Treatment and Causes of Pimples and Blackheads

Acne

Published by Bupa's health information team, September 2005

This factsheet is for people who have acne.

Acne is a skin condition that causes spots. Most people affected by acne are aged between 12 and 25. However, men and women in their 30s and 40s can also suffer. There are many treatments available to help deal with the condition.

What is acne?

Acne is a skin condition that typically causes one or more of the following:

• blackheads (comedones)
• whiteheads
• red or yellow spots
• greasy skin
• scars

Acne typically affects the skin of the face, back, neck, chest and arms and the severity of the condition can vary.

Acne affects people of all skin colours. The processes that cause acne are exactly the same in people with black or brown skin but the impact is altered by the skin pigmentation.

Acne is very common and affects about 80 in 100 people aged 11-30 at some time.

The skin

The surface of the skin has lots of small sebaceous glands just below the surface. These glands make an oily substance called sebum that keeps the skin smooth and supple.

Tiny pores (holes in the skin) allow the sebum to come to the skin surface. Hairs also grow through these pores.

The structures and layers of the skin

What causes acne?

Acne is caused by the overactivity of the sebaceous glands that secrete oily substances onto the skin.

The sebaceous glands of people with acne are especially sensitive to normal blood levels of a hormone called testosterone, found naturally in both men and women.

Testosterone in people prone to acne triggers the sebaceous glands to produce an excess of sebum. At the same time, the dead skin cells lining the openings of the hair follicles (the tubes that hold the hair) are not shed properly and clog up the follicles.

These two effects combined cause a build-up of oil in the hair follicles. This causes blackheads and whiteheads to form.

For some people, their acne does not progress beyond this stage.

However in other people, the build-up of oil in the hair follicles creates an ideal environment for a bacterium called Propionibacterium acnes to grow.

These bacteria normally live harmlessly on your skin but when this ideal environment is created, they grow. They feed off the sebum and produce substances that cause a response from your body's immune system. This inflames the skin and creates the redness associated with spots.

In more severe 'inflammatory acne', cysts develop beneath the skin's surface. These acne cysts can rupture, spreading the infection into nearby skin tissue. This can result in scarring.

Acne myths

Contrary to popular belief acne is not caused by:

• eating fatty food or chocolate
• dirt - blackheads get their dark colour through excess skin pigment - not dirt so washing more does not help, although if you do not wash your skin at all, bacteria will be able to multiply

Acne is not contagious, so you cannot catch it.

What makes acne worse?

There are a number of things that can make your acne worse. These include the following:

• picking and squeezing the spots may cause further inflammation and scarring
• stress can make acne worse in some people, although it is not clear why
• in women, outbreaks may be affected by the hormonal changes that occur during the menstrual cycle
• excessive production of male hormones such as testosterone from conditions such as polycystic ovary syndrome may be another cause. For more information, please see the separate Bupa factsheet Polycystic ovary syndrome
• some contraceptive pills may make acne worse. This is due to the type of progestogen hormone in some pills whereas some other types of contraceptive pills can improve acne - see Treatments section below. Your GP will advise you which contraceptive pill to take
• some medicines can make acne worse. For example, some medicines taken for epilepsy, and steroid creams and ointments that are used for eczema. Do not stop a prescribed medicine if you suspect it is making your acne worse, but tell your GP. An alternative may be an option
• steroids can cause acne as a side-effect

Diagnosing acne

Acne is easily recognised by the appearance of the spots, and by their distribution on the body.

There are several varieties of acne and your doctor will be able to tell you which type you have after examining your skin.

Treatment

Acne may cause you considerable emotional distress but there is a range of treatment options to help you tackle the problem. No treatment will completely 'cure' your acne. The aims of treatment are to prevent new spots forming, to improve those already present, and to prevent scarring.

Home treatment

It is important to keep spot-prone areas clean, so wash the affected area twice a day with an unperfumed cleanser.The skin needs a certain amount of oil to maintain its natural condition, so avoid aggressive washing with strong soaps.

