Acne Basics: Part 1

Written by Dr. Paul M. Graham

Acne is a chronic inflammatory skin disease that is characterized by the presence of blackheads, whiteheads, papules, pustules, cyst, and nodules that occur on the face, neck, arms, chest, and back. It is primarily a skin disease of adolescence, but can occur at any age. In this week’s article, we will cover the basic science of acne and discuss the various types that exist.

Acne affects approximately 50 million individuals annually in the United States. Additionally, it is estimated that at least 85% of Americans between the ages of 12 to 24  will suffer from some form of acne during their lifetime. Significant psychosocial and physical distress is associated with this common skin condition, but the good news is that it can be treated successfully by dermatologists. Acne often responds well to various topical and oral medication regimens.

Four factors play a role in the development of acne vulgaris

1. Abnormal hair follicle development
   • Clogging of the follicle pores due to an increased “stickiness” of the cells to each other
2. Colonization of Propionibacterium acnes bacteria in the oil glands
   • P. acnes is a bacteria that lives in oil glands
   • This bacteria produces chemicals that break down the sebum (oil) produced by the oil glands
3. Inflammation
   • The breakdown product of the sebum stimulates inflammatory chemicals to be produced causing inflammation
   • Inflammation can be seen on the skin by the presence of redness and swelling
4. Hormone effects on oil gland secretion
   • An elevation in specific hormones causes increased production of sebum from the oil glands
   • This increased sebum continues to feed the P. acnes bacteria, leading to increased inflammation

The most common form of acne is termed acne vulgaris. Interestingly, the latin word “vulgaris” means “common”, thus supporting the high prevalence of this skin condition. Acne vulgaris skin lesions have various appearances, which include blackheads, whiteheads, papules, pustules, cyst and nodules. The face is the most common location for acne, but the neck, chest, and back can be involved.

Blackheads, also known as open comedomes, are very common and seen mostly on the nose, central cheeks, chin, and forehead. Many people believe that blackheads are caused by a dirty face, but this is not the case. The black substance seen in the pores is actually a collection of dead skin cells from within the follicle. The main reason these skin lesions appear black is because of a chemical reaction that occurs when the clogged poor is exposed to oxygen.

Whiteheads/Papules/Pustules, also known as closed comedomes, are what most people associate with acne vulgaris. They are often red in appearance and elevated above the surface of the skin. These lesions typically occur when the pore opening does not allow the extrusion of dead skin cells from the follicle/pore. Oftentimes, people think that squeezing or popping these skin lesions will result in quicker resolution. This is largely inaccurate and in most cases may actually make it worse. Anytime aggressive pressure is placed around whiteheads, this may cause rupture of the follicular wall, allowing extrusion of the foreign material to enter the surrounding skin. This may cause the formation of a severely inflamed cyst. It is highly recommended to refrain from squeezing or popping of any acne skin lesions as this most likely will make it worse and result in long-lasting redness or pigmentation of the skin.

Cyst/Nodules are the least common of all acne vulgaris skin lesions, but are the most destructive and distressing to individuals. As mentioned previously, cysts may form from manipulation of whiteheads or develop spontaneously. Cystic acne is a common cause of facial scarring. It is imperative to see a dermatologist immediately if you suspect you have cystic acne as various successful treatment options currently exist.

There are many types of acne that exist and each type is dependent on a variety of factors such as age, genetics, hormones, environmental stimuli, medications, and health status.

• Neonatal acne:  Occurs around 2 weeks to 3 months of age
• Infantile acne:  Begins around 3-6 months and resolves within 1-2 years
• Mechanical acne:  Occurs secondary to repeated friction or pressure (ex. football helmets or sweaty clothing)
• Medication-induced acne:  Rapid-onset acne after starting certain medications (ex. prednisone, anabolic steroids)
• Industrial acne: Occurs after exposure to certain oils and chemicals (common in factory workers)
• Secondary acne from underlying disease:  Occurs with various underlying systemic diseases (ex. PCOS, ovarian cancer)
• Acne excoriée:  Occurs from repetitive skin picking and squeezing
• Acne conglobata:  Rapid-onset cystic acne
• Acne fulminans:  Severe cystic acne with systemic symptoms (ex. fever, bone pain)

Acne is an extremely common skin disorder affecting millions of individuals each year. This skin disorder is easily treated, if not curable, by dermatologists worldwide. If you or someone you know is suffering from acne, schedule an appointment with your dermatologist today. Acne treatment is generally successful when in the hands of persistent and motivated individuals. Although acne treatment may be prolonged, clear , smooth, acne-free skin is always worth the time and effort.

In our next article, we will cover the basics of acne skin care and discuss the various treatment options currently available. Stay tuned!

Photo Credit: Rosaceatreatment.org; Natrasanuk.com; Proactiv.com; Befittoo.com

References:

1. https://www.aad.org/media/stats/conditions
2. James, William D, Dirk M. Elston, Timothy G. Berger, and George C. Andrews. Andrews’ Diseases of the Skin: Clinical Dermatology. London: Saunders/ Elsevier, 2011. Print.
3. Bolognia, Jean, Joseph L. Jorizzo, and Julie V. Schaffer. Dermatology. Philadelphia: Elsevier Saunders, 2012. Print.

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