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Part-II: Understanding Acne

2. What is Acne?

Pimples! We have all experienced those nasty, painful blots on our faces as teenagers, varying in size from the ultra-small and almost unnoticeable, to the big, attention-grabbing ones!

Pimples appear at all the wrong places, at equally wrong times. They invariably appear at the tip of our nose the night of the first date or the school prom. However, the outbreak of pimples is episodic, not continual. They merely require a few years of endurance and a lot of patience before disappearing altogether from our lives, remaining just an interesting part of the memories of our adolescent years.

However, there is another skin condition which is similar in some ways to that disorder, but more severe in its appearance. It occurs on various parts of the body besides the face, and is much more difficult to cure. It can appear at any time during a person’s life, although the disorder most often begins in adolescence. This dermatological condition is called Acne.

This book will, hopefully, give you the answers to all your questions, including:

• What is acne?

• What are the various forms of acne?

• How can you treat each of these disorders?

• What causes acne?

It will focus especially on the most severe forms of acne and the symptoms, and provide a comprehensive guide to the various treatment options available.

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Whether you are an anxious teenager, a forty-year old patient or a worried parent, the in-depth information on the condition will reduce your fears and help you negotiate your way through the worries that come with acne.

Definition of Acne

Acne is one of the most common skin disorders worldwide. It occurs on almost 45% teenagers and adults, and is seen in a smaller percentage of young children. Pimples, blackheads, whiteheads and lesions appear in the various oil-producing areas of the body; the face, back, chest, neck, shoulders and upper arms.

The main reason for this is an over-production of oil by the sebaceous glands in the skin. This causes the oil to combine with dead skin cells, which clogs the pores in that area. Scientists are focusing on the roles played by hormones, bacteria and genes that can increase the risk of developing acne.

Acne exists in several forms, including acne vulgaris, acne fulminans and acne conglobata. Each differs in its cause, severity and prognosis. Some forms cannot be successfully treated but most acne is completely curable.

With the wide range of treatment options available today, ranging from topical ointments to surgical procedures, the best treatment depends upon the type and severity of the condition. Nonprescription drugs, such as topical medications, may cure some forms but oral medications or even surgery may be required for others.

Patients with moderate to severe acne must consult with a qualified doctor or a dermatologist who will help them to decide the most suitable treatment combinations for them.

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3. Who Develops Acne?

Acne affects millions of people all over the world. The statistical distribution of the condition, by age and gender is:

1 85% of adolescents and pre-adolescents are affected by acne.

2 The condition occurs on some children under 10 years of age.

3 Boys are more likely to have a severe form of the disease than teenage girls.

4 About 12% of women between 22 and 45 years of age are affected by acne.

5 About 3% of all men are affected during their adult life.

6 Women are more prone to acne during adulthood because of premenstrual hormonal changes as well as consistent use of cosmetics.

7 The incidences of acne reduce sharply after the age of 45.

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4. What is the Real Cause of Acne?

For most people, acne begins during adolescence. One of the main reasons is the excessive production of sebum due to the higher levels of sex hormones in the body during puberty.

To understand the various factors which cause acne, we need a brief insight into the anatomy of the skin surface; the hair follicles, as well as the production and role of sebum.

Here is some background before we get to the actual causes.

The Hair Follicle and the Sebaceous Glands

There are many hair follicles on our skin. The sebaceous glands (oil glands) exist near the surface of the skin and open into the hair follicles. The oil, or sebum, which they produce constantly, enters the follicle. This helps in protecting the skin from drying out.

Overproduction of sebum is a major factor in the development of acne. Before covering the various causes of acne, here is information about the production, role and regulation of sebum.

Sebum

Sebum, an oily and complex mixture of lipids (a group of fats and similar compounds including waxes, oils, sterols, triglycerides, phosphatides and phospholipids), is produced by the sebaceous glands.

Sebaceous glands exist over almost all of the body, but especially on the forehead, chin and back.

Cells in these glands disintegrate in about a week and produce sebum. The rate of production depends on age and gender:

1 Adult females produce less sebum than adult males

2 Production of sebum increases almost five times in boys with the onset of puberty Copyright © 2006 All rights reserved

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3 Sebum production declines significantly with age

4 Production of sebum also falls steeply in women after menopause

Hormonal control of sebum

The sex hormones, or androgens, stimulate the cells in the sebaceous glands to produce sebum.

