Acne Vulgaris

What is Acne Vulgaris?

Acne vulgaris, often simply called acne, is a common skin condition that affects the oil-producing glands in the skin and often continues for a long time. It usually causes small raised spots, or bumps filled with pus, mainly on the face, but it can also occur on the upper arms, trunk, and back. The development of acne involves various factors that come together to form what’s called a “comedo”, or more commonly known as a pimple.

While acne is often associated with teenagers, it’s not exclusive to this age group and can affect people at different ages. The severity of acne can range widely. In mild cases, a person might only have a few pimples. But in severe cases, acne can cause large, painful, and inflamed areas on the skin which can lead to dark spots, scarring, and can even affect a person’s mental wellbeing.

What Causes Acne Vulgaris?

Acne usually happens when the oil-producing glands in the skin react excessively to normal hormone levels. This reaction can be made worse by the presence of a bacteria called Cutibacterium acnes, leading to inflammation.

Several things might contribute to the development of acne, such as:

* Taking certain medications like lithium, steroids, or anticonvulsants
* Spending too much time in the sun
* Using tight clothing accessories like shoulder pads, headbands, backpacks, or underwire bras
* Using oil-based beauty products or massaging the face.
* Suffering from hormones-related health issues like polycystic ovarian syndrome and pregnancy. In fact, acne tends to flare up before menstruation in 70% of female patients due to swelling in the skin pores.
* Certain genes can also play a big role in acne, influencing the amount of a particular kind of fatty acid present in skin oils.
* Regularly scrubbing skin with soaps and detergents can aggravate acne.

Research suggests a link between acne and diet, especially dairy intake and high sugar foods, potentially due to the growth-promoting and hormone-boosting substances found in milk. Meanwhile, it’s important to note that contrary to popular belief, there is no significant proof that eating chocolate worsens acne. Moreover, experiencing a lot of stress can make acne worse, likely due to the increase in stress hormones.

People who have insulin resistance, which is a condition that affects the body’s ability to use insulin, may also have acne. This is because those individuals tend to have more of a certain growth factor that is associated with increased skin oil production. However, the connection between body weight and acne is not well-established; studies on this have had conflicting results.

Risk Factors and Frequency for Acne Vulgaris

Acne vulgaris, often just known as acne, is mostly seen in teenagers and young adults. Between 35% and 90% of teenagersmight potentially develop acne. The condition can start to appear when kids are about 7 to 12 years old, and it usually goes away by the time they hit their 30s. However, sometimes acne can continue into adulthood or can even start for the first time when a person is an adult.

• Teenage acne is more common in boys than girls. However, adult acne mostly occurs in women.
• People living in cities tend to have acne more often than those who live in the countryside.
• About 20% of people with acne will have severe symptoms which can cause scars.
• Certain races and ethnicities might have different experiences with acne. For instance, Asians and Africans are more likely to have severe acne, while mild acne is more commonly seen in White people. In general, people with darker skin tend to get dark spots from acne.
• Babies can sometimes get acne too, but this usually goes away on its own without needing any treatment. Infant acne, which is another type of acne, can happen in babies. It is rare for children 1 to 6 years of age to have acne. But if they do, it may be a sign of another health problem and will need further checkup.

Signs and Symptoms of Acne Vulgaris

Acne typically appears in areas of the body with a high number of oil glands, such as the face, neck, chest, upper back, and arms. Acne conditions and severity come in various types and degrees:

• Grade 1: Commonly known as “comedones”, it can be open or closed. Open ones appear as little bumps with gray, brown, or black spots in the center. Closed ones appear as small, dome-shaped bumps that can be skin-colored, white, or gray.
• Grade 2: These are small, red, and inflamed bumps.
• Grade 3: These are bumps filled with pus, known as pustules.
• Grade 4: A severe form of acne where multiple pustules combine to form large lumps and cysts, known as nodulocystic acne.

Acne severity is determined by several factors, including its psychological impact on the patient, type of acne, presence of scars, whether lesions are actively oozing or not, and the patient’s response to treatment. Severe acne is described in cases of big, inflamed bumps (nodules) and pus-filled lesions, especially when they’re accompanied by scarring, even if nodules are not present.

