Acne vulgaris

Main article: Acne Vulgaris

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2]Tayyaba Ali, M.D.[3]

Acne Vulgaris is a skin disease caused by changes in the pilosebaceous units (skin structures comprising a hair follicle and its related sebaceous gland). Severe acne is inflammatory, but acne can also manifest in noninflammatory forms.^[1] Acne lesions are defined as pimples, spots, or zits. Acne diminishes with age, by early twenties acne disappears. There is no set age for acne to disappear, some individuals have acne decades later, into their thirties and forties and even beyond.^[2] The term acne comes from a Greek word άκμή (acme in the sense of a skin eruption) in the writings of Aëtius Amidenus. The vernacular term bacne or backne is often used to show acne found specifically on one’s back.^[3]

There are multiple grading scales for rating the severity of acne vulgaris. ^[4] Three techniques include the Leeds acne grading technique, which counts and categorizes lesions into inflammatory and non-inflammatory (ranges from 0 to 10.0), Cook’s acne grading scale, which uses photographs to rate severity from 0 to 8 (0 being the least severe and 8 being the most severe), and the Pillsbury scale, which classifies the severity of the acne from 1 (least severe) to 4 (most severe). ^[5]

In the United States, acne affects 17 million people. It is most common during adolescence, affecting more than 85% of teenagers, and frequently continues into adulthood. ^[6]

Acne is the most common skin disease that occurs in all races and ages, including teenagers and young adults. About 80 percent of all people between the ages of 11 and 30 have acne outbreaks in life. Some people in their forties and fifties still suffer from acne.^[7]

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Main article: Acne Vulgaris

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2] Tayyaba Ali, M.D.[3]

The historical backdrop of skin acne compasses back to the beginning of written history. In Ancient Egypt, it is recorded that few pharaohs were skin inflammation victims. From Ancient Greece comes the English word ‘acne’ (signifying ‘point’ or ‘pinnacle’). Skin inflammation medicines are likewise of the significant relic: :

• Ancient Rome: Taking a hot bath, and frequently sulfurous, mineral water was one of only a handful few accessible skin acne medicines. Probably the soonest text to specify skin issues is De Medicina by the Roman author Celsus.
• The 1800s: Nineteenth-century dermatologists used sulfur in the treatment of acne. It was believed to dry the skin.
• The 1920s: Benzoyl Peroxide is used.
• The 1930s: Laxatives were used as a cure for ‘chastity pimples’. Radiation also was used.
• The 1950s: At the point when anti-toxins opened up, it was found that they effectively affected acne. They were taken orally, regardless. A significant part of the advantage was not from eliminating microscopic organisms but from the mitigating effects of antibiotic medication and its family drugs. Effective antimicrobial opened up later.
• 1970s: Tretinoin (original Trade Name Retin A) was found effective for acne.^[1] This preceded the development of oral isotretinoin (sold as Accutane and Roaccutane) in 1980.^[2]
• The 1980s: Accutane is introduced in America.
• The 1990s: Laser treatment introduced.
• The 2000s: Blue/red light therapy.

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Main article: Acne Vulgaris

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hamid Qazi, MD, BSc [2] Tayyaba Ali, M.D.[3]

There are multiple grading scales for rating the severity of acne vulgaris.^[1] Three techniques include the Leeds acne grading technique, which counts and categorizes lesions into inflammatory and non-inflammatory (ranges from 0 to 10.0), Cook’s acne grading scale, which uses photographs to rate severity from 0 to 8 (0 being the mildest or least severe and 8 being the most severe), and the Pillsbury scale, which classifies the severity of the acne from 1 (least severe) to 4 (most severe).^[2]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Inside the pore are sebaceous glands which produce sticky sebum. When the outer layers of skin shed (as it does continuously), the dead skin cells left behind may become ‘glued’ together by the sticky sebum. This causes a blockage in the pore, especially when the skin becomes thicker at puberty.^[1] The sebaceous glands produce more sebum which builds up behind the blockage, and this sebum harbors various bacteria including the species Propionibacterium acnes. Since the body’s natural defense against bacteria is primarily phagocytes (white blood cells), these rush to the site behind the blockage (where the bacteria are). This is what gives some pimples the ‘whiteheads’ (unless the phagocytes are deeper in the skin, which means you can’t see the ‘white’ caused by them). The white blood cells then destroy (by phagocytosis) the bacteria to prevent infection. The pain one may feel when a pimple is present is caused by the widening of skin around the white blood cells.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [3] Tayyaba Ali, M.D.[4]

