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Prepared by :
Meaad Ghazouli
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.
Acne is an inflammatory skin disorder of the skin's sebaceous glands
and hair follicles that affects about 80% of people between the ages of
12 and 24. During puberty high levels of hormones are produced in both
girls and boys. This leads to the production of large quantities of sebum.
Sebum is an irritant that can clog the pores and form a pimple which
may become infected and form a pustule. Hormones don't go away after
adolescence. Many women still get premenstrual acne from of the
release of progesterone after ovulation.
The sebaceous glands located in each hair follicle or tiny
pit of skin, produce oil that lubricate the skin and keep it
soft. Sebaceous glands are found in large numbers on
the face, back, chest and shoulders. If this oil becomes
trapped, bacteria multiply in the follicle and the skin
becomes inflamed. Blackheads form when sebum
combines with skin pigments and plugs the pores. If
scales below the surface of the skin become filled with
sebum "white heads" appear. In severe cases white
heads build up, spread under the skin and rupture, which eventually
spreads the inflammation.
The Skin
The skin is the largest organ of the body. One of its
functions is to eliminate a portion of the body's waste
products through sweating. If toxins escape through the
skin they disrupt the skin's health integrity. This is one of
the key factors behind many skin disorders including acne.
The skin also "breathes". If the pores become clogged, the
microbes that are involved in causing acne flourish and
then you get pimples, blackheads and often inflammation.
Acne Myths
Myth #1: Acne is caused by poor hygiene. If you believe this myth,
and wash your skin hard and frequently, you can actually make
your acne worse. Acne is not caused by dirt or surface skin oils.
Although excess oils, dead skin and a day's accumulation of dust
on the skin looks unsightly, they should not be removed by hand
scrubbing. Vigorous washing and scrubbing will actually irritate
the skin and make acne worse. The best approach to hygiene and
acne: Gently wash your face twice a day with a mild soap, pat
dry--and use an appropriate acne treatment for the acne.
Myth #2: Acne is caused by diet. Extensive scientific studies have
not found a connection between diet and acne. In other words,
food does not cause acne. Not chocolate. Not french fries. Not
pizza. Nonetheless, some people insist that certain foods affect
their acne. In that case, avoid those foods. Besides, eating a
balanced diet always makes sense. However, according to the
scientific evidence, if acne is being treated properly, there's no
need to worry about food affecting the acne.
Myth #3: Acne is caused by stress. The ordinary stress of day-today living is not an important factor in acne. Severe stress that
needs medical attention is sometimes treated with drugs that can
cause acne as a side effect. If you think you may have acne
related to a drug prescribed for stress or depression, you should
consult your physician.
Myth #4: Acne is just a cosmetic disease. Yes, acne does affect
the way people look and is not otherwise a serious threat to a
person’s physical health. However, acne can result in permanent
physical scars--plus, acne itself as well as its scars can affect the
way people feel about themselves to the point of affecting their
Myth #5 : You just have to let acne run its course. The truth is,
acne can be cleared up. If the acne products you have tried
haven’t worked, consider seeing a dermatologist. With the
products available today, there is no reason why someone has to
endure acne or get acne scars.
Types of Acne
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—a physical change in body 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)—A 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 skincolored 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. The following photos are characteristic of acne with
(Photos used with permission of the American Academy of Dermatology
National Library of Dermatologic Teaching Slides)
Papule—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. This photo shows
papules and comedones on the face of an acne patient:
Pustule—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. This photo
shows pustules, papules and comedones on the face of an acne
(Photos used with permission of the American Academy of Dermatology
National Library of Dermatologic Teaching Slides)
Macule—A 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.
This photo shows the "red face" appearance of acne with macules:
(Photos used with permission of the American Academy of Dermatology
National Library of Dermatologic Teaching Slides
Nodule—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 that may not respond to therapies other than isotretinoin
Cyst—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, may be very painful, and can result in
scarring. Cysts and nodules often occur together in a severe form
of acne called nodulocystic. Systemic therapy with isotretinoin is
sometimes the only effective treatment for nodulocystic acne.
Some acne investigators believe that true cysts rarely occur in
acne, and that (1) the lesions called cysts are usually severely
inflamed nodules, and (2) 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. These photos show nodular, cystic acne:
(Photos used with permission of the American Academy of Dermatology
National Library of Dermatologic Teaching Slides)
Who gets acne?