The extent of skin affected by acne could range from a few small comedones to many inflamed nodules. Acne can cause various types of scars, such as depressed, hypertrophic, or keloidal scars. Everyone’s experience with acne is different, which is why some people may develop scars while others don’t. Aside from scars, post-inflammatory hyperpigmentation, commonly seen in individuals with darker skin, can also occur as a result of acne.

Among the different types of acne, some may include:

• Acne conglobata: A severe form of acne commonly seen in young males, where large inflamed comedones, cysts, and abscesses form.
• Acne fulminans or acne maligna: A rare skin disorder, marked by acute, painful, ulcerating, and bleeding acne. It might be associated with other symptoms like fever and polyarthritis, along with changes in blood tests and bone lesions.
• Acne excoriée: A condition often seen in young women with a mental health disorder. It leads to obsessive picking and scarring of mild acne.
• Infantile acne: This variant appears between ages 3 to 6 months mainly due to elevated hormones in girls from the immature adrenal gland and in boys from the immature adrenal gland and testes.

There are also rare syndromes associated with acne, such as SAPHO syndrome characterized by arthritis or bone inflammation, and PAPA syndrome which presents with a condition known as ‘sterile pyogenic arthritis’ along with another skin disease known as ‘pyoderma gangrenosum’.

To provide an adequate diagnosis, the patient’s history should be carefully reviewed. This includes noting when the acne first appeared, the patient’s general medical history, previous treatments, lifestyle habits, signs of any hormonal imbalance, and the emotional impact of their acne. A skin examination to identify the type and distribution of lesions will also be necessary.

Testing for Acne Vulgaris

Acne vulgaris, a common type of acne, is normally diagnosed with a physical check-up, rather than through lab or x-ray tests. However, further testing might be necessary if the clinical check-up suggests that the patient could have more complex conditions, such as hyperandrogenism, which means they may have too many male hormones. For these diagnostic tests, a skin biopsy is not usually needed.

It’s especially crucial for women who could get pregnant to share their medical history with their doctors, particularly any past experiences with excessive body hair (hirsutism) or painful periods (dysmenorrhea). If they have had these symptoms, additional tests should be done to analyze their levels of specific hormones, such as testosterone, luteinizing hormone, follicle-stimulating hormone, and dehydroepiandrosterone.

If severe acne appears suddenly and doesn’t respond to typical treatments, this could indicate an issue linked to hyperandrogenism due to an ovarian or adrenal tumor. This situation would likely require laboratory and imaging tests as well.

In cases of acne fulminans, a severe form of acne, a thorough check-up is important. This will include a complete blood count, liver function tests, and a measure of inflammation in the body through an erythrocyte sedimentation rate and C-reactive protein test. Depending on the symptoms presented, other tests such as a pregnancy test for women, cholesterol and triglyceride tests, or x-rays may be recommended. These tests help doctors understand whether the acne has affected other parts of the body and helps them prepare a treatment plan using isotretinoin, a medicine often used for severe acne.

Treatment Options for Acne Vulgaris

Treating acne vulgaris, whether mild or severe, starts with a thorough patient consultation. This should cover understanding the condition itself, the right skincare habits, and realistic outcomes of various treatments. Some important points to address during this discussion include:

• Treatment results may take time, with actual improvements becoming noticeable after about 2-3 months of consistent treatment. The aim of the treatment isn’t necessarily to completely clear up acne, but to reduce the number of active breakouts and prevent new ones.
• Long-term maintenance therapy is often necessary as most acne treatments tend to control the condition rather than completely cure it.
• Patient should use mild skin cleansers as opposed to harsh soaps or scrubs, which can irritate and dry out the skin, potentially leading to more acne. Patients should also avoid scrubbing or picking at their skin, as these actions can lead to more breakouts and potential scarring.

While there’s some research suggesting that milk consumption and high-glycemic diets may cause acne, there are currently no specific dietary recommendations for acne patients. Treatment plans should be tailored according to the severity of the acne.

In terms of actual treatment, different strategies are recommended for mild and moderate-to-severe acne.

