WHAT CAUSES ACNE?

The exact cause of acne is unknown, but doctors believe it results from several related factors. One important factor is an increase in hormones called androgens (male sex hormones). These increase in both boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum. Hormonal changes related to pregnancy or starting or stopping birth control pills can also cause acne.

Another factor is heredity or genetics. Researchers believe that the tendency to develop acne can be inherited from parents. For example, studies have shown that many school-age boys with acne have a family history of the disorder. Certain drugs, including androgens and lithium, are known to cause acne. Greasy cosmetics may alter the cells of the follicles and make them stick together, producing a plug.

TREATING SEVERE ACNE

Severe acne is characterized by deep cysts, inflammation, extensive damage to the skin and scarring. It requires an aggressive treatment regimen and should be treated by a dermatologist. Severe, disfiguring forms of acne can require years of treatment and may experience one or more treatment failures. However, almost every case of acne can be successfully treated. 

Physical methods and prescription medications that dermatologists use to treat severe acne include:  
Drainage and Surgical Excision
Some large cysts do not respond to medication and may require drainage and extraction. Drainage and extraction, or “acne surgery” as it is also called, should not be performed by patients. Dermatologists are trained in the proper technique and perform acne surgery under sterile conditions. Patient attempts to drain and extract comedones by squeezing or picking, can lead to infection, worsening of the acne and scarring.  
 

Interlesional Corticosteroid Injection
When an acne cyst becomes severely inflamed, there is a good chance it will rupture and scarring may result. To treat these severely inflamed cysts and prevent scarring, dermatologists may inject such cysts with a much-diluted corticosteroid. This lessens the inflammation
and promotes healing. An interlesional corticosteroid injection works by "melting" the cyst over a period of
3 to 5 days.

  

Isotretinoin
Isotretinoin is a potent drug reserved for treating severe cystic acne and acne that has proven itself resistant to other medications. Isotretinoin is a synthetic (man-made) retinoid (form of vitamin A) that comes in pill form. It is usually taken once or twice a day for 16 to 20 weeks.

Today, it is the most effective acne treatment available because it is the only acne treatment that works on all four factors that predispose a person to acne - excess oil production, clogged skin pores, P.acnes and inflammation. The remissions achieved with isotretinoin usually last for many months to many years. For many patients, only one course of isotretinoin therapy is needed. 

While isotretinoin is the most effective acne treatment available, it cannot be prescribed to everyone due to a number of potential side effects—some serious. One of the most serious side effects is the potential to cause severe birth defects in a developing fetus. For this reason, the U.S. Food and Drug Administration (FDA) requires that women not be (or become) pregnant while taking isotretinoin. FDA regulations require women of childbearing age to take 2 pregnancy tests prior to beginning isotretinoin therapy and use 2 forms of birth control for 1 month before therapy begins, while taking the drug and for 1 full month after therapy. It is also important that women not breast feed during this time. Women who wish to become pregnant after taking isotretinoin should talk to their dermatologist and gynecologist about when it is safe to get pregnant after receiving isotretinoin therapy.

Other possible severe side effects that may occur while taking isotretinoin include:

• Severe pain in the chest or abdomen
• Trouble swallowing or painful swallowing
• Severe headache, blurred vision or dizziness
• Bone and joint pain
• Nausea or vomiting
• Diarrhea or rectal bleeding
• Depression
• Dryness of the skin, eyes and nose
• Thinning hair

If any side effect occurs, the patient’s dermatologist or other healthcare practitioner should be contacted immediately because some of these side effects can lead to serious health problems.

While taking isotretinoin, patients are regularly monitored for side effects through follow-up visits. For most people, these side effects are tolerable and not a reason to discontinue therapy before remission is achieved. However, it is important to keep appointments for follow-up visits because monitoring can reveal conditions that a patient might not notice. For example, a patient may not realize a rapid increase in bad cholesterol that is detected through a blood test.

The decision to use isotretinoin should be made jointly by patient and dermatologist. When used with all due caution under close medical supervision, isotretinoin can resolve severe acne that has not responded to other therapy. It has proven especially effective in resolving cystic acne, a severe form of acne that usually does not respond to other therapies.

For a substantial number of patients, one course of isotretinoin therapy is all they will ever need. A small number of patients require more than one course of isotretinoin therapy to control severe acne.

It is important to take isotretinoin as prescribed—even if the skin clears before all of the pills have been taken—to prevent relapse. At the end of an effective course of isotretinoin therapy, all or most of the acne lesion will have cleared. Patients may notice residual erythematous (reddish) macules (flat spots) where acne lesions were present. These macules are not scars, and they will fade in 6 to 8 weeks.

Oral Antibiotics
Oral antibiotics have been a mainstay of therapy for severe acne for many years. Like topical antibiotics, oral antibiotics work to reduce the P. acnes population (a contributing factor in acne), which, in turn, decreases inflammation. Treatment with oral antibiotics usually begins with a high dosage, which is reduced as the acne resolves. Over time, the P. acnes bacteria can become resistant to the antibiotic being used to treat it. When this happens, another antibiotic can be prescribed. Numerous studies support the effectiveness of the following broad-spectrum oral antibiotics that are used to treat acne in the United States: doxycline, erythromycin, minocycline and tetracycline.

Oral Contraceptives
Oral contraceptives have been shown to effectively clear acne in women by suppressing the overactive sebaceous glands. Oral contraceptives can be used as long-term acne therapy; however, this medication should not be prescribed to women who smoke, have a blood-clotting disorder, are older than 35 or have a history of migraine headaches—without the advice of a gynecologist.

