Clogged pores can cause various types of acne like nodules, blackheads, and whiteheads. Benzoyl peroxide often works as acne treatment for mild symptoms of acne.

Acne

Humza Khizer

Overview

Acne typically affects the face, upper part of the chest, and back, and is a common skin condition that causes pimples According to recent research, acne affects 9.4% of the world&rsquo;s population and is the 8th&nbsp;most prevalent disease in the world<a href="#accordion">[1]</a>. According to the American Academy of Dermatology, acne is the most common skin condition in the United States and affects 50 million Americans annually<a href="#accordion">[2]</a>. In Pakistan, approximately 5% of the population is affected by acne<a href="#accordion">[3]</a>. While acne does not have any adverse health risks associated with it, it can be painful and may cause scarring. Acne and acne scars also contribute to emotional distress and can affect self-confidence in the long run, causing permanent physical and mental scarring.

During adolescence, acne more commonly affects males than females, and the reverse is seen in adulthood. Neonatal acne is a condition affecting newborns in the first few weeks of life, possibly due to the influence of maternal hormones. The lesions seen in neonatal acne often occur spontaneously, and a few cases require therapy with topical retinoids.

Adolescent acne affects many adolescents and young adults. It generally begins at the onset of puberty and affects 85% of people between the ages of 12 and 24 years. However, acne is not limited to adolescence and can occur at any stage of life. For example, it can affect people in their 30s and 40s. 12% to 15% of women suffer from adult acne, and by age 45, 5% of both men and women may be affected<a href="#accordion">[4]</a>. 
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The term &ldquo;breakout&rdquo; is often used to describe all forms of acne. However, this is an incorrect use of the word as not all types of acne spread across the skin. Identifying the type of acne is essential for successful treatment. Acne may be non-inflammatory or inflammatory with the subtypes:

<ul>
	<li>Blackheads</li>
	<li>Whiteheads</li>
	<li>Papules</li>
	<li>Pustules</li>
	<li>Nodules</li>
	<li>Cysts</li>
</ul>

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<h5>Non-Inflammatory Acne </h5>

Non-inflammatory acne includes blackheads and whiteheads that don&rsquo;t cause swelling and can be treated with over-the-counter (OTC) treatments. Salicylic acid works well in treating non-inflammatory acne due to its ability to remove dead skin cells during exfoliation.

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<h5>Blackheads </h5>

Blackheads occur when a combination of sebum and dead skin cells clog pores. However, despite the pore being clogged, the top of the pore stays open, resulting in the black color seen on the surface.

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<h5>Whiteheads</h5>

Whiteheads are also caused by clogged pores. But unlike blackheads, the top of the pore is closed, giving the appearance of a small bump protruding from the skin. Whiteheads are more difficult to treat as the pores are already closed.

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<h5>Inflammatory Acne </h5>

Inflammatory acne is characterized by pimples that are red and swollen. Bacteria play an essential role in clogging up pores and can trigger infection deep within the skin&rsquo;s surface. This results in painful acne spots. Subtypes of inflammatory acne include papules, pustules, nodules, and cysts.

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<h5>Papules</h5>

Papules occur when the walls surrounding the pores break down because of severe inflammation, resulting in hard, clogged pores that are also tender to the touch. Generally, the skin around the pores is pink.

&nbsp;

<h5>Pustules </h5>

Though similar in appearance, pustules are filled with pus. The bumps are red with a yellow center or whiteheads on top.

&nbsp;

<h5>Nodules </h5>

Nodules can develop when irritation causes the swollen pores to become larger. Unlike pustules and papules, the nodules are deep underneath the skin.

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<h5>Cysts </h5>

Cysts are painful pus-filled lumps under the skin that occur when the pores are clogged by a combination of bacteria, sebum, and dead skin cells. The clogs are deeper within the skin, below the surface than nodules. Cysts are the largest form of acne and appear as large red or white bumps that are often painful to touch. An acne is a form of severe infection that is also most likely to scar. 
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Signs And Symptoms

The signs and symptoms of acne depend on the severity of the condition. Acne can be found almost anywhere on the body; however, breakouts are most noticeable on the face and neck, back, shoulders, and <a href="https://merisehat.pk/disease/breast-cancer">chest</a>. With acne, you might experience:

