Acne

Acne is a chronic skin lesion accompanied by polymorphic inflammatory and non-inflammatory rashes. The main elements in acne are pustular and papular acne, comedones, nodular formations and cystic cavities. They are located on the face, chest, back, shoulders. The disease is diagnosed according to a clinical examination, sowing from the foci of inflammation. Treatment is carried out with the use of external (topical retinoids, acids, keratolytics) and systemic agents (antibiotics, antiandrogens), phototherapy, laser therapy.

ICD 10

L70.0 Common acne 

General information

The disease of the sebaceous glands, characterized by blockage and inflammation of the hair follicles, is called acne. The variety of causes and clinical manifestations of acne, its frequent occurrence at different ages, caused cosmetic problems make this disease relevant for many medical professionals.

Acne occurs at almost any age: from the newborn period to old age. Previously, acne was considered a purely adolescent problem, but over the past decades, cases of acne in patients aged 25-35 have become more frequent. The most common form of acne is juvenile acne, observed in patients aged 12-24 in almost 90% of cases. Acne brings a lot of worries about their appearance to people of any gender and age.

Causes

The concept of “acne” reflects the causal dependence of skin manifestations on the general condition of the body. Infections, disorders in the genetic, endocrine and immune apparatus, digestive and neuropsychiatric disorders play an important role in the occurrence of acne. The basis of the appearance of acne is a violation of the function of the sebaceous glands – hypersecretion of sebum. This happens under the influence of a number of internal and external reasons that create favorable conditions for the development of acne.

Endogenous factors

Testosterone and acne

One of the most common causes of acne in adolescence is hormonal restructuring of the body. The active release of steroid hormones, especially androgens – male sex hormones, in both girls and boys causes increased secretion of the sebaceous glands. Sebum changes its properties, turning from liquid to dense and viscous.

Features of the hormonal background and skin reactions can be inherited. Therefore, the probability of teenage acne in young people whose parents suffered from acne is much higher than in their peers with unencumbered heredity.

Premenstrual acne

The level of steroid hormones in women fluctuates during the menstrual cycle and increases in its final phase. This circumstance is associated with the appearance of acne about a week before menstruation in 70% of women. Even those who do not suffer from acne often note the appearance of single pimples on the chin on the eve of menstruation.

“Hormonal” acne

The appearance of pimples and blackheads in adolescence is physiologically caused. However, if acne persists into adulthood, then this is a serious signal to think about your health. Usually, the presence of such pimples indicates violations of the production of sex hormones. In women, the so-called hormonal acne can be caused by polycystic ovaries, pregnancy or abortion, i.e. conditions associated with sudden changes in the hormonal background.

Endocrine disorders in the activity of the adrenal glands or pituitary gland also affect the occurrence of acne. So, the state of hyperandrogenism (excess of male sex hormones – androgens) is often accompanied by the appearance of acne. Therefore, for adults suffering from acne, it is mandatory not only to visit a cosmetologist or dermatologist, but also a number of laboratory tests, consultations with an endocrinologist and gynecologist (for women).

Hyperkeratosis

Thickening of the superficial stratum corneum of the skin – hyperkeratosis – can develop under the influence of a number of factors: hormonal background, vitamin A deficiency, exposure to harmful chemicals on the skin (for example, lubricating oils) or mechanical factors (friction, pressure). Thickened horny scales along with altered sebum clog the pores, being a favorable environment for the development of the microbial process.

Diseases of the gastrointestinal tract

Many researchers put the appearance of acne in direct dependence on the nature of nutrition and the condition of the gastrointestinal tract of the patient. Indeed, the predominance of carbohydrate foods in the diet and the deficiency of essential amino acids and healthy fats lead to hyperfunction of the sebaceous glands. In some cases, the correction of nutrition allows you to normalize the secretion of sebum and get rid of acne.

According to medical statistics, more than 50% of people have acne against the background of already existing gastritis and dysbiosis, another 30% – against the background of pathological intestinal conditions. The places of localization of rashes depend on the lesion of one or another part of the digestive tract. Rashes in the area of the bridge of the nose, cheeks, corners of the mouth may indicate changes in the pancreas, in the temporal region – the gallbladder, above the upper lip – the thick, and on the forehead – the small intestine. Therefore, the state of the digestive tract plays an important role in maintaining skin health. Normal intestinal microflora, which provides 70% of human immunity, prevents the formation of new pimples and ensures the healing of existing ones.

