Acne

Acne is a common skin condition producing pimples on the face and upper torso.
Acne is caused by an interaction between hormones, skin oils, and bacteria that results in inflammation of hair follicles. Acne occurs mostly on the face, upper chest, shoulders, and back and is characterized by pimples, cysts, and sometimes abscesses. Both cysts and abscesses are pus-filled pockets, but abscesses are somewhat larger and deeper.
Sebaceous glands, which secrete an oily substance (sebum), lie in the dermis, the middle layer of skin. These glands are attached to the hair follicles. The sebum, along with dead skin cells, passes up from the sebaceous gland and hair follicle and out to the surface of the skin through the pores.
Acne results when a collection of dried sebum, dead skin cells, and bacteria clog the hair follicles, blocking the sebum from leaving through the pores. If the blockage is incomplete, a blackhead (open comedone) develops; if the blockage is complete, a whitehead (closed comedone) develops. The blocked sebum-filled hair follicle promotes overgrowth of the bacteria Propionibacterium acnes, which are normally present in the hair follicle.
These bacteria break down the sebum into substances that irritate the skin. The resulting inflammation and infection produce the skin eruptions that are commonly known as acne pimples. If the infection worsens, an abscess may form, which may rupture into the skin, creating even more inflammation. Acne occurs mainly during puberty, when the sebaceous glands are stimulated by increased hormone levels, especially the androgens (such as testosterone) , resulting in excessive sebum production. By a person's early to mid 20s, hormone production stabilizes and acne usually disappears. Other conditions that involve hormonal changes can affect the occurrence of acne as well. For example, acne may occur with each menstrual period in young women and may clear up or substantially worsen during pregnancy. The use of certain drugs, particularly corticosteroids and anabolic steroids, can cause acne by stimulating the sebaceous glands. Certain cosmetics may worsen acne by clogging the pores.
Because acne naturally varies in severity for most people-sometimes worsening, sometimes improving-pinpointi ng the factors that may produce an outbreak is difficult. Acne is often worse in the winter and better in the summer, for unknown reasons. There is no relationship, however, between acne and specific foods or sexual activity.

Symptoms
Acne ranges from mild to very severe. Yet, even mild acne can be vexing, especially to teenagers, who see each pimple as a major cosmetic challenge. People with mild (superficial) acne develop only a few noninflamed blackheads or a moderate number of small, mildly irritated pimples. Most acne occurs on the face but is also common on the shoulders, back, and upper chest. Anabolic steroid use typically causes acne on the shoulders and upper back. Blackheads appear as tiny, dark dots at the center of a small swelling of normal-colored skin. Pimples are mildly uncomfortable and have a white center surrounded by a small area of reddened skin. People with severe (deep, or cystic) acne have numerous large, red, painful pus-filled lumps (nodules) that sometimes even join together under the skin into giant, oozing abscesses.
Mild acne usually does not leave scars. However, squeezing pimples or trying to open them in other ways increases inflammation and the depth of injury to the skin, making scarring more likely. The nodules and abscesses of severe acne often rupture and, after healing, typically leave scars. Scars may be tiny, deep holes (ice pick scars); wider pits of varying depth; or large, irregular indentations. Acne scars last a lifetime and, for some people, are cosmetically significant and a source of psychologic stress.

Treatment
General care of acne is very simple. Affected areas should be gently washed once or twice a day with a mild soap. Antibacterial or abrasive soaps, alcohol pads, and heavy frequent scrubbing provide no added benefit and may further irritate the skin. Cosmetics should be water-based; very greasy products can worsen acne. Although there are no restrictions on specific foods (for example, pizza or chocolate), a healthy, balanced diet should be followed.
Beyond these routine measures, acne treatment depends on the severity of the condition. Mild acne requires the simplest treatment, which poses the fewest risks of side effects. More severe acne or acne that does not respond to preliminary treatment requires additional treatment.
Mild Acne: Drugs used to treat mild acne are applied to the skin (topical drugs). They work by either killing bacteria (antibacterials) or drying up or unclogging the pores.
The two most commonly prescribed antibacterials are the antibiotics clindamycin and erythromycin. Benzoyl peroxide, another effective antibacterial, is available with or without a prescription.
Older nonprescription creams that contain salicylic acid, resorcinol, or sulfur work by drying out the pimples and causing slight scaling. These drugs, however, are less effective than antibiotics or benzoyl peroxide. If topical antibacterials fail, family doctors use other topical prescription drugs that help unclog the pores. The most common such drug is tretinoin. Tretinoin is very effective but is irritating to the skin and makes it more sensitive to sunlight. Family doctors therefore use this drug cautiously, starting with low concentrations and infrequent applications, which can be gradually increased. Benzoyl peroxide inactivates tretinoin, so the two must not be applied together. Newer drugs with effects similar to tretinoin include adapalene, azelaic acid, and tazarotene.
Blackheads and whiteheads can be removed by a family doctor. A large pimple may be opened with a sterile needle. Other instruments, such as a loop extractor, can also be used to drain plugged pores and pimples. Severe Acne: Antibiotics given by mouth, including tetracycline, doxycycline, minocycline, and erythromycin, are reserved for the treatment of severe acne. People may need to take one of these drugs for weeks, months, or even years to prevent a recurrence. Some of these drugs have potentially serious side effects, so close monitoring by a family doctor is necessary. Women who take antibiotics for a long time sometimes develop vaginal yeast infections that may require treatment with other drugs. If controlling the yeast infection proves difficult, oral antibiotic therapy for acne may not be practical.
For the most severe acne, when antibiotics do not work, oral isotretinoin is the best treatment. Isotretinoin, which is related to the topical drug tretinoin, is the only drug that can potentially cure acne. However, isotretinoin can have very serious side effects. Isotretinoin can harm a developing fetus, and women taking it must use strict contraceptive measures so they do not become pregnant. Other, less serious side effects may occur as well. Therapy generally continues for 20 weeks. If more therapy is needed, it should not be restarted for at least 4 months.
Other acne treatments are useful for specific people. For example, a woman with severe acne that worsens with her menstrual period may be helped by taking oral contraceptives. This treatment takes 2 to 4 months to produce results.
Family doctors sometimes treat large, inflamed nodules or abscesses by injecting corticosteroids into them. Occasionally, a family doctor cuts open a nodule or abscess to drain it.
Treatment of severe acne scars depends on their shape, depth, and location. Individual scars of any depth may be cut out and the skin sewn back together. Wide indented scars can be improved cosmetically in a procedure called subcision, in which small cuts are made under the skin to release the scar tissue. This procedure often allows the skin to resume its normal contours. Multiple shallow scars may be treated with chemical peels or laser resurfacing. Dermabrasion, a procedure in which the skin surface is rubbed with an abrasive metal instrument to remove the top layer, also may help remove small scars. Sometimes scars are injected with various substances such as collagen, fat, or a variety of synthetic materials. These substances may raise the scarred area to make it level with the rest of the skin.
[Merck]