Dr. Connelly talks about
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Questions and Answers About Acne
What Is Acne?
Acne is a disorder resulting from the action of hormones and
other substances on the skin's oil glands (sebaceous glands) and hair
follicles. These factors lead to plugged pores and outbreaks of lesions
commonly called pimples or zits. Acne lesions usually occur on the face,
neck, back, chest, and shoulders. Although acne is usually not a serious
health threat, it can be a source of significant emotional distress. Severe
acne can lead to permanent scarring.
Doctors describe acne as a disease of the pilosebaceous
units (PSUs). Found over most of the body, PSUs consist of a sebaceous gland
connected to a canal, called a follicle, that contains a fine hair (see
"Normal Pilosebaceous Unit" diagram). These units are most numerous on the
face, upper back, and chest. The sebaceous glands make an oily substance
called sebum that normally empties onto the skin surface through the opening
of the follicle, commonly called a pore. Cells called keratinocytes line the
follicle.
Normal Pilosebaceous Unit
The hair, sebum, and keratinocytes that fill the narrow
follicle may produce a plug, which is an early sign of acne. The plug
prevents sebum from reaching the surface of the skin through a pore. The
mixture of oil and cells allows bacteria Propionibacterium acnes (P.
acnes) that normally live on the skin to grow in the plugged follicles.
These bacteria produce chemicals and enzymes and attract white blood cells
that cause inflammation. (Inflammation is a characteristic reaction of
tissues to disease or injury and is marked by four signs: swelling, redness,
heat, and pain.) When the wall of the plugged follicle breaks down, it
spills everything into the nearby skin – sebum, shed skin cells, and
bacteria – leading to lesions or pimples.
People with acne frequently have a variety of lesions, some
of which are shown in the diagrams below. The basic acne lesion, called the
comedo (KOM-e-do), is simply an enlarged and plugged hair follicle. If the
plugged follicle, or comedo, stays beneath the skin, it is called a closed
comedo and produces a white bump called a whitehead. A comedo that reaches
the surface of the skin and opens up is called an open comedo or blackhead
because it looks black on the skin's surface. This black discoloration is
due to changes in sebum as it is exposed to air. It is not due to dirt. Both
whiteheads and blackheads may stay in the skin for a long time.
Types of Lesions
Other troublesome acne lesions can develop, including the
following:
Papules – inflamed lesions that usually
appear as small, pink bumps on the skin and can be tender to the touch
Pustules (pimples) – papules topped by
white or yellow pus-filled lesions that may be red at the base
Nodules – large, painful, solid lesions
that are lodged deep within the skin
Cysts – deep, painful, pus-filled
lesions that can cause scarring.
The exact cause of acne is unknown, but doctors believe it
results from several related factors. One important factor is an increase in
hormones called androgens (male sex hormones). These increase in both boys
and girls during puberty and cause the sebaceous glands to enlarge and make
more sebum. Hormonal changes related to pregnancy or starting or stopping
birth control pills can also cause acne.
Another factor is heredity or genetics. Researchers believe
that the tendency to develop acne can be inherited from parents. For
example, studies have shown that many school-age boys with acne have a
family history of the disorder. Certain drugs, including androgens and
lithium, are known to cause acne. Greasy cosmetics may alter the cells of
the follicles and make them stick together, producing a plug.
Doctors usually recommend an OTC or prescription topical
medicine for people with mild signs of acne. Topical medicine is applied
directly to the acne lesions or to the entire area of affected skin.
There are several OTC topical medicines used for mild acne.
Each works a little differently. Following are the most common ones:
Benzoyl peroxide – destroys P.
acnes, and may also reduce oil production
Resorcinol – can help break down
blackheads and whiteheads
Salicylic acid – helps break down
blackheads and whiteheads. Also helps cut down the shedding of cells
lining the hair follicles
Sulfur – helps break down blackheads
and whiteheads.
Topical OTC medicines are available in many forms, such as
gels, lotions, creams, soaps, or pads. In some people, OTC acne medicines
may cause side effects such as skin irritation, burning, or redness, which
often get better or go away with continued use of the medicine. If you
experience severe or prolonged side effects, you should report them to your
doctor.
OTC topical medicines are somewhat effective in treating
acne when used regularly; however, it may take up to 8 weeks before you see
noticeable improvement.
People with moderate to severe inflammatory acne may be
treated with prescription topical or oral medicines, alone or in
combination.
