Difference between revisions of "Acne" - New World Encyclopedia

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'''Acne''' is a group of skin rashes that have different causes.
 
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* [[#Acne vulgaris|Acne vulgaris]] - most commonly experienced around puberty, typically of the face and shoulders/chest
 
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* [[#Rosacea|Acne rosacea]] - a red rash predominantly on the face
 
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* [[#Pseudofolliculitis barbae|Acne keloidalis nuchae]] (Pseudofolliculitis nuchae) - a rash caused by shaving
 
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* [[#Hidradenitis suppurativa|Acne conglobata]] (Hidradenitis suppurativa) - chronic [[abscess]]es or [[boil]]s of [[sweat glands]] and hair follicles; in the underarms, groin and buttocks, and under the breasts in women
 
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* [[#Acne cosmetica|Acne cosmetica]] - acne caused by cosmetics
 
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* [[#Acne fulminans|Acne fulminans]] - an extreme form of acne conglobata
 
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* [[#Acne medicamentosa|Acne medicamentosa]] - acne caused by starting or stopping a medicine
 
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* [[#Baby acne|Baby acne]] - a rash seen on the cheeks, chin, and forehead of [[infant|infants]]
 
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* [[#Chloracne|Chloracne]] - an acne rash caused by exposure to chlorinated hydrocarbons such as [[dioxins]] or [[PCB]]s
 
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==Acne vulgaris==
 
 
{{DiseaseDisorder infobox |
 
{{DiseaseDisorder infobox |
 
   Name        = Acne |
 
   Name        = Acne |
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   Caption    = Acne of a 14 year old boy during [[puberty]] |
 
   Caption    = Acne of a 14 year old boy during [[puberty]] |
 
   DiseasesDB  = 10765|
 
   DiseasesDB  = 10765|
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  ICDO        = |
 
   ICD10      = {{ICD10|L|70|0|l|60}} |
 
   ICD10      = {{ICD10|L|70|0|l|60}} |
 
   ICD9        = {{ICD9|706.1}} |
 
   ICD9        = {{ICD9|706.1}} |
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  OMIM        = | 
 
   eMedicineSubj  = derm |
 
   eMedicineSubj  = derm |
 
   eMedicineTopic = 2 |
 
   eMedicineTopic = 2 |
 
   MedlinePlus    = 000873|
 
   MedlinePlus    = 000873|
 
}}
 
}}
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[[Image:AcneVulgarisUSMIL.jpg|thumb|200px|right|Different types of Acne Vulgaris: A: Cystic acne on the face, B: Subsiding tropical acne of trunk, C: Extensive acne on chest and shoulders.]]
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'''Acne''' is a group of skin rashes that have different causes but present with similar lesions. It is a condition that affects [[human]]s as well as some [[mammal]]s, and being the most common skin disease, it is considered by some as a part of the normal human growth process. It varies in its etiology, as well as its severity. Occasionally a direct cause may be identified, while commonly no inciting agent is ever seen. Acne is an important and sometimes overlooked state, which if left untreated could lead to a lifetime of disease sequelae, such as scarring and skin hyperpigmentation. Some forms have been associated with even more severe acute manifestations that require emergent therapy.  
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'''Acne vulgaris''' is an inflammatory disease of the [[skin]], caused by changes in the pilosebaceous units (skin structures consisting of a hair follicle and its associated sebaceous [[gland]]). Acne lesions are commonly referred to as pimples, spots or zits.
 
  
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Acne affects a large percentage of humans at some stage in life.
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Some forms of acne include: 
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The condition is most common during puberty and is considered an abnormal response to normal levels of the male [[hormone]] testosterone. The response for most people diminishes over time and acne thus tends to disappear, or at least decrease, after one reaches his or her early twenties. However, there is no way to predict how long it will take for it to disappear entirely, as some individuals will continue to suffer from acne decades later into their thirties, forties,and beyond. {{Fact|date=March 2007}}
 
  
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===Symptoms===
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* [[#Acne vulgaris|Acne vulgaris]] - most commonly experienced around puberty, typically of the face and shoulders/chest
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[[Image:Acne_face.jpg|thumb|200px|left|Acne of an older teenager.]]
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* [[#Acne rosacea|Acne rosacea]] - a red rash predominantly on the face
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The most common form of acne is known as "acne vulgaris." Excessive secretion of oils from the sebaceous glands, accompanied by the plugging of the pores with naturally occurring dead skin cells (corneocytes), results in a blockade of the [[hair follicle]]s. The accumulation of these corneocytes in the duct appears to be due to a failure of the normal keratinization process in the skin which usually leads to shedding of skin cells lining the pores. Once blocked, the oil build up provides a favorable environment for the bacteria
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* [[#Acne keloidalis nuchae|Acne keloidalis nuchae]] - a rash caused by shaving particularly on the nape of the neck
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''Propionibacterium acnes'' and the lipophilic (oil/lipid-loving) yeast [[Malassezia]]{{Fact|date=February 2007}} to multiply uncontrollably. In response to the bacterial and yeast populations, the skin inflames, producing the visible lesion. The lesions have a propensity to affect the face, chest, back, shoulders and upper arms.
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* [[#Acne conglobata|Acne conglobata]] - chronic form of inflammatory acne marked by communicating blackheads, communicating cysts, abscesses, papules, pustules, and draining sinus tracts
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The lesions occur as various forms and include: comedones, papules, pustules, nodules, and inflammatory [[cysts]]. These are the more inflamed form of pus-filled or reddish bumps, even boil-like tender swellings. Non-inflamed 'sebaceous cysts', more properly called epidermoid cysts, occur either in association with acne or alone but are not a constant feature.  After resolution of acne lesions, prominent unsightly scars may remain.
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* [[#Acne fulminans|Acne fulminans]] - an extreme form of acne conglobata
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Aside from scarring, its main effects are psychological, such as reduced self-esteem <ref name="Goodman">{{cite journal |author=Goodman G |title=Acne and acne scarring - the case for active and early intervention |journal=Aust Fam Physician |volume=35 |issue=7 |pages=503-4 |year=2006 |id=PMID 16820822 | url=http://www.racgp.org.au/Content/NavigationMenu/Publications/AustralianFamilyPhys/2006issues/afp200607/20060705goodman.pdf | format=PDF}}</ref> and [[clinical depression|depression]] or [[suicide]].<ref>{{cite journal |author=Purvis D, Robinson E, Merry S, Watson P |title=Acne, anxiety, depression and suicide in teenagers: a cross-sectional survey of New Zealand secondary school students |journal=J Paediatr Child Health |volume=42 |issue=12 |pages=793-6 |year=2006 |id=PMID 17096715}}<br>One study has estimated the incidence of suicidal ideation in patients with acne as 7.1% :</br>* {{cite journal |author=Picardi A, Mazzotti E, Pasquini P |title=Prevalence and correlates of suicidal ideation among patients with skin disease |journal=J Am Acad Dermatol |volume=54 |issue=3 |pages=420-6 |year=2006 |id=PMID 16488292}}</ref> Acne usually appears during [[adolescence]], when people already tend to be most socially insecure. Early and aggressive treatment is therefore advocated to lessen the overall impact to individuals.<ref name="Goodman"/>
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* [[#Acne cosmetica|Acne cosmetica]] - acne caused by cosmetics
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* [[#Acne medicamentosa|Acne medicamentosa]] - acne caused by starting or stopping a medicine
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* [[#Acne neonatorum|Baby acne]] - a rash seen on the cheeks, chin, and forehead of infants
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* [[#Chloracne|Chloracne]] - an acne rash caused by exposure to chlorinated hydrocarbons such as dioxins or PCBs
  
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===Causes of acne===
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When used generically, the term "acne" refers to acne vulgaris. Even though broadly stated under the category of acne, the various conditions stated above are separate [[disease]] entities. However, they present with similar lesions.   
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Exactly why some people get acne and some do not is not fully known. It is known to be partly hereditary. Several factors are known to be linked to acne:
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{{toc}}
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While acne has a variety of causes, and rarely is a direct cause identified, in some cases it is clearly tied to human social responsibility, such as the cases of acne resulting from cosmetics or chlorinated hydrocarbons. Furthermore, individuals have an individual responsibility for treatment, given the potential for later scarring. On the other hand, as undesirable as acne is for the sufferer, it is almost always a temporary condition, with effects that diminish and disappear over time. The main responsibility for the sufferer may be an internal one, to maintain a healthy balance in one's life with a positive attitude where physical appearance is not overemphasized.
  
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* Hormonal activity, such as [[menstruation|menstrual cycles]] and [[puberty]]
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==Acne vulgaris==
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* Diet
 
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* Stress, through increased output of hormones from the adrenal (stress) glands.
 
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* Hyperactive sebaceous glands, secondary to the three hormone sources above.
 
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* Accumulation of dead skin cells.
 
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* Bacteria in the [[Sebaceous gland|pores]], to which the body becomes 'allergic'.
 
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* Skin irritation or scratching of any sort will activate inflammation.
 
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* Use of anabolic [[steroid]]s.
 
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* Any medication containing halogens (iodides, chlorides, bromides), lithium, barbiturates, or [[androgen]]s.
 
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* Exposure to high levels of chlorine compounds, particularly chlorinated dioxins, can cause severe, long-lasting acne, known as ''[[Chloracne]]''.
 
  
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Traditionally, attention has focused mostly on hormone-driven over-production of sebum as the main contributing factor of acne. More recently, more attention has been given to narrowing of the follicle channel as a second main contributing factor. Abnormal [[shed (disambiguation)|shedding]] of the cells lining the follicle, abnormal cell binding ("[[hyperkeratinization]]") within the follicle, and water retention in the skin (swelling the skin and so pressing the follicles shut) have all been put forward as important mechanisms.
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[[Image:AcneVulgarisUSMIL.jpg|thumb|200px|right|Different types of Acne Vulgaris: A: Cystic acne on the face, B: Subsiding tropical acne of trunk, C: Extensive acne on chest and shoulders.]]
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Several [[hormone]]s have been linked to acne: the [[androgen|male hormone]]s [[testosterone]], dihydrotestosterone (DHT) and [[Dehydroepiandrosterone|dehydroepiandrosterone sulfate]] (DHEAS), as well as insulin-like growth factor 1 (IGF-I). In addition, acne-prone skin has been shown to be [[insulin]] resistant {{Fact|date=February 2007}}.
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'''Acne vulgaris''' is an inflammatory disease of the [[skin]], caused by changes in the pilosebaceous units (skin structures consisting of a [[hair]] follicle and its associated sebaceous [[gland]]). Acne lesions are commonly referred to as pimples, spots, or zits.  
  
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Development of acne vulgaris in later years is uncommon, although this is the age group for [[Rosacea]] which may have similar appearances. True acne vulgaris in adults may be a feature of an underlying condition such as pregnancy and disorders such as [[polycystic ovary syndrome]] or the rare [[Cushing's syndrome]]. Dermatologists are seeing more cases of menopause-associated acne as fewer women replace the natural anti-acne ovarian hormone estradiol whose production fails as women arrive at menopause.  
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Acne vulgaris is the most common form of acne. Acne affects a large percentage of humans at some stage in life. The condition is most common during puberty and is considered an abnormal response to normal levels of the male [[hormone]] [[testosterone]]. The response for most people diminishes over time and acne thus tends to disappear, or at least decrease, after one reaches his or her early twenties. However, there is no way to predict how long it will take for it to disappear entirely, as some individuals will continue to suffer from acne decades later into their thirties, forties, and beyond.
  
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====Misconceptions about causes====
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===Overview and symptoms===
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There are many misconceptions and rumors about what does and does not cause the condition:
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Excessive secretion of oils from the sebaceous glands (mostly due to [[gland]] enlargement during puberty), accompanied by the plugging of the pores with naturally occurring dead skin cells (corneocytes), results in a blockade of the hair follicles. The accumulation of these corneocytes in the duct appears to be due to a failure of the normal keratinization process in the [[skin]] that usually leads to shedding of skin cells lining the pores.
  
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=====Diet=====
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Once this defect in the keratinization process leads to these cells blocking the pore, the oil build up within the pore provides a favorable environment for the [[bacteria]] ''Propionibacterium acnes'' to multiply uncontrollably. In response to the bacterial populations, there is [[inflammation]] with attraction of white blood cells (neutrophils) to combat the bacteria, producing the visible lesion.
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Diet. One study suggested that [[chocolate]], french fries, potato chips and [[sugar]], among others, affect acne. A high GI (glycemic index) diet that causes sharp rises in blood sugar worsens acne. This, however, has been refuted by dermatologists and has been accepted as myth.<ref name="ChoiceUSA">{{cite web | author=CHOICE - Citizens for Healthy Options In Children's Education | title=Acne Has Nothing to Do with Diet - Wrong! |  url=http://www.choiceusa.net/news_articleAcne&Diet11.03.htm | month=Nov | year=2003}}</ref> If this study's conclusions are verified then a low GI diet may help acne, but a recent review of somewhat dated scientific literature cannot affirm either way.<ref name="FamPrac">{{cite journal | author=Magin P, Pond D, Smith W, Watson A | title=A systematic review of the evidence for 'myths and misconceptions' in acne management: diet, face-washing and sunlight | journal=Fam Pract | year=2005 | pages=62-70 | volume=22 | issue=1 | id=PMID 15644386}}</ref> A recent study, based on a survey of 47,335 women, did find a positive epidemiological association between acne and consumption of partially skimmed [[milk]], instant breakfast drink, sherbet, cottage cheese and cream cheese.<ref name="JAmAcadDermatol52">{{cite journal | author=Adebamowo CA, Spiegelman D, Danby FW, Frazier AL, Willett WC, Holmes MD | title=High school dietary dairy intake and teenage acne | journal=J Am Acad Dermatol | year=2005 | pages=207-14 | volume=52 | issue=2|id=PMID 15692464}}</ref> The researchers hypothesize that the association may be caused by hormones (such as several sex hormones and bovine [[insulin-like growth factor 1|IGF-I]]) present in cow milk. Although the association between milk and acne has been definitively shown, the ingredient in the milk responsible for the acne is still unclear.  Most dermatologists are awaiting confirmatory research linking diet and acne but some support the idea that acne sufferers should experiment with their diets, and refrain from consuming such fare if they find such food affects the severity of their acne.<ref name="AnnAllergy">{{cite journal | author=Fries JH | title=Chocolate: a review of published reports of allergic and other deleterious effects, real or presumed | journal=Ann Allergy | year=1978 | pages=195-207 | volume=41 | issue=4 | id=PMID 152075}}</ref>
 
  
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[[Seafood]], on the other hand, may contain relatively high levels of [[iodine]]. Iodine is known to make existing acne worse but there is probably not enough to cause an acne outbreak.<ref name="JAmAcadDermatol56">{{cite journal | author=Danby FW | title=Acne and iodine: Reply | journal=J Am Acad Dermatol | year=2007 | pages=164-5 | volume=56 | issue=1|id=PMID 17190637}}</ref>< Still, people who are prone to acne may want to avoid ''excessive'' consumption of foods high in iodine.
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The lesions have a propensity to affect the face, chest, back, shoulders, and upper arms.
 +
The lesions occur as various forms and include comedones, papules, pustules, nodules, and inflammatory cysts. Commonly, a pore that remains open (open comedo) but continues to distend with the keratinocytes, then sebum oxidized by the bacteria, as well as the skin pigment melanin, is referred to as a "blackhead." On the contrary, when a pore is occluded (closed comedo) by the dead skin cells, leading to accumulation of the materials below it, it is referred to as a "whitehead." Cysts, pustules, papules, and nodules are more extensive lesions that usually arise when the accumulations within the pore rupture into the surrounding skin. The level of the rupture determines the severity of these lesions. After resolution of acne lesions, prominent unsightly scars may remain. Hyperpigmentation of the skin around the lesion also has been noted, especially in darker skinned individuals.
  
