Acne Vulgaris

Learn about acne vulgaris. From its causes, triggers, symptoms to its treatment, Dr Lim provides useful self-help tips and the latest medical treatments available. Alternatively, watch Dr Lim’s video on acne vulgaris.

Watch Dr Lim’s video on Acne

Acne vulgaris or acne is the medical term for pimples. It usually begins in puberty in both sexes when the adrenal glands (which sit on top of the kidneys) and sex organs start producing androgens (male hormones). Acne is most common between the ages of 16 – 18 and becomes less common thereafter. However, about 1 in 5 adults, especially women continue to be troubled by acne, although it is usually less severe.

Causes
The main causative factors are:

  1. Increased sebum (skin oil) production by the sebaceous glands (skin’s oil-glands) under the influence of endogenous and exogenous androgenic hormones.
  2. Hyperkertinisation causing blockage of the hair follicles (skin pores), resulting in comedones (whiteheads and blackheads).
  3. Proliferation of Propionibacterium acnes (the acne bacteria) which converts sebum into irritating fatty acids.
  4. Inflammation caused by the seepage or release of irritating fatty acids into the dermis, resulting in inflamed papules (red bumps) or pustules (“pusheads”) and in some patients, nodules (deep and sometimes painful swellings that look like boils). .

Learn about the triggers of acne vulgaris

  • Family history of severe acne.
  • Stress.
  • Hot, humid environment.
  • Hormones – pre-menstrual flares are common in females.
  • Friction from headbands and chin straps.
  • Polycystic ovary syndrome (PCOS) which produce androgenic (musculinising) hormones.
  • Excessive production of corticosteroids (Cushing’s syndrome).

Symptoms

  • Comedones – open comedones (blackheads due to oxidized melanin) and closed closed comedones (whiteheads).
  • Papules are inflamed bumps less than 1 cm in size
  • Pustules are papules toped by pus (pusheads)
  • Nodules are papules 1 cm or larger in size (can be painful and look like boils).
  • Cysts are fluid filled nodules
  • Seborrhoea (increased oiliness) is often present and can be very annoying.
Papules and pustules

Learn about the less common types of acne vulgaris

  • Acne neonatorum is a form of acne in neonates characterized by closed comedones due to maternal androgens.
  • Comedogenic acne is characterized by comedones (blackhead and whiteheads).
  • Acne conglobata is the unusually severe type of acne characterized by pustules, nodules and cysts and abscesses. It can cause severe skin scarring.
  • Acne fulminans is characterized by haemorrhagic, ulcerating, and painful acne lesions associated with systemic symptoms such as polyarthritis (joint pains) and fever. It can occur in some patients treated with isotretinoin and those taking anabolic steroids.
  • Adult acne is acne that occurs in an individual aged 25 years or more. Adult acne is more common in females. It may be triggered by hormone fluctuations during pregnancy, menstrual cycle and menopause, stress, drugs and cosmetics.
  • Acne aestivalis is a form of acne that is caused by the interaction between ultraviolet light and chemicals in sun blocks and other cosmetic products. It usually affects the chest and armpits rather than the face.
  • Acne excoriee is a form of acne exacerbated by picking, squeezing or popping, which may lead to scarring.
  • Acne medicamentosa is caused by medication such as lithium (used to treat manic-depressive states), barbiturates, phenytoin (anticonvulsant for epilepsy or fits), iodides, anti-tuberculous drugs (ethionamide, rifampicin, isoniazid), systemic corticosteroids, testosterone and anabolic steroids (sometimes abused by athletes and body-builders) and excessive vitamins D, B6 and B12 . It generally improves after discontinuation of the causative medicines. New chemotherapeutic drugs for cancer such as the epidermal growth factor receptor inhibitors (EGFRi).
  • Acne cosmetica is also called make-up acne and cosmetic acne, and arises when comedogenic agents in some cosmetics react with the skin. These agents clog the sebaceous glands and cause acne. It usually subsides when the product’s use is discontinued.
  • Chloracne is a form of acne caused by occupational exposure to acne causing chemicals such as mineral oil and halogenated aromatic hydrocarbons, including dioxin.

Complications

  • Discolourations – post-inflammatory erythema (red marks from recently healed spots), post-inflammatory hyperpigmentation (dark marks from healed spots). Discolorations generally heal on their own over time but can be treated if desired.
  • Scars – ice pick scars, box-car scars, rolling scars and keloids. Scars are more difficult to treat than acne, hence acne should be treated early. See acne scars.
  • Psychological problems such as anxiety, depression and loss of self-esteem.

