Risk factors/Triggers
1. Food/Diet
Foods such as nuts, cola, milk, cheese, fried foods and
iodised salts have been implicated as triggers of acne vulgaris; however, the
connections between nutrition and acne has not definitely been proven as they
are rarely supported by good analytical, epidemiological or therapeutic studies
[4, 5]. On the other hand, recurrent acne as noted by Niemeier et al (2006) may
be a cutaneous sign of an underlying eating disorder.
2. Genetics
A genetic background is supported by a case control study by
Goulden et al, as noted by Rzany et al (2006). This stated that the risk of
adult acne vulgaris in relatives of patients with acne as compared with those
of patients without acne is significantly higher [4].
3. Hormones
According to Rzany et al (2006), hormonal influences on acne
vulgaris are undisputed as shown by the higher incidence of acne in male
adolescents. Premenstrual flare has also been recorded as causing acne [5].
4. Nicotine
Smoking has also been named as a risk factor for acne
vulgaris; however, conflicting data exists as to the link between smoking and
acne. Some population based studies have found links between smoking and acne
whilst some others have not [4].
Important!
Contrary to popular misconceptions by young patients and
occasionally their parents, acne does not come from bad behaviour nor is it a
disease of poor hygiene. It also has nothing to do with lack of cleanliness
[2].
Types of acne vulgaris
There are two main types of acne vulgaris, inflammatory and
non-inflammatory; these can be manifested in different ways,
1. Comedonal acne, which is a non-inflammatory acne
2. Papules and pustules of inflammatory acne
3. Nodular acne (inflammatory acne)
4. Inflammatory acne with hyperpigmentation (this occurs
more commonly in patients with darker skin complexions) [1]
Clinical manifestations
In general, acne is limited to the parts of the body, which
have the largest and most abundant sebaceous glands such as the face, neck,
chest, upper back and upper arms. Among dermatologists, it is almost
universally accepted that the clinical manifestation of acne vulgaris is the
result of four essential processes as described below [1, 6],
1. Increased sebum production in the pilosebaceous follicle.
Sebum is the lipid-rich secretion product of sebaceous glands, which has a
central role in the development of acne and also provides a growth medium for
Propionibacterium acnes (P acnes), an anaerobic bacterium which is a normal
constituent of the skin flora. Compared with unaffected individuals, people
with acne have higher rates of sebum production. Apart from this, the severity
of acne is often proportional to the amount of sebum produced [1, 6].
2. Abnormal follicular differentiation, which is the
earliest structural change in the pilosebaceous unit in acne vulgaris [1].
3. Colonisation of serum-rich obstructed follicle with
Propionibacterium acnes (P acnes). P acnes is an anaerobic bacterium which is a
normal constituent of the skin flora and which populates the
androgen-stimulated sebaceous follicle [androgen is a steroid hormone such as
testosterone or androsterone, that controls the development and maintenance of
masculine characteristics]. Individuals with acne have higher counts of P acnes
compared with those without acne [1, 6].
4. Inflammation. This is a direct or indirect result of the
rapid and excessive increase of P acnes [1].
Non-inflammatory acne lesions include open and closed
comedones, which are thickened secretions plugging a duct of the skin,
particularly sebaceous glands. Open comedones, also known as blackheads,
"appear as flat or slightly raised brown to black plugs that distend the
follicular orifices". Closed comedones, also known as whiteheads,
"appear as whitish to flesh-coloured papules with an apparently closed
overlying surface" [1].
Inflammatory lesions on the other hand include papules,
pustules, and nodules; papules and pustules "result from superficial or
deep inflammation associated with microscopic rupture of comedones".
Nodules are large, deep-seated abscesses, which when palpated may be compressible.
In addition to the typical lesions in acne, other features may also be present.
These include scarring and hyperpigmentation, which can result in substantial
disfigurement [1].
Psychological Aspects
Numerous psychological problems such as diminished
self-esteem, social embarrassment, social withdrawal, depression and even
unemployment stem from acne. However, differential diagnosis from a
psychosomatic point of view indicates two serious psychological problems, which
can arise from acne. These are,
1. Psychogenic excoriation, and
2. Body dysmorphic disorder (BDD)
Psychogenic excoriation also referred to as neurotic
excoriation, pathological or compulsive skin picking "is characterised by
excessive scratching or picking of normal skin or skin with minor
irregularities" [5]. According to Niemeier et al (2006) it is estimated to
occur in 2% of dermatological patients. Patients with this disorder can also
have psychiatric disorders such as mood and anxiety disorders, as well as
associated disorders such as obsessive compulsive disorder, substance abuse
disorder, obsessive compulsive personality disorder, compulsive buying, eating
disorder, and borderline personality disorder, to mention a few [5].
Body dysmorphic disorder (BDD) "is a condition
characterised by an extreme level of dissatisfaction or preoccupation with a
normal appearance that causes disruption in daily functioning" [3].
Niemeier et al (2006) described it as "a syndrome characterised by
distress, secondary to imagined or minor defects in one's appearance." The
onset of BDD is usually during adolescence, and it occurs equally in both male
and female. Common areas of concern include the skin, hair and nose, with acne
being one of the most common concerns with BDD patients [3].