The testis in males, the ovaries in females and the adrenal glands produce these hormones.

The androgens that influence the production of sebum the most are:

1 5-testosterone (DHT)

2 5-androstene-317diol

Role of Sebum

Some of the functions of sebum are:

1 It acts as a protective barrier against bacteria and fungi.

2 It helps to reduce excessive water loss from the surface of the skin.

It is an environment that supports the bacteria Proprionibacterium acnes, which researchers believe may play an important role in the regulation of the immune system.

With your new insight into the working of sebaceous glands and the production of sebum, you will understand the factors that cause acne more easily.

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Why Do We Get Acne?

Acne develops when the sebaceous glands in a person's skin start producing excessive levels of sebum. This oil combines with the cells lining the walls of the glands and clog the skin's pores, plugging them. This plug can enlarge and rupture the hair follicle, so that the follicle spills the oil and debris on to the skin. This causes inflammation and swelling.

Various factors can cause an increase in the production of sebum, including:

Hormones: There is a sudden surge in the level of hormones at puberty. These hormones react with the skin to form dihydrotestosterone, or DHT, which makes the sebaceous glands increase in size. It also stimulates these glands to increase the production of sebum. The increase in sebum leads to the plugging of hair follicles, which eventually leads to the development of acne.

Hormones in Women: At puberty, an increase in the production of estrogen results in menses.

The menstrual cycle results from changes in the levels of estrogen. The severity of acne differs as she goes through her monthly cycle.

Bacteria in acne: Propionibacterium acnes are bacteria found commonly on the surface of the skin, as well as in pimples. With the onset of puberty, the bacteria increase. Other types of bacteria, such as Proprionibacterium granulosum and Staphylococcus epidermidis can also be found at this time. It has been found that people with an excessive production of sebum have more bacteria on their skin, but the link between bacteria and acne has not been discovered yet.

Medications: Acne can sometimes occur as a reaction to a particular drug. This type of acne typically clears up as soon as the medication is discontinued.

Pregnancy: Pregnant women usually develop acne, due to a rise in the levels of hormones in their body. However, their acne clears up soon after the birth of the baby. Newborn babies have acne at times as well. This can be due to the stress of birth or because some hormones from the mother may have permeated the umbilical cord and passed to the baby.

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Endocrine disorders: Less frequently, acne is found in young children and old people. This could be due to a rare disorder of their endocrine system.

Genes: Researchers have found evidence that genes may play a vital role in causing acne. It has been found that children whose parents had acne in their childhood are much more likely to develop acne. In addition, the severity of their acne was similar to the severity of their parents'

acne.

Hypersensitivity to P. acnes: Acne fulminans, an extremely severe form of acne, can be caused due to a body’s hypersensitivity to the bacteria P. acnes.

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5. Types of Acne Lesions

We often get confused with the terminology when we read about acne. For example, the different types of lesions like papules, cysts and comedones or the meaning of the word lesion itself. These definitions should help you in learning about your specific need for treatment.

Lesions- Any physical change in the body tissues caused by a disease or an injury is called a lesion. This may be either external (like acne, skin cancer, or even a knife cut) or internal (like lung cancer or liver cirrhosis). An acne lesion is a physical change caused by a diseased process in the sebaceous follicle.

Comedo lesions- Comedones (plural of comedo) are skin-colored, small bumps that are most commonly found on the chin and forehead of those who suffer with acne. A comedo is a sebaceous follicle. Dead cells from this follicle, sebum, tiny hairs and even small bacteria sometimes plug the sebaceous follicle. The cells lining the sebaceous duct proliferate in acne (this is called cornification) and the result is formation of a comedo.

Some are so small that they may not be visible to the naked eye; these are called

‘microcomedones.’ An open comedo is called a blackhead because the surface of the plug appears black due to exposure to air. A closed comedo that appears as a bump in the skin is called a whitehead. Whiteheads and blackheads should only be extracted under sterile conditions by a qualified dermatologist. If whiteheads and blackheads are squeezed or picked, staphylococci, streptococci and other skin bacteria could infect the area.

