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This article is about a skin disease commonly found during adolescence. For other acneform skin diseases, see Acne (disambiguation).
Acne
Classification and external resources
Acne of a 14-year-old boy during puberty
ICD-10 L70.0
ICD-9 706.1
DiseasesDB 10765
MedlinePlus 000873
eMedicine derm/2 

Acne vulgaris (commonly called acne) is a skin disease caused by changes in the pilosebaceous units (skin structures consisting of a hair follicle and its associated sebaceous gland). The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The International Statistical Classification of Diseases and Related Health Problems 10th Revision ( ICD -10) is a coding of diseases and signs symptoms abnormal findings L00-L99 - Diseases of the Skin and Subcutaneous tissue (L00-L08 Infections of the Skin and Subcutaneous tissue The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify Diseases The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. The Diseases Database is a free Website that provides information about the relationships between medical conditions Symptoms, and Medications. MedlinePlus, with the MedlinePlus Medical Encyclopedia, is a website network containing Health information from the world's largest medical Library eMedicine is an online clinical medical knowledge base that was founded in 1996 by Scott Plantz and Richard Lavely two medical doctors The skin is the outer covering of living tissue of an animal (or plant A hair follicle is part of the Skin that grows Hair by packing old cells together The sebaceous glands are Glands found in the Skin of Mammals Locations and morphology A branched type of Acinar gland, these Severe acne is inflammatory, but acne can also manifest in noninflammatory forms. Inflammation ( Latin, inflamatio, to set on fire is the complex biological response of vascular tissues to harmful stimuli such as Pathogens [1] Acne lesions are commonly referred to as pimples, spots, or zits. A pimple is a result of a blockage of the Skin 's Pore. It can be a Pustule or Papule.

Acne is most common during adolescence, affecting more than 85% of teenagers, and frequently continues into adulthood. [2] For most people, acne diminishes over time and tends to disappear—or at the very least decrease—after one reaches his or her early twenties. There is, however, no way to predict how long it will take to disappear entirely, and some individuals will continue to suffer well into their thirties, forties and beyond. [3]

The term acne comes from a corruption of the Greek άκμή (acme in the sense of a skin eruption) in the writings of Aëtius Amidenus. Greek (el ελληνική γλώσσα or simply el ελληνικά — "Hellenic" is an Indo-European language, spoken today by 15-22 million people mainly Aëtius Amidenus or Aëtius of Amida ( Gr) was a Byzantine physician and medical writer particularly distinguished by the extent The most common form of acne is known as "acne vulgaris", meaning "common acne". Many teenagers get this type of acne.

The face and upper neck are the most commonly affected, but the chest, back and shoulders may have acne as well. The term face refers to the central sense organ complex for those animals that have one normally on the ventral surface of the head and can depending on the definition The chest is a part of the Anatomy of humans and various other animals sometimes referred to as the Thorax. "Back" redirects here For other uses please see Back (disambiguation. In Human anatomy, the shoulder joint comprises the part of the body where the Humerus attaches to the Scapula. The upper arms can also have acne, but lesions found there are often keratosis pilaris, not acne. In Anatomy, an arm is one of the Upper limbs of an animal The term arm can also be used for analogous structures such as one of the paired upper limbs Keratosis pilaris (KP also follicular keratosis is a very common genetic follicular condition that is manifested by the appearance of rough bumps on the skin Typical acne lesions are comedones, inflammatory papules, pustules and nodules. Some of the large nodules were previously called "cysts" and the term nodulocystic has been used to describe severe cases of inflammatory acne. A cyst is a closed sac having a distinct membrane and Division on the nearby tissue. [4]

Aside from scarring, its main effects are psychological, such as reduced self-esteem[5] and, according to at least one study, depression or suicide. In Psychology, self-esteem reflects a Person 's overall evaluation or appraisal of her or his own worth Major depressive disorder, also known as major depression, unipolar depression, unipolar disorder, clinical depression, or simply depression [6] Acne usually appears during adolescence, when people already tend to be most socially insecure. Early and aggressive treatment is therefore advocated by some to lessen the overall impact to individuals. [5]

Different types of Acne Vulgaris: A: Cystic acne on the face, B: Subsiding tropical acne of trunk, C: Extensive acne on chest and shoulders.
Different types of Acne Vulgaris: A: Cystic acne on the face, B: Subsiding tropical acne of trunk, C: Extensive acne on chest and shoulders.

