Acne vulgaris is a chronic skin disease that bothers millions around the world. This article explains all you need to know about acne.
Acne vulgaris is a multifactorial chronic skin disease. The condition involves a blockage and/or swelling of the hair follicles and their sebaceous gland (known as pilosebaceous units).
It is not life-threatening and does not reduce life expectancy. However, acne can become a severe burden for those who have it. Acne is an important source of emotional distress and can cause social isolation and depression. Therefore, in the last three decades, research laboratories and cosmetic dermatologists have made an enormous effort in developing effective treatment options.
Nowadays, many different treatment options reduce the number of pimples, blackheads, and whiteheads and decrease permanent scarring risk.
Acne is by far the most customary skin condition in the United States and many other developed and developing countries. Approximately eight out of ten Americans suffer from acne at some point in their lives. There are around 50 million new cases each year. Most of these persons (about 80%) have moderate or mild acne. The rest (approximately 20%) suffer from severe acne, resulting in severe and permanent scarring, with all the psychological consequences this carries.
This disease usually begins with puberty, thanks to an increased release of sex hormones. During adolescence, acne vulgaris is more frequent in men, but it affects mostly women during adulthood. Although it is more frequent during the ages 12 to 24, it may continue into the 30s and even 40s. In fact, the frequency of adult acne is increasing, affecting up to 15% of women.
Why do humans get acne?
Acne does not have a unique cause; instead, it is the consequence of the interplay within several different factors. These factors include:
- Genetic predisposition
- Plugging of the sebaceous glands within the hair follicle
- Skin colonization by the bacterium Cutibacterium acnes (formerly known as Propionibacterium acnes)
- An inflammatory response in the skin
- Excess sebum production
The skin has several different glands within its surface; of these glands, the sebaceous gland has a lot to do with acne. The function of sebaceous glands is to produce sebum, an oily substance that keeps the skin lubricated.
However, sometimes the pores through which this sebum comes out of the gland are blocked. This can occur for several reasons, such as too much sebum production, dead skin cells accumulating within the pores, or bacteria building up in the pores.
Accumulated sebum is the ideal environment for Propionibacterium acnes to grow. The presence of Cutibacterium acnes (formerly known as Propionibacterium acnes) causes inflammation. All of these alterations put together lead to the appearance of typical acne lesions such as a pimple, a blackhead, or a whitehead.
What does polycystic ovary syndrome have to do with acne vulgaris?
Women with the polycystic ovarian syndrome have enlarged ovaries with multiple cysts in their outer layer. It is the consequence of a hormonal imbalance in which there are abnormalities in the production of certain androgenic hormones in the pituitary gland. The condition affects women’s fertility and produces several hormonal symptoms such as acne.
Androgens stimulate sebum production within the sebaceous glands, which increases the risk of blockage and bacterial colonization. Patients with the polycystic ovarian syndrome also experience other problems such as:
- Oily skin
- Metabolic syndrome
- Type 2 diabetes
- Sleep apnea
- Fatty liver disease
- Increased cardiovascular risk
The polycystic ovarian syndrome is the most important cause of acne during adulthood.
What are the symptoms of acne vulgaris?
Acne symptoms include inflammatory and noninflammatory lesions distributed through areas with a high density of sebaceous glands. These areas include the face, the chest, and the back. There are two kinds of lesions in acne: noninflammatory lesions and inflammatory lesions.
What are the noninflammatory lesions in acne?
- Blackheads (open comedones): A clogged pore by sebum and dead skin cells in which the top of the pore persists open despite the rest of the gland being clogged. This results in a small (about a millimeter in diameter) spot in the face.
- Whiteheads (closed comedones): Like the previous example, except in this case, the top of the pore is also blocked by sebum. Giving the appearance of a small white head protruding in the skin, whiteheads are typically more difficult to treat than blackheads.
What are the inflammatory lesions in acne?
Inflammatory lesions are different from blackheads and whiteheads because they have typical inflammation signs such as redness and pain to palpation (in some cases). Inflammation is the result of colonization by Cutibacterium acnes (formerly known as Propionibacterium acnes) interacting with the host’s immune system. These inflammatory lesions are typically referred to as pimples.
Inflammatory acne lesions include:
- Papules (pimples): In this case, the walls surrounding a clogged pore break down because of the inflammation produced by Cutibacterium acnes (formerly known as Propionibacterium acnes). This causes the skin around the pore to turn reddish, harden, and increase in volume.
- Pustules: Basically, papules filled with pus. They appear as pimples with white or yellow pus heads on top.
- Nodules: When papules and pustules endure further inflammation, they grow larger and larger, thus evolving into nodules and get deep beneath the skin. Most nodules are severe enough to require special medication prescribed by a dermatologist.