Individual microflora of the skin

Propionbacteria acne and granulosum, epidermal Stapholococcus, mites, fungi, etc. live in the skin and mouths of the sebaceous glands of a healthy person. Under normal conditions, they do not cause any problems, but an imbalance in the body (hyperandrogenism, acne or acne) leads to their active reproduction and inflammatory processes in the skin.

Stress

Stress itself does not directly cause the formation of acne, but its effect on the hormonal and immune status of the body can worsen the manifestation of acne, causing new acne rashes and weakening the protective mechanisms.

Disorders of the immune system

The weakening of the immune system can be caused by a number of reasons: stress, diseases of the digestive system, etc., but always has the consequence of a decrease in the body’s resistance to various adverse effects. Against the background of a decrease in the protective mechanisms of the skin, even usually “neutral” microorganisms can cause considerable harm.

Exogenous factors

1. Cosmetics (comedogenic cosmetics as causes of acne). The “provocateur” of acne can also serve as the so-called comedogenic cosmetics, i.e. clogging pores and contributing to the appearance of acne: creams, powder, lotions, blush, etc. Comedogenic substances include oils (corn, coconut, mineral, peach, almond, soy), lanolin, vaseline, oleic acid, sulfur, squalene, sorbitoleate, sodium lauryl sulfate, myristillactate , etc . Masking acne with cosmetics further aggravates the course of acne. Therefore, when buying care products and decorative cosmetics, you should choose products with the inscription: “not comedogenic.”
2. Heat and humid climate. High humidity and a hot climate can aggravate the course of acne or cause its appearance. Rashes are more often localized on the chest, neck, back – those areas that are most irritated afterwards.
3. The sun and ultraviolet. Ultraviolet light in moderate doses dries and disinfects pimples, and a sun tan evens out the skin color, thereby masking acne acne elements. However, an overabundance of ultraviolet light has exactly the opposite effect. Increased sebum secretion and additional desiccation of the stratum corneum lead to an exacerbation of acne and an increase in the number of pimples. This mechanism works both when tanning on an open beach and in a solarium.
4. Professional contact with toxic substances. The professional activity of many people is connected with direct contacts with household and industrial chemicals (for example, petroleum products, lubricating oils, chlorine, etc.), which causes the appearance of acne through the development of hyperkeratosis of the skin and hair follicles.
5. Squeezing out pimples. Attempts to squeeze out pimples and thereby get rid of them yourself can lead to the exact opposite result. When squeezing out pimples, the infection penetrates into the deeper layers of the skin, seeding non-inflamed elements, leading to their infection and suppuration. It is especially dangerous to squeeze out pimples in the face area of the nasolabial triangle, because there is a great danger of infection with blood flow into the meninges. Cleaning the face with a scrub during the period of inflammatory rashes on the skin should be excluded. Effective and safe acne treatment can only be carried out by a dermatocosmetologist.
6. Skin irritation. Constant friction and mechanical pressure on the skin (when wearing hats, tight collars, etc. clothes) causes the appearance of acne in these areas.
7. Medications. In the treatment of many diseases of the internal organs, steroid hormones are currently used, causing the appearance of drug-induced acne. This form of acne is characterized by the sudden appearance of acne, coinciding in time with the start of taking corticosteroids. The appearance of acne is also observed in women who stop taking birth control pills.
8. Excessive cleanliness. Excessive cleanliness, paradoxically, can also provoke the appearance of acne. Frequent washing dries the skin of the face, lowers its protective properties and exacerbates the manifestations of acne. At the same time, hand washing should be regular in order to exclude the spread of infection from the source of inflammation over the entire surface of the skin.

Pathogenesis

The mechanism of acne is caused by the mutual action of 4 factors: excessive increase in sebaceous gland secretion, follicular hyperkeratosis, proliferation of propionic bacteria and inflammation.

Hypersecretion of sebum leads to a decrease in its bactericidal properties and a change in consistency. The secret of the sebaceous glands becomes dense, forming plugs in the ducts and blocking them. It is often observed during the period of rapid puberty in adolescents and in the last week of the menstrual cycle in women. Thickening of the superficial stratum corneum of hair follicles along with sebaceous plugs creates an additional obstacle to the outflow of sebaceous gland secretions.

Microorganisms living in large numbers on the skin of healthy people, under certain conditions, can cause the development of acute inflammatory reactions. The sebaceous-horny plugs of hair follicles are a favorable environment for their enhanced reproduction and active vital activity. The leading role in the appearance of acne belongs to propionic acne bacteria (Propionibacterium acnes). The active reproduction of propionic acne bacteria leads to a tissue response and the development of inflammation in them.

