Acne vulgaris is a natural consequence of what makes men as we know them. That’s because one of the key factors that lead to acne vulgaris is increased sebum production, a direct result of increases in the male hormone – in both men and women – during puberty.
Abnormal blockage of the hair follicle opening may be the causative factor that is acne’s smoking gun. This blockage is thought to result from an increased amount of sticky keratin due to hormonal changes and the increase in sebum production. These keratin cells accumulate in the hair follicle canal directly above the opening of the oil gland duct, resulting in a plug formation known as a microcomedone.
This microcomedone then enlarges just below the surface of the skin in the pore itself. Later it becomes visible as a closed comedone, or whitehead, which is a firm white papule. If, however, the pore dilates, an open comedone, or blackhead, will occur.
Further, enlargement of the open comedone can cause the pore to enlarge further, resulting in the large pores often seen in patients with acne. Although these open and closed comedones, blackheads, and whitehead themselves are not inflammatory, they set the stage for inflammatory lesions that may occur.
Another important cause of acne is a bacterium known as Propionibacterium acnes (often referred to simply as P. acnes.). This tiny germ normally lives happily in the oil gland yet plays a significant role by producing substances that contribute to the inflammation of acne. As this bacterium incites inflammation in the follicle the wall of the hair follicle becomes thinner and eventually may rupture. When this happens you get yet another manifestation of acne: the red, hot bump or papule.
Once it actually ruptures, a bit like a volcano in turmoil, a much larger inflammatory red papule or pustule may develop, a lesion that can be very tender.
But acne is not exclusively an inside job. Oil-based makeup and hair gels, hormonal changes that occur in the premenstrual period and pregnancy can make things worse, as can frequent manipulation of skin lesions. In fact, one of the commandments of dermatology is: Do not pick. Picking your face can make lesions worse and, of greater concern, can lead to discoloration and even acne scarring.
Treating Acne Vulgaris
Acne vulgaris is certainly treatable and should be. Remember, if left untreated it may lead to acne scars that can last a lifetime. The cost of treating acne, whether you have insurance or not, should not be an impediment to therapy. An entire year of topical therapy for mild to moderate acne may cost as little as $60 to about $250.
If you have more severe acne and require something like Accutane, treatment is more expensive – including medication costs, blood tests, and doctor visits, it can run over $2,500 for a twenty week course. On the other hand, if it works, the nice thing about Accutane is you may never need treatment again.
A warning about Accutane: isotretinoin can cause severe birth defects. Unfortunately, many of the people who would benefit most from Accutane are women of child-bearing age, so special precautions are needed when using this drug. Accutane side effects can occur over its normal twenty-week course.
In treating acne, an extensive history should be taken to determine how you wash your face and what substances you have been putting on it, since many of these can irritate your skin and worsen the acne. Next, an exam of your skin will result in an inventory of the type of acne lesions you have. That will help in rating the severity and developing a treatment plan.
Basic management steps include washing with gentle soaps or nonsoap cleansers such as Cetaphil and decreasing the frequency of moisturisation. Remember, one of the causes of acne is the oil your own glands produce. Why import extra oil to the scene of the potential disaster? It’s okay to use moisturisers but they must be specifically designed for people with acne. Such products will often say “non-comedogenic” (won’t cause pimples) or ‘oil-free’ on their labels.
Several topical agents can correct the abnormal accumulation of keratin in the hair follicles; this decreases the amount of follicular plugging, thus getting at one of the causes of acne. Such acne medication includes:
- Retin-A (tretinoin, a form of vitamin A that has been chemically altered).
- Differin (adapalene gel).
- Benzoyl peroxide, which comes in may formulations and a range of brands.
Benzoyl peroxide is available over-the-counter in low concentrations while Retin-A and Differin require a prescription. Benzoyl peroxide kills the bacteria of acne better than any topical or oral antibiotic, and because it kills P. acnes by producing oxygen (P. acnes cannot survive in the presence of oxygen), the bacteria never develops a resistance to it. Benzoyl peroxide is the cheapest, most effective over-the-counter acne remedy.
More than 50 years ago, X-ray was used to treat acne. It was thought it would dry up the oil glands. It was even used to remove facial hair, and it worked. Fast-forward to today and guess what? Patients who received radiation to the face for these purposes now have an increased incidence of skin cancer.
Salicylic acid can be used alone or along with a sulfur product. It works as an anti-inflammatory agent and is an excellent first-line choice for mild acne. It is the active ingredient in many over-the-counter drying agents.
Oral antibiotics may be a good approach to managing acne because they seem to strike at P. acnes, the bacterial instigator of the problem. Tetracycline is considered ‘the old standby’. It is inexpensive and works well, but some patients do experience tetracycline side effects.
Minocycline, a once-a-day medication (which makes it easier to remember to take), can be very effective, but does have rare side effects such as discoloring the skin and dizziness. If you will benefit from minocyclin, most dermatologists consider these side effects well within the reasonable risk-benefit ratio. Read more about minocycline side effects.
Tetracyline and minocycline also possess anti-inflammatory properties apart from killing bacteria, which may play a role in calming down inflamed acne lesions. Whatever your treatment plan, none of the medications will work if they stay in your medicine cabinet. Managing acne is a daily task. Your body makes new acne lesions daily, so it makes sense to fight it daily with total compliance to the prescribed plan. And remember: Don’t pick!!
Once acne lesions clear they may leave behind either scars or a dark or light patch on the skin. The scarring that results from acne can often be bothersome and permanent, so it is best to get your acne under control while the getting is good. The dark and lighter discoloration in the skin is a result of the skin’s reaction to the inflammation of the acne lesions. This discoloration often does fade, but it may take many months to do so. It does not indicate that the acne is still active.
Very often, after the flare settles down redness may persist for many months from acne vulgaris, depending on your skin type. If you are fair, redness would not be surprising; if you are more darkly complected hyperpigmentation may result.
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