Contents

Causes of acne

Acne develops as a result of blockages in follicles. Hyperkeratinization and formation of a plug of keratin and sebum (a microcomedo) is the earliest change. Hyperkeratinization is a disorder of the cells lining the inside of a hair follicle. Keratins are a family of fibrous structural proteins; tough and insoluble they form the hard but nonmineralized structures found in Reptiles Birds The sebaceous glands are Glands found in the Skin of Mammals Locations and morphology A branched type of Acinar gland, these Enlargement of sebaceous glands and an increase in sebum production occur with increased androgen (DHEA-S) production at adrenarche. Androgen is the generic term for any natural or synthetic compound usually a Steroid Hormone, that stimulates or controls the development and maintenance of masculine Dehydroepiandrosterone ( DHEA) is a natural Steroid Prohormone produced from Cholesterol by the Adrenal glands the Gonads Adrenarche refers to a stage of maturation of the cortex of the human Adrenal glands It typically occurs between ages 6 and 10 years and involves both structural and functional The microcomedo may enlarge to form an open comedo (blackhead) or closed comedo (whitehead). A blackhead (medically known as an open comedo, plural comedones) is a yellowish or blackish bump or plug on the skin In these conditions the naturally occurring largely commensual bacteria Propionibacterium acnes can cause inflammation, leading to inflammatory lesions (papules, infected pustules, or nodules) in the dermis around the microcomedo or comedo, which results in redness and may result in scarring or hyperpigmentation. Propionibacterium acnes is a relatively slow growing typically Aerotolerant Anaerobic Gram positive Bacterium that is linked to the Inflammation ( Latin, inflamatio, to set on fire is the complex biological response of vascular tissues to harmful stimuli such as Pathogens A papule is a small and solid elevation of the Skin. Papules do not contain Pus, which distinguishes them from Pustules Papules often occur in clusters The dermis is a layer of Skin beneath the epidermis that consists of Connective tissue, and cushions the body from stress and strain Scars (also called cicatrices) are areas of fibrous tissue that replace normal Skin (or other tissue after injury In Dermatology, hyperpigmentation is the darkening of an area of Skin or nails caused by increased Melanin. [7]

Primary causes

Acne of an older teenager.
Acne of an older teenager.

Exactly why some people get acne and some do not is not fully known. It is known to be partly hereditary. Several factors are known to be linked to acne:

Several hormones have been linked to acne: the androgens testosterone, dihydrotestosterone (DHT) and dehydroepiandrosterone sulfate (DHEAS), as well as insulin-like growth factor 1 (IGF-I). Hormones (from Greek ὁρμή - "impetus" are chemicals released by cells that affect cells in other parts of the body Testosterone is a Steroid hormone from the Androgen group In mammals testosterone is primarily secreted in the testes of males and the Ovaries Dihydrotestosterone ( DHT) (Full name 5α-Dihydrotestosterone, abbreviating to 5α-DHT; INN: androstanolone; commonly called Dehydroepiandrosterone ( DHEA) is a natural Steroid Prohormone produced from Cholesterol by the Adrenal glands the Gonads Insulin-like growth factor 1 (IGF-1 that was once called somatomedin C is a Polypeptide Protein Hormone similar in Molecular structure In addition, acne-prone skin has been shown to be insulin resistant. Insulin is a Hormone with intensive effects on both metabolism and several other body systems (eg vascular compliance

Development of acne vulgaris in later years is uncommon, although this is the age group for Rosacea which may have similar appearances. Rosacea (rəʊˈzeɪʃə is a common but often misunderstood condition that is estimated to affect over 45 million people worldwide True acne vulgaris in adults may be a feature of an underlying condition such as pregnancy and disorders such as polycystic ovary syndrome or the rare Cushing's syndrome. Polycystic ovary syndrome abbreviated PCOS or PCO (also known clinically as Stein-Leventhal syndrome, Sclerocystic ovary syndrome, Hyperthecosis Menopause-associated acne occurs as production of the natural anti-acne ovarian hormone estradiol fails at menopause. The lack of estradiol also causes thinning hair, hot flashes, thin skin, wrinkles, vaginal dryness, and predisposes to osteopenia and osteoporosis as well as triggering acne (known as acne climacterica in this situation).

Diet

Milk

A recent study, based on a survey of 47,335 women, did find a positive epidemiological association between acne and consumption of partially skimmed milk, instant breakfast drink, sherbet, cottage cheese, and cream cheese. Milk is an opaque white liquid produced by the Mammary glands of female Mammals (including Monotremes. Sorbet is a frozen Dessert made from sweetened Water flavored with iced Fruit (typically Juice or Puree) Chocolate, Cottage cheese is a Cheese Curd product with a mild flavor It is drained but not pressed so some Whey remains Cream cheese is a sweet soft mild-tasting white Cheese, defined by the US Department of Agriculture as containing at least 33% Milkfat (as marketed [11] The researchers hypothesize that the association may be caused by hormones (such as several sex hormones and bovine IGF-I) present in cow milk. Insulin-like growth factor 1 (IGF-1 that was once called somatomedin C is a Polypeptide Protein Hormone similar in Molecular structure Though there is evidence of an association between milk and acne, the exact cause is unclear. Most dermatologists are awaiting confirmatory research linking diet and acne but some support the idea that acne sufferers should experiment with their diets, and refrain from consuming such fare if they find such food affects the severity of their acne. [12]