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=====Hygiene=====
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Aside from scarring, its main effects are psychological, such as reduced self-esteem,<ref name=Goodman>G. Goodman, "Acne and acne scarring: the case for active and early intervention," ''Aust Fam Physician'' 35(7) (2006): 503-504. PMID 16820822. Retrieved December 30, 2019. </ref> [[clinical depression|depression]], embarrassment, and rarely [[suicide]].<ref>D. Purvis, E. Robinson, S. Merry, and P. Watson, "Acne, anxiety, depression and rarely suicide in teenagers: a cross-sectional survey of New Zealand secondary school students," ''J Paediatr Child Health'' 42(12) (2006): 793-796. PMID 17096715. </ref>One study has estimated the incidence of suicidal ideation in patients with acne as high as 7.1 percent <ref>A. Picardi, E. Mazzotti, and P. Pasquini, "Prevalence and correlates of suicidal ideation among patients with skin disease," ''J Am Acad Dermatol'' 54(3) (2006): 420-426. PMID 16488292.</ref> Acne usually appears during [[adolescence]], when people already tend to be most socially insecure. Early and aggressive treatment is therefore advocated to lessen the overall impact to individuals.<ref name=Goodman/>
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Deficient personal [[hygiene]]. Acne is not caused by dirt. This misconception probably comes from the fact that comedones look like dirt stuck in the openings of pores. The black color is simply not dirt but compact keratin. In fact, the blockages of keratin that cause acne occur deep within the narrow follicle channel, where it is impossible to wash them away. These plugs are formed by the failure of the cells lining the duct to separate and flow to the surface in the sebum created there by the body.  
 
  
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=====Sex=====
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===Factors in getting acne===
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[[Human sexuality|Sex]]. Common myths state that [[masturbation]] causes acne and, conversely, that [[celibacy]] or [[sexual intercourse]] can cure it. Though it has been widely accepted that these are not true due to lack of scientific study on the subject, it is also important to note sexual activity has been observed to result in hormonal spikes, which has been linked to acne.<ref>[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=135817&dopt=Abstract Endocrine effects of masturbation in men.]</ref>
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Exactly why some people get acne and some do not is not fully known. It is known to be partly hereditary. Several factors are known to be linked to acne lesion formation:
  
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===Treatments===
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* Hormonal activity, such as [[menstruation|menstrual cycles]] and [[puberty]]
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==== Timeline of acne treatment ====
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* Stress, through increased output of hormones from the adrenal (stress) glands
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The history of acne reaches back to the dawn of recorded history. In Ancient Egypt, it is recorded that several pharaohs were acne sufferers. From Ancient Greece comes the English word 'acne' (meaning 'point' or 'peak'). Acne treatments are also of considerable antiquity:
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* Hyperactive sebaceous glands, secondary to the three hormone sources stated above
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* Ancient Rome : bathing in hot, and often sulfurous, mineral water was one of the few available acne treatments. One of the earliest texts to mention skin problems is ''De Medicina'' by the Roman writer [[Aulus Cornelius Celsus|Celsus]].
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* Accumulation of dead skin cells
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* 1800s: Nineteenth century dermatologists used sulphur in the treatment of acne. It was believed to dry the skin.
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* Bacteria in the pores, particularly ''Propionibacterium acnes''
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* 1920s: [[Benzoyl Peroxide]] is used
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* Skin irritation or scratching, resulting in inflammation
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* 1930s: [[Laxative]]s were used as a cure for what were known as 'chastity pimples'
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* Use of anabolic [[steroid]]s
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* 1950s: When antibiotics became available, it was discovered that they had beneficial effects on acne. They were taken orally to begin with. Much of the benefit was not from killing bacteria but from the anti-inflammatory effects of tetracycline and its relatives. Topical antibiotics became available later.
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* Any medication containing halogens (iodides, chlorides, bromides), lithium, barbiturates, or [[androgen]]s
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* 1960s: [[Tretinoin]] (original Trade Name Retin A) was found effective for acne. This preceeded the development of oral [[isotretinoin]] (sold as Accutane and Roaccutane) since the early 1980s.
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* Exposure to high levels of chlorine compounds, particularly chlorinated dioxins, causing severe, long-lasting acne, known as Chloracne
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* 1980s: Accutane is introduced in America
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*Pregnancy, disorders such as Polycystic ovary syndrome (PCOS),[[Cushing's syndrome]], and increasing cases of menopause-associated acne as fewer women replace the natural anti-acne ovarian hormone estradiol whose production fails as women arrive at menopause.
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* 1990s: Laser treatment introduced
 
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* 2000s: Blue/red light therapy
 
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Some old treatments, like laxatives, have fallen into disuse but others, like [[Day spa|spa]]s, are recovering their popularity.
 
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====Available treatments====
 
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There are many products sold for the treatment of acne, many of them without any scientifically-proven effects. Generally speaking successful treatments give little improvement within the first week or two; and then the acne decreases over approximately 3 months, after which the improvement starts to flatten out. Treatments that promise improvements within 2 weeks are likely to be largely disappointing. Short bursts of cortisone, quick bursts of antibiotics and many of the laser therapies offer a quick reduction in the redness, swelling and inflammation when used correctly, but none of these empty the pore of all the materials that trigger the inflammation. Emptying the pores takes months.
 
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Modes of improvement are not necessarily fully understood but in general treatments are believed to work in at least 4 different ways (with many of the best treatments providing multiple simultaneous effects):
 
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*normalising shedding into the pore to prevent blockage
 
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*killing [[P. acnes]]
 
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*antinflammatory effects
 
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*hormonal manipulation
 
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A combination of treatments can greatly reduce the amount and severity of acne in many cases. Those treatments that are most effective tend to have greater potential for side effects and need a greater degree of monitoring, so a step-wise approach is often taken. Many people consult with doctors when deciding which treatments to use, especially when considering using any treatments in combination. There are a number of treatments that have been proven effective:
 
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[[Image:Salicylic acid pads.jpg|thumb|right|250px|Cotton pads soaked in salicylic acid solution can be used to exfoliate the skin.]]
 
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=====Exfoliating the skin=====
 
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This can be done either mechanically, using an abrasive cloth or a liquid scrub, or chemically.  Common chemical exfoliating agents include [[salicylic acid]] and [[glycolic acid]], which encourage the peeling of the top layer of skin to prevent a build-up of dead skin cells which combine with skin oil to block pores.  It also helps to unblock already clogged pores.{{Fact|date=March 2007}}  Note that the word "peeling" is not meant in the visible sense of [[shed (disambiguation)|shedding]], but rather as the destruction of the top layer of skin cells at the microscopic level.  Depending on the type of exfoliation used, some visible flaking is possible.  Moisturizers and anti-acne topicals containing chemical exfoliating agents are commonly available [[over-the-counter drug|over-the-counter]]. Mechanical exfoliation is less commonly used as many benefits derived from the exfoliation are negated by the act of mechanically rubbing and irritating the skin.
 
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[[Image:Benzoyl peroxide gel.jpg|thumb|right|250px|Benzoyl peroxide cream.]]
 
  
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=====Topical Bactericidals=====
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'''Misconceptions''': There are many misconceptions about what does and does not cause the condition including diet, hygiene, and sexual activity. Various studies have been done, but the role of these factors still remains unclear and uncertain.
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Widely available [[over-the-counter drug|OTC]] bactericidal products containing [[benzoyl peroxide]] may be used in mild to moderate acne. The gel or cream containing benzoyl peroxide is rubbed, twice daily, into the pores over the affected region. Bar soaps or washes may also be used and vary from 2 to 10% in strength. In addition to its therapeutic effect as a keratolytic (a chemical that dissolves the keratin plugging the pores) benzoyl peroxide also prevents new lesions by killing ''[[Propionibacterium acnes|P.acnes]]''. Unlike antibiotics, benzoyl peroxide has the advantage of being a strong oxidizer (essentially a mild bleach) and thus does not appear to generate bacterial resistance. However, it routinely causes dryness, local irritation and redness. A sensible regimen may include the daily use of low-concentration (2.5%) benzoyl peroxide preparations, combined with suitable [[Comedones|non-comedogenic]] moisturisers to help avoid overdrying the skin.<!--
 
  
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==Other types of acne==
  
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Care must be taken when using benzoyl peroxide, as it can very easily bleach any fabric or hair it comes in contact with. Use of benzoyl peroxide does increase free radicals in the skin, not unlike sun damage, ultimately leading to prematurely aged skin {{Fact|date=February 2007}}.
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===Acne cosmetica===
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''Acne cosmetica'' refers to acne caused by or made worse by [[cosmetics]]. The mechanism was presumably a chemically induced plugging of the pilosebaceous orifice. This was a significant problem for dermatologists in the 1970s and 1980s, but with the improved formulations produced by cosmetic chemists over the past thirty years, this is now a relatively rare diagnosis in daily practice.
  
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Other antibacterials that have been used include [[triclosan]], or [[chlorhexidine gluconate]] but these are often less effective.
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The terms "non-comedogenic" appeared on moisturizers and other cosmetic compounds as re-formulations were introduced, sometimes associated with claims that the products were oil-free or water-based. Although early work produced lists of comedogenic chemicals in various strengths and vehicles, it became apparent that the actual comedogenicity of a product could not be predicted from its contents; rather the finished product itself needed to be use-tested.  
  
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=====Topical antibiotics=====
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The production of a low-grade folliculitis by some components of the cosmetic product has led to misdiagnosis on occasion.
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Externally applied antibiotics such as [[erythromycin]], [[clindamycin]], Stiemycin or [[tetracycline]] aim to kill the bacteria that are harbored in the blocked follicles. Whilst topical use of antibiotics is equally as effective as oral, this method avoids possible side effects of stomach upset or drug interactions (e.g. it will not affect the oral contraceptive pill), but may prove awkward to apply over larger areas than just the face alone.
 
  
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=====Oral antibiotics=====
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===Acne medicamentosa===
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Oral antibiotics used to treat acne include erythromycin or one of the [[tetracycline antibiotics]] ([[tetracycline]], the better absorbed [[oxytetracycline]], or one of the once daily [[doxycycline]], [[minocycline]] or [[lymecycline]]). [[Trimethoprim]] is also sometimes used ([[off-label use]] in UK). However, reducing the ''P. acnes'' bacteria will not, in itself, do anything to reduce the oil secretion and abnormal cell behaviour that is the initial cause of the blocked follicles. Additionally the antibiotics are becoming less and less useful as resistant ''P. acnes'' are becoming more common. Acne will generally reappear quite soon after the end of treatment&mdash;days later in the case of [[topical]] applications, and weeks later in the case of oral antibiotics.
 
  
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=====Hormonal treatments=====
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''Acne medicamentosa'' refers to acne that is caused or aggravated by medication. Because acne is generally a disorder of the pilosebaceous units caused by [[hormone]]s, the medications that trigger acne medicamentosa most frequently are hormones.
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In females, acne can be improved with [[Hormone|hormonal]] treatments. The common combined [[Estrogen|oestrogen]]/[[Progestagen|progestogen]] methods of [[hormonal contraception]] have some effect, but the anti-[[testosterone]], [[Cyproterone]], in combination with an oestrogen (''Diane 35'') is particularly effective at reducing androgenic hormone levels. Diane-35 is not available in the USA, but a newer oral contraceptive containing the progestin [[drospirenone]] is now available with fewer side effects than Diane 35 / Dianette. Both can be used where blood tests show abnormally high levels of [[androgen]]s, but are effective even when this is not the case. Along with this, treatment with low dose spironolactone can have anti-androgenetic properties, especially in patients with polycystic ovarian syndrome.
 
  
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If a pimple is large and/or does not seem to be affected by other treatments, a dermatologist may administer an injection of [[cortisone]] directly into it, which will usually reduce redness and inflammation almost immediately.  This has the effect of flattening the pimple, thereby making it easier to cover up with makeup, and can also aid in the healing process. Side effects are minimal, but may include a temporary whitening of the skin around the injection point. This method also carries a much smaller risk of scarring than surgical removal.
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Although the male's hormone [[testosterone]] is most often blamed, and although men with acne occurring secondary to bodybuilding hormones is seen from time to time, the major hormonal medication that causes acne is the progestin/progestagen present in birth control pills.<ref>J. Tan, "Hormonal treatment of acne: review of current best evidence," ''J Cutan Med Surg; 8 Suppl'' 4(2004): 11. </ref> Other medications can produce 'acneiform' eruptions (usually pimply bumps and pustules that look like acne).  
  
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=====Topical retinoids=====
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Some conditions mimic acne medicamentosa. The most common mimic is the [[yeast]] folliculitis produced by an overgrowth of the ''Malassezia'' species, often secondary to oral or systemic corticosteroids, or secondary to broad-spectrum antibiotics such as the tetracycline family used in acne. This is often misinterpreted as "tetracycline-resistant acne."
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Normalizing the follicle cell lifecycle. A group of medications for this are [[topical]] [[retinoids]] such as [[tretinoin]] (brand name Retin-A), [[adapalene]] (brand name Differin) and [[tazarotene]] (brand name Tazorac).  Like isotretinoin, they are related to [[vitamin A]], but they are administered as topicals and generally have much milder side effects. They can, however, cause significant irritation of the skin. The retinoids appear to influence the cell creation and death lifecycle of cells in the follicle lining. This helps prevent the [[hyperkeratinization]] of these cells that can create a blockage.  [[Retinol]], a form of vitamin A, has similar but milder effects and is used in many over-the-counter moisturizers and other topical products. Effective topical retinoids have been in use over 30 years but are available only on prescription so are not as widely used as the other topical treatments. Topical retinoids often cause an initial flare up of acne within a month or so, which can be severe.
 