- Cysts: Cysts go deeper into the skin surface than nodules and represent the more severe acne lesion. Cysts always come together with major colonization by C. acnes (formerly P. acnes). Nodulocystic acne is a severe acne form with many nodules and cysts distributed throughout the face, chest, and back. This variant of acne vulgaris is more likely to cause significant scarring. Therefore it requires very aggressive treatment.
How is acne severity assessed?
Dermatologists classify acne severity into three main categories:
- Mild acne: Includes mostly noninflammatory lesions (blackheads and whiteheads). There may also be a few papules and pustules.
- Moderate acne: It has a higher proportion of papules and pustules than mild acne
- Nodulocystic acne (severe acne): Presence of cysts and nodules, scarring is almost always present in these patients.
Are there other types of acne besides acne vulgaris?
There are other types of acne different from acne vulgaris. These forms of acne are very uncommon and severe.
Some other types of acne include:
- Acne conglobata: This unusually severe form of acne has multiple interconnecting abscesses and deep, irregular scars. The condition is potentially disfiguring. Also, in these cases, cysts contain purulent material with a foul smell that requires drainage. Lesions appear in the face, chest, and back as acne vulgaris and arms and legs. It can occur as a sudden complication of normal inflammatory acne vulgaris.
- Acne fulminans: This is a sudden presentation of severe conglobate acne often accompanied by ulcerative lesions combined with high fever and arthritis (joint swelling). It is a severe condition that can even have bone lesions and blood test abnormalities. Sadly, the condition can be life-threatening without prompt and adequate treatment.
How long does acne vulgaris last?
Each case is different, and it is impossible for a dermatologist, no matter how good or experienced, to know how exactly long your acne will last. Most acne cases that begin during puberty resolve themselves when they reach adulthood (around the twenties). Still, a minority of patients will carry on acne into their adult years.
Moreover, there is no way to predict who will have acne in the forties. Thankfully, acne patients don’t just need to sit around and wait for acne to go away on its own, thanks to modern medicine. There are many ways to prevent it and make it disappear before it runs its course. This helps prevent psychological stress during adolescence (a very stressful period on its own).
What is the treatment for acne vulgaris?
Treatment for acne vulgaris targets the different factors contributing to it, including bacterial colonization, inflammation, clogging of the sebaceous gland, and excess sebum production.
Importantly, options include topical treatments, systemic treatments (oral drugs), and surgical treatment. Each form of treatment is for a particular level of severity. For example, topical treatment is great for mild acne cases; oral treatment is for more advanced cases. The surgical option is reserved for the most severe cases with significant scarring.
What are the topical treatments for acne?
There are three main types of drug in topical therapy:
- Topical retinoids: A retinoid is a vitamin A derivate. There are currently many different types of retinoids in the market, each with different strengths and indications. A topical retinoid has two main effects; it decreases inflammation and reduces clogging by decreasing cell hyperproliferation within the hair follicle. Therefore, retinoids decrease the number of noninflammatory lesions (comedones) and inflammatory lesions (papules and pustules). Retinoids are the first line of treatment for mild and moderate cases of inflammatory and non-inflammatory acne. Some examples of commonly used agents include tretinoin, adapalene, tazarotene. During the first week of use, patients might experience skin irritation and increased sun sensitivity. However, these side effects go away with time and adequate moisturizing.
- Topical antibiotics: Topical antibiotics play a key role against C. acnes as well as in decreasing inflammation. However, unlike topical retinoids, they do not have the capacity of unclogging comedones. Accordingly, topical antibiotics are not effective against non-inflammatory acne. Bacteria have developed increased resistance towards antibiotics throughout the years. For this reason, doctors recommend the use of topical benzoyl peroxide and topical retinoids along with topical antibiotics to decrease resistance. Commonly used antibiotics for acne include clindamycin, erythromycin, dapsone, and minocycline.
- Androgen receptor antagonists: These drugs block the receptors of androgenic hormones. They are, consequently, inhibiting effects such as increased sebum production that promote pore-clogging. Clascoterone is the only FDA approved drug of this kind so far.
What are the systemic treatments available for acne vulgaris?
In moderate to severe cases, topical treatment alone is often not effective enough. That is where oral agents come in.
- Systemic antibiotics: Just as topical retinoids were the standard of care in mild to moderate acne vulgaris, an oral antibiotic represents the standard for treating moderate to severe acne. Like topical antibiotics, oral antibiotics are effective against C. acnes and also have anti-inflammatory properties. The only difference between oral and topical antibiotics is that the former ones are much more potent. Doxycycline, Minocycline, and Erythromycin are the three most common oral antibiotics, although there are others like trimethoprim alone or with sulfamethoxazole, and more. Just as with topical antibiotics, the use of topical benzoyl peroxide reduces the risk of producing bacterial resistance.
