Blackheads is a particular manifestation of acne – skin rash elements, and does not reflect the full clinical picture of the disease. The concept of “blackheads” includes various types of rashes in adolescence, as well as a group of dermatoses with like rashes (rosacea, small nodular sarcoidosis of the face, perioral dermatitis, skin tuberculosis). Depending on the type and the course, the method of its treatment is determined.
Blackheads is a particular manifestation of blackheads – skin rash elements, and does not reflect the full clinical picture of the disease. Blackheads, characterized by inflammation of the sebaceous glands, develops for various reasons and has its own characteristic features depending on the age of the patient and the pathogenetic mechanisms of its occurrence. The concept of “blackheads” includes various types of rashes in adolescence, adult form, as well as a group of dermatoses with like rashes (pink acne, rosacea, small nodular sarcoidosis of the skin, perioral dermatitis, tuberculosis of the skin). Depending on the type of blackheads and the course of this disease, the method of its treatment is determined.
Disease are a manifestation of the chronic inflammatory process of the sebaceous glands of the face, chest and back, as a result of which comedones are formed. The disease is caused by gram-positive rods Propionibacterium acnes. The appearance is a fairly common phenomenon: at the age of 12 to 24 years, it occurs in 60-80% of people. A third of patients require therapeutic treatment.
The relevance of treatment is determined by their influence on the psycho-emotional state of the patient. Blackheads causes psychological discomfort and worries about aesthetic problems of appearance. Patients with symptoms suffer from loss of attractiveness, their self-esteem decreases, they do not adapt well in society, they experience anxiety and depression. The decision to treat blackheads is dictated by the elimination of psychological problems, in particular dysmorphic phobia (fear, the idea of a far-fetched ugliness of appearance) and the desire for free socialization in society.
In the occurrence, genetic predisposition is of no small importance. The development occurs under the influence of certain factors that allow you to trace the mechanism, the development and course of blackheads.
Excessive sebum secretion
Excessive sebum secretion is one of the manifestations of seborrhea. In seborrhea, the secret secreted by the sebaceous glands is characterized by a decrease in bactericidal properties, which causes an active reproduction of bacteria and the creation of prerequisites for skin inflammation and the appearance of blackheads.
The appearance of black-dotted blackheads is a serious aesthetic problem for patients. The appearance is accompanied by increased keratinization of epithelial cells in the funnels of hair follicles, into which the excretory ducts of the sebaceous gland open (follicular hyperkeratosis). Usually this process proceeds at a moderate pace, so that the horny scales have time to peel off at the mouth of the follicle and, together with sebum, stand out. Hyperkeratosis prevents the normal outflow of sebaceous gland secretions and leads to its accumulation in the follicle. The accumulation of dead cells and sebum leads to clogging of the pores and causes the appearance of black dots – microcomedons that do not manifest themselves clinically.
With the further accumulation of sebum and pressure on the clogged follicle, its cystic expansion occurs, which is clinically manifested in the form of closed comedones (non-inflamed dense nodules). Further development of the process causes atrophic changes in the sebaceous gland and pore expansion. This is how black-spot acne or open comedones appear. At the same time, sebum has a dense structure, is poorly excreted due to a large accumulation of horny scales. The black staining of the secretion visible from the enlarged pore is due to the content of the melanin pigment in it.
Reproduction of microorganisms
Human skin and hair follicles are populated by a multitude of saprophytic and opportunistic microorganisms (epidermal Staphylococcus, Mycobacteria, clostridia, demodex mites, etc.). When pores are blocked and sebum accumulates, favorable conditions are created for their reproduction inside the hair follicles.
Propionibacterium acnes plays a special role in the development of the inflammatory process in blackheads. Its reproduction in the follicle and the release of waste products have an irritating effect on tissues and cause a local inflammatory reaction. The inflammatory process can occur at any stage, affect the superficial or deep layers of the skin, which explains the variety of forms and clinical manifestations of the disease.
