Did you know that…

Whenever you wash your face with soap, pop up pimples, or when you smoke, you disturb the filter that naturally protects your skin?
Acne is not caused by the environment but it is in part induced by a bacteria, P. acnes that lives inside of your skin?
Before acne sets in, there is inflammation inside your skin?

What is Acne?

Acne is one of the most common skin problems. It occurs due to clogging of pores with sebum (a type of fat produced by the sebaceous glands) and with dead cells. It is more frequent in adolescents, but can occur at any age, from infancy and up to the fourth and even fifth decade in life.

Acne may occur just before puberty, triggered by the normal hormonal changes that lead to an increased secretion of androgen hormones, more specifically testosterone and its derivatives. It is known that between 10 and 20 years of age, 80-85% of adolescents have acne of various degrees of severity.

Around the age of 25-30, women are doubly affected by acne compared to men, due to hormonal alterations but also to the use of cosmetics that are inappropriate for each particular type of skin.

Recently, an increase has been observed in adult acne, so that about 5% of population around 45 years of age still suffer from some form of acne.

Acne Classification

On our skin, especially on the face, neck, décolleté and shoulders, there are many small hairs, which open on the surface as skin pores. The sebaceous glands near the hair (sebaceous) release their content out to the skin surface using the hair as a route. Acne occurs when there is an event that prevents sebum from flowing to the skin surface.
There are several forms of acne lesions.

At first, several clusters of small (1-2MM) yellowish-white dots become visible on the skin, usually on the forehead and nose. These lesions are called ”microcomedones” or ”closed comedones”, and they contain sebum, melanin (the pigment in the skin) and bacteria, and at this point have no contact with air.

When skin pores open, secretions within microcomedones come in contact with air, inducing the oxidation of melanin, which changes color to black. This new lesion is the open comedone or the very well-known blackhead.
When the skin displays predominantly comedones – closed or open – (i.e. white or black spots), this type of acne is called ”retentional acne” or ”non-inflammatory acne.

Normally, sebum secretion is discharged through the pores to the skin surface. When there is an obstacle on this route, or when trying to discharge the lesions by squeezing them, the content of the comedones flows into the surrounding skin and causes inflammation, manifested by redness and swelling in that specific area.

At this time, retentional acne turns into inflammatory acne with papules (former black and white dots are becoming larger, swollen and red).

The next stage is pustules meaning papules that have a reddish base and a top filled with yellowish secretions resulting from the action of the immune system which tries to limit the extent of the inflammation.

When inflammation involves many pores, new forms of acne appear. They are called cysts and nodules, are located frequently on the shoulders and on the chest; they are sometimes painful and have a significant scarring potential.
Depending on the combination of these types of lesions and the area affected acne may be classified into mild, moderate and severe.

Why does acne occur?

At the onset of acne, excess sebum is produced by the sebaceous glands and the area around the lesions eventually becomes inflamed.  Dead skin cells do not properly peel off and too much keratin is produced inside the hair follicles. These events lead to occlusion of the pore and thus the excess sebum cannot be expelled on the surface of the skin. Another important event is the multiplication of the bacteria Propionibacterium Acnes bacteria (P. acnes) inside the sebaceous gland. This bacteria is responsible for aggravating the local inflammation.

Genes play an important role and when one or both parents had acne, it is expected that their children are at an increased risk for developing acne.

Sebum secretion begins to increase just before puberty, in direct relationship with the hormonal changes of this period. Male hormones namely androgens such as testosterone and its derivatives are those involved in the onset and progression of acne. (their values can and should be measured in women when we want to effectively treat blemishes).

The increasing number of layers of cells lining the hair follicles and a decrease in their peeling off speed leads to clogging of pores and the onset of lesions, especially under the form of small black and white dots.
Inflammation is another important triggering factor, and it starts before the accumulation of layers of cells inside follicles. Depending on the inflammation size, lesions become increasingly red and possibly painful; the greater the inflammation, the greater the risk of scarring.

Infection in acne is the result of lesions becoming colonized by Propionibacterium Acnes (P. acnes). P. acnes is a bacteria that lives in oxygen-free environments, that is in the sebaceous glands and is responsible for producing substances that pass through the wall of the gland and boost inflammation.

Besides the above-mentioned factors, several other contributing events related to diet, the accumulation of oxidizing factors, stress and the possible hormone production by skin itself are discussed. Such mechanisms are complex and are still studied as hypotheses.

What we generally don’t know about acne?

Acne is a condition like many others. We can consider it to be normal for a particular age group, but this does not mean that there is no need for treatment.

In most cases, no physician can realistically estimate how the lesions will evolve.

For acne to perpetuate, all it needs is for the individual to squeeze the lesions, to put on foundation cream without associating local or oral treatment, or not complying with doctor’s instructions.

We should also know that acne treatments do not work overnight, as we would all want.

The skin changes, at a microscopic level, every 3 weeks. This is the reason why we need several months of treatment before we get a visible, and especially stable, effect.

The risk of permanent scarring increases as the inflammation is more important (i.e. the number or the area covered by red, large, nodular or cystic lesions).

