For teenagers, acne is the most common cause the leads to a visit to the dermatologist. Acne is a skin disease that occurs primarily in adolescence and results in increased oil secretion from the skin as well as to a variety of lesions on the face and body.
Acne is caused by the hyperactivity of sebaceous glands, in combination with the occlusion of their excretory duct. Another contributing factor to the occurrence of acne is skin colonization by the bacterium Propionibacterium acnes.
Common acne (Acne vulgaris)
This is the most common form of acne. It is one of the first manifestations of puberty. Common acne exhibits greatest activity at the ages of 16 and 18 years and then gradually subsides. However, acne often does not go away until the beginning or the middle of the third decade of age.
Almost 100% of teenagers present to some degree acne and thus, for some people, acne is considered entirely normal and is often ignored. In other people acne represents a disease for which treatment is required. Acne is usually found in areas abound with sebaceous glands, i.e. on the face, back and chest.
This type of acne is very common in women during the third and fourth decade of life. These are adult women who have never had acne problems during their adolescence. This acne usually resolves in the middle or the end of the forth decade of life, but not in all cases.
The pimples of this type of acne show a characteristic preference for the chin and the jaw and lead to painful nodules deep into the skin.
Postadolescent acne flares up few days before the expected menstruation. Most of the patients have low levels of sex hormone-binding globulin and the subsequent increase of circulating free testosterone in blood accounts for the occurrence of acne. Some of the patients who have adult acne, present characteristics of polycystic ovarian syndrome (PCOS).
This type of acne is very common at the beginning of infantile age and may be due to the transplacental stimulation of sebaceous glands by the adrenal androgens rather than the androgen uptake via breastfeeding.
Acne mainly affects the cheeks and subsides after a few months. In rare cases, infantile acne may indicate an early sign of virilization (virilizing tumor) or congenital adrenal hyperplasia.
Mild to moderate comedonal acne
This is a mild form of acne, in which the skin characteristically presents comedones (blackheads). In this form of acne, the formation of comedones is observed as a result of the obstruction of the pilosebaceous pore by a plug of keratin. This is because the cell lining of the pilosebaceous pore does not undergo normal keratinization, resulting to the abnormal excretion of keratin.
Keratin scales are adhered together and along with sebum and microorganisms plug the adrenal causing acne.
Acne comedones are distinguished to closed (whiteheads) which occur when the pore does not come in contact with air, and open (blackheads), when the pores come in contact with air.
This form of inflammatory acne is more common. The common sites of localization are the face, chest, back and shoulders. The rash of this acne is diverse and characterized by comedones, papules, pustules and many times unsightly scars.
It may relapse even when the patient is under treatment. It is a quite severe form of acne which causes unpleasant psychological feeling.
This is an extremely unpleasant form of acne. It differs from common acne in severity of the lesions, its chronicity and, until recently, its relevant resistance to standard treatment.
The onset of cystic acne is at puberty, it occurs in both sexes, but possibly more often in men. The lesions that distinguish cystic acne from common acne include deep and painful papules and nodules, as well as the subsequent scarring which causes malformation with scarring.
Cystic acne lesions may be atrophic, hypertrophic or keloid (keloid acne).
Cystic acne does not resolve after puberty but persists until the beginning of middle age. Site of localization include the face, chest and the back alone, but at the same time it can occur at all sites. The use of orally administered retinoids (13-cis-retinoic acid) brought a revolution in treating this form of acne.
This form of acne nearly affects solely male adolescents, aged 13 to 17 years. This acne is characterized by acute onset and has a severe cystic form with concomitant purulence always accompanied with ulceration. Moreover, patients with acne fulminans present additional generalized symptoms such as malaise, fatigue, fever, generalized joint pain, leukocytosis and increase ESR (Erythrocyte Sedimentation Rate).
Acne aestivalis – Summer acne or “Mallorca Acne”
This form of acne occurs following sun exposure, particularly in females aged 20‑30 years. The main sites of localization include the trunk and the shoulders. The lesions of this form of acne are monomorphic and no comedones are observed.