  
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=====Oral retinoids=====
+
===Acne neonatorum===
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Reducing the secretion of oils from the glands. This is done by a daily oral intake of [[vitamin A]] derivatives like [[isotretinoin]] (marketed as Accutane, Sotret, Claravis) over a period of 4-6 months. It is believed that isotretinoin works primarily by reducing the secretion of oils from the glands, however some studies suggest that it affects other acne-related factors as well. Isotretinoin has been shown to be very effective in treating severe acne and can either improve or clear well over 80% of patients. The drug has a much longer effect than anti-bacterial treatments and will often cure acne for good. The treatment requires close medical supervision by a [[dermatologist]] because the drug has many known [[Adverse effect (medicine)|side effects]] (many of which can be severe). About 25% of patients may relapse after one treatment. In those cases, a second treatment for another 4-6 months may be indicated to obtain desired results.  It is often recommended that one lets a few months pass between the two treatments, because the condition can actually improve somewhat in the time after stopping the treatment and waiting a few months also gives the body a chance to recover. Occasionally a third or even a fourth course is used, but the benefits are often less substantial.  The most common side effects are dry skin and  occasional nosebleeds (secondary to dry nasal mucosa). Oral retinoids also often cause an initial flare up of acne within a month or so, which can be severe. There are reports that the drug has damaged the liver of patients. For this reason, it is recommended that patients have blood samples taken and examined before and during treatment. In some cases, treatment is terminated due to elevated liver enzymes in the blood, which might be related to liver damage. Others claim that the reports of permanent damage to the [[liver]] are unsubstantiated, and routine testing is considered unnecessary by some dermatologists. Blood triglycerides also need to be monitored. However, routine testing are part of the official guidelines for the use of the drug in many countries. Some press reports suggest that isotretinoin may cause [[clinical depression|depression]] but as of September 2005 there is no agreement in the medical literature as to the risk.  The drug also causes birth defects if women become pregnant while taking it or take it while pregnant.  For this reason, female patients are required to use two separate forms of [[birth control]] or vow [[abstinence]] while on the drug. Because of this, the drug is supposed to be given to females as a [[last resort]] after milder treatments have proven insufficient. Restrictive rules (see [[IPLEDGE|iPledge]] Program) for use were put into force in the USA beginning in March 2006 to prevent misuse.<!--
+
''Acne neonatorum'' ('''Baby acne''') refers to a condition that affects roughly 20% of newborn babies. Lesions appear at around two weeks postpartum and commonly disappear after three months. Lesions include small, red, papules, which mainly affect the cheeks, as well as the nasal bridge of infants. Infants usually develop neonatal acne because of stimulation of the baby's sebaceous glands by lingering maternal hormones after delivery. These hormones cross the placenta into the baby and after delivery they cause the oil glands on the skin to form bumps that look like pimples. Baby acne usually clears up within a few weeks, but it can linger for months.
−
  —><ref name="IPledgeGuide">{{cite web | title=The iPLEDGE Program - Guide to Best Practices for Isotretinoin - "The resource to help the prescriber prepare, plan treatments, and prevent pregnancies during the course of isotretinoin therapy" | year=2005 | url=https://www.ipledgeprogram.com/Documents/Prescribers%20Guide%20v3_0A.pdf | format=PDF}}</ref>
 
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This has occasioned widespread editorial comment.<!--
 
−
  —><ref name="USnews-Healy">{{cite news | author=Bernadine Healy | title=Pledging for Accutane | date=[[2005-05-09]] | publisher=US News Best Health | url=http://www.usnews.com/usnews/opinion/articles/050905/5healy.htm}}</ref>
 
  
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=====Phototherapy=====
+
Commonly mistaken for baby acne, tiny bumps on a baby's face after birth that disappear within a few weeks are called milia and are unrelated.
−
======Blue and red light======
 
−
It has long been known that short term improvement can be achieved with sunlight. However, studies have shown that sunlight worsens acne long-term, presumably due to UV damage. {{Fact|date=February 2007}} More recently, visible light has been successfully employed to treat acne ([[Phototherapy]]) - in particular intense blue light generated by purpose-built fluorescent lighting, [[dichroic]] bulbs, [[LED]]s or [[lasers]]. Used twice weekly, this has been shown to reduce the number of acne lesions by about 64%;<!--
 
−
  —><ref name="JDermatolSci-Kawada">{{cite journal | author=Kawada A, Aragane Y, Kameyama H, Sangen Y, Tezuka T | title=Acne phototherapy with a high-intensity, enhanced, narrow-band, blue light source: an open study and in vitro investigation | journal=J Dermatol Sci | year=2002 | pages=129-35 | volume=30 | issue=2 | id=PMID 12413768}}</ref>
 
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and is even more effective when applied daily. The mechanism appears to be that a [[porphyrin]] (Coproporphyrin III) produced within ''P. acnes'' generates [[free radicals]] when irradiated by blue light.<!--
 
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  —><ref name="ZNaturforsch-Kjeldstad">{{cite journal | author=Kjeldstad B | title=Photoinactivation of Propionibacterium acnes by near-ultraviolet light | journal=Z Naturforsch [C] | year=1984 | pages=300-2 | volume=39 | issue=3-4 | id=PMID 6730638}}</ref>
 
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Particularly when applied over several days, these free radicals ultimately kill the bacteria.<!--
 
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  —><ref name="FEMSImmunolMedMicrobiol-Ashkenazi">{{cite journal | author=Ashkenazi H, Malik Z, Harth Y, Nitzan Y | title=Eradication of Propionibacterium acnes by its endogenic porphyrins after illumination with high intensity blue light | journal=FEMS Immunol Med Microbiol | year=2003 | pages=17-24 | volume=35 | issue=1|id=PMID 12589953}}</ref>
 
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Since porphyrins are not otherwise present in skin, and no UV light is employed, it appears to be safe, and has been licensed by the [[United States|U.S.]] [[Food and Drug Administration|FDA]].<!--
 
−
  —><ref name="FDA-Light">"New Light Therapy for Acne" U.S. [[Food and Drug Administration]], FDA Consumer magazine, November-December 2002 [http://www.fda.gov/fdac/departs/2002/602_upd.html#acne Notice]</ref>
 
−
The treatment apparently works even better if used with red visible light (660 nanometer) resulting in a 76% reduction of lesions after 3 months of daily treatment for 80% of the patients;<!--
 
−
  —><ref name="BrJDerm-Papageorgiou">{{cite journal | author=Papageorgiou P, Katsambas A, Chu A | title=Phototherapy with blue (415 nm) and red (660 nm) light in the treatment of acne vulgaris. | journal=Br J Dermatol | volume=142 | issue=5 | pages=973-8 | year=2000 | id=PMID 10809858 | url=http://acne-advice.com/products/beautyskin/british-journal.pdf | format=PDF}}</ref>
 
−
and overall clearance was similar or better than benzoyl peroxide. Unlike most of the other treatments few if any negative side effects are typically experienced, and the development of bacterial resistance to the treatment seems very unlikely. After treatment, clearance can be longer lived than is typical with topical or oral antibiotic treatments; several months is not uncommon. The equipment or treatment, however, is relatively new and reasonably expensive.
 
  
 +
===Chloracne===
 +
''Chloracne'' is an acne-like eruption of blackheads, cysts, and pustules associated with over-exposure to certain [[halogen]]ic aromatic hydrocarbons, such as chlorinated dioxins and dibenzofurans. The lesions are most frequently found on the cheeks, behind the ears, in the armpits and groin region.
  
 +
The condition was first described in German industrial workers in 1897 by Von Bettman, and was initially believed to be caused by exposure to toxic [[chlorine]] (hence the name "chloracne"). It was only in the mid-1950s that chloracne was associated with aromatic hydrocarbons<ref>D. E. Williams, W. H. Wolfe, M. B. Lustik, et al., ''An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides.'' Vol. 4. (1995)</ref>. The substances that may cause chloracne are now collectively known as "chloracnegens."
  
−
====Less widely used treatments====
+
In some instances, chloracne may not appear for three to four weeks after toxic exposure; however in other cases, particularly in events of massive exposure, the symptoms may appear within days.<ref>B. De Marchia, and J. R. Ravetzb, "Risk management and governance: a post-normal science approach," ''Futures'' 31(1999): 743–757.</ref>. Once chloracne has been identified, the primary action is to remove the patient and all other individuals from the source of contamination. Further treatment is symptomatic.
−
* [[Azelaic acid]] (brand names ''Azelex'', ''Finevin'', ''Skinoren'') is suitable for mild, comedonal acne.<!--
 
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  —><ref name="MedlinePlus-Azelaic">{{cite web | author=MedlinePlus | title=Azelaic Acid  (Topical) | url=http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202783.html  | date=2001-07-24}}</ref>
 
−
* Zinc. Orally administered [[zinc]] gluconate has been shown to be effective in the treatment of inflammatory acne, although less so than [[tetracycline]]s.<!--
 
−
  —><ref name="ActaDermVenereol-Dreno">{{cite journal | author=Dreno B, Amblard P, Agache P, Sirot S, Litoux P | title=Low doses of zinc gluconate for inflammatory acne | journal=Acta Derm Venereol | year=1989 | pages=541-3 | volume=69 | issue=6 | id=PMID 2575335}}</ref><!--
 
−
  —><ref name="Dermatology-Dreno">{{cite journal | author=Dreno B, Moyse D, Alirezai M, Amblard P, Auffret N, Beylot C, Bodokh I, Chivot M, Daniel F, Humbert P, Meynadier J, Poli F | title=Multicenter randomized comparative double-blind controlled clinical trial of the safety and efficacy of zinc gluconate versus minocycline hydrochloride in the treatment of inflammatory acne vulgaris | journal=Dermatology | year=2001 | pages=135-40 | volume=203 | issue=2 | id=PMID 11586012}}</ref>
 
−
* [[Tea tree oil (melaleuca oil)|Tea Tree Oil (Melaleuca Oil)]] has been used with some success, and has been shown to be an effective anti-inflammatory in skin infections <!--
 
−
  —><ref name="TeaTree">{{cite journal | author=Koh KJ; Pearce AL; Marshman G; Finlay-Jones JJ; Hart PH Department of Dermatology, Flinders Medical Centre, Bedford Park, South Australia, Australia| title=Tea tree oil reduces histamine-induced skin inflammation | journal=Dermatology | year=2002 | pages=147| id=ISSN 0007-0963}}</ref>
 
−
* Heat therapy - [[Zeno (acne treatment)|Zeno]] product uses heat at a specific temperature to kill bacteria and to treat mild to moderate acne.{{Fact|date=February 2007}}
 
−
* [[Niacinamide]], (Vitamin B3) used topically in the form of a gel, has been shown in a 1995 study to be more effective than a topical antibiotic used for comparison, as well as having less side effects.<!--
 
−
  —><ref name="Shalita1995">{{cite journal | author = Shalita A, Smith J, Parish L, Sofman M, Chalker D | title = Topical nicotinamide compared with clindamycin gel in the treatment of inflammatory acne vulgaris. | journal = Int J Dermatol | volume = 34 | issue = 6 | pages = 434-7 | year = 1995 | id = PMID 7657446}}</ref> Topical niacinamide is available both on prescription and [[Over-the-counter drug|over-the-counter]]. Some users choose to make their own at home, mixing together crushed niacinamide pills with aloe vera gel.{{Fact|date=February 2007}} The property of topical niacinamide's benefit in treating acne seems to be it's anti-inflammatory nature. It is also purported to result in increased synthesis of collagen, keratin, involucrin and flaggrin.{{Fact|date=February 2007}}
 
−
* In some cases, people found that bathing in salt water (pure from the ocean) noticed lessened redness and decreased size in their acne.
 
  
−
====Future treatments====
+
Severe or persistent lesions may be treated with oral antibiotics or isotretinoin. However, chloracne may be highly resistant to any treatment.
−
[[Laser]] surgery has been in use for some time to reduce the scars left behind by acne, but research is now being done on lasers for prevention of acne formation itself. The laser is used to produce one of the following effects:
 
−
* to burn away the follicle sac from which the hair grows
 
−
* to burn away the sebaceous gland which produces the oil
 
−
* to induce formation of [[oxygen]] in the bacteria, killing them
 
  
−
Since  lasers and intense pulsed light sources  cause thermal damage to the skin there  are  concerns  that  laser  or intense pulsed light treatments  for acne will induce  hyperpigmented macules (spots) or  cause long term dryness of the skin. As of 2005, this is still mostly at the stage of medical research rather than established treatment.
+
===Acne fulminans===
 +
''Acne fulminans (acne maligna)'' is a rare and severe form of acne involving a sudden onset of bleeding and ulcerative acne lesions spreading over the face, back, and chest. It may be part of SAPHO syndrome, which comprises of synovitis, acne, pustulosis, hyperostosis, and osteitis. It is a severe condition treated with wound care, corticosteriods, nonsteroidal anti-inflammatory drugs, isotretinoin, and infliximab.<ref>M. Iqbal, and M. Kolodney, "Acne fulminans with synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome treated with infliximab," ''Journal of the American Academy of Dermatology'' 52(Suppl 1, 2005): 5.</ref>.  
  
−
Because acne appears to have a significant hereditary link, there is some expectation that cheap whole-genome DNA sequencing may help isolate the body mechanisms involved in acne more precisely, possibly leading to a more satisfactory treatment. (Crudely put, take the DNA of large samples of people with significant acne and of people without, and let a computer search for statistically strong differences in genes between the two groups). However, as of 2005, DNA sequencing is not yet cheap, and all this may still be decades off.  It is also possible that [[gene therapy]] could be used to alter the skin's DNA.
+
===Acne conglobata===
  
−
[[Phage therapy]] has been proposed to kill [[P. acnes]], and has seen some use, particularly in [[Georgia (country)|Georgia]].<ref>[http://www.nj.com/specialprojects/index.ssf?/specialprojects/plague/plague3.html The star ledger- Germs that fight germs]</ref>
+
''Acne conglobata'' refers to a chronic form of inflammatory acne marked by communicating blackheads, communicating cysts, abscesses, papules, pustules, and draining sinus tracts. Due to its chronic and highly inflammatory course, it usually ends with keloidal and atrophic scarring. It is part of a larger follicular occlusion syndrome consisting of acne conglobata, hidradenitis suppurativa, and dissecting cellulitis of the scalp.
  
−
==== Preferred treatments by types of acne vulgaris ====
+
===Acne keloidalis nuchae===
−
*[[Comedo]]nal (non-inflammatory) acne: local treatment with [[azelaic acid]], [[salicylic acid]], topical [[retinoids]], benzoyl peroxide.
 
−
*Mild [[papule|papulo]]-[[pustule|pustular]] (inflammatory) acne: [[benzoyl peroxide]] or topical retinoids, topical [[antibiotic]]s (such as [[erythromycin]]).
 
−
*Moderate inflammatory acne: [[benzoyl peroxide]] or topical retinoids combined with oral antibiotics ([[tetracycline]]s). [[Isotretinoin]] is an option.
 
−
*Severe inflammatory acne, nodular acne, acne resistant to the above treatments: [[isotretinoin]], or contraceptive pills with [[cyproterone]] for females with [[virilization]] or [[drospirenone]].
 
−
*Most physicians state that topical retinoids are the preferred treatment for all forms of acne vulgaris.
 