High carbohydrates/High GI

It has also been suggested that there is a link between diets high in refined sugars and processed foods and acne. The hypothesis is that rapidly digested carbohydrate foods, such as white bread and refined sugars, produces an overload in metabolic glucose that is rapidly converted into the types of fat that can build up in sebaceous glands. According to this hypothesis, the startling absence of acne in non-westernized societies could be explained by the low glycemic index of these cultures' diets. The Glycemic index (also glycaemic index) or GI is a measure of the effects of Carbohydrates on Blood glucose levels Others have cited possible genetic reasons for there being no acne in these populations, but similar populations shifting to these diets do develop acne. Note also that the populations studied consumed no milk or other dairy products. [13] Further research is necessary to establish whether a reduced consumption of high-glycemic foods (such as soft drinks, sweets, white bread) can significantly alleviate acne, though consumption of high-glycemic foods should in any case be kept to a minimum, for general health reasons. [14] Avoidance of 'junk food' with its high fat and sugar content is also recommended. [15] The University of Pennsylvania and the US Naval Academy conducted experiments that fed subjects chocolate or a bar with similar amounts of macronutrients (fat, sugar etc. The University of Pennsylvania (also known as Penn) is a private University located in Philadelphia, Pennsylvania, USA. The United States Naval Academy is an undergraduate college in Annapolis, Maryland, United States that educates and commissions officers of the United States ) and found that consumption of chocolate, frequent or not, had no effect on the developing of acne. [16]

A 2005 systematic review found "surprisingly little evidence exists for the efficacy or lack of efficacy of dietary factors, face-washing and sunlight exposure in the management of acne. A systematic review is a Literature review focused on a single question which tries to identify appraise select and synthesize all high quality research evidence relevant to "[17] A study in November 2006 in Australia gave a 50% reduction in 12 weeks in mild-moderate facial acne by introducing its subjects to a high protein, low GI diet. [18]

The American Medical Association says chocolate does not contribute to acne. [19]

A recent study[20] shows that a diet high enough in sugars triggers the liver to convert these sugars into lipid; as a side-effect this stops production of Sex hormone binding globulin, a chemical that reduces the level of testosterone in the blood. Sex hormone-binding globulin ( SHBG) is a Glycoprotein that binds to Sex hormones, specifically Testosterone and Estradiol. Since high testosterone levels generally trigger acne, the researchers believe this can be a cause.

Vitamins A and E

Studies have shown that newly diagnosed acne patients tend to have lower levels of vitamin A circulating in their bloodstream than those that are acne free. Vitamin A refers to a family of similarly shaped molecules the Retinoids. [21] In addition people with severe acne also tend to have lower blood levels of vitamin E. See also Tocopherol, Tocotrienol Vitamin E is the collective name for a set of 8 related Tocopherols and Tocotrienols which are fat-soluble [22]

Hygiene

Acne is not caused by dirt. This misconception probably comes from the fact that blackheads look like dirt stuck in the openings of pores. A blackhead (medically known as an open comedo, plural comedones) is a yellowish or blackish bump or plug on the skin The black color is not dirt but simply oxidised keratin. In fact, the blockages of keratin that cause acne occur deep within the narrow follicle channel, where it is impossible to wash them away. Keratins are a family of fibrous structural proteins; tough and insoluble they form the hard but nonmineralized structures found in Reptiles Birds These plugs are formed by the failure of the cells lining the duct to separate and flow to the surface in the sebum created there by the body. Built up oil of the skin can block the passages of these pores, so standard washing of the face could wash off old oil and help unblock the pores.

Treatments

Available treatments

There are many products available for the treatment of acne, many of which are without any scientifically-proven effects. Generally speaking, successful treatments show little improvement within the first two weeks, instead taking a period of approximately three months to improve and start flattening out. Many treatments that promise big improvements within two weeks are likely to be largely disappointing. However, short bursts of cortisone can give very quick results, and other treatments can rapidly improve some active spots, but usually not all active spots.

Modes of improvement are not necessarily fully understood but in general treatments are believed to work in at least 4 different ways (with many of the best treatments providing multiple simultaneous effects):

A combination of treatments can greatly reduce the amount and severity of acne in many cases. Propionibacterium acnes is a relatively slow growing typically Aerotolerant Anaerobic Gram positive Bacterium that is linked to the Those treatments that are most effective tend to have greater potential for side effects and need a greater degree of monitoring, so a step-wise approach is often taken. Many people consult with doctors when deciding which treatments to use, especially when considering using any treatments in combination. There are a number of treatments that have been proven effective:

Benzoyl peroxide cream.
Benzoyl peroxide cream.

