from moderate to severe often occur when oil, bacteria and other debris spill out from the follicle to affect other areas of the skin. These lesions can be tougher to treat and include:
- Nodules: these large, painful lesions penetrate deep within the skin on the face and body and may be the result of multiple infected follicles that are adjacent to one another. Nodules are more likely to form scars and can last for a longer period of time – especially if squeezed. An acne condition that’s characterized by nodules is called “nodular acne.”
- Cysts: similar to nodules, cysts are large lesions, but these contain pus. An acne condition with cysts is often referred to as “cystic acne.” If acne contains both cysts and nodules, it’s referred to as “nodulo-cystic acne.”
- Acne Mechanica: It originates as a result of excessive heat and friction on the skin surface. It is usually seen in people involved in sports or those who wear helmets, caps or sports gear for prolonged periods of time on a regular basis. Use of high necks, scarves or even supporting your face with hands can lead to acne in the lower half of face. Also if you’re constantly on your cell phone; rubbing it against your face can lead to acne mechanica.
- Acne cosmetica: This is very common these days and mostly leads to acne in the lower half of face and chin. This type of acne is caused due to comedogenic ingredients present in the cosmetics as well as skincare products. Comedogenic ingredient means a particular ingredient which can lead to comedones or black/whiteheads if applied on oily or acne prone skin.Therefore it is important to choose skincare as well as cosmetic products wisely. Choosing incorrect skincare products and regime is one of the major culprets in causing acne. Make sure you use only those skincare products that are non-comedogenic, skin pH friendly, formulated specifically for your skin type/ concerns/ needs and are safe (do not contain toxic/ harmful ingredients in them) for application on human skin.Avoid products containing denatured alcohols, skin irritants like menthol (irritating or drying ingredients only make matters worse, because they actually trigger more oil to be produced directly in the oil gland), colourant dyes, excessive fragrance, sulphates, plant oils (eucalyptus, peppermint, citronella), isopropyl myristate, cocoa butter, shea butter etc.
- Acne Rosacea: Rosacea is a chronic, inflammatory skin condition characterized by excessive redness on the nose, cheeks, chin and forehead. When this is accompanied with acne it is called as acne rosacea. Small Red solid Bumps or pus-filled Pimples in this case resemble acne but the blackheads are absent. Also it is accompanied by burning or stinging sensation.
- Body builders acne: With increased use of anabolic steroids at the gym or by sports persons there is an upsurge in pimples especially at chest and back in young males.
- Occupational acne: Handling of greasy products like greases, tar, heavy oils, etc. can lead to acne.Hot and humid weather: Acne can also be precipitated due to heat and humidity in the case of females who cook in hot weather.
- Drug-induced acne: Certain drugs most commonly steroids, oral contraceptive pills, isoniazid, lithium, vitamin B12, iodides and bromides.
- The most severe cases of acne vulgaris are rare and more difficult to treat. These conditions include:
- Acne conglobata: this extreme form of acne vulgaris is rare and most common in males between the ages of 18 and 30. It occurs when nodules and cysts spread beneath the surface of the skin to create large, often painful lesions and can be accompanied by blackheads and an unpleasant odor. This chronic condition is tough to treat and can cause significant scarring.
- Acne fulminans: if chronic acne conglobata is unsuccessfully treated, it can develop into acne fulminans. This condition is characterized by sudden, extreme & painful necrotic filled ulcerations over face, neck, chest & back; associated with fever, joint pains and muscular pain. Isotretenoin taken orally; could be a triggering factor for acne fulminans.
- Gram-negative folliculitis: this type of acne is caused by a bacterial infection and includes pustules and cysts. Gram-negative folliculitis is linked with the long-term treatment of acne using antibiotics. The bacteria that cause this type of acne are resistant to most medications, making it difficult to treat.
- Pyoderma faciale: also referred to as “rosacea fulminans,” this rare form of acne is characterized by the sudden appearance of red, painful nodules and pustules on the face. This condition typically affects females between the ages of 20 and 40. It rarely lasts longer than one year and may cause scarring.
CAUSES OF ACNE
- Genetics: genetic predisposition plays a large part in the development of acne and blemish prone skin. Acne tends to run in the family. If your parents experienced acne, then you and your children are more likely to develop this condition.