Prescription Topical Medicines
Several types of prescription topical medicines are used to
treat acne. They include:
Antibiotics – help stop or slow the
growth of bacteria and reduce inflammation
Vitamin A derivatives (retinoids) –
unplug existing comedones (plural of comedo), allowing other topical
medicines, such as antibiotics, to enter the follicles. Some may also
help decrease the formation of comedones. These drugs contain an altered
form of vitamin A. Some examples are tretinoin (Retin-A2),
adapalene (Differin), and tazarotene (Tazorac)
Others – may destroy P. acnes
and reduce oil production or help stop or slow the growth of bacteria
and reduce inflammation. Some examples are prescription strength Benzoyl
peroxide, sodium sulfacetamide/sulfur-containing products, or Azelaic
acid (Azelex).
Like OTC topical medicines, prescription topical medicines
come as creams, lotions, solutions, gels, or pads. Your doctor will consider
your skin type when prescribing a product. Creams and lotions provide
moisture and tend to be good choices for people with sensitive skin. If you
have very oily skin or live in a hot, humid climate, you may prefer an
alcohol-based gel or solution, which tends to dry the skin. Your doctor will
tell you how to apply the medicine and how often to use it.
For some people, prescription topical medicines cause minor
side effects, including stinging, burning, redness, peeling, scaling, or
discoloration of the skin. With some medicines, such as tretinoin, these
side effects usually decrease or go away after the medicine is used for a
period of time. If side effects are severe or don't go away, notify your
doctor.
2 Brand names included in
this booklet are provided as examples only, and their inclusion does not
mean that these products are endorsed by the National Institutes of Health
or any other Government agency. Also, if a particular brand name is not
mentioned, this does not mean or imply that the product is unsatisfactory.
As with OTC medicines, the benefits of prescription topical
medicines are not immediate. Your skin may seem worse before it gets better.
It may take from 4 to 8 weeks to notice improvement.
Prescription Oral Medicines
For patients with moderate to severe acne, doctors often
prescribe oral antibiotics. Oral antibiotics are thought to help control
acne by curbing the growth of bacteria and reducing inflammation.
Prescription oral and topical medicines may be combined. Common antibiotics
used to treat acne are tetracycline (Achromycin V), minocycline (Dynacin,
Minocin), and doxycycline (Adoxa, Doryx, and Monodox).
Other oral medicines less commonly used are clindamycin (Cleocin),
erythromycin, or sulfonamides (Bactrim). Some people taking these
antibiotics have side effects, such as an upset stomach, dizziness or
lightheadedness, changes in skin color, and increased tendency to sunburn.
Because tetracyclines may affect tooth and bone formation in fetuses and
young children, these drugs are not given to pregnant women or children
under age 14. There is some concern, although it has not been proven, that
tetracycline and minocycline may decrease the effectiveness of birth control
pills. Therefore, a backup or another form of birth control may be needed.
Prolonged treatment with oral antibiotics may be necessary to achieve the
desired results.
People with nodules or cysts should be treated by a
dermatologist. For patients with severe inflammatory acne that does not
improve with medicines such as those described above, a doctor may prescribe
isotretinoin (Accutane), a retinoid (vitamin A derivative). Isotretinoin is
an oral drug that is usually taken once or twice a day with food for 15 to
20 weeks. It markedly reduces the size of the oil glands so that much less
oil is produced. As a result, the growth of bacteria is decreased.
Advantages of Isotretinoin (Accutane)
Isotretinoin is a very effective medicine that can help
prevent scarring. After 15 to 20 weeks of treatment with isotretinoin, acne
completely or almost completely goes away in most patients. In those
patients where acne recurs after a course of isotretinoin, the doctor may
institute another course of the same treatment or prescribe other medicines.
Disadvantages of Isotretinoin (Accutane)
Isotretinoin can cause birth defects in the developing fetus
of a pregnant woman. It is important that women of childbearing age
are not pregnant and do not get pregnant while taking this medicine.
Women must use two separate effective forms of birth control at the same
time for 1 month before treatment begins, during the entire course of
treatment, and for 1 full month after stopping the drug. You should ask your
doctor when it is safe to get pregnant after you have stopped taking
isotretinoin.
Some people with acne become depressed by the changes in the
appearance of their skin. Changes in mood may be intensified during
treatment or soon after completing a course of medicines like isotretinoin.
There have been a number of reported suicides and suicide attempts in people
taking isotretinoin; however, the connection between isotretinoin and
suicide or depression is not known. Nevertheless, if you or someone you know
feels unusually sad or has other symptoms of depression, such as loss of
appetite, loss of interest in once-loved activities, or trouble
concentrating, it's important to consult your doctor.
Other possible side effects of isotretinoin include:
dry eyes, mouth, lips, nose, or skin (very common)
itching
nosebleeds
muscle aches
sensitivity to the sun
poor night vision
changes in the blood, such as an increase in fats in the
blood (triglycerides and cholesterol)
change in liver function.
To be able to determine if isotretinoin should be stopped if
side effects occur, your doctor may test your blood before you start
treatment and periodically during treatment. Side effects usually go away
after the medicine is stopped.