Close to 100% of people between the ages of twelve and
seventeen have at least an occasional 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
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.
Normal distribution of acne
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.
Acne Scarring
A detailed and comprehensive discussion of acne scars starts with
causes of scarring, prevention of scarring, types of scars, and
treatments for scars.
Before talking about scars, a word about spots that may look like
scars but are not scars in the sense that a permanent change has
occurred. Even though they are not true scars and disappear in
time, they are visible and can cause embarrassment.
Macules or "pseudo-scars" are flat, red or reddish spots that are
the final stage of most inflamed acne lesions. After an inflamed
acne lesion flattens, a macule may remain to "mark the spot" for
up to 6 months. When the macule eventually disappears, no trace
of it will remain—unlike a scar.
Post-inflammatory pigmentation is discoloration of the skin at the
site of a healed or healing inflamed acne lesion. It occurs more
frequently in darker-skinned people, but occasionally is seen in
people with white skin. Early treatment by a dermatologist may
minimize the development of post-inflammatory pigmentation.
Some post-inflammatory pigmentation may persist for up to 18
months, especially with excessive sun exposure. Chemical peeling
may hasten the disappearance of post-inflammatory
Causes of Acne Scars
In the simplest terms, scars form at the site of an injury to tissue.
They are the visible reminders of injury and tissue repair. In the
case of acne, the injury is caused by the body’s inflammatory
response to sebum, bacteria and dead cells in the plugged
sebaceous follicle. Two types of true scars exist, as discussed
later: (1) depressed areas such as ice-pick scars, and (2) raised
thickened tissue such as keloids.
When tissue suffers an injury, the body rushes its repair kit to the
injury site. Among the elements of the repair kit are white blood
cells and an array of inflammatory molecules that have the task
of repairing tissue and fighting infection. However, when their
job is done they may leave a somewhat messy repair site in the
form of fibrous scar tissue, or eroded tissue.
White blood cells and inflammatory molecules may remain at the
site of an active acne lesion for days or even weeks. In people
who are susceptible to scarring, the result may be an acne scar.
The occurrence and incidence of scarring is still not well
understood, however. There is considerable variation in scarring
between one person and another, indicating that some people are
more prone to scarring than others. Scarring frequently results
from severe inflammatory nodulocystic acne that occurs deep in
the skin. But, scarring also may arise from more superficial
inflamed lesions. Nodulocystic acne that is most likely to result in
scars is seen in these photos:
(Photos used with permission of the American Academy of Dermatology
National Library of Dermatologic Teaching Slides)
The life history of scars also is not well understood. Some people
bear their acne scars for a lifetime with little change in the scars,
but in other people the skin undergoes some degree of
remodeling and acne scars diminish in size.
People also have differing feelings about acne scars. Scars of
more or less the same size that may be psychologically
distressing to one person may be accepted by another person as
"not too bad." The person who is distressed by scars is more
likely to seek treatment to moderate or remove the scars.
Prevention of Acne Scars
As discussed in the previous section on Causes of Acne Scars, the
occurrence of scarring is different in different people. It is
difficult to predict who will scar, how extensive or deep scars will
be, and how long scars will persist. It is also difficult to predict
how successfully scars can be prevented by effective acne
Nevertheless, the only sure method of preventing or limiting the
extent of scars is to treat acne early in its course, and as long as
necessary. The more that inflammation can be prevented or
moderated, the more likely it is that scars can be prevented.
(Click on Acne Treatments for more information about treatment
of mild, moderate and severe acne). Any person with acne who
has a known tendency to scar should be under the care of a
dermatologist. (Click on Find a Dermatologist to locate a
dermatologist in your geographic area).
Types of Acne Scars
There are two general types of acne scars, defined by tissue
response to inflammation: (1) scars caused by increased tissue
formation, and (2) scars caused by loss of tissue.
Scars Caused by Increased Tissue Formation:
The scars caused by increased tissue formation are called keloids
or hypertrophic scars. The word hypertrophy means
"enlargement" or "overgrowth." Both hypertrophic and keloid
scars are associated with excessive amounts of the cell substance
collagen. Overproduction of collagen is a response of skin cells to
injury. The excess collagen becomes piled up in fibrous masses,
resulting in a characteristic firm, smooth, usually irregularlyshaped scar. The photo shows a typical severe acne keloid:
(Photo used with permission of the American Academy of Dermatology
National Library of Dermatologic Teaching Slides)
The typical keloid or hypertrophic scar is 1 to 2 millimeters in
diameter, but some may be 1 centimeter or larger. Keloid scars
tend to "run in families"—that is, abnormal growth of scar tissue
is more likely to occur in susceptible people, who often are people
with relatives who have similar types of scars.