- Hormones: the most obvious examples of hormonal acne are the ones you get during puberty, menstrual cycles, pregnancy, and menopause. Most cases of acne are triggered by a reaction of the sebaceous glands in response to increased androgen hormone levels.The sebaceous glands respond to the androgens by producing an excessive amount of sebum. During puberty, both boys and girls produce high levels of androgens as a result of the hormonal changes that take place in the body in this stage.
- Bacteria: P. acnes (Propionibacterium acnes) exists on everyone’s skin, whether it’s clear or riddled with pimples. P. acnes feeds off sebum. In people with acne-prone skin, the excessive production of sebum creates an ideal environment in which the normally harmless acne bacteria can multiply in manifold. This triggers inflammation and the formation of red or pus-filled spots.
- Diseases: like Poly cystic ovarian syndrome, ovarian tumours, adrenal or pituitary gland diseases, diabetes, thyroid etc. lead to the formation of acne. Menstrual irregularities, increase hair growth on face and body, weight gain, infertility are the visible symptoms of poly cystic ovarian syndrome. In fact with lifestyle changes PCOS has become very common in females these days.
- Medications: certain drugs, including corticosteroids, lithium, anticonvulsants, immunosuppressant, barbiturates, androgenic steroids, Isoniazid, DHEA, and medicationsthat contain bromides or iodides, can cause true acne or acne-like eruptions. Corticosteroids are prescribed for asthma or other chronic diseases. Immunosuppressants are prescribed for auto-immune diseases and organ transplant. Lithium is prescribed for bipolar disorder. Anticonvulsants are prescribed for epilepsy or seizures. As for bromides or iodides, they may be found in sedatives or cough medicines. Isoniazid is one of the most popular drug used to treat tuberculosis.
- Stress: the mind and the body are connected. Emotional stress affects our endocrine (hormone) system, disgestive system, repiratory system, immune system, and various other bodily systems. Over-taxing the body through an overly demanding exercise schedule or lack of sleep may also cause physical stress, which can adversely affect our bodily processes. Stress can cause as well as worsen acne by releasing inflammatory chemicals called neuropeptides and hormonal changes.
- Skincare products and cosmetics: this is also at times referred to as acne cosmetic. This type of acne is caused due to comedogenic, irritatating and sebum triggering ingredients present in the cosmetics as well as skincare products. Acne is triggered when cosmetic ingredients clog pores, leading to a build up of comedones.
- Disrupted Skin Barrier Function: skin acts as a protective barrier for the body by keeping out microbes, allergens, radiations etc. When your skin barrier is disrupted/ broken/ compromised the skin loses water, gets dried out, and becomes more permeable to irritants and allergens. This makes the skin vulnerable to p. acnes and inflammation causing acne. This reasons for a disrupted barrier can be using harsh or wrong skincare products containing sensitizing or toxic ingredients, environmental conditions, medications, excessive erosion of the top layer, injury etc.
- Vitamin & mineral deficiency: inadequate levels of vitamin D, selenium, zinc in our bodies causes acne in some cases. Healthy levels of Vitamin D in the body helps in controlling the production of serum, controls the response of the immune system towards infections caused by bacteria hence it is helpful to counter the attack of P. acnes and controls the inflammation caused in acne.
TREATMENT OF ACNE
The first treatment option for acne would be maintaining basic hygiene, incorporating salicylic acid or benzoyl cleansers, home remedies and medicated creams.
Medical intervention or consulting a dermatologist is very important to find out the underlying cause of acne, to prevent it from developing into severe stages and minimise the risk of permanent scarring.
Note: using correct skincare products also play an important role in combating acne. It is important to use mild yet specific non-comedogenic skincare products. Also it is always advisable to discuss your skincare regime with your dermatologist or professionals skincare experts.