−
*There are also certain treatments for acne mentioned in Ayurveda using herbs such as Aloevera, Aruna, Haldi, and Papaya.<ref name="ayushveda">[http://www.ayushveda.com/health/acne.htm Ayurveda Encyclopedia, "Acne Treatment"]</ref>
 
  
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===Acne scars===
+
''Acne keloidalis nuchae'' refers to a condition of unknown etiology marked by the presence of perifollicular papules and nodules on the nape of the neck. Limiting frequent and close shaving and have been found to be somewhat helpful, along with topical retinoids and benzoyl peroxide products. <ref>A. Yan, "Current concepts in acne management," ''Adolescent Medicine Clinics'' 17(2006): 3. </ref>
−
Severe acne often leaves small [[scar]]s where the skin gets a "volcanic" shape. Acne scars are difficult and expensive to treat, and it is unusual for the scars to be successfully removed completely.{{Fact|date=February 2007}}<!-- need citation that lists rates of success, rather than a support group just stating thats it is difficult. User:Davidruben, 6 Sept 2006 —>
 
  
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The psychological and emotional effects caused by acne scars can be as devastating to one's confidence as the acne once was.
+
===Acne rosacea===
  
−
Acne scars generally fall into two categories: physical scars and pigmented scars.
+
''Acne rosacea'' is a chronic cutaneous condition affecting the chin, cheeks, nose, and forehead. It is characterized by the presence of flushing, erythema, telangiectasia (spider veins), rhinophyma (of the nose), swelling, papules, pustules, and may even involve the eye.<ref>J. Wilkin, M. Dahl, M. Detmar, L. Drake, A. Feinstein, R. Odom, and F. Powell, "Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea," ''Journal of the American Academy of Dermatology'' 46(2002): 4.</ref> It is currently treated with tetracyclines, topical antibiotics such as metronidazole, as well as other measures to provide symptomatic treatments.<ref>E. J. van Zuuren, A. Gupta, M. Gover, M. Graber, and S. Hollis, "Systematic review of rosacea treatments," ''Journal of the American Academy of Dermatology'' 56 (2007): 1.</ref>
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Physical acne scars are often referred to as "Icepick" scars. This is because the scars tend to cause an indentation in the skins surface.
 
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Pigmented scars is a slightly misleading term, suggesting a change in the skin's pigmentation. This is not true. Pigmented scars are usually the result of nodular or cystic acne (the painful 'bumps' lying under the skin). They often leave behind an inflamed red mark. Often, the pigmentation scars can be avoided simply by avoiding aggravation of the nodule or cyst. When sufferers try to 'pop' cysts or nodules, pigmentation scarring becomes significantly worse, and may even bruise the affected area. Pigmentation scars often fade with time, and those who suffered from acne before, and have developed scars are generally relieved that the acne has gone, and emotional effects of acne scars tend to be less distressing.
 
  
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Acne scars are unsightly, and it is for this reason they can be psychologically and emotionally distressing. However, there are a range of treatments available. If acne scars are causing severe psychological distress, social withdrawal and/or emotional ill-health, a physician should be contacted.
+
==Treatments==
 +
=== Timeline of acne treatment ===
 +
The history of acne reaches back to the dawn of recorded history. In Ancient Egypt, it is recorded that several pharaohs were acne sufferers. From Ancient Greece comes the English word "acne" (meaning "point" or "peak"). Acne treatments are also of considerable antiquity:
 +
* Ancient Rome : bathing in hot, and often sulfurous, mineral water was one of the few available acne treatments. One of the earliest texts to mention skin problems is ''De Medicina'' by the Roman writer Celsus.
 +
* 1800s: Nineteenth century dermatologists used sulphur in the treatment of acne. It was believed to dry the skin.
 +
* 1920s: Benzoyl Peroxide is used
 +
* 1930s: Laxatives were used as a cure for what were known as 'chastity pimples'
 +
* 1950s: When [[antibiotic]]s became available, it was discovered that they had beneficial effects on acne. They were taken orally to begin with. Much of the benefit was not from killing bacteria but from the anti-inflammatory effects of tetracycline and its relatives. Topical antibiotics became available later.
 +
* 1960s: Tretinoin (original Trade Name Retin A) was found effective for acne. This preceeded the development of oral isotretinoin (sold as Accutane and Roaccutane) since the early 1980s.
 +
* 1980s: Accutane is introduced in America
 +
* 1990s: Laser treatment introduced
 +
* 2000s: Blue/red light therapy
  
−
=== Grading scale ===
+
Some old treatments, like laxatives, have fallen into disuse but others, like spas, are recovering their popularity.
−
There are multiple grading scales for grading the severity of acne vulgaris,<ref>Leeds, Cook's and Pillsbury scales obtained from [http://www.clinicalevidence.com/ceweb/conditions/skd/1714/1714_background.jsp#outcomes here]</ref> three of these being:
 
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''Leeds acne grading technique:'' Counts and categorises lesions into inflammatory and non-inflammatory (ranges from 0-10.0).
 
−
'''Cook's acne grading scale:'' Uses photographs to grade severity from 0 to 8 (0 being the least severe and 8 being the most severe).
 
−
''Pillsbury scale:'' Simple classifies the severity of the acne from 1 (least severe) to 4 (most severe).
 
  
 +
===Available treatments===
 +
There are many products sold for the treatment of acne, many of them without any scientifically-proven effects. Generally speaking, successful treatments manifest usually after eight weeks, the time it takes for a comedone to mature completely. Other treatments may offer quick, temporary relief as they reduce [[inflammation]]. 
  
−
==
+
Modes of improvement are not necessarily fully understood but in general treatments are believed to work in at least 4 different ways (with many of the best treatments providing multiple simultaneous effects):
 +
*normalizing shedding into the pore to prevent blockage
 +
*killing ''Propionibacterium acnes''
 +
*anti-inflammatory effects
 +
*hormonal manipulation
  
−
==Rosacea==
+
A combination of treatments can greatly reduce the amount and severity of acne in many cases. Those treatments that are most effective tend to have greater potential for side effects and need a greater degree of monitoring, so a step-wise approach is often taken. Many people consult with doctors when deciding which treatments to use, especially when considering using any treatments in combination. There are a number of treatments that have been proven effective:
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:''[[Rosacea (genus)|Rosacea]] may also refer to a genus of [[siphonophore]].''
 
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{{Infobox_Disease
 
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| Name          = Rosacea
 
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| Image          = Rosacea mild.jpg
 
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| Caption        = Moderate erythematotelangiectatic and mild papulopustular rosacea.
 
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| DiseasesDB    = 96
 
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| ICD10          = {{ICD10|L|71||l|60}}
 
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| ICD9          = {{ICD9|695.3}}
 
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| ICDO          =
 
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| OMIM          =
 
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| MedlinePlus    = 000879
 
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| eMedicineSubj  = derm
 
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| eMedicineTopic = 377
 
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| DRNASE.COM*********very helpful for rosacea suffers****************        =
 
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}}
 
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'''Rosacea''' ({{IPA2|ɹəʊ.ˈzeɪ.ʃə}}) is a common but often misunderstood condition that is estimated to affect over 45 million people worldwide. It affects fair-skinned people of mostly north-western European descent, and has been nicknamed the 'curse of the Celts' by some in Ireland. It begins as erythema (flushing and redness) on the central face and across the cheeks, nose, or forehead but can also less commonly affect the neck and chest. As rosacea progresses, other symptoms can develop such as semi-permanent [[erythema]], [[telangiectasia]]  (dilation of superficial blood vessels on the face), red [[domed papule]]s (small bumps) and [[pustule]]s, red gritty eyes, burning and stinging sensations, and in some advanced cases, a red lobulated nose ([[rhinophyma]]). The disorder can be confused and co-exist with [[acne vulgaris]] and/or [[seborrheic dermatitis]]. Rosacea affects both sexes, but is almost three times more common in women, and has a peak age of onset between 30 and 60. The presence of rash on the scalp or ears suggests a different or co-existing diagnosis, as rosacea is primarily a facial diagnosis.
 
  
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==Subtypes and symptoms==
+
====For comedonal acne:====
−
There are four identified rosacea subtypes<ref name="JAmAcadDermatol2004-Wilkin">{{cite journal | author=Wilkin J, Dahl M, Detmar M, Drake L, Liang MH, Odom R, Powell F | title=Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea | journal=J Am Acad Dermatol | year=2004 | pages=907-12 | volume=50 | issue=6 | id=PMID 15153893 | url=http://www.rosacea.org/grading/gradingsystem.pdf | format=PDF reprint}}</ref> and patients may have more than one subtype present.
+
This type is mild in nature and is characterized by the presence of comedones without much surrounding inflammation. The treatment of this entity focuses on the correction of the abnormal follicular keratinization process. Drugs such as topical retinoids (i.e., tretinoin, adapalene, tazorotene), are preferred and available only by prescription.<ref>J. J. Leyden, "Therapy for acne vulgaris," ''New England Journal of Medicine'' 336(1997): 1156.</ref> Many over the counter preparations containing salicylic acid, benxoyl peroxide, or glycolic acid have also been found to have some use as they exhibit antimicrobial and comedolytic properties. They are especially useful when the side effects of the retinoids (excessive dry skin) can not be tolerated.<ref>J. S. Weiss, "Current options for the topical treatment of acne vulgaris," ''Pediatric Dermatology'' 14(1997): 480.</ref>. Mechanical methods to open the pores are also used as an adjunct to the topical medications. 
  
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#''Erythematotelangiectatic rosacea:'' Permanent redness ([[erythema]]) with a tendency to [[Flushing (physiology)|flush]] and [[Blushing|blush]] easily. It is also common to have small blood vessels visible near the surface of the skin ([[telangiectasias]]) and possibly burning or itching sensations.
+
[[Image:Salicylic acid pads.jpg|thumb|right|250px|Cotton pads soaked in salicylic acid solution]]
−
#''Papulopustular rosacea:'' Some permanent redness with red bumps ([[papule]]s) with some pus filled ([[pustule]]s) (which typically last 1-4 days); this subtype can be easily confused with acne.
+
[[Image:Benzoyl peroxide gel.jpg|thumb|right|250px|Benzoyl peroxide cream.]]
−
#''Phymatous rosacea:'' This subtype is most commonly associated with [[rhinophyma]], an enlargenent of the nose. Symptoms include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea can also on the chin (gnatophyma), forehead (metophyma), cheeks, eyelids (blepharophyma), and ears (otophyma).<ref>{{cite journal |author=Jansen T, Plewig G |title=Clinical and histological variants of rhinophyma, including nonsurgical treatment modalities |journal=Facial Plast Surg |volume=14 |issue=4 |pages=241-53 |year=1998 |id=PMID 11816064}}</ref> Small blood vessels visible near the surface of the skin (telangiectasias) may be present.
 
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#''[[Ocular rosacea]]:'' Red, dry and irritated eyes and eyelids. Some other symptoms include foreign body sensations, itching and burning.
 
  
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There have been other descriptive terms applied to presentations of rosacea, but these are not formally accepted as subtyes of rosacea:<ref name="JAmAcadDermatol2002-Wilkin">{{cite journal | author=Wilkin J, Dahl M, Detmar M, Drake L, Feinstein A, Odom R, Powell F | title=Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea | journal=J Am Acad Dermatol | year=2002 | pages=584-7 | volume=46 | issue= | id=PMID 15153893 | url=http://www.rosacea.org/class/classystem.pdf |format=PDF reprint}} - <small>this earlier classification noted terms of Granulomatous Rosacea, Rosacea fulminans and Perioral dermatitis as probably not meeting the accepted definitions for Rosacea. Such terms not mentioned in the later 2004 classification.</small></ref>
+
====For mild to moderate inflammatory acne:====
−
* ''[[Granuloma]]tous rosacea''.<ref>{{cite journal |author=Helm K, Menz J, Gibson L, Dicken C |title=A clinical and histopathologic study of granulomatous rosacea |journal=J Am Acad Dermatol |volume=25 |issue=6 Pt 1 |pages=1038-43 |year=1991 |id=PMID 1839796}}</ref>
+
As comedonal acne progresses with the appearance of increasing inflammatory lesions, combination therapy has proved to be very efficacious. A topical antibiotic (i.e. erythromycin, clindamycin, metronidazole) along with a topical retinoid, are being used together with greater success than either agent alone.<ref>W. F. Bergfeld, and R. B. Odom, "New perspectives on acne," ''Clinician'' 12(1996): 4.</ref> Benzoyl peroxide or adapalene are also being used in combinations with the topical antibiotics and topical retinoids with greater success than either agent alone.<ref>S. Hurwitz, "Acne vulgaris: pathogenesis and management," ''Pediatric Review'' 15(1994): 47.</ref><ref>D. P. Lookingbill, D.K. Chalker, J. S. Lindholm, "Treatment of acne with a combination clindamycin/benzoyl peroxide gel and vehicle gel: Combined results of two double-blind investigations," ''Journal of the American Academy of Dermatology'' 37(1997): 590.</ref>.
−
* The rare and severely scarring ''Rosacea fulminans'' (pyoderma faciale) occurring exclusively in women after adolescence and most commonly in their  early 20s,<ref>{{cite journal |author=Jansen T, Plewig G, Kligman A |title=Diagnosis and treatment of rosacea fulminans |journal=Dermatology |volume=188 |issue=4 |pages=251-4 |year=1994 |id=PMID 8193395}}</ref><ref>{{cite journal |author=Helm T, Schechter J |title=Biopsy may help identify early pyoderma faciale (rosacea fulminans) |journal=Cutis |volume=77 |issue=4 |pages=225-7 |year=2006 |id=PMID 16706239}}</ref>
 
−
* ''Perioral dermatitis'', which is better described as ''periorificial [[dermatitis]]'', but similarly treated with topical [[metronidazole]].<ref>{{cite journal |author=Nguyen V, Eichenfield L |title=Periorificial dermatitis in children and adolescents |journal=J Am Acad Dermatol |volume=55 |issue=5 |pages=781-5 |year=2006 |id=PMID 17052482}}</ref>
 
−
* Persistent edema of rosacea.{{Fact|date=February 2007}}
 
−
* ''Rosacea Conglobata''.{{Fact|date=February 2007}}
 
−
* Persisting redness and [[oedema]] of the upper half of the face has been termed ''Morbihan disease''.<ref>{{cite journal |author=Hölzle E, Jansen T, Plewig G |title=[Morbihan disease—chronic persistent erythema and edema of the face] |journal=Hautarzt |volume=46 |issue=11 |pages=796-8 |year=1995 |id=PMID 8641887}}</ref><ref>{{cite journal | author=Landow K | title=Unraveling the mystery of rosacea —  Keys to getting the red out | journal=Postgraduate Medicine | volume=112 | issue=6 | year=2002 | month=December | url=http://www.postgradmed.com/issues/2002/12_02/landow.htm}}</ref>
 
  
−
Rosacea sufferers often report periods of depression stemming from cosmetic disfigurement, painful burning sensations, and decreases in quality of life.<!--
+
====For moderate to severe inflammatory acne:====
−
  —><ref name="ClinDermatol1984-Panconesi">{{cite journal | author=Panconesi, E.| title=Psychosomatic dermatology | journal=Clin Dermatol | year=1984 | pages=94-179 | volume=2 | id=PMID 6242532}}</ref>
+
As lesions progress to involve larger areas on the face as well as other body parts such as the back and trunk, topical therapies combining benzoyl peroxide, topical antibiotics, and topical retinoids are used to provide relief.<ref>Bergfeld, (1996): 4</ref> Patients not responding to this therapy are requested to add an oral antibiotic (ie. tetracycline, doxycycline, trimethoprim-sulfamethoxazole, etc.) or isotretinoin. <ref>J. Leyden, D. M. Thiboutot, A. R. Shalita, et al., "Comparison of tazarotene and minocycline maintanence therapies in acne vulgaris: a multicenter, double blind, randomized, parallel-group study," ''Archives Dermatology'' 142(2006): 605.</ref> It is important to note that isotretinoin carries potentially severe side effects that require strict monitoring and stringent guidelines before it is prescribed. Women that have been found to have hormonal abnormalities may also benefit from estrogen or antiandrogenic hormonal therapy.<ref>Leyden, (1997): 1156.</ref>
  
−
===Causes===
+
====Photo, laser, and heat therapies====
−
The precise pathogenesis of rosacea still remains unknown, but most experts believe that rosacea is a disorder where the [[blood vessels]] become damaged when repeatedly dilated by stimuli. The damage causes the vessels to dilate too easily and stay dilated for longer periods of time or remain permanently dilated, resulting in flushing and redness. [[Immune cells]] and inflammatory mediators can leak from the microvascular bed causing inflammatory pustules and papules, especially with those with papulopustular rosacea.
+
Of these various modalities that have been approved for the treatment of acne, phototherapy with high intensity narrow-band blue light (405 to 420nm) is the only therapy that has been proven to be efficacious in the treatment of acne.<ref>A. Kawada, Y. Aragane, H. Kameyama, et. al., "Acne phototherapy with high intensity, enhanced, narrow band, blue light source: an open study and in vitro investigation," ''Journal of Dermatological Science'' 30(2002): 129.</ref>. The equipment or treatment, however, is relatively new and reasonably expensive, and therefore not generally recommended or used for this purpose.
  
