Acne

Acne is a condition of the sebaceous gland/hair follicle structure. It occurs in more than 80 % of adolescents and young adults between the ages of 10 and 25. In rare cases, it can even continue until people are in their thirties. Girls usually get “spots” at an earlier age than boys. Boys, however, are usually more severely affected than girls. The condition also tends to get worse in autumn and winter.

The inflamed skin manifestations occur mostly in the face, but in severer cases also on the chest and back, the scalp, the armpits and groin, the area of the genitals and also in the fold of the buttocks. The most frequent form of acne is acne vulgaris, or common acne. Acne is in large part caused by hormonal factors, e.g. the changes in hormone levels that occur during puberty, but predisposition and also external factors play a role. Some forms of acne are triggered by pharmaceutical drugs, chemical substances, or even cosmetics. A special form of acne is the so-called acne excoriata, caused by squeezing and scratching of spots. Babies may also develop a mild form of acne soon after birth or in their first few weeks of life, which then disappears again spontaneously after a few months. The cause of acne is raised levels of androgens (male sex hormones) and increased response of the sebaceous gland follicles to this hormone.

Akne vulgaris

Akne vulgaris

All forms of acne are characterised by increased sebum secretion and hornification disturbances of the excretory ducts of the sebaceous glands. These hornification disturbances are known as black heads/white heads/zits (comedones). There are open, black comedones and closed, white ones. These plugs of hornified matter prevent the increased quantities of sebum from being able to escape from the sebaceous glands. The sebum is then colonised by bacteria which, through their enzymes (lipase), cause fatty acids to be released from the grease. The build-up of sebum and fatty acids triggers an inflammatory response of the sebaceous glands/hair follicles. The inflamed, extended follicle walls produce the typical lumps (papules) or, where there is heavy bacterial colonisation, the spots (pustules) filled with matter. Depending on the severity of the inflammation, the follicle walls may burst inwards, whereby the content of sebum, fatty acids and horn can cause abscesses, foreign body reactions and the formation of lumps in the surrounding dermis, which frequently leave scars on healing.

Of major importance for the occurrence of acne are hormonal factors, and especially the influence of male sex hormones (androgens). Androgens are also produced in small quantities in the ovaries and the adrenal cortex of women. However, boys produce ten times more androgens than girls. This explains why male adolescents tend to be worse affected by acne. As a general rule, however, it is not so much the increased androgen level itself that causes the acne, but an increased, genetically predisposed response of the androgen receptors on the sebaceous glands. These receptors are differently structured. So even only low concentrations of androgens may be sufficient during puberty to trigger a substantial rise in sebaceous gland function. In women, the ratio between the androgens and the other hormones, especially female sex hormones, plays an important role in the occurrence of acne. So high-oestrogen pills and anti-androgens can often bring about a significant improvement in the acne condition. When women stop taking these pills, the result is frequently a renewed deterioration in the skin condition. Acne also often flares up again after a woman has given birth. This is because after the birth of a child, the woman’s oestrogen level falls, allowing the acne to recur.

Other factors that can encourage acne are emotional stress, pressure, friction and the exclusion of air. A rucksack rubbing against the back, for example, can cause acne on that part of the body to worsen. Pressure resulting from resting the face on the hands can reinforce the inflammatory response of acne. Acne is, however, not affected by diet. Sweets and chocolate, fatty and spicy foods or fast foods do not have any significant influence. However, a varied diet containing ballast, fruit and vegetables is always to be generally recommended.

Contact at work with mineral oils or medication containing iodine and bromine, lithium and hydantoin, local and systematic corticosterone as well as oral contraceptives can also cause acne to worsen.

The treatment of acne depends on the degree of severity. Treatment should begin early and be undertaken consistently, especially in people who suffer from blackheads and the like at an early age or whose parents or brothers/sisters also have or had acne. Early treatment can reduce the severity of the acne or shorten the length of suffering, and also help to prevent scarring. Treating the acne improves people’s visual appearance. This strengthens their self-confidence and self-esteem, and not infrequently also helps to improve their employment opportunities.

Regular cleaning of greasy skin with soft, grease-absorbing wipes, lukewarm water, pH-neutral soaps, mild washing lotions or antibacterial cleaning gels is recommended. This enables grease, dirt and make-up to be gently removed, and so prepares the skin for the subsequent treatment. It is best to clean the skin in this way in the morning and evening. Too frequent and too intensive cleaning may irritate the skin. Peeling creams with aluminium oxide particles or fruit acids are also often recommended for “cleaning”. These frequently also help to remove blackheads/whiteheads. For people with a very “shiny” facial skin, it is better to remove the excess grease by patting the face all over with a paper handkerchief several times a day, rather than washing the face too often.

