Compiled and edited by Lahle Wolfe
Much of this article comes from Wikipedia.com, but has been edited for content, and expanded.
Acne Fact Sheets
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Acne is an inflammatory disease of the skin, caused by changes in the pilosebaceous units (skin
structures consisting of a hair follicle and its associated sebaceous gland).
The condition is common in puberty
as a result of an abnormal response to normal levels of the male hormone testosterone. The response for most people
diminishes over time and acne thus tends to disappear, or at least decrease,
after one reaches their early twenties. There is, however, no way to predict how
long it will take for it to disappear entirely, and some individuals will
continue to suffer from acne decades later, into their thirties and forties and
even beyond. Acne affects a large percentage of humans at some stage in
Many persons with metabolic disorders continue to suffer from acne into adulthood due to hormonal imbalance. These include:
The most common form of acne is known as "acne vulgaris", which means common
acne. Excessive secretion of oils from the glands combines with naturally occurring dead skin cells
to block the hair
follicles. Oil secretions build up beneath the blocked pore, providing a
perfect environment for the skin bacteria Propionibacterium acnes to multiply
uncontrolled. In response, the skin inflames, producing the visible lesion. The
face, chest, back, shoulders and upper arms are especially affected.
The typical acne lesions are: comedones, papules, pustules, nodules and inflammatory cysts. These are the
more inflamed form of pus-filled or reddish
bumps, even boil-like tender swellings. Non-inflamed 'sebaceous cysts', more properly
called epidermoid cysts, occur either in association with acne or alone but are
not a constant feature. After resolution of acne lesions, prominent unsightly
scars may remain.
Aside from scarring, its main effects are psychological, such as reduced self-esteem and depression.
Acne usually appears during adolescence, when people already tend to be most
Causes of Acne
Exactly why some people get acne and some do not is not fully known. It is
known to be partly hereditary. Several factors are known to be linked to
- Hormonal activity, such as menstrual cycles
- Stress, through increased output of hormones from the adrenal (stress) glands
- Hyperactive sebaceous glands, secondary to the three hormone sources above
- Accumulation of dead skin cells
- Bacteria in the pores, to which the
body becomes 'allergic'
- Skin irritation or scratching of any sort will activate inflammation
- Use of anabolic
- Any medication containing halogens (iodides, chlorides, bromides), lithium, barbiturates, or androgens
- Exposure to high levels of chlorine compounds, particularly chlorinated dioxins, can cause severe, long-lasting
acne, known as Chloracne
Traditionally, attention has focused mostly on hormone-driven over-production
of sebum as the main contributing factor of acne. More recently, more attention
has been given to narrowing of the follicle channel as a second main
contributing factor. Abnormal shedding of the cells lining the
follicle, abnormal cell binding ("hyperkeratinization") within the follicle,
and water retention in the skin (swelling the skin and so pressing the follicles
shut) have all been put forward as mechanisms involved.
Several hormones have been linked
to acne: the male hormones testosterone, dihydrotestosterone (DHT) and dehydroepiandrosterone sulfate (DHEAS),
as well as insulin-like growth factor 1
(IGF-I). In addition, acne-prone skin has been shown to be insulin resistant.
There are many misconceptions and rumors about what causes the condition:
- Diet. Chocolate, french fries, potato chips and sugar, among others, have not been shown to affect acne.
This means that the scientific studies done to date did not find a statistically significant difference
between acne in two groups of people, one group eating the food in question and
one group avoiding it. However, one recent study,
based on a survey of 47,335 women, did find a positive epidemiological
association between milk consumption and
acne, particularly skimmed. The researchers hypothesize that the association may
be caused by hormones (such as bovine IGF-I) present in cow milk; but
this has not been definitively shown. Seafood, on the other hand, may contain relatively high
levels of iodine, but probably not
enough to cause an acne outbreak. Still, people who are prone to acne may want
to avoid excessive consumption of foods high in iodine. It has also been
suggested that there is a link between a diet high in refined sugars and acne.