Papule- A localized cellular reaction to acne produces a papule. It is a small, solid lesion elevated above the surface of the skin. Although a group of papules and microcomedomes may be invisible to the naked eye, they may give a ‘sandpaper’ feel to the touch.

Macule- A macule is a temporary red, or red-pink, spot that is left after the acne has healed. This has a well-defined border and may stay for many days before disappearing.

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Pustule- A pustule is a fragile, dome-shaped lesion that contains pus (white blood cells, bacteria and dead cells). If a pustule does not worsen into a cyst, it does not leave a scar.

Cyst- A cyst is a severe form of acne, a sac-like lesion containing white blood cells, bacteria and dead cells in a liquid or a semi-liquid form. This is inflammatory and may damage the deeper layers of the skin and cause scarring. Treatments for this lesion are usually not very effective. It is usually very painful.

Nodule- A nodule is the most severe form of acne and sufferers should seek therapies like isotretitnoin. A nodule is a solid, irregularly shaped lesion. It is inflammatory and may penetrate the deeper layers of the skin, causing tissue destruction and scarring. A nodule is generally very painful.

A nodule and a cyst often occur together. That form of acne is called nodulocystic acne.

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6. Scars and Stripes - Scarring in Acne

In teenagers, as well as adults, severe acne can lead to atrophic, or pit-like, scars in the affected area. This can be the source of a huge inferiority complex and leads to depression in many people.

This section describes:

• How to define scarring

• The various types of scars that result from the different kinds of acne … and

• Are they treatable?

Definition

The human body is tuned to respond to any foreign body or abnormal change, whether in it or outside, in a similar way to how an animal would attack an intruder encroaching upon its territory. The body automatically acts to ‘normalize’, or heal the change that took place in it.

For example, if the body receives an external injury, it immediately initiates production of clotting to heal the wound. The body instigates a similar healing process when scarring occurs.

In biological terms, ‘scarring’ is the fibrous process that initiates production of collagen to heal the acne-induced changes in the body.

People suffering from either moderate or severe forms of acne vulgaris (e.g. acne fulminans, acne conglobata) are particularly prone to scarring or pigmentation. Hence, it is advisable for patients suffering from severe acne to seek immediate treatment that will reduce their chances of developing deep, or untreatable, scars.

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Types of Scars

I. Color changes due to inflammatory lesions

The healing of inflammatory acne lesions can lead to the emergence of patches of pigmentation in the affected area. These changes in skin color are temporary and curable. With the right treatment, the patches disappear after a few months and do not recur.

The color changes are classified into three types:

(1) Post- inflammatory pigmentation: Results in brown pigmentation

(2) Post- inflammatory hypopigmentation: White marks appear on the skin (3) Post- inflammatory erythema: Purple, or pink, patches are seen.

Treatment for post- inflammatory pigmentation

Treatment options for post-inflammatory pigmentation include:

Chemical peel-offs: These are face packs with glycolic acid or Jessner’s solution added to them.

Azelaic acid cream: This cream, also prescribed for treating moderate acne, is successful in treating pigmentation.

Protection from the sun: Brown marks darken under moderate to excessive exposure to the sun.

Always apply an oil-free sunscreen with an SPF of 15 or more before going out of the house.

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II. Physical disfigurations in the form of pits or lumps

Severe acne causes three kinds of scarring. These are -

1. Ice Pick scars: Appear as a series of small pits.

2. Hypertrophic/ Keloid scars: Extremely thick, lumpy scars that protrude from the skin.

3. Atrophic scars: In contrast to keloid scars, atrophic scars are thin, flat scars.

Treatment Options

There are various treatment options for each type of scar. Most scars heal completely with the right treatment, though it may take many months for this to occur. However, in a few cases, the scar recurs, even after being successfully treated.

Here are the different ways in which the three kinds of scars can be treated. For details on the procedures, please refer to the Section on Treatment.

1. Ice pick scars can be treated by:

1 Dermabrasion

2 Cutting out larger scars

3 Laser resurfacing

2. Atrophic scars:

1 Dermabrasion

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2 Increasing the soft tissue through fat or collagen implants

3. Hypertrophic, or keloid scars, are the most difficult of the three to treat successfully. Despite apparently effective treatment, the scars are liable to recur within a short time.