Classification

The development of acne is based on disorders in the sebaceous glands, leading to the formation of sebaceous-horny plugs in their ducts. Pathogenic bacteria begin to actively multiply on the surface of traffic jams (comedones), causing irritation and purulent inflammation of the surrounding tissues. Acne eruptions are mainly localized in the chin, nose, forehead, back and chest – the areas with the largest accumulation of sebaceous glands. Acne elements can be non-inflammatory (comedones) or inflammatory (papules, pustules) in nature.

Depending on the severity of acne, there are 4 stages of the process.

• Stage 1. A mild form. It is characterized by the presence of closed and open comedones on the skin without signs of inflammation, single papules. Acne treatment at this stage is not difficult.
• Stage 2. Moderate manifestation of acne. Acne elements on the skin are represented by a large number of closed and open comedones, pimples (10-20 papules) with signs of inflammation. The prognosis of cure at this stage is long (6-8 weeks), but favorable.
• Stage 3. Severe form. The same signs are noted as in the second stage, but the number of inflammatory elements on the skin increases to 20-40 pieces. The appointment of specialized therapy is required.
• Stage 4. An extremely severe form. It is characterized by a large number of papules, pustules, nodes (more than 40 elements). Requires serious specialized treatment.

Acne symptoms

Rash elements are represented by closed and open comedones, papular and pustular acne, nodular and cystic formations. Closed comedones are non-inflammatory nodular formations of white color that do not have access to the surface of the skin. Further accumulation of sebaceous gland secretions, epithelial cells, pigment, and dust in the pores leads to the formation of open comedones with a black tip protruding above the surface of the skin. Typical places of localization of comedones are the skin of the forehead and chin.

Further attachment of the inflammatory process to the already existing blockage of the hair follicle leads to the development of papulo-pustular acne, and in severe forms – cystic cavities, phlegmonous and necrotic acne elements. Papular acne (Latin “papula” – nodule, pimple) is an elevation, a dense bump above the skin up to the size of a pea of a reddish-bluish color. Multiple papules give an uneven appearance to the skin. Papules may undergo reverse development or further transition into pustules. Pustular acne is a painful bubble with purulent contents of a softer consistency than papule. Small, up to 5 mm in diameter, pustules usually heal without a trace, scarring defects often remain after large pustules.

Further development of inflammatory elements can lead to the appearance of nodes and cystic cavities. Nodes are large infiltrates (with a diameter of more than 5 mm) located in the dermis and subcutaneous fat. With the reverse development, the nodes disintegrate, ulcerate and heal with a scar. Cysts are cavities filled with pus, purplish-cyanotic in color. The healing of cysts also occurs with the formation of a scar.

Acne treatment

Main tasks

• Prevention of the occurrence of new comedones. It includes proper care for problem skin and measures for the general improvement of the body.
• Removal of existing comedones. It is carried out with the help of comedolytic drugs and comedo extractors at home or in beauty salons.
• Reduction of sebum secretion. Achieving a tangible clinical effect is possible with a decrease in secretion by 30 percent or more. Drugs of the retinoid group, hormones – estrogens, antiandrogens are used.
• Removal of the inflammatory process and prevention of its spread. It is achieved by the use of antibacterial drugs externally and internally.
• Reducing the cosmetic disadvantages of scarring. It is produced by dermabrasion, laser therapy, cryotherapy.

Complex therapy

• Taking a course of procedures in a beauty salon plus active home care with recommended medications.
• Combined treatment with external agents with systemic drugs (having an effect on the whole body).
• The use of drugs that affect the entire chain of the mechanism of acne development (hypersecretion of sebum, increased keratinization of hair follicles, reproduction of microbes, inflammation).
• The presence of chronic processes in the body (gynecological, endocrine, gastrointestinal diseases, foci of chronic infection) can interfere with the treatment of acne and reduce its effectiveness. Therefore, in parallel with the treatment of acne, treatment of concomitant pathology should be carried out.

In the treatment, a large number of external drugs are currently used.

Preparations of external action

Benzoyl peroxide, azelaic acid and tretinoin are the first-line drugs in the treatment. They are effective for long-term use (from 3 months or more). Sometimes their use causes skin irritation, which, as a rule, is eliminated by reducing the frequency of application to the skin or reducing the concentration. In the treatment with these drugs, the simultaneous use of two or more drugs, as well as temperature changes and active insolation, is unacceptable.