According to this hypothesis, the startling absence of acne in non-westernized
societies could be explained by the low glycemic index of these tribes' diets.
Further research is necessary to establish whether a reduced consumption of
high-glycemic foods (such as soft drinks, sweets, white bread) can significantly
alleviate acne, though consumption of high-glycemic foods should in any case be
kept to a minimum, for general health reasons.
- Deficient personal hygiene Acne is not caused by dirt. This misconception probably comes from the fact that acne involves skin infections. In fact the blockages that cause acne occur deep within the narrow follicle channel, where it is impossible to wash them away. These plugs are formed by the cells and sebum created there by the body. The bacteria involved are the same bacteria that are always present on the skin. It
is advisable to clean the skin on a regular basis, but doing so will not
prevent acne. Anything beyond very gentle cleansing can actually worsen existing
lesions and even encourage new ones by damaging or overdrying skin.
Common myths state that either celibacy or masturbation cause acne and, conversely, that sexual
intercourse can cure it. There is no scientific evidence suggesting that any
of these are factual. It is true, though, that anger and stress affect hormone
levels and thus bodily oil production, which can cause acne.
There are many products sold for the treatment of acne, many of them without
any scientifically-proven effects. However, a combination of treatments can
greatly reduce the amount and severity of acne in many cases. It is highly
advisable to ask a dermatologist about the tradeoffs between these
treatments for any individual case, especially when considering using any of
them in combination. There are a number of treatments that have been proven
- Killing the bacteria that are harbored in the blocked follicles. This is
done either by the intake of antibiotics like the "three 'cyclines" (tetracycline, doxycycline and
minocycline), or by treating the affected areas externally with bactericidal
substances like benzoyl peroxide or erythromycin. However, reducing the P.
acnes bacteria will not, in itself, do anything to reduce the oil secretion
and abnormal cell behaviour that is the initial cause of the blocked follicles.
Additionally the antibiotics are becoming less and less useful as resistant
P. acnes is becoming common. Benzoyl Peroxide has the advantage of being
a strong oxidiser and does not appear to generate resistance. Acne will
generally reappear quite soon after the end of treatment—days later in the case
of topical applications, and weeks
later in the case of oral antibiotics.
- Reducing the secretion of oils from the glands. This is done by a daily oral intake of vitamin A derivatives like isotretinoin (marketed as Accutane) over a period
of a few months. It is believed that isotretinoin works primarily by reducing
the secretion of oils from the glands, however some studies suggest that it
affect other acne-related factors as well. Isotretinoin has been shown to be
very effective in treating severe acne and is effective in well over 80% of
patients. The drug has a much longer effect than anti-bacterial treatments and
will often cure acne for good. The treatment requires close medical supervision
by a dermatologist because
the drug has many known side
effects (which can be severe). About 25% of patients may relapse after one
treatment. In those cases, a second treatment for another few months may be
indicated to obtain desired results. It is often recommended that one lets a few
months pass between the two treatments, because the condition can actually
improve somewhat in the time after stopping the treatment and waiting a few
months also give the body a chance to recover. The most common side effects are
dry skin and nosebleed. There are reports that the drug has damaged the liver of
patients. For this reason, it is recommended that patients have blood samples
taken and examined before and during treatment. In some cases, treatment is
terminated due to changes in various levels of chemicals in the blood, which
might be related to liver damage. Others claim that the reports of permanent
damage to the liver are unsubstantiated,
and routine testing is considered unnecessary by some dermatologists. However,
routine testing are part of the official guidelines for the use of the drug in
many countries. Some press reports suggest that isotretinoin may cause depression but
as of September 2005 there is no agreement in the medical literature as to the
risk. The drug also causes birth defects if women become pregnant while taking
it or take it while pregnant. For this reason, female patients are required to
use two separate forms of birth control or vow abstinence while on the drug. Because of this, the
drug is supposed to be given as a last resort after
milder treatments have proven insufficient. Very restrictive rules for use will
be in force in the USA beginning in 2006.
