Acne Overview

Acne is a red, irritating skin rash primarily affecting teenagers and young adults. It can, however, occur at all ages. Typical acne appears in the oil-producing areas of the body—namely, the face, chest, and back. Acne can also occur on the neck and upper arms.

Acne can have a short-term, potentially lasting psychological effect. Decreased self-esteem and self-confidence can lead to social withdrawal and even depression. Left untreated, severe acne can lead to disfiguring scarring, which can itself be difficult to treat.

• Several myths exist about acne.
  • Acne is not a result of uncleanliness or infrequent washing. In other words, acne does not result from too much dirt on the skin or in the pores. Too much scrubbing may actually make acne worse.

     

  • Acne does not come from eating a lot of so-called bad foods such as chocolate or fried foods. No foods cause acne or make it worse.

Several factors contribute to the development of acne. The primary problem is that the abnormal flaking of cells inside the hair follicle leads to the formation of a plug. The plug can enlarge and even rupture the hair follicle. A ruptured hair follicle spills its contents of oil and debris into the skin where it leads to swelling and causes redness (inflammation).

• Bacteria that normally live on the skin also play a role in acne development. The bacteria known as Propionibacterium acnes are responsible for causing acne. These bacteria produce substances that cause redness and irritation (inflammation). They also make enzymes, which dissolve the sebum (oil from oil glands in the skin) into irritating substances. These substances also make the inflammation worse.

   

• Certain hormones called androgens are an additional factor in causing acne. Androgens are male hormones that are present in both men and women, but are higher in men. Androgens do two things: First, they enlarge the sebaceous glands in the skin. Second, they cause these glands to increase sebum (oil) production. The increased sebum leads to plug formation and serves as more “food” for the bacteria. Androgens surge at puberty, which is why teens develop armpit and pubic hair, and why boys develop facial hair and deeper voices. This hormonal surge also contributes to the development of acne in teens.

   

• Estrogens, which are the female hormones, actually can help to improve acne in girls. A woman’s monthly menstrual cycle is due to changes in the estrogen levels in her body. This is why acne in a female may get better and then get worse as she goes through her monthly cycle. A doctor may recommend acne treatment with birth control pills, which contain the helpful estrogens.

   

• We also now believe that acne can run in some families. This may be due to some genetic factor that has not yet been discovered.

   

• Anatomy of the hair follicle: Hair follicles exist on virtually all skin except for the palms of the hands and soles of the feet. Inside the follicle, the hair extends up from the deep layers of the skin and comes out of a pore. Near the surface, the oil gland (sebaceous gland) enters the hair follicle where it empties oil (sebum) at a relatively constant rate. The sebum lubricates the skin and provides a protective barrier to prevent drying. Skin on the face, chest, and back has an especially large number of sebaceous glands. These are the areas where acne occurs.

   

• Acne lesions: There are 2 major types of acne lesions: noninflammatory and inflammatory. Noninflammatory acne lesions include blackheads (open comedones) and whiteheads (closed comedones). Open and closed comedones along with papules and pustules are referred to as papulopustular acne—a form of inflammatory acne. Nodular acne is the most severe form of inflammatory acne.
  • Noninflammatory acne: Open comedones result from the enlargement and dilation of a plug that forms from oil and flakes of skin inside the hair follicle.
    • The hair follicle pore remains open exposing a black plug (known as a blackhead). The dark color is not dirt inside the pore. Instead it is the oil inside the pore, which has become exposed from the outside air.

       

    • A closed comedo forms if the hair follicle pore remains closed. The plug in a closed comedo or whitehead is therefore not exposed to the outside air, and no black color develops. The closed comedo simply appears as a tiny, sometimes pink bump in the skin.

     

  • Inflammatory acne: Inflammatory acne lesions consist of red blemishes, pimples also called zits (papules, pustules), and larger, deeper swollen tender lesions (nodules).
    • Papules are closed comedos, which have become red, swollen, and inflamed.

       

    • Pustules are closed comedos, which become inflamed and begin to rupture into the skin forming pustular heads of various sizes.

       

    • Nodules represent large, tender, swollen acne lesions, which have become intensely inflamed and rupture under the skin. If untreated, these can produce deep scarring.

• Acne that does not improve with over-the-counter medicines should be evaluated by a doctor.

• People with acne that is severe and tender or already scarring should also be seen by a doctor.

• Women with acne who develop facial hair or have irregular periods require evaluation by a doctor.

• Anyone with a sudden severe worsening of their acne or acne with fever and severe swelling should see a doctor immediately. These could be signs of a serious skin infection.

No specific tests are usually required for diagnosing or treating acne. A doctor will occasionally want to check hormone blood tests or blood tests before starting some medications.

|Self-Care at Home|
 

• Wash once or twice daily with soap and water to remove excess oil from the skin. An acne cleanser purchased over-the-counter in any drug store can also be helpful. Avoid scrubbing too abrasively because this can actually irritate the skin and cause acne to worsen.

• Over-the-counter acne medications can be used either at bedtime or during the day. Always follow the directions on any acne product.