Acne develops because of occlusion of follicles. The earliest change in acne development is hyperkeratinization and formation of a plug of keratin and sebum (a micro-comedo). Sebaceous glands enlarge, and sebum production increases with increased androgen (DHEA-S) production at the adrenarche. The micro-comedo may enlarge to form an open comedo (blackhead) or closed comedo (whitehead). Increased sebum production provides an environment for the overgrowth of Propionibacterium acnes. Bacterial overgrowth of Propionibacterium acnes can cause inflammation, leading to inflammatory lesions (papules, pustules, or nodules) in the dermis around the micro-comedo or comedo, which may cause scarring or hyperpigmentation.^[1]

There are many misconceptions and myths about 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:

• Family/Genetic history: The tendency to develop acne runs in families. For example, school-age boys with acne have other members of their family with acne. I associate a family history of acne with an earlier acne occurrence and increased acne lesions. ^[2]
• Hormonal activity, such as menstrual cycles and puberty: During puberty, increased male sex hormones called androgens, cause the glands to get larger and make more sebum. ^[3]
• Stress: The increased output of hormones from the adrenal (stress) glands.
• Hyperactive sebaceous glands, secondary to the three hormone sources above.
• Accumulation of dead skin cells.
• Bacteria in the pores, to which the body becomes ‘allergic.’: Propionibacterium acnes (P. acnes) is the anaerobic bacterium that causes acne. In-vitro resistance of P. acnes to commonly used antibiotics has been increasing. ^[4]
• Skin irritation or scratching of any sort will activate 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, can cause severe, long-lasting acne, known as Chloracne.
• Exposure to certain drugs and chemical compounds, including narcotics (opiates and opioids), especially when taken intravenously

Several hormones have been linked to acne: the androgens testosterone, dihydrotestosterone (DHT) and dehydroepiandrosterone sulfate (DHEAS), 17-hydroxyprogesterone, and insulin-like growth factor 1 (IGF-I). Besides, acne-prone skin is insulin resistant.

In later years, the development of acne vulgaris 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. Menopause-associated acne occurs as the production of the natural anti-acne ovarian hormone estradiol fails at menopause. The lack of estradiol also causes thinning hair, hot flashes, thin skin, wrinkles, vaginal dryness, predisposes to osteopenia and osteoporosis, and triggering acne (known as acne climacteric in this situation).

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.^[5] The researchers hypothesize that the association may be caused by hormones (such as several sex hormones and bovine IGF-I) present in cow milk. Though there is evidence of an association between milk and acne, the exact cause is 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.^[6]

Seafood often contains relatively high levels of iodine. Iodine is known to make existing acne worse but there is probably not enough to cause an acne outbreak.^[7] Still, people who are prone to acne may want to avoid excessive consumption of foods high in iodine.

It has also been suggested that there is a link between a diet high in refined sugars and other processed foods and acne. The theory is that rapidly digested carbohydrate food such as white bread and refined sugars produces an overload in metabolic glucose that is rapidly converted into the types of fat that can build up in sebaceous glands. According to this hypothesis, the startling absence of acne in non-westernized societies could be explained by the low glycemic index of these cultures’ diets. Others have cited possible genetic reasons for there being no acne in these populations, but similar populations shifting to these diets do develop acne. Note also that the populations studied consumed no milk or other dairy products.^[8] Further research is necessary to establish whether a reduced consumption of high-glycemic foods (such as soft drinks, sweets, white bread) can significantly alleviate acne, though consumption of high-glycemic foods should in any case be kept to a minimum, for general health reasons.^[9] Avoidance of ‘junk food’ with its high fat and sugar content is also recommended.^[10] On the other hand there is no evidence that fat alone makes skin oilier or acne worse.

The University of Pennsylvania and the US Naval Academy conducted experiments that fed subjects chocolate or a bar with similar amounts of macronutrients (fat, sugar etc.) and found that consumption of chocolate, frequent or not, had no effect on the developing of acne. ^[11]

A 2005 systematic review found “surprisingly little evidence exists for the efficacy or lack of efficacy of dietary factors, face-washing and sunlight exposure in the management of acne.”^[12] A study in November 2006 in Australia gave a 50% reduction in 12 weeks in mild-moderate facial acne by introducing its subjects to a high protein, low GI diet. ^[13]

The American Medical Association says chocolate does not contribute to acne. ^[14]

A recent study^[15] shows that a diet high enough in sugars triggers the liver to convert these sugars into lipid; as a side-effect this stops production of sex hormone binding globulin– a chemical which reduces the level of testosterone in the blood. Since high testosterone levels generally trigger acne, the researchers believe that this can be a cause.

