What is Acne!!!!!!!
Acne is usually a condition of teenage years but can also be a cause for suffering in later years. People who suffer with acne have inflamed skin and get irritation on applying topical Acne treatment, do they have more Sensitive skin!!!!!!.
Our understanding of this condition is improving but still there are lots of gaps.
Why do we get Acne!!!!!!!
Acne is a problem originating in the hair follicles of the skin which are associated with sebum or oil producing glands.
Following are the main underlying pathological process responsible for causing acne:
The initial lesion has been described as a microcomedone which is a spot in the early stages. This is due to blockage of the hair follicle opening.
The blockage can be due to dead skin cells called keratin, sebum or oil produced by skin, hormonal changes which produce more oil.
Propionibacterium acnes, a bacteria which is normally present on the skin but produces inflammation in acne due to oil rich environment leading to increased numbers of these organisms on skin
The quality and not just the quantity of the oil produced by the oil glands also play a role. Hence the reason why improvement is noted sometimes with the intake of Omega 3 oils.
Stress and acne
Stress aggravates acne but how is still unclear. The probable mechanism is by release of different pro inflammatory chemical agents in the body in stressful periods and also hormones like corticotropin-releasing hormone, cortisol and glucocorticoids or endogenous steroids.
Diet and acne
Historically foods such as chocolate & sugars were blamed for acne and more recently milk, especially skimmed milk and other dairy products have been shown to aggravate acne. Hypothesis is that the hormonal content in the milk and not the fat in milk, may be responsible for the exacerbation of acne. The role of glycaemic load in diet has also been studied to show that people who follow a low glycaemic diet lost more weight and had improved acne when compared to the subjects that had been on a high glycaemic diet. High glycaemic foods are those which cause an abrupt increase in blood sugar and hence insulin spike in the body.
What is the natural course of Acne
Acne usually start to resolve about the age of 20 years and most teenagers developing acne will be clear by the age of 25 years. But acne persists into the 30s in around 43 % of individuals. Most patient still having acne in 30s or those developing acne later in life are women. In 3 to 5 % of patients it can persist in their 40s
Do Genes play a role
There is increasing evidence that hereditary factors contribute to the presence of acne. So having a history of bad acne in the family makes one more likely to get acne and probably a worse case of acne.
Acne is the most common skin disease but despite of it being so common our understanding of this condition is still limited. It can lead to physical and emotional scarring, both of which can be slow to recover from. So how do we treat acne to minimise its impact on individuals.
Topical Acne treatment
Antiobiotics , Retinoids, Azelaic Acid, Benzoyl peroxide, Salicylic acid, Alpha hydroxy acids
Looking at the pathophysiology, treatment would help if we can reduce the blockage of hair follicles by reducing dead skin cells, reduce the production of oil or sebum, reduce the Propionibacterium on the skin and reduce the inflammation produced in acne. All the topical medications can achieve that but to varying degrees.
Retinoids are the only topical medication to improve the division of skin cells hence prevent the blockage of pores and avoid microcomedone formation. It is a slow process, hence any treatment has to be continued for 3 months to be able to see results. They can often cause irritation, so use a light moisturiser to avoid the skin getting dry as dry skin is more prone to irritation
Avoid oil based or heavy moisturisers as it best to not increase the oil load on the skin.
Benzoyl peroxide is mainly antimicrobial hence reduces the bacterial load but is also a keratolytic which dissolves dead skin cells hence reduces blockage as well.
Topical antibiotics reduce bacterial load and reduce inflammation as well
All others help by reducing bacterial load and being keratolytic to varying degrees.
Topical treatments are mainly for mild acne and usually used in combination especially topical antibiotics as otherwise bacteria become resistant quickly.
Topical retinoids would help with treatment but also prevention by reducing the formation of microcomedones.
Moderate acne treatment needs to be treated with oral antibiotics
Acne is not an infection per se though the Propionibacterium play a role in causing inflammation. Oral antibiotics reduce the number of Propionibacterium and also reduce inflammation through other mechanisms as well. They should always be combined with a topical keratolytic agent as they do nothing to the blockage of pores with dead skin cells. Oral antibiotics used are different types of Tetracyclines and Erythromycin.
Oral contraceptives in Acne treatment
Studies have suggested that oral contraceptive tablets can be a useful alternative as acne treatment for women with mild to moderate acne. The oestrogen in the pill inhibits luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which suppress ovulation and ovarian androgen production which has an effect on the oil producing glands. Oestrogen also stimulates the production of steroid hormone-binding globulin (SHBG), which decreases levels of testosterone. So it is worth discussing with your doctor to consider an oral contraceptive pill as a treatment for acne.
Isotretinoin is only used for severe acne and for patient with moderate to severe acne who have failed to respond to conventional treatment and also taking into account the psychological effect of the condition on patients. It is taken for about 6 months. Its use is limited due to the side effect profile. It is highly teratogenic causing birth side effects in babies born to mothers taking this medication. So there are strict regulations around prescribing to women of child bearing age. Apart from that there are other side effects including but not limited to headaches, muscle and joint pains, hypertriglyceridemia and depression and suicidal ideation which is uncommon but a potential serious side effect.
Propionibacterium acnes produces chemicals known as porphyrins. These porphyrins when exposed to visible light can produce a chemical reaction that kills the bacteria. Several types of light sources have been used from red to blue along with yellow and green. Several studies have shown improvement in acne lesions but the improvement has been variable with frequent relapses. Side effects have been few unless it was combined with a topical Photosensitising cream. Laser devices have also been tried in treatment of acne but not enough evidence of their efficacy has emerged.
To conclude, acne causes a lot of misery and suffering, not just physical but also psychological. Our understanding is limited but improving. There are effective Acne treatment to control acne and avoid scarring which can be lifelong if severe. Hence be proactive about treating acne and not let it affect your quality of life significantly. Acne scarring will form a long post in itself which I will write and post later.