- Topical prescription medications (creams/ ointments/ gels)-
- Benzoyl peroxide: benzoyl peroxide is a common topical treatment. It has three actions – it kills germs (bacteria), reduces inflammation and helps to unplug blocked pores. Therefore, it often works well to clear inflamed spots and it helps to clear blackheads and whiteheads (comedones). It comes in different brand names and strengths – 2.5%, 4%, 5% and 10% strength. Your dermatologist will prescribe one of the above mentioned strength after evaluating your acne and skin condition.Points of caution: benzoyl peroxide commonly causes mild skin irritation hence if your skin becomes extremely red or you feel an itchy or burning sensation; stop using it and consult your dermatologist. Benzoyl peroxide also makes your skin more sensitive to sunlight, so avoid too much sun exposure and always wear sunscreen. Benzoyl peroxide can have a bleaching effect, so avoid getting it on your hair or clothes. Benzoyl peroxide can make your skin dry and sensitized therefore using appropriate skincare products alongside is important.
- Retinoids: topical retinoids work by removing dead skin cells from the surface of the skin (exfoliating) which helps to prevent them building up within hair follicles, unplugging blocked pores and also encouraging cell turnover. Tretinoin (Avita, Retin-A, Renova) and adapalene (Differin) are topical retinoids used to treat acne. They’re available in a gel or cream and are usually applied once a day before you go to bed.Points of caution: retinoids commonly causes mild skin irritation, reddening, stinging and peeling; hence if your skin becomes extremely red or you feel an itchy or burning sensation; stop using it and consult your dermatologist. Retinoids aren’t suitable for use during pregnancy, as there’s a risk they might cause birth defects. Retinoids make your skin extremely sensitive to sunlight hence always apply this at night, avoid too much sun exposure and always wear sunscreen. Retinoids can make your skin dry and sensitized therefore using appropriate skincare products alongside is important.
- Topical antibiotics: topical antibiotics help kill the bacteria on the skin that can infect plugged hair follicles and reduce inflammation. They’re available as a lotion or gel that is applied once or twice a day. These are often used for mild to moderate acne. Usually they are prescribed for a limited period from 6-8 weeks as they there’s a risk that the bacteria on your face could become resistant to the antibiotics. They may cause dryness other than this these are quite well tolerated. Some of the most common are clindamycin, erythromycin, and topical metronidazole, the last of which is usually used for rosacea.They may be used alone but are more often used in conjunction with one of the above-mentioned topical medications.
- Azelaic acid: azelaic acid is often used as an alternative treatment for acne if the side effects of benzoyl peroxide or topical retinoids are particularly irritating or painful. Azelaic acid works by getting rid of dead skin unplugging blocked pores and killing bacteria. It’s available as a cream or gel form. This is usually well tolerated by most skin types and this also does not make your skin extra sensitive to sunlight. This is also useful for post acne hyperpigmentation.
- Combinations: some preparations contain a mixture of ingredients. For example, benzoyl peroxide plus an antibiotic, or a retinoid plus an antibiotic. These are better tolerated by most skin types and work better than either ingredient alone.
- Oral prescription medications-
- Oral antibiotics: when the inflammation is too advanced and the plug in the hair follicle is too deep (moderate to severe acne); oral antibiotics are sought. Oral antibiotics fight the bacteria in the acne lesion and some have anti-inflammatory properties as well. Oral antibiotics may be prescribed to treat severe to moderate acne. Often, these are prescribed in tandem with a topical ointment. The trend in dermatology is to prescribe oral antibiotics less frequently and for more limited time periods to avoid antibiotic resistance. Some of the most commonly prescribed antibiotics include minocycline, doxycycline, tetracycline, erythromycin, or sometimes amoxicillin or penicillin derivatives if you are allergic to some of the antibiotics mentioned above.Note: Tetracyclines can make your skin sensitive to sunlight and UV light.
- Oral contraceptives: oral contraceptives can be extremely effective in treating acne, particularly for young women in their late teens, 20s or 30s and if their acne seems to be partly related to their hormonal changes. For example, women with polycystic ovary syndrome, acne that began or became worse in adulthood, or if acne seems to flare up around the time of a period. However, these medications may be accompanied by side effects including depression, headaches and nausea. Other health risks associated with oral contraceptives go up significantly after the age of 35. It is important to consult with your doctor before taking oral contraceptives for acne, especially if you or any other family members have a history of blood clots.