<ul>
	<li>Rough and uneven skin tone (hyperpigmentation)</li>
	<li>Skin discoloration, dark patches, spots, and redness</li>
	<li>Scarring</li>
	<li>Swelling and inflammation</li>
	<li>Pain</li>
	<li>Tenderness</li>
</ul>

Popping pimples raises the chances of scarring; therefore, avoid squeezing them no matter how tempted you are. Once a pimple appears, it can take a few days to several weeks to clear up completely. 
&nbsp;

Causes

Acne develops when the pores of the skin become clogged with oil, dead skin cells, or bacteria. Underneath each pore is a follicle which is made up of hair and an oil gland. The oil gland releases oil that travels to the hair and out of the pore onto your skin. The purpose of this oil is to keep your skin soft and lubricated. Acne is triggered if the follicles produce excessive oil. Thus, leading to the accumulation of dead skin cells and the buildup of bacteria in the pore. A pimple develops when bacteria grow in the clogged pore and there is no escape route for the oil. 
&nbsp;

Studies have further shown that the underlying causes of acne are:

<ul>
	<li>Genetic tendency</li>
	<li>Cosmetics and hair products that may worsen acne</li>
	<li>Medications e.g. steroids, lithium, iodides, and anti-epileptics can also promote the development of acne.</li>
	<li>Certain medical conditions such as congenital adrenal hyperplasia, <a href="https://merisehat.pk/disease/polycystic-ovary-syndrome-pcos">polycystic ovarian syndrome</a>, and endocrine disorders can lead to an increased production of androgens, which can trigger the development of acne.</li>
	<li>Pregnancy</li>
	<li>Mechanical trauma with headbands, underwire bras, backpacks, and shoulder pads.</li>
	<li>Excessive exposure to <a href="https://cms.merisehat.pk/article/sunscreens-spf-explained">sunlight</a> or ultraviolet rays can also cause acne flares.</li>
	<li>Sometimes nonprescription acne lotions, cleansers, and other skin products can cause redness, irritation, and <a href="https://merisehat.pk/disease/allergies">itchiness</a> where the product is applied. Seek emergency medical help if there are signs of faintness, difficulty breathing, tightness of the throat, or swelling of the face, lips, or tongue. 
	&nbsp;</li>
</ul>

<ul>
</ul>

Diagnosis

If you suspect that you may have acne, it is advisable to get a diagnosis from a certified dermatologist. The dermatologist will examine your skin and help identify the types of lesions. The type and severity of lesions will help develop a treatment plan that works best for you.

Local symptoms of acne include pain, tenderness, and erythema. In rare cases, acne may present as highly inflamed cysts and abscesses with systemic symptoms including fever, joint pain, and general malaise. Patients with pre-existing medical conditions, such as <a href="https://merisehat.pk/disease/polycystic-ovary-syndrome-pcos">polycystic ovarian syndrome (PCOS)</a>, generally present to dermatologists for acne. 
&nbsp;

<h5>When To See A Doctor?</h5>

Some women experience acne flares a week before menstruation, which generally clears up without treatment.&nbsp;

If self-care remedies are insufficient to clear your acne, seek professional help. A dermatologist will be able to prescribe medications to treat acne. Also, the sudden onset of acne in older adults may be a sign of an underlying disease that requires prompt medical attention. 
&nbsp;

Treatment

Current treatment guidelines recommend a combination of topical retinoids and antibacterial therapy as the first line of treatment for most patients with acne. However, it is important to bear in mind that the grade and severity of acne will help determine the appropriate treatment.&nbsp; 
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<h5>Topical Treatments 
&nbsp;</h5>

Retinoids

Topical retinoids are a class of chemical compounds that reduce the number of inflammatory lesions. Topical retinoids are the first line of therapy and should be continued as maintenance therapy to prevent acne formation. The most prescribed topical retinoids for acne are adapalene, tazarotene, and tretinoin.&nbsp;

Retinoids should be applied once a week at night (for beginners) and then increased to 2 to 3 days a week if no irritation, skin peeling, or redness is seen. Irritation due to retinoids can be countered with the use of mild and nonirritating cleansers and moisturizers. Retinoids are associated with skin sensitivity and it is important to apply sunscreen during the day.&nbsp;

If irritation persists, the topical treatment can be used on alternate days. Retinoids are also known to be associated with skin sensitivity; therefore, it is important to use sun protection.

