ACNE

Acne is a common skin condition that afflicts nearly 90% of teenagers and consists of blackheads, whiteheads, red spots, and sometimes deeper boil-like lesions that dermatologists call nodules or cysts. 

Although acne is most common in adolescents, and specifically is most frequent in the late teenage years, the condition may appear for the first time in the mid-twenties or even later; in fact, acne persists in a large number of people into their 40s or even their 50s!

The importance of acne should not be underestimated because the disease can have important negative psychosocial consequences for the affected individual, including diminished self-esteem, social withdrawal due to embarrassment, depression, and unemployment. Provision of adequate therapy is therefore important, especially because satisfactory results from treatment can be achieved in most cases.

The exact cause of acne is not known. It develops in the oil-producing structures of the skin called pilosebaceous follicles, which are present in large quantities on the face, chest, upper back and shoulders. One theory is that acne develops when hormone levels increase during puberty, causing the skin of the acne prone persons to react by producing excess sebum . The bacteria on the skin alters sebum to produce substances that cause acne. Dead skin cells, bacteria, hormones and altered sebum plug the hair follicle, the site where acne begins. This obstruction results in swelling and the development of lesions that dermatologists call "comedones," but that most people commonly refer to as simply whiteheads and blackheads. Emotional stress, fatigue and cosmetics can aggravate acne.

There are several types of acne lesions, including blackheads and whiteheads (collectively termed comedones), larger pimples (papules) and eventually, pustules and large cysts. Scars occur after papules, pustules and cysts. They are often permanent.

Although some cosmetics can make acne worse, there is usually no reason to avoid cosmetics entirely. Of course, avoid oily and greasy cosmetics. Use of water-based, oil-free cosmetics is unlikely to cause of exacerbate acne. You can use eyeliners, eye shadows and lipsticks without any risk of making acne worse. However, do ensure that  all cosmetics are washed off thoroughly before going to bed. Do not wash with harsh or high pH soaps. Acne is not caused by dirt or poor hygiene, so don't be concerned about being "unclean." 

Some patients with acne will develop psychologic problems as a consequence of their condition. Even mild to moderate disease can be associated with significant depression and suicidal ideation and psychologic change does not necessarily correlate with disease severity. Acne scars themselves have been shown to produce significant psychopathology.Recent works confirmed that female acne patients can suffer from hypochondriasis, depression and schizoid problems, whereas in male patients with acne, paranoia and anxiety are more common.76% of acne patients considered that their skin changes were unattractive and this had an adverse effect on their sexual life.

When initiating treatment it is important to consider the aims of therapy. Treatment should be aimed at achieving clearance of acne, prevention of scarring and, where necessary, relief from any psychologic stress resulting from the acne. Therapy should be commenced early in the disease process in order to prevent scarring and it is important to select appropriate therapies according to the clinical signs and psychologic disability. Waiting to outgrow acne can be a serious mistake, since early treatment can immediately improve your appearance and prevent the formation of scars. It is also important to ensure that the patient is able to comply with therapy and clear guidelines regarding treatment, possible adverse effects and realistic expectations should be provided. To reduce the possibility of formation of scars, never pick, squeeze or scratch lesions. Although it is much easier said than done, a dermatologist will advise a person with acne to keep their hands off of their the face.

Three broad categories of therapy are useful in the treatment of acne:

• Creams and lotions that are applied to the face to break up blackheads and whitehead -- called comedolytic agents.
• Antibiotics that may be either applied directly to the face in the form of a cream or lotion, or taken internally in pill form.
• Topical or systemic retinoids -- these are drugs like Retin-A, which is applied to the face as a cream, and Accutane, which is systemic medicine that is taken as a capsule. This drug s approval in 1982 revolutionized therapy, since it was the first oral acne-specific drug, and it provided prolonged remissions. In addition, it may prevent the emergence of resistant bacteria, a problem linked to the traditional use of antibiotics for acne

Topical therapy is the mainstay for the management of all but the most severe forms of acne. 

Oral treatment with 13-cis-retinoic acid in severe acne is normally successful, lasting for a number of years, and has improved the quality of life for many adolescents. It reduces the sebum excretion rate, restores desqumation and normalises the keratinisation process. However, the side effects of 13cRA include epistaxis, pruritus and effects on mucous membranes, leading to a lack of adherence by patients, as well as teratogenicity. In fact, the first few weeks of treatment may actually make the condition worse.

1. Use repeat courses of benzoil peroxide, as this is known to reduce P.acnes resistance. However, no one agent is able to eradicate resistant strains completely and as resistant strains correlate to poor clinical response to therapy, prescribing strategies are required to minimize the occurrence of resistance to P. acnes.
2. Do not prescribe antibiotics unless absolutely necessary.
3. Use oral antibiotics for a short period of time, say 6 months.
4. Avoid simultaneous topical and oral use of different antibiotics.
5. Not all patients respond to isotretinoin.
6. Stress the importance of good compliance.