This has occasioned widespread editorial comment.
- Normalizing the follicle cell lifecycle. A group of medications for this are
topical retinoids such as tretinoin (brand name Retin-A), adapalene (brand name Differin) and tazarotene (brand name Tazorac).
Like isotretinoin, they are related to vitamin A, but they are administered as topicals and
generally have much milder side effects. They can, however, cause significant
irritation of the skin. The retinoids appear to influence the cell creation and
death lifecycle of cells in the follicle lining. This helps prevent the hyperkeratinization of these cells that can
create a blockage. Retinol, a form of
vitamin A, has similar but milder effects and is used in many over-the-counter
moisturizers and other topical products. Effective topical retinoids have been
in use over 30 years but are available only on prescription so are not as widely
used as the other topical treatments.
- Exfoliating the skin. This can be done either mechanically, using an
abrasive cloth or a liquid scrub, or chemically. Common chemical exfoliating
agents include salicylic
acid and glycolic
acid, which encourage the peeling of the top layer of skin to prevent a
build-up of dead skin cells which combine with skin oil to block pores. It also
helps to unblock already clogged pores. Note that the word "peeling" is not
meant in the visible sense of shedding, but rather as the
destruction of the top layer of skin cells at the microscopic level. Depending
on the type of exfoliation used, some visible flaking is possible. Moisturizers
and anti-acne topicals containing chemical exfoliating agents are commonly
- Hormonal treatments. In women,
acne can be improved with a combined oestrogen/progestogen contraceptive pill. Cyproterone (Diane 35) is particularly
effective at reducing androgenic hormone levels and until recently was the best
oral contaceptive treatment. It is not available in the USA, but a newer oral
contraceptive containing the progestin drospirenone is now available with fewer side
effects than Diane 35 / Dianette. Both can be used where blood tests show
abnormally high levels of androgens,
but are effective even when this is not the case.
- Phototherapy. It has
long been known that short term improvement can be achieved with sunlight.
However studies have shown that sunlight worsens acne long-term, presumably due
to UV damage. More recently, visible light has been successfully employed to
treat acne - in particular intense blue light generated by purpose-built
fluorescent lighting, LEDs or lasers. Used twice weekly, this has been shown to reduce
the number of acne lesions by about 64%;
and is even more effective when applied daily. The mechanism appears to be that
porphyrins produced by P.
acnes generate free radicals when irradiated by blue light. Particularly
when applied over several days, these ultimately kill the bacteria.
Extensive basic science and clinical work first initiated by dermatologists
Yoram Harth and Alan Shalita have shown that intense blue/violet light (405-425
nanometer) can decrease the number of inflammtory acne lesion by 60-70% in 4
weeks of therapy. Since porphyrins are not otherwise present in skin, and no UV
light is employed, it appears to be safe, and has been licensed by the U.S. FDA. The
treatment apparently works even better if used with red visible light; and
overall it has better clearance than benzoyl peroxide. Unlike most of the other
treatments few if any negative side effects are typically experienced, and
bacterial resistance is unlikely. After treatment, clearance can be longer lived
than is typical with topical or oral antibiotic treatments, several months is
not uncommon. However, the equipment is relatively expensive, and the treatment
works best for mild-moderate acne.
Less widely used treatments include:
- Azelaic acid(brand
names Azelex, Finevin, Skinoren) is suitable for mild,
- Zinc. Orally administered zinc gluconate
has been shown to be effective in the treatment of inflammatory acne, although
less so than tetracyclines.
- Insulin treatment - insulin treatment has been reported to work, although no
big studies have been performed
- Chromium - Chromium supplementation appeared to work in a small study
- Alternative treatments. Nicholas Perricone's controversial book
The Acne Prescription proposes an alternative treatment for adult acne,
including a strict diet (dairy is totally avoided in all but two recipes) and
topicals containing alpha lipoic acid. Perricone's claims did not
seem to be backed up by strong scientific evidence until the publication of the
acne / milk link in early 2005. There are no double-blind studies proving the effectiveness of
fatty acids against acne.