 
Topical Antibiotics

Topical antibiotics have anti-inflammatory properties. Commonly prescribed topical antibiotics consist of clindamycin, erythromycin, dapsone, and minocycline. Topical dapsone is a sulfone antibiotic with anti-inflammatory properties that is effective against mild-to-moderate acne. It is available in formulations that can be applied once a day.

Over-the-counter benzoyl peroxide products are also effective for the treatment of acne. They are available in the form of gels, creams, lotions, washes, and soaps. These products can be used once or twice a day. In some cases, it may cause an allergic reaction, especially if used in combination with tretinoin or aggressive washing methods.

Before starting any treatment, do perform a patch test.&nbsp; 
 
Oral Antibiotics 
Systemic antibiotics are the mainstay treatment for moderate-to-severe acne. The agents have anti-inflammatory properties and are effective against acne-causing bacteria. The antibiotics commonly prescribed for acne are either a tetracycline (minocycline, doxycycline) or a macrolide (erythromycin, azithromycin).

 
Isotretinoin 
Isotretinoin is a systemic retinoid used for the treatment of severe acne. It reduces oil production, promotes cell turnover, and has anti-inflammatory and antibacterial properties. The medication helps reduce acne scarring and is specifically prescribed to individuals who have not had success with other medications.

 
Mild Acne 
For mild acne, over-the-counter (OTC) medicated spot treatments, creams, and cleansers are available to treat pimples as they first appear. Acne creams and gels are made of common ingredients including benzoyl peroxide and salicylic acid.

<ul>
	<li>Benzoyl Peroxide: Helps dry existing acne and prevents new ones from forming. This topical treatment also helps kill acne-causing bacteria.</li>
	<li>Salicylic Acid: Helps exfoliate the skin and prevents acne-causing bacteria from clogging pores.</li>
</ul>

&nbsp;

Moderate Acne 
If the symptoms persist even after using over-the-counter medications for a few weeks, it is recommended that you reach out to a professional for help. A healthcare professional or dermatologist (skin specialist) can prescribe medications that can help reduce the symptoms of acne, as well as prevent scarring. For moderate acne, the dermatologist generally prescribes benzoyl peroxide, antibiotics, erythromycin, clindamycin, and retinoids, for example, retinol.

In some cases, the dermatologist may also recommend oral antibiotics and hormonal birth control to help manage acne. Typically, antibiotics are prescribed for a short period, so that the body does not build any resistance against them and make you prone to infections. 
 
Severe 
A dermatologist may recommend oral antibiotics, benzoyl peroxide, topical retinoids, topical antibiotics, or combine the medications for severe acne. In some cases, the dermatologist may also recommend oral isotretinoin, which goes by the brand name Accutane, or hormonal birth control. Accutane is a vitamin A medication used for the treatment of nodular acne. Doctors usually only prescribe it when other treatments do not work.

Your dermatologist may further recommend medical procedures for the treatment of severe acne and preventing scarring. The procedures work by reducing oil production and removing damaged skin cells.

<ul>
	<li>Photodynamic Therapy (PDT): In photodynamic therapy, the skin specialist uses medication and a special laser or light for reducing the production of oil and bacteria. Other laser treatment options are also available to address acne and related scarring.</li>
	<li>Dermabrasion: This is a type of exfoliation that removes the top layers of your skin with the help of a rotating brush. While the procedure is best recommended for the treatment of acne scarring, it is not for treating acne. Microdermabrasion is a milder form of treatment that helps remove dead skin cells.</li>
	<li>Chemical Peel: This help removes the top layer of skin and reveal the less damaged skin underneath. The procedure is recommended for improving mild acne scarring.</li>
	<li>Cortisone Injections: The injections help in reducing inflammation and improve healing. Cortisone is typically prescribed with other acne treatments, especially in cases that involve large cysts.</li>
</ul>

&nbsp;

<h5>Home Remedies For Acne </h5>

While there are several acne home remedies, they don&rsquo;t always work, and some might even make acne worse. Instead of using toothpaste on your face, you can use these at-home remedies to reduce acne and prevent any future breakouts:

<ul>
	<li>Apply tea tree oil, aloe vera, or a honey mask.</li>
	<li>Use green tea to refresh your face.</li>
	<li>Avoid touching your face as it can transfer bacteria from your hands.</li>
	<li>Never pick or squeeze pimples because it can cause bacteria and excess oil to spread and increase the risk of scarring.</li>
</ul>

&nbsp;

<h5>Can You Take Acne Medication During Pregnancy? </h5>

There are severe consequences of many acne treatments, including Accutane, for a developing fetus (an unborn baby). If you are pregnant or plan to become pregnant, ask your doctor whether you can continue taking it.