Topical bactericidals

Widely available OTC bactericidal products containing benzoyl peroxide may be used in mild to moderate acne. Over-the-counter (OTC drugs are medicines that may be sold without a prescription, in contrast to Prescription drugs The name "over-the-counter" Benzoyl peroxide (ˈbɛnzɔɪl pəˈrɒksaɪd is a Chemical in the Organic peroxide family The gel or cream containing benzoyl peroxide is rubbed, twice daily, into the pores over the affected region. Bar soaps or washes may also be used and vary from 2 to 10% in strength. In addition to its therapeutic effect as a keratolytic (a chemical that dissolves the keratin plugging the pores) benzoyl peroxide also prevents new lesions by killing P.acnes. Propionibacterium acnes is a relatively slow growing typically Aerotolerant Anaerobic Gram positive Bacterium that is linked to the In one study, roughly 70% of participants using a 10% benzoyl peroxide solution experienced a reduction in acne lesions after 6 weeks. [23]Unlike antibiotics, benzoyl peroxide has the advantage of being a strong oxidizer (essentially a mild bleach) and thus does not appear to generate bacterial resistance. However, it routinely causes dryness, local irritation and redness. A sensible regimen may include the daily use of low-concentration (2. 5%) benzoyl peroxide preparations, combined with suitable non-comedogenic moisturisers to help avoid overdrying the skin. A blackhead (medically known as an open comedo, plural comedones) is a yellowish or blackish bump or plug on the skin

Care must be taken when using benzoyl peroxide, as it can very easily bleach any fabric or hair it comes in contact with.

Other antibacterials that have been used include triclosan, or chlorhexidine gluconate but these are often less effective, but also give less side-effects. Triclosan ( IUPAC name: 5-chloro-2-(24-dichlorophenoxyphenol is a potent wide spectrum antibacterial and antifungal agent Chlorhexidine is a chemical Antiseptic.It kills (is bactericidal to both Gram-positive and Gram-negative Microbes although it is less effective

Prescription-strength benzoyl peroxide preparations do not necessarily differ with regard to the maximum concentration of the active ingredient (10%), but the drug is made available dissolved in a vehicle that more deeply penetrates the pores of the skin.

Topical antibiotics

Externally applied antibiotics such as erythromycin, clindamycin, Stiemycin, or tetracycline aim to kill the bacteria that are harbored in the blocked follicles. Erythromycin is a Macrolide Antibiotic that has an antimicrobial spectrum similar to or slightly wider than that of Penicillin, and is often used for people Clindamycin ( rINN; klɪndəˈmaɪsɨn is a lincosamide Antibiotic. This article deals with the specific antibiotic called tetracycline While topical use of antibiotics is equally as effective as oral use, this method avoids possible side effects including upset stomach and drug interactions (e. g. it will not affect use of the oral contraceptive pill), but may prove awkward to apply over larger areas than just the face alone.

Oral antibiotics

Oral antibiotics used to treat acne include erythromycin or one of the tetracycline antibiotics (tetracycline, the better absorbed oxytetracycline, or one of the once daily doxycycline, minocycline, or lymecycline). Tetracyclines are a group of Broad-spectrum antibiotics whose general usefulness has been reduced with the onset of bacterial resistance This article deals with the specific antibiotic called tetracycline Oxytetracycline was the second of the broad-spectrum tetracycline group of Antibiotics to be discovered Doxycycline ( INN) (ˌdɒksɪˈsaɪkliːn is a member of the Tetracycline antibiotics group and is commonly used to treat a variety of Infections Doxycycline Minocycline hydrochloride, also known as minocycline, is a member of the broad spectrum Tetracycline antibiotics, and has a broader spectrum than the other members Lymecycline is a tetracycline Broad-spectrum antibiotic marketed by the pharmeceutical company Galderma Trimethoprim is also sometimes used (off-label use in UK). Trimethoprim ( INN) (traɪˈmɛθəprɪm is a bacteriostatic Antibiotic mainly used in the Prophylaxis and treatment of Urinary tract infections Off-label use is the practice of prescribing drugs for a purpose outside the scope of the drug's approved label most often concerning the drug's indication. However, reducing the P. acnes bacteria will not, in itself, do anything to reduce the oil secretion and abnormal cell behaviour that is the initial cause of the blocked follicles. Additionally the antibiotics are becoming less and less useful as resistant P. acnes are becoming more common. Acne will generally reappear quite soon after the end of treatment—days later in the case of topical applications, and weeks later in the case of oral antibiotics. In Medicine, a topical Medication is applied to body surfaces such as the Skin or Mucous membranes for example the Vagina

It has been found that sub-antimicrobial doses of antibiotics such as minocycline also improve acne. It is believed that minocycline's anti-inflammatory effect also prevents acne. These low doses do not kill bacteria and hence cannot induce resistance.