• Many cover-up products are available without a prescription to improve the appearance of blemishes while they have a chance to heal. Most work well and should not worsen acne.

• Some cosmetics and other skin care products, however, can cause acne to worsen. Look for make-up, cosmetics, and skin care products labeled with the word noncomedogenic. This means that it does not cause or worsen acne.

|Medical Treatment|
 

Many treatment options are available to treat all forms of acne. Medications are the main treatment for acne and usually work well. Several preparations are available over-the-counter, while others require a prescription from a doctor.

• Over-the-counter medications: Nonprescription or over-the-counter medications for acne are plentiful and can be effective for milder forms of acne. They come in the form of soaps, washes, and cleansers.
  • Many contain benzoyl peroxide, which does two things. First, benzoyl peroxide kills the acne-causing bacteria, which are thought to play a role in acne. Second, benzoyl peroxide can cause drying and flaking off of skin, which can help prevent the pores from becoming plugged. Plugged pores can develop into acne blemishes.

     

  • Scrubbing excessively with any over-the-counter preparation can actually cause acne to worsen by additionally irritating the hair follicles.

   

• Prescription medications: Doctors can prescribe medications when acne becomes moderate to severe or is not controlled by over-the-counter medications. Prescription drugs can be used effectively alone or in combination with other prescription and nonprescription medications.
  • Antibiotics: Antibiotics can be effective in treating most inflammatory acne (papules and pustules). They work by killing the bacteria and also by decreasing the redness and swelling seen in the inflammatory forms of acne.
    • Antibiotics may be applied to the skin in the form of gels and lotions, or by way of pills. We now know that using a combination of 2 medications together may be very effective in treating acne. Using a topical antibiotic with topical benzoyl peroxide, for example, may prevent bacterial resistance to the antibiotic. Giving an antibiotic by mouth is often needed for acne that is more extensive, red, and tender.

       

    • Antibiotics taken by mouth can be associated with more side effects than if applied to the skin and may interact with other medicines such as birth control pills. Sensitivity to the sun can result in a “bad sunburn” in some people who take the antibiotic tetracycline by mouth.

     

  • Retinoids: Medicines made from vitamin A (retinoids) are useful in treating several types of acne lesions. Topical retinoids are effective in treating the noninflammatory types of acne (blackheads and whiteheads).
    • Topical retinoids (applied directly to the skin) help to open clogged pores by creating a mild peeling effect. Drying of the skin can be a frequent side effect. Oral retinoids are reserved for treating the more extensive nodular type of acne or severe inflammatory acne, which has not responded to other treatments. Oral retinoids not only have a peeling effect but also decrease the production of oil.

       

    • They can also be associated with a number of serious side effects including birth defects in babies of women who become pregnant while taking the medicine. They can also cause elevated blood fats (triglycerides) and damage to the liver. Your doctor may recommend certain blood tests to check for these problems (and to make sure you are not pregnant) if you are given oral retinoids. Depression and suicidal thoughts have been reported while taking oral retinoids.

     

  • Other medications: A doctor may recommend other types of drugs or therapy to improve acne. For women, medications such as birth control pills or certain “water pills” may be helpful. These drugs counteract the acne-causing effect of male hormones. Newer treatments for acne include the use of light or zinc. Your doctor can advise you whether these types of acne therapy might be good for you.

|Outlook|
 

The prognosis for most acne is excellent. Most people experience their worst acne during the teen years and grow out of it. The goal in all acne treatment is to prevent scarring. Severe acne left untreated for a long time can result in scarring. The scars can appear as pits (usually on the face) or as big, bumpy scars (usually on the chest and back). The scarring of acne can also be treated. Your doctor can tell you about various ways available to treat acne scars.

• Pits and depressions left in the skin from acne scarring can be treated with a “skin-sanding” procedure called dermabrasion or by chemical peels.

• Bumpy scars are often treated with injections of a steroid medicine.

• Lasers can be used in treating scars but can be expensive.

American Academy of Dermatology
930 E Woodfield Road
Schaumburg, IL 60173
(847) 330-0230

|Web Links|
 

KidsHealth, Acne

National Institute of Arthritis and Musculoskeletal and Skin Disesaes, Questions and Answers About Acne

AcneNet, What is Acne?

pimples, zits, skin blemishes, whiteheads, blackheads, comedo, comedones, papules, pustules, acne

Author: Brian W Russ, MD, Consulting Staff, Department of Dermatology, Walter Reed Army Medical Center, Andrews Air Force Base.

Coauthor(s): Christopher Sartori, MD, Chief of Dermatology Clinic, United States Air Force Academy Hospital; Associate Clinical Professor, Department of Dermatology, University of Colorado School of Medicine; Paula Vogel, MD, Chief, Section of Dermatologic Surgery, Wilford Hall Medical Center; Assistant Clinical Professor, Department of Dermatology, University of Texas Health Science Center at San Antonio.

Editors: Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Anthony Anker, MD, FAAEM, Attending Physician, Emergency Department, Mary Washington Hospital, Fredericksburg, VA.