There are a number of over-the-counter remedies available from pharmacies to treat mild acne. These usually contain antibacterial agents such as benzoyl peroxide (eg Oxy and Clearasil Max).

As well as its antibacterial effects, benzoyl peroxide can dry out the skin and encourage it to shed the surface layer of dead skin. Together, these effects make it harder for pores to become blocked and for infection to develop.

Benzoyl peroxide can cause redness and peeling, especially to start with. This tends to settle down if you reduce the number of times you use it. You can then build up your use gradually.

No home treatments for acne will work immediately. It can take weeks, if not months, for significant effects to be noticeable. If home treatments have not worked after two months, or you have severe acne, you should visit your GP.

Prescription medicines

Your GP may start your treatment by prescribing a preparation containing benzoyl peroxide. If this does not work, or if you have more severe acne, there are a range of other treatment options that you can either rub onto your skin (topical) or take in tablet form (oral).

Topical treatments

There are several topical treatments you may be prescribed including those listed below:

• azelaic acid (Skinoren) is an alternative to benzoyl peroxide and may not make your skin as sore as benzoyl peroxide
• topical retinoids (eg Adapalene) are medicines based on vitamin A, which are rubbed into the skin once or twice a day. They work by encouraging the outer layer of skin to flake off
• a topical antibiotic lotion applied to the skin can be used to control the P. acnes bacteria (eg Dalacin T). Treatment needs to continue for at least six months. Preparations that combine an antibiotic with other acne medication are available (eg Benzamycin which combines an antibiotic with benzoyl peroxide)

Oral treatments

There are several oral treatments you may be prescribed including those listed below:

• oral antibiotics (tablets), such as tetracycline, can be prescribed for inflammatory acne. They should be taken daily for around three months, although it might take four to six months for the benefits to be seen. The success of this treatment can be limited because the strains of bacteria are often resistant to the common antibiotics. Antibiotics do not prevent pores from becoming blocked so treatment to prevent blackheads, such as benzoyl peroxide, is often also prescribed at the same time
• some types of oral contraceptive tablets help women who have acne. A combination of the usual pill hormone called ethinylestradiol with cyproterone acetate (eg Dianette) suppresses male hormone activity so is often used in women with acne
• isotretinoin (eg Roaccutane) is a medicine known as an oral retinoid, which also exists in a topical form (see above). Isotretinoin works by drying up oily secretions. It tends to be prescribed to people with severe forms of acne that have proved resistant to other treatments. There a number of serious side-effects of this drug, such as liver disorders and depression. You should not take isotretinoin if you are pregnant, as it is very dangerous to an unborn baby. For safety reasons, isotretinoin is only prescribed under the supervision of dermatology specialists

Acne scar treatment

Doctors may be able to use certain procedures to diminish scars left by acne. These include fillers, dermabrasion, intense light therapy and laser resurfacing.

• Soft tissue fillers. Collagen or fat can be injected under the skin and into scars to fill out or stretch the skin, making the scars less noticeable. Results from this acne scar treatment are temporary, so you'd need to repeat the injections periodically.
• Dermabrasion. Usually reserved for more severe scarring, dermabrasion involves removing the top layer of skin with a rapidly rotating wire brush. Surface scars may be completely removed and deeper acne scars may appear less noticeable. Dermabrasion may cause pigmentation changes for people with darker skin.
• Microdermabrasion. This newer acne scar treatment involves a hand-held device that blows crystals onto skin. These crystals gently abrade or "polish" the skin's surface. Then, a vacuum tube removes the crystals and skin cells. Because just the surface cells are removed, the skin isn't damaged. However, results are subtle and scars may still be noticeable, even after several sessions.
• Laser, light source and radiofrequency treatments. In laser resurfacing, a laser beam destroys the outer layer of skin (epidermis) and heats the underlying skin (dermis). As the wound heals, new skin forms. Less intense lasers (nonablative lasers), pulsed light sources and radiofrequency devices don't injure the epidermis. These treatments heat the dermis and cause new skin formation. After several treatments, acne scars may appear less noticeable. This means shorter recovery times, but treatment typically needs to be repeated more often and results are subtle.
• Skin surgery. A minor procedure (punch excision) cuts out individual acne scars. Stitches or a skin graft repairs the hole left at the scar site.