−
Rosacea has a hereditary component and those that are fair-skinned of European or Celtic ancestry have a higher genetic predisposition to developing it. Women are more commonly affected but when men develop rosacea it tends to be more severe. People of all ages can get rosacea but there is a higher instance in the 30-50 age group. The first signs of rosacea are said to be persisting redness due to exercise, changes in temperature, and cleansing.
+
====Alternate treatments====
 +
These are treatments, generally home remedies, that are used with or without success around the world:
 +
* Zinc - Orally administered zinc gluconate has been shown to be effective in the treatment of inflammatory acne.<ref>B. Dreno, P. Amblard, P. Agache, S. Sirot, and P. Litoux, "Low doses of zinc gluconate for inflammatory acne," ''Acta Derm Venereol'' 69(6, 1989): 541-543. PMID 2575335. Retrieved December 30, 2019.</ref><ref>B. Dreno, D. Moyse, M. Alirezai, P. Amblard, N. Auffret, C. Beylot , I. Bodokh, M. Chivot, F. Daniel, P. Humbert, J. Meynadier, and F. Poli, "Multicenter randomized comparative double-blind controlled clinical trial of the safety and efficacy of zinc gluconate versus minocycline hydrochloride in the treatment of inflammatory acne vulgaris," ''Dermatology'' 203(2, 2001): 135-140. PMID 11586012. Retrieved December 30, 2019.</ref>
 +
* Tea tree oil (Melaleuca oil)|Tea Tree Oil (Melaleuca Oil) has been used with some success, and has been shown to be an effective anti-inflammatory agent in skin infections <ref>K. J. Koh, A. L. Pearce, G. Marshman, J. J. Finlay-Jones, and P. H. Hart, "Tea tree oil reduces histamine-induced skin inflammation," ''Dermatology'' (2002): 147. {{ISSN|0007-0963}}</ref>
 +
* Niacinamide (Vitamin B3) is used topically in the form of a gel. The property of topical niacinamide's benefit in treating acne seems to be its anti-inflammatory nature.
 +
* In some cases, people found bathing in salt water noticed lessened redness and decreased size in their acne.
 +
*There are also certain treatments for acne mentioned in Ayurveda using herbs such as Aloevera, Aruna, Haldi, and Papaya.
  
−
Triggers that cause episodes of flushing and blushing play a part in the development of rosacea. Exposure to temperature extremes can cause the face to become flushed as well as strenuous exercise, heat from sunlight, severe [[sunburn]], stress, cold wind, moving to a warm or hot environment from a cold one such as heated shops and offices during the winter. There are also some foods and drinks that can trigger flushing, these include [[alcohol]], foods and beverages containing [[caffeine]], foods high in [[histamine]] and [[spicy food]].
+
====Future treatments====
−
 
+
[[Laser]] surgery has been in use for some time to reduce the scars left behind by acne, but research is now being done on lasers for prevention of acne formation itself. The laser is used to produce one of the following effects:
−
Certain medications and topical irritants can quickly progress rosacea. If redness persists after using a treatment then it should be stopped immediately. Some acne and wrinkle treatments that have been reported to cause rosacea include microdermabrasion, chemical peels, high dosages of [[isotretinoin]], benzoyl peroxide and [[tretinoin]]. ''[[Steroid]] induced rosacea'' is the term given to rosacea caused by the use of topical or nasal steroids. These steroids are often prescribed for seborrheic dermatitis. Dosage should be slowly decreased and not immediately stopped to avoid a flare up.
+
* to burn away the follicle sac from which the hair grows
−
 
+
* to burn away the sebaceous gland which produces the oil
−
Studies of rosacea and [[demodex mite]]s have revealed that some people with rosacea have increased numbers of the mite, especially those with steroid induced rosacea.<ref name="IntJDermatol1998-Erbagcaronci">{{cite journal | author=Erbagcaronci Z, Özgöztascedili O | title=The significance of Demodex folliculorum density in rosacea | journal=Int J Dermatol. | month=June | year=1998 | pages=421-5 | volume=37 | issue=6 | id=PMID 9646125}}</ref> When large numbers are present they may play a role along with other triggers. On other occasions [[Mange|Demodicidosis]] (Mange) is a separate condition that may have "rosacea-like" appearances.<ref name="Baima2002">{{cite journal |author=Baima B, Sticherling M |title=Demodicidosis revisited |journal=Acta Derm Venereol |volume=82 |issue=1 |pages=3-6 |year=2002 |id=PMID 12013194}}</ref>
+
* to induce formation of [[oxygen]] in the bacteria, killing them
−
 
 
−
It has also been suggested that rosacea might be a neurological disorder resulting from hypersensitization of sensory neurons following activation of the plasma [[kinin-kallikrein system|kallikrein-kinin system]] by exposure to [[intestinal bacteria]] in the digestive tract.<ref name="ClinExpDermatol2004-KendallSN">{{cite journal | author=Kendall SN | title=Remission of rosacea induced by reduction of gut transit time. | journal=Clin Exp dermatol. | month=May | year=2004 | pages=297-9 | volume=29 | issue=3 | id=PMID 15115515}}</ref>
 
  
−
===Treatments===
+
Because acne appears to have a significant hereditary link, there is some expectation that cheap whole-genome DNA sequencing may help isolate the body mechanisms involved in acne more precisely, possibly leading to a more satisfactory treatment. However, DNA sequencing is not yet cheap, and all this may still be decades off. It is also possible that gene therapy could be used to alter the skin's DNA.
−
Treating rosacea varies from patient to patient depending on severity and subtypes. Dermatologists are recommended to take a subtype-directed approach to treating rosacea patients.<ref name="JAmBoardFamPract2002-Aaron">{{cite journal | author=Aaron F. Cohen, MD, and Jeffrey D. Tiemstra, MD | title=Diagnosis and treatment of rosacea | journal=J Am Board Fam Pract. | month=May-June | year=2002 | pages=214-7 | volume=15 | issue=3 | id=PMID 12038728}}</ref>
 
  
−
Trigger avoidance can help reduce the onset of rosacea but alone will not normally cause remission for all but mild cases. The National Rosacea Society recommends that a diary be kept to help identify and reduce triggers.
+
Phage therapy has been proposed to kill ''Propionibacterium acnes'' and has seen some use.<ref> M. D. Farrar, K. M. Howson, R. A. Bojar, D. West, J. C. Towler, J. Parry, K. Pelton, and K. T. Holland,  "Genome sequence and analysis of a Propionibacterium acnes bacteriophage," ''J Bacteriol'' 189(11, 2007): 4161-4167. PMID 17400737. Retrieved December 30, 2019.</ref>
  
−
It is important to have a gentle skin cleansing regimen using non-irritating cleansers. Protection from the sun is important and daily use of a [[sunscreen]] of at least SPF 15 containing a physical blocker such as [[zinc oxide]] or [[titanium dioxide]] is advised.
+
====Acne scars====
 +
Severe acne often leaves small scars where the skin gets a "volcanic" shape. Acne scars are difficult and expensive to treat, and it is unusual for the scars to be successfully removed completely.
  
−
Oral [[tetracycline antibiotics]] ([[tetracycline]], [[doxycycline]], [[minocycline]]) and topical antibiotics such as [[metronidazole]] are usually the first line of defence prescribed by doctors to relieve papules, pustules, inflammation and some redness.<ref name="ArchDermatol1998-Dahl">{{cite journal | author=Dahl MV, Katz HI, Krueger GG, Millikan LE, Odom RB, Parker F, Wolf JE Jr, Aly R, Bayles C, Reusser B, Weidner M, Coleman E, Patrignelli R, Tuley MR, Baker MO, Herndon JH Jr, Czernielewski JM | title=Topical metronidazole maintains remissions of rosacea | journal=Arch Dermatol | month=June | year=1998 | pages=679-83 | volume=134 | issue=6 | id=PMID 9645635}}</ref> Oral antibiotics may also help to relieve symptoms of ocular rosacea. If papules and pustules persist, then sometimes [[isotretinoin]] can be prescribed.<ref name="IntJDermatol1986-Hoting">{{cite journal | author=Hoting E, Paul E, Plewig G | title=Treatment of rosacea with isotretinoin | journal=Int J Dermatol | month=December | year=1986 | pages=660-3 | volume=25 | issue=10 | id=PMID 2948928}}</ref> Isotretinoin has many side effects and is normally used to treat severe acne but in low dosages is proven to be effective against papulopustular and phymatous rosacea.
+
Acne scars generally fall into two categories: physical scars and pigmented scars. Physical acne scars are often referred to as "icepick" scars. This is because the scars tend to cause an indentation in the skins surface. Pigmented scars are usually the result of nodular or cystic acne. They often leave behind an inflamed red mark. Often, the pigmentation scars can be avoided simply by avoiding aggravation of the nodule or cyst. When sufferers try to "pop" cysts or nodules, pigmentation scarring becomes significantly worse, and may even bruise the affected area.
−
 
 
−
The treatment of flushing and blushing has been attempted by means of the centrally-acting α-2 agonist [[clonidine]], but there is no evidence whatsoever that this is of any benefit. The same is true of the beta-blockers nadolol and propanolol. If flushing occurs with red wine consumption, then complete avoidance helps. There is no evidence at all that antihistamines are of any benefit in rosacea.
 
−
 
 
−
People who develop infections of the eyelids must practice frequent eyelid hygiene. Daily scrubbing the eyelids gently with diluted baby shampoo or an over-the-counter eyelid cleaner and applying warm (but not hot) compresses several times a day is recommended.
 
−
 
 
−
Dermatological vascular [[laser]] (single wavelength) or [[Intense Pulsed Light]] (broad spectrum) machines offer one of the best treatments for rosacea, in particular the erythema (redness) of the skin.<ref name="JCutanLaserTher1999-Marla">{{cite journal | author=Marla C Angermeier | title=Treatment of facial vascular lesions with intense pulsed light | journal=J Cutan Laser Ther. | year=1999 | pages=95-100 | volume=1 | issue=2 | id=PMID 11357295}}</ref> They use light to penetrate the [[Epidermis (skin)|epidermis]] to target the capillaries in the [[dermis]] layer of the skin. The light is absorbed by oxy-[[hemoglobin]] which heat up causing the capillary walls to heat up to 70ºC, damaging them, causing them to be absorbed by the body's natural defense mechanism.
 
−
 
 
−
CO<sub>2</sub> lasers can be used to remove excess tissue caused by phymatous rosacea. CO<sub>2</sub> lasers emit a wavelength that is absorbed directly by the skin. The laser beam can be focused into a thin beam and used as a scalpel or defocused and used to vaporise tissue. Low level light therapies have also been used to treat rosacea.
 
−
One alternative skin treatment, fashionable in the Victorian and Edwardian eras, was Sulphur. Recently Sulphur has re-gained some credibility as a safe alternative to steroids and coal tar.
 
−
 
 
−
===Famous people===
 
−
Famous people with Rosacea include:
 
−
*[[Bill Clinton]].<ref>{{cite news | author=Jane E. Brody | title=Sometimes Rosy Cheeks Are Just Rosy Cheeks | url=http://query.nytimes.com/gst/fullpage.html?sec=health&res=9400E5DB1631F935A25750C0A9629C8B63 | date=March 16, 2004 | publisher=New York Times}}</ref>
 
−
*[[J. P. Morgan]]<ref>{{cite web | title=John Pierpont "J.P." Morgan | url=http://www.findagrave.com/cgi-bin/fg.cgi?page=gr&GRid=733 | date=Jan 1, 2001 | publisher=findagrave.com | accessdate=2007-03-26}}</ref>
 
−
*[[Diana, Princess of Wales]] {{Fact|date=February 2007}}
 
−
*[[W. C. Fields]]
 
−
*[[Alex Ferguson]]
 
−
*[[Rosie O'Donnell]] {{Fact|date=February 2007}}
 
−
*[[Mariah Carey]]<ref>{{cite news | title=I've Got Thighs and Buttocks | url=http://www.mcarchives.com/news/spec.asp?id=6271 | date=February 16, 2007 | publisher=Mariah Carey Archives | accessdate=2007-03-26}}</ref>
 
−
 
 
−
==Pseudofolliculitis barbae==
 
−
 
 
−
{{Infobox_Disease |
 
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  Name          = Pseudofolliculitis barbae |
 
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  Image          = |
 
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  Caption        = |
 
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  DiseasesDB    = 31373 |
 
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  ICD10          = {{ICD10|L|73|1|l|60}} |
 
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  ICD9          = {{ICD9|704.8}} |
 
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  ICDO          = |
 
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  OMIM          = |
 
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  MedlinePlus    = 000823 |
 
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  eMedicineSubj  = derm |
 
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  eMedicineTopic = 354 |
 
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  MeshID        = |
 
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}}
 
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'''Pseudofolliculitis barbae''' (pronounced /{{IPA|'suː.dɒ.fɒ.lɪk.kjuːˌliː.tɪs 'bɑː.beɪ}}/) is a medical term for persistent inflammation caused by [[shaving]]. The etymology comes from "pseudo" (false) "follicle" (hair) "itis" (inflammation) "barbae" (of the beard). It is also known by the initials '''PFB''' or colloquial terms such as '''"razor bumps."'''
 
−
 
 
−
PFB is most common on the male face, but it can also happen on other parts of the body where hair is shaved or plucked, especially areas where hair is curly and the skin is sensitive, such as [[pubic_hair|genital]] shaving (more properly termed ''psuedofolliculitis pubis'' or PFP).
 
−
 
 
−
After a hair has been shaved, it begins to grow back. Curly hair tends to curl into the skin instead of straight out the follicle. PFB can make the skin look itchy and red, and in some cases, it can even look like pimples. These inflamed papules or pustules can form especially if the area becomes infected. 
 