For less severe forms of acne, disinfecting gels, tinctures or creams, which may also contain antibacterial and comedo-releasing substances, should first be applied to the skin. Preparations with erythromycin or clindamycin and tetracycline are those most frequently used. Benzyl peroxide also has a horn-releasing and comedo-removing effect. The following substances, which are used in the severer forms of acne, also have a peeling effect and therefore allow the sebum to escape from the blocked sebaceous glands. Among these products with a stronger peeling effect are the retinoids, e.g. vitamin A acid (tretinoin), isotretinoin and adapalen. Azelaic acid also has a slight peeling effect.

For moderately severe cases of acne, antibiotics to be taken internally may also be given, e.g. tetracyclin, doxycyclin or minocyclin. Another possibility for women is therapy with a high-oestrogen “pill”. These are contraceptives with an anti-androgen effect, which produce a substantial improvement in greasy skin and the formation of comedones. It should be noted, however, that antibiotics may reduce the contraceptive effect of the “pill”.

If desired, a cosmetic therapy with coloured anticomedo creams – with or without anti-inflammatory additives – can be used. These creams should be applied in addition to the basic therapy.

As far as the normal cosmetics used are concerned, care should be taken to use those which are not comedogenic, i.e. which do not encourage the formation of blackheads. Many sun creams also contain substances that activate the formation of comedones. Therefore, gels, cream gels and water-in-oil emulsions with a high water content should be used.

acne
Severe forms of acne
Severe forms of acne tend not to respond adequately to the external and internal treatment as described above. If no improvement is found after 6 months of treatment, the vitamin A acid isotretinoin (13-cis retinic acid) can be given internally.

However, this drug may only be given to women who are absolutely certain not to conceive. Because of the strong effect on the sebaceous glands, isotretinoin is also teratogenic, i.e. it can harm the embryo. The substance effectively blocks sebum production and the formation of comedones, and hypertrophic sebaceous glands “shrink” to normal size. It also has an anti-inflammatory effect, and even thick lumps under the skin are reduced in size. Long-term success is obtained in about 80 % of patients treated in this way, and may last for months or sometimes even years. For people with severe acne, treatment with isotretinoin can be safely repeated.

On healing, bad acne often leaves crater-like, wormhole-like or even raised (hypertrophic) scars. As these usually improve over a period of 1-3 years, gentle remediation measures should first be attempted, e.g. cryotherapy with repeated local application of freezer sprays. In the case of hypertrophic scars, injections of cortisone into the scar tissue may help. Once the acne spots are no longer inflamed, peeling may be performed with fruit acids or trichloracetic acid. If this is not sufficient, surgical “peeling” methods in the form of dermabrasion or laser ablation can be used. If they do not respond to cryotherapy or cortisone injections, acne lumps can be removed by excision, i.e. cutting them out. After peeling or surgery, sun protection must be used consistently for several months in order to prevent unnecessary hyperpigmentation.

Acne inversa (hidradenitis suppurativa, “Sweat gland abscesses in adults”)

Acne inversa is the name for a chronic condition with inflamed abscesses in the armpits, groin and genital area, and in rare cases also on the scalp. It is characterised by the intermittent occurrence of painful, festering inflammatory processes. This may result, side by side, in abscesses, fistulae, comedones and scarred areas of skin, with marked hypertrophic and bridge scarring. The condition can occur from puberty, right up to the forties. In women, the abscesses occur predominantly in the armpits, in men more frequently in the genital and anal area. This illness mostly affects patients with a congenital predisposition to acne. Overweight is a further influencing factor.

The illness varies strongly from individual to individual. Some patients only suffer at long intervals, with reddish-blue spots that are painful under pressure, but which heal spontaneously. In other patients, the condition progresses continuously, affecting more and more areas. Deep fistulae and scars can develop, which are very painful and cause movement restrictions.

The condition is treated by internal antibiotics such as erythromycin and tetracyclin. Cortisone may also be used locally, and sometimes also internally. In the early stages, isotretinoin given orally sometimes helps. Troublesome lumps may be removed surgically under local anaesthetic. In the case of processes covering a large area, healing is sometimes only achieved by radical surgical removal of the whole area of affected skin. For these operations, skin shifting techniques or skin transplants are necessary.skinpilot side tour