Acne - Decoding the Hate Relationship

What Is Acne?

Acne vulgaris, commonly known as acne, is a chronic inflammatory skin condition with a multifactorial etiology which may be of two types: inflammatory or non-inflammatory. Inflammatory acne leads to the formation of papules, pustules, nodules, and cystic lesions. They are most commonly called zits, pimples, or breakouts. Non-inflammatory acne, on the other hand, is a milder form of acne vulgaris leading to the formation of closed and open comedones. They are commonly called blackheads, whiteheads, bumps on the skin, and so on.

Acne vulgaris is caused due to inflammatory disorders of the pilosebaceous unit (hair follicle, hair shaft, and the sebaceous gland), which is commonly triggered by excess sebum secretion due to multiple factors and aggravated by Propionibacterium acnes (a gram-positive bacterial involved in acne formation on human skin). They most commonly affect adolescents. However, they are also seen among prepubertal age groups, adults, and postmenopausal women. They appear in multiple locations in the body, including the face, trunk, upper chest, and back. They usually run a chronic course and may be self-limiting.

Acne tends to leave residual marks and scars on the affected areas. Due to the chronic and persistent nature of most acne, be it active or residual acne, it may lead to depression, anxiety, and social isolation, especially among adolescents. Although there is no single cure for acne or post-acne hyperpigmentation due to their recurrent nature based on various factors, they may be managed with medications and procedures to reduce their appearance and prevent recurrences. This article will discuss the cause of acne, risk factors, types of acne, complications, and various management options available for reducing their appearance.

How Common Are Acne?

• Acne vulgaris is a common cutaneous condition and the world’s eighth most prevalent disease. They affect an estimated 9.4 % of the world’s population.

• In India, the prevalence of acne vulgaris is about 0.74 % of the total population.

• Acne vulgaris affects more than 80 % of teenagers. It affects about 80 % to 95 % of young men and 79 % to 81 % of young women. They usually are prevalent among adolescents. However, they are not uncommon among young adults and postmenopausal women.

• Although young men are more affected during adolescence, they are less commonly seen among men after 25. Beyond 25 years of age, acne tends to persist among 3 % of men and 12 % of women and is common mostly among women of the postmenopausal age group as compared to men.

• Acne is seen among all races and ethnicities. Still, it may vary in severity and with respect to post-acne complications in the form of PIH (post-inflammatory hyperpigmentation). About 37 % of African American community, followed by 32 % of Hispanic and 30 % of the Asian community, and then Indian and Caucasian communities, around 23 % to 24 % are affected in the order.

What Are the Etiology and Risk Factors Associated With the Development of Acne?

Acne vulgaris is a multifactorial cutaneous condition. The following factors contribute to the formation of acne:

• Genetic Factors: In the case of a family history of acne vulgaris, there is a chance of transmitting them genetically through the generations.

• Hormonal Fluctuations and Imbalances: During prepuberty and puberty, there are sudden fluctuations in the hormones called androgens in both sexes; however, these androgen fluctuations are relatively prominent among young males. The excess formation of androgen hormones leads to changes in the skin cells, and sebum secretion within the skin is altered, thereby making the skin susceptible to infections. Similarly, hormone fluctuations among young females are very common due to PCOS (polycystic ovarian syndrome). In this condition, ovaries tend to secrete increased amounts of androgens, thereby causing alterations in sebum production and increasing susceptibility to the formation of acne lesions. They also cause excess unwanted hair growth, especially around the chin, and leads to irregular menstruation. Hormone fluctuations and imbalances are also common among pregnant women and lactating mothers, leading to acne due to sudden hormone level fluctuations.

• Skin Care Products: Certain cosmetic creams and lotions, when applied on the face, may also trigger the formation of acne.

• Medications (Drug-Induced Acne): Medications taken for certain underlying medical conditions, including SSRIs (selective serotonin reuptake inhibitors) used for depression, lithium, anticonvulsants, Barbiturates, Corticosteroids, vitamin A derivatives, especially for first-time users, birth control pills (OCPs), Lamotrigine used for anxiety, bipolar disorder, and seizures can trigger acne formation.