Treatments and drugs

Acne treatments work by reducing oil production, speeding up skin cell turnover, fighting bacterial infection, reducing the inflammation or doing all four. With most prescription acne treatments, you may not see results for four to eight weeks, and your skin may get worse before it gets better.

Your doctor or dermatologist may recommend a prescription medication you apply to your skin (topical medication) or take by mouth (oral medication). Oral prescription medications for acne should not be used during pregnancy, especially during the first trimester.

Types of acne treatments include:

• Topical treatments. Acne lotions may dry up the oil, kill bacteria and promote sloughing of dead skin cells. Over-the-counter lotions are generally mild and contain benzoyl peroxide, sulfur, resorcinol, salicylic acid or lactic acid as their active ingredient. These products can be helpful for very mild acne. If your acne doesn't respond to these treatments, you may want to see a doctor or dermatologist to get a stronger prescription lotion. Tretinoin (Avita, Retin-A, Renova) and adapalene (Differin) are examples of topical prescription products derived from vitamin A. They work by promoting cell turnover and preventing plugging of the hair follicles. A number of topical antibiotics also are available. They work by killing excess skin bacteria. Often, a combination of such products is required to achieve optimal results.
• Antibiotics. For moderate to severe acne, prescription oral antibiotics may be needed to reduce bacteria and fight inflammation. You may need to take these antibiotics for months, and you may need to use them in combination with topical products.
• Isotretinoin. For deep cysts, antibiotics may not be enough. Isotretinoin (Accutane) is a powerful medication available for scarring cystic acne or acne that doesn't respond to other treatments. This medicine is reserved for the most severe forms of acne. It's very effective, but people who take it need close monitoring by a dermatologist because of the possibility of severe side effects. Isotretinoin is associated with severe birth defects, so it can't be taken by pregnant women or women who may become pregnant during the course of treatment or within several weeks of concluding treatment. In fact, the drug carries such serious potential side effects that women of reproductive age must participate in a Food and Drug Administration-approved monitoring program to receive a prescription for the drug. In addition, isotretinoin may increase the levels of triglycerides and cholesterol in the blood and may increase liver enzyme levels. Although cause and effect hasn't been proved, studies have reported the development of inflammatory bowel disease with isotretinoin use.
• Oral contraceptives. Oral contraceptives, including a combination of norgestimate and ethinyl estradiol (Ortho-Cyclen, Ortho Tri-Cyclen), have been shown to improve acne in women. However, oral contraceptives may cause other side effects that you'll want to discuss with your doctor.
• Laser and light therapy. Laser- and light-based therapies reach the deeper layers of skin without harming the skin's surface. Laser treatment is thought to damage the oil (sebaceous) glands, causing them to produce less oil. Light therapy targets the bacterium that causes acne inflammation. These therapies can also improve skin texture and lessen the appearance of scars, so they may be good treatment choices for people with both active acne and acne scars.
• Cosmetic procedures. Chemical peels and microdermabrasion may be helpful in controlling acne. These cosmetic procedures — which have traditionally been used to lessen the appearance of fine lines, sun damage and minor facial scars — are most effective when used in combination with other acne treatments.

Frequently Asked Questions About Acne

Acne is a very common disease. People who have it tend to have similar kinds of questions about it and its treatment. This section addresses some of the common questions asked by people with acne. Please remember that your dermatologist is always the best source of specific information about your individual health issues, including acne.

1. What causes acne?
   The causes of acne are linked to the changes that take place as young people mature from childhood to adolescence (puberty). The hormones that cause physical maturation also cause the sebaceous (oil) glands of the skin to produce more sebum (oil). The hormones with the greatest effect on sebaceous glands are androgens (male hormones), which are present in females as well as males, but in higher amounts in males.
   
