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Acne Vulgaris



MD- Wm Medicalpark Maltepe Hospital, Department of Dermatology

"Acne vulgaris is the most common skin disease in adolescence and young adulthood, affects the quality of life, and can be treated, although it can be recurrent."

Akne Vulgaris

What is acne vulgaris?

Acne is a chronic inflammatory skin disease that usually starts in adolescence and the face, neck, upper back, chest and shoulders are the most common sites affected where hormone-sensitive sebaceous glands are dense. While acne disappears in adulthood for most patients, it can persist into adulthood for others. Clinical manifestations are open and closed comedones (white and black spots), and inflammatory lesions* such as raised papules, pustules, and nodules. There may be pain and tenderness in the lesions. Acne lesions can cause problems such as skin discoloration and scars while healing. Since the findings are seen especially in the face area, they may have negative psychological and social effects.
*Lesion: A medical term that generally refers to pathological, abnormal changes that occur in the body or in an area of the organism.

Prevalence of acne

A 2010 global burden of disease study showed that acne affects 9.4% of the world's population and is the eighth most common disease of all diseases. Although the incidence of acne varies according to different countries and age groups, the incidence of acne in adolescents varies between 35% and 100%. 
Acne formation begins with increased sebum production with puberty. It occurs at an earlier age in girls than in boys due to the early onset of puberty. But in general, acne is more common and more severe in men. Acne improves over time in the majority of patients. However, it can persist in adulthood in some of the patients. Persistent acne is more common in women.

Clinical manifestations of acne

The diagnosis of acne is based on clinical findings. Acne lesions are divided into non-inflammatory and inflammatory lesions. Non-inflammatory lesions: They are closed and open comedones. Closed comedones, also known as white spots, are skin-colored dome-shaped bumps formed by the blockage of the tip of the hair follicle. Open comedones, also known as blackheads, are bumps with large follicle openings filled with keratin in the middle. Inflammatory lesions: Papules, pustules, and nodules. Papules are pink bumps. Pustules are filled with pus are yellow in the middle and have red bumps at the base. Nodules are bumps that look like papules but can be larger and painful.

While acne lesions heal, they can have consequences such as scarring. Most often, atrophic scars from the skin are seen. Apart from this, hypertrophic scars, dark spots, and redness can also be seen on the skin. 

Are laboratory tests necessary?

Routine laboratory tests are not recommended for acne. However, hormonal tests should be performed in patients with symptoms such as menstrual irregularity, hirsutism, androgenic alopecia or recalcitrant acne. In particular, polycystic ovary syndrome and acne can be seen together 

What are the factors that cause acne?

There are four main events in the formation of acne: 1) Increase in sebum production with the activity of androgens 2) Formation of comedones with the proliferation of keratinocytes 3) Inflammation in the pilosebaceous follicle 4) Bacterial colonization. 
Genetic and environmental factors are effective in the formation of acne. The presence of a family history of acne increases the risk of acne formation. Environmental factors that affect the formation of acne are diet, stress, sleep, use of cosmetics and medications [3].
In a review on acne and diet, western diet, use of cow's milk, whey protein and vitamin B12 supplements increased acne; A low glycemic index diet, omega-3 and omega-6 supplements have been suggested to reduce acne [7].
Oily cosmetic products used for the face and hair can trigger acne formation. Too much use of washing products, such as soap used to wash the face, can also irritate the skin and cause acne.
Birth control pills, lithium and steroids can cause acne breakouts 

Acne Treatment

Topical treatments, systemic antibiotics, hormonal therapy, isotretinoin, peeling, laser, light systems and radiofrequency can be used according to the severity and type of acne. 
Topical treatments: Topical retinoids, benzoyl peroxide, antibiotics, salicylic acid and azeleic acid. Topical treatments can be used alone or in combination with other topical and oral treatments for mild to severe acne. It can also be used in maintenance treatments. At the beginning of the treatment, there may be irritation side effects such as redness and burning [6,9].
Systemic antibiotics can be used in moderate and severe acne. Tetracyclines (doxycycline, minocycline) and macrolides (azithromycin, erythromycin) are the most commonly used antibiotics in acne. Topical benzoyl peroxide use in combination with antibiotic therapy reduces antibiotic resistance [6,9]. 
Hormonal therapy may be preferred in late-onset acne in female patients, in cases where there is no response to conventional treatments, or if it is accompanied by hormonal abnormalities (such as polycystic ovary syndrome). Combined oral contraceptives, spironolactone, cyproterone acetate and flutamide are drugs used in hormonal therapy [6,9].
Isotretinoin is a very effective drug of choice in moderate and severe acne, in cases where there is no response to systemic treatments, and in patients who are prone to scarring. The most important side effect of this drug, which has been used since 1982, is teratogenicity. For this reason, it should be used in women of childbearing age with pregnancy test follow-up [6,9]. 
Although laser, light systems and radiofrequency are not first-line treatments for acne, they can be preferred to support other treatments or in cases where systemic treatment cannot be used. 