Treatments that can be used are -

1 Dressing of scars with silicone gel

2 Application of strong topical steroids

3 Steroidal injections in the lesions

4 Cryotherapy (Cold therapy)

5 Surgery

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7. Seborrhea Due to Hormonal Changes

Seborrhea refers to a condition where the sebaceous glands produce high quantities of oil (or sebum) and the skin becomes excessively oily. The ailment is common in both men and women.

The person suffering from seborrhea complains of unpleasant and excessively oily skin. This may lead to acne or seborrheic dermatitis. It may, rarely, also lead to Parkinson’s disease and acromegaly. A doctor should be consulted at the first sign of the condition and treatment begun immediately.

Causes of High Levels of Androgens in Women

Statistics reveal that about half of the women who suffer from acne have a hormonal imbalance.

Some causes of high levels of male sex hormones in women are:

1

Disease of the Pituitary Gland -

Acromegaly (gigantism)

Problems in lactation (galactorrhoea) due to tumor-producing prolactin

'Moon face’, stretch marks, tiredness and/or easy bruising due to excessive ACTH

(adrenocorticotrophic hormone)

2

Disease of the Adrenal Gland -

Benign, or malignant, adrenal tumors

Partial deficiency of enzyme 21- hydroxylase

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3

Disease of the ovaries -

Benign, or malignant, ovarian tumors

Infertility, irregular menstruation and hirsutism (abnormal growth of hair) caused by Polycystic ovarian syndrome

4

Obesity- Body fat also results in the synthesis of more androgens.

Any of the conditions listed above can stimulate the sebaceous glands and lead to seborrhea.

While diagnosing acne, doctors must check for signs of any of these disorders as the underlying cause of the acne and even perform a laboratory analysis to rule them out.

If any of the above conditions is the cause of acne, it should be tackled first.

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8. Factors Which Aggravate Acne

Some of the factors that can aggravate acne are -

Genetic Factors - If a person’s parents had severe acne, they may also suffer bad acne.

Stress- Like a lot of other health problems, acne also may be caused by severe stress.

Hormonal Factors - If a person has a high level of androgenic hormones, due to any of the following reasons, it may lead to acne.

- Enzyme deficiency

- Polycystic ovaries

- Excessive corticosteroids

- Certain medicines

Clothes or other equipment rubbing against the body - Wearing tight straps, headbands, chinstraps, turtleneck sweaters or bra straps may make acne worse. Wearing equipment like helmets, shoulder pads, or holding a violin between your chin and neck may also make the acne get worse.

- Using harsh soap or very hot water may also aggravate acne.

- Rubbing your face too often or too hard can make the acne get worse.

- Sweating too much may also be an aggravating factor.

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Acne Lesions

The two types of acne are inflammatory and non-inflammatory. Blackheads, or open comedones, and whiteheads, or closed comedones, are examples of non-inflammatory acne.

Nodular acne is an example of inflammatory acne.

Inflammatory acne

Inflammatory acne includes pimples (or ‘zits’), red blemishes and deeper, swollen lesions called nodules.

1 Pustules are closed comedones that become inflamed and then begin to rupture into the skin. Then, they form pustular heads of different sizes.

2 Papules are closed comedones that become swollen, red and then inflamed.

3 Nodules are the most severe form of acne and can produce scarring if they are not treated in time. These are large, swollen and tender acne lesions. They become intensely inflamed and rupture under the skin. Proper treatment should be sought quickly for them.

Non-Inflammatory acne

Non-Inflammatory acne is of two types; blackheads and whiteheads.

1 Open comedones are enlargement of the plug formed by oil and flakes of skin inside the hair follicle.

2 A closed comedo is formed if the hair follicle plug is not exposed to outside air and, thus, no black color develops. It appears as a tiny, pink bump on the skin.

3 If, however, the plug is exposed to outside air, the oil inside the plug turns black (the black color is not due to dust) and is known as a blackhead.

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9. Acne Vulgaris

A cne vulgaris is the most commonly-occurring type of acne in adolescents and young adults worldwide. Affecting almost 90% of people at some point in their lives, the condition usually starts at puberty and may become more severe in adulthood. It mostly affects the face, the back and the upper chest. This dermatological condition is characterized by the following kinds of lesions –

1 Non-inflammatory nodules (cysts), open comedones (blackheads) and closed comedones (whiteheads) in its mild to moderate forms

2 Inflammatory papules, nodules and pustules in its severe forms

3 Macules (dark scars seen on dark skin)

4 Erythematous macules (reddish-colored scars from recently healed blemishes, seen mostly in fair-skinned people)

These lesions may disappear without any treatment after a few weeks. However, more severe forms of acne require extensive treatment and may take a few months to a few years to heal.