   Sebaceous glands are found together with a hair shaft in a unit called a sebaceous follicle. During puberty, the cells of the skin that line the follicle begin to shed more rapidly. In people who develop acne, cells shed and stick together more so than in people who do not develop acne. When cells mix with the increased amount of sebum being produced, they can plug the opening of the follicle. Meanwhile, the sebaceous glands continue to produce sebum, and the follicle swells up with sebum.

   In addition, a normal skin bacteria called P. acnes, begins to multiply rapidly in the clogged hair follicle. In the process, these bacteria produce irritating substances that can cause inflammation. Sometimes, the wall of the follicle bursts, spreading inflammation to the surrounding skin. This is the process by which acne lesions, from blackheads to pimples to nodules, are formed.

2. I wash my face several times a day. Why do I still get acne?
   Many people still believe that acne is caused by dirty skin. The truth is, washing alone will not clear up or prevent acne. Washing does, however, help remove excess surface oils and dead skin cells. Many people use all kinds of products, including alcohol-based cleansers, and scrub vigorously, only to irritate the skin further and worsen their acne. Washing the skin twice a day gently with water and a mild soap is usually all that is required. However, acne is actually caused by a variety of biologic factors that are beyond the control of washing. For that reason, you should use appropriate acne treatments for the acne.
   

3. Does stress cause acne?
   Stress is commonly blamed for the development of acne. Stress can have many physiologic effects on the body, including changes in hormones that may theoretically lead to acne. In some cases the stress may actually be caused by the acne lesions, not the other way around! If the acne is being treated effectively, stress is not likely to have much impact on the majority of people.
   

4. I never had acne as a teenager. Why am I now getting acne as an adult?
   Usually, acne begins at puberty and is gone by the early 20s. In some cases, acne may persist into adulthood. Such types of acne include severe forms that affect the body as well as the face (which afflict males more than females) and acne associated with the menstrual cycle in women. In other cases, acne may not present itself until adulthood. Such acne is more likely to affect females than males.
   
   There are several reasons for this. As females get older, the pattern of changes in hormones may itself change, disposing sebaceous glands to develop acne. Ovarian cysts and pregnancy may also cause hormonal changes that lead to acne. Some women get acne when they discontinue birth control pills that have been keeping acne at bay. Sometimes young women may wear cosmetics that are comedogenic-that is, they can set up conditions that cause comedones to form.
   

5. What role does diet play in acne?
   Acne is not caused by food. Following a strict diet will not, clear your skin. While some people feel that their acne is aggravated by certain foods, particularly chocolate, colas, peanuts, shellfish and some fatty foods, there is no scientific evidence that suggests food causes or influences acne. Avoid any foods which seem to worsen your acne and, for your overall health, eat a balanced diet--but diet shouldn't really matter if the acne is being appropriately treated.
   

6. Does the sun help acne?
   Many patients feel that sunlight improves their acne lesions and go to great lengths to find sources of ultraviolet light. There is no proven effect of sunlight on acne. In addition, ultraviolet light in sunlight increases the risk of skin cancer and early aging of the skin. It is, therefore, not a recommended technique of acne management, especially since there are many other proven forms of treatment for acne. Moreover, many acne treatments increase the skin's sensitivity to ultraviolet light, making the risk of ultraviolet light exposure all the worse.
   

7. What is the best way to treat acne?
   Everyone's acne must be treated individually. If you have not gotten good results from the acne products you have tried, consider seeing a dermatologist. Your dermatologist will decide which treatments are best for you. For more information about the types of acne treatments that are available, and for basic acne treatment guidelines, please see Acne Treatments in the main part of AcneNet.
   

8. What kind of cosmetics and cleansers can an acne patient use?
   Look for "noncomedogenic" cosmetics and toiletries. These products have been formulated so that they will not cause acne.

   Some acne medications cause irritation or pronounced dryness particularly during the early weeks of therapy, and some cosmetics and cleansers can actually worsen this effect. The choice of cosmetics and cleansers should be made with your dermatologist or pharmacist.

   Heavy foundation makeup should be avoided. Most acne patients should select powder blushes and eye shadow over cream products because they are less irritating and noncomedogenic. Camouflaging techniques can be used effectively by applying a green undercover cosmetic over red acne lesions to promote color blending.
   

