What is Acne?

Acne occurs when the oil glands of the skin become plugged. It is more common in people with oily skin. Acne occurs in adolescents and young adults. In acne there are blackheads (the plugs found in blocked-off oil glands), whiteheads (pimples), or red bumps on the face, neck, and shoulders.

What is the cause?

Acne is due to over activity and plugging of the oil glands. The main underlying cause of acne is increased levels of hormones during adolescence. Acne is not caused by diet. A person who has acne does not have to avoid eating fried foods, chocolates, or any other food.

Acne is not caused by sexual activity. It is not caused by dirt nor by not washing the face often enough. The tops of blackheads are black because of the chemical reaction of the oil plug with the air. Acne usually lasts until the age of 20 or sometimes 25. It is rare for acne to leave any scars, and people worry needlessly about this.

How to take care of acne?

Good skin care can keep acne under control and at a mild level.

* Wash the skin twice a day using a mild soap, especially after exercise. Avoid scrubbing the skin. Hard scrubbing of the skin is harmful because it irritates the openings of the oil glands and can cause them to be more tightly closed.

* Avoid putting any oily or greasy substances on the face. Oily and greasy substances make acne worse by blocking oil glands. If unavoidable, use water-based cover-up cosmetics, and wash them off at bedtime.

* Shampoo the hair daily. Avoid hair tonics or hair creams especially greasy ones. These substances spread to the face and aggravate the acne.

* Avoid picking blackheads as this delays healing. In general, it is better not to "pop" pimples.

* Exercise regularly and keep fit.

* Don't stop the acne medicine too soon. It may take up to 8 weeks for a good response.

What are the types of acne?

Acne can be classified into four main types: purely comedonal i.e. non-inflammatory acne; mild papular; scarring papular and nodular or scarring acne.

Comedonal acne: It is the non-inflammatory acne, which is the mildest form of disease but can be the hardest to treat. Comedones are usually firmly seated in the follicle.

Inflammatory acne: It is the mild papulopustular acne, which rarely results in scarring and typically is responsive to aggressive, twice daily, topical treatment.

What is the treatment?

Many doctors seem tempted to use as many as five or six treatments. Most acne can be treated effectively with two drugs, or at most three, at any one time. Failure to respond to a regimen within four to eight weeks should prompt a substantial change in drugs, not merely the addition of another product.

Tretinoin, isotretinoin, adapalene, and tazarotene are topical retinoids which, if applied daily, inhibit formation of comedones and usually clear even severe comedonal acne within a few months. The only major drawback is irritation, which is greatest after a few weeks, but the irritation usually requires no more than simple moisturising. Azelaic acid is a dicarboxylic acid with modest antibacterial and comedolytic effects. It is the least irritating preparation. The side effects: in dark skinned patients, inflammation results in hyperpigmentation, which could otherwise remain for weeks or months.

Usually, two drugs are prescribed an antibacterial and a comedolytic. Benzoyl peroxide 2.5-10% is extremely effective against this type of acnes. Its major disadvantage is irritation, which can be minimised by using lower concentrations in a cream vehicle. Topical erythromycin and clindamycin are available as alcoholic solutions, lotions, creams, and gels, all of which are about equally effective. A combination of clindamycin and benzoyl peroxide in gel form is superior to a topical antibiotic alone. Azelaic acid 20% cream is also an effective alternative. Failure to respond to topical treatment within four to eight weeks should automatically prompt a change in treatment. Other options for resistant P acnes include oral antibiotics and isotretinoin.

Solutions for acne that is resistant to treatment:

Investigate compliance
Increase frequency of topical treatment
Begin or increase oral antibiotic dosage
Search for hormonal derangement
Begin oral isotretinoin therapy

Oral treatment:

Acne that is resistant to topical treatment requires oral antibiotics. Many of the antibiotics useful in acne also have an anti-inflammatory activity, which is nearly as important as their effect on the P acnes itself. Oral erythromycin used to be a common treatment for acne, but the rise of resistance has greatly reduced its utility. It is necessary to begin the treatment with doxycycline or minocylcine. Acquired resistance to minocycline and doxycycline is less common than to erythromycin but is still a concern, and use of these drugs should be limited to those patients who truly need them. Patients are instructed to take the drug with food this minimises stomach complaints and maximises compliance. If minocycline or doxycycline cannot be used, alternatives include co-trimoxazole and ciprofloxacin. Risk of acquiring resistance to these drugs after long-term use has not been studied, but the use of these drugs should be minimised. In general, cephalosporins and penicillins are not very effective in treating acne. The increased cost of some of these newer drugs may make using isotretinoin an attractive option in the long-term treatment.

Hormonal treatment:

It is wrong to assume that any woman with acne have a hormonal derangement. In fact, androgen levels do not correlate with acne severity among people with acne. Acne resistant to treatment, especially in a woman with irregular menses, should be investigated. Measurements of total and free testosterone as well as dehydroepiandrosterone sulphate. If these levels are raised, four approaches may be taken: suppression with low dose oral corticosteroid, oral contraception, cyproterone acetate or spironolactone.

Isotretinoin revolutionised the treatment of severe acne. It is used in case of severe nodular acne, but it is commonly used for severe acne that is resistant to oral antibiotics as well. Patients should be monitored routinely.

Acne and pregnancy:

Erythromycin, topical or oral, is safe in pregnancy, although oral erythromycin is often poorly tolerated in patients whose lower oesophageal sphincter is already relaxed by pregnancy. Benzoyl peroxide is also safe. Topical tretinoin in pregnancy is theoretically safe as circulating vitamin A. No increase in foetal abnormalities has been seen in women using topical tretinoin while pregnant.