Acne Symptoms, Causes, Treatment Options
- The more severe cases of acne tend to occur most often in men, because they produce more of the male hormones that stimulate acne formation.
- In most people, acne will last for about three to four years and in 15% of the cases, acne can continue for eight-12 years.
- Blackheads are not dirt, they're actually the result of oil and dead cells getting trapped in a pore where they block the duct and mix with bacteria. They then turn black when exposed to air.
- While not a life-threatening condition, acne can have a significant psychological and physical impact on a person's life, causing poor self-image, anxiety, depression, and permanent scarring of the skin.
- Adolescent girls are more vulnerable than boys to the negative psychological effects of acne2
Acne (also called acne vulgaris) is a common skin disease that causes pimples, blackheads, or red and swollen bumps. Acne occurs when the hair follicles become plugged with oil and dead skin cells. It usually forms on the face, neck, back, chest and shoulders.
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 forms of acne. However, 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 as well in adulthood.
There are 2 major types of acne lesions: noninflammatory and inflammatory.
Noninflammatory lesions
- Blackheads. Blackheads form when the pores are clogged close to the surface of the skin. Because they are exposed to the skin surface, blackheads don't usually become inflamed. They are dark due to the presence of a dark pigment - a substance that produces a characteristic color in skin tissue. This color is not the result of dirt in the pores.
- Whiteheads. Whiteheads develop from a blockage deeper in a pore. Lacking a drainage path, the oil accumulates in the skin, causing small flesh-colored or white-colored bumps. Unlike blackheads, whiteheads are more likely to lead to the inflammation known as pimples or zits.
Inflammatory lesions
- Papules. Papules are small (5 millimeters or less), firm, red-colored lesions slightly elevated above the surface of the skin. Although they may contain pus, is not easily seen because of the redness. Papules often continue to grow in size and become pustules.
- Pustules. Pustules (also known as pimples or zits) are dome-shaped, fragile lesions that occur when the walls of the blocked follicle ruptures. Oil, dead skin cells, and bacteria normally found on the skin surface get into the skin and irritate it, forming small areas of inflammation. Although they contain pus, they generally don't have a lot of bacteria inside. Acne pustules that heal without progressing to cystic form usually leave no scars.
- Nodules. 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 that may not respond to therapies other than isotretinoin.
- Cysts. A 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, and may be very painful. Cysts and nodules often occur together in a severe form of acne called nodulocystic. Unlike the other types of lesions, upon healing, nodules generally leave scars.
The exact cause of acne remains unknown. But a number of factors - including hormones, bacteria, certain medications and heredity - seem to play a role. However, exactly why some people get acne and some do not is not clear.
- Excess androgen hormones (testosterone or androsterone). One important factor is an increase in hormones called androgens (male sex hormones). Increases in androgen hormone levels lead to increased sebum production by oil glands, which in turn increases the likelihood of developing acne. Hormonal changes related to puberty, menstrual periods, pregnancy, birth control pills, or stress, induce an increase in male sex hormones.
- Family history. The tendency to develop acne runs in families. While studies have been highly suggestive of a hereditary link for acne, no "acne gene" has been discovered yet.
- Overgrowth of normal skin bacteria. Although acne is not caused by a bacterial infection, bacteria do play a role in making the situation worse. A bacterium called Propionibacterium acnes or P. acnes is a normal inhabitant of the skin and uses sebum as a nutrient for growth. When oil is trapped in the hair follicles, the normal skin bacteria P. acnes will grow in the blocked pore. The bacteria produce chemicals that alter the composition of the oil, which makes it more irritating to the skin and causes inflammation. All of these processes can result in inflammation. People with acne have more P. acnes in their follicles than people without acne.
- Irregular shedding of dead skin cells. Irregular shedding of dead skin cells can result in plugged and irritated hair follicles.
- Medications. Certain medications (such as steroids, testosterone, estrogen, birth control pills) which are androgenic by nature can enhance acne by increasing oil production and pore blockage. Other medications which can aggravate acne include lithium, and some anti-seizure medications.