&nbsp;

<h5>Are There Any Side Effects To The Treatments? </h5>

Oral antibiotics for acne are generally well-tolerated by most individuals, however, in some people, it may lead to side effects. For example nausea, stomach upset, rashes, sensitivity to the sun, and muscle aches. If you experience any of these side effects, stop taking the medications immediately and consult your doctor.

Additionally, isotretinoin causes dry skin, eyes, and lips. While less common side effects include, an upset stomach and muscle aches. Female patients should not take isotretinoin during pregnancy as it can lead to birth defects. Also, people living with depression and Crohn&rsquo;s disease may also not be able to tolerate isotretinoin. 
&nbsp;

There is currently no reliable data on why some people experience acne while others don&rsquo;t. Studies have shown that several risk factors can contribute to the worsening of acne. The risk factors are as follows:

<ul>
	<li>Hormonal changes caused by puberty or pregnancy</li>
	<li>Polycystic ovarian syndrome, and other endocrine conditions</li>
	<li>Family history of acne</li>
	<li>Use of certain medications, for example, steroids, anticonvulsants, hormonal birth control, and medications containing lithium.</li>
	<li>Comedogenic (tending to cause acne by blocking pores of the skin), cleansers, moisturizers, creams, and other skin products with high oil content.</li>
	<li><a href="https://merisehat.pk/disease/anxiety">Stress</a></li>
	<li><a href="https://merisehat.pk/disease/sleep-apnea-91">Poor sleep</a></li>
	<li>Cigarette smoking</li>
</ul>

There is a high risk of developing acne during puberty because the body is undergoing many hormonal changes. The changes can trigger the production of oil, and consequently increase the risk of acne. Hormonal acne because of puberty generally improves as we grow older, and the breakouts may even stop completely. Studies have further shown that certain foods or diets may also trigger acne:

<ul>
	<li>Foods Low In Glycemic Index (a figure that represents the relative ability of food to increase the level of glucose in the blood): For example, processed meats and refined carbs help curb acne lesions.</li>
	<li>Milk Products: For example, milk and ice cream have been shown to worsen acne. However, there is no data on non-milk dairy products, such as cheese, worsening acne.</li>
	<li>Fat And Fatty Acids: Omega-3 and omega-6 fatty acids are known to help reduce acne.</li>
	<li>Vegetarian And Vegan Diets: Vegetarian and vegan diets offer plenty of health benefits; however, evidence is rare with respect to controlling or treating acne</li>
	<li>Probiotics: According to experts, probiotics found in supplements, yogurts, and other fermented foods can help improve acne. However, there is no conclusive evidence on whether probiotics can be used for the treatment of acne. 
	&nbsp;</li>
</ul>

Key Points

<ul>
	<li>Acne is a common skin condition that affects 9.4% of the world&rsquo;s population and 5% of Pakistan&rsquo;s population.</li>
	<li>Acne has two subtypes: inflammatory and non-inflammatory. Identifying the type of acne is essential for successful treatment.</li>
	<li>Local symptoms of acne include pain, tenderness, and erythema. In rare cases, acne may present as highly inflamed cysts and abscesses with systemic symptoms including fever, joint pain, and general malaise. Currently, the first line of treatment recommended for most acne patients is a combination of topical retinoids and antibacterial therapy. 
	&nbsp;</li>
</ul>

[1] Tan, J.K. and Bhate, K., 2015. A global perspective on the epidemiology of acne. British Journal of Dermatology, 172, pp.3-12.

[2] American Academy of Dermatology. Skin conditions by the numbers. www.aad.org.

[3] Babar, O. and Mobeen, A., 2019. Prevalence and psychological impact of acne vulgaris in female undergraduate medical students of Rawalpindi and Islamabad, Pakistan. Cureus, 11(9).

[4] Lynn, D.D., Umari, T., Dunnick, C.A. and Dellavalle, R.P., 2016. The epidemiology of acne vulgaris in late adolescence. Adolescent health, medicine and therapeutics, 7, p.13.