Acne: Overview of the Problem and Introduction to Treatment Options

by

Michael H. Berkson, M.D.

This is the first in a series of eleven short articles that I wrote on the subject of acne, which is a widespread problem that affects millions of people including pre teens, teenagers, and adults.  The purpose of these articles is to help people who suffer from acne better understand their condition and the treatments that are available to manage it.  This series brings together more than 25 years of experience as a practicing dermatologist, during which time I have had the privilege of helping guide thousands of acne patients to clearer skin.  I hope that you enjoy reading these articles and find the content helpful.

–Dr. Mike-

Acne is a vexing problem that affects most people at some point during their lives, often starting in the preteen and teen years and sometimes continuing into the early 20’s.

It may come as a surprise to some that acne is also common in adults. Approximately 20-30% of women experience acne in their mid 20’s 30’s and 40’s. A significant number of adult men in similar age groups also have acne.  Adult acne is a continuation of teenage acne in about 75% of people affected, or it can start for the first time when people are in their mid 20’s or beyond.

Although not life threatening, acne can profoundly threaten the quality of life of those who suffer from it.  It often leaves physical and psychological scars that can impact self image and self esteem, and negatively affect day to day functioning at work, school and in social settings. People who have acne are more prone to anxiety and depression, and have been shown to be viewed with a negative bias during job interviews.  For these reasons, aggressive treatment should be sought early on.

Fortunately, with proper management, those with acne can enjoy a happy and productive life, unencumbered by the negative appearance and stigma that can accompany the condition when left untreated.

Acne is a complicated condition for which there is no single cause.  A combination of mostly internal factors set the stage for the development of acne.  The anatomical site of acne is the pilosebaceous follicle which is a large hair follicle that grows an imperceptible hair, and is connected to a sebaceous ( oil ) gland.  Pilosebaceous follicles are found in greatest numbers on the face, neck, and trunk, which are the same areas where acne usually occurs.

There are 4 main internal factors that contribute to the formation of acne:

Sebum:  Sebum is the oil produced by the sebaceous gland that is secreted into the sebaceous follicle and helps protect the skin against water loss.  Sebum production starts before puberty under the influence of androgen hormones from the adrenal glands.

Comedogenesis:  Comedogenesis is a process in which a build up of epithelial cells that line the sebaceous follicle cause a plugging effect that can lead to dilation of the follicle and subsequent swelling and the formation of a structure which is known as a comedone. When they first form, comedones are microscopic  When they enlarge and become visible, comedones are referred to as closed and open comedones, also known as whiteheads and blackheads.

Bacteria:   Cutibacterium acnes -C. acnes- is a type of bacteria which normally lives in the sebaceous follicle and grows to large numbers as sebum secretion increases and comedogenesis ensues.  These bacteria  promote inflammation as well as more comedogenesis, setting up sort of a vicious cycle.

 Inflammation:  Inflammation is a very complex process which is in part triggered and perpetuated by the P. acnes bacteria and carried out by the body’s white blood cells and other arms of the immune response.  This results in the inflammatory lesions of acne (“pimples”) technically referred to as papules, pustules, and nodules, which are sometimes incorrectly labeled as cysts.

Acne can present on the skin in many different ways.  Closed and open comedones predominate and are most abundant in early acne. As the condition progresses, inflammatory papules and pustules become evident. Eventually deep seated inflammatory nodules – “cysts”- may appear. These can sometimes lead to scarring.

Although the internal factors previously discussed, over which one has little control, are mainly at play, certain external factors may aggravate or influence the severity of acne in some individuals. These include over aggressive attempts to cleanse the skin, picking at or attempting to “pop” the pimples, and certain skin care products and regimens. Other factors such as stress and over-consumption of sugars and dairy products can worsen acne in some, but not all people.  Finally, genetics can play a significant role in determining the course and severity of acne in any given individual. Severe acne, in particular, tends to run in families.

Although acne is a chronic condition that can go on for an indefinite period of time, there is much that can be done to effectively treat it and greatly improve one’s complexion and outlook. Early intervention is key to reducing the chance of complications such as scarring.

There are a variety of over the counter treatments such as benzoyl peroxide and adapalene ( Differin Gel)  that can be very helpful in early and milder forms of acne.

For more moderate acne that consists of inflammatory papules and pustules, seeking the advice of a medical practitioner who is well versed in the management of acne offers the best chance of yielding good results.  In cases of more severe acne, including the nodular -“cystic”- variant, care from a dermatologist is highly recommended to aggressively control the inflammation and try to prevent or limit scarring.

A variety of effective prescription medications are available to treat acne. Topical preparations such as tretinoin ( Retin-A) and benzoyl peroxide, either alone or combined with the topical antibiotic clindamycin( Benzaclin) or adapalene (Epiduo/Epiduo Forte) can be very helpful for mild to moderate acne.

The oral antibiotics doxycycline and minocycline, especially when used with benzoyl peroxide are useful for more moderate to severe breakouts.

The birth control pill and spironolactone help to modulate the hormonal influence that can trigger acne in women and are thus very useful alternatives to antibiotics for many women.

Isotretinoin, formerly sold under the brand name Accutane, is a very potent oral medication that can result in dramatic, sustained improvement in those with more severe nodular acne.

There are a variety of procedures such as the use of intralesional cortisone injections, “acne surgery”/extractions, chemical peels, and in some cases lasers and light, which can complement the above mentioned medical treatments.

The bottom line is that although acne is a complex and chronic condition, it can be effectively managed in practically all who suffer from it.

The next two articles will discuss in more detail what is going on in acne at the microscopic level as well as what one sees on the skin

References:

Acne vulgaris: pathogenesis, treatment, and needs assessment.  Knutsen-Larson S, Dawson AL, Dunnick CA, Dellavalle RP.  Dermatol Clin. 2012 Jan;30(1):99-106.

Quality-of-Life Research in Acne Vulgaris: Current Status and Future Directions.  Marron SE, Chernyshov PV, Tomas-Aragones L.  Am J Clin Dermatol. 2019 Apr 4.

Acne vulgaris.  Williams HC, Dellavalle RP, Garner S.  Lancet. 2012 Jan 28;379(9813):361-72.

The prevalence of acne in adults 20 years and older.  Collier CN, Harper JC, Cafardi, JA, et al.  J Am Acad Dermatol 2008; 58(1):  56-59.

Recent advances in acne pathogenesis:  Implications for therapy.  Das S, Reynolds RV.  Am J Clin Dermatol. 2014 Dec;15(6):479-88

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