Pathophysiology of Acne vulgaris

Acne lesions develop in the following four stages –

1 Follicular epidermal hyperproliferation (rapid multiplying of cells) and

hyperkeratinization (cells convert to keratin, a natural part of the hair, too fast and clump wrongly, causing acne or keratosis pilaris).

2 Excess sebum

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3 Propionibacterium acnes

4 Inflammation

Frequency: Acne vulgaris affects 85-95% of people worldwide at some point in their lives. It is one of the most commonly occurring dermatological disorders in the world. Acne vulgaris seems to strike people of all races in equal ratios.

Gender: Acne develops in girls between the ages of 10 to 18 years. In boys, acne usually develops between the ages of 14 to 20 years.

1 Acne vulgaris affects a larger number of boys than girls during adolescence.

2 There is a reversal after adolescence; a greater number of women than men have acne during adulthood.

Causes: Acne vulgaris can be due to the following reasons:

• A history of acne in the family

• Endocrine disorders such as polycystic ovary syndrome and adrenal hyperplasia

• Excessive production of sebum by the sebaceous glands

Diagnosis

The doctor diagnoses acne vulgaris through a physical examination. No laboratory tests are required to confirm the diagnosis. However, if the doctor suspects the acne to be a result of an underlying disorder, such as Cushing’s syndrome, he will order a set of laboratory tests.

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These tests are needed when:

• There is no response to the standard treatment. The doctor will take a culture from a lesion to rule out the presence of gram-negative bacteria, which causes folliculitis (inflammation of hair follicles).

• The Doctor sees signs of symptoms of polycystic ovarian syndrome such as

hyperandrogenism (women with high levels of male hormones) and anovulation (women who do not ovulate). They will order a test to assess the level of serum lipids.

• Patients show evidence of virilization (women displaying male characteristics). In such a case, the total testosterone and DHEAS (a steroid) levels need to be checked.

• The doctor suspects Cushing’s syndrome, where they will check the urine cortisol level.

• If women have hirsutism (excessive hair growth) and dysmenorrheal (painful menstrual cramps), a hormonal evaluation needs to be carried out.

Management of Acne Vulgaris

Treatment Options

Treatment of acne vulgaris depends on the severity of the acne. The doctor decides whether a single mode of treatment, or a combination, is required. The various kinds of treatment are shown below. For a more in-depth look, please refer to the Section on Treatments.

Topical treatments

Topical Antibiotics: Topical antibiotics are useful against P acnes and for controlling inflammation . Unlike topical retinoids, however, these can cause bacterial resistance to Copyright © 2006 All rights reserved

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develop, so they are best used in combination with benzoyl peroxide. Clindamycin and erythromycin are two of the topical antibiotics which are used.

Topical retinoids: Topical retinoids are anti-inflammatory and they help to reduce the number of comedones, microcomedones and inflammatory lesions. Some of the most commonly used retinoids are tazarotene, adapalene and tretinoin. CAUTION: these retinoids peel away the upper layers of the skin, so patients should use non-comedogenic moisturizers and sunscreen regularly.

Benzoyl peroxide products: These are extremely effective against P acnes and do not foster bacterial resistance. They are available without prescription in a number of forms, such as soaps, creams, lotions and gels.

Systemic treatments

Systemic antibiotics: Systemic antibiotics, such as the tetracycline group of antibiotics, are usually effective for treating acne. They contain anti-inflammatory agents and help fight P acnes. However, bacteria have become resistant to these agents. To reduce the resistance, antibiotics should be combined with benzoyl peroxide.

Hormonal therapies: Some hormonal therapies are effective in treating acne vulgaris.

Birth control pills increase the level of the sex-hormone-binding globulin. This causes the testosterone circulating in the body to fall, which reduces the production of sebum.

