What are the other Names for this Condition? (Also known as/Synonyms)

• Environmental Acne
• Pimples
• Zits

What is Acne? (Definition/Background Information)

• Acne refers to a family of multiple subtypes. Acne is a very common skin condition, with many variations in physical findings and course. Many factors play a role in the onset of the different forms of Acne, as well as the different Acne types, such as whiteheads, blackheads, and pimples, noted
• The site of origin of all forms of Acne is the sebaceous glands. Sebaceous glands form a mixture of oils that lubricate the skin and perform other functions. Several forms of sebaceous glands are recognized
• The sebaceous glands on the pink lip, oral mucosa, eyelid margin, areola of nipples, and the vulva and prepuce of the foreskin, are not associated with hair follicles. Acne is unusual to occur in the sebaceous glands in these locations
• The other three types of sebaceous glands are associated with hair follicles, with vellus follicles having tiny downy hairs seen on the cheeks and upper lips. Sebaceous follicles have larger oil glands and slightly larger hairs. Terminal follicles have thick hair, such as seen on the scalp. Acne is less frequently seen in terminal follicles
• Sebaceous gland growth and activity are driven by androgenic hormones produced in the adrenal gland, testis, and ovary. Production of these hormones normally begins at the onset of puberty, which results in Acne presenting most frequently in this age group. Acne occurs when the pilosebaceous glands become clogged with dead cells and oil
• Acne lesions include whiteheads and blackheads (closed and open comedones), pimples (pustules and papules), nodules, and cysts. The comedones, inflamed red spots and yellow spots (papules and pustules), and other lesions appear on the face, neck, shoulders, chest, and other regions. This distribution is explained by the density of pilosebaceous glands being greatest in these locations
• The treatment options are extensive, and treatments are tailored to the variables seen in individual patients. Depending on the severity of the condition, Acne may be treated with both passive and active measures. These include the use of cleansers, topical creams and gels, oral medications, light-based treatments, and many other options
• Acne skin conditions may not be preventable, but the contributing factors, such as cosmetics, inflammation, follicular plugging, and other triggers, which aggravate the condition may be controlled

There are several forms of Acne, and these include:

• Acne Vulgaris
• Acne Cosmetica
• Acne Excoriée
• Neonatal Acne
• Infantile Acne
• Drug-Induced Acne
• Steroid-Induced Acne
• Chloracne
• Acne Agminata
• Acne Conglobata
• Acne Fulminans
• Acne Keloidalis Nuchae
• Acne Scars
• Acne in Pregnancy

Who gets Acne? (Age and Sex Distribution)

• Acne is commonly seen during adolescence. However, newborns, younger children, and adults can also be affected
• The skin condition affects teenage boys and girls equally. Although, Acne in boys is statistically more likely to be severe
• Acne is seen worldwide, and there is no racial or ethnic predilection observed

What are the Risk Factors for Acne? (Predisposing Factors)

Following are the risk factors of Acne:

• Increase in the hormone testosterone and other androgens that takes place during puberty puts adolescents at a high risk for Acne
• The severity of the condition can run in families; and hence, those with parents/siblings having a positive medical history, may develop Acne
• Acne is sometimes associated with hormonal fluctuations, such as menstrual periods, pregnancy, and menopause. Hormonal  disorders such as polycystic ovary syndrome (PCOS)
• Medications containing glucocorticosteroids and androgens can trigger this skin condition
• Applying oily or greasy substances on skin, such as certain cosmetics
• Tight clothes and innerwear, helmets, bags, and even the frequent use of mobile phones, which put constant pressure or cause friction on the skin, are risk factors
• Some rare syndromes with increased inflammatory processes are linked with severe Acne

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Acne? (Etiology)

The roots of the hair (called follicles) are attached to sebaceous glands. These glands secrete oil (sebum) to lubricate the hair shaft and skin surface skin around it. When excess oil mixes with dead skin cells to plug the hair follicles, it leads to the formation of Acne.

• The facial pilosebaceous glands have a tiny, barely detectable hair associated with the oil   (sebaceous) gland complex
• The blocked hair follicles appear as a surface lump (white, black or red, inflamed) or a bulge, in which normal skin bacteria grow in abnormally high numbers.
• If the opening of the oil gland stays small, the accumulation appears as a yellowish, white, or flesh-colored bump termed a whitehead
• If the opening is spread wider than usual, letting the oil contents oxidize and darken, this is termed a blackhead
• If the increased bacteria or other biochemical phenomena trigger inflammation, then redness or pustule formation appears, called papules or pustules
• From deeper sources of inflammation, Acne cysts and nodules appear

The following factors may trigger Acne by increasing the sebum production or have a worsening effect on an individual already with Acne:

• Hormonal changes during puberty
• Certain medications that contain androgens and corticosteroids
• There are some contributions of diet to Acne, but they are generally considered to be of lesser impact. Therefore, if a patient and provider determine a dietary trigger, good compliance with restriction is necessary
• Stress

What are the Signs and Symptoms of Acne?

The signs and symptoms of Acne are as follows:

• The face, neck, chest, back, and shoulders are usual sites of Acne skin lesions
• However, almost all individuals are affected by lesions on the face

The skin lesions are categorized as inflammatory and non-inflammatory:

• Inflammatory lesions are of the following type:
  • Firm red lesions formed in deeper layers of the skin known as cysts
  • Firm or fluctuant lesions on the surface of the skin known as nodules
  • Small raised projections, called papules
  • Pustules or pimples, which are pus-filled tiny  bumps
• Non-inflammatory lesions are of the following type:
  • Whiteheads and blackheads (collectively called comedones) that form when hair follicle openings are clogged with oil, dead cells, and bacteria

Nodules and skin cysts that are deep into the skin may cause scarring of the skin, which may be permanent.

