Acne Diagnosis

  • Diagnosis

    Acne is an abnormal blockage in a pore that results in an inflamed lesion or non-inflamed "blackhead" on the surface of the skin Figure 01.

    Click to enlarge: Anatomy of the skin

    Figure 01. Anatomy of the skin

    Most people between the ages of 12 and 17 have some acne. Most cases of acne start between the ages of 8 and 13, when the body starts to produce increased amounts of hormones. The increase in hormone levels creates excess oil production and changes within the pore, which leads to acne. In most cases, acne resolves within five to ten years.

    Acne lesions usually occur on the face, but they can also occur on the neck, chest, back, shoulders, scalp, upper arms, and legs.

    Many people are able to manage their acne with over-the-counter treatments [Table 1].

    If you are not able to control your outbreaks with over-the-counter therapies, there are prescription drugs available to help you. For about 40% of adolescents, acne is a more serious condition that requires treatment by a physician. A doctor may prescribe topical therapy (cream, gel, or lotion) to be applied to inflamed areas. In some cases, oral antibiotic therapy is warranted.

    Occasionally, acne may persist into the late twenties, thirties, or beyond. Although acne affects young men and women equally, men are more likely than women to have severe, longer lasting forms of acne. Young women often experience mild to moderate acne that occurs during the week of their period.

    Plugged pores in the skin are the cause of acne. Acne usually emerges when adolescents enter puberty and their hormone levels begin to change. The hormones cause extra oil production and changes within the pilosebaceous unit that lead to acne. Acne occurs when the tiny hair follicles or pores (pilosebaceous units) become clogged. Inside the pilosebaceous unit is a hair and several sebaceous glands that produce a thick, oily substance called sebum. Sebum is the skin’s natural lubricant and softener. Under normal circumstances, the skin undergoes a process of renewal without any trouble—new cells replace the dead ones, and the sebum travels up the hair follicle, bringing the dead cells with it to be disposed of on the surface of the skin. However, during puberty, the hormones cause more sebum production, and dead cells are shed more quickly. The extra sebum increases the size of the pore, changes the inner lining of the hair follicle, and makes the skin appear oily. These changes may prevent dead skin cells from shedding normally. Usually, the dead cells inside the follicle are shed gradually, and are expelled onto the surface of the skin. However, in patients with acne, dead cells are shed more rapidly and tend to stick together. When they mix with sebum, they can form a plug in the follicle.

    The clogged follicle creates a perfect environment for breeding bacteria, which causes the inflammation and results in redness and pus. There are bacteria that exist on the surface of the skin normally, even in people who do not have acne. These bacteria can multiply as a result of the oil buildup around the hair. The bacteria break down the oil into very inflammatory chemicals that cause redness, pus formation, and pain.

    Types of acne lesions include nonscarring, noninflamed blackheads (e.g., comedomes) or whiteheads, or inflammatory lesions (such as pustules, papules, and nodules). As the lesions heal, scarring may occur Figure 02, Figure 03, Figure 04. Blackheads appear to have black debris within a dilated pore, while the whitehead is a lesion with a white top. The black of the blackhead is not due to dirt, but to a change in pigment in the blockage of the pore. Nodules are larger, often painful, and can become very inflamed deep under the surface of the skin. They take longer to heal, and have the potential to scar. Scars from acne lesions can be red and flat, and tend to not leave permanent marks on the face. Other kinds of scars, however, can be permanent, and leave the surface of the skin nicked or indented (depressed) where the lesion was.

    Click to enlarge: Mild acne on forehead of young girl

    Figure 02. Mild acne on forehead of young girl

    Click to enlarge: A mixture of comedonal and inflammatory acne

    Figure 03. A mixture of comedonal and inflammatory acne

    Click to enlarge: Severe popular, pustular and nodular acne

    Figure 04. Severe popular, pustular and nodular acne

    Because of the increased hormone levels in the body, being a teenager between the ages of 12 and 17 increases your chances of having acne.

    If your family members have certain types of acne, you may be predisposed to the condition also. Similarities exist among family members in the patterns of acne lesions, as well as the duration and severity of acne.

    Wearing cosmetics or using toiletries or hair care products that contain ingredients that cause the pores to clog (such as oil or talc) can put you at greater risk of developing acne. Some cosmetics, including makeup, foundation, night cream, and moisturizers, are called "comedogenic" because they cause pores to clog and acne lesions to form. Individuals should look for cosmetics and toiletries labeled as "noncomedogenic."