Medications that may cause acne as a side effect:
| Drug | Incidence |
|---|---|
| Abilify Tablets | 1% or less |
| Aclovate | Infrequent |
| Activella Tablets | |
| AeroBid/AeroBid-M | 1% to 3% |
| Alesse-28 Tablets | |
| Ambien Tablets | Rare |
| Amerge Tablets | Rare |
| Anadrol-50 Tablets | |
| Analpram-HC | |
| AndroGel | 1% to 8% |
| Antabuse Tablets | |
| Arava Tablets | 1% to 3% |
| Asacol Delayed-Release Tablets | 1% to 2% |
| Aygestin Tablets | |
| Bextra Tablets | 0.1% to 1.9% |
| Bravelle for Intramuscular or Subcutaneous Injection | 2.9% |
| Caduet Tablets | Less than 2% |
| Campral Tablets | Infrequent |
| Canasa Rectal Suppositories | 1.2% |
| Capex Shampoo | |
| Celexa | Infrequent |
| CellCept Capsules, Intravenous, Oral Suspension, Tablets | 3% to less than 20% |
| Clobevate Gel | |
| Clobex Lotion | |
| Clobex Shampoo | |
| Clomid Tablets | |
| CombiPatch Transdermal System | 4% to 5% |
| Copaxone for Injection | At least 2% |
| Cortisporin Cream | |
| Cortisporin-TC Otic Suspension | |
| Cosmegen for Injection | |
| Crinone 8% Gel | Less than 5% |
| Cutivate Cream | Infrequent |
| Cutivate Ointment | Infrequent to more frequent |
| Cymbalta Delayed-Release Capsules | Infrequent |
| Dantrium Capsules | Less frequent |
| Delatestryl Injection | |
| Depo-Provera Contraceptive Injection | 1% to 5% |
| Depo-Provera Sterile Aqueous Suspension | |
| Diprolene AF Cream 0.05% | Infrequent |
| Dostinex Tablets | 1% to less than 10% |
| Doxil Injection | Less than 1% |
| Effexor Tablets | Infrequent |
| Effexor XR Capsules | Infrequent |
| Elidel Cream 1% | 0.9% to 1.8% |
| Elocon Cream 0.1% | Infrequent |
| Elocon Ointment 0.1% | Infrequent |
| Eskalith | |
| Estratest | |
| Evoxac Capsules | Less than 1% |
| Fortovase Capsules | Less than 2% |
| Gabitril Tablets | 1% or more |
| Gengraf Capsules | 1% to 6% |
| Gonal-F RFF Pen for Injection | 3.6% |
| HIVID Tablets | Less than 1% |
| Herceptin I.V. | 2% |
| Humatrope Vials and Cartridges | Up to 5.8% |
| Intron A for Injection | Less than 5% |
| Invirase Capsules | Less than 2% |
| Iressa Tablets | 25% to 37% |
| Kaletra | Less than 2% |
| Lamictal | 1.3% |
| Levlen | |
| Levlite 28 Tablets | |
| Lexapro Oral Solution | Infrequent |
| Lexapro Tablets | Infrequent |
| Lipitor Tablets | Less than 2% |
| Lo/Ovral-28 Tablets | |
| Locoid Lipocream Cream | Infrequent |
| Lofibra Capsules | |
| Loprox Gel | |
| Lotronex Tablets | Rare |
| Lunelle Monthly Injection | |
| Lupron Depot-3 Month 11.25 mg | Up to 10% |
| Lupron Depot-PED Month 7.5 mg, 11.25 mg and 15 mg | 2% |
| Lupron Injection Pediatric | |
| Luxiq Foam | One patient |
| Maxalt Tablets | Rare |
| Maxalt-MLT Orally Disintegrating Tablets | Rare |
| Meridia Capsules | 1% |
| Mirena Intrauterine System | 5% or more |
| Myfortic Tablets | 3% to less than 20% |
| Namenda Tablets | More than ona patient |
| Neoral Soft Gelatin Capsules | 1% to 6% |
| Neoral Solution | 1% to 6% |
| Neurontin Capsules, Oral Solution, Tablets | |
| Nexium Delayed-Release Capsules | Less than 1% |
| Nimotop Capsules | Up to 1.4% |
| Nipent for Injection | Less than 3% |
| Noritate Cream, 1% | One patient |
| Norvir | Less than 2% |
| Olux Foam | |
| Ortho Evra Transdermal System | |