How is Acne Diagnosed?

• Acne is diagnosed through a simple physical examination by a physician or dermatologist
• The healthcare provider may also ask questions related to the individual’s age, family medical history, current medications, cosmetics, body lotions used, other medical conditions, infections, etc.

Other tests and analyses for Acne may include:

• If an infection is suspected, or secondary infections develop, then a bacterial culture may be performed
• In non-adolescent individuals, further medical investigations are often needed to determine the cause of increased testosterone and other androgens. For example, if Acne is caused by polycystic ovary syndrome (PCOS), then an ultrasound of the abdomen looking for ovarian cysts may be performed, and hormonal blood levels analyzed
• Invasive methods, such as a skin biopsy, are typically not required; Acne diagnosis can be made through a physical examination itself
• Skin biopsy would be needed to detect Pityrosporum Folliculitis, also known as Malassezia Folliculitis. This condition is an overgrowth of the Pityrosporum yeast in the sebaceous gland. Pityrosporum organisms are normal oil gland inhabitants. In immunocompromised patients, or in other circumstances, excessive colonization with these yeasts will trigger an actual infection, which can be difficult to differentiate from the many forms of Acne

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Acne?

Some of the complications of Acne include:

• Increased psychological stress, which affects one’s performance at school and college
• Permanent pitting and scarring of the skin on one’s face and neck - cosmetic surgery may be required to remove such scars and marks in some cases
• Side effects of the local/topical (antiseptic or anti-inflammatory) applications and oral medications

How is Acne Treated?

Acne skin condition has several passive and active treatment measures available. All these measures work in different ways to treat any or all of the causative factors such as:

• By regulating the excess oil production
• Through dead skin cell management
• Destroying infectious bacteria, thereby controlling the inflammation
• Blocking the effect of hormones on the pilosebaceous glands

Treatment measures prescribed are dependent upon the severity of the skin condition. These measures are outlined below:

• Gentle soaps and other cleansers remove surface oils and help control Acne. Alpha and beta hydroxy acids (salicylic acid and glycolic acid) help soften the plugs when used as cleansers or peels
• Use of antiseptic, antibiotic topical applications, anti-inflammatory gels, lotions and creams
  • Benzoyl peroxide is the most common topical for milder forms of Acne and topical retinoids are used for opening the hair follicles and decreasing sebum (oil) production
  • Azelaic acid opens plugged sebaceous glands
  • Topical retinoids (tretinoin, tazarotene, and adapalene) help treat Acne by removing the plugs from the follicle openings
• A newly FDA-approved topical medication clascoterone blocks the androgen receptors
• Oral antibiotics are often used in the treatment of Acne, both to decrease the colonization by normal bacteria and because they have an anti-inflammatory effect
• Spironolactone is used as an oral antiandrogen medication in females, particularly in cases of PCOS
• In case of severe Acne, isotretinoin is prescribed (though, NOT for pregnant women). However, there may be some adverse side effects for this drug, and therefore, the patient needs to be closely monitored
• If scarring has developed, many treatment options are available. Before attempting scar treatments, the active Acne must be controlled to avoid the need for additional treatments

Note: Isotretinoin should NOT be used on pregnant women, or on women who are planning to become pregnant. This is very important because isotretinoin can cause fetal abnormalities and malformations during the growth of the fetus in the mother’s womb, termed teratogenic defects of isotretinoin. Hence, a pregnancy test is usually performed in women of childbearing age before starting treatment with isotretinoin.

Taking care of oneself, being clean and hygienic (especially face and hands), avoiding the urge to touch/break the blisters, avoiding oily make-ups and creams, drinking lots of water, etc., are all simple practices that can ensure a faster recovery from Acne.

How can Acne be Prevented?

• Acne occurs due to various medical factors and conditions that come together; it cannot be prevented
• There are factors that either contribute to Acne formation or aggravate the severity of its state/condition - factors that can be controlled have to be recognized in order to achieve an early recovery from Acne
• Heavy cover-up, makeup, constant high humidity, and exposure to aerosolized oils contribute to Acne risk
• Avoid a high glycemic diet: The glycemic index measures the rate of increase in blood glucose levels following a meal. Foods with a high glycemic index include processed carbohydrates, among others. Vegetables, nuts, beans, whole grains, and many fruits have a low glycemic index

What is the Prognosis of Acne? (Outcomes/Resolutions)

Normally, Acne disappears after a period of time, once the adolescence-teenage years pass. In some cases, they are known to be present well into adulthood (even up to the mid-thirties).

• Depending on the severity of the condition, Acne shows a clinical response within 8-12 weeks of suitable and early treatment, leaving no scars in most cases
• Very severe cases of Acne may cause permanent facial marks, deep pits, pigmented scars, etc., if proper treatment is not administered
• Due to its physical appearance, Acne could impose psychological trauma on individuals, especially on teenagers, causing depression and reduced self-esteem

Additional and Relevant Useful Information for Acne:

• There is no evidence to prove that oily foods and chocolate-based products have an influence on Acne
• Cleaning the skin too hard with strong chemicals or soaps may aggravate the skin condition
• The presence of dirt on the body is not a causative factor for Acne; but it helps to be clean and hygienic