Hypertrophic and keloid scars persist for years, but may diminish
in size over time.
Scars Caused by Loss of Tissue:
Acne scars associated with loss of tissue—similar to scars that
result from chicken pox—are more common than keloids and
hypertrophic scars. Scars associated with loss of tissue are:
Ice-pick scars usually occur on the cheek. They are usually small,
with a somewhat jagged edge and steep sides—like wounds from
an ice pick. Ice-pick scars may be shallow or deep, and may be
hard or soft to the touch. Soft scars can be improved by
stretching the skin; hard ice-pick scars cannot be stretched out.
Depressed fibrotic scars are usually quite large, with sharp edges
and steep sides. The base of these scars is firm to the touch. Icepick scars may evolve into depressed fibrotic scars over time.
Soft scars, superficial or deep are soft to the touch. They have
gently sloping rolled edges that merge with normal skin. They are
usually small, and either circular or linear in shape.
Atrophic macules are usually fairly small when they occur on the
face, but may be a centimeter or larger on the body. They are soft,
often with a slightly wrinkled base, and may be bluish in
appearance due to blood vessels lying just under the scar. Over
time, these scars change from bluish to ivory white in color in
white-skinned people, and become much less obvious.
Follicular macular atrophy is more likely to occur on the chest or
back of a person with acne. These are small, white, soft lesions,
often barely raised above the surface of the skin—somewhat like
whiteheads that didn’t fully develop. This condition is sometimes
also called "perifollicular elastolysis." The lesions may persist for
months to years.
Treatments for Acne Scars
A number of treatments are available for acne scars through
dermatologic surgery. The type of treatment selected should be
the one that is best for you in terms of your type of skin, the cost,
what you want the treatment to accomplish, and the possibility
that some types of treatment may result in more scarring if you
are very susceptible to scar formation.
A decision to seek dermatologic surgical treatment for acne scars
also depends on:
The way you feel about scars. Do acne scars psychologically
or emotionally affect your life? Are you willing to "live with
your scars" and wait for them to fade over time? These are
personal decisions only you can make.
The severity of your scars. Is scarring substantially
disfiguring, even by objective assessment?
A dermatologist’s expert opinion as to whether scar
treatment is justified in your particular case, and what scar
treatment will be most effective for you.
Before committing to treatment of acne scars, you should have a
frank discussion with your dermatologist regarding those
questions, and any others you feel are important. You need to tell
the dermatologist how you feel about your scars. The
dermatologist needs to conduct a full examination and determine
whether treatment can, or should, be undertaken.
The objective of scar treatment is to give the skin a more
acceptable physical appearance. Total restoration of the skin, to
the way it looked before you had acne, is often not possible, but
scar treatment does usually improve the appearance of your skin.
The scar treatments that are currently available include:
Collagen injection. Collagen, a normal substance of the body, is
injected under the skin to "stretch" and "fill out" certain types of
superficial and deep soft scars. Collagen treatment usually does
not work as well for ice-pick scars and keloids. Collagen derived
from cows or other non-human sources cannot be used in people
with autoimmune diseases. Human collagen or fascia is helpful
for those allergic to cow-derived collagen. Cosmetic benefit from
collagen injection usually lasts 3 to 6 months. Additional collagen
injections to maintain the cosmetic benefit are done at additional
Autologous fat transfer. Fat is taken from another site on your
own body and prepared for injection into your skin. The fat is
injected beneath the surface of the skin to elevate depressed
scars. This method of autologous (from your own body) fat
transfer is usually used to correct deep contour defects caused by
scarring from nodulocystic acne. Because the fat is reabsorbed
into the skin over a period of 6 to 18 months, the procedure
usually must be repeated. Longer lasting results may be achieved
with multiple fat-transfer procedures.
Dermabrasion. This is thought to be the most effective treatment
for acne scars. Under local anesthetic, a high-speed brush or
fraise used to remove surface skin and alter the contour of scars.
Superficial scars may be removed altogether, and deeper scars
may be reduced in depth. Dermabrasion does not work for all
kinds of scars; for example, it may make ice-pick scars more
noticeable if the scars are wider under the skin than at the
surface. In darker-skinned people, dermabrasion may cause
changes in pigmentation that require additional treatment.