Hormonal treatments

In females, acne can be improved with hormonal treatments. Hormones (from Greek ὁρμή - "impetus" are chemicals released by cells that affect cells in other parts of the body The common combined oestrogen/progestogen methods of hormonal contraception have some effect, but the antiandrogen, Cyproterone, in combination with an oestrogen (Diane 35) is particularly effective at reducing androgenic hormone levels. Estrogens (US otherwise oestrogens or œstrogens) are a group of Steroid compounds named for their importance in the Estrous cycle, Progestagens (also spelled progestogens or gestagens) are Hormones that produce effects similar to those of Progesterone, the only natural progestagen Hormonal contraception refers to Birth control methods that act on the hormonal system An antiandrogen, or androgen antagonist, is any of a group of Hormone Receptor antagonist compounds that are capable of preventing or inhibiting the biologic Cyproterone acetate ( Androcur, Cyprostat, Cyproteron, Procur, Cyprone, Cyprohexal, Ciproterona, Cyproteronum Diane-35 is not available in the USA, but a newer oral contraceptive containing the progestin drospirenone is now available with fewer side effects than Diane 35 / Dianette. Cyproterone acetate ( Androcur, Cyprostat, Cyproteron, Procur, Cyprone, Cyprohexal, Ciproterona, Cyproteronum Drospirenone is a synthetic Progestin that is an analog to Spironolactone, with a Molecular weight of 366 Both can be used where blood tests show abnormally high levels of androgens, but are effective even when this is not the case. Androgen is the generic term for any natural or synthetic compound usually a Steroid Hormone, that stimulates or controls the development and maintenance of masculine Along with this, treatment with low dose spironolactone can have anti-androgenetic properties, especially in patients with polycystic ovarian syndrome.

If a pimple is large and/or does not seem to be affected by other treatments, a dermatologist may administer an injection of cortisone directly into it, which will usually reduce redness and inflammation almost immediately. Cortisone (ˈkɔrtɨsoʊn or /ˈkɔrtɨzoʊn/ (ˈkôrtəˌsōn or -zōn (17-hydroxy-11-dehydrocorticosterone is a Steroid Hormone. This has the effect of flattening the pimple, thereby making it easier to cover up with makeup, and can also aid in the healing process. Side effects are minimal, but may include a temporary whitening of the skin around the injection point; and occasionally a small depression forms, which may persist, although often fills eventually. This method also carries a much smaller risk of scarring than surgical removal.


Topical retinoids

A group of medications for normalizing the follicle cell lifecycle are topical retinoids such as tretinoin (brand name Retin-A), adapalene (brand name Differin), and tazarotene (brand name Tazorac). In Medicine, a topical Medication is applied to body surfaces such as the Skin or Mucous membranes for example the Vagina The retinoids are a class of Chemical compounds that are related chemically to Vitamin A. Tretinoin is the acid form of Vitamin A and so also known as all-trans retinoic acid or ATRA. Adapalene is a topical Retinoid primarily used in the treatment of acne and is also used ( off-label) to treat Keratosis pilaris as Tazarotene (marketed as Tazorac, Avage and Zorac) is a prescription topical Retinoid sold as a cream or gel Like isotretinoin, they are related to vitamin A, but they are administered as topicals and generally have much milder side effects. Vitamin A refers to a family of similarly shaped molecules the Retinoids. They can, however, cause significant irritation of the skin. The retinoids appear to influence the cell creation and death lifecycle of cells in the follicle lining. This helps prevent the hyperkeratinization of these cells that can create a blockage. Hyperkeratinization is a disorder of the cells lining the inside of a hair follicle. Retinol, a form of vitamin A, has similar but milder effects and is used in many over-the-counter moisturizers and other topical products. Retinol (Afaxin, the animal form of Vitamin A, is a fat-soluble vitamin important in vision and Bone growth Effective topical retinoids have been in use over 30 years but are available only on prescription so are not as widely used as the other topical treatments. Topical retinoids often cause an initial flare up of acne and facial flushing. For a person to flush is to become markedly Red in the Face and often other areas of the skin from various physiological conditions