Studies have shown that newly diagnosed acne patients tend to have lower levels of vitamin A circulating in their bloodstream than those that are acne free.^[16] In addition people with severe acne also tend to have lower blood levels of vitamin E.^[17]

Acne is not caused by dirt. This misconception probably comes from the fact that blackheads 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.

Common myths state that masturbation causes acne and, conversely, that celibacy or sexual intercourse can cure it. Acne has not been linked to any type of sexual activity.

• A diet high in glycemic index foods and dairy products
• 17-hydroxyprogesterone
• Antiepileptics
• Bromides
• Chloracne
• Chlorides
• Cidofovir
• Congenital adrenal hyperplasia
• Consumption of cottage cheese and cream cheese
• Consumption of partially skimmed milk
• Cosmetic agents
• Cushing’s syndrome
• Dehydroepiandrosterone sulfate (DHEAS)
• Desogestrel and Ethinyl Estradiol
• Dihydrotestosterone (DHT)
• Dioxins
• Eflornithine
• Gefitinib
• Genetic
• Increased androgen production
• Increased stress levels
• Industrial exposure to halogenated hydrocarbons
• Insulin-like growth factor 1 (IGF-I)
• Iodides
• Isoniazid
• Ivacaftor
• Lithium
• Low Vitamin A levels
• Low Vitamin E levels
• Menstrual cycles
• Oral contraceptives
• Phenytoin
• Polycystic ovary syndrome
• Pregnancy
• Propionibacterium acnes infection
• Puberty
• Skin irritation or scratching
• Staphylococcus epidermidis
• Steroids
• Testosterone

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]

Acne vulgaris must be differentiated from other diseases that cause scaly red skin, comedones, papules, nodules, and possibly scarring, including chickenpox, herpes zoster, erythema multiforme, among others.

Different rash-like conditions can be confused with acne and are thus included in its differential diagnosis. The various conditions that should be differentiated from acne include:^{[1][2][3][4][5][6][7]}

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In the United States, acne affects 17 million people. It is most common during adolescence, affecting more than 85% of teenagers, and frequently continues into adulthood. ^[1]

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Acne is the most common skin disease. People of all races and ages get acne. But it is most common in teenagers and young adults. An estimated 80 percent of all people between the ages of 11 and 30 have acne outbreaks at some point. Some people in their forties and fifties still get acne.

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See Acne scarring.

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.

Physical acne scars are often referred to as “Icepick” scars. This is because the scars tend to cause an indentation in the skin’s surface. There are a range of treatments available.

Although quite rare, the medical condition Atrophia Maculosa Varioliformis Cutis results in “acne like” depressed scars on the face.

Ice pick scars – Deep pits, that are the most common and a classic sign of acne scarring.
Box car scars – Angular scars that usually occur on the temple and cheeks, and can be either superficial or deep, these are similar to chickenpox scars.
Rolling scars – Scars that give the skin a wave-like appearance.
Hypertrophic scars – Thickened, or keloid scars. ^[1]

Pigmented scars is a slightly misleading term, suggesting a change in the skin‘s pigmentation, and that they are true scars. Neither is true. Pigmented scars are usually the result of nodular or cystic acne (the painful ‘bumps’ lying under the skin). They often leave behind an inflamed red mark. Often, the pigmentation scars can be avoided simply by avoiding aggravation of the nodule or cyst. When sufferers try to ‘pop’ cysts or nodules, pigmentation scarring becomes significantly worse, and may even bruise the affected area. Pigmentation scars nearly always fade with time taking between 3 months to two years to do so, although rarely can persist.

On the other hand, some people, particularly people with naturally tanned skin do develop brown hyperpigmentation scars which is caused by a local increased production of the pigment melanin. These too typically fade over time.

Acne usually goes away after the teenage years, but it may last into middle age. The condition often responds well to treatment after 6 – 8 weeks, but it may flare up from time to time. Scarring may occur if severe acne is not treated. Some people, especially teenagers, can become very depressed if acne is not treated.

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