Acne scars and their treatment

Scarring may occur during the acne healing process.  Most frequently, atrophic scars are seen. Hypertrophic scars, dark spots and rashes can also be seen. In addition to individual factors in scar formation, many factors such as delay in starting treatment, recurrent acne, acne starting in adulthood and a family history of acne scars increase the risk of scarring. In order to reduce the risk of scar formation, medical treatment should be started immediately. Lesions should not be squeezed by hand. Most of the time, despite compliance with treatment, scar formation may be inevitable. While acne treatment continues, scar treatments can also be started [10].
A wide variety of treatments such as surgical treatments (subcision, punch, excision), chemical peeling, microneedling, radiofrequency, laser treatments, fillers and mesotherapy can be used alone and in combination in acne scar treatments 

Preventing acne

● Daily cleansing: In the evening, the skin should be free of make-up products and cleaned with a non-irritating product suitable for the skin. Depending on the oily condition of the skin, a washing product can also be used in the morning routine [11].
● Applying tonic after cleansing the skin reduces sebum production.
● Ingredients that balance sebum and reduce the risk of comedone formation can be used in consultation with your doctor. These are agents such as alpha hydroxy acids (glycolic acid, lactic acid), beta hydroxy acids (salicylic acid) and retinol.
● Moisturizing: Noncomedogenic, water-based and oil-free products should be preferred. Oily skin also needs moisturizing.
● Sunscreens should be used in a daily routine to minimize the effects of ultraviolet.
● Matte or semi-matte foundations and transparent powders for cosmetic concealer purposes can be preferred.
● When oily hair comes into contact with our face, it can increase the formation of acne, it should be washed regularly to purify the oil in the hair.

Myths about acne

1. Acne is caused by the face being dirty. 
No. In acne, the sebum production of the skin is increased. However, washing the face more than twice a day may do more harm than good.
2. Acne is a disease of the liver. 
No. Acne is the primary disease of the pilosebaceous glands. It has nothing to do with liver diseases.
3. Acne only happens in adolescence and heals. 
No. It may persists in adulthood in some of the patients.
4. Squeezing acne allows them to heal quickly. 
No. Squeezing acne lesions increases the risk of irritation and bacterial infection, causing scarring.
5. People with acne cannot wear makeup. 
No. People with acne may prefer non-greasy make-up products to cover their lesions.

Summary

Acne vulgaris is a chronic skin disease that most people encounter at some point in their lives, most commonly diagnosed and treated by dermatologists. It is most common in adolescence and young adulthood.
 The clinical presentation is in the form of a wide variety of lesions such as open and closed comedones, papules, pustules and nodules in areas where sebum production is intense, especially on the face. Since it affects the physical appearance, it may have negative psychosocial effects on patients. Therefore, acne must be treated. Treatment is determined by the age of the patient, the severity of acne, and the type of acne. Regular use of topical or systemic treatments is important. Since acne is a chronic disease, follow-up treatments are required after the treatment of active lesions. Scar treatments may be required in some patients after treatment. It is important to follow the skin care routine during and after the treatment. Regular cleaning and moisturizing of the skin, and not squeezing acne increase the success of the therapy.

1.         Williams HC, Dellavalle RP, and Garner S, Acne vulgaris. (2012).

2.         Vos T, et al., Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. (2012).

3.         Heng AHS and Chew FT, Systematic review of the epidemiology of acne vulgaris. (2020).

4.         Heath CR and Usatine RP, Acne vulgaris. (2021).http://europepmc.org/abstract/MED/34818170

https://cdn.mdedge.com/files/s3fs-public/JFP07009356.PDF

https://doi.org/10.12788/jfp.0271

5.         Clark AK, Saric S, and Sivamani RK, Acne Scars: How Do We Grade Them? (2018).

6.         Reynolds RV, et al., Guidelines of care for the management of acne vulgaris. (2024).

7.         González-Mondragón EA, et al., Acne and diet: a review of pathogenic mechanisms. (2022).

8.         Titus S and Hodge J, Diagnosis and treatment of acne. (2012).

9.         Fox L, et al., Treatment Modalities for Acne. (2016).

10.       Boen M and Jacob C, A Review and Update of Treatment Options Using the Acne Scar Classification System. (2019).

11.       Conforti C, et al., Topical dermocosmetics and acne vulgaris. (2021).