What is Acne?

Acne is the term for plugged pores (blackheads and whiteheads), pimples, and even deeper lumps (cysts or nodules) that occur on the face, neck, chest, back, shoulders and even the upper arms. Acne affects most teenagers to some extent. However, the disease is not restricted to any age group; adults in their 20s - even into their 40s - can get acne. While not a life threatening condition, acne can be upsetting and disfiguring. When severe, acne can lead to serious and permanent scarring. Even less severe cases can lead to scarring. When you read about acne or other skin diseases, you encounter words or phrases that may be confusing. For example, the words used to describe the lesions of acne-comedo, papule, pustule, nodule and cyst-are understandable only if you know each word's definition. It also is helpful to have a photo that is characteristic for each type of lesion. Here is a brief summary of definitions of words used to describe acne, with accompanying photos. Let's begin, though, with the definition of lesion, an all-purpose word, lesion or a physical change in skin tissue caused by disease or injury. A lesion may be external (e.g., acne, skin cancer, psoriatic plaque, knife cut), or internal (e.g., lung cancer, atherosclerosis in a blood vessel, cirrhosis of the liver). Thus, when you read about acne lesions you understand what is meant-a physical change in the skin caused by a disease process in the sebaceous follicle.

Acne lesions range in severity from comedones (blackheads and whiteheads) to nodules and cysts. Here is a brief definition of acne lesions: Comedo (plural comedones)-An acne comedo is a sebaceous follicle plugged with sebum, dead cells from inside the sebaceous follicle, tiny hairs, and sometimes bacteria. When a comedo is open, it is commonly called a blackhead because the surface of the plug in the follicle has a blackish appearance. A closed comedo is commonly called a whitehead; its appearance is that of a skin-colored or slightly inflamed "bump" in the skin. The whitehead differs in color from the blackhead because the opening of the plugged sebaceous follicle to the skin's surface is closed or very narrow, in contrast to the distended follicular opening of the blackhead. Neither blackheads nor whiteheads should be squeezed or picked open, unless extracted by a dermatologist under sterile conditions. Tissue injured by squeezing or picking can become infected by staphylococci, streptococci and other skin bacteria. A papule is defined as a small (5 millimeters or less), solid lesion slightly elevated above the surface of the skin. A group of very small papules and microcomedones may be almost invisible but have a "sandpaper" feel to the touch. A papule is caused by localized cellular reaction to the process of acne.

An acne pustule is a dome-shaped, fragile lesion containing pus that typically consists of a mixture of white blood cells, dead skin cells, and bacteria. A pustule that forms over a sebaceous follicle usually has a hair in the center. Acne pustules that heal without progressing to cystic form usually leave no scars.

An acne macule is the temporary red spot left by a healed acne lesion. It is flat, usually red or red-pink, with a well defined border. A macule may persist for days to weeks before disappearing. When a number of macules are present at one time they can contribute to the "inflamed face" appearance of acne. An acne nodule is like a papule, a nodule is a solid, dome-shaped or irregularly-shaped lesion. Unlike a papule, a nodule is characterized by inflammation, extends into deeper layers of the skin and may cause tissue destruction that results in scarring. A nodule may be very painful. Nodular acne is a severe form of acne. An acne cyst is a sac-like lesion containing liquid or semi-liquid material consisting of white blood cells, dead cells, and bacteria. It is larger than a pustule, may be severely inflamed, extends into deeper layers of the skin, may be very painful, and can result in scarring. Cysts and nodules often occur together in a severe form of acne called nodulocystic. Some acne investigators believe that true cysts rarely occur in acne, and that the lesions called cysts are usually severely inflamed nodules, and the term nodulocystic should be abandoned. Regardless of terminology, this is a severe form of acne that is often resistant to treatment and likely to leave scars after healing.

Close to 100% of people between the ages of twelve and seventeen have at least an occasional acne symptom such as a whitehead, blackhead or pimple, regardless of race or ethnicity. Many of these young people are able to manage their acne with over-the-counter (nonprescription) treatments. For some, however, acne is more serious. In fact, by their mid-teens, more than 40% of adolescents have acne severe enough to require some treatment by a physician. In most cases, acne starts between the ages of ten and thirteen and usually lasts for five to ten years. It normally goes away on its own sometime in the early twenties. However, acne can persist into the late twenties or thirties or even beyond. Some people get acne for the first time as adults. Acne affects young men and young women about equally, but there are differences. Young men are more likely than young women to have more severe, longer lasting forms of acne. Despite this fact, young men are less likely than young women to visit a dermatologist for their acne. In contrast, young women are more likely to have intermittent acne due to hormonal changes associated with their menstrual cycle and acne caused by cosmetics. These kinds of acne may afflict young women well into adulthood.