According to the Diagnostic and Statistics Manual of Mental
Disorders (2000), BDD has three diagnostic criteria,
1. A preoccupation with an imagined defect in appearance;
where a slight physical anomaly is present, the person's concern is markedly
excessive,
2. The preoccupation causes clinically significant distress
or impairment in social, occupational, or other important areas of functioning,
3. The preoccupation is not caused by another mental
disorder (e.g. Anorexia Nervosa)
Characteristic behaviours include skin picking, mirror
checking, and camouflaging by wearing a hat or excessive make up. Apart from
these, patients often seek reassurance frequently by asking questions such as
"Can you see this pimple?" or "Does my skin look okay?"
Some patients also have a tendency to doctor shop, which is essentially going
from one specialist to another in search of a dermatologist or plastic surgeon,
willing to carry out a desired procedure or dispense a certain drug, to improve
their perceived defect [3, 5].
Although it is a relatively common disease, BDD is still an
under diagnosed psychiatric disorder and is estimated to affect 0.7 to 5% of
the general population. Other psychiatric conditions associated with BDD
include major depression, anxiety, and obsessive compulsive disorder. It is
also associated with high rates of functional impairment and suicide attempts,
high levels of perceived stress, and markedly poor quality of life [3, 5, 8].
Acne Treatment
1. Topical treatment, particularly for individuals with
non-inflammatory comedones or mild to moderate inflammatory acne (See types of
acne vulgaris). Medications include tretinoin (available as gels, creams, and
solutions), adapalene gel, salicylic acid (available as solutions, cleansers,
and soaps), isotretinoin gel, azelaic acid cream, benzoyl peroxide (available
as gels, lotions, creams, soaps, and washes), to mention a few [1, 2].
2. Oral treatment, particularly for acne that is resistant
to topical treatment or which manifests as scarring or nodular lesions.
Medications include oral antibiotics (e.g. tetracycline, doxycycline,
minocycline, erythromycin, and co-trimoxazole), oral isotretinoin, and hormonal
agents (e.g. oral contraception, oral corticosteroid, cyproterone acetate, or
spironolactone) [1, 2].
3. Physical or surgical methods of treatment, which are
sometimes useful as adjuvant to medical therapy. Methods include comedo
extraction, intralesional injections of corticosteroids, dermabrasion, chemical
peeling, and collagen injections, to mention a few [1, 9].
4. Sun exposure, reported by up to 70% of patients to have a
beneficial effect on acne [10].
5. Light therapy, which is becoming more popular due to the
growing demand for a convenient, low risk and effective therapy, as many
patients fail to respond adequately to treatment or develop side effects, from
the use of various oral and topical treatments available for the treatment of
acne [11].
Methods include the use of visible light (e.g. blue light, blue/red
light combinations, yellow light, and green light), laser treatment and
monopolar radiofrequency [11]. Many of these light therapy treatments can be
used at home.
Recommended Products for Acne
References
1. Brown SK, Shalita AR. Acne vulgaris. Lancet 1998;
351:1871-1876.
2. Webster GF. Acne vulgaris. Br Med J 2002; 325: 475-479.
3. Bowe WP et al. Body dysmorphic disorder symptoms among
patients with acne vulgaris. J Am Acad Dermatol 2007; DOI:
10.1016/j.jaad.2007.03.030.
4. Rzany B, Kahl C. Epidemiology of acne vulgaris. JDDG
2006; DOI: 10.1111/j.1610-0387.2006.05876.x
5. Niemeier V, Kupfer J, Gieler U. Acne
vulgaris-Psychosomatic aspects. JDDG 2006; DOI:
10.1111/j.1610-0387.2006.06110.x
6. Gollnick H. Current perspectives on the treatment of acne
vulgaris and implications for future directions. Eur Acad Dermatol Venereol
2001; 15 (Suppl. 3):1-4.
7. American Psychiatric Association. Diagnostic and
Statistics Manual of Mental Disorders. 4th Ed. Accessed via: BehaveNet®
Clinical CapsuleTM; http://www.behavenet.com/capsules/disorders/bodydysdis.htm.
Accessed on: 28th June 2007.
8. Phillips KA et al. A retrospective follow-up study of
body dysmorphic disorder. Comprehensive Psychiatry 2005; 46: 315-321.
9. Taub AF. Procedural treatments of acne vulgaris. Dermatol
Surg 2007; 33: 1-22.
10. Cunliffe WJ, Goulden V. Phototherapy and acne
vulgaris.Br J Dermatol 2000; 142 (5): 855-856.
11. Dierickx CC. Lasers, Light and Radiofrequency for
treatment of acne. Med Laser Appl 2004; 19: 196-204.
Disclaimer
This article is only for informative purposes. It is not
intended to be a medical advice and is not a substitute for professional
medical advice. Please consult your doctor for all your medical concerns.
Kindly follow any information given in this article only after consulting your
doctor or qualified medical professional. The author is not liable for any
outcome or damage resulting from any information obtained from this article.
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