−
 
 
−
This is especially problematic for men of [[African]] descent and other people with curly hair. If left untreated over time, this can cause [[keloid]] scarring in the beard area.
 
−
 
 
−
===Prevention and treatment===
 
−
Prevention and treatment varies by person. Some males use shaving powders (a kind of [[chemical depilatory]]) to avoid the irritation. Others may use a [[razor]] with a single blade or special wire-wrapped blade to avoid shaving too closely. Some men trim or grow a beard instead of shaving. In severe cases or in occupations where shaving is a requirement (such as the military), some men get [[electrology|electrolysis]], [[laser hair removal]], or use [[exfoliation (cosmetology)|exfoliating product]]s to minimize PFB.
 
−
 
 
−
A 100% effective detreatment is to let the beard grow. Once the hairs get to be a certain length they will not grow back into the skin. For most cases, totally avoid shaving for 3 to 4 weeks until all lesions have subsided, while applying a mild prescription cortisone cream to the involved skin each morning.
 
−
 
 
−
Shaving every other day, rather than daily, will improve pseudo-folliculitis barbae. If one must use a blade, water soften the beard first with a hot, wet washcloth for 5 minutes.
 
−
 
 
−
Electrolysis and laser hair removal should be considered when all else fails, but these are expensive and take repeated visits. There is a very small risk of scarring. A few insurance companies will cover some or all of the cost.
 
−
 
 
−
Medications are also prescribed to speed healing of the skin. [[Glycolic acid]] lotion 8% (Alpha-hydrox, Neo-Strata, others) is effective. Prescription antibiotic gels (Benzamycin, Cleocin-T) or oral antibiotics are also used. Retin-A is a potent treatment that helps even out any scarring after a few months. It is added as a nightly application of Retin-A Cream 0.05 - 0.1% to the beard skin while beard is growing out. Use as tolerated, as it is somewhat irritating.
 
−
 
 
−
===Related conditions===
 
−
[[Razor burn]] is a less serious condition caused by shaving, characterized by mild to moderate redness and irritation on the surface of the skin. Unlike PFB, it is usually transient and there is no infection involved.
 
−
 
 
−
There is also a condition called ''[[folliculitis]] barbae''. The difference between the two is the cause of the inflammation in the hair follicles. Folliculitis barbae is caused by viral or bacterial infections, where pseudofolliculitis is caused by irritation from shaving and ingrown hairs.
 
−
 
 
−
A related condition,  '''''Pseudofolliculitis nuchae''''', occurs on the back of the neck, often along the posterior hairline, when curved hairs are cut short and allowed to grow back into the skin. Left untreated, this can develop into '''acne keloidalis nuchae''', a condition where hard, dark [[keloid]]-like bumps form on the neck.
 
−
 
 
−
 
 
−
==Hidradenitis suppurativa==
 
−
{{Infobox_Disease
 
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| Name          = Hidradenitis suppurativa
 
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| Image          =
 
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| Caption        =
 
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| DiseasesDB    = 5892
 
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| ICD10          = L73.2
 
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| ICD9          = {{ICD9|705.83}}
 
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| ICDO          =
 
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| OMIM          =
 
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| MedlinePlus    =
 
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| eMedicineSubj  = emerg
 
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| eMedicineTopic = 259
 
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| eMedicine_mult = {{eMedicine2|med|2717}} {{eMedicine2|derm|892}}
 
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| MeshID        =
 
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}}
 
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'''Hidradenitis suppurativa''' or '''HS''' is a [[skin disease]] that affects areas bearing [[apocrine]] [[sweat gland]]s and [[hair]] [[follicle]]s; such as the underarms, groin and buttocks, and under the breasts in women.
 
−
 
 
−
The disease manifests as clusters of chronic [[abscess]]es or [[boil]]s, sometimes as large as baseballs, that are extremely painful to the touch and may persist for years with occasional to frequent periods of [[inflammation]], culminating in drainage of [[pus]], often leaving open wounds that will not heal. Drainage provides some relief from severe, often debilitating, pressure pain.  Flare-ups may be triggered by stress, [[hormone|hormonal]] changes (such as monthly cycles in women), humid heat, and clothing friction. Persistent lesions may lead to scarring and the formation of sinus tracts, or tunnels connecting the abscesses under the skin. At this stage, complete healing is usually not possible, and progression varies from person to person, with some experiencing remission anywhere from months to years at a time, others may worsen and require surgery in order to live comfortably. Occurrences of bacterial infections and [[cellulitis]] (deep tissue inflammation) may occur at these sites. HS [[Pain and nociception|pain]] can be difficult to manage. [http://www.hs-usa.org/hidradenitis_suppurativa.htm]
 
−
 
 
−
HS often goes undiagnosed for years because patients are too ashamed to speak with anyone.[http://www.hs-usa.org/hidradenitis_suppurativa.htm] When they do see a doctor, the disease is frequently misdiagnosed or prescribed treatments are ineffective, temporary and sometimes even harmful. There is no known cure nor any consistently effective treatment. Carbon dioxide laser surgery is currently considered the last resort for those who have advanced to its highest stage, where the affected areas are excised, and the skin is grafted. Surgery doesn't always alleviate the condition, however, and can be very expensive.
 
−
 
 
−
It is possible that there is genetic predisposition to the disease. ([http://www.nature.com/jid/journal/v126/n6/abs/5700272a.html Gao, et al., 2006])  HS is not contagious,  and isn't affected nor caused by good or bad hygiene. HS is often called an 'orphan illness', due to little research being conducted on the disease at this time.  Because HS is considered a rare disease, its incidence rate is not well known, but has been estimated as being between 1:24 (4.1%) and 1:600 (0.2%).[http://hs-usa.org/pub/articles/prevalence.htm]
 
−
 
 
−
====Other names for HS====
 
−
Hidradenitis suppurativa has been referred to by multiple names in the literature, as well as in various cultures.  Some of these are also used to describe different diseases, or specific instances of this disease.  [http://hs-usa.org/hidradenitis_suppurativa.htm]
 
−
 
 
−
*Acne conglobata - not really a synonym - this is a similar process but in classic acne areas of chest and back
 
−
*Acne Inversa (AI) - a new term (Plewig and others) struggling for acceptance
 
−
*Apocrine Acne - a misnomer, out-dated, based on the disproven concept that apocrine glands are primarily involved
 
−
*Apocrinitis - another misnomer, out-dated, based on the disproven concept that apocrine glands are primarily involved
 
−
*Fox-den disease - a catchy term not used in medical literature, based on the deep fox den / burrow - like sinuses
 
−
*Hidradenitis Supportiva - a misspelling
 
−
*Pyodermia sinifica fistulans - an older term, considered archaic now, misspelled here
 
−
*Velpeau's disease - commemorating the French surgeon who first described the disease in 1833
 
−
*Verneuil's disease - recognizing the French surgeon whose name is most often associated with the disorder as a result of his 1854-1865 studies
 
−
 
 
−
===Stages===
 
−
HS presents itself in three stages.[http://www.hs-usa.org/hidradenitis_suppurativa.htm][http://dermnetnz.org/acne/hidradenitis-suppurativa.html]
 
−
 
 
−
# Solitary or multiple isolated abscess formation without scarring or sinus tracts.  (A few minor sites with rare inflammation; may be mistaken for [[Acne vulgaris|acne]].)
 
−
# Recurrent abscesses, single or multiple widely separated lesions, with sinus tract formation.  (Frequent inflammations restrict movement and may require minor surgery such as incision and drainage.)
 
−
# Diffuse or broad involvement across a regional area with multiple interconnected sinus tracts and abscesses.  (Inflammation of sites to the size of golf balls, or sometimes baseballs; scarring develops, including subcutaneous tracts of infection - see [[fistula]].  Obviously, patients at this stage may be unable to function.)
 
−
 
 
−
===Causes===
 
−
As this disease is poorly studied, the causes are controversial and experts disagree.  However, potential indicators include:
 
−
* post-pubescent
 
−
* females are more likely than males
 
−
* genetic predisposition
 
−
* plugged apocrine (sweat) gland or hair follicle
 
−
* excessive sweating
 
−
* [[bacteria]]l infection
 
−
* sometimes linked with other [[auto-immune]] conditions
 
−
* [[androgen]] dysfunction
 
−
* [[genetic disorder]]s that alter [[cell (biology)|cell]] structure
 
−
 
 
−
The historical understanding of the disease is that there is a misfunction in either the apocrine glands [http://dermnetnz.org/acne/hidradenitis-suppurativa.html] or hair folliciles [http://www.hs-foundation.org/abouths/what.htm], possibly triggered by a blocked gland, creating inflammation, pain, and a swollen lesion.  More recent studies imply there is an autoimmune component.{{Fact|date=February 2007}}  HS is '''not''' caused by any bacterial infection — any infection is secondary. Most cultures done on HS lesions come back negative for bacteria, so antibiotics should be used only when a bacterial infection has been confirmed by a physician.{{Fact|date=February 2007}}<sup>[http://www.acne-guide-pro.com]</sup>
 
−
 
 
−
Hidradenitis suppurativa is not contagious.
 
−
 
 
−
=== Severe complications ===
 
−
Left undiscovered, undiagnosed, or untreated, the fistulas from severe stage-3 HS can lead to the development of [[squamous cell carcinoma]] in the [[anus]] or other affected areas. ([http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6W8M-4J9N10S-2&_coverDate=02%2F28%2F2006&_alid=436410596&_rdoc=1&_fmt=&_orig=search&_qd=1&_cdi=6658&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=1747b618bf0e486fe96cbf1db30226b4 Talmont, et al., 2005]; [http://www.blackwell-synergy.com/doi/abs/10.1111/j.1365-2230.2005.01875.x Short, et al., 2005])
 
−
 
 
−
=== Treatments ===
 
−
Treatments may vary depending upon presentation and severity of the disease.  Due to the poorly-studied nature of this disease, the effectiveness of the drugs and therapies listed below is not yet clear, and patients should discuss all options with their doctor or dermatologist.  Nearly a quarter of patients state that nothing relives their symptoms [http://abscesses.org/hidradenitisSuppurativa/content/view/22/33/]. A list of treatments that are possible treatments for some patients is as follows.
 
−
 
 
−
* changes in [[Diet (nutrition)|diet]]
 
−
* warm compresses, baths (to induce drainage)
 
−
* intralesional [[corticosteroid]] injections (to reduce inflammation)
 
−
* [[incision and drainage]] or [[lancing (surgical procedure)|lancing]]
 
−
* oral [[antibiotics]] (to treat inflammation and bacterial infection)
 
−
* [[isotretinoin]] (Accutane®), a prescription-only oral acne treatment (benefits for HS are very controversial, but it is generally considered to be ineffective)
 
−
* [[wide local excision]] (with or without [[skin graft]]ing), or [[laser]] surgery
 
−
* [[radiotherapy]]
 
−
* [[anti-androgen]] therapy
 
−
* sub-cutaneous injection or [[IV]] infusion of anti-inflammatory (anti-[[TNF-alpha]]) drugs such as [[infliximab]] (Remicade®)and [[etanercept]] (Enbrel®).  This use of the drugs is not currently [[Food and Drug Administration]] (FDA) approved and is somewhat controversial, and therefore may not be covered by insurance.
 
−
* Acitretin
 
−
 
 
−
==Acne cosmetica==
 
−
'''Acne cosmetica''' is a term refering to [[acne]] caused by or made worse by [[cosmetics]].  The mechanism was presumably a [[chemical]]ly induced plugging of the [[pilosebaceous]] orifice.  This was a significant problem for [[dermatologist]]s in the 1970s and 1980s, but with the improved formulations produced by cosmetic [[chemists]] over the past thirty years, this is now a relatively rare diagnosis in daily practice.
 
−
 
 
−
The terms "non-comedogenic" and "non-acne(i)genic" appeared on [[moisturizer]]s and other cosmetic compounds as re-formulations were introduced, sometimes associated with claims that the products were oil-free or water-based.  Although early work produced lists of [[comedogenic]] chemicals in various strengths and vehicles, it became apparent that the actual [[comedogenicity]] of a product could not be predicted from its contents; rather the finished product itself needed to be use-tested.
 
−
 
 
−
The production of a low-grade [[folliculitis]] by some components of the cosmetic product has led to misdiagnosis on occasion.
 
−
 
 
−
 
 
−
==Acne fulminans==
 
−
'''Acne fulminans''', also known as [[Acne Maligna]], is a rare severe form of acne.
 
−
 
 
−
==Acne medicamentosa==
 
−
'''Acne medicamentosa''' is acne that is caused or aggravated by medication.  Because [[acne]] is generally a disorder of the [[pilosebaceous]] units caused by [[hormones]], the medications that trigger acne medicamentosa most frequently are hormones.
 
−
 
 
−
Although the male's hormone [[testosterone]] is most often blamed, and although men with acne secondary to [[bodybuilding]] hormones is seen from time to time, the major hormonal medication that causes acne is the [[progestin]] / progestagen present in [[birth control pills]].  Other medications can produce 'acneiform' eruptions (usually pimply bumps and [[pustules]] that look like acne).
 
−
 
 
−
Some conditions mimic acne medicamentosa.  The most common mimic is the [[yeast]] [[folliculitis]] produced by an overgrowth of the [[Malassezia]] species, often secondary to oral or systemic [[corticosteroids]], or secondary to broad-spectrum [[antibiotics]] such as the [[tetracycline]] family used in acne. This is often misinterpreted as 'tetracycline-resistant acne'.
 
−
 
 
−
==Baby acne==
 
−
'''Baby acne''', also known as '''acne neonatorum''', is a condition that affects roughly 20% of newborn babies. Lesions appear at around 2 weeks postpartum and commonly disappear after 3 months. Lesions include small, red, papules, which mainly affect the cheeks, as well as the nasal bridge of infants. [[Infant|Infants]] usually develop neonatal acne because of stimulation of the baby's [[sebaceous glands]] by lingering maternal hormones after delivery. These [[hormones]] cross the [[placenta]] into the baby and after delivery they cause the oil glands on the skin to form bumps that look like pimples.[http://www.womenshealthcaretopics.com/baby_acne.htm]
 
−
Baby acne usually clears up within a few weeks, but it can linger for months.
 
−
 
 
−
Tiny bumps on a baby's face after birth that disappear within a few weeks are called [[milia]] and are unrelated to baby acne.
 
−
 
 
−
Baby acne has recently been described to be caused by saprophytic yeast of the ''Malassezia'' species, which cause a primary skin infection leading to the appearance of acne-like pustules. Initially it was believed to be the common yeast species, ''Malassezia furfur'', which also causes 'cradle-cap' in infants. However, new publications have pointed to another species, ''Malassezia sympolais''. Treatment options are still the same for both species, which includes low dose topical antifungals.
 