For mild acne, the primary treatment option is typically topical therapy. This approach involves the use of skincare products that contain retinoids (vitamin A derivatives), topical antibiotics, and benzoyl peroxide. Retinoids help to normalize the skin’s shedding and exfoliation process, which prevents the build-up of skin cells and oil that can lead to clogged pores. Topical antibiotics and benzoyl peroxide both help to kill the bacteria that contributes to acne.

For moderate-to-severe acne, both topical and systemic treatments are typically necessary. Systemic therapies include oral antibiotics, hormonal therapies, and oral isotretinoin. It’s important to note that oral antibiotics and hormonal therapies are typically not first-line treatments and are often used in more severe cases or when other treatments have been unsuccessful.

If a patient’s acne results in complications like residual scars or noticeable discolouration, there are specific treatments available for these concerns. These may include procedures such as chemical peels, laser therapy, skin reconstruction, or filler injections, depending on the type of scar or discolouration.

Overall, managing acne involves understanding the condition, implementing consistent skincare habits, and tailoring treatments to the individual’s specific needs and the severity of their condition.

What else can Acne Vulgaris be?

When people think about acne, they’re usually thinking of a specific condition called acne vulgaris. However, there are many other conditions that look similar but are actually different from acne.

• Rosacea is one of these – it doesn’t cause blackheads but can cause skin redness.
• Perioral dermatitis creates red bumps around the mouth but not directly on the lip’s edge, which differs from acne vulgaris.
• Demodex folliculitis causes inflammatory red bumps and pus-filled pimples and comes into consideration when acne or rosacea treatments don’t work.
• Facial angiofibroma in tuberous sclerosis usually occurs in children as pink or red bumps on the cheeks and nose.
• Pseudofolliculitis barbae brings about red bumps, pus-filled pimples, and scarring in the beard area, especially in people with tightly curled hair.
• Nevus comedonicus, common in babies or children, is a condition featuring a cluster of blackheads.

Sebaceous hyperplasia is marked by small, yellowish bumps often seen on the forehead and cheeks. Flesh-colored bumps are typical indication of skin growths from hair follicles (like trichoepithelioma, trichodiscoma, and fibrofolliculoma). Favre-Racouchot syndrome usually occurs in elderly people, caused by sun damage, and results in blackheads on the upper cheeks.

What to expect with Acne Vulgaris

With the right treatment, acne generally has a good outcome. Although acne itself isn’t life-threatening, it can have lasting emotional impacts. People dealing with acne and acne scars may suffer from higher levels of anxiety and depression. It can be tough to effectively treat acne scars. Interestingly, a Swedish study hints at a possible link between acne in teenage boys and a higher chance of getting prostate cancer in their later years.

Possible Complications When Diagnosed with Acne Vulgaris

Acne vulgaris, commonly known as acne, can cause a number of complications:

• Psychological effects: These can include depression, anxiety, and lower self-esteem. These may occur as a result of the visible appearance of the skin during an acne breakout or from the scars left behind after the acne has healed.
• Acne fulminans: This is an acute eruption of large inflammatory nodules along with ulcers and crusted bleeding. This mainly occurs in teenage boys who already have acne. It can either be triggered by a medication called isotretinoin or can occur spontaneously. People with this condition may also have symptoms like fever, a general feeling of discomfort, pains in the bones, skin redness, joint pain, and changes in blood tests and X-rays. Lab tests may show increased white cell count, anemia, and increased markers of inflammation, and X-rays can show areas of bone loss, typically in the breastbone, collarbones, hip and sacroiliac joints.
• Solid facial edema, or Morbihan’s disease: This disease presents as redness and swelling of the face. This condition has periods of symptom flare-ups and periods of no symptoms, but often needs treatment to get better. There are several treatment options, including isotretinoin, steroids, and a medication called clofazimine.
• Gram-negative folliculitis: This is seen in patients who have been taking systemic antibiotics, particularly tetracyclines, for a long time for acne. These people initially respond to the antibiotic therapy, but over time, their acne worsens and becomes resistant to oral antibiotics. The nose and middle of the face are most commonly affected, showing inflammatory pustules and nodules. Cultures from the lesions usually show the presence of certain types of bacteria like Enterobacter, Klebsiella, Pseudomonas, Proteus, or Escherichia species.