9. Is it harmful to squeeze my blemishes?
   Yes. In general, acne lesions should not be picked or squeezed by the patient. In particular, inflammatory acne lesions should never be squeezed. Squeezing forces infected material deeper into the skin, causing additional inflammation and possible scarring.
   

10. Can anything be done about scarring caused by acne?
    Scarring is best prevented by getting rid of the acne. Dermatologists can use various methods to improve the scarring caused by acne. The treatment must always be individualized for the specific patient. Chemical peels may be used in some patients, while dermabrasion or laser abrasion may benefit others. It is important that the acne be well controlled before any procedure is used to alleviate scarring.
    

11. How long before I see a visible result from using my acne medication?
    The time for improvement depends upon the product being used, but in almost all cases it is more a matter of weeks or months instead of days. Most dermatologists would recommend the use of a medication or combination of medications daily for 4 to 8 weeks before they would change the treatment. It is very important for patients to be aware of this time frame so they do not become discouraged and discontinue their medications. Conversely, if you see no change whatsoever, you might want to check with your dermatologist regarding the need to change treatments.
    

12. Would using my medication more frequently than prescribed speed up the clearing of my acne?
    No--always use your medication exactly as your dermatologist instructed. Using topical medications more often than prescribed may actually induce more irritation of the skin, redness and follicular plugging, which can delay clearing time. If oral medications are taken more frequently than prescribed, they won't work any better, but there is a greater chance of side effects.
    

13. My topical treatment seems to work on the spots I treat, but I keep getting new acne blemishes. What should I do?
    Topical acne medications are made to be used on all acne-prone areas, not just individual lesions. Part of the goal is to treat the skin before lesions can form and to prevent formation, not just to treat existing lesions. Patients are generally advised to treat all of the areas (forehead, cheeks, chin and nose) that tend to break out rather than just individual lesions.
    

14. My face is clear! Can I stop taking my medication now?
    If your dermatologist says you can stop, then stop--but follow your dermatologist's instructions. Many times patients will stop their medication suddenly only to have their acne flare up several weeks later. If you are using multiple products, it may be advisable to discontinue one medication at a time and judge results before discontinuing them all at once. Ask your dermatologist before you stop using any of your medications.
    

15. Does it matter what time I use my medication?
    Check with your dermatologist or pharmacist. If you were taking one dose a day of an antibiotic, you could probably take it in the morning, at midday or in the evening, although you should pick one time of day and stay with it throughout your treatment. With oral medications prescribed twice a day or three times a day, you should try your best to spread out the doses evenly. Some antibiotics should be taken on an empty or nearly empty stomach. For optimal results with topical treatments, you should strictly follow your dermatologist's recommendations. For example, if instructed to apply benzoyl peroxide in the morning and a topical retinoid at bedtime, it is important to follow these directions strictly. If the two were applied together at bedtime, for example, you could decrease the efficacy of the treatment because of chemical reactions that make them less effective.
    

16. I have trouble remembering to take my oral medication every day. What's a good way to remember? What should I do if I forget a dose?
    This is a common problem. Many patients try to associate taking their medication with a routine daily event such as brushing teeth or applying makeup. It also helps to keep the medication close to the area where the reminder activity is carried out.

    In most cases, if you miss a day of your oral treatment, do not double up the next day; rather, get back to your daily regimen as soon as possible--but there may be different instructions for different oral medications. Ask your dermatologist or pharmacist about what to do if you miss a dose of your particular medication.

When to See a Dermatologist

You may feel awkward about seeing a dermatologist, especially if you’ve been told that acne is something you will eventually outgrow. To help you decide whether or not it’s time to consult a dermatologist, listed below are some statements. Do any apply to you?

• My acne makes me shy.

• I am embarrassed by my acne.

• My outlook on life is less optimistic since I developed acne.

• None of the over-the-counter products and/or remedies I’ve tried has worked.

• I am beginning to see scars after acne lesions clear.