- Isotretinoin: Isotretinoin (commonly known as Accutane) is an oral retinoid. Oral isotretinoin is highly effective in reducing the number of inflammatory and noninflammatory lesions in patients with moderate to severe acne. However, Accutane can cause many severe side effects like dryness in the skin, eyes, mouth, and nose, skin reactions, headaches, back pain, cold-like symptoms, liver and pancreas problems, depression, increased thirst, increased urination, hallucinations (extremely rare), and inflammatory bowel disease. The use of isotretinoin during pregnancy is strictly forbidden because it can lead to premature birth, miscarriage, severe congenital disabilities, and fetal death. Before starting Accutane, female patients must present a negative pregnancy test and subject themselves to birth control if necessary.
- Oral contraceptives: Oral contraceptives reduce the number of circulating androgens, decreasing sebum production, and the hyperproliferation of follicle cells. But not just any oral contraceptive pill will do the trick. For a pill to do the trick, it must contain two hormones, progestin, and estrogen, to be effective against acne. Some oral contraceptives contain only progestin and have no activity against acne. Oral contraceptives are particularly useful in women with the polycystic ovarian syndrome; in this context, oral contraceptives are the treatment of choice.
What is surgical therapy for acne?
There are several types of interventions for acne. The main idea behind all of these procedures is to destroy damaged skin, decreasing sebum production, and allowing new skin to grow.
Some standard procedures include:
- Dermabrasion: The procedure consists of removing several skin layers using a special rotating brush. This treatment is not as effective in treating acne as in curing acne scars. Microdermabrasion is a milder form of dermabrasion more suited for treating acne lesions.
- Photodynamic therapy: The idea behind photodynamic therapy is to apply a photosensitizer in the skin. When this photosensitizer comes in contact with certain light wavelengths, it kills the nearby cells by creating toxic substances., reduces oil production, and kills bacteria. Some lasers can be used alone (without a photosensitizer) to heal moderate to severe acne scarring.
- Chemical peel: The procedure consists of exfoliating the skin and peeling off the skin by applying a substance in the affected area. The peeled off skin reveals new healthy skin underneath; chemical peels are particularly useful in treating mild acne scars.
- Intralesional corticosteroid injections: This treatment is a bit different from the others. It does not remove damaged skin and is mostly useful for cystic acne.
What type of diet is useful for acne?
There isn’t much emphasis on diet as an important factor influencing acne flares. However, data suggests that processed food and junk food have contributed to the increasing acne frequency in the last five decades.
Some foods have a high glycemic index. This means your blood sugar shoots up fast after eating them; these foods are carbohydrates with a very simple molecular structure that makes them very easy to break down into glucose. Higher blood glucose, in turn, causes high blood insulin and eventually leads to insulin resistance and diabetes. High insulin blood levels stimulate the sebaceous follicle to produce more sebum, thus contributing to acne vulgaris pathology. Some food with a high glycemic index that triggers high insulin levels include:
- White Rice
- White Bread
- Sweet corn
- Rice noodles
- Instant oat porridge
- Boiled potatoes
Some studies have also found a relationship between the western diet (typical in the western world) and acne. A typical western diet contains high levels of carbohydrates with a high glycemic index, dairy, trans and saturated fats. This diet promotes the production of certain hormones (androgenic hormones) that favor increased oil production.
In contrast, people who live in the eastern world follow an eastern diet (low in red meat and animal fats and high in whole grains, fruits, vegetables, and seafood). An eastern diet not only lowers the incidence of acne vulgaris flare-ups, but it also lowers the prevalence of cancer, heart disease, and diabetes.
What foods are good for an acne patient?
Although so far, the evidence behind it is still weak, certain foods and supplements appear to benefit some acne patients.
Some of these foods include:
- Complex carbohydrates (which are hard to metabolize into glucose): Some examples include legumes, whole grains, and unprocessed fruits (only some of them, like pears), and vegetables.
- Mineral zinc: Found in pumpkin seeds, turkey, quinoa, and lentils. Zinc plays an essential role in hormonal regulation. Some studies that low levels of zinc correlate with a higher incidence of acne.
- Vitamins A and E: Given that retinoids are the standard of care for acne treatment, low vitamin levels correlate with a greater acne risk.
- Antioxidants and Omega 3 fatty acids: Some studies suggest that consuming omega-three and other antioxidant supplements might reduce inflammatory activity in the skin and help with acne symptoms. However, this is far from verified.
What are some home care tips for acne vulgaris?
Some cases of mild acne can go away with some simple skincare tips you can follow at home; some tips include:
- Cleaning your skin every day to remove excess oil, preferably with a mild soap
- Use non-comedogenic makeup (it is usually advertised in the label)
- Avoid squeezing or picking pimples; it can lead to permanent scarring
- Avoid touching your face as much as possible
- Apply a moisturizer, preferably after bathing
Do you have symptoms of acne vulgaris?
This tool is an Acne Symptoms Checker. It gathers the most important signs, symptoms, and risk factors for this disease. Therefore, the tool will tell anybody who uses it the likelihood of their symptoms because of acne vulgaris. Using the tool is free and would only take a few minutes.