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Though common and virtually never
life-threatening, acne is a potentially disfiguring skin disease which often strikes those
in an emotionally and developmentally vulnerable stage of life-adolescence. It affects the
glands in the skin which secrete the natural lubrication (sebum) for the hair follicles
and surrounding skin, which are located in greatest concentrations on the face, back,
shoulders and chest.
Acne lesions are of several types. Blackheads (comedones) are glands plugged with
excessive material which discolours on exposure to air. Whiteheads are small collections
of pus within glands, and nodules or papules are the red, inflamed areas of more extensive
infection.
Acne is a response in the skin to the hormone testosterone. In most people the testosterone is present in normal levels in the blood, but the skin reacts in an abnormal way to it. What causes this "abnormality" is unknown, but it is self limiting and will eventually correct itself. This may, however, take years or even decades and there is no way of predicting how long this may take.
Over-production of oil: - Oil or sebum in the skin is produced by specialised glands attached to the tiny hairs that cover the skin. These sebaceous glands are first activated at puberty by the hormone testosterone and start to produce oil to lubricate the skin. Activity of the sebaceous glands is a prerequisite to developing acne which is why acne only starts at or after puberty.
In patients who develop acne, abnormally high levels of sebum secretion are usually found. This seems to be due to an increased sensitivity of the sebaceous glands to normal levels of testosterone.
Blockage of the hair duct: - Blockage of the hair ducts is due to an abnormality of the cells lining the duct. In normal skin these cells continually grow and die and are shed into the duct and thus onto the surface of the skin. In patients with acne, the cells react abnormally to testosterone and become "sticky’ and instead of being shed, progressively block the duct- rather like a kettle becoming furred up. This leads to a partial obstruction of sebum flow from the sebaceous glands with pooling of sebum in the hair ducts. The oil solidifies and this, with the plug in the duct which becomes pigmented, gives rise to blackheads and whiteheads which are the non-inflammatory spots of acne.
Inflammation: - The cause of inflammation and pus formation in acne is still poorly understood. It is thought that periodically the partial blockages of the hair ducts become complete. This leads to an acute build-up of oil in the hair duct which is broken down by bacteria present with the production of inflammatory chemicals. These penetrate into the skin and cause the redness and swelling which heralds the new spot. At this time there can be itching or tenderness at the site. Pus cells are then recruited into the area and eventually a pustule develops. In the natural evolution of the spot, the pus eventually ruptures onto the surface of the skin and the spot settles down. If the inflammation is present deep in the hair duct, or if the spot is squeezed too early, the pus can rupture into the skin which will cause even more inflammation and potentially more scarring.
Acne is not an inherited disease in the medical sense of the word. However, acne is more common in children of parents who have had or still have acne. Looking at it the other way, if you look at parents of children with acne, more of them have acne or have had acne than parents of children who do not have acne. If you look at twins, you will usually see acne in both twins if they are identical while the incidence of acne affecting both non-identical twins is much less.
There is no way of predicting whether or not the child of a patient with severe acne will develop acne or if the child does, how severe it will be.
Is acne hormonal?: - Although the abnormality in the skin is caused by the effect of the hormone testosterone, the levels of this hormone in patients with acne is generally normal.
Testosterone is the male sex hormone and is present in both men and women. In women its main effects are counteracted by the female hormones.
Men with acne usually have normal levels of testosterone in the blood. Women with acne may have slight abnormalities in the levels of testosterone but these do not influence treatment and there is no reason to measure hormone levels in these patients.
There is a condition called the polycystic ovary syndrome, in which women may be overweight, develop excessive body and facial hair, have irregular periods and may suffer from infertility. Some of these patients do develop acne, and this seems to be related to an abnormality of hormone levels in these patients.
What affects it - fact and fiction
Does diet affect acne?: - No direct link has been found between acne and diet. It is a myth that chocolate and fried foods make acne worse. However a good balanced diet will improve your general well-being and this will be reflected in the condition of your skin.
Does sex affect acne?: - No. Although the sex hormone testosterone is the primary cause of acne you do not develop spots because you have too much of this hormone or are over-sexed. Masturbation and whether you have sex or not has no effect on acne and certainly does not cause it.
Is acne caused by dirt?: - No. The black of blackheads is due to the pigment or colouring of the plug of "sticky" cells blocking the hair duct. In fact most people with acne wash more frequently than those without the condition to try to clear away the excess oil produced by their skin. But over-washing can actually make acne worse by drying the skin and making it sore. Normal regular washing with mild soap twice a day is all that is needed. If you have a combination skin, non-oily moisturiser on dry patches will not make the acne worse.
Does acne become worse before periods?: - Yes. Many women notice that their acne gets worse two to seven days before their period starts. This is probably due to changes in their hormone levels at this stage in the menstrual cycle.
Will pregnancy improve acne?: - Yes and no. Some women’s acne virtually disappears but often recurs at the end of pregnancy while, for others, pregnancy heralds the reactivation of acne or the worsening of an existing condition.
Does sweating affect acne?: - Yes. Up to 15 per cent of sufferers find their acne flares up when they have been sweating a lot. This is probably due to water swelling the partial hair duct obstruction causing a complete blockage and therefore inflammation.
Do humid atmospheres make acne worse?: - Yes. Going on holiday to a very humid climate or working in an environment such as a kitchen or steam room can cause acne to flare up in the same way as sweating does. This is due to hydration and swelling of the ductal blockages, which precipitate the inflammatory phase of acne.
Can medicines make acne worse?: - Yes. Many medicines may do this, most commonly corticosteroids and anti-epilepsy drugs. If you think that medicines you are taking have made your acne worse, you should speak to your doctor. Never stop medication without medical advice.
Can cosmetics make acne worse?: - Some cosmetics, particularly those in USA and the ethnic Indian make-ups may induce blackhead formation in the skin.
Certain hair oils or pomades, particularly those used to "defrizz" very curly hair may induce blackheads and whiteheads along the hair margin. These should be avoided by those with a tendency towards developing acne.
In the same way, some people react to suntan oils with a worsening of acne. Always test suntan oils on a small area of the chest first to make sure you do not react to them.
Can clothes affect acne?: - Continual pressure from headbands, tight bra straps and collars may cause spots in those areas of skin. The reason for this is unclear but may be related to localisation of sweat in those areas.
Can my work exacerbate my acne?: - Yes. Coming into contact with cutting and mineral oils can cause acne-like spots on the arms and legs and make existing acne worse where the oil comes in contact with the skin.
Source: - Acne Support Group
Various approaches to
treatment are available, the most direct method being topical preparations. Chemicals
(known as 'Keraolytics') are designed to soften the horny layer of skin and make it peel
away. The aim is to remove the plugs of keratin and thereby allow the sebum to drain
freely. Other products contain antibacterial agents, but since acne is not actually caused
by bacteria, it is unlikely that these substances alone will eradicate the problem. but
they are generally somewhat abrasive and irritating and are not useful for the more
inflammatory types.
(1) British National Formulary 1986.