−
 
 
−
==Chloracne==
 
−
{{Infobox_Disease
 
−
| Name          = {{PAGENAME}}
 
−
| Image          = Viktor Yuschenko.jpg
 
−
| Caption        = An example of chloracne on [[Viktor Yushchenko]]
 
−
| DiseasesDB    = 31706
 
−
| ICD10          = {{ICD10|L|70|8|l|60}}
 
−
| ICD9          =
 
−
| ICDO          =
 
−
| OMIM          =
 
−
| MedlinePlus    =
 
−
| eMedicineSubj  = topic
 
−
| eMedicineTopic = 620
 
−
| eMedicine_mult = <br>(Acneiform Eruptions)
 
−
| MeshID        =
 
−
}}
 
−
'''Chloracne''' is an [[Acne vulgaris|acne]]-like eruption of [[blackhead]]s, [[cyst]]s, and [[pustule]]s associated with over-exposure to certain [[halogen]]ic [[aromatic hydrocarbon]]s, such as [[chlorine|chlorinated]] [[dioxin]]s and [[dibenzofuran]]s. The lesions are most frequently found on the cheeks, behind the ears, in the armpits and groin region.
 
−
 
 
−
The condition was first described in German industrial workers in 1897 by Von Bettman, and was initially believed to be caused by exposure to toxic [[chlorine]] (hence the name "chloracne"). It was only in the mid-1950s that chloracne was associated with aromatic hydrocarbons<ref name="ref1">Williams, D.E.; Wolfe, W.H.; Lustik, M.B. ''et al.'' (1995). ''An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides.'' Vol. 4.</ref>. The substances that may cause chloracne are now collectively known as "chloracnegens".
 
−
 
 
−
Chloracne is particularly linked to toxic exposure to [[dioxin]]s (byproducts of many chemical processes, including the manufacture of [[herbicides]] such as [[Agent Orange]]) &mdash; so much so that it is considered a clinical sign of dioxin exposure. The severity and onset of chloracne may follow a typical [[asymptote|asymptotic]] [[dose response]] [[curve]].
 
−
 
 
−
===Etiology and progression===
 
−
Chloracne normally results from direct skin contact with chloracnegens, although ingestion and inhalation are also possible causative routes.
 
−
 
 
−
Chloracnegens are fat-soluble, meaning they persist in the body fat for a very long period following exposure. Chloracne is a chronic [[inflammation|inflammatory]] condition that results from this persistence, in combination with the toxin's chemical properties. It is believed, at least from [[rodent]] models, that the toxin activates a series of [[receptor (biochemistry)|receptors]] promoting [[macrophage]] proliferation, inducing [[neutrophilia]] and leading to a generalised inflammatory response in the skin. This process may also be augmented by induction of excess [[tumor necrosis factor]] in the blood [[blood plasma|serum]].
 
−
 
 
−
The inflammatory processes lead to the formation of [[keratin]]ous plugs in skin pores, forming yellowish cysts and dark pustules. The skin lesions occur mainly in the face, but in more severe cases they involve the shoulders and chest, the back, and the abdomen. In advanced cases, the lesions appear also on the arms, thighs, legs, hands and feet.
 
−
 
 
−
In some instances, chloracne may not appear for three to four weeks after toxic exposure; however in other cases - particularly in events of massive exposure - the symptoms may appear within days <ref name="ref1"/><ref name="ref2">De Marchia, B, and Ravetzb, J.R. (1999). Risk management and governance: a post-normal science approach. ''Futures'' 31:743–757.</ref>.
 
−
 
 
−
===Treatment===
 
−
Once chloracne has been identified, the primary action is to remove the patient and all other individuals from the source of contamination. Further treatment is [[symptomatic]].
 
−
 
 
−
Severe or persistent lesions may be treated with oral [[antibiotics]] or [[isotretinoin]]. However, chloracne may be highly resistant to any treatment.
 
−
 
 
−
The course of the disease is highly variable. In some cases the lesions may resolve within two years or so; however, in other cases the lesions may be effectively permanent (mean duration of lesions in one 1984 study was 26 years, with some workers remaining disfigured over three decades after exposure <ref name="ref3">Moses, M. ''et al.'' (1984). ''American Journal of Industrial Medicine'' 5(3):161-82.</ref>).
 
−
 
 
−
Recent research by groups at [[University of Cincinnati]] School of Medicine in [[Ohio]] and the [[University of Western Australia]] indicated that [[Polychlorinated biphenyl|PCB]] poisoning, including chloracne symptoms, can be treated with fat substitute [[olestra]].
 
−
 
 
−
==Related conditions==
 
−
Chloracne is very often seen in combination with [[hyperhidrosis]] (clammy, sweaty skin) and [[porphyria cutanea tarda]] (a skin condition of increased pigmentation, hair coarsening and blistering).
 
−
 
 
−
===Notable cases===
 
−
* 193 cases of chloracne occurred in [[Seveso]], [[Italy]] in 1976 following the [[Seveso disaster]] in which several kilograms of [[dioxin|TCDD]] were released into the atmosphere.
 
−
 
 
−
* Hundreds of individuals suffered chloracne after chronic exposure to [[PCB]]s and [[PCDF]]s in central [[Taiwan]] in 1979.
 
−
 
 
−
* Ukrainian President [[Viktor Yushchenko]] suffered from extremely prominent facial chloracne after being diagnosed with dioxin [[poison]]ing in late 2004. His diagnosis of chloracne was put forth by prominent toxicologist [[John Henry (toxicologist)|John Henry]].
 
−
 
 
−
==Footnotes==
 
−
<!--This article uses the Cite.php citation mechanism. If you would like more information on how to add references to this article, please see http://meta.wikimedia.org/wiki/Cite/Cite.php —>
 
−
<div class="references-small"><references/></div>
 
  
 +
The treatment for severe scarring include punch excision, punch elevation, subcutaneous incision, scar excision, and laser skin resurfacing.
  
 +
==Notes==
 +
<references/>
  
 
==References==
 
==References==
−
* {{cite journal | author=James W | title=Clinical practice. Acne. | journal=N Engl J Med | volume=352 | issue=14 | pages=1463-72 | year=2005 | month=April 7 | id=PMID 15814882}}
+
* Habif, T. P. ''Clinical Dermatology: A Color Guide to Diagnosis and Therapy''. Edinburgh: Mosby, 2004. ISBN 0323013198.
−
* {{cite journal | author=Webster G | title=Acne vulgaris. | journal=BMJ | volume=325 | issue=7362 | pages=475-9 | year=2002 | month=31 August | id=PMID 12202330  | url=http://bmj.bmjjournals.com/cgi/content/full/325/7362/475}}
+
* James, W. Clinical practice. Acne. ''N Engl J Med'' 352(14) (2005): 1463-1472. PMID 15814882.
−
 
+
* Webster, G. F. [http://bmj.bmjjournals.com/cgi/content/full/325/7362/475 Acne vulgaris]. ''BMJ'' 325(7362) (2002): 475-479. PMID 12202330. Retrieved December 30, 2019.
−
 
 
−
 
 
−
==External links==
 
−
*[http://en.wikibooks.org/wiki/Rosacea/Websites_and_Organisations Directory of rosacea organisations and websites]
 
−
*[http://www.rosacea.org National Rosacea Society (U.S.)]
 
−
*[http://www.irosacea.org Rosacea Research & Development Instititute (U.S.)]
 
−
 
 
  
 
{{credit|Acne|118690628|Acne_vulgaris|118706845|Rosacea|118642784|Hidradenitis_suppurativa|118670391|Pseudofolliculitis_barbae|117787586|Acne_cosmetica|116447014|Acne_fulminans|118143079|Acne_medicamentosa|118611711|Baby_acne|112618008|Chloracne|104024336}}
 
{{credit|Acne|118690628|Acne_vulgaris|118706845|Rosacea|118642784|Hidradenitis_suppurativa|118670391|Pseudofolliculitis_barbae|117787586|Acne_cosmetica|116447014|Acne_fulminans|118143079|Acne_medicamentosa|118611711|Baby_acne|112618008|Chloracne|104024336}}
 +
[[Category:Life sciences]]
 +
[[Category:Health and disease]]
 +
[[Category:Diseases]]

Latest revision as of 00:54, 31 December 2019

Acne
Akne-jugend.jpg

Acne of a 14 year old boy during puberty
ICD-10 L70.0
ICD-O:
ICD-9 706.1
OMIM [1]
MedlinePlus 000873
eMedicine derm/2
DiseasesDB 10765

Acne is a group of skin rashes that have different causes but present with similar lesions. It is a condition that affects humans as well as some mammals, and being the most common skin disease, it is considered by some as a part of the normal human growth process. It varies in its etiology, as well as its severity. Occasionally a direct cause may be identified, while commonly no inciting agent is ever seen. Acne is an important and sometimes overlooked state, which if left untreated could lead to a lifetime of disease sequelae, such as scarring and skin hyperpigmentation. Some forms have been associated with even more severe acute manifestations that require emergent therapy.

Some forms of acne include:

  • Acne vulgaris - most commonly experienced around puberty, typically of the face and shoulders/chest
  • Acne rosacea - a red rash predominantly on the face
  • Acne keloidalis nuchae - a rash caused by shaving particularly on the nape of the neck
  • Acne conglobata - chronic form of inflammatory acne marked by communicating blackheads, communicating cysts, abscesses, papules, pustules, and draining sinus tracts
  • Acne fulminans - an extreme form of acne conglobata
  • Acne cosmetica - acne caused by cosmetics
  • Acne medicamentosa - acne caused by starting or stopping a medicine
  • Baby acne - a rash seen on the cheeks, chin, and forehead of infants
  • Chloracne - an acne rash caused by exposure to chlorinated hydrocarbons such as dioxins or PCBs

When used generically, the term "acne" refers to acne vulgaris. Even though broadly stated under the category of acne, the various conditions stated above are separate disease entities. However, they present with similar lesions.

While acne has a variety of causes, and rarely is a direct cause identified, in some cases it is clearly tied to human social responsibility, such as the cases of acne resulting from cosmetics or chlorinated hydrocarbons. Furthermore, individuals have an individual responsibility for treatment, given the potential for later scarring. On the other hand, as undesirable as acne is for the sufferer, it is almost always a temporary condition, with effects that diminish and disappear over time. The main responsibility for the sufferer may be an internal one, to maintain a healthy balance in one's life with a positive attitude where physical appearance is not overemphasized.

Acne vulgaris

Different types of Acne Vulgaris: A: Cystic acne on the face, B: Subsiding tropical acne of trunk, C: Extensive acne on chest and shoulders.

Acne vulgaris is an inflammatory disease of the skin, caused by changes in the pilosebaceous units (skin structures consisting of a hair follicle and its associated sebaceous gland). Acne lesions are commonly referred to as pimples, spots, or zits.

Acne vulgaris is the most common form of acne. Acne affects a large percentage of humans at some stage in life. The condition is most common during puberty and is considered an abnormal response to normal levels of the male hormone testosterone. The response for most people diminishes over time and acne thus tends to disappear, or at least decrease, after one reaches his or her early twenties. However, there is no way to predict how long it will take for it to disappear entirely, as some individuals will continue to suffer from acne decades later into their thirties, forties, and beyond.

Overview and symptoms

Excessive secretion of oils from the sebaceous glands (mostly due to gland enlargement during puberty), accompanied by the plugging of the pores with naturally occurring dead skin cells (corneocytes), results in a blockade of the hair follicles. The accumulation of these corneocytes in the duct appears to be due to a failure of the normal keratinization process in the skin that usually leads to shedding of skin cells lining the pores.

Once this defect in the keratinization process leads to these cells blocking the pore, the oil build up within the pore provides a favorable environment for the bacteria Propionibacterium acnes to multiply uncontrollably. In response to the bacterial populations, there is inflammation with attraction of white blood cells (neutrophils) to combat the bacteria, producing the visible lesion.

The lesions have a propensity to affect the face, chest, back, shoulders, and upper arms. The lesions occur as various forms and include comedones, papules, pustules, nodules, and inflammatory cysts. Commonly, a pore that remains open (open comedo) but continues to distend with the keratinocytes, then sebum oxidized by the bacteria, as well as the skin pigment melanin, is referred to as a "blackhead." On the contrary, when a pore is occluded (closed comedo) by the dead skin cells, leading to accumulation of the materials below it, it is referred to as a "whitehead." Cysts, pustules, papules, and nodules are more extensive lesions that usually arise when the accumulations within the pore rupture into the surrounding skin. The level of the rupture determines the severity of these lesions. After resolution of acne lesions, prominent unsightly scars may remain. Hyperpigmentation of the skin around the lesion also has been noted, especially in darker skinned individuals.

Aside from scarring, its main effects are psychological, such as reduced self-esteem,[1] depression, embarrassment, and rarely suicide.[2]One study has estimated the incidence of suicidal ideation in patients with acne as high as 7.1 percent [3] Acne usually appears during adolescence, when people already tend to be most socially insecure. Early and aggressive treatment is therefore advocated to lessen the overall impact to individuals.[1]

Factors in getting acne

Exactly why some people get acne and some do not is not fully known. It is known to be partly hereditary. Several factors are known to be linked to acne lesion formation:

  • Hormonal activity, such as menstrual cycles and puberty
  • Stress, through increased output of hormones from the adrenal (stress) glands
  • Hyperactive sebaceous glands, secondary to the three hormone sources stated above
  • Accumulation of dead skin cells
  • Bacteria in the pores, particularly Propionibacterium acnes
  • Skin irritation or scratching, resulting in inflammation
  • Use of anabolic steroids
  • Any medication containing halogens (iodides, chlorides, bromides), lithium, barbiturates, or androgens
  • Exposure to high levels of chlorine compounds, particularly chlorinated dioxins, causing severe, long-lasting acne, known as Chloracne
  • Pregnancy, disorders such as Polycystic ovary syndrome (PCOS),Cushing's syndrome, and increasing cases of menopause-associated acne as fewer women replace the natural anti-acne ovarian hormone estradiol whose production fails as women arrive at menopause.

Misconceptions: There are many misconceptions about what does and does not cause the condition including diet, hygiene, and sexual activity. Various studies have been done, but the role of these factors still remains unclear and uncertain.

Other types of acne

Acne cosmetica

Acne cosmetica refers to acne caused by or made worse by cosmetics. The mechanism was presumably a chemically induced plugging of the pilosebaceous orifice. This was a significant problem for dermatologists in the 1970s and 1980s, but with the improved formulations produced by cosmetic chemists over the past thirty years, this is now a relatively rare diagnosis in daily practice.

The terms "non-comedogenic" appeared on moisturizers and other cosmetic compounds as re-formulations were introduced, sometimes associated with claims that the products were oil-free or water-based. Although early work produced lists of comedogenic chemicals in various strengths and vehicles, it became apparent that the actual comedogenicity of a product could not be predicted from its contents; rather the finished product itself needed to be use-tested.

The production of a low-grade folliculitis by some components of the cosmetic product has led to misdiagnosis on occasion.

Acne medicamentosa

Acne medicamentosa refers to acne that is caused or aggravated by medication. Because acne is generally a disorder of the pilosebaceous units caused by hormones, the medications that trigger acne medicamentosa most frequently are hormones.

Although the male's hormone testosterone is most often blamed, and although men with acne occurring secondary to bodybuilding hormones is seen from time to time, the major hormonal medication that causes acne is the progestin/progestagen present in birth control pills.[4] Other medications can produce 'acneiform' eruptions (usually pimply bumps and pustules that look like acne).