Acne severity can be assessed with the GAGS (Global Acne Grading System)

What you can do

  • You should learn everything you can about acne vulgaris.
  • Home treatment with topical keratolytics (peeling agents) containing benzoyl peroxide, sulphur or salicylic acid can be used but stop if irritation occurs.
  • Do not pick or squeeze acne as this causes more inflammation and increases the risk of scarring and a condition known as acne excoriee.
  • Emotional stress can worsen acne. Learn to cope with stress.
  • Some drugs can make acne worse. Check with your doctor.
  • Many cosmetic ingredients can cause acne so switch products if you notice more acne appearing.
  • Avoid using moisturisers routinely. If you must, use only water-based moisturisers and check that the label says “non-comedogenic” or “non-acnegenic”.
  • The use of make-up is permissible if they are water-based or oil-free and non-comedogenic.

Diagnostic tests
Acne can be diagnosed clinically and tests are usually unnecessary. In selected cases however, the doctor may order blood tests to exclude excessive hormones, pelvic ultrasound to exclude polycystic ovaries in women or take swabs for bacterial culture.

Treatment
Acne vulgaris is treatable and early treatment of inflammatory acne is important to prevent unsightly scars and psychological morbidity. However, treatment may be prolonged, spanning months or even years and relapses are common, especially in adolescents and may require repeated treatments.

Topical treatment for mild acne
Topical retinoids are useful for both inflammatory acne and non-inflammatory comedogenic acne. They can be used alone in combination with the antibiotics. Examples include tretinoin and adapalene. Retinoids prevent the new pimple formation as well as decrease the number of pimples and can be used as maintenance following treatment. It is important to avoid heat and sun exposure while using retinoids because they can increase the sensitivity to sunlight.
Topical antibiotics are useful for mild to moderate inflammatory acne. Examples include erythromycin and clindamycin. Bacterial resistance may occur especially with erythromycin.
Benzoyl peroxide is effective for mild acne treatment and there is no risk of it inducing bacterial resistance. It is often combined with oral and local antibiotics in order to reduce the risk of bacterial resistance. Salicylic acid is also useful for treating comedones.

Oral treatment of moderate acne
Oral antibiotics are useful for inflammatory acne. Commonly used antibiotics include erythromycin and tetracycline family of antibiotics including minocycline and doxycycline. Erythromycin is preferred in pregnancy, during breat feeding and in children under the age of 11 years. Trimethoprim-sulfamethoxazole is used as a third line agent when resistance to erythromycin or tetracycline is suspected or contraindicated. Acne requires 3 – 4 months of treatment. Relapses do occur and if frequent, patients may be continued on topical treatment for a longer duration.

Oral treatment of severe acne
Isotretinoin (Roaccutane) is very effective for persistent acne or severe acne that has shown poor response to other treatments. Isotretinoin is particularly effective as it acts against the 4 main causes of acne. Dryness is a common side effects. Pregnancy must be avoided as it causes severe malformation in the fetus. Other common side effects include headaches, muscle pains, gastrointestinal upset, and dryness of eyes and of mucous membranes of nose and mouth, increase in blood lipids (fats) and liver enzymes.

Hormonal therapy is also effective in severe form of acne such as cystic acne or nodular acne. Spironolactone, oral contraceptives, and a combination of ethinyl oestradiol and cyproterone acetate are all recommended hormonal therapies for the treatment of acne. Spironolactone decreases production of sebum and improves acne and is mainly reserved for females who cannot use isotretinoin. Oral contraceptives reduce the production of ovarian androgens and treats acne, particularly the nodular one. Estrogen containing oral contraceptives are generally considered for treatment of acne in females with perimenstrual flare-ups or adult-onset acne. Pregnancy should be avoided while using these hormonal therapies, especially with cyproterone owing to its potentially harmful effects on the fetus.

  • Other treatments include
  • Light therapy using blue wavelength (watch video on Forever Clear BBL below), photodynamic therapy (PDT) to destroy Propionibacterium acnes bacteria.
  • Chemical peels (retinoic acid & glycolic acid)
  • Intralesional steroids (triamcinolone injections)
  • Microdermabrasion
  • Manual extraction of comedones