- Anti-androgen drugs- Aldactone/ spironolactone: these may be considered for women and adolescent girls if oral antibiotics aren’t helping. It works by blocking the effect of androgen hormones on the sebaceous glands. Doctors sometimes prescribe spironolactone for women who have polycystic ovary disease. Besides helping to control acne and excess hair growth, it has a positive side effect in many women of reducing PMS-type symptoms slightly. It seems to reduce the bloating that occurs pre-period. Points of caution: You shouldn’t take it if you have low blood pressure or borderline low blood pressure and if you are pregnant or thinking about getting pregnant.
- Accutane (Isotretinoin): this medicine is reserved for people with the most severe acne or for people whose acne doesn’t respond to other treatments. Accutane is extremely effective as it helps to normalise sebum production, prevent follicles becoming clogged, decreases the amount of bacteria on the skin and reduces inflammation. However, this drug can cause severe side effects that range from increased sun sensitivity, increased risk of depression & suicide, severe birth defects if taken during pregnancy, ulcerative colitis, dryness & cracking of the skin lips nostrils, changes in your blood sugar levels and in rarer cases hepatitis, pancreatitis, kidney disease. But because of its potential side effects isotretinoin can only be prescribed by a dermatologist and dermatologists need to closely monitor anyone they treat with this drug. Regular blood tests are conducted before and during treatment.
- Cosmetic treatments: These may be suggested in select cases, either alone or in combination with medications. It is extremely important to get these procedures done only by a dermatologist.
- Derma rollers or micro needle rollers: this creates thousands of micro channels in the top skin layer. The roller stimulates blood flow to the surface, gives a skin massage, cleans out the pores and stimulates collagen re-growth. The entire process of skin remodelling takes several months, however visible results start appearing in 3-5 skin needling treatments.
- Blue-light therapy: professional and at-home light therapy devices expose acne to specific wavelengths of light that kill blemish-causing bacteria.
- Chemical peel: this procedure uses repeated applications of a chemical solution, such as salicylic acid. It is most effective when combined with other acne treatments. Chemical peels aren’t recommended for people taking oral retinoids because together these treatments can significantly irritate the skin. Chemicals peels may cause temporary redness or scaling.
- Extraction of whiteheads and blackheads: your dermatologist uses special tools to gently and efficiently remove whiteheads and blackheads (comedos) that haven’t cleared up with topical medications.
- Microdermabrasion: this is done depending on what type of acne you have. If your acne is mostly comedonal (blackheads and whiteheads) or with a few red bumps (papules), it should respond well. Usually a series of microdermabrasion treatments followed by maintenance treatments will be recommended. Other types of acne, particularly those red (inflamed), very pustular or cystic, will get worse. With these types of acne, microdermabrasion is not advised without first being seen by a dermatologist. You may need to have the inflammation brought under control first.
- Laser therapy: if overactive oil glands are to blame for acne, professional laser treatments can damage these glands to impair their ability to produce oil.
Treating acne scars: Acne scars are best treated with fractional ablative lasers, more specifically the fractional carbon dioxide laser. Occasionally, fractional radiofrequency treatments may be combined with the above to give desired results. Non-ablative lasers like Erbium glass lasers help for milder scars.
The parameters used for each patient differs depending on the sensitivity of the skin, depth and extent of scars, skin colour of patient, etc.
- Light therapy: certain lasers, pulsed light sources and radiofrequency devices that don’t injure the epidermis can be used to treat scars. These treatments heat the dermis and cause new skin to form. After several treatments, acne scars may appear less noticeable. This treatment has shorter recovery times than some other methods. But you may need to repeat the procedure more often and results are subtle.
- Soft tissue fillers: injecting soft tissue fillers, such as collagen or fat, under the skin and into indented scars can fill out or stretch the skin. This makes the scars less noticeable. Results are temporary, so you would need to repeat the injections periodically. Side effects include temporary swelling, redness and bruising.
- Chemical peels: high-potency acid is applied to your skin to remove the top layer and minimize deeper scars.
- Dermabrasion: this procedure is usually reserved for more severe scarring. It involves sanding (planing) the surface layer of skin with a rotating brush. This helps blend acne scars into the surrounding skin.
- Laser resurfacing: this is a skin resurfacing procedure that uses a laser to improve the appearance of your skin.
- Skin surgery: using a minor procedure called punch excision, your doctor cuts out individual acne scars and repairs the hole at the scar site with stitches or a skin graft.