As I started to do my physical exam on Matthew, I was struck by how much he had grown these past few years. At 16 years of age, he was a young man, nearly as tall as me. And while he was here for a sports physical, both Matthew and his mother were deeply concerned about his acne.
Matthew is a polite and happy individual, but as his mother spoke, he put his head down and appeared embarrassed. "Nothing works! His acne is getting worse and his face looks awful," she went on, oblivious to the fact that Matthew rolled his eyes and looked down.
"I won't let him eat pizza, chocolate, mayonnaise or drink Cokes...just like the books say. We've tried medicated pads, special soaps and buff puffs, but nothing helps. He is such a good looking boy, but LOOK at his face," she continued. By now poor Matthew's face was flushed red, and he looked as if he wanted a hole to crawl in.
Sensing his predicament, I asked Matthew if he knew what acne truly was, and if he knew what caused it. There was a long pause during which time it seemed appropriate to discuss acne. Matthew shifted is his seat, sat straight-up and listened intently. So did his mother.
Acne is a very common skin disorder that affects nearly 85% of all people between the ages of 12 and 25 years. It affects individuals differently and in varying degrees. It typically starts 1-2 years before the onset of puberty. Acne involves the oil gland ducts, or sebaceous glands of the skin that are located near the hair follicle. These make up the pilo-sebaceous unit (see Fig.1).
There are four major factors that are key in the genesis of acne: 1) There is an increased "stickiness" and hardening of the dead cells that line the sebaceous duct which plug the opening of the gland. 2) There is an increased production of the fatty substance produced by the glands that oil the skin known as sebum. 3) There is a proliferation of a particular bacteria Proprionobacter acne (P. acne) that plays an important role in the inflammatory reaction of acne. 4) There is inflammation of the gland itself.
Sebum, a substance that is made of triglycerides and waxy esters, is produced by the body to oil and protect the skin. P. acne produces an enzyme that breaks down the triglycerides into free-fatty acids which are essential in the inflammatory process of the pilo-sebaceous unit. P. acne also produce substances which damage the lining of the gland that further enhances the inflammation and causes the migration of white blood cells to the area to "fight" the inflammation. This leads to the formation of pustules.
The two major lesions seen in acne are blackheads and white heads. The blackhead, or open comedone, is caused by a plugging of the gland with thickened and keratinized cells, and an overabundance of sebum. The dilated and plugged pore takes on a blackened color. Contrary to popular belief, the black color is NOT caused by dirt or poor hygiene. It is felt to be due to the presence of melanin, the skin's pigment (see Fig. 2).
The whitehead, or closed comedone, occurs when the glands opening is closed over. The contents in the gland become trapped inside. The gland continues to produce sebum which the P. acne breaks down into free-fatty acids. The walls of the gland are destroyed and burst, releasing the contents into the surrounding tissue. The body tries to "wall-off" the inflammation by increasing the number of white blood cells to the area. This causes the formation of pus with a resulting pustule being formed (see Fig. 3).
In more severe cases, the pustules can progress to form thickened nodules and cysts which can lead to permanent scarring. The severity of scarring depends on the degree and depth of the inflammatory reaction.
Acne typically involves the face, chest, shoulders and back. It tends to be worse in the winter months. Milder forms of acne usually respond well to treatment and do not leave scars.
When discussing the treatment of acne, it is imperative to address the emotional impact this disorder has on the patient. Few teenagers are willing to discuss their frustration or concerns about acne, but it can tremendously affect their lives. They are very appreciative to time and interest spent discussing their concerns...if someone will just listen and not harangue them. I noticed a big change in Matthew as we talked about acne. He was not the least bit intimidated about asking questions, and clearly showed that he was interested in learning about his problem.
When I mentioned that diet has not been shown to have any relevance on the worsening of acne, his mother was somewhat dumbfounded. He flashed her a victorious grin and said, "I TOLD you!". I reaffirmed that substantial data has shown that dietary restriction was of no value.
Over the years, there has been a myriad of over the counter items such as medicated pads, abrasives, special soaps, astringents, ultra violet light and iodine containing preparations available for the treatment of acne. Some of these do cause superficial peeling or drying of the skin, or do remove excess sebum. Few, if any, prevent new lesions from forming or prevent them from getting worse. One of the reasons for this is that these agents are unable to get inside the gland where the sebum is trapped along with the P. acne.
The major agents used today in the treatment of acne are:
Benzol Peroxide - this is available as a wash or a gel. It's main mode of action is felt to be the inhibition of P. acne. It also helps in the unplugging of the pore and decreases the formation of free-fatty acids. There are mild forms which are available over the counter, but the most effective are the gel preparations which do require a prescription. Benzoyl peroxide can be drying and irritating to the skin. It is important to apply thinly, and start with a mild concentration and gradually increase the strength as tolerated.
Tretinoin - this is a preparation of Retinoic acid and vitamin A. It comes as a liquid, a cream or a gel. It is very effective in unplugging or "disimpacting" the plugged follicle and keeping them open. It is probably the single most effective agent in the treatment of comedomal acne. It can irritate the skin, and can also cause significant peeling. One should start with a mild form and start with every other night applications. If tolerated, the frequency, and then the strength can be increased.
Systemic Antibiotics - in certain cases, long term use of oral antibiotics may be necessary to control acne. The antibiotics decrease the numbers of P. acne within the glands. The antibiotics usually used are tetracycline, erythromycin, doxycycline and minocycline. The goal with their use is to get control of the acne, and then taper the amount of antibiotic necessary to achieve the desired results. Long term use of these antibiotics has not been shown to carry any risks.
Accutane - this is a very potent drug that is reserved for severe pustulo-cystic acne where the formation of nodules and scarring is a concern. It has a number of potential serious side- effects, and is only used in selected cases. One of the most serious side-effects is a high incidence of birth defects when used during pregnancy. The manufacturer recommends that women of child bearing age, who needs Accutane, be on oral contraceptives one month before starting the drug, during, and for one month after stopping Accutane. Accutane can give "miraculous" results, but it's use should be limited to individual cases.
Topical Antibiotics -there are antibiotics available that can be applied to the skin. These come in solutions, lotions and gels and are helpful in inhibiting the growth of the P. acne. These are usually used in milder forms of acne, and are often employed in combination with a benzoyl peroxide or a retinoic acid preparation.
After our discussion of acne and it's treatment, Matthew was a different person. He was animated and in good spirits. He said that for the first time he felt as if there was hope. He was glad to know that his acne was not something he would just have to "live with".
We worked out a regimen for him to follow, knowing that we would have to make changes along the way. I stressed that the goal was to use the least amount of medicine to achieve clear skin. He knew that this would take time, and that there would be times when his acne flared-up. But he also knew that this could be dealt with. When we finished, he stood up and gave me a firm handshake. Looking at my watch I realized that I was 30 minutes behind schedule. It was worth every minute.