Existing classifications are based, as a rule, on the clinical manifestations or on the degree of their severity. The most complete classification of eels was proposed in 1994 by scientists G. Plewig and A. Kligman (Plewig, Kligman).
- Of newborn.
- Of children.
- Globular or piled.
- Pyoderma faciale.
4. Blackheads caused by mechanical factors.
The appearance in newborns is a borderline physiological condition of this period and occurs as a result of a sexual (hormonal) crisis. Its manifestations also include breast enlargement, hydrocele, physiological vulvovaginitis. These conditions are caused by the action of maternal hormones received by the fetus in the prenatal period. Blackheads rashes of newborns are closed comedones located on the nose, cheeks, chin and forehead in the form of dotted white or yellowish papules. As a rule, they disappear on their own without a trace within 1.5-2 weeks.
In children, blackheads can appear at the age of 3-6 months and cause prolonged, severe forms of blackheads. Their development may be associated with a dangerous congenital pathology (hyperplasia or tumor of the adrenal glands) and requires a thorough examination of the child.
Juvenile blackheads – occurs in a third of adolescents aged 12 to 16 years. According to statistics, girls suffer from blackheads more often than boys. In 75% of cases, juvenile blackheads is localized on the face, in 16% – on the face and back. In the vast majority of adolescents, blackheads disappears by the age of 18-20. However, sometimes blackheads occurs for a long time and occurs in 3% of men and 5% of women aged 40-50 and even 60 years (“physiological blackheads”). This variety refers to the manifestations of adult blackheads.
Comedones are formed as a result of blockage of hair follicles by accumulation of horny scales and sebum. Weakly expressed comedones in the absence of an inflammatory component are considered a variant of the physiological norm. The initial manifestation of blackheads is microcomedones, which do not manifest themselves clinically in any way. At the next stage, closed comedones are formed, that is, white dense non-inflamed nodules with a diameter of about 2 mm, covered with skin and having no open exit to the surface. Inflammation is not expressed in them, but there are favorable conditions for its further development. Further accumulation of sebum in them leads to an increase in nodules and the transformation of closed comedones into open ones.
The nodulocystic form of blackheads is characterized by the formation of purulent cystic cavities and infiltrates deep in the dermis, their tendency to merge and the formation of inflammatory conglomerates. With the reverse development, such elements always heal with the formation of scars. This form of blackheads usually lasts for a long time (for several years), even with a moderate degree of the process.
The rarest form of blackheads in appearance and the most severe in clinical manifestations is lightning blackheads. It usually develops in adolescents 13-18 years old who have papulopustular or nodular cystic blackheads. The lightning-fast form is characterized by a sudden, sharp onset, the appearance of ulcerative-necrotic areas on the trunk, an increase in symptoms of intoxication. The lightning-fast form of blackheads is close in its course to the gangrenous form of pyoderma.
The reasons for the development of the lightning form are not fully understood. Probably, toxic-allergic and infectious-allergic mechanisms play a certain role here. Blackheads fulminans usually develops in patients suffering from severe lesions of the digestive system (ulcerative colitis, Crohn’s disease, etc.), or after taking certain medications: tetracyclines, androgens, synthetic retinoids.
The development of the disease is rapid. The general symptoms and phenomena of intoxication come to the fore: a rise in body temperature above 38 ° C, pain in joints and muscles, abdominal pain, anorexia, a sharp deterioration in well-being. Sometimes changes in organs and tissues develop: softening of bones, enlargement of the liver and spleen. In the blood – an increased content of leukocytes, a decrease in the level of hemoglobin and acceleration of ESR, blood backfeed – negative. Areas of erythema with pustules and then ulcers form on the skin of the trunk and upper extremities. There are no rashes on the face. Subsequently, numerous scars, including keloid scars, form at the site of rashes.
