Leslie Capin, M.D.
Peggy Vernon, RN, MA, C-PNP
Aurora/Parker Skin Care Center
Aurora, Colorado
What is acne?
Acne is the most common skin disorder seen in the United States today. It is most commonly associated with whiteheads, blackheads, and pustules (small bumps under the skin containing pus); although, severe acne patients also experience tender red nodules and acne cysts.
What causes acne?
Prior to and during puberty, increased hormones cause an over-production of oil, which then plugs the oil glands, called sebaceous glands. These glands are most prominent on the face, chest, shoulders, and back-the most common areas of acne lesions. Poor diet or dirt does not cause acne. However, a well-balanced diet and proper washing make acne treatment more successful.
A number of other factors also contribute to acne. Stress and emotions can make acne worse. Conversely, acne can create stress. Oil-based soaps, lotions, cosmetics, and hair products cause increased plugging of the oil glands, and can make acne worse. Certain medications, such as epilepsy drugs, steroids, anti-tuberculosis medications, and some antidepressant medications, can cause acne or make it worse.
Who gets acne?
Derived from the Greek word akme, meaning "peak of life," and the Latin word acme, meaning "prime of life," acne is most prominent during adolescence. However, 40% of children aged 8 to 10 years begin to experience acne, and up to 10% of individuals in their midlife years continue to struggle with acne lesions. There appears to be a familial or hereditary tendency; if one or both parents had acne, it is more likely that their children will also have the disorder. Although it is more common in males, females seek medical help more often.
How does acne cause disease?
Acne appears on the skin in the form of blackheads and whiteheads ("comedones"), as well as pustules, nodules, and cysts-the result of the bacteria, Propionibacterium acnes, that cause inflammation of the oil glands. Although the bacteria do not cause serious illness, the psychological effects of acne and resultant scars can be devastating. Advances in acne treatment offer successful management. Therefore, acne should never be dismissed as a minor condition that will be outgrown.
What are the common findings of acne?
There are two types of acne: comedonal acne, which appears as whiteheads and blackheads, and inflammatory acne, which includes pustules, nodules, and cysts. Generally, acne begins as whiteheads and blackheads that progress to inflammatory acne. Most adolescents have a combination of comedonal acne and inflammatory acne, consisting of whiteheads, blackheads, and pustules. Cystic acne is the most severe type of acne and requires intensive treatment.
How is acne diagnosed?
Although acne is easily recognized, a thorough history is important in treating this disorder properly. The duration of acne, past treatment, and products used (including soaps, lotions, and cosmetics) are helpful in developing an appropriate and effective treatment plan. Family history, medical history, and current medications also are very important. It is usually not necessary to perform laboratory tests to diagnose acne, unless a hormonal abnormality is suspected.
How is acne treated?
Acne treatment and management take weeks to months to see improvement. Patience and compliance are crucial.
Goals of treatment include decreasing oil production; opening the plugged oil glands; reducing the bacteria, Propionibacterium acnes; and eliminating or reducing scarring. Mild soaps and lotions are recommended. Gentle washing in the morning and at bedtime to remove cosmetics and debris is essential. Buff puffs and grainy soaps cause additional irritation and should be avoided. Moisturizers, make-up, and hair products should be water based.
Squeezing and picking acne lesions cause irritation and injure the underlying tissue, resulting in scarring, and should be avoided unless performed by a health care professional.
Topical agents, called keratolytics, relieve plugging of the oil glands. Over-the-counter preparations, such as Benzoyl peroxide and salicylic acid, are beneficial for mild comedonal acne. Applied twice daily after washing, results are usually seen within six to eight weeks. Consult your health care provider if results are not satisfactory. Prescription medications, such as Retin A, Differin, and Azelex, may be used once daily after washing. These medications are applied to the entire area, not just to the acne lesions.