Acne lesions are most common on the face, but they can also occur on the neck, chest, back, shoulders, scalp, and upper arms and legs. Acne also has significant economic impact. Americans spend well over a hundred million dollars a year for nonprescription acne treatments, not even taking into account special soaps and cleansers. But there are also the costs of prescription therapies, visits to physicians and time lost from school or work. A person may try to cure acne with home remedies or nonprescription items from the drugstore. A person may decide it is time to see a doctor. With a dermatologist's help, almost every case of acne can be cleared up. If any of the following apply, make an appointment: The results achieved with nonprescription acne products are unsatisfactory , the acne interferes with enjoyment of life, there are acne scars in addition to acne lesions ,the acne lesions are large and painful or the acne is causing dark patches to appear in a dark skinned person . If seeing a dermatologist has not produced good results, perhaps it is time for a second opinion. Comedo extraction: Extraction of comedones should be performed only by a dermatologist, under sterile conditions, and usually only when comedones have not responded to other treatment. Acne patients should not attempt to extract comedones by squeezing or picking. Ultraviolet light has not been proven effective as an acne treatment. At most, skin tanning may mask acne. However, skin tanning increases risk for other, more serious skin conditions such as melanoma and other skin cancers. Glycolic acid and other chemical agents are applied by a dermatologist to loosen blackheads and decrease acne papules. Male hormones found in both males and females rise during adolescence (puberty) and stimulate and enlarge the oil (sebaceous) glands of the skin. These glands are found in areas where acne is common (the face, upper back, and chest).

Rarely, acne can be due to a hormonal imbalance. The oil glands are connected to a hair-containing canal called a follicle. The sebaceous glands make an oily substance called sebum which reaches the skin surface by emptying through the skin surface opening of the follicle. The hair follicle opening is sometimes called the pore. The oil (sebum) causes the cells from the follicular lining to shed more rapidly and stick together, forming a plug at the hair follicle opening. Bacteria grow in the mixture of oil and cells in the follicle. These bacteria make chemicals that stimulate inflammation and cause the wall of the follicle to break. The sebum, bacteria, and shed skin cells spill into the skin causing redness, swelling, and pus or in other words, a pimple. The black in a blackhead is dried oil and shed skin cells in the openings of the hair follicles, not dirt. For the normal care of your skin, wash your face with soap and warm water twice a day. Acne is not caused by dirt. Washing too often or too vigorously may actually make your acne worse. Regular shampooing is also recommended. If your hair is oily, you may want to wash it more often. Your dermatologist can recommend the best face and hair washing routine. Men with acne who shave should try both an electric and a safety razor to see which is more comfortable. If you use a safety razor, soften your beard thoroughly with soap and warm water before applying shaving cream. To avoid nicking pimples, shave as lightly as possible. Shave only when necessary and always use a sharp blade.

Acne is not caused by the foods you eat. Dermatologists have differing opinions on the importance of your diet in the management of acne. One thing is certain; a strict diet by itself will not clear your skin. On the other hand, if certain foods seem to make your acne worse, then try to avoid them. But be careful about jumping to conclusions, acne may get better or worse on its own. It is always important to eat a well balanced diet. Choose a sunscreen that is oil-free, such as a gel or light lotion. Control of acne is an ongoing process. All acne treatments work by preventing new acne. Existing blemishes must heal on their own.

Improvement takes time. If your acne has not improved after 6 to 8 weeks, you may need a change in your treatment. The treatment your dermatologist recommends will vary according to your type of acne. Occasionally, an acne-like rash can be due to another cause - such as from makeup, lotions, or from an oral medication. It's important to help your dermatologist by providing a history of what you are using on your skin or taking internally. Many non-prescription acne lotions and creams help milder cases of acne. However, many will also make your skin dry if used too often. If you use these products, follow instructions carefully.

Your dermatologist may prescribe topical creams, gels or lotions with vitamin A acid or benzoyl peroxide to help unblock the pores and reduce bacteria. These products may cause some drying and peeling. Your dermatologist will advise you on the correct use and how to handle side effects. There are also antibiotics that are applied to the skin. These are used in less severe cases of acne. When large red bumps (cysts) are present, the dermatologist may inject cortisone directly into the bumps to help them go away. Your physician may open pimples or remove blackheads and whiteheads. Don't pick, scratch, pop or squeeze your pimples yourself. When the pimples are squeezed, more redness, swelling, inflammation and scarring may result.