Isotretinoin: Isotretinoin is a systemic retinoid that is effective in treating severe and recalcitrant acne vulgaris. It normalizes the epidermal differentiation and, at the same time, reduces the quantity of sebum excreted by the sebaceous glands up to 70%. Also, it is anti-inflammatory and reduces the number of P acnes. In severe cases, isotretinoin is recommended to be used with steroids at the start of therapy.

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Patients should be aware of these precautions and possible side effects:

Pregnant women should never use Isotretinoin, a strong teratogen. Women should be tested to rule out pregnancy before this therapy is started and pregnant women must not take isotretinoin. Routine pregnancy tests should be done during the course of the treatment.

Safer options would be erythromycin and amoxicillin.

Some of the side effects associated with isotretinoin are depression and mood swings. The doctor should make patients aware of this before the start of the treatment.

Patients should be aware that they may develop larger quantities of granulation tissues and have an abnormal rate of healing, so procedures such as waxing, epilating, tattooing and piercing are strictly prohibited. Dermatologists delay surgical procedures such as dermabrasion and laser resurfacing for up to one year after the end of this treatment.

Surgical Options

Apart from the therapeutic options mentioned above, severe cases may also require surgery.

Some surgical procedures are -

1 Manual extraction of comedones

2 Steroid injections into the lesion

3 Superficial peels containing glycolic and salicylic acid.

4 Phototherapy and photodynamic therapy using red or blue light

5 Laser resurfacing

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6 Dermabrasion

Prognosis

The prognosis for acne vulgaris is good overall, but it can leave physical as well as psychosocial scars in its wake.

1 In male patients, acne generally clears up by the late teens.

2 Acne usually continues into adulthood in female patients.

Precaution for Patients

• Patients should gently wash their face twice a day with mild cleansers.

• Cosmetics should be mild and non-abrasive. It is better to buy non-comedogenic (non-greasy) cosmetics.

• Prescriptions should be discussed with the doctor for any potential adverse effects.

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10. Acne Conglobata or Cystic Acne

Acne conglobata, or cystic acne, is a rare but severe form of nodulocystic acne vulgaris. It is seen mostly in males between the ages 18-35, and occasionally in infants. The disease affects the face, chest, back and the scalp. It is characterized by inflamed nodules, which leave deep scars when they heal. Treating the disease is a long process which, in some cases, has taken more than twenty years.

Patho-physiology of Acne conglobata

Scientists still do not know the primary cause of the disease, but they identified factors that may stimulate or provoke the disease.

These factors include:

1 Chromosomal defects in the XXY karyotype (a picture of chromosomes which is used when checking for abnormalities)

2 Androgens (male sex hormones)

3 Anabolic steroids

Characteristics

o

The nodules are dome shaped and tender to the touch

o

Nodules start forming early in puberty, and keep forming until the mid-forties.

o

Nodules often keep on increasing in size before breaking down, forming unusual shapes.

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o

A main characteristic of Acne conglobata is that blackheads are formed in groups.

Treatment

Patients should consult a dermatologist as soon as they notice symptoms. The disease can be treated by -

1 Isotretinoin

2 Oral tetracycline or erythromycin alone or in combination with isotretinoin.

3 Systemic steroids in combination with isotretinoin

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11. Severe Acne: Acne Fulminans or Acne Maligna

Acne fulminans, also known as Acne maligna, is a rare and severe form of acne conglobata that occurs due to an immune complex reaction to Propionibacterium acnes. It is only seen in adolescent boys. In this condition, pimples spread rapidly on the person’s chest and back. The face is usually unaffected.

Features of Acne fulminans

Physical Features: Some features of Acne fulminans that are visible physically are -

1 A sudden onset of severe, mostly ulcerating pimples

2 A bent posture, due to pain from Polyarthritis (inflammation affecting many joints) 3 Muscle pain

4 Inflammatory arthralgia (joint pain).

5 Fever

6 Deep scars left by the pimples

Laboratory analysis shows that the following features are common to Acne fulminans -

• Leukocytosis (high number of white blood cells)

• Anemia

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• A high Erythrocyte Sedimentation Rate (ESR is an increased rate of red cells settling in blood)

• Protein urea

• Sterile blood cultures

• No response to anti-bacterial medications

Imaging Studies: By using advanced scientific equipment, such as radiographs and ultrasound, doctors can detect these lesions or cysts in patients suffering from Acne fulminans: 1 Destructive lesions are seen in 30% of patients on doing radiography.