In some women, acne is caused by an excess of androgen
(male) hormones. Clues that this may be the case include hirsutism
(excessive growth of hair on the face or body), premenstrual acne flares,
irregular menstrual cycles, and elevated blood levels of certain androgens.
The doctor may prescribe one of several drugs to treat women
with this type of acne:
Birth control pills – to help suppress
the androgen produced by the ovaries
Low-dose corticosteroid drugs, such as
prednisone (Deltasone) or dexamethasone (Decadron, Hexadrol) –
to help suppress the androgen produced by the adrenal glands
Antiandrogen drugs such as spironolactone (Aldactone)
– to reduce the excessive oil production.
Side effects of antiandrogen drugs may include irregular
menstruation, tender breasts, headaches, and fatigue.
Doctors may use other types of procedures in addition to
drug therapy to treat patients with acne. For example, the doctor may remove
the patient's comedones during office visits. Sometimes the doctor will
inject corticosteroids directly into lesions to help reduce the size and
pain of inflamed cysts and nodules.
Early treatment is the best way to prevent acne scars. Once
scarring has occurred, the doctor may suggest a medical or surgical
procedure to help reduce the scars. A superficial laser may be used to treat
irregular scars. Dermabrasion (or microdermabrasion), which is a form of
"sanding down" scars, is sometimes used. Another treatment option for deep
scars caused by cystic acne is the transfer of fat from another part of the
body to the scar. A doctor may also inject a synthetic filling material
under the scar to improve its appearance.
If you have acne, you should gently wash your face with a
mild cleanser, once in the morning and once in the evening, as well as after
heavy exercise. Wash your face from under the jaw to the hairline and be
sure to thoroughly rinse your skin.
Ask your doctor or another health professional for advice on
the best type of cleanser to use.
Using strong soaps or rough scrub pads is not helpful and
can actually make the problem worse. Astringents are not recommended unless
the skin is very oily, and then they should be used only on oily spots.
It is also important to shampoo your hair regularly. If you
have oily hair, you may want to wash it every day.
Avoid Frequent Handling of the
Skin
Avoid rubbing and touching skin lesions. Squeezing, pinching
or picking blemishes can lead to the development of scars or dark blotches.
Shave Carefully
Men who shave and who have acne should test both electric
and safety razors to see which is more comfortable. When using a safety
razor, make sure the blade is sharp and soften your beard thoroughly with
soap and water before applying shaving cream. Shave gently and only when
necessary to reduce the risk of nicking blemishes.
Avoid a Sunburn or Suntan
Many of the medicines used to treat acne can make you more
prone to sunburn. A sunburn that reddens the skin or suntan that darkens the
skin may make blemishes less visible and make the skin feel drier. However,
these benefits are only temporary, and there are known risks of excessive
sun exposure, such as more rapid skin aging and a risk of developing skin
cancer.
Choose Cosmetics Carefully
While undergoing acne treatment, you may need to change some
of the cosmetics you use. All cosmetics, such as foundation, blush, eye
shadow, moisturizers, and hair-care products should be oil free. Choose
products labeled noncomedogenic (meaning they don't promote the formation of
closed pores). In some people, however, even these products may make acne
worse.
For the first few weeks of treatment, applying foundation
evenly may be difficult because the skin may be red or scaly, particularly
with the use of topical tretinoin or benzoyl peroxide.
Medical researchers are working on new drugs to treat acne,
particularly topical antibiotics to replace some of those in current use. As
with many other types of bacterial infections, doctors are finding that,
over time, the bacteria that are associated with acne are becoming resistant
to treatment with certain antibiotics, though it is not clear how
significant a problem this resistance represents.
Scientists are also trying to better understand the
mechanisms involved in acne so that they can develop new treatments that
work on those mechanisms. For example, one group of NIAMS-supported
researchers is studying the mechanisms that regulate sebum production in
order to identify ways to effectively reduce its production without the side
effects of current medicines. Another group is trying to understand how
P. acnes activates the immune system in order to identify possible
immunologic interventions. Other areas of research involve examining the
effects of isotretinoin on an area of the brain that might lead to
depression and developing a laser system to treat acne and acne-related
scars without damaging the outer layers of the skin.
Researchers in Germany, funded by German institutions, have
taken P. acnes and identified its genetic information (genome).
This information may help researchers develop new treatments to target the
bacteria.
Acknowledgments
NIAMS gratefully acknowledges the assistance of Laurence H.
Miller, M.D., Chevy Chase, MD; Kenneth A. Katz, M.D., M.Sc., University of
Pennsylvania School of Medicine, Philadelphia; Edward W. Cowen, M.D.,
National Cancer Institute, NIH; and Alan Moshell, M.D., NIAMS, NIH, in the
preparation and review of this booklet.