Acne tropicalis – tropical acne
This form of acne usually occurs in tropical climates, i.e. humid and warm climates, as well as in people where their working environment is characterized by high temperatures. Tropical acne presents sudden flares and is characterized by papules. The sites of localization include the back, trunk, thighs and shoulders. Tropical acne lesions usually disappear with the change of the environment.
This form of acne occurs in patients who come in contact with certain substances in their workplace. Thus, acne can be observed in workers who come in contact with oils, such as mineral oils, petroleum, tar products, etc.
This case presents open comedones, papules or pustules on the face, arms and thighs. Chloracne is a different form of occupational acne. It is acne that is caused by chlorinated compounds and occurs in workers who are exposed to chloronapthalenes, dioxins and other chemicals. This form of acne presents open comedones, papules, pustules and cysts and their sites of localization include the face, thighs and hands.
Acne due to medicines
This form of acne is derived from medicinal products which are either administered topically or systemically, such as androgens, estrogens, anti-tuberculosis drugs, corticosteroids, lithium, etc. Steroid acne has a characteristic clinical feature as is monomorphic, which means it only presents with pustules and not papules and comedones.
Acne caused by cosmetics (Acne cosmetica)
This form of acne is observed during use of various cosmetic products and is particularly caused by the raw materials used to produce them, such as lanoline, petrolatum (vaseline), cocoa butter, vegetable or chemical oils, etc. This form of acne is characterized by closed comedones, papules and more rarely pustules, whereas its common site of localization is at the sites of cosmetic product application, i.e. the face, forehead and cheeks.
Acne excoriee of young women
This form of acne is limited almost exclusively to women, who may not always be very young. Many people with acne are constantly concerned about their “pimples” and use various ways to squeeze or peak their spots, mainly by pressing them with their fingers. When the excessive picking of acne lesions becomes obsessive then acne is induced, i.e., it is the form of acne caused by the person herself/himself. Chances are that there is actually no acne, or if present, is mild. It is a protective engagement that hides an underlying emotional frustration.
The lesions of induced acne are almost exclusively those resulting from self-harm. This form of acne presents unsightly scratches, post-inflammatory hyper-pigmentation and scars, and lesions are mainly located on the face, cheeks and the chin. Although the people who suffer from induced acne admit that they constantly pick their skin, it is basically impossible to convince them to give up this habit. Thus, in this form of acne psychological support, although with doubtful results, is deemed necessary.
Acne rosacea or Rosacea
Acne rosacea is not a form of acne, nonetheless because it is also called acne is often mistaken and thus it is described in this section. Basically it is a chronic acne disorder of the pilosebaceous units of the face, accompanied by increased activity of capillaries in heat, leading to redness (flushing) and finally to spider veins. It does not seem to be associated with acne although it often coexists, while there are cases where acne precedes rosacea.
Rosacea is a cause of significant aesthetic deformity. It occurs more often in females aged 30 to 50 years. Initially rosacea results in papules, pustules and nodules with characteristic symmetrical distribution on the face, (cheeks, chin, forehead, glabella, nose), red face, while there are no comedones. Later the rush may be replaced by spider veins (telangiectases).
Hormonal factors play an important role in adult acne, as testosterone is locally converted to dihydrotestosterone on the sebaceous glands.
The latter leads to seborrhea and to the increase of keratinization, thus favoring the colonization of the pilosebaceous pore by P. acnes. Other important factors of this form of acne include the use of cosmetics with petrolatum and vegetable oils, smoking, stress and the potential use of drugs, such as corticosteroids, antidepressants, antiepileptic drugs, etc.
Acne treatment – Topical treatment
Topical acne treatment is ideal for mild, common, puberty acne and mild pregnancy acne. Topical acne treatment is also used as an adjuvant to systemic treatment. Treatment of acne using topical therapy leads to better response at the face relative to the trunk. The formulations used for topical treatment of acne are mostly antimicrobial or keratolytic, and limit keratinization in the pilosebaceous pore.
