Acne, pimple, breakouts, whatever we may call it, 90%of us has to face it at some point of our life. Acne is a chronic inflammatory disease of the pilosebaceous unit, skin structure consisting of a hair follicle and its associated sebaceous glands. It has a chronic course but it is self limiting.
Acne Vulgaris Causes
Major factors are involved in the pathogenesis
- Hormonal factors: usually seen in the adolescence due to increase androgen, insulin resistance, insulin growth factor 1.
- Increase in the interleukin 1 Alpha activity
- Decrease in the linoleic acid
- Increase sebum production known as Seborrhea
- Hypercornification of the pilosebaceous duct
- Abnormality of the microbial Flora: specially colonization of the duct with Cutibacterium acnes.[Previously Propionibacterium acnes (P. acnes)]
Activity of the bacteria (C.acnes) within the comedones releases free fatty acid from Sebum, causes inflammation within the cyst and results in the rupture of the cyst.
Acne Vulgaris Clinical Features
Polymorphic lesions including
Papules: small red tender bumps.
Pustules: which are papules with pus at their tips.
Nodules: large solid painful lumps under the skin.
Cystic lesions: painful pus filled bumps under the skin. In severe cases abscess may be seen.
Site of Acne
Face, forehead, chest, upper back and Shoulders.
Most characteristic of acne are Comedones which are of two types:
Open/black( blackheads ), a plug of sebum in a hair follicle, darkened by oxidation of Keratin.
Close/white( whiteheads ), pale or white-topped pustule on the skin.
Classification of Acne
Grade 1: 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: Inflammatory lesions present as a small papule with erythema.
Grade 3: Pustules
Grade 4: Many pustules coalesce to form nodules and cysts, also known as nodulocystic acne, most severe.
Acne Variants:
1.Neonatal Acne, seen in baby less than 1 month of age due to the increased maternal androgens.
2.Infantile acne, seen in the baby more than one month due to the increase in the DHEA(dehydroepiandrosterone sulfate).
3. Senile acne, in old age.
4.Acne Excorie, usually seen in female patients suffering from OCD who picks evry acne that erupts leading to excoriation.
5.Morbihan disease (MD), “solid persistent facial edema and erythema”, “rosacea lymphedema”, and “solid facial edema in acne”, is a rare and often unrecognizable entity, that presents with a slow occurrence of persistent lymphoedema of the upper two-thirds of the face.
6.Acne Fulminans, also known as acne maligna, is a rare painful ulcerative form of acne with an abrupt onset and systemic symptoms. Its incidence appears to be decreasing, possibly because of earlier and better treatment of acne.
7. Monomorphic Acne/ Drug induced Acne, caused by drugs like Steroid, Oral Contraceptive Pills(OCPs), lithium, vitamin B12, thyroid hormones, halogen compounds (iodine, bromine, fluorine, and chlorine), antibiotics (tetracycline and streptomycin), antituberculosis drugs (INH/isoniazide),etc.
Syndromes associated with acne: SAPHO
S: Synovitis
A: Acne
P: Pustulosis
H: Hyperostosis
O: Osteitis
Treatment of Acne (Pimple)
Treatment options include:
1.Topical: that is applying the cream or gel on the face.
Clindamycin, benzoyl peroxide, retinoids (adapalene, tretinoin)
They come in different concentration like 0.1, 0.2, 0.5,etc which is used as per the condition of the acne.
Not more than pea sized amount is used at single application over whole face.
Caution is to be taken to apply SPF before going in the sun since the sensitivity of the skin increases after using such products.
Sometimes a combination of Retinoids (Adapalene) with antibiotics (clindamycin) is found to be very effective.
2.System: Medications in the form of tablets of injectables.
A. Antibiotics like Doxycycline, Azithromycin, Minocycline.
B. Retinoids, isotretinoin(13 cis- retinoic acid) is the drug of choice in severe/Grade 4/Nodulo-Cystic Acne, at a dose of 0.5-1mg/kg/Body weight, until the cumulative dose of 120-150mg/kg/Body weight is achieved.
Side effects of Retinoids
Dryness of lips, hypertriglyceridemia, hepatotoxic, teratogenic hence avoided in pregnancy hence if a female patient wants to conceive the patient must avoid the drug one month before conceiving, pseudotumor cerebri (benign raised intracranial tension).
Hence avoid it’s concomitant use with tetracycline, Vit A else it will precipitate Pseudo tumor cerebri, most serious side effect being DISH(diffuse interstitial skeletal hyperostosis)
3 Scarring following the acne can be:
ice pick scar, rolling scar, boxcar scar, hypertrophic scars, which can be treated by chemical peeling.
Chemical Peeling
Process of control removal of superficial layer of the skin by application of a solution
It works on the principle of wound healing.
Chemical peels act by skin resurfacing and collagen remodeling.They help in the removal of scars and pigmentation. Chemical peeling is indicated in melasma, acne, acne scars and photo aging.
Agents used are pyruvic acid, glycolic acid, malic acid, citric acid, lactic acid, tartaric acid, salicylic acid, trichloroacetic Acid(TCA), mandelic acid.
Jessener’s solution: salicylic acid, lactic acid, resorcinol.
Apart from chemical peeling, dermabrasion and using Niacinamide for acne scars are also found to be useful.
Take Home 10 Points
- Using a mild cleanser is a must and to avoid multiple cleansing since it would lead to dryness of skin and will exacerbate Acne. Cetaphil cleanser or Cleanser with salicylic acid would be a great option.
- Having patience while dealing with Acne since it is a chronic condition it is bound to take around 4-8weeks to heal. In severe cases it may take as long as 3-6months.
- Never scrub harshly, in fact it’s best to avoid Scrubbing Acne rich face.
- Don’t touch your face often since the bacteria from your hands gets transferred to face leading to more acne.
- Change your pillow case at least once in a week and to maintain hygiene by making sure not to touch you face with any material that might have bacteria for instance you mobile, keep it’s screen clean and try to use headphones while on call.
- No matter how tempting it might be, DON’T EVER PRICK YOUR ACNE, all it will do is give you scar spots even after healing.
- Follow a proper Skin Care routine, it’s often said that: “too much of anything is harmful to your skin”, so don’t get tempted on applying too many products or too much of a product at the same time in the hope of getting it healed soon, rather the opposite happens.
- Even when you want to use multiple products make sure that the active ingredients in them doesn’t cross react and cancel the effects of each other. For instance don’t ever mix Retinol with benzoyl peroxide, Vitamin C, AHA and BHA. (Alpha and Beta Hydroxy acids).Likewise, don’t mix Vitamin C with Niacinamide.
- Follow the basic CTM rule: Cleanser, Toner, Treatment, Moisturizer.
- Last but not the least, The Golden Rule:
“Always apply your SPF(minimum 30) in the daytime no matter whether you are out or indoors and reapply after 2-3hrs.”