• Lifestyle, Diet, and Climate Factors: These factors may also induce acne. A sedentary lifestyle, excess sweating, stress, inadequate water intake, and consuming oily food, sweets, red meat, and dairy products may induce the formation of acne due to excess oil and sebum secretion.

What Is the Mechanism of Acne Formation?

Acne vulgaris develops due to three main causes; excess sebum production, propionibacterium build-up, and inflammation. They occur due to the following three processes:

1. Excess Sebum Production: Sebum and oil is produced in excess in the facial and body skin pores due to various factors, followed by excess deposition of the protein keratin on the follicular or hair-containing area of the pilosebaceous unit (unit with the follicle, hair shaft, and sebaceous gland within the skin) due to changes in the normal keratinization on the skin surface leading to the formation of comedones.

2. Bacterial Colonization: Cutibacterium acnes, specifically Propionibacterium acnes, which is present as a normal commensal within the body, gets triggered by the changes in sebum production as they are anaerobic bacteria obtaining energy from fatty acids obtained from the sebum. Colonization of P. acnes leads to inflammation.

3. Inflammation: The presence of bacteria, P. acnes, leads to the release of inflammatory mediators via inducing monocyte cytokine production through a toll-like receptor-dependant mechanism and through nuclear factor Kappa B mechanism, thereby leading to inflammatory mediators causing the formation of inflammatory responses.

What Are the Principle Signs and Symptoms of Acne Vulgaris?

• Age Group: Most commonly seen among adolescents. However, it may be present among young men and women beyond 25 and postmenopausal women.

• Distribution: They are most commonly seen on facial skin but may be present on the upper chest, back and arms.

• Symptoms: In the non-inflammatory type, the presence of comedones in the form of white and blackheads, also called closed and open comedones, respectively, may be present. Oily skin and open pores may also be seen. In the inflammatory type, papules, which may be skin-colored or red, and inflamed pimple-like raised lesions may be present on the skin. Pustules which are raised pimples consisting of white pus within them may be present. It can be tender and painful to touch and may cause itching and discomfort. They are inflamed nodules and cysts in the form of round raised lumps present within the skin and may appear 1 mm to 5 mm in size on the skin surface consisting of pus which may be inflamed, painful, and tender to touch.

How to Grade Acne Severity?

Based on the classification of the severity of acne present, they are graded as follows:

• Grade 1: Mild acne consisting of mostly whiteheads and blackheads with less than 10 papules.

• Grade 2: Moderate acne or pustular acne consisting of multiple (10 to 40) papules and pustules along with comedones.

• Grade 3: Moderately severe acne consisting of multiple, more than 40 papules and pustules and with the presence of nodular and cystic acne less than 0.5 cm in size with less than 3 nodules.

• Grade 4: Severe acne with multiple painful and deep-seated nodules and cystic acne with inflammation and scarring may be present. They may eventually form sinus tracts and may last for weeks.

What Are the Various Methods of Acne Management?

Management of acne requires a holistic approach. The main aim of managing acne is to reduce excess sebum production and prevent acne formation. Medication in the form of topical and oral medications coupled with undergoing procedures would help with regularizing the formation of sebum. Lifestyle modifications in the form of dietary changes and avoiding triggering factors are also helpful in managing acne. Management of acne is also done depending on age, the severity of acne, and factors causing acne vulgaris. The various methods to treat and manage acne are as follows:

A. Topical Medication: Topical medications help with mild to moderate acne and are more beneficial when accompanied by oral medication and procedures.

Topical Antibiotics:

• Clindamycin: Clindamycin formulations such as creams, gels, foams, suspensions, and solutions are very helpful in treating the acne of grades 1 to 4. They act on the bacterial protein, disrupting their synthesis and interfering with their multiplication. However, they are not used for curing acne; they help manage acne and reduce their recurrences.