Treatment of acne with Benzoyl peroxide
It is an effective antibacterial as well as comedolytic used for the treatment of common acne. It is available at strengths of 5 and 10%. Because it causes skin irritation, acne treatment should be initiated using a formulation of small concentration and applied every other night, in order to enhance patient’s tolerability.
Treatment of acne with Retinoic acid
Retinoic acid is used as a keratolytic agent, because it accelerates mitosis of the cells on the basal stratum, epithelial rotation and the breaking down of the comedones. It is an important tool in the treatment of acne, although it can cause inflammation, which is not acceptable for some patients.
Treatment of acne with Sulfur, salicylic acid and resorcinol
It is believed that resorcinol (1,3‑dihydroxybenzene) which is often used in combination with salicylic acid and sulfur, acts as a keratolytic agent and aids in the treatment of acne.
Treatment of acne with Azelaic acid
Azelaic acid helps treat acne through its antimicrobial and anti-inflammatory action. Furthermore, it is the only topical formulation for the treatment of acne in pregnant women.Treatment of acne with Topical antibiotics
Common acne of moderate severity can be treated with topical use of antibiotic creams. For the treatment of acne, the following topical antibiotics are used: tetracyclines, erythromycin, clindamycin at a concentration of 1‑4%.Acne treatment – Systemic treatment
Treatment of acne with orally administered antibiotics
Treating acne with antibiotics is recommended in papulopustular forms of acne that do not respond to topical treatment. Antibiotics are also used for the treatment of acne which develops on the back and the chest. Tetracyclines are recommended for the treatment of acne (tetracycline, oxytetracycline, minocycline, doxycycline). Tetracyclines aid in the treatment of acne through their anti-inflammatory action. Erythromycin is a second line antibiotic for treating acne and is the only one that can be used in pregnant women.
Treatment of acne with isotretinoin
It is the drug of choice for treating cystic acne or severe papulopustular acne resistant to antibiotics. Treatment of acne with isotretinoin is achieved by decreasing the activity of the sebaceous glands, the regulation of keratinization and the reduction of P. acnes population.
The use of isotretinoin in the treatment of acne has provided the solution in cases of severe acne. However, it has side effects, the most significant being that of teratogenicity.
Thus, isotretinoin should be administered with caution in women of child-bearing potential with acne. Women who are treated with isotretinoin should avoid pregnancy for the entire duration of treatment and for 2 months after the end of treatment.
Treatment of acne – Hormonal therapy
Hormonal therapy for the treatment of acne is used when there are menstrual disturbances or polycystic ovaries. Hormone preparations used for the treatment of acne include cyproterone acetate and ethinylestradiol (Gynofen), drospirenone (Yasmin), flutamide, and metformin.
Acne treatment – Other treatments
Treatment of acne with facial cleansing
Facial cleansing can help in treating acne, mainly comedonal acne. For the treatment of acne dermatological facial cleansing should be preferred that aims at sebum removal and the opening of the comedones. In this way the formation of new pustules is reduced; it has to be conducted at the first stages of the treatment of acne. The use of steam is not recommended in facial acne as it may lead to flare ups and cross-contamination.
Treatment of acne with chemical peeling
Chemical peels are mainly recommended for the treatment of mild to moderate comedonal acne. Salicylic acid is mainly preferred for treating acne, requiring 2 to 4 sessions with excellent results. The first beneficial outcome of chemical peeling in acne treatment is the reduction of oiliness and sebo-regulation.
Treatment of acne with fractional laser
Treating acne with fractional laser is recommended for the treatment of acne scarring and for active acne that is resistant to other treatments. Four to 5 sessions are required for the complete treatment of acne.
Treatment of acne with Photodynamic therapy (PDT)
Photodynamic therapy is ideal for active and pustular acne and is either applied in conjunction with topical or systemic medication or alone. It is ideal for people with acne flares who, due to the side effects, do not want or cannot take drugs. Moreover, it is preferred to be used in teenagers, where some drugs can not be used due to age limitations. Four to 6 sessions are required and the results in active acne are spectacular.
In Cosmetic Derma Medicine we offer all acne treatment methods ranging from pharmaceutical treatments to the most modern acne treatments with laser.