Oral retinoids

Main article: Accutane

A daily oral intake of vitamin A derivative isotretinoin (marketed as Accutane, Amnesteem, Sotret, Claravis) over a period of 4-6 months can cause long-term resolution or reduction of acne. Isotretinoin ( INN) (aɪsoʊtrɨˈtɪnoʊɨn or /ˌaɪsoʊtrɨˈtɪnoʊɨn/ is a Medication used for the treatment of severe acne. Vitamin A refers to a family of similarly shaped molecules the Retinoids. Isotretinoin ( INN) (aɪsoʊtrɨˈtɪnoʊɨn or /ˌaɪsoʊtrɨˈtɪnoʊɨn/ is a Medication used for the treatment of severe acne. It is believed that isotretinoin works primarily by reducing the secretion of oils from the glands, however some studies suggest that it affects other acne-related factors as well. Isotretinoin has been shown to be very effective in treating severe acne and can either improve or clear well over 80% of patients. The drug has a much longer effect than anti-bacterial treatments and will often cure acne for good. The treatment requires close medical supervision by a dermatologist because the drug has many known side effects (many of which can be severe). Dermatology (from Greek grc δέρμα derma, "skin" and grc -λογία -logia) is a branch of Medicine dealing with In Medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as Chemotherapy or Surgery. About 25% of patients may relapse after one treatment. In those cases, a second treatment for another 4-6 months may be indicated to obtain desired results. It is often recommended that one lets a few months pass between the two treatments, because the condition can actually improve somewhat in the time after stopping the treatment and waiting a few months also gives the body a chance to recover. Occasionally a third or even a fourth course is used, but the benefits are often less substantial. The most common side effects are dry skin and occasional nosebleeds (secondary to dry nasal mucosa). Oral retinoids also often cause an initial flare up of acne within a month or so, which can be severe. There are reports that the drug has damaged the liver of patients. For this reason, it is recommended that patients have blood samples taken and examined before and during treatment. In some cases, treatment is terminated or reduced due to elevated liver enzymes in the blood, which might be related to liver damage. Others claim that the reports of permanent damage to the liver are unsubstantiated, and routine testing is considered unnecessary by some dermatologists. The liver is a vital organ in the human body and is present in Vertebrates and some other animals Blood triglycerides also need to be monitored. However, routine testing are part of the official guidelines for the use of the drug in many countries. Some press reports suggest that isotretinoin may cause depression but as of September 2005 there is no agreement in the medical literature as to the risk. Major depressive disorder, also known as major depression, unipolar depression, unipolar disorder, clinical depression, or simply depression The drug also causes birth defects if women become pregnant while taking it or take it while pregnant. For this reason, female patients are required to use two separate forms of birth control or vow abstinence while on the drug. Birth control, sometimes synonymous with contraception, is a regimen of one or more actions devices or Medications followed in order to deliberately prevent Abstinence is a voluntary restraint from indulging a desire or appetite for certain bodily activities that are widely experienced as giving pleasure Because of this, the drug is supposed to be given to females as a last resort after milder treatments have proven insufficient. Restrictive rules (see iPledge Program) for use were put into force in the USA beginning in March 2006 to prevent misuse. The iPLEDGE program is a mandatory distribution program in the United States for Isotretinoin (commonly sold under the trade names Accutane Amneesteen Claravis or [24] This has occasioned widespread editorial comment. [25]

Phototherapy

'Blue' and red light

It has long been known that short term improvement can be achieved with sunlight. However, studies have shown that sunlight worsens acne long-term. More recently, visible light has been successfully employed to treat acne (phototherapy) - in particular intense violet light (405-420nm) generated by purpose-built fluorescent lighting, dichroic bulbs, LEDs or lasers. Light therapy or phototherapy consists of exposure to daylight or to specific wavelengths of light using Lasers, LEDs Fluorescent lamps, Dichroic redirects here For the filter see Dichroic filter. For the glass see Dichroic glass. A laser is a device that emits Light ( Electromagnetic radiation) through a process called Stimulated emission. Used twice weekly, this has been shown to reduce the number of acne lesions by about 64%;[26] and is even more effective when applied daily. The mechanism appears to be that a porphyrin (Coproporphyrin III) produced within P. A porphyrin is a heterocyclic Macrocycle derived from four Pyrroline subunits interconnected via their α carbon atoms via Methine bridges (=CH- acnes generates free radicals when irradiated by 420nm and shorter wavelengths of light. In Chemistry, radicals (often referred to as free radicals) are atoms molecules or ions with Unpaired electrons on an otherwise Open shell [27] Particularly when applied over several days, these free radicals ultimately kill the bacteria. [28] Since porphyrins are not otherwise present in skin, and no UV light is employed, it appears to be safe, and has been licensed by the U.S. FDA. The United States of America —commonly referred to as the [29] The treatment apparently works even better if used with red visible light (660 nanometer) resulting in a 76% reduction of lesions after 3 months of daily treatment for 80% of the patients;[30] and overall clearance was similar or better than benzoyl peroxide. Unlike most of the other treatments few if any negative side effects are typically experienced, and the development of bacterial resistance to the treatment seems very unlikely. After treatment, clearance can be longer lived than is typical with topical or oral antibiotic treatments; several months is not uncommon. The equipment or treatment, however, is relatively new and reasonably expensive to buy initially, although the total cost of ownership can be similar to many other treatment methods (such as the total cost of benzoyl peroxide, moisturiser, washes) over a couple of years of use.

Photodynamic therapy

In addition, basic science and clinical work by dermatologists Yoram Harth and Alan Shalita and others has produced evidence that intense blue/violet light (405-425 nanometer) can decrease the number of inflammatory acne lesion by 60-70% in 4 weeks of therapy, particularly when the P. acnes is pretreated with delta-aminolevulinic acid (ALA), which increases the production of porphyrins. D-Aminolevulinic acid (dALA or δ-ALA or 5-aminolevulinic acid is the first compound in the Porphyrin synthesis pathway the pathway that leads to Hemoglobin in mammals However this photodynamic therapy is controversial and apparently not published in a peer reviewed journal.