Papulopustular blackheads is characterized by attachment to closed or open comedones of the inflammatory process. This form of blackheads is characterized by the formation of inflammatory elements – papules (nodules) and pustules (pustules). The outcome of papulopustular blackheads depends on the depth of the lesion of the skin layers. The mild form usually heals without a trace, when the deep layers of the dermis are involved in the inflammatory process and its structure is damaged, the inflammatory elements heal with the formation of a scar defect.
Comedones and papulopustular blackheads are the most common forms of blackheads. Other types of blackheads in clinical practice are quite rare, characterized by a more severe course and require different treatment tactics.
If blackheads persists until the patient reaches adulthood or appears for the first time in adults, then they are referred to as manifestations of blackheads adultorum or adult blackheads. They occur in 3-5% of men and women aged 40 to 50 years and older. In some cases, their late resumption is noted years after the resolution of juvenile blackheads.
This form of blackheads is more common in women and requires additional consultation with a gynecologist. In 20% of cases, adult women complain about the appearance of rashes a few days before the start of menstruation and the independent disappearance of blackheads with the beginning of a new cycle. Often, late blackheads is constantly present. Usually these are papular, papulopustular or nodular-cystic blackheads elements. The cause of late blackheads is often polycystic ovaries, complicated by hirsutism and anovulatory menstrual cycle. It is also necessary to exclude tumor lesions of the ovaries and adrenal glands.
One of the most severe manifestations of blackheads – globular (piled up) blackheads – occurs in men against a background of thick seborrhea. Globular blackheads is manifested by multiple nodular cystic elements and large comedones, located not only in areas of seborrhea, but also on the skin of the extremities, abdomen and back. Their healing occurs with the formation of keloid, hypertrophic and atrophic scars. Globular blackheads occurs in adolescence and persists, as a rule, up to 40 years or more.
Inverse (hidradenitis suppurativa)
The clinic of inverse blackheads is associated with the secondary involvement in the inflammatory process of apocrine or large sweat glands of the armpits, perineum, pubis, navel, etc. They are predisposed to their development by increased body weight, injury to the corresponding areas by combing or tight clothing. The disease is characterized by the formation of bumpy painful infiltrates with purulent or bloody-purulent discharge. Individual elements, merging, lead to an increase in the area of the lesion. They heal for a long time with the formation of fistulas and scars. Inverse blackheads has a chronic course with frequent relapses.
Many researchers attribute pyoderma to the manifestation of rosacea, not blackheads. Pyodermitis of the skin of the face is more often affected by young women 20-40 years old. The disease begins with the appearance of persistent erythema on the face, against which papulopustular rashes and nodes rapidly develop, then merging into purulent conglomerates. Inflammatory elements are localized exclusively on the face, while there are no comedones and general symptoms. The healing of the elements occurs slowly, for a year or more.
The occurrence of bodybuilding blackheads is associated with the use of androgens or anabolic steroids. The resulting hyperandrogenism causes increased sebum secretion. A similar effect occurs as a result of long-term administration of glucocorticoids. Taking anabolic steroids is often combined with vitamin cocktails, which include B vitamins and cause the appearance of nodular cystic blackheads. With this form of blackheads in patients, it is necessary to exclude endocrine disorders.
Caused by mechanical factors
The appearance of this type of blackheads is associated with mechanical blockage of the follicle ducts as a result of pressure or friction (wearing a tight headdress, plaster, with severe sweating, etc.).
Caused by exogenous causes
Toxic blackheads, professional blackheads. Occur when a person comes into contact with chemicals and compounds that lead to clogging of pores and the appearance of blackheads (tar, lubricating oils, chlorine, etc.).
- Cosmetic. They appear as a result of excessive or improper use of cosmetics (more often face creams).
- Blackheads from detergents. They develop from frequent use of detergents, leading to the formation of comedones.
- Solar form. Blackheads eruptions that manifest or worsen in hot and humid climates.