Topical antibiotics also may be prescribed in combination with a keratolytic agent. These antibiotics reduce bacteria on the skin and control inflammation. They are beneficial for comedonal and inflammatory acne treatment, as well as for maintenance after control has been achieved with oral antibiotics. They are applied once daily to the entire area after washing. The most common topical antibiotics include Erythromycin, Clindamycin, and Sulfonamides. It is important to advise your health care provider if you have had an allergic reaction to any of these medications in the past.
Oral antibiotics reduce the bacteria, Propionibacterium acnes. They are used in combination with topical medications for more severe inflammatory acne. Common oral antibiotics are Erythromycin, Doxycycline, Tetracycline, and Minocycline. They must be taken for three to four weeks to begin to see improvement, and treatment often lasts several months.
For severe cystic acne, Accutane may be prescribed. This vitamin A derivative is taken orally for four to five months. The response rate is as high as 90%, with most patients experiencing prolonged remissions. Careful monthly follow-up by a dermatologist during treatment is required.
Oral contraceptives have proven helpful in some females with inflammatory acne, either alone or in combination with other acne treatment.
What are the complications?
Scarring and pigment change result from squeezing acne lesions. These can be treated by a dermatologist or plastic surgeon with dermabrasion, chemical peels, or laser resurfacing. These procedures are costly, and they are not covered by most insurance plans. Therefore, picking at acne lesions should be avoided.
Cystic acne can cause thickened scars called keloids. These are unsightly and often painful. Keloids can be treated with steroid injections, or they can be surgically removed by a dermatologist or plastic surgeon after acne treatment is completed.
Benzoyl peroxide, keratolytics, and some topical antibiotics cause dryness and redness in the areas of application. Applying a water-based lotion or moisturizer (that is non-acne causing) can relieve these side effects.
Some keratolytics and oral antibiotics cause sensitivity to the sun. Therefore, sun exposure should be limited, and sunscreens should be used daily.
Accutane causes dry skin, mucous membrane irritation, sun sensitivity, and elevated triglycerides. It should be used in combination with appropriate moisturizers and sunscreens. Close follow-up with a health care professional and monitoring of triglyceride levels are necessary during treatment. Accutane can cause birth defects and miscarriages, and pregnant women should not take it.
How can acne be prevented?
Currently, acne cannot be prevented. However, proper treatment and home compliance offer successful management and remission of this frustrating disorder. Acne is not contagious, and it should not be allowed to take over one's life. Psychological support and encouragement aid in treatment and promote well being.
References
1. Buttaro, T., Trybulski, J., Bailey, P., Sandberg-Cook, J.: Primary Care: A Collaborative Practice, ed. 1, St. Louis, 1999, Mosby, Inc.
2. Hurwitz, S.: Clinical Pediatric Dermatology, ed. 2., Philadelphia, 1993, W.B. Saunders Company
3. Weston, W.L., Lane, A.T., and Morrelli, J.G.: Color Textbook of Pediatric Dermatology, ed. 2, St. Louis, 1996, Mosby, Inc.
Leslie Capin, M.D.
Dr. Capin received her medical education and completed her dermatology residency at the University of Colorado. A Fellow of the American Academy of Dermatology, she is board certified in Dermatology. She has been in practice at the Aurora/Parker Skin Care Center for twelve years, and recently opened CARA MIA Medical Day Spa in Parker, Colorado. She enjoys teaching, and often has students with her during office hours. She is experienced in medical and surgical dermatology, as well as cosmetic dermatology. She is often asked to participate in conferences, and speaks internationally.
Peggy Vernon, RN, MA, C-PNP
Peggy Vernon received her nurse practitioner education at the University of Colorado and is a certified Pediatric Nurse Practitioner. In addition, she holds a Master in Counseling from the University of Northern Colorado. She is on the Clinical Faculty at Regis University and Associate Faculty at the University of Colorado in the Masters Nurse Practitioner programs. Her special interests are pediatric dermatology, patient education, and research. She speaks nationally on various dermatology topics.