Microdermabrasion. This new technique is a surface form of
dermabrasion. Rather than a high-speed brush,
microdermabrasion uses aluminum oxide crystals passing
through a vacuum tube to remove surface skin. Only the very
surface cells of the skin are removed, so no additional wound is
created. Multiple procedures are often required but scars may not
be significantly improved.
Laser Treatment. Lasers of various wavelength and intensity may
be used to recontour scar tissue and reduce the redness of skin
around healed acne lesions. The type of laser used is determined
by the results that the laser treatment aims to accomplish. Tissue
may actually be removed with more powerful instruments such as
the carbon dioxide laser. In some cases, a single treatment is all
that will be necessary to achieve permanent results. Because the
skin absorbs powerful bursts of energy from the laser, there may
be post-treatment redness for several months.
Skin Surgery. Some ice-pick scars may be removed by "punch"
excision of each individual scar. In this procedure each scar is
excised down to the layer of subcutaneous fat; the resulting hole
in the skin may be repaired with sutures or with a small skin graft.
Subcision is a technique in which a surgical probe is used to lift
the scar tissue away from unscarred skin, thus elevating a
depressed scar.
Skin grafting may be necessary under certain conditions—for
example, sometimes dermabrasion unroofs massive and
extensive tunnels (also called sinus tracts) caused by
inflammatory reaction to sebum and bacteria in sebaceous
follicles. Skin grafting may be needed to close the defect of the
unroofed sinus tracts.
Treatment of keloids. Surgical removal is seldom if ever used to
treat keloids. A person whose skin has a tendency to form keloids
from acne damage may also form keloids in response to skin
surgery. Sometimes keloids are treated by injecting steroid drugs
into the skin around the keloid. Topical retinoic acid may be
applied directly on the keloid. In some cases the best treatment
for keloids in a highly susceptible person is no treatment at all.
In summary, acne scars are caused by the body’s inflammatory
response to acne lesions. The best way to prevent scars is to treat
acne early, and as long as necessary. If scars form, a number of
effective treatments are available. Dermatologic surgery
treatments should be discussed with a dermatologist.
Find out what acne treatments are currently available
to help reduce or eliminate acne
Because acne is the most widespread skin disorder in the world, a lot
of research has been done to determine how acne forms and how it is
eliminated. Over the years a number of different treatments,
medicines, and products have been developed to help control and
eliminate acne.
Currently there are about 7 different treatments that are widely used
in the prevention and elimination of acne. Subsequently, there are
literally thousands of different products that use these treatments in
one form or another. .
Acne Treatments
Accutane (Isotetinoin): Accutane is a very powerful drug that is a
derivative of vitamin A. It is normally prescribed for severe acne in
cases where other treatments have failed to work. Accutane is
normally taken for 4-6 months. The downside to Accutane is the high
occurrence of side effects, some very serious.
Antibiotics: Antibiotics are designed to fight bacteria and are thus
used to control acne mainly from the inside. There are topical
antibiotics such as clindamycin that are applied directly to the
skin. Other antibiotics such as tetracycline are in pill form.
Benzoyl Peroxide: This is an anti-bacterial agent that has been used to
control acne for many years. It has been proven to work very well in
the elimination and prevention of acne. Benzol Peroxide can be found
in many prescription and over-the-counter medicines and products.
Herbal Remedies: A relative newcomer to mainstream acne fighting
are herbal remedies. It is thought that certain herbs are effective in
regulating oil levels and other bodily functions that pertain directly to
Retin-A (tretinoin): Retin-A is a combination of retinoic acid and
vitamin A acid. It is designed to treat acne, wrinkles, and sun
damage. It supposedly does this by unplugging follicles and turnover
over dead skin cells.
Salicylic Acid: This is another widely used formula in controlling
acne, especially preventing future breakouts. Salicylic acid helps slow
down the shedding of cells inside the follicle. It is available in many
over-the-counter treatments.
Sulfur: Sulfur is used in acne control mainly to promote drying and
peeling of the skin. This may be good for eliminating existing acne but
its effects on preventing future acne are questionable.
There you have it. Most acne regimens consist of one or more of the
above formulas. It is important to note that everyone's skin seems to
react differently to these treatments. For some people, benzoyl
peroxide works great. For others salicylic acid may work better. You
really have to experiment a bit and find out which treatment works
best for you.