| Ortho Micronor Tablets | Rare |
| Ortho Tri-Cyclen Lo Tablets | |
| Ortho-Cept Tablets | |
| Ortho-Cyclen/Ortho Tri-Cyclen | |
| Ovral-28 Tablets | |
| Ovrette Tablets | |
| Oxandrin Tablets | |
| Pandel Cream, 0.1% | |
| Paxil CR Controlled-Release Tablets | Infrequent |
| Paxil | Infrequent |
| Pentasa Capsules | 0.2% |
| Pepcid Injection | Infrequent |
| Pepcid | Infrequent |
| Permax Tablets | Infrequent |
| Pramosone | |
| Premphase Tablets | |
| Prempro Tablets | |
| Prevacid Delayed-Release Capsules | Less than 1% |
| Prevacid NapraPAC | Less than 1% |
| Prevacid SoluTab Delayed-Release Orally Disintegrating Tablets | Less than 1% |
| Prevacid for Delayed-Release Oral Suspension | Less than 1% |
| Prevpac | Less than 1% |
| Priftin Tablets | 2.2% |
| ProSom Topical | Rare |
| Prochieve 4% Gel | |
| Prochieve 8% Gel | |
| ProctoFoam-HC | |
| Prograf Capsules and Injection | 3% to 15% |
| Prometrium Capsules (100 mg, 200 mg) | Less than 5% |
| Protonix I.V. | Less than 1% |
| Protonix Tablets | Less than 1% |
| Protopic Ointment | 2% to 7% |
| Prozac Pulvules and Liquid | Infrequent |
| Rapamune Oral Solution and Tablets | 20% to 31% |
| Raptiva for Injection | 4% |
| ReFacto Vials | |
| Relafen Tablets | Less than 1% |
| Retrovir Capsules | |
| Retrovir I.V. Infusion | |
| Retrovir | |
| Rifater Tablets | Rare |
| Risperdal Consta Injection | 2% |
| Risperdal M-Tab Tablets | Infrequent to 2% |
| Risperdal | Infrequent to 2% |
| Rowasa Rectal Suspension Enema | 1.2% |
| Sandimmune | 1% to 6% |
| Sandostatin LAR Depot | 1% to 4% |
| Seasonale Tablets | |
| Seroquel Tablets | Infrequent |
| Simulect for Injection | Greater than or equal to 10% |
| Sonata Capsules | Infrequent |
| Soriatane Capsules | Less than 1% |
| Striant Mucoadhesive | |
| Sular Tablets | Less than or equal to 1% |
| Symbyax Capsules | Infrequent |
| Targretin Capsules | |
| Temovate Cream | |
| Temovate E Emollient | Infrequent |
| Temovate Gel | Infrequent |
| Temovate Ointment | |
| Temovate Scalp Application | Infrequent |
| Testim 1% Gel | Less than 1% |
| Testred Capsules, 10 mg | |
| Thalomid Capsules | 3.1% to 11.1% |
| Topamax Sprinkle Capsules, Tablets | Frequent |
| Trecator-SC Tablets | |
| Tri-Levlen | |
| Tri-Luma Cream | 5% |
| Tricor Tablets | |
| Trileptal Oral Suspension, Tablets | 1% to 2% |
| Triphasil-28 Tablets | |
| Uniretic Tablets | Less than 1% |
| Valcyte Tablets | Less than 5% |
| Vaniqa Cream, 13.9% | 10.8% to 21.3% |
| Vantin Tablets and Oral Suspension | Less than 1% |
| Vivelle Transdermal System | 2.3% |
| Vivelle-Dot Transdermal System | 2.3% |
| Wellbutrin SR Sustained-Release Tablets | At least 1% |
| Wellbutrin Tablets | Rare |
| Wellbutrin XL Extended-Release Tablets | At least 1% |
| Yasmin 28 Tablets | Greater than 1% |
| Zenapax for Injection | Greater than 5% |
| Zoladex 3-month | |
| Zoladex | 42% |
| Zoloft | Infrequent |
| Zonegran Capsules | Infrequent |
| Zyban Sustained-Release Tablets | Infrequent |
| Zyrtec Chewable Tablets | Less than 2% |
| Zyrtec-D 12 Hour Extended-Release Tablets | Less than 2% |
| Zyrtec | Less than 2% |
Although the condition is benign, because of its dermal component and tendency to relapse, acne is often difficult to treat.