When we act on lesions (squeeze) to release content, their healing is slower, and the risk of scarring is much higher. It is best to treat them locally and not touch them aggressively.

There are several options available to treat acne: a combination of locally applied substances and general – mostly oral treatments, for people with large-scale moderate or severe acne.

Acne is a disease that can be treated under strict instructions given by a medical skin specialist and with strict compliance with such instructions, according to each particular case.

Myths on Acne

Many people believe that acne, and especially blackheads are a result of pores being clogged with various environmental substances/dirt, hence it is popular to recommend using soap many times a day to wash and even scrub the face in order to remove black spots. In reality, frequent face washing with inadequate substances causes a worsening of lesions, especially in case of inflammatory acne with papules, pustules, nodules or cysts. Common practice is for the physicians to recommend washing the affected areas twice a day, with gentle formulated soap, special cleanser for acne, and with bare hands without using brushes, pealing gloves or other such devices.

Most people affected by acne consider that they have an infection (either on the skin or inside their body) that causes the lesions to persist, because the infection is not treated. There is real information in that – there is a bacteria involved in the onset and persistence of lesions, and it is called Propionibacterium acnes (P. acnes), but it does not live on the skin but right under the skin surface, inside the sebaceous glands and does not migrate into the blood. P. acnes is not contagious, so people with acne do not transmit their affection to family members or other people with whom they come into daily contact. The lesions are not prone to appear throughout the entire body, as we would expect in the case of a general infection. In fact, acne occurs only in areas where there are more sebaceous glands, that is, face, head, neck, shoulders and chest.

Up until nowadays, researchers have not found a universally valid treatment/prevention recommendation for people with acne. Most studies have investigated the role of highly concentrated sweets and milk consumption that were suspected to stimulate the occurrence or/and persistence of lesions. To date, there is not enough information available to justify a recommendation that acne patients should no longer eat such foods. The actual recommendation is that each person should try to see if there is a worsening of the lesions related to certain foods and if there is, eating such foods should be avoided.

This idea is still quite widespread, but there is no evidence whatsoever that sexual activity is influencing acne. There is acne in pregnant women, there is acne after birth, and there is acne in married couples. If one has expectation that acne would heal itself after starting ones sexual life, then chances are to see patients with even more severe lesions and, of course, with more permanent scars.

Many acne patients say that in Summer, lesions improve. It is true that sun rays (specifically ultraviolet radiation) have an active anti-inflammatory action, so some improvements can be seen, especially on the body and less on the face. Improvement occurs after a maximum of 10-20 minutes’ exposure at controlled and recommended times of day, and it is known that patients are not compliant to such timeframes. Usually, exposure is significantly longer than 10-20 minutes, with no adequate sunscreen, and although there is an initial improvement in acne, 10-14 days after exposure a severe worsening in lesions is often seen as compared to their initial status.

More and more studies show that acne is part of adult life, even around the age of 40. Such cases are related to genetic inheritance and to the onset of new/untreated hormonal problems, possibly associated with obesity, insulin resistance and diabetes. Covering lesions with layers of various make-up is a significant contributor to acne worsening.

This idea is false. We should not wait because, in most cases, the lack of treatment leads to scars. There is a significant array of treatments available and if we institute early treatment we have the best chances to efficiently treat acne.

How do we approach Acne?

As a general rule, each physician has a specific treatment framework to comply with.

There are many factors influencing a treatment decision: patient’s age and sex, a family history of acne, skin condition, previous treatments, personal preferences, the medical history, life plans, etc.

Acne is a chronic inflammatory disease and in many cases it can even resolve without treatment. The problem is that no physician can predict what the evolution of each patient would be, and, most importantly, if patients shall bear permanent scars. The best approach is to treat lesions as early as possible and not wait until they worsen and only then to investigate for possible causes and identify the most adequate treatment – often a combined treatment (topical and internal acting drugs).

In very young patients, at the beginning of puberty, we usually choose local topical treatments and recommend specific care rules: how to correctly clean and care for the affected areas and how to apply appropriate daycare products on a regular basis. The skin changes periodically, more precisely at the level of the layer separating the epidermis from the dermis, in 21 days cycles. Such changes first occur at the microscopic level. That is why, in order to observe clinically relevant changes with the naked eye, it is obvious that we need to apply treatment over several skin change cycles. Patients should understand that in acne, the minimum duration of topical application of a specific product is three months. Patience and the regular use of small amounts of any topical local treatment are the key to success in fighting acne.

When lesions are rebellious, in girls/women the physician intervenes through hormone dosing to determine if there is an internal problem that causes the appearance and permanence/persistence of the lesions.

In addition to hormonal tests, we can also ask for regular tests to be performed, which we regularly monitor, so that we have a complete biological picture of the patient, and we can decide together in each particular case on which therapy is best suited. There are no two identical cases, and it is important to recognize that when we work as a team and when explaining why a particular treatment is indicated, we can gain patient confidence and thus achieve the desired results in the shortest time.

In short, acne is a condition that can be successfully treated without scarring… neither physical nor mental.

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