2 Radiographs also show that almost 50% of patients have lytic bone lesions.

3 Using technetium scintillography, doctors can also detect multifocal osteolytic cysts.

Pathophysiology

Acne fulminans is an immunologically-induced condition, believed to be triggered by Propionibacterium acnes. According to some researchers, higher-than-normal levels of testosterone can also cause the disease.

Isotretinoin can also act as a precipitator of the disease.

Genes too may be an important factor in some patients. However, nothing concrete has been established on this theory yet.

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Medical Care

Over the past few years, fewer cases of acne fulminans have been recorded. It is believed that earlier and better treatment therapies are the main factors in the reduction.

For those who do have this disease, the treatment is long and severe. Broad-spectrum antibiotics offer no relief at all. Doctors usually recommend a combined therapy of isotretinoin, oral steroids and intra-lesion injections.

Prognosis

Though it is difficult to treat, the prognosis for acne fulminans is good.

• The disease rarely recurs after successful treatment.

• Bone lesions resolve with treatment, though there may be some scars left behind.

• The pimples may cause scarring and fibrosis on healing.

Management

Boys who develop Acne fulminans must consult a physician or a dermatologist immediately. Left untreated, the disease can develop fast, become more severe and leave permanent scarring.

Managing the disease is a tough process as topical medications do not help and large doses of other drugs are required, but it can be treated successfully.

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These medications are used:

1 Isotretinoin

2 Systemic oral steroids such as prednisone

3 Oral antibiotics such as erythromycin and amoxicillin

4 Anti-inflammatory medications such as salicylates.

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12. Comedonal Acne

Seborrhea (excessive production of sebum) causes keratin in the skin to mix with the oil, leading to blocked skin pores. These blockages, or plugs, are called comedones. This form of acne is called Comedonal Acne.

There are two types of comedones -

1 Open comedones, or white heads

2 Closed comedones, or black heads

Comedonal acne mostly affects the forehead and the chin.

This condition can occur at any time in a person’s life.

Some factors aggravating the occurrence of comedonal acne are-

• Hormonal imbalance in the body- This may be due to pregnancy, intake of testosterone supplements, obesity, Cushing’s syndrome, etc.

• Oil-based cosmetics- Use of products for care of oily skin like sunscreen lotions and petroleum-based moisturizers can also cause comedonal acne.

• Humid weather

The Way Out

Some of the ways to avoid or treat comedonal acne are -

• Wash your face twice daily with a mild soap and water.

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• Use oil-free cosmetics and skin-care products. Check for products that have ‘non-comedonal’ on them.

Some oral medications which may be successful in treatment of comedonal acne are -

Isotretition

Hormonal Therapy

One of the most effective cures is topical medication. The results may take a few months, but this method has proved its effectiveness. The medicine should be smeared, once or twice daily, on the affected area.

Some of the most common topical agents are -

Benzoyl peroxide- 2.5-10%

Azelaic acid- 20%

Glycolic acid- 10-20%

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13. Acne Keloidalis Nuchae

Acne keloidalis nuchae (also known as ‘cheloidalis’) is a type of acne that is seen only in men of African or Caribbean origin, who have curly hair. The condition mostly affects the nape of the neck, but it can also affect the forehead.

The most common symptom of the condition is ingrown hairs. These hairs rub against the wall of the hair follicles and irritate them, which leads to inflammation. Patients should wear loose-fitting clothes that do not rub against the back of the neck.

Treatment

Acne keloidalis nuchae is difficult to treat. It can persist for many years, and can recur after treatment. On healing, the more severe forms of this acne can result in scarring.

Here are some of the most common treatments prescribed by doctors for this condition: 1 Oral isotretinoin

2 Topical steroids

3 Laser vaporization

4 Radiotherapy and

5 Oral antibiotics (in case of secondary infection)

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14. Acne in Pregnancy

Pregnant women are also prone to acne. This occurs due to an increase in the levels of estrogens in their bodies. Although the acne gets worse during the first trimester, it eventually improves as the pregnancy goes on. One major hitch in treating acne that occurs during pregnancy is the intake of certain drugs to cure it. Oral medicines must be totally avoided as they can affect the developing fetus.

Pregnant women should never take medications without first consulting their doctor.