• I have painful, pus-filled lesions (nodules) in addition to blackheads and whiteheads (comedones), and reddened spots on my skin.

• I have dark skin, and a patch that is darker than my skin appears when an acne lesion clears.

If you said “yes” to any of the above statements, seeing a dermatologist may be beneficial. Today, virtually every case of acne can be successfully resolved. Not only can dermatologists help resolve existing acne, they can also help prevent new lesions from forming and reduce your chance of developing disfiguring scars.

Acne Myths

Myth #1: Acne is caused by poor hygiene. If you believe this myth, and wash your skin hard and frequently, you can actually make your acne worse. Acne is not caused by dirt or surface skin oils. Although excess oils, dead skin and a day's accumulation of dust on the skin looks unsightly, they should not be removed by hand scrubbing. Vigorous washing and scrubbing will actually irritate the skin and make acne worse. The best approach to hygiene and acne: Gently wash your face twice a day with a mild soap, pat dry--and use an appropriate acne treatment for the acne.

Myth #2: Acne is caused by diet. Extensive scientific studies have not found a connection between diet and acne. In other words, food does not cause acne. Not chocolate. Not french fries. Not pizza. Nonetheless, some people insist that certain foods affect their acne. In that case, avoid those foods. Besides, eating a balanced diet always makes sense. However, according to the scientific evidence, if acne is being treated properly, there's no need to worry about food affecting the acne.

Myth #3: Acne is caused by stress. The ordinary stress of day-to-day living is not an important factor in acne. Severe stress that needs medical attention is sometimes treated with drugs that can cause acne as a side effect. If you think you may have acne related to a drug prescribed for stress or depression, you should consult your physician.

Myth #4: Acne is just a cosmetic disease. Yes, acne does affect the way people look and is not otherwise a serious threat to a person’s physical health. However, acne can result in permanent physical scars--plus, acne itself as well as its scars can affect the way people feel about themselves to the point of affecting their lives.

Myth #5: You just have to let acne run its course. The truth is, acne can be cleared up. If the acne products you have tried haven’t worked, consider seeing a dermatologist. With the products available today, there is no reason why someone has to endure acne or get acne scars.

Treatments for Acne Scars

A number of treatments are available for acne scars through dermatological surgery. The type of treatment selected should be the one that is best for you in terms of your type of skin, the cost, what you want the treatment to accomplish, and the possibility that some types of treatment may result in more scarring if you are very susceptible to scar formation.

A decision to seek dermatological surgical treatment for acne scars also depends on:

• The way you feel about scars. Do acne scars psychologically or emotionally affect your life? Are you willing to "live with your scars" and wait for them to fade over time? These are personal decisions only you can make.
  

• The severity of your scars. Is scarring substantially disfiguring, even by objective assessment?

• A dermatologist’s expert opinion as to whether scar treatment is justified in your particular case, and what scar treatment will be most effective for you.

Before committing to treatment of acne scars, you should have a frank discussion with your dermatologist regarding those questions, and any others you feel are important. You need to tell the dermatologist how you feel about your scars. The dermatologist needs to conduct a full examination and determine whether treatment can, or should, be undertaken.

The objective of scar treatment is to give the skin a more acceptable physical appearance. Total restoration of the skin, to the way it looked before you had acne, is often not possible, but scar treatment does usually improve the appearance of your skin.

The scar treatments that are currently available include:

Collagen injection. Collagen, a normal substance of the body, is injected under the skin to "stretch" and "fill out" certain types of superficial and deep soft scars. Collagen treatment usually does not work as well for ice-pick scars and keloids. Collagen derived from cows or other non-human sources cannot be used in people with autoimmune diseases. Human collagen or fascia is helpful for those allergic to cow-derived collagen. Cosmetic benefit from collagen injection usually lasts 3 to 6 months. Additional collagen injections to maintain the cosmetic benefit are done at additional cost.

