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 |
Line 20: Line 5:
 
   Caption    = Acne of a 14 year old boy during [[puberty]] |
 
   Caption    = Acne of a 14 year old boy during [[puberty]] |
 
   DiseasesDB  = 10765|
 
   DiseasesDB  = 10765|
 +
  ICDO        = |
 
   ICD10      = {{ICD10|L|70|0|l|60}} |
 
   ICD10      = {{ICD10|L|70|0|l|60}} |
 
   ICD9        = {{ICD9|706.1}} |
 
   ICD9        = {{ICD9|706.1}} |
 +
  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 (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 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 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.
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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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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, sebum oxidized by the bacteria, as well as the skin pigment melanin, is reffered 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 reffered to as a "whitehead." Cysts, pustules, papules, and nodules are severer lesions that usually form 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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* [[#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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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 fulminans|Acne fulminans]] - an extreme form of acne conglobata
 +
* [[#Acne cosmetica|Acne cosmetica]] - acne caused by cosmetics
 +
* [[#Acne medicamentosa|Acne medicamentosa]] - acne caused by starting or stopping a medicine
 +
* [[#Acne neonatorum|Baby acne]] - a rash seen on the cheeks, chin, and forehead of infants
 +
* [[#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.
+
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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'''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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====Available treatments====
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==Other types of acne==
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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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===Acne cosmetica===
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*normalising shedding into the pore to prevent blockage
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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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*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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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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[[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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The production of a low-grade folliculitis by some components of the cosmetic product has led to misdiagnosis on occasion.
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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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===Acne medicamentosa===
  
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=====Topical Bactericidals=====
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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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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.<!--
 
  
 +
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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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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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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Other antibacterials that have been used include [[triclosan]], or [[chlorhexidine gluconate]] but these are often less effective.
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===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.
  
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=====Topical antibiotics=====
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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.
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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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===Chloracne===
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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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''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.
  
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=====Hormonal treatments=====
+
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."
−
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.
 
  
−
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.
+
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.
  
−
=====Topical retinoids=====
+
Severe or persistent lesions may be treated with oral antibiotics or isotretinoin. However, chloracne may be highly resistant to any treatment.
−
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.
 
  
−
=====Oral retinoids=====
+
===Acne fulminans===
−
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 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>.   
−
  --><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>
 
−
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>
 
  
−
=====Phototherapy=====
+
===Acne conglobata===
−
======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>
 
−
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.<!--
 
−
  —><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>
 
−
Particularly when applied over several days, these free radicals ultimately kill the bacteria.<!--
 
−
  —><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>
 
−
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.
 
  
 +
''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===
  
−
====Less widely used treatments====
+
''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>
−
* [[Azelaic acid]] (brand names ''Azelex'', ''Finevin'', ''Skinoren'') is suitable for mild, comedonal acne.<!--
 
−
  —><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====
+
===Acne rosacea===
−
[[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 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>
  
−
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.
+
==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
  
−
[[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>
+
Some old treatments, like laxatives, have fallen into disuse but others, like spas, are recovering their popularity.
  
−
==== Preferred treatments by types of acne vulgaris ====
+
===Available treatments===
−
*[[Comedo]]nal (non-inflammatory) acne: local treatment with [[azelaic acid]], [[salicylic acid]], topical [[retinoids]], benzoyl peroxide.
+
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]].
−
*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>
 
  
−
===Acne scars===
+
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):
−
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.
+
*normalizing shedding into the pore to prevent blockage
−
Acne scars generally fall into two categories: physical scars and pigmented scars.
+
*killing ''Propionibacterium acnes''
−
Physical acne scars are often referred to as "Icepick" scars. This is because the scars tend to cause an indentation in the skins surface.
+
*anti-inflammatory effects
−
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.
+
*hormonal manipulation
−
The treatment for severe scarring is usually surgical in nature.
 
  
−
=== Grading scale ===
+
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:
−
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:
 
−
''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).
 
  
 +
====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.<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. 
  
−
==
+
[[Image:Salicylic acid pads.jpg|thumb|right|250px|Cotton pads soaked in salicylic acid solution]]
 +
[[Image:Benzoyl peroxide gel.jpg|thumb|right|250px|Benzoyl peroxide cream.]]
  
−
==Acne cosmetica==
+
====For mild to moderate inflammatory acne:====
−
'''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.
+
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 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.  
+
====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.<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>
  
−
The production of a low-grade [[folliculitis]] by some components of the cosmetic product has led to misdiagnosis on occasion.
+
====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.<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.
  
 +
====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.
  
−
==Acne fulminans==
+
====Future treatments====
−
'''Acne fulminans''', also known as [[Acne Maligna]], is a rare severe form of acne.
+
[[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
  
−
==Acne medicamentosa==
+
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.
−
'''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).  
+
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>
  
−
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 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.
−
==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
 
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| Name          = {{PAGENAME}}
 
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| Image          = Viktor Yuschenko.jpg
 
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| Caption        = An example of chloracne on [[Viktor Yushchenko]]
 
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| DiseasesDB    = 31706
 
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| ICD10          = {{ICD10|L|70|8|l|60}}
 
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| ICD9          =
 
−
| ICDO          =
 
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| OMIM          =
 
−
| MedlinePlus    =
 
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| eMedicineSubj  = topic
 
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| eMedicineTopic = 620
 
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| eMedicine_mult = <br>(Acneiform Eruptions)
 
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| MeshID        =
 
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}}
 
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'''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===
+
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.
−
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==
 
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<!--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 —>
 
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<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}}
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[[Category:Life sciences]]
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[[Category:Health and disease]]
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[[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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