Antibiotics taken by mouth such as tetracycline, doxycycline, minocycline or erythromycin are often prescribed for moderate or severe cases, especially when there is a lot of acne on the back or chest. Antibiotics reduce the bacteria in the follicle and may also decrease the skin redness directly. As with most medicines, check with your doctor about taking antibiotics if you are pregnant or nursing, or if you are trying to get pregnant. In cases of severe acne, other drugs may be used. These may include female hormones or medications that decrease the effects of male hormones. Another oral medication, isotretinoin is sometimes used for severe acne that has not responded to other treatments. Patients using isotretinoin must thoroughly understand the side effects of this drug. Frequent follow-up visits are necessary to monitor side effects. Prevention of pregnancy is a must, since the drug causes severe birth defects if taken during pregnancy.

Should scarring be already present prior to treatment or be a residual of treatment, your dermatologist can treat these scars by a variety of methods. Combination skin resurfacing with laser, dermabrasion, chemical peeling or electrosurgery, can flatten depressed scars. Soft tissue elevation with collagen, filling products or fat can elevate scars. Scar revision by your dermatologic surgeon with a microexcision and punch grafting can correct pitted scars, and combinations of these dermatologic surgical treatments can make noticeable differences on the appearance of the scars. No matter what special treatments your dermatologist may use, remember that you must continue proper skin care until the tendency to have acne has passed. There is no instant or permanent cure for acne, but it is controllable, and proper treatment may prevent scars. Scars result when the skin repairs wounds caused by accident, disease, or surgery. They are a natural part of the healing process. The more the skin is damaged and the longer it takes to heal, the greater the chance of a noticeable scar. Typically, a scar may appear redder and thicker at first, then gradually fade. Many actively healing scars that seem unsightly at three months may heal nicely if given more time.

The way a scar forms is affected by an individual's age and the location on the body or face. Younger skin makes strong repairs and tends to overheal, resulting in larger, thicker scars than does older skin. Skin over a jawbone is tighter than skin on the cheek and will make a scar easier to see. If a scar is indented or raised, irregular shadows will be seen, giving the skin an uneven appearance. A scar that crosses natural expression lines or is wider than a wrinkle, will be more apparent because it will not follow a natural pattern nor look like a naturally occurring line. Any one, or a combination of these factors may result in a scar that, although healthy, may be improved by dermatologic surgical treatment. Several techniques can minimize a scar. Most of these are done routinely in the dermatologist's office. Only severe scars, such as burns over a large part of the body may require general anesthesia or a hospital stay. Surgical scar revision can improve the way scars look by changing the size, depth, or color. However, no scar can ever be completely erased; and no magic technique will return the scar to its normal uninjured appearance. Surgical scar revision typically results in a less obvious mark. Because each scar is different, each will require a different approach.

The most important step in the treatment of scars is careful consultation between the patient and the dermatologic surgeon - finding out what bothers a patient most about a scar and deciding upon the best treatment. Surgical Scar Revision is based on the ability of the skin to stretch with time, surgical scar revision is a method of removing a scar and rejoining the normal skin in a less obvious fashion. The surgical removal of scars is best suited for wide or long scars, those in prominent places, or scars that have healed in a particular pattern or shape. Wide scars can often be cut out and closed, resulting in a thinner scar, and long scars can be made shorter. A technique of irregular or staggered incision lines, rather than straight-line incisions, to form a broken-line scar that is much more difficult to recognize may be used. Sometimes, a scar's direction can be changed so that all or part of the scar that crosses a natural wrinkle or line falls into the wrinkle, making it less noticeable. This method can also be used to move scars into more favorable locations, such as into a hairline, or a natural junction (for instance, where the nose meets the cheek). Best results are obtained when the scar is removed and wound edges are brought together without tension or movement (pull) on the skin.

Dermabrasion is a method of treating acne scars, pockmarks, some surgical scars, or minor irregularities of the skin's surface. An electrical machine is used by a dermatologist to remove the top layers of skin to give a more even contour to the surface of the skin. While it can offer improvement for certain scars, it cannot get rid of the scar entirely. Patients can usually return to work within a week. If defects are minor, only one dermabrasion will be needed. Several abrasions may be required if defects are deep and extensive, as in deep acne scars.

Laser Scar Revision is another method of improving acne and chicken pox scars is laser skin resurfacing. High-energy light is used to remove unwanted, damaged skin. Patients can return to work or regular activity within one week, but skin may stay pink for several weeks or months. Several different lasers are available depending on the skin defect requiring improvement. A pulsed dye laser, for example, uses yellow light to remove scar redness and to flatten out raised scars (hypertrophic scars or keloids). This laser can also improve itching and burning sensations in the scar. Hypertrophic scars or keloids typically need two or more pulsed dye laser treatments every two months. Acne scars or other indented (atrophic) scars can also be improved with laser skin resurfacing.