Laser treatment

Laser surgery has been in use for some time to reduce the scars left behind by acne, but research has been done on lasers for prevention of acne formation itself. A laser is a device that emits Light ( Electromagnetic radiation) through a process called Stimulated emission. The laser is used to produce one of the following effects:

Since lasers and intense pulsed light sources cause thermal damage to the skin, there are concerns that laser or intense pulsed light treatments for acne will induce hyperpigmented macules (spots) or cause long-term dryness of the skin. Oxygen (from the Greek roots ὀξύς (oxys (acid literally "sharp" from the taste of acids and -γενής (-genēs (producer literally begetteris the

In the United States, the FDA has approved several companies, such as Candela Corp. The United States of America —commonly referred to as the , to use a cosmetic laser for the treatment of acne. [31] However, efficacy studies have used very small sample sizes (fewer than 100 subjects) for periods of six months or less, and have shown contradictory results. [32][33] Also, laser treatment being relatively new, protocols remain subject to experimentation and revision,[34] and treatment can be quite expensive. Also, some Smoothbeam laser devices had to be recalled due to coolant failure, which resulted in painful burn injuries to patients. [35]

Less widely used treatments

History of some acne treatments

The history of acne reaches back to the dawn of recorded history. In Ancient Egypt, it is recorded that several pharaohs were acne sufferers. From Ancient Greece comes the English word 'acne' (meaning 'point' or 'peak'). Acne treatments are also of considerable antiquity:

Future treatments

A 2007 microbiology article reporting the first genome sequencing of a Propionibacterium acnes bacteriophage (PA6) said this "should greatly enhance the development of a potential bacteriophage therapy to treat acne and therefore overcome the significant problems associated with long-term antibiotic therapy and bacterial resistance. Microbiology (from Greek grc μῑκρος mīkros, "small" grc βίος bios, " Life " and grc -λογία In classical genetics the genome of a Diploid Organism including Eukarya refers to a full set of chromosomes or genes in a Gamete, thereby The term DNA sequencing encompasses biochemical methods for determining the order of the Nucleotide bases Adenine, Guanine, Cytosine Propionibacterium acnes is a relatively slow growing typically Aerotolerant Anaerobic Gram positive Bacterium that is linked to the This article is about a biological infectious particle for other uses see Phage (disambiguation. Phage therapy is the Therapeutic use of Bacteriophages to treat Pathogenic Bacterial infections Antibiotic resistance is the ability of a Microorganism to withstand the effects of Antibiotics. "[53]

Preferred treatments by types of acne vulgaris

Acne scars

See Acne scarring. Acne scarring occurs when the visible remnants of Acne are permanently left on the skin after the acne itself subsides

Acne often leaves small scars where the skin gets a "volcanic" shape. Scars (also called cicatrices) are areas of fibrous tissue that replace normal Skin (or other tissue after injury Acne scars are difficult and expensive to treat, and it is unusual for the scars to be successfully removed completely.

Physical acne scars are often referred to as "Icepick" scars. This is because the scars tend to cause an indentation in the skin's surface. There are a range of treatments available. Most recently fractional lasers such as the Fraxel laser are becoming widely used as an effective treatment method[54].

Although quite rare, the medical condition Atrophia Maculosa Varioliformis Cutis results in "acne like" depressed scars on the face. Atrophia Maculosa Varioliformis Cutis (AMVC is a condition involving the spontaneous appearance of depressed Scars on the face occurring over a period of months to years


Ice pick scars - Deep pits, that are the most common and a classic sign of acne scarring.
Box car scars - Angular scars that usually occur on the temple and cheeks, and can be either superficial or deep, these are similar to chickenpox scars.
Rolling scars - Scars that give the skin a wave-like appearance.
Hypertrophic scars - Thickened, or keloid scars.

Pigmentation

Pigmented scars is a slightly misleading term as it suggests a change in the skin's pigmentation and that they are true scars; however, neither is true. Pigmented scars are usually the result of nodular or cystic acne (the painful 'bumps' lying under the skin). They often leave behind an inflamed red mark. Often, the pigmentation scars can be avoided simply by avoiding aggravation of the nodule or cyst. When sufferers try to 'pop' cysts or nodules, pigmentation scarring becomes significantly worse, and may even bruise the affected area. Pigmentation scars nearly always fade with time taking between 3 months to two years to do so, although rarely can persist.

On the other hand, some people—particularly those with naturally tanned skin—do develop brown hyperpigmentation scars due to increased production of the pigment melanin. In Dermatology, hyperpigmentation is the darkening of an area of Skin or nails caused by increased Melanin. Melanin is a class of compounds found in the Plant, Animal and Protista kingdoms, where it serves predominantly as a Pigment. These too typically fade over time.

Grading scale

There are multiple grading scales for grading the severity of acne vulgaris,[55] three of these being: Leeds acne grading technique: Counts and categorises lesions into inflammatory and non-inflammatory (ranges from 0-10. 0). 'Cook's acne grading scale: Uses photographs to grade severity from 0 to 8 (0 being the least severe and 8 being the most severe). Pillsbury scale: Simply classifies the severity of the acne from 1 (least severe) to 4 (most severe).

