Acne. A single word that makes the entire teenage population cringe and scratch their faces at the mere thought of it. No one likes those nasty little blobs popping up on their faces and whenever they do, they take serious hits at our self-esteem and we rush to do all that we can to get rid of them. Imagine if those rarely occurring events that you detest so much became more frequent or worse yet, routine. That is how bad some people have it and for those who suffer from clinical acne, life is not that easy.
Acne is a skin condition that occurs when your hair follicles become plugged with oil and dead skin cells. It often causes whiteheads, blackheads or pimples, and usually appears on the face, forehead, chest, upper back and shoulders. Acne is most common among teenagers, though it affects people of all ages. Acne typically appears on these areas of skin because they have the greatest density of oil (sebaceous) glands. Hair follicles are connected to oil glands. The follicle wall may bulge and produce a whitehead. Or the plug may be open to the surface and darken, causing a blackhead. A blackhead may look like dirt stuck in pores. But actually, the pore is congested with bacteria and oil, which turns brown when it’s exposed to the air. Pimples are raised red spots with a white center that develop when blocked hair follicles become inflamed or infected with bacteria. Blockages and inflammation that develop deep inside hair follicles produce cyst-like lumps beneath the surface of your skin. Other pores in your skin, which are the openings of the sweat glands, aren’t usually involved in acne.
There are different gradations for acne which then determine their mode of treatment. Mild acne is classically defined by the presence of clogged skin follicles (known as comedones) limited to the face with occasional inflammatory lesions. Moderately severe acne is said to occur when a higher number of inflammatory papules and pustules occur on the face as compared to mild cases of acne and are found on the trunk of the body. Severe acne is said to occur when nodules (the painful ‘bumps’ lying under the skin) are the characteristic facial lesions and involvement of the trunk is extensive.
There are quite a few factors that account for causing acne which are delineated below:
i) Genetics: The predisposition to acne for specific individuals is likely explained by a genetic component, a theory which is supported by studies examining the rates of acne among twins and first-degree relatives. Severe acne may be associated with the XYY syndrome. Acne susceptibility is likely due to the influence of multiple genes, as the disease does not follow a Mendelian inheritance pattern. This cements the idea that genetics have an audible say in how vulnerable a person is to acne.
ii) Hormones: Hormonal activity, especially the one that occurs during menstrual cycles and puberty, may contribute to the onset or worsening of acne. During puberty, an increase in sex hormones called androgens causes the skin follicle glands to grow larger and secrete more oily sebum. Several hormones have been linked to acne, including the androgens testosterone, dihydrotestosterone (DHT), and dehydroepiandrosterone (DHEA); high levels of growth hormone (GH) and insulin-like growth factor 1 (IGF-1) have also been associated with worsened acne. Both androgens and IGF-1 seem to be essential for acne to occur, as acne does not develop in individuals with complete androgen insensitivity syndrome (CAIS) or Laron syndrome (insensitivity to GH, resulting in very low IGF-1 levels). Medical conditions that commonly cause a high-androgen state, such as polycystic ovary syndrome, congenital adrenal hyperplasia, and androgen-secreting tumors, can lead to the onset of severe acne in affected individuals. Conversely, people who lack androgenic hormones or are insensitive to the effects of androgens rarely have acne. An increase in androgen and oily sebum synthesis may be seen during pregnancy which can lead to acne whilst one is pregnant.
iii) Stress: Few high-quality studies have been performed which demonstrate that stress causes or worsens acne. While the connection between acne and stress has been debated over, recent research indicates that increased severity is associated with high stress levels in certain contexts such as hormonal changes seen in premenstrual syndrome so there is a fair correlation.
iv) Diet: The relationship between diet and acne is ambiguous to say the least, as there is no high-quality evidence that establishes any definitive link between them. High-glycemic-load diets have been found to have different degrees of effect on acne severity. Multiple randomized controlled trials and non-randomized studies have found a lower-glycemic-load diet to be effective in reducing acne. There is weak observational evidence suggesting that dairy milk consumption is positively associated with a higher frequency and severity of acne. Milk contains whey protein and hormones such as bovine IGF-1 and precursors of dihydrotestosterone. These components are hypothesized to promote the effects of insulin and IGF-1 and thereby increase the production of androgen hormones, sebum, and promote the formation of comedones. Available evidence does not support a link between eating chocolate or salt and acne severity. Chocolate does contain varying amounts of sugar, which can lead to a high glycemic load, and it can be made with or without milk. Few studies have examined the relationship between obesity and acne. Vitamin B12 may trigger skin outbreaks similar to acne (acneiform eruptions), or worsen existing acne, when taken in doses exceeding the recommended daily intake. Scientifically speaking, eating greasy foods does not increase acne nor make it worse.
v) Medication: Several medications can markedly worsen pre-existing acne, with examples being lithium, hydantoin, isoniazid, glucocorticoids, iodides, bromides, and testosterone.
