Acne Vulgaris and it's Management

What Is Acne Vulgaris?

Acne vulgaris is a common skin concern in adolescents and may sometimes persist in adulthood too. It is a skin disorder involving pilosebaceous follicles or oil glands and is therefore seen to involve areas where oil glands are dense. Hence face, chest, back, upper arms are common sites of involvement.

Though acne is commonly seen in oily skin, it can involve dry skin too due to blockage of oil glands when excessive creams or thick greasy creams are used to moisturize the skin.

Acne can present as whiteheads, blackheads, papules, pustules, nodules, and abscesses. If not treated properly, it will leave extensive scarring and pigmentation in the skin.

What Is the Pathophysiology of Acne Vulgaris?

Acne occurs due to four major factors. They are,

• Excessive sebum production.
• Follicular plugging of sebum and keratinocytes.
• Colonization of follicles by Cutibacterium acnes, a normal human anaerobe.
• Release of multiple inflammatory mediators.

How Are Acne Vulgaris Classified?

They can be classified as,

• Non-inflammatory Acne - Characterized by comedones.
• Inflammatory Acne - Characterized by pustules, papules, nodules, and cysts.

Non-Inflammatory Acne:

Comedones are sebaceous plugs that are impacted within the follicles. Depending on the follicle being dilated or closed at the skin surface, they are named opened and closed comedones. The plugs are easily removed from open comedones but are difficult to remove from closed comedones. Closed comedones can lead to inflammatory acne.

Inflammatory Acne:

Papules and pustules occur when Cutibacterium acnes in the closed comedones break down sebum into free fatty acids. It irritates the follicular epithelium by the inflammatory response of neutrophils and lymphocytes. The inflamed follicle ruptures into the dermis, where the comedone contents cause a further local inflammatory reaction, producing papules. When the inflammation is severe, grossly purulent pustules occur.

What Are the Common Causes of Acne?

Excessive use of cosmetics, oily creams, facials, medicines like steroids, menses, humid weather, a hormonal disorder like polycystic ovarian disease can precipitate acne. Diet has a role in acne too. It has been documented that dairy products and foods with a high glycemic index like refined carbohydrates may cause acne.

What Are the Symptoms and Signs of Acne Vulgaris?

Skin lesions and scarring can cause significant emotional distress, while nodules and cysts are more painful.

1. Comedones - There are different types of skin lesions where comedones appear as whiteheads or blackheads. Whiteheads are closed comedones that are whitish palpable lesions (flesh-colored) of 1 to 3 mm in diameter. Blackheads are open comedones that are similar in appearance with a dark center.

2. Pustule - Pustules are elevated, yellow-topped lesions that contain pus, and they appear scattered on the face of the person with acne. They are 2 to 5 mm in diameter and are more superficial.

3. Papules - Papules are red lesions of 2 to 5 mm in diameter, which are relatively deep.

4. Nodules - Nodules are more prominent, more profound, and more solid than papules. These lesions resemble inflamed epidermoid cysts, although they lack actual cystic structure.

5. Cysts - Cysts are suppurative nodules that rarely form deep abscesses. In the case of long-term cystic acne, scarring manifests as tiny and deep pits (icepick scars), shallow depressions, larger pits, or hypertrophic scarring or keloids.

How Is Acne Managed?

In order to understand the management of acne, it is essential to understand its pathogenesis. Acne is basically seen in excessively oily skin (seborrhoea) due to the blockade of oil glands by the shedding of ductal cells. This blockade leads to the growth of a bacteria known as propionibacterium acnes.

Also, androgen (hormone) has a role to play in acne. The medicines used in acne are basically meant to target these underlying causes.

• Antibiotics like Clindamycin, Nadifloxacin, Benzoyl peroxide are used to control the bacteria Propionibacterium acnes.
• Seborrhoea is controlled by using Glycolic or Salicylic acid-based face washes or Tretinoin/ Adapalene gels.
• Retinoids are a group of drugs (Isotretinoin) that are said to work on all stages of acne. In cases of hormonal derangement, medicines like Cyproterone acetate, oral contraceptives, etc., are added to control acne flare-ups.

How Is Acne Treated?

Treatment is suggested according to the type of acne.

• If lesions are mainly comedonal - Salicylic or Glycolic acid-based face wash along with night application of Adapalene gel helps. Sometimes for faster response, Salicylic acid peels are added too. Also, the patient should be advised to get blackheads or whiteheads extracted daily.

• If lesions are red bumps or pustules - Benzoyl peroxide-based face wash along with the application of Clindamycin and/or Benzoyl peroxide cream and Tretinoin or Adapalene gel in the night helps. If required, antibiotics like Azithromycin, Doxycycline, Minocycline, or lymecycline can be added.

• If lesions are severe, like nodules and cysts - Oral Isotretinoin is the drug of choice and gives magnificent results.

Home Remedies:

You can try to control mild or moderate acne with good basic skin care and other self-care techniques. They are,

1. Wash your face with a gentle skin cleanser.
2. Avoid facial scrubs, astringents and masks frequently as they can irritate the skin.
3. Products like Benzoyl peroxide, Salicylic acid, Glycolic acid can be used to dry the excess oil and peel the skin.
4. Avoid oily, greasy cosmetics, hair styling products, sunscreens. Instead, use non-comedogenic or water-based products.
5. After excessive sweating, heat and oil can lead to breakouts so having a bath will help.
6. Do not prick or touch the acne as it may cause infection and scarring.
7. Avoid contact with phones, tight collars or straps, helmets, and backpacks.

What Skin Care Is Needed in Acne-Prone Skin?

• Use Salicylic acid or Glycolic acid-based face wash.
• Get your comedones extracted regularly.
• Use a mud mask weekly.
• Use a water-based moisturizer, and even oily skin needs hydration.
• Scrub your face two times a week.
• Take Glycolic acid or Salicylic acid peels twice a week or monthly once to improve skin texture, for acne control, and reduce scars and marks.
• Take a well-balanced nutritious diet and exercise daily.
• Avoid face massages or the application of greasy cosmetics and oils.

Acne-prone skin needs proper skincare. If the right medicines and products are used, it is easy to manage acne.

Conclusion:

It is advisable that one should consult a dermatologist for a proper personalized prescription and skincare regime rather than using home remedies, as acne can have long-term sequelae in the form of scars and marks if not treated adequately. Acne and acne scars cause anxiety and affect social relationships and self-image. Stress can even worsen acne. So, try to manage stress by practicing relaxation techniques and getting enough sleep.