• Benzoyl Peroxide: Benzoyl peroxide formulations in the form of foam, face washes, gels, and creams may help when used alone or along with Clindamycin as a combination topical medication. They have bactericidal properties; therefore, they destroy acne-forming bacteria. They also have anti-inflammatory properties and are particularly helpful for moderate to severe acne. Since they are strong, they are usually not advised to be used along with other peeling agents and retinoids.

• Dapsone: Dapsone gels are also used in some cases as they have anti-inflammatory properties and help reduce acne.

Topical Retinoids:

• Retinoids: Retinoidsare useful, especially in the case of moderate to severe forms of acne. They are available in multiple formulations in the form of serums, creams, ointments, gels, and lotions. A variety of retinoids and retinoid-like agents are available, namely Tretinoin, Adapalene, and Tazarotene are most commonly used alone or in combination with topical antibiotics for better effect. Due to the strength of these medications, they are usually advised to start slowly on a once-weak basis and slowly build up as per the adaptation of one’s skin to the medication. They are usually applied only at night as the skin becomes photosensitive and hypersensitive due to these medications. Side effects of retinoids include; exfoliation, dermatitis, burning sensation, irritation, pain and inflammation or redness, drying, and itching may also be seen among some individuals; therefore, usage with caution in a minimum quantity is advised.

Glycolic Acid, Salicylic Acid, and Azelaic Acids:

• Glycolic Acid: Glycolicacid creams, gels, and face washes in various strengths ranging from 1 percent to 12 percent and more are available. They are helpful in grade 1 (comedonal) acne and mild to moderate acne. They help with reducing the formation of acne, regularisation of excess sebum secretion, and also helps with post-acne hyperpigmentation. They are usually used once daily and sometimes once a week, depending on the formulation used.

• Salicylic Acid: Salicylic acid in the form of face washes, gels, and creams in 0.5 % to 5 % strength are also available that help with reducing acne by working within the acne areas as they have a capacity to deeply penetrate, thereby reducing the excess sebum secretion. They also help with shedding of dead cells and in reducing swelling and inflammation. They may also be used as a spot treatment. They are also used in the same way as Glycolic acid. Certain formulations, like peels and face washes, are used in combination depending on the severity of the acne.

• Azelaic Acid: Available in strengths of 10 % and 20 % in the form of foams, creams, and gels may also be used for managing acne. They work by reducing acne-causing bacteria on the skin and help keep pores unclogged and open.

B. Systemic Medications: Systemic medications like antibiotics are extremely helpful in managing acne, especially when used in combination with topical medications.

Oral Antibiotics:

• Tetracycline: Tetracyclineantibiotics in the form of Doxycycline and Minocycline may be used to treat acne. They act on the proteins present in the bacteria, thereby arresting their growth by inhibiting protein synthesis.

• Macrolides: Macrolide antibiotics in the form of Erythromycin and Azithromycin may be used as well. They have bacteriostatic properties to arrest the growth of bacteria as well. Oral Antibiotics are usually taken with or after food for at least five days or maybe longer, up to two weeks, for better effect. They are not recommended to be used while pregnant and during lactation. Severe side effects are seldom seen with their usage.

Oral Isotretinoin:

They are used in various strengths ranging from 5 mg to 40 mg. Although their exact action is unknown, they are hypothesized to act by inhibiting the sebaceous gland function, thereby reducing the excess sebum secretion and helping reduce hyperkeratinization. They also have anti-inflammatory properties. Side effects include; dryness of the eyes, nose, and lips, skin dryness, irritation, itching of skin and rashes, headaches, sore and dry throat, and pain in the back, muscles, and joints.

As they are a very strong medication, they are initially used in low strength daily, and hydration is always advised along with their usage. They are also not recommended for children below 12 years and in case of pregnancy or breastfeeding. They are also not advised in case of diabetes, obesity, congenital malformations, dyslipidemia, osteoporosis, osteomalacia, and if under Corticosteroid therapy.