Acne treatments work by reducing oil production, speeding up skin cell turnover, fighting bacterial infection, reducing the inflammation or doing all four. An important goal of acne treatment is to prevent or minimize scarring. Specific treatment regimens will vary from person to person, depending on acne severity and tolerance to the medication.
Generally, mild acne is treated with topical products, including topical retinoids, antimicrobials (benzoyl peroxide, clindamycin, or erythromycin), salicylic acid or azelaic acid. Moderate acne can be managed with topical retinoids in combination with oral antibiotics. Severe acne that is not responsive to conventional treatments may require treatment with oral isotretinoin (Accutane).
Oral Antibiotics
Antibiotics are frequently used to treat acne, either systemically or topically. Antibiotics work by killing bacteria that contribute to the cause of acne. They also have a direct effect of reducing inflammation. Oral antibiotics are indicated as treatment of moderate and quite severe acne or if acne is considered as very serious by the patient for psychological or social reasons. During pregnancy the best antibiotic is erythromycin.
Oral antibiotics used for acne unclude:
- Tetracycline
- Doxycycline
- Minocycline
- Erythromycin
Topical Antibiotics
Topical antibiotics improve acne by inhibiting the growth of bacteria P. acnes. They may also help reduce inflammation and decrease the amount of blocked pores, depending on the form used. Topical antibiotics are most often prescribed to treat mild to moderately severe inflammatory acne. They may be used alone or combined with a medication that works on another factor that leads to acne aside from P. acnes.
Common topical antibiotics used to treat acne include:
- Clindamycin
- Erythromycin
- Sodium sulfacetamide
Isotretinoin (Accutane)
Isotretinoin (Accutane) is reserved for the most severe forms of acne. This is a powerful medication available for scarring cystic acne or acne that doesn't respond to other treatments. Isotretinoin works by shrinking the sebaceous glands within the dermis, reducing the amount of oil produced. After 15 to 20 weeks of treatment with isotretinoin, acne completely or almost completely goes away in up to 90% of people.
While isotretinoin is the most effective acne treatment available, it cannot be prescribed to everyone due to a number of potential side effects - some serious. Isotretinoin is associated with severe birth defects, so it can't be taken by pregnant women or women who may become pregnant during the course of treatment or within several weeks of concluding treatment. In addition, isotretinoin may increase the levels of triglycerides and cholesterol in the blood and may increase liver enzyme levels.
Tretinoin (Retin-A, Renova)
Topical retinoids, a derivative of vitamin A, are prescribed to treat acne ranging from mild to moderately severe. Topical retinoids help to open clogged pores by creating a mild peeling effect. Side effects include redness, scaling, dryness, itching and burning.
Azelaic acid
Azelaic acid is a prescription cream or gel for mild to moderate acne. It works by reducing P. acnes, the bacteria responsible for acne breakouts. It also helps normalize shedding of dead skin cells, and decreases inflammation. Azelaic acid has the added benefit of improving post-inflammatory hyperpigmentation.
Benzoyl peroxide
Benzoyl peroxide works to clear up acne by reducing P. acnes and removing dead cells from the skin to prevent comedones. It was one of the first agents found to be effective in treating mild acne and has been used in acne treatment for decades. The principal side effect is excessive dryness of the skin. Care should also be taken when applying it to avoid the bleaching effect. Benzoyl peroxide has been known to bleach hair, sheets, towels and clothing. Benzoyl peroxide is available over-the-counter as a lotion or gel. Use of benzoyl peroxide should be continued after acne clears to prevent new lesions from forming.
Salicylic acid
Salicylic acid is effective in treating non-inflammatory acne. It helps correct the abnormal shedding of skin cells and unclog pores to resolve and prevent lesions. Salicylic acid does not have any effect on sebum production or P. acnes.
Cosmetic procedures
Chemical peels and microdermabrasion may be helpful in controlling acne. These cosmetic procedures - which have traditionally been used to lessen the appearance of fine lines, sun damage and minor facial scars - are most effective when used in combination with other acne treatments.
References and Sources:
- 1. What is Acne? American Academy of Dermatology.
- 2. Aktan S, Ozmen E, Sanli B. Anxiety, depression, and nature of acne vulgaris in adolescents. Int J Dermatol. 2000 May;39(5):354-7. PubMed
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