Rashes in which there are no comedones are called blackheads-like. These include a large group of dermatoses: rosacea, pink acne, perioral dermatitis, skin tuberculosis, sarcoidosis of the face, drug rash. For blackheads-like rashes, inflammation of the sebaceous hair follicle is primary. When diagnosing them, they should be distinguished from blackheads.
With a diet
To date, there is no scientifically substantiated evidence of a direct dependence of the occurrence of blackheads on the nature of the patient’s diet. Nevertheless, many of them note the aggravation of blackheads when eating citrus fruits, chocolate, coffee, pork, red wine, cheeses.
The conducted studies have shown that the qualitative composition of the sebaceous gland secretion does not depend on the nature of the patient’s nutrition. Also, the dependence of the severity of blackheads on the total caloric content of food, the amount of fats, carbohydrates, proteins, mineral compounds and vitamins in it has not been established. Therefore, it is impossible to speak unequivocally about the treatment of blackheads with the help of diet therapy. This issue is solved by doctors in each case individually. General recommendations on the nature of nutrition of patients with blackheads are aimed at reducing body weight and limiting drinks and foods that stimulate the secretion of sebaceous glands.
The use of external remedies is almost always used in the complex treatment of blackheads. Their pharmacological action is aimed at suppressing the mechanisms of blackheads development: excessive sebum secretion, hyperkeratosis, reproduction of microorganisms, development of the inflammatory process.
External blackheads remedies lubricate the entire area of the affected skin (face, chest, back), and not individual elements of blackheads. A combination of drugs is acceptable, but not their simultaneous application. Treatment is carried out for several months before the disappearance of blackheads. In the future, a supportive course with less frequent use of external drugs is required. For external use in blackheads, the following drugs are used: synthetic retinoids, azelaic acid derivatives, benzoyl peroxide and antibiotics. However, all of them have a weakly pronounced effect on sebum hypersecretion.
Treatment of blackheads with retinoids
Retinoids are synthetic analogues of retinol (vitamin A). Forms of release – solutions, creams and gels. Indications for the use of retinoids are a mild degree of blackheads, accompanied by increased sebum secretion, as well as intolerance to benzoyl peroxide. Preparations with retinol dissolve comedones, normalize the processes of keratinization of hair follicles, have an antibacterial effect and somewhat reduce sebum secretion.
With azelaic acid
Azelaic acid is a part of gels and creams for external use. The therapeutic effect of azelaic acid is associated with the normalization of the processes of keratinization of the walls of hair follicles, the suppression of increased reproduction of microbes and the development of inflammation in the sebaceous gland. It is suitable for use by patients with comedones or a moderate form of papulopustular blackheads, as well as in cases of inefficiency or poor tolerance of benzoyl peroxide and retinoids. Noticeable improvement usually occurs after a month, and the most pronounced effect is achieved after 2-3 months.
With benzoyl peroxide
Benzoyl peroxide is an active component that is part of many external preparations, has been used in dermatological practice for over 20 years. Possessing a powerful keratolytic (“dissolving” keratinized tissues) and bleaching effect, benzoyl peroxide preparations are used in the treatment of ichthyosis, pigmented formations. Benzoyl peroxide is also effective against blackheads. The drug is available in various dosage forms (lotions, liniments, creams, gels) and concentrations (10%, 5%, 2,5%). It can be used in pure form or as part of complex preparations in combination with erythromycin, sulfur, hydroxyquinolone or imidazoles. The indication for the use of benzoyl peroxide is a mild degree of blackheads, characterized by the formation of comedones and elements of inflammation.
It is possible to use a combined remedy for blackheads, including benzoyl peroxide and erythromycin. This gel is prepared immediately before use. The keratolytic, antibacterial and anti-inflammatory effect of benzoyl peroxide in combination with the bacteriostatic action of the antibiotic erythromycin on propionic blackheads bacteria give good results in the treatment of blackheads.
