Acne is a skin disorder caused by overactivity of the sebacious glands, leading to the formation of lesions and lumps on the skin. It is most common in areas such as the face, neck, chest and back, due to the high density of sebaceous glands in those areas. Acne is most common during a person’s adolescent stage; according to a survey, 70% to 80% of adolescents and young adults suffer from acne. It also affects women more than men, owing to hormonal differences. Comedones (skin lesions) usually form around affected hair follicles. Dead skin and oil plugs the hair follicle and accumulates, leading to the buildup of comedones. Scarring results from the production of the inflammatory papules, pustules and nodules when the comedones rupture.

Acne, while not life-threatening, has been a source of emotional and psychological distress due to its unpleasant appearance, which may lead to anger, depression and anxiety. Adolescents suffer the worst attacks due to increased hormonal and sebaceous gland activity. While acne may be unavoidable in certain cases, various treatments and dietary and lifestyle modifications have been proven effective in reducing the magnitude and frequency of attacks.

Causes – The Role of Sebum

According to studies, there are at least four factors involved in acne formation. These are: (1) the sebum produced by the sebaceous gland; (2) the colonization of the hair follicles by propionibacterium acnes; (3) hyperkeranization of the upper follicle; and (4) release of inflammatory mediators on the skin. Genetic factors may also play a role in acne development, though this theory is yet unsubstantiated.

The main source of acne production is the sebaceous gland, as it is responsible for sebum production. Acne cannot occur without sebum, and thus reducing sebum production should be central to most acne treatment therapies.

Hormones increase sebum production and play an important role in acne formation, but the exact process is yet unknown. Androgens increase the size of sebaceous glands through follicular hyperkeratinization, which in turn stimulates sebum secretion. While most sites on the body have a density of around 100 sebaceous glands per square centimeter, the face, neck, chest and back areas have anywhere from 400 to 900. The increase in sebaceous gland density in these areas explains why acne attacks these areas much more frequently than in others.

Acne’s pathophysiology is still poorly understood, despite its well-known infamy.

Treatment

Selecting the right treatment for acne involves first knowing its severity, which may either be mild, moderate, or severe. The magnitude and distribution of comedones, papules, pustules, and nodules should provide this information. Severe acne can involve papules, pustules and nodules, while milder comedonal acne can only involve non-inflammatory comedones such as blackheads. The worst kind of acne involves heavy inflammation and scarring.

A doctor evaluates acne severity by focusing on the locations, numbers, and sizes of the more severe lesions. Then the patient’s medical history is checked for any history of similar afflictions, as acne can tend to run in families—in such cases, longer treatment protocols may be necessary to address a more treatment-resistant form of acne. The patient must also be checked for any related medical conditions—for instance, a woman with an underlying hormonal problem (such as Polycystic ovary syndrome) may develop hirsutism (excess facial and body hair growth) and acne together. In such a case, the underlying problem may need to be treated first before any improvement in the acne can be observed. Finally, the patient’s drug treatment intake will be evaluated. Some medicines aggravate acne, and others may inadvertently interact with the drugs prescribed to treat it.

Mild acne: For this type of acne, the topical retinoid drug therapy is usually recommended. Retinoids contain anti-inflammatory action that is suitable in treating inflammatory acne. Aside from retinoid, another commonly prescribed drugs such as tretninoin, isotretinoin and adapalene are used to cure inflammatory acne, but the disadvantages include the possibility of some irritation. Antibiotics such as erythromycin are mildly anti-inflammatory, but increasing bacterial resistance to date is limiting its efficacy.

Moderate acne: When acne is widespread and threatens the possibility of scarring or hyperpigmentation, systemic drug therapy is always advised. Other treatment options include tetracycline, hormonal therapy, and oral retinoids.

Tetracycline interacts with oral contraceptives, and may not be the best acne treatment for women. Hormonal therapy combined with oral antibiotics is often more recommendable, as it is suitable for women suffering from hirsutism, androgenetic alopecia, and severe sebum secretion. Ethinyl estradiol, an anti-androgenic oral contraceptive, is commonly used for hormonal treatment.

Severe acne: In severe acne cases, and in patients with severe scarring, the best drug available is Isotretinoin. The drug can be dangerous, however, as it can cause ophthalmologic, neurological and gastrointestinal side effects. Teratogenecity should be considered in this treatment. The dermatologist must make sure that a woman patient should be on effective contraception one (1) month prior to the onset of isotretinoin use. Contraceptive use must also be continued throughout acne treatment and up to six (6) weeks after the end of isotretinoin treatment.

It has been found that one-third of patients relapse after a successful isotretinoin treatment, in which cases another round of isotretinoin (or any other suitable treatment) may be safely administered. It has also been found that combination therapies produce better results as opposed to administering a singular form of treatment.

Physical treatment of lesions

Physical treatment, where a fine needle is used to remove acne lesions, is recommended alongside other treatments for maximized therapeutic benefits. While these treatments may be temporary, it does not pose the risk of excessive inflammation in cases where the patient has numerous lesions. Physical treatments may also help reduce scarring.

After every successful treatment, maintenance therapy is mandatory to prevent any further acne attacks. Topical retinoids are usually recommended to keep the skin disease in check, while cosmetics help improve skin appearance. Isotretinoin therapy may require patients to use moisturizing agents for the lips and skin, as the drug has drying effects.

As of yet, modern acne treatments such as laser and photo therapy are still at in their test phases. As treatment becomes more targeted, agents such as leukotriene inhibitors may be included in other acne treatments in the future.