Spironolactone, a synthetic steroid, may be used in combination with oral contraceptives to treat acne in adult females. Spironolactone inhibits androgen production. Side effects include irregular menstruation, breast tenderness, headache and fatigue.

TREATING MODERATE ACNE

Prescription acne treatments are often needed to treat moderate acne. As acne progresses from mild to moderate, blackheads and whiteheads become more numerous. The frequency of papules and pustules also increases. With moderate acne, breakouts will be more obvious, and there will be slight inflammation apparent on the skin. Often, those with moderate acne will start noticing breakout activity on areas other than the face.
Some cases of moderate acne can be treated with over-the-counter products containing benzoyl peroxide, sulfur, and/or salicylic acid. However, if visible improvement of the skin is not seen in six to eight weeks of home treatment, it is time to see a dermatologist. Your doctor will be able to prescribe medications that will effectively treat your acne.

Azelaic Acid

Azelaic acid is a prescription cream or gel for mild to moderate acne. It is believed that azelaic acid works by reducing  the bacteria responsible for acne breakouts. It also helps normalize shedding of dead skin cells, and decreases inflammation. Azelaic acid has the added benefit of improving PIH(post inflamatory hyperpigmentation), the discoloration left after an acne lesion has healed. Azelaic acid is sold under the brand names:

• Azelex
• Finacea

Topical Retinoids

Retinoids are popular and effective acne treatments, derived from synthetic vitamin A.Topical retinoids rapidly exfoliate the skin, thereby keeping pores unclogged and preventing comedones. Retinoids adapalene, tazarotene, and tretinoin are prescribed for those with moderate to severe acne. Retinoids, especially tretinoin, have other advantages. It is often used to reduce the look of fine lines and wrinkles, making it a popular treatment choice for adult onset acne sufferers.

TOPICAL ANTIBIOTICS

Topical antibiotics improve acne by inhibiting the growth of bacteria. They may also help reduce inflammation and decrease the amount of blocked pores, depending on the form used. Topical antibiotics are most often prescribed to treat moderate to severe acne.

TREATMENT FOR MILD ACNE

Mild acne consists of small lesions, such as blackheads, whiteheads or pustules, which appear at or near the surface of the skin. As such, mild cases of acne can sometimes be controlled at home by:

• Gently washing the affected area(s) with warm water and a mild soap twice a day to remove dead skin cells and excess oil.
•   Using a topical (applied to the skin) over-the-counter acne treatment containing benzoyl peroxide or salicylic acid.
  At-home treatment requires 4-8 weeks to see improvement. Once acne clears, treatment must be continued to prevent new lesions from forming.
  Even mild cases of acne may require the help of a dermatologist. If the acne does not respond to at-home treatment, a dermatologist can assess the situation and determine an appropriate therapy. In these cases, combination therapy (two or more treatments) may be used. Combination therapy may include use of a prescription topical antimicrobial or topical retinoid. These prescription topicals can be very effective in clearing mild acne. 
  

Types of acne

There are many variations of acne, ranging in severity from mild to severe.

Mild to moderate acne:

WHITEHEADS:
When the trapped sebum and bacteria stay below the skin surface, a whitehead is formed. Whiteheads may show up as tiny white spots, or they may be so small that they are invisible to the naked eye.

BLACKHEADS:

A blackhead occurs when the pore opens to the surface, and the sebum, which contains the skin pigment melanin, oxidizes and turns a brown/black color. It is not dirt and can not be washed away. Blackheads can last for a long time because the contents very slowly drain to the surface

PAPULES:

A papule occurs when there is a break in the follicular wall. White blood cells rush in and the pore becomes inflamed.

PUSTULES:

A pustule forms several days later when white blood cells make their way to the surface of the skin. This is what people usually refer to as a "zit" or a "pimple".

NODULES:

When a follicle breaks along the bottom, total collapse can occur, causing a large, inflamed bump that can be sore to the touch.

CYSTS:

Sometimes a severe inflammatory reaction can result in very large pus filled lesions.

MILIA :

Milia are tiny white bumps that occur when normally sloughed skin cells get trapped in small pockets on the surface of the skin. Milia is common in newborns across the nose and upper cheeks and can also be seen on adult skin. The bumps disappear as the surface is worn away and the dead skin is sloughed. In newborns, the bumps usually disappear within the first few weeks of life. However, for adults milia may persist indefinitely.

WHAT is acne?

All acne is a disorder of the pilosebaceous unit, which is made of a hair follicle, sebaceous gland, and a hair. These units are found everywhere on the body except on the palms, soles, top of the feet, and the lower lip. The number of pilosebaceous units is greatest on the face, upper neck, and chest.
Sebaceous glands produce a substance called sebum, which is responsible for keeping the skin and hair moisturized. During adolescence, sebaceous glands enlarge and produce more sebum under the influence of hormones, also called androgens. After about age 20, sebum production begins to decrease.
Sebum produced by the sebaceous gland combines with cells being sloughed off within the hair follicle and "fills up" the hair follicle. When the follicle is "full," the sebum spreads over the skin surface, giving it an oily appearance. When this process works correctly, the skin is moisturized and remains healthy.
Several factors contribute to the start of an acne lesion:

• Corneocytes, or skin cells, become more "sticky" as they are shed and accumulate in the pore instead of flowing out onto the skin.
• More skin cells are shed at the top of the pore than the bottom.
• Sebum production is increased.