Autologous fat transfer. Fat is taken from another site on your own body and prepared for injection into your skin. The fat is injected beneath the surface of the skin to elevate depressed scars. This method of autologous (from your own body) fat transfer is usually used to correct deep contour defects caused by scarring from nodulocystic acne. Because the fat is reabsorbed into the skin over a period of 6 to 18 months, the procedure usually must be repeated. Longer lasting results may be achieved with multiple fat-transfer procedures.

Dermabrasion. This is thought to be the most effective treatment for acne scars. Under local anesthetic, a high-speed brush or fraise used to remove surface skin and alter the contour of scars. Superficial scars may be removed altogether, and deeper scars may be reduced in depth. Dermabrasion does not work for all kinds of scars; for example, it may make ice-pick scars more noticeable if the scars are wider under the skin than at the surface. In darker-skinned people, dermabrasion may cause changes in pigmentation that require additional treatment.

Microdermabrasion. This new technique is a surface form of dermabrasion. Rather than a high-speed brush, microdermabrasion uses aluminum oxide crystals passing through a vacuum tube to remove surface skin. Only the very surface cells of the skin are removed, so no additional wound is created. Multiple procedures are often required but scars may not be significantly improved.

Laser Treatment. Lasers of various wavelength and intensity may be used to recontour scar tissue and reduce the redness of skin around healed acne lesions. The type of laser used is determined by the results that the laser treatment aims to accomplish. Tissue may actually be removed with more powerful instruments such as the carbon dioxide laser. In some cases, a single treatment is all that will be necessary to achieve permanent results. Because the skin absorbs powerful bursts of energy from the laser, there may be post-treatment redness for several months.

Skin Surgery. Some ice-pick scars may be removed by "punch" excision of each individual scar. In this procedure each scar is excised down to the layer of subcutaneous fat; the resulting hole in the skin may be repaired with sutures or with a small skin graft. Subcision is a technique in which a surgical probe is used to lift the scar tissue away from unscarred skin, thus elevating a depressed scar.

Skin grafting may be necessary under certain conditions—for example, sometimes dermabrasion unroofs massive and extensive tunnels (also called sinus tracts) caused by inflammatory reaction to sebum and bacteria in sebaceous follicles. Skin grafting may be needed to close the defect of the unroofed sinus tracts.

Treatment of keloids. Surgical removal is seldom if ever used to treat keloids. A person whose skin has a tendency to form keloids from acne damage may also form keloids in response to skin surgery. Sometimes keloids are treated by injecting steroid drugs into the skin around the keloid. Topical retinoic acid may be applied directly on the keloid. In some cases the best treatment for keloids in a highly susceptible person is no treatment at all.

Acne Treatment

Today, virtually every case of acne can be resolved. The key to getting rid of acne lesions and preventing new ones from forming lies in knowing that:

• Resolution takes time.

• What works for one person may not work for another.

• A dermatologist’s help may be required.

Resolution takes time. Treatments that promise “fast,” miraculous” or “overnight” results often capture the attention of acne sufferers hoping for quick resolution. However, the fact remains that acne does not clear overnight. On average, 6 to 8 weeks are needed to see initial results. Once acne significantly improves or clears, continued treatment is needed to keep acne from re-appearing. If acne does not improve in 6 to 8 weeks, treatment may need to be adjusted as not every acne treatment clears every case of acne.

What works for one person may not work for another. What is an appropriate treatment for one person may not clear another’s acne because many factors affect resolution, including the cause(s) of the acne, a person’s skin type and the kind of acne lesions present.

A dermatologist’s help may be required. With so many factors affecting clearance and a multitude of treatment options available (some only by prescription), a dermatologist’s help can make a difference. Before prescribing treatment, dermatologists consider several factors, including the severity of the acne, types of lesions present, co-existing conditions, as well as the patient’s age, skin type, lifestyle and motivation.

The knowledge gained from considering these factors allows dermatologists to create effective individualized therapy that will resolve the patient’s acne over time and prevent new lesions from forming.

Sometimes a dermatologist may combine two or more treatment options. A patient may be instructed to use one medication in the morning and the other at night. Or, two medications may be combined in one prescription medication. Due to possible side effects, over-the-counter medications should not be combined unless directed by a dermatologist or other medical practitioner.