In the treatment of blackheads topically, antibiotics are usually used in cases of inefficiency or intolerance to retinoids, benzoyl peroxide and azelaic acid. Sometimes antibiotics are used as an additional drug to the first three main drugs. 1% liniment or lotion containing the antibiotic clindamycin is used to treat a moderate form of blackheads in the absence of effect from the use of other drugs. Penetrating into the sebaceous glands, clindamycin stops the reproduction of propionibacteria and staphylococci.
A drug containing a powder complex of erythromycin and zinc acetate for the preparation of lotion is successfully used. Erythromycin is effective against propionic blackheads bacteria and epidermal staphylococcus, and zinc suppresses excessive sebum secretion. Indications for the use of this drug are mild and moderate degrees of blackheads. Of the tetracycline antibiotics, doxycycline and minocycline are more often used in the treatment of blackheads. These antibiotics tend to accumulate in the sebaceous glands, have high antimicrobial activity and are better tolerated by patients.
By its action, erythromycin is close to tetracycline antibiotics, but microflora resistance is rapidly developing to it. As the drug of choice in the treatment of blackheads, it can be used during pregnancy and breastfeeding, in children’s practice, as well as in case of inefficiency of tetracyclines or their intolerance.
With the ineffectiveness of antibiotics
The lack of effect from the treatment of blackheads with antibiotics may be caused by the habituation of flora to an antibacterial drug in case of its prolonged use or the development of gram-negative folliculitis (inflammation of the hair follicle caused by gram-negative bacteria). To establish the sensitivity of microflora to an antibiotic, bacteriological seeding of the separated blackheads elements is carried out. Next, the question is raised about the replacement of an antibiotic or the appointment of retinoids.
The treatment in men and women has its own differences. In men with signs of seborrhea and multiple blackheads on the trunk, there is an increased separation of sebum, therefore, high-dose antibiotics in combination with isotretinoin are required for their treatment. Isotretinoin is a drug of the group of synthetic retinoids that suppresses sebum secretion. Already 2 weeks after the start of treatment, sebum production decreases by 90% and remains at this level for up to several months. After stopping the use of isotretinoin, sebum secretion returns to normal limits. In addition, against the background of isotretinoin treatment, keratinization processes in hair follicles are normalized, the number of comedones and propionibacteria and associated inflammatory manifestations are reduced.
Hormone therapy may be effective in the treatment in women. The gynecologist-endocrinologist should decide on the appropriateness of hormone therapy after analyzing the hormonal background of a woman. It is permissible to combine local treatment of blackheads with the use of hormonal combined oral contraceptives containing antiandrogens or an estrogenic profile. Usually, with such treatment, the effect manifests itself after 3-6 months and is observed for a long time.
Among the combined estrogen–progestin contraceptives, the most effective are ciproterone and ethinyl estradiol, which can be prescribed for the treatment of both individually and in combination with each other. Corticosteroid antiandrogens are used to suppress adrenal hyperandrogenism. The duration of treatment with antiandrogens and estrogens can last for several months or even years.
Severe cases require combination therapy combining standard local and general treatment. In such cases, women may be prescribed contraceptives with estrogens or antiandrogens after a preliminary consultation with a gynecologist-endocrinologist.
General warming-up procedures (massage, warming-up, hot baths) are categorically contraindicated in blackheads, because they can aggravate inflammation. However, the use of local hot medicinal compresses helps to remove comedones and resorption of infiltration. For this purpose, an Alibur solution containing copper and zinc sulfates is used.
Phototherapy and ozone therapy can be used in the treatment. Mesotherapy is prescribed to correct scarring that remains after the resolution of blackheads elements.
In the acute period, surgical manipulations are usually not resorted to. During the formation of cystic cavities, they are exposed to liquid nitrogen (cryotherapy) or a triamcinolone solution is injected inside with a thin needle. Surgical opening of cystic cavities leads to the formation of scars. Multiple subcutaneous keratin cysts (milium) can be removed with a laser.