Combined Oral Contraceptive Pills:

• Progesterone and Estrogen Pills: A combination of progesterone and estrogen pills is recommended in a few cases among women to treat acne. They are usually combined with the other treatments or used alone. They may take weeks to show any improvement. They may lead to weight gain, breast tenderness, vomiting, and nausea. They are also associated with a risk factor for breast and cervical cancers.

• Spironolactone: They are consumed orally in case of a lack of response from other oral agents in managing acne. They help by producing an anti-androgenic response and blocking the effect of androgen hormones on the production of excess sebum secretion. They may sometimes lead to breast tenderness and dysmenorrhea.

C. Procedures and Other Treatments:

Several other treatment options are also available that help in reducing acne, managing them, and reducing its reappearance. They also help with post-acne marks and scarring. Medications commonly used for acne show the best results when coupled with procedures which are as follows:

• Chemical Peels: Chemical peels in the form of Glycolic acid, Salicylic acid, Mandelic, and Azelaic acid peels are available. A professional does them in a dermatologist or cosmetologist clinical setting. They are combination gels applied on the facial skin or affected area, left for 5 minutes to 10 minutes, neutralized using an alkaline neutralizing agent, and rinsed off. Most often, they are done in sessions of 6 to 12 once every 14 to 28 days for the best effect.

• Intralesional Corticosteroids: Intralesional corticosteroids in the form of Triamcinolone injections are injected into the acne in the smallest dosage of about 2.5 mg/ml. They are done for severe acne with cysts and nodules. A single session effectively reduces acne as they have anti-inflammatory properties. However, in some cases, multiple injections and sessions may be needed.

• Drainage and Extraction: In cases of comedonal acne, extraction using a comedones extractor under sterile conditions is done in a single session to remove active comedones. Cystic acne is also removed with drainage, but it may cause scarring. They are usually done in the lack of benefit from topical treatments.

• Laser Therapy: Laser techniques, including Q-switch lasers and erbium lasers, are used for active moderate acne and, in the case of comedonal acne, respectively. The laser beams penetrate the active inflammatory area through the skin, thereby reducing acne via their anti-bacterial and germicidal properties. Erbium lasers also help with comedonal acne and improve skin texture via mild to moderate peeling. They are usually done in multiple sessions every three weeks for better results.

D. Lifestyle Modifications and At-Home Remedies:

For the management of acne, external factors leading to the formation and factors acting as a trigger for the formation of acne may be considered:

• Avoid oily and fried food, red meat, milk, dairy products, and sweets. These foods trigger the formation of acne.

• Daily water consumption should be at least 2 liters to 2.5 liters for women and at least 3 liters to 3.5 liters for men.

• Make sure to avoid stagnation of sweat and moisture that may trigger the formation of acne.

• Regular exercise for managing weight is helpful in regularizing hormone imbalances.

• Gynecological consultation and check-ups among women would help rule out PCOS, a major cause of acne.

• Ensure adequate early morning sun exposure for 15 mins at least. It helps with acne prevention to a certain level. Avoid too much exposure as they may lead to hyperpigmentation and sunburn.

• Make sure to use facial cleansers consisting of Salicylic acid and Glycolic acid twice daily.

• Avoid habitual picking of acne to avoid scarring and hyperpigmentation.

• Avoid excess skincare, which may aggravate acne as they may be irritants.

Conclusion

Acne vulgaris may be chronic but self-limiting. Although it may recur depending on multiple factors mentioned in the article, with the appropriate and timely treatment, they can be managed. Most often, they may cause long-lasting and detrimental psychosocial and physical effects in the form of depression, anxiety, and isolation, especially among teenagers who require counseling and assurance to provide confidence in themselves. Acne vulgaris is time-consuming to treat depending on its severity but may eventually reduce with treatment; therefore, it is always advisable to follow the treatment consistently and patiently. For most individuals, acne may reduce with age as the hormone levels regularize. The most important aspect to be kept in mind is that consistency is key in managing acne. The treatment methods may have to be followed for months.