By Dr Rakesh Newaj
Acne, commonly known as pimples or zits, is a chronic disease of the sebaceous glands. It results in eruptions on the face, torso, and other areas where these glands are present. While animals require the gland for waterproofing of their fur, it has during the course of evolution become something of an inconvenient appendage in hominids, similar to the appendix. Even though acne is more common during teenage years, it can occur at any age and can affect up to 85% of humans. It is more prevalent in males before the age of 30, but adult-onset acne tends to be more common in females. This disease can lead to severe distress, low self-esteem and permanent scarring.
Androgens and other mediators (insulin growth-like factor, peroxisome proliferator-activated receptor agonists and melanocortins) control the rate of production and composition of sebum from sebaceous glands. In addition, there is a failure of the epidermal lining of the ducts to keratinise properly; as a result, the keratinous squames adhere to one another, blocking the exit of the sebum onto the skin. This causes distention of the glands and with the action of certain bacteria (P. acnes), the sebum is broken down into free fatty acids. These fatty acids distend the glands further and once the follicular walls get damaged, the contents are extruded into the dermis, causing more inflammation. The resultant comedones and pustules form the basis of acne lesions.
The facial skin contains a high density of sebaceous glands, which renders it more prone to acne lesions. However, other parts of the skin, like the neck, back, chest and upper arms are also frequently affected. Therefore one should not forget to examine other areas of the body when assessing the severity of acne in a patient. A simple way of grading the disease (see Table 1) can help formulate treatment strategies according to the set guidelines. This is particularly useful in the primary health care setting. Early identification of severe cases and referral to a dermatologist can avert permanent scars.
The most common form of pimples is called acne vulgaris and commonly afflicts teenagers. However, there are several variants of acne that can be more difficult to diagnose and treat (see Table2). Diseases like rosacea, perioral dermatitis, milia, syringomas, folliculitis, papulopruritic eruption of HIV, trichoepitheliomas and keratosis pilaris are fairly common in our population. Thus a good history, proper skin examination and familiarity with those other conditions will prevent the wrong diagnosis. A biopsy or other lab tests are only performed when in doubt or in resistant cases.
There are many causes that result in acne becoming more resistant to and recurrent after treatment. Basically the causes are multifactorial and their impact is difficult to measure. However, one can correlate stress, certain foods, obesity, global weather instability, pollution, certain medications, gym supplements, poor habits and overzealous use of cosmetics to the increase and persistence of acne.
Stress is a factor in almost all major skin diseases, as our brain and skin are made of the same embryological tissue and thus are closely related. Many common diseases like eczema and psoriasis are very resistant to treatment if the stress factor is not addressed. As far as acne is concerned, one tends to have a breakout during very stressful times, like examinations or during big projects. This could be due to certain hormones produced that stimulate the sebaceous glands. However, it is very difficult to measure the true impact as not everyone is affected.
Certain foods have been implicated in the pathogenesis of acne for more than half a century. Many dermatologists have disputed this fact for years, but many new publications have reached more conclusive answers. High glycaemic diet, skimmed milk, chocolates and consumption of excessive sweets can cause acne in susceptible individuals. Nowadays, most of our foods are processed and many have been enhanced with hormones and growth factors. These have a negative impact on our skin by stimulating the sebaceous glands to produce more oil, resulting in pimples. Therefore a change in diet can assist in the treatment of severe cases.
The percentage of overweight individuals has increased over the last three decades as people tend to consume more fast foods and are exercising less. This increase-in-body-mass index has resulted in increased insulin resistance, which leads to derangement in many hormones that stimulate the sebaceous glands. In cases of severe resistant acne, patients (especially females) benefit from weight loss. This normalises the androgens and improves the insulin resistance, impacting positively on the sebaceous glands. In addition, many patients benefit from medication that improves insulin resistance as well as an exercise routine.
The skin is exposed to the external environment, thus global weather instability causes added stress to our skin and this can manifest as an increase in sebum production. More harsh weather can cause dryness and this results in a negative feedback mechanism to the brain that produces more oil to lubricate the epidermal layer. Pollution in cities can also increase the production of keratin in the epidermis, causing the blockage of the pores, which results in acne. Notwithstanding the above, the impact of global warming and pollution on the production of sebum is difficult to measure.
The incidence of systemic and psychiatric illnesses has increased considerably in all populations. Many mood stabilisers, antidepressants and antiepileptics cause acne eruptions on the face and trunk. Several drugs that are used to treat systemic diseases have been implicated in adult-onset acne and one therefore has to check the package insert properly. These lesions tend to be more resistant to treatment. Furthermore gym supplements tend to contain anabolic substances that increase the androgen levels, which leads to acne formation. Steroids used as medication or for body-building, also increase the incidence of acne.
Excess consumption of alcohol and smoking are detrimental to our skin. Smoking renders acne more resistant to treatment and excess alcohol use can cause the dilatation of small arteries that supply the facial skin. This results in over-stimulation of the sebaceous glands, leading to acne and aggravating diseases like acne rosacea. The use of excessive cosmetics can also block the pores and stimulate the production of sebum. Overzealous use of occlusive creams or scrubs can cause more harm than good to the skin. Therefore, one has to be very careful and choose only products from reputable companies that have been properly tried and tested, preferably for the African environment.
Most medical practitioners tend to ignore the psychological impact that acne has on the individuals. The disease leads to low self-esteem, relationship problems and social withdrawal. The psychosocial impact is not always proportional to the severity of the disease, thus one has to take the mental status into consideration while deciding on the type of therapy. Patients need to be warned that in most cases the lesions may get worse at the start of the treatment and then improve over a period of two to three months. In addition, the chronicity of the disease needs to be emphasised and the need for maintenance treatment explained. It is common for patients to have poor compliance due to side-effects from the treatment and therefore the proper application needs to be explained. If these measures do not work, it will be important to make use of a psychologist to assist in the wellbeing of the individual.
The goal of a treatment strategy is to firstly get the disease under control, prevent and minimise scars and maintain the skin. Each case is different and several parameters need to be taken into consideration. The age, sex, occupation, pregnancy, habits, type of acne, cause (if identifiable), budget and availability of the medication as well as the psychological state of the patient need to be considered before formulating a plan. Patients are treated with topical, oral, surgical or light therapy. It is common practice to use a combination of treatment to target more than one pathway in the pathogenesis of acne to achieve a higher success rate.
Early intervention is the golden rule in the treatment of acne and prevention of scars. Patients not properly managed can end up with severe disfigurement and permanent keloidal scars. Fortunately, there are various cosmetic procedures such as chemical peels, lasers and fillers that can improve the scars caused by severe acne. A comprehensive discussion of the various treatment modalities available for acne and acne scars and how to deal with resistant cases will be elaborated on in Part II of this discussion.