See also

Footnotes

  1. ^ eMedicine - Acne Vulgaris : Article by Julie C Harper
  2. ^ James WD (2005). A blackhead (medically known as an open comedo, plural comedones) is a yellowish or blackish bump or plug on the skin Keratosis pilaris (KP also follicular keratosis is a very common genetic follicular condition that is manifested by the appearance of rough bumps on the skin Rosacea (rəʊˈzeɪʃə is a common but often misunderstood condition that is estimated to affect over 45 million people worldwide Chloracne is an acne -like eruption of Blackheads Cysts and Pustules associated with over-exposure to certain Halogenated Aromatic Feline acne is a common problem seen in cats In most cases symptoms are mild and pass unnoticed "Clinical practice. Acne". N Engl J Med 352 (14): 1463-72. The New England Journal of Medicine ( N Engl J Med or NEJM) is an English-language Peer-reviewed Medical journal published PMID 15814882.  
  3. ^ Anderson, Laurence. 2006. Looking Good, the Australian guide to skin care, cosmetic medicine and cosmetic surgery. AMPCo. Sydney. ISBN 0 85557 044 X.
  4. ^ Thiboutot, Diane M. ; Strauss, John S. (2003). "Diseases of the sebaceous glands", in Burns, Tony; Breathnach, Stephen; Cox, Neil; Griffiths, Christopher: Fitzpatrick's dermatology in general medicine, 6th ed. , New York: McGraw-Hill, pp. 672-87. ISBN 0-07-138076-0.  
  5. ^ a b Goodman G (2006). "Acne and acne scarring - the case for active and early intervention" (PDF). Aust Fam Physician 35 (7): 503-4. PMID 16820822.  
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    One study has estimated the incidence of suicidal ideation in patients with acne as 7. 1% :
    * Picardi A, Mazzotti E, Pasquini P (2006). "Prevalence and correlates of suicidal ideation among patients with skin disease". J Am Acad Dermatol 54 (3): 420-6. doi:10.1016/j.jaad.2005.11.1103. A digital object identifier ( DOI) is a permanent identifier given to an Electronic document. PMID 16488292.  
  7. ^ Simpson, Nicholas B. ; Cunliffe, William J. (2004). "Disorders of the sebaceous glands", in Burns, Tony; Breathnach, Stephen; Cox, Neil; Griffiths, Christopher: Rook's textbook of dermatology, 7th ed. , Malden, Mass. : Blackwell Science, pp. 43. 1-75. ISBN 0-632-06429-3.  
  8. ^ F. Ballangera, P. Baudrya, J. M. N'Guyenb, A. Khammaria, B. Dréno Heredity: A Prognostic Factor for Acne 5/2/2005
  9. ^ US Dept Health and Human Services January 2005
  10. ^ National Guideline Clearinghouse 11/12/2007
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  15. ^ Anderson, Laurence. 2006. Looking Good, the Australian guide to skin care, cosmetic medicine and cosmetic surgery. AMPCo. Sydney. ISBN 0-85557-044-X.
  16. ^ Sweet news about chocolate. usaweekend. com (1998-06-05). Year 1998 ( MCMXCVIII) was a Common year starting on Thursday (link will display full 1998 Gregorian calendar) Events 70 - Titus and his Roman Legions breach the middle wall of Jerusalem in the Siege of Jerusalem Retrieved on 2007-05-27. Year 2007 ( MMVII) was a Common year starting on Monday of the Gregorian calendar in the 21st century. Events 927 - Simeon the Great, Tsar of Bulgaria, dies 1120 - Richard III of Capua is anointed
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  19. ^ JAMA Patient Page - Acne
  20. ^ Too much sugar turns off gene that controls the effects of sex steroids
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  24. ^ The iPLEDGE Program - Guide to Best Practices for Isotretinoin - "The resource to help the prescriber prepare, plan treatments, and prevent pregnancies during the course of isotretinoin therapy" (PDF) (2005).
  25. ^ Bernadine Healy. "Pledging for Accutane", US News Best Health, 2005-05-09. Year 2005 ( MMV) was a Common year starting on Saturday (link displays full calendar of the Gregorian calendar. Events 1457 BC - Battle of Megiddo (15th century BC between Thutmose III and a large Canaanite coalition under the King of  
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  31. ^ For Immediate Release
  32. ^ BBC NEWS | Health | Doubts over acne laser treatment
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  35. ^ Enforcement Report for January 14, 2004
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  54. ^ Zelickson, Brian; Fraxel Laser for Acne Scars
  55. ^ Leeds, Cook's and Pillsbury scales obtained from here

Further reading

Review articles and guidelines

Reference books and chapters

External links

Dictionary

acne vulgaris

-noun

  1. (pathology) An inflammatory disease of the skin, caused by changes in the pilosebaceous units.
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