Medicines to be avoided during Pregnancy

Oral medicines can seriously affect the cognitive, neurological and physical growth of the fetus.

Pregnant women and those considering pregnancy, should NOT to take the following medicines:

× Oral isotetrinion

× Tetracycline

× Topical Retinoids

One exception, but only if prescribed by your Doctor, is oral erythromycin for severe acne during pregnancy.

Treatment of Acne during Pregnancy

Instead of oral medicines, patients can apply certain topical drugs to heal the acne. These include: 1 Benzoyl Peroxide

2 Azelaic Acid

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15. Acne Excorié

Many people tend to squeeze or pick at their pimples, out of extreme self-consciousness or just not knowing any better. It makes them look worse, instead of improving their appearance,. It causes secondary infection and this could lead to scarring, which may even become permanent.

Patients suffering from acne should not pick at their pimples. Acne excorié is scarring which is sometimes caused by scratching, squeezing or picking pimples.

Patients should also be aware that acne excorié could be a result of intense stress or depression. If this is the case, help from a psychiatrist could be beneficial. Antidepressants may also be useful in reducing the patients’ depression and their tendency to squeeze their pimples. Statistics show that women tend to develop acne excorié much more frequently than men do, so women should be particularly careful about not picking at their pimples.

Treatment

Acne excorié can result from deep embarrassment in a person about his or her looks. The scars that are formed in this condition are particularly tough to treat. Treatment, therefore, is highly aggressive. Doctors usually prescribe oral isotretinoin to clear the scars. Patients should keep in mind that this could be a long process.

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16. Newborn or Infantile Acne

About 20% of newborns have acne. Reasons for this may include:

1 Their mothers passed certain hormones to them through the placenta just before delivery.

2 The baby’s body has released certain hormones because of the stress of the birth.

Acne in newborns is usually in the form of whiteheads.

Infantile Acne

Babies between 3 and 6 months may develop infantile acne. Some children have acne at the time of birth. Infantile acne is generally mild in the form of blackheads, whiteheads and pimples. This acne generally settles down by the time the child is five years old. These pimples hardly ever leave scars. It is more common in boys and usually develops on the cheeks, forehead and chin.

Children with infantile acne are more likely to suffer from very severe acne (acne vulgaris) during their teenage years.

The most likely cause of infantile acne is fetal hormones. Most common are adrenal androgens like dehydroepianandrosterone, excessive testosterone, LH or luteinizing hormone and FSH

(follicle-stimulating hormone).

In most cases of infantile acne, no medical investigations are required.

Treatments include -

1 Topical agents like benzoyl peroxide and erythromycin gel.

2 Oral antibiotics like erythromycin and isotretinoin.

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The antibiotic tetracycline should not be used on young children because it can cause yellow staining of the teeth.

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17. Acne Due to Medicines

It is widely accepted that acne can be caused or aggravated by the intake of certain medications or drugs. Research firmly supports this. These are some of the drugs that can cause acne: Hormonal Medicines

Several hormonal supplements have been known to cause acne. They raise the level of hormones in the body, upset the endocrine system and act on the sebaceous glands in the skin.

The hormonal supplements that may cause acne are:

Testosterone supplements: An increase in testosterone levels in the body can stimulate the sebaceous glands to produce greater quantities of sebum. This ultimately results in acne.

Oral steroids: These cause steroidal acne.

Anabolic Steroids- Anabolic steroids, such as danazol and stanozolol, are known to cause severe acne, such as acne conglobata and acne fulminans. Acne due to the intake of anabolic steroids is mostly seen in athletes, who take steroids to build muscles.

Other Types of Medicines

Some of the other medicines that may cause acne are -

1 Antidepressants such as lithium and amoxapine

2 Anti-tuberculosis drugs like ethionamide, isoniazid and rifampicin.

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3 Halogens like iodides, chlorides, bromides and halothane.

4 Vitamin B12 (Cyanocobalamin).

5 Antiepileptics like carbamazepine, phenytoin and Phenobarbital

Precautions

Now that you know the various types of medications that can cause, or even aggravate acne, it is important for you to be careful. Discuss the use of any drug, even over-the-counter drugs, with your doctor before taking them. If you find that a certain drug is causing your acne to worsen, ask your doctor for an alternative.

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