    If you are exposed repeatedly to an environment that promotes oil production and clogging of the pores, you are at risk for irritated acne-prone skin. Risky or comedogenic environments include places where you are exposed regularly to grease and oil (e.g., fast food restaurants, or a mechanic's shop). Rubbing and friction from clothing, hair, or sporting equipment may also irritate acne-prone skin. If you play sports, especially those that require a helmet, it is a good idea to wash your face before and after you play, and tie your hair back, because it contains oil. If possible, replace the pads on the inside of the helmet regularly and keep your hair clean, especially if you tend to break out on your forehead.

    If you are sensitive to seasonal changes and stress and are on medication for it, you may be prone to acne. In some cases, acne may be related to a drug prescribed for depression, seizures, or other mental illness. Certain other drugs can also increase the likelihood of developing acne. These drugs include lithium, isoniazid, halogens, phenytoin, and corticosteroids Ordinary, day-to-day stress is not enough to cause acne.

    Acne blemishes (e.g., whiteheads, blackheads, pimples, pustules, or cysts) occur wherever there are numerous oil or sweat glands, mainly on the face, chest, and back. The earliest lesions are usually mildly inflamed or noninflammatory blackheads on the forehead. More typical whiteheads develop on the cheeks, nose, and chin. The most common location for acne is the face.

    A dermatologist will examine your skin in a brightly lit room to determine the severity of your acne. Depending on how long you have suffered from acne, what types of lesions you have, and other factors, your doctor may prescribe topical ointments that contain benzoyl peroxide, salicylic acid, vitamin A derivatives (retinoids), or other agents.

    Your doctor will also review steps that you should follow in order to prevent further lesions from developing. It is recommended that you wash your face gently twice daily with a mild cleanser. Avoid touching your face, as your hands contain oil that can lead to more pimples.

    If you have severe acne, the doctor may offer you the option of injecting an anti-inflammatory medication (e.g., corticosteroids) directly into an inflamed acne lesion to aid in healing. The injection is quick, and can decrease swelling overnight in a lesion that might otherwise take over a week to heal.

    If you are born with a genetic predisposition to certain types of acne, you should initiate treatment early. If your parents or older siblings have had severe acne, you are more likely to have severe acne also. Therefore, you should consider seeing a dermatologist before the acne becomes severe.

    Avoid wearing cosmetics or toiletries that contain ingredients such as mineral oil that cause the pores to clog. Cosmetics, including makeup, foundation, night cream, and moisturizers, may clog pores and promote the formation of acne lesions. You should look for cosmetics and toiletries labeled as "noncomedogenic."

    Avoid repeated exposure to an environment that promotes oil production and clogging of the pores. Avoid places where you are exposed regularly to grease and oil (e.g., fast food restaurants or a mechanic's shop). Rubbing and friction from clothing, hair, and sporting equipment may also irritate acne-prone skin.

    Try not to touch your face, as your hands contain oil that can add to the problem. Do not pick at existing pimples, because that can lead to scarring and longer healing time. Like most people, it is likely that you absent-mindedly touch your face all day. Once you become aware of how often you rub your nose, forehead, or rest your chin in your hands while at your desk, it will be easier to catch yourself and get out of the habit. The oil on your hands can be transferred to your face and make your acne worse.

  • Prevention and Screening

    If you are born with a genetic predisposition to certain types of acne, you should initiate treatment early. If your parents or older siblings have had severe acne, you are more likely to have severe acne also. Therefore, you should consider seeing a dermatologist before the acne becomes severe.

    Avoid wearing cosmetics or toiletries that contain ingredients such as mineral oil that cause the pores to clog. Cosmetics, including makeup, foundation, night cream, and moisturizers, may clog pores and promote the formation of acne lesions. You should look for cosmetics and toiletries labeled as "noncomedogenic."

    Avoid repeated exposure to an environment that promotes oil production and clogging of the pores. Avoid places where you are exposed regularly to grease and oil (e.g., fast food restaurants or a mechanic's shop). Rubbing and friction from clothing, hair, and sporting equipment may also irritate acne-prone skin.

    Try not to touch your face, as your hands contain oil that can add to the problem. Do not pick at existing pimples, because that can lead to scarring and longer healing time. Like most people, it is likely that you absent-mindedly touch your face all day. Once you become aware of how often you rub your nose, forehead, or rest your chin in your hands while at your desk, it will be easier to catch yourself and get out of the habit. The oil on your hands can be transferred to your face and make your acne worse.

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