Popping a pimple or any physical acne
treatment generally should not be attempted by anyone but a qualified dermatologist.
Pimple popping irritates skin, can spread the infection deeper into the skin, and
can cause permanent scarring.
Lasers have been in use for
some time to reduce the scars left behind by acne, but research is now being
done on lasers for prevention of acne formation itself. The laser is used to
produce one of the following effects:
- to burn away the follicle sac from which the hair grows
- to burn away the sebaceous gland which produces the oil
- to induce formation of oxygen in the bacteria, killing them
Since lasers and intense pulsed light sources cause thermal damage to the
skin there are concerns that laser or intense pulsed light treatments for acne
will induce hyperpigmented macules (spots) or cause long term dryness of the
skin. As of 2005, this is still mostly at the stage of medical research rather
than established treatment.
Because acne appears to have a significant hereditary link, there is some
expectation that cheap whole-genome DNA sequencing may help isolate the body
mechanisms involved in acne more precisely, possibly leading to a more
satisfactory treatment. (Crudely put, take the DNA of large samples of people
with significant acne and of people without, and let a computer search for
statistically strong differences in genes between the two groups). However, as
of 2005 DNA sequencing is not yet cheap and all this may still be decades off.
It is also possible that gene
therapy could be used to alter the skin's DNA.
Severe acne often leaves small scars
where the skin gets a "volcanic" shape. Acne scars are very difficult (and
expensive) to treat and it is unusual for the scars to be successfully removed
completely. In those cases, scar treatment may be appropriate. The most commonly
used forms of scar treatments are:
- Dermabrasion. The top
layer of the skin is removed with a high-speed rotary wire brush or
diamond-coated fraise (a grinding wheel) to make the scar look less pitted. It
makes the scar less visible but does not remove it completely. Multiple
treatments may be necessary to get the desired results. This procedure is
usually performed by a dermatologist or cosmetic surgeon and is less commonly done now
because of the risk of blood-borne diseases.
- Microdermabrasionis a newer technique that
has a similar effect to traditional dermabrasion, but is less radical. While
dermabrasion is a surgical procedure, microdermabrasion is performed by blasting
tiny crystals at the skin or rubbing the skin with a rough tool under suction.
Many dermatologists and cosmetic surgeons offer this procedure.
- Laser resurfacing. A laser is used to burn off the top layer of the skin. This procedure is commonly known by the brand names of the machines used to perform it, including SmoothBeam. Many
dermatologists and cosmetic surgeons offer this procedure.
- Punch excision. The
scar is excised with a punch tool and the edges are sutured together. This
procedure is usually performed by a dermatologist or cosmetic surgeon.
- Chemical peels(also known as acid peels). A type of organic acid, most commonly glycolic, salicylic, or lactic, is applied to the skin so that a smoother layer can surface. Despite its unpleasant name, superficial peels are painless if performed properly and require no anaesthetic. Peels are typically performed several times over a period of weeks or months. The procedure can also be beneficial for active acne. Many dermatologists and cosmetologists offer this procedure, although the peels given by dermatologists are generally of a higher concentration and therefore potentially more effective. Deep peels are more aggressive and painful and require significant expertise.
- Subcision. The scar is detached from deeper tissue, allowing a pool of blood to form under the scar which helps form a connective tissue under the scar, levelling it with the surface. This procedure is usually performed by a dermatologist or cosmetic surgeon.
- Dermal filler. The
scar is filled with an injectable dermal filler. There are several trade names.
- Rosacea (ro-ZAY-she-ah) sometimes
called "Adult Acne" occurs in people of all ages, especially older women when
they go through the menopause. Two
famous men with the affliction are W.C. Fields and former United States President Bill Clinton. The disorder is characterized by
redness, pimples, and, in advanced stages, thickened skin. People who suffer
from flushing or blush easily are most at risk of developing rosacea.