Since we now know about the causes of acne, it would be wise to be familiar with its cures as well. Acne medications work by reducing oil production, speeding up skin cell turnover, fighting bacterial infection or reducing inflammation which helps prevent scarring. With most prescription acne drugs, you may not see results for four to eight weeks, and your skin may get worse before it gets better. It can take many months or years for your acne to clear up completely. The treatment regimen your doctor recommends depends on your age, the type and severity of your acne, and what you are willing to commit to. For example, you may need to wash and apply medications to the affected skin twice a day for several weeks. Often topical medications and drugs you take by mouth (oral medication) are used in combination. Pregnant women will not be able to use oral prescription medications for acne. Common topical medication is listed below:
i) Retinoids and Retinoid-like drugs: These come as creams, gels and lotions. Retinoid drugs are derived from vitamin A and include tretinoin, adapalene and tazarotene. You apply this medication in the evening, beginning with three times a week, then daily as your skin becomes used to it. It works by preventing plugging of the hair follicles.
ii) Antibiotics: These work by killing excess skin bacteria and reducing redness. For the first few months of treatment, you may use both a retinoid and an antibiotic, with the antibiotic applied in the morning and the retinoid in the evening. The antibiotics are often combined with benzoyl peroxide to reduce the likelihood of developing antibiotic resistance. Examples include clindamycin with benzoyl peroxide and erythromycin with benzoyl peroxide. Topical antibiotics alone aren’t recommended.
iii) Dapsone: Dapsone 5 percent gel twice daily is recommended for inflammatory acne, especially in adult females with acne. Side effects include redness and dryness.
iv) Salicylic acid & Azelaic Acid: Azelaic acid is a naturally occurring acid found in whole-grain cereals and animal products. It has antibacterial properties. A 20 percent azelaic acid cream seems to be as effective as many conventional acne treatments when used twice a day for at least four weeks. It’s even more effective when used in combination with erythromycin. Prescription azelaic acid is an option during pregnancy and while breast-feeding. Side effects include skin discoloration and minor skin irritation.
If the acne is more severe and conventional medication fails to be effective, surgical procedures are resorted to. These procedures aren’t the first line of defense against acne. Rather, they’re used to treat stubborn breakouts that aren’t improving with other treatments. In most cases, acne treatment medication is needed to supplement the acne surgery procedure. The more common of the surgical procedures are as follows:
i) Blemish Excision: Some blemishes are extra stubborn and don’t want to respond to the medications your doctor has prescribed. In this case, your dermatologist may decide that blemish excision will be helpful. Excision is probably what most people imagine when they think “acne surgery.” A small incision is made in the skin, and the dermatologist drains the pus and debris from the blemish. You’re awake the entire time. The doctor may use a numbing agent to help dull the sensations in that area and keep you comfortable during the procedure. Ideally, after the pus and comedonal core is cleared, the blemish begins to heal. The procedure itself may cause a slight scar, so you’ll have to decide with your doctor if this is the right treatment for you.
ii) Blemish Extraction: Blemish extractions are used to remove non-inflamed blemishes like blackheads and milia. Extractions can also be used to drain small, surface pustules. Unlike blemish excision, this procedure doesn’t have to be done in a medical setting. An esthetician can take care of extractions for you at your local salon or day spa. Extractions are relatively painless, so you don’t need any type of numbing agent or anesthetic. Excision and extractions don’t stop new breakouts from forming, though. They only work on existing blemishes. You’ll still need to use an acne treatment medication to get breakouts under control. These procedures are best left to the medical professionals. Don’t ever try to lance and drain any blemish, tiny or not. You open yourself up to infection and could easily scar your skin.
iii) Laser Surgery: There are many different types of laser treatments. They type that is best for you depends on many factors, like your skin type and color, and what your ultimate goal is. During a laser treatment, a high-intensity pulse of light is directed onto the skin. Depending on the treatment used, a laser can reduce inflammation and acne-causing bacteria, help existing pimples heal, and stimulate the skin to rejuvenate itself. Lasers are used to treat both acne and acne scars. Some lasers need only one treatment to do the job, while others require a few treatments. Laser treatments are expensive and generally aren’t covered by insurance.
iv) Chemical Surgery: Superficial peels are best for treating mild acne. There are different types of chemical peels, too. Your dermatologist will help you decide which is best for your skin. All peel procedures are basically the same, though. A chemical agent is applied to the skin and left for a period of time. The chemical removes the surface of the skin, triggering a remodeling process. Over the next several days to weeks, your skin will flake or “peel” off, allowing the renewed skin to come to the surface. Just like laser treatments, chemical peels can be used to treat both acne and scarring.
Fortunately, in a developing country like Pakistan, these facilities are available and can be opted by people suffering from such afflictions. Acne is a major problem in the Pakistani youth and if left untreated, can not only lead to physical scarring but a huge deal of psychological damage as well. Notable issues include damaged self-esteem, clinical depression and even suicidal thoughts in extreme cases. Metropolitan cities like Lahore, Islamabad and Karachi have medical centres ready to dispense such services to those seeking.