Soft Tissue Fillers (collagen injections or fat transfer) - Injectable collagen, a natural animal protein, is a substance used to elevate indented, soft scars. The amount of collagen injected will vary with the size and firmness of the scar. Patients with a personal history of certain collagen diseases or "autoimmune" diseases cannot safely receive injectable bovine collagen. Patients are always tested on the forearm and observed prior to treatment to ensure that they are not allergic to the collagen. Allergic patients or those with collagen vascular diseases may not use human collagen or other related filler materials. Improvement is immediate but is not permanent. Collagen injections typically need to be repeated every three to six months. The patient's own fat or injectable donated fascia can be used in full-thickened deep depressed scars. New research may develop more permanent substances to inject into scars.

Punch Grafts and Punch Excisions - Punch grafts are small pieces of normal skin used to replace scarred skin. A tiny instrument is used to punch a hole in the skin and remove the scar. The area is then filled in with a matching piece of unscarred skin, usually taken from the skin behind the ear. The "plugs" are taped into place for five to seven days as they heal. Punch excisions, on the other hand, involve the use of stitches to close the holes produced by the tiny skin punch. The stitches are removed in five to seven days. Even though the punch grafts and excisions form scars of their own, they provide a smoother skin surface which is less visible than depressed scars. Deep or "pitted" acne scars are best treated by punch grafts or excisions.

Chemical peels involve the use of a chemical to remove the top layer of the skin in order to smooth depressed scars and give the skin a more even color. It is most helpful for shallow superficial scars.

The chemical is applied to the skin with an ordinary cotton-tipped applicator beginning on the forehead and moving over the cheeks to the chin. Different chemicals can be used for different depth peels. Light peels require no healing time while deeper peels can require up to two weeks to heal. The amount of scarring and color change determines the type of peel selected. Pressure bandages and massages can flatten some scars if used on a regular basis for several months. Silicone-containing gels, creams, and bandages have also been helpful in reducing scar thickness and pain. They must also be used regularly and results are variable.

Cryosurgery involves freezing the upper skin layers which causes blistering of the skin. This can sometimes cause scars to diminish in size. This technique has been used on raised acne scars. Cortisone (steroid) injections or tapes are effective in softening very firm scars (or keloids) causing them to shrink and flatten. This is usually the treatment of choice for hypertrophic scars and keloids. Silicone impregnated gels can be used by the patient at home to remodel elevated scars in addition to injections of scar tissue. Interferon is a chemical that can be given by injection and may help improve the hardness and cosmetic appearance of the scar.

Cosmetics applied correctly can be very good at covering up scars. Physicians encourage patients to wear make-up after scar treatments. Make-up will improve the appearance while nature completes the healing process. There are three major types of burn related scars: Keloid, Hypertrophic and Contractures. Keloid scars are an overgrowth of scar tissue. The scar will grow beyond the site of the injury. These scars are generally red or pink and will become a dark tan over time. Hypertrophic scars are red, thick and raised, however they differ from Keloid scars in that they do not develop beyond the site of injury or incision. A contracture scar is a permanent tightening of skin that may affect the underlying muscles and tendons that limit mobility and possible damage or degeneration of the nerves.

Keloid scars are an overgrowth of scar tissue. The scar will grow beyond the site of the injury. These scars are generally red or pink and will become a dark tan over time. They occur when the body continues to produce collagen a tough fibrous protein, after the wound has healed. Keloid scars are thick, nodular, ridged and itchy during formation and growth. Extensive keloids may become binding and limit your mobility. Additionally, clothing rubbing or other types of friction may irritate them. Dark-skinned people are more likely to develop Keloids than those with fair skin and the possible occurrence of Keloids reduces with age. Keloids may be reduced in size by cryotherapy (freezing), external pressure, cortisone injections, steroid injections, radiation or surgical removal. If injections and external pressure such as pressure garments are inadequate, the scar tissue can be cut away, this is generally an outpatient surgery performed under local anesthesia and you should be able to return to work or school within a few days.

Your doctor may recommend that you wear pressure garments over the area for up to a year to prevent the Keloids from re-occurring. It is possible that this procedure will need to be repeated every few years because Keloids have a tendency to re-occur. Hypertrophic scars are red, thick and raised, however they differ from Keloid scars in that they do not develop beyond the site of injury or incision. Additionally, Hypertrophic scars will improve over time. This time however can be reduced with the help of steroid application or injections.
(information resources include.....www.skincarephysians.com/acnenet/acne.html and www.aad.org/patient_intro.html)