Some conditions mimic acne medicamentosa. The most common mimic is the yeast folliculitis produced by an overgrowth of the Malassezia species, often secondary to oral or systemic corticosteroids, or secondary to broad-spectrum antibiotics such as the tetracycline family used in acne. This is often misinterpreted as "tetracycline-resistant acne."

Acne neonatorum

Acne neonatorum (Baby acne) refers to a condition that affects roughly 20% of newborn babies. Lesions appear at around two weeks postpartum and commonly disappear after three months. Lesions include small, red, papules, which mainly affect the cheeks, as well as the nasal bridge of infants. Infants usually develop neonatal acne because of stimulation of the baby's sebaceous glands by lingering maternal hormones after delivery. These hormones cross the placenta into the baby and after delivery they cause the oil glands on the skin to form bumps that look like pimples. Baby acne usually clears up within a few weeks, but it can linger for months.

Commonly mistaken for baby acne, tiny bumps on a baby's face after birth that disappear within a few weeks are called milia and are unrelated.

Chloracne

Chloracne is an acne-like eruption of blackheads, cysts, and pustules associated with over-exposure to certain halogenic aromatic hydrocarbons, such as chlorinated dioxins and dibenzofurans. The lesions are most frequently found on the cheeks, behind the ears, in the armpits and groin region.

The condition was first described in German industrial workers in 1897 by Von Bettman, and was initially believed to be caused by exposure to toxic chlorine (hence the name "chloracne"). It was only in the mid-1950s that chloracne was associated with aromatic hydrocarbons[5]. The substances that may cause chloracne are now collectively known as "chloracnegens."

In some instances, chloracne may not appear for three to four weeks after toxic exposure; however in other cases, particularly in events of massive exposure, the symptoms may appear within days.[6]. Once chloracne has been identified, the primary action is to remove the patient and all other individuals from the source of contamination. Further treatment is symptomatic.

Severe or persistent lesions may be treated with oral antibiotics or isotretinoin. However, chloracne may be highly resistant to any treatment.

Acne fulminans

Acne fulminans (acne maligna) is a rare and severe form of acne involving a sudden onset of bleeding and ulcerative acne lesions spreading over the face, back, and chest. It may be part of SAPHO syndrome, which comprises of synovitis, acne, pustulosis, hyperostosis, and osteitis. It is a severe condition treated with wound care, corticosteriods, nonsteroidal anti-inflammatory drugs, isotretinoin, and infliximab.[7].

Acne conglobata

Acne conglobata refers to a chronic form of inflammatory acne marked by communicating blackheads, communicating cysts, abscesses, papules, pustules, and draining sinus tracts. Due to its chronic and highly inflammatory course, it usually ends with keloidal and atrophic scarring. It is part of a larger follicular occlusion syndrome consisting of acne conglobata, hidradenitis suppurativa, and dissecting cellulitis of the scalp.

Acne keloidalis nuchae

Acne keloidalis nuchae refers to a condition of unknown etiology marked by the presence of perifollicular papules and nodules on the nape of the neck. Limiting frequent and close shaving and have been found to be somewhat helpful, along with topical retinoids and benzoyl peroxide products. [8]

Acne rosacea

Acne rosacea is a chronic cutaneous condition affecting the chin, cheeks, nose, and forehead. It is characterized by the presence of flushing, erythema, telangiectasia (spider veins), rhinophyma (of the nose), swelling, papules, pustules, and may even involve the eye.[9] It is currently treated with tetracyclines, topical antibiotics such as metronidazole, as well as other measures to provide symptomatic treatments.[10]

Treatments

Timeline of acne treatment

The history of acne reaches back to the dawn of recorded history. In Ancient Egypt, it is recorded that several pharaohs were acne sufferers. From Ancient Greece comes the English word "acne" (meaning "point" or "peak"). Acne treatments are also of considerable antiquity:

  • Ancient Rome : bathing in hot, and often sulfurous, mineral water was one of the few available acne treatments. One of the earliest texts to mention skin problems is De Medicina by the Roman writer Celsus.
  • 1800s: Nineteenth century dermatologists used sulphur in the treatment of acne. It was believed to dry the skin.
  • 1920s: Benzoyl Peroxide is used
  • 1930s: Laxatives were used as a cure for what were known as 'chastity pimples'
  • 1950s: When antibiotics became available, it was discovered that they had beneficial effects on acne. They were taken orally to begin with. Much of the benefit was not from killing bacteria but from the anti-inflammatory effects of tetracycline and its relatives. Topical antibiotics became available later.
  • 1960s: Tretinoin (original Trade Name Retin A) was found effective for acne. This preceeded the development of oral isotretinoin (sold as Accutane and Roaccutane) since the early 1980s.
  • 1980s: Accutane is introduced in America
  • 1990s: Laser treatment introduced
  • 2000s: Blue/red light therapy

Some old treatments, like laxatives, have fallen into disuse but others, like spas, are recovering their popularity.

Available treatments

There are many products sold for the treatment of acne, many of them without any scientifically-proven effects. Generally speaking, successful treatments manifest usually after eight weeks, the time it takes for a comedone to mature completely. Other treatments may offer quick, temporary relief as they reduce inflammation.

Modes of improvement are not necessarily fully understood but in general treatments are believed to work in at least 4 different ways (with many of the best treatments providing multiple simultaneous effects):

  • normalizing shedding into the pore to prevent blockage
  • killing Propionibacterium acnes
  • anti-inflammatory effects
  • hormonal manipulation

A combination of treatments can greatly reduce the amount and severity of acne in many cases. Those treatments that are most effective tend to have greater potential for side effects and need a greater degree of monitoring, so a step-wise approach is often taken. Many people consult with doctors when deciding which treatments to use, especially when considering using any treatments in combination. There are a number of treatments that have been proven effective:

For comedonal acne:

This type is mild in nature and is characterized by the presence of comedones without much surrounding inflammation. The treatment of this entity focuses on the correction of the abnormal follicular keratinization process. Drugs such as topical retinoids (i.e., tretinoin, adapalene, tazorotene), are preferred and available only by prescription.[11] Many over the counter preparations containing salicylic acid, benxoyl peroxide, or glycolic acid have also been found to have some use as they exhibit antimicrobial and comedolytic properties. They are especially useful when the side effects of the retinoids (excessive dry skin) can not be tolerated.[12]. Mechanical methods to open the pores are also used as an adjunct to the topical medications.

Cotton pads soaked in salicylic acid solution
Benzoyl peroxide cream.

For mild to moderate inflammatory acne:

As comedonal acne progresses with the appearance of increasing inflammatory lesions, combination therapy has proved to be very efficacious. A topical antibiotic (i.e. erythromycin, clindamycin, metronidazole) along with a topical retinoid, are being used together with greater success than either agent alone.[13] Benzoyl peroxide or adapalene are also being used in combinations with the topical antibiotics and topical retinoids with greater success than either agent alone.[14][15].

For moderate to severe inflammatory acne:

As lesions progress to involve larger areas on the face as well as other body parts such as the back and trunk, topical therapies combining benzoyl peroxide, topical antibiotics, and topical retinoids are used to provide relief.[16] Patients not responding to this therapy are requested to add an oral antibiotic (ie. tetracycline, doxycycline, trimethoprim-sulfamethoxazole, etc.) or isotretinoin. [17] It is important to note that isotretinoin carries potentially severe side effects that require strict monitoring and stringent guidelines before it is prescribed. Women that have been found to have hormonal abnormalities may also benefit from estrogen or antiandrogenic hormonal therapy.[18]

Photo, laser, and heat therapies

Of these various modalities that have been approved for the treatment of acne, phototherapy with high intensity narrow-band blue light (405 to 420nm) is the only therapy that has been proven to be efficacious in the treatment of acne.[19]. The equipment or treatment, however, is relatively new and reasonably expensive, and therefore not generally recommended or used for this purpose.

Alternate treatments

These are treatments, generally home remedies, that are used with or without success around the world:

  • Zinc - Orally administered zinc gluconate has been shown to be effective in the treatment of inflammatory acne.[20][21]
  • Tea tree oil (Melaleuca oil)|Tea Tree Oil (Melaleuca Oil) has been used with some success, and has been shown to be an effective anti-inflammatory agent in skin infections [22]
  • Niacinamide (Vitamin B3) is used topically in the form of a gel. The property of topical niacinamide's benefit in treating acne seems to be its anti-inflammatory nature.
  • In some cases, people found bathing in salt water noticed lessened redness and decreased size in their acne.
  • There are also certain treatments for acne mentioned in Ayurveda using herbs such as Aloevera, Aruna, Haldi, and Papaya.

Future treatments

Laser surgery has been in use for some time to reduce the scars left behind by acne, but research is now being done on lasers for prevention of acne formation itself. The laser is used to produce one of the following effects:

  • to burn away the follicle sac from which the hair grows
  • to burn away the sebaceous gland which produces the oil
  • to induce formation of oxygen in the bacteria, killing them

Because acne appears to have a significant hereditary link, there is some expectation that cheap whole-genome DNA sequencing may help isolate the body mechanisms involved in acne more precisely, possibly leading to a more satisfactory treatment. However, DNA sequencing is not yet cheap, and all this may still be decades off. It is also possible that gene therapy could be used to alter the skin's DNA.

Phage therapy has been proposed to kill Propionibacterium acnes and has seen some use.[23]

Acne scars

Severe acne often leaves small scars where the skin gets a "volcanic" shape. Acne scars are difficult and expensive to treat, and it is unusual for the scars to be successfully removed completely.

Acne scars generally fall into two categories: physical scars and pigmented scars. Physical acne scars are often referred to as "icepick" scars. This is because the scars tend to cause an indentation in the skins surface. Pigmented scars are usually the result of nodular or cystic acne. They often leave behind an inflamed red mark. Often, the pigmentation scars can be avoided simply by avoiding aggravation of the nodule or cyst. When sufferers try to "pop" cysts or nodules, pigmentation scarring becomes significantly worse, and may even bruise the affected area.

The treatment for severe scarring include punch excision, punch elevation, subcutaneous incision, scar excision, and laser skin resurfacing.

Notes

  1. ↑ 1.0 1.1 G. Goodman, "Acne and acne scarring: the case for active and early intervention," Aust Fam Physician 35(7) (2006): 503-504. PMID 16820822. Retrieved December 30, 2019.
  2. ↑ D. Purvis, E. Robinson, S. Merry, and P. Watson, "Acne, anxiety, depression and rarely suicide in teenagers: a cross-sectional survey of New Zealand secondary school students," J Paediatr Child Health 42(12) (2006): 793-796. PMID 17096715.
  3. ↑ A. Picardi, E. Mazzotti, and P. Pasquini, "Prevalence and correlates of suicidal ideation among patients with skin disease," J Am Acad Dermatol 54(3) (2006): 420-426. PMID 16488292.
  4. ↑ J. Tan, "Hormonal treatment of acne: review of current best evidence," J Cutan Med Surg; 8 Suppl 4(2004): 11.
  5. ↑ D. E. Williams, W. H. Wolfe, M. B. Lustik, et al., An Epidemiologic Investigation of Health Effects in Air Force Personnel Following Exposure to Herbicides. Vol. 4. (1995)
  6. ↑ B. De Marchia, and J. R. Ravetzb, "Risk management and governance: a post-normal science approach," Futures 31(1999): 743–757.
  7. ↑ M. Iqbal, and M. Kolodney, "Acne fulminans with synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) syndrome treated with infliximab," Journal of the American Academy of Dermatology 52(Suppl 1, 2005): 5.
  8. ↑ A. Yan, "Current concepts in acne management," Adolescent Medicine Clinics 17(2006): 3.
  9. ↑ J. Wilkin, M. Dahl, M. Detmar, L. Drake, A. Feinstein, R. Odom, and F. Powell, "Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea," Journal of the American Academy of Dermatology 46(2002): 4.
  10. ↑ E. J. van Zuuren, A. Gupta, M. Gover, M. Graber, and S. Hollis, "Systematic review of rosacea treatments," Journal of the American Academy of Dermatology 56 (2007): 1.
  11. ↑ J. J. Leyden, "Therapy for acne vulgaris," New England Journal of Medicine 336(1997): 1156.
  12. ↑ J. S. Weiss, "Current options for the topical treatment of acne vulgaris," Pediatric Dermatology 14(1997): 480.
  13. ↑ W. F. Bergfeld, and R. B. Odom, "New perspectives on acne," Clinician 12(1996): 4.
  14. ↑ S. Hurwitz, "Acne vulgaris: pathogenesis and management," Pediatric Review 15(1994): 47.
  15. ↑ D. P. Lookingbill, D.K. Chalker, J. S. Lindholm, "Treatment of acne with a combination clindamycin/benzoyl peroxide gel and vehicle gel: Combined results of two double-blind investigations," Journal of the American Academy of Dermatology 37(1997): 590.
  16. ↑ Bergfeld, (1996): 4
  17. ↑ J. Leyden, D. M. Thiboutot, A. R. Shalita, et al., "Comparison of tazarotene and minocycline maintanence therapies in acne vulgaris: a multicenter, double blind, randomized, parallel-group study," Archives Dermatology 142(2006): 605.
  18. ↑ Leyden, (1997): 1156.
  19. ↑ A. Kawada, Y. Aragane, H. Kameyama, et. al., "Acne phototherapy with high intensity, enhanced, narrow band, blue light source: an open study and in vitro investigation," Journal of Dermatological Science 30(2002): 129.
  20. ↑ B. Dreno, P. Amblard, P. Agache, S. Sirot, and P. Litoux, "Low doses of zinc gluconate for inflammatory acne," Acta Derm Venereol 69(6, 1989): 541-543. PMID 2575335. Retrieved December 30, 2019.
  21. ↑ B. Dreno, D. Moyse, M. Alirezai, P. Amblard, N. Auffret, C. Beylot , I. Bodokh, M. Chivot, F. Daniel, P. Humbert, J. Meynadier, and F. Poli, "Multicenter randomized comparative double-blind controlled clinical trial of the safety and efficacy of zinc gluconate versus minocycline hydrochloride in the treatment of inflammatory acne vulgaris," Dermatology 203(2, 2001): 135-140. PMID 11586012. Retrieved December 30, 2019.
  22. ↑ K. J. Koh, A. L. Pearce, G. Marshman, J. J. Finlay-Jones, and P. H. Hart, "Tea tree oil reduces histamine-induced skin inflammation," Dermatology (2002): 147. ISSN 0007-0963
  23. ↑ M. D. Farrar, K. M. Howson, R. A. Bojar, D. West, J. C. Towler, J. Parry, K. Pelton, and K. T. Holland, "Genome sequence and analysis of a Propionibacterium acnes bacteriophage," J Bacteriol 189(11, 2007): 4161-4167. PMID 17400737. Retrieved December 30, 2019.

References
ISBN links support NWE through referral fees

  • Habif, T. P. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. Edinburgh: Mosby, 2004. ISBN 0323013198.
  • James, W. Clinical practice. Acne. N Engl J Med 352(14) (2005): 1463-1472. PMID 15814882.
  • Webster, G. F. Acne vulgaris. BMJ 325(7362) (2002): 475-479. PMID 12202330. Retrieved December 30, 2019.

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