acne



CLINICAL PRESENTATION:  Acne is a disease which can occur infants between
the ages of one and six months,  however, becomes a common problem in the
pre-teen and teenage years of life.  About 40% of children will develop
acne between the ages of 8 and 10, although at this time it is usually
limited to the face.  About 85% of adolescents will eventually develop acne
to some degree.  The main areas of involvement are the face, shoulders,
back and chest.  The fundamental cause of acne (acne vulgaris) is unknown.
Foods such as sugar and chocolate, soaps, and environmental factors have
little to do with causing acne or with having an effect on its course.
A family history of acne is a strong factor.  At puberty, sebaceous
follicles are stimulated by androgens (male hormones), produced by both
sexes, but clearly more abundant in males.  Excessive, and possibly
abnormal sebum is produced, plugging the glands, irritating them, and
exposing them to common skin bacteria resulting in more inflammation and
infection.

Plugging of the mouth of the sebaceous follicle results in the common
blackhead (open comedone).  This plugging is by cells of the most
superficial layer of the skin (strateum corneum).  The color pigment of
the skin (melanin) undergoes a chemical reaction (oxidation) resulting
in the black color.  Blackheads are the simplest of acne lesions.  When
the sebaceous follicle is plugged below the neck of the follicle, this
produces a swelling (nodule) just beneath the skin.  As more and more
skin elements are deposited in this swelling, it enlarges.  This makes
it more susceptible to inflammation and infection, and, if not controlled,
may lead to scarring.  These scars are initially reddened due to lots of
blood vessels in them from the inflammation.  In time, many will fade
back into normal skin color.  These acne nodules suggest the need for
medical attention.

TREATMENT:  Topical agents to remove the most outermost layers of the skin
(keratolytic agents) are the primary method of treatment.  Benzoyl peroxide
gel and tretinoin (retinoic acid) are the most potent.  Either may be used
alone, once daily, or a combination of retinoic acid used at bedtime and
benzoyl peroxide gel applied once daily in the morning will control about
80-85% of adolescent acne.

Topical antibiotics may also be used, the most common being clindamycin and
erythromycin.  These are used mainly to avoid some of the potential side
effects of antibiotics taken orally.  In comparison, these are usually no
better than a small dose of oral antibiotics.

Tetracycline, a close relative called minocycline, and erythromycin are oral
antibiotics that are concentrated in sebum and are very effective in
inflammatory acne.  The usualy dose of tetracycline and erythromycin is
500 mg to 1 Gm taken once or twice daily on an empty stomach (one hour
before meals).  (The dose of minocycline is 100-200 mg daily.)  The
antibiotics should be continued for 2-3 months until the acne lesions
come under control.

For the most severe cases, isotretinoin (Accutane) may be utilized.  Its
exact mechanism of action is not fully understood, but there are reports
of decreased sebum production, decreased follicular obstruction, decreased
skin bacteria, and some general anti-inflammatory  activity.  It is
definitely not useful in simple comedone acne.  Dry lips, dryness and
scaliness of the skin are common side effects.  Up to 10% of patients have
some mild reversible hair loss.  There are potential changes in liver
functions and lipids (fats in the blood).  Finally, it produces abnormalities
of the developing embryo and must be utilized with strict adherence to
the manufacturer's guidelines regarding adequate birth control beginning
before starting the drug and for a period of time after discontinuing
its use.  In my opinion, this is a drug which should only be prescribed
by physicians having the experience, or the interest to gain the experience,
in its usage.

PATIENT EDUCATION AND FOLLOW-UP:  It is important to recognize that treatment
of acne is not an overnight success.  There will not be much improvement
for the first 4-8 weeks.  There is no absolute control.  The best that may
be accomplished is to minimize the new lesions to  1-2 new pimples per month.
A more realistic control would be only a few lesions every two weeks.
Generally speaking, follow-up visits should be made every 4-6 weeks until
the condition is stabilized.

[Editor's Note:  As I wrote and rewrote this article, I have tried, when
possible, to simplify the language.  But as I read and reread what I have
written, I realize how hard it is for me to write at a level easily
understood by the early adolescent.  I make my apologies now, and if there
are any questions about this article, please send me a message on the forum.