Acne responds especially well to early treatment. Dermatologists recommend that acne be treated early to maximize effectiveness as well as help prevent scarring.

Reference:
Thiboutot, D. “New Treatments and Therapeutic Strategies for Acne.” Archives of Family Medicine 2000: 9:179-187.

Acne - Causes, Symptoms & Cures

The most common form of acne is Acne Vulgaris, which generally manifests itself in several types of pimple, including whiteheads, blackheads, pustules, papules and the more severe form of cysts and nodules.

Moderate or mild acne vulgaris
Whiteheads are the result of a skin pore becoming blocked which then traps sebum (oil), dead skin cells and bacteria under the skin surface resulting in a white appearance on the surface. The cycle of a whitehead is generally more rapid than that of a blackhead, which leads us nicely into our next section.

Blackheads are caused when a skin pore is partially blocked which allows a little of the trapped material which would otherwise cause a whitehead to drain to the skin’s surface. The resulting black colour which appears on the skin’s surface is caused by melanin, the skins own pigment, as it reacts with the atmosphere, in particular, oxygen. A blackhead often, unless squashed, takes considerably longer to naturally clear than a whitehead.

Pustules are more generally known as regular spots or zits. They are inflamed whiteheads with a yellow or white centre.
Papules are bumps with no head; can be inflamed and tender and should never be squeezed as, there being no head, they will only pop under the surface and squeezing may result in scarring.

More severe acne vulgaris

Cysts and nodules may appear to be similar, but cysts are generally acknowledged to be 5mm or more in diameter, filled with pus and painful. As a natural reaction to this type of acne the sufferer will want to squeeze the cyst which can lead to deeper infection, a lengthier problem and scarring.
Nodules are generally larger than the spots associated with mild and moderate acne vulgaris. They are long lasting, painful and often leave scarring, especially if squeezed or rubbed. It is imperative that nodule sufferers do not try to eradicate them by applying pressure to them. This will cause severe problems and injury to the skin and almost certainly result in scarring.

Although similar in appearance to acne vulgaris, Acne Rosacea generally affects people over the age of 25 to 30.
As a rule acne rosacea sufferers do not have blackheads and the acne confines itself to the face and forehead.
It manifests itself as a rash, red in appearance, with whiteheads, lumps and general blemishes of the skin including visible blood vessels.
Generally acne rosacea is more common in women although when men have it, it is more severe.
Without treatment acne rosacea can result in ‘rhinophyma, an excessive growth of skin tissue and swelling of the facial features, predominantly, the nose. It is important to obtain medical advice as to whether you have acne vulgaris or rosacea, as the treatments for the two conditions can be very different.

The four main types of severe acne are Acne Fulminans, Acne Conglobata, Pyoderma Faciale and Gram-negative Folliculitis.

Acne Conglobata is a form of acne vulgaris, although relatively uncommon. It is more prevalent in men and can cause severe damage to the skin resulting in scarring. It appears as several large, usually connected areas of spots, lesions and blackheads and is found on the face, arms, chest, back, buttocks and upper thighs. Usually starting between sixteen and twenty-five, Acne Conglobata may remain a problem for several years. The cause is unknown, and treatment includes accutane over a lengthy period, although very often this condition is resistant to treatment.

Acne Fulminans is characterised by the speed of its appearance and is a variation of acne conglobata. Generally affecting young men it appears as severe nodular acne and is very often responsible for severe scarring. It has the distinction of being responsible for flu-like symptoms such as aching joints and raised temperature.

Pyoderma Faciale is a facial acne, generally affecting females between the ages of eighteen and fifty, and appears as large pustules, sores and nodules on the face, which can leave scarring. Rapid in its onset, it may affect women who have never before had problems with acne. Although relatively short lasting, usually no more than a year it is without doubt one of the most serious forms of acne.

Caused by a bacterial infection, Gram-Negative Folliculitis is a rare form of acne, as yet not fully researched. At present the causes are unknown and it is also unknown whether it is more common in males or females.

By: Paul Schaverien

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