• Benzoyl peroxide has a strong keratolytic and whitening effect, thanks to which it has been used in dermatology for over 20 years for the treatment of ichthyosis and skin pigmentation. Its property of “dissolving” keratinized tissues and pronounced antibacterial effect make it possible to use benzoyl peroxide for the treatment of mild and moderate acne. The combination of benzoyl peroxide with antibiotics, azole compounds, sulfur preparations in the composition of combined preparations significantly increases the effectiveness of its use.
• Azelaic acid has a pronounced anti-comedogenic, antibacterial and anti-inflammatory effect, but does not affect the production of sebum in any way.
• Synthetic retinoids, analogues of vitamin A. Are used in the treatment of acne externally with inefficiency or individual intolerance to benzoyl peroxide. Eliminate existing comedones, and prevents the appearance of new ones by normalizing the processes of keratinization of the epithelium and reducing sebum secretion.
• Topical antibiotics. The external use of antibiotics (macrolides, lincosamides) in the treatment is resorted to in cases of lack of effect from treatment with first-line drugs or combination therapy in the treatment of complicated forms of the disease. The disadvantages of treating acne with antibiotics include the development of an addictive effect and insensitivity of propionic bacteria. The high antibacterial and anti-inflammatory activity of these agents is even more pronounced in its combination with zinc. Zinc, in turn, reduces the secretion of sebaceous glands and loosens the pores, facilitating the local action of erythromycin.

Systemic drugs

Systemic antibiotics are used orally in combination with local therapy for moderate acne. Tetracyclines are more often used from antibiotics due to their high antimicrobial activity, rapid absorption and intensive accumulation in the sebaceous glands. Less often, macrolides and sulfonamide group preparations are used in the treatment .

Acne treatment with systemic antibiotics involves taking them for a long time (at least a month). During this period, intestinal and vaginal dysbiosis may develop, a steady habituation of the skin microflora. Other complications from taking antibiotics are ulcerative lesions of the esophagus, stomach ulcer, softening of the nail plates (onycholysis), the appearance of hyperpigmentation on the skin and nails, etc.

The interaction of antibiotics with other drugs should be taken into account so that their effect does not overlap. If the effect of antibiotic treatment is not expressed or is absent for a long time, the question of changing the drug or prescribing retinoid drugs should be considered.

In the treatment of acne in women, a combination of external treatment and the use of hormonal contraceptives containing antiandrogens or an estrogenic profile is possible. Severe forms of acne require combined (external and general) treatment.

The absence of a clinical effect from the treatment for more than 3 months is one of the indications for the appointment of a synthetic analogue of vitamin A. The advantage of this drug is its effect on all mechanisms of acne (increased sebum secretion, follicular hyperkeratosis, reproduction of microorganisms, inflammation). The course of treatment is from 4 months to a year.

Other methods

Hardware methods treatment are additional and are applicable only at the stage of comedones. These include massage and facial cleansing, surface cryotherapy, laser therapy, darsonvalization, etc. Surgical manipulations are not widely used in the treatment, because it leads to the formation of rough scars. In the treatment of abscessing forms, it is possible to prick purulent foci with corticosteroid drugs.

Forecast

When predicting the long-term results, the following points should be taken into account:

• Acne is a chronic, intractable disease, because hereditary predisposition or provoking factors can cause a new exacerbation, even if the disease has not been resumed for several years. However, knowing the reasons provoking a new wave of acne rashes, you can clearly control and quickly remove acne exacerbations, prevent the development of rough scarring of the skin (post-acne) and the formation of persistent cosmetic defects.
• If the disease has already occurred, then the changes in the skin are irreversible, and it will be impossible to achieve its former ideal state.
• A full course treatment is a long process that takes from 4 months or more.
• Treatment can occur with exacerbations of the process, especially in the first months, when the mechanisms of disease development are suppressed.
• It is necessary to conduct a full course treatment, without interruptions, even if there is a noticeable improvement. Untreated acne can manifest itself at any time with a new exacerbation.

Despite the fact that adult acne is a disease that remains for life, you should not despair. The modern choice of methods and preparations for external and systemic use can significantly ease the course of acne, carry out timely prevention of its exacerbations, avoid serious complications and destructive skin changes. Today, acne treatment is carried out at all stages of the development of the disease, allowing you to achieve good cosmetic results and long-term remission.