Acne: Causes, Symptoms, Diagnosis and Treatment

Acne is a very common follicular disorder that affects the susceptible hair follicles, most commonly found on the face, neck, and upper trunk. Both males and females are affected equally, but it is slightly earlier seen in girls. Acne becomes more marked at puberty and during adolescence as the endocrine glands that influence the secretions of the sebaceous glands are functioning at peak activity

During puberty, androgens stimulate the sebaceous glands, causing them to enlarge and secrete natural oil, sebum, which rises to the top of the hair follicle and flows out onto the skin surface. In adolescents who develop acne, androgenic stimulation produces a more response in the sebaceous glands so that acne occurs when accumulated sebum plugs the pilosebaceous ducts. This accumulated material forms comedones.

Acne: Causes

The probable causes of acne may include −

• Occlusion of Pilosebaceous Glands − Occlusion by keratinous plug caused by chemicals and reduced level of linoleic acid in sebum causes retention of sebum encouraging the growth of microbes. Distended follicle rupture, releasing proinflammatory chemicals into the dermis Stimulate inflammation.

• Increased Sebum Secretion − Occurs due to sensitivity to androgens. Increased activity of 5α reductase in a sebaceous gland. Converts testosterone to 5 α testosterone Binds to receptors in sebaceous gland Increase sebaceous secretion.

• Bacterial Involvement − Organisms such as-Propioni bacterium, and Malassezia furfur.

• Hormonal Imbalance − Hormonal changes or imbalances among the younger age group can cause acne by increasing the sebum production

Apart from these, genetic reasons and a family history of having acne too can be the reasons.

Acne: Symptoms

Acne presents as papules, pustules, nodules, cysts, and pathognomic open and closed comedones with a background of oiliness.

Comedones

These are the hyperkeratotic plug that is made of sebum and keratin in the follicular canal. These are pathognomic lesions of acne vulgaris. Comedones can be grouped into the following categories −

• Open Comedones − These are known as Blackheads and occur due to the plugging of the pilosebaceous orifice by keratin and sebum on the skin surface.

• Closed Comedones − These occur due to keratin and sebum accretions plugging the pilosebaceous ducts below the skin surface.

• Submarine Comedones − these are deep-seated and seen by stretching the skin.

Based on the presentation, the acne can be graded as −

• Grade I − Comedones can be open or closed, occasionally pustules or papules, no scarring is present

• Grade II − Papules, comedones, few pustules with mild scarring

• Grade III − predominant pustules, nodules, and abscesses with moderate scarring.

• Grade IV − Mainly cysts, abscesses, scars; severe scarring.

Acne presents multiple variants. Some of them are −

• Acne Conglobata − It is a severe form of acne characterized by intercommunicating abscesses, cysts, and sinuses loaded with serosanguinous fluid or pus. Multiporous comedones are seen. Lesions take months to heal and on healing they leave behind deep pitted or hypertrophic scars.

• Occupational Acne − Caused by exposure to industrial chemicals such as tar, chlorinated hydrocarbons, and cutting oils. It predominantly presents as comedones.

• Cosmetic Acne − Seen in women using oil-based cosmetics Comedones are frequently seen on the chin.

• Drug-Induced Acne − Some of the drugs such as steroids, androgens, oral contraceptives, antitubercular drugs, iodides, bromides, and anticonvulsants. Lesions are monomorphic, consisting of papules and pustules mainly present at the trunk, especially the back.

• Infantile Acne − occurs due to the presence of maternal hormones in the child. Common in males.

• Late-Onset Acne − Occurs after 25 years of age, more commonly seen in women. Deep-seated persistent lesions on the lower half of the face are seen

• Acne Excoriee − Seen in young girls, who obsessively pick their mild acne. Results in discrete excoriations on the face, while comedones, and papules are few and far between.

• Acne Fulminans − Acute onset. Presents with crusted ulcerated lesions, associated with fever, myalgia, and arthralgia.

• Acne After Facial Massage − Occurs 3-6 weeks later as acneiform eruption after the massage presents as indolent deep-seated nodules with very few comedones. Seen predominantly on cheeks along the mandible.

Risk Factors

The major risk factors include −

• Genetic − Familial identical twins show greater concordance of the severity of acne compared to normal.

• Diet − high carbohydrate and fat diet.

• Cosmetics − some women using oil-based cosmetics for a long time can cause acne

• Menstrual cycle premenstrual edema of pilosebaceous duct.

• Hormonal imbalance

• Psychological factors

Acne: Diagnosis

To diagnose acne, some of the prominent methods are −

• History Collection

• Physical Examination

• Biopsy of Lesions

Acne: Treatment

Given below are some of the common methods followed for the treatment of acne −

General Measures

• Local hygiene Regular cleansing with soap and water and

• Avoiding the use of oil-based cosmetics

• Diet Avoid the use of a high glycemic diet

• Avoid Stress

Topical Therapy

• Retinoids − The most frequently used agent in acne, these are more effective against comedones and inflammatory acne, and also reduce the formation of microcomedones.

• Benzoyl Peroxide − These are powerful antimicrobials that decrease infection of Propionibacterium acnes. Used in both inflammatory acne and non-inflammatory acne.

• Topical Antibiotics − Clindamycin and erythromycin are used in inflammatory acne since they suppress P. acnes.

Systemic Treatment

• Antibiotics such as doxycycline, minocycline, erythromycin, and azithromycin are commonly used.

• Oral Retinoids − Synthetic vitamin A compounds (i.e., Retinoids) are used in patients who are not responsive to conventional therapy, for active inflammatory papulopustular acne which tends to scar. Isotretinoin reduces sebaceous gland size and inhibits sebum production and also causes the epidermis to shed, thereby unseating and expelling existing comedones.

Hormone Therapy

Estrogen therapy (including progesterone–estrogen preparations) acts by suppressing sebum production and reducing skin oiliness.

Surgical Management

• Extraction of Comedo Contents

• Drainage of Pustules and Cysts

• Excision of Sinus Tracts and Cysts

• Intralesional Corticosteroids for Anti-inflammatory Action

• Cryotherapy

• Dermabrasion for Scars

• Laser Resurfacing of Scars

Nursing Management

Major nursing activities include patient education, particularly about proper skin care techniques, and managing potential problems related to skin disorders or therapy.

Preventing Scarring

Patients should be warned that discontinuing these medications can exacerbate acne, lead to more sudden outbursts, and increase the chance of deep scarring. Manipulation of the comedones, papules, and pustules increases the potential for scarring

Acne: Prevention

Some of the methods that can reduce acne include −

• Avoid oil-based cosmetics

• Wash face regularly

• Avoid stress

• Have a proper diet and avoid high carbohydrate and fat content food, milk, and milk products

Conclusion

Acne is the more common follicular disorder affecting the younger age group and mainly occurs by the excessive sebum collection which gets plugged and also by bacterial infection ace presents with different forms and variants.

Acne can be easily diagnosed based on the history, physical examination, and biopsy of the lesions. Acne can be treated effectively. Even though acne is not life-threatening but it can make people lose self-confidence and some people especially women can undergo depression. Hence should be treated effectively

Various methods are available to treat acne. Early stages of acne can be treated conservatively with topical and systemic therapy. Long standing late stage acne needs to be treated both conservatively as well as surgically.