Adult acne

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The quest for perfect skin is almost as elusive as the search for eternal youth. For most of us, the blackheads and pimples of adolescence aren't entirely a thing of the past; they can erupt premenstrually, flare during pregnancy, and return in full force during menopause. And for 10-20% of women, acne persists for decades.

Acne's origin
Common acne, or acne vulgaris, like most other medical conditions, has a broad spectrum of symptoms. (Although often confused with acne rosacea, which is usually accompanied by flushing and tiny broken vessels, it has a different cause.) Generally, common acne is classified as mild, if it consists exclusively of blackheads or whiteheads; moderate, if it includes closed, pus-containing pockets; and severe, if large nodules or cysts have formed.

Acne begins in pilosebaceous units, which consist of sebaceous glands and a single hair follicle. The sebaceous glands produce a clear, oily liquid called sebum that has two roles: to lubricate the skin and to flush out the debris that results when cells within the follicle die and are replaced. The follicle is home to microscopic organisms, particularly a bacterium, Propionobacterium acnes, which breaks sebum down into fatty acids.

When sebum is overproduced and the rate of cell turnover increases, as is often the case in adolescence, a sticky debris builds up in the follicle. The pore is blocked and P acnes proliferates. What we see is a blackhead or whitehead, or in medical terms, an open comedo or closed comedo.

If the pocket of sebum, bacteria, and debris becomes too large, the follicle will rupture, spilling its contents into the surrounding tissue. As the body's immune system tries to clean up, chemicals are released that damage these tissues. Pimples (also called papules and pustules) as well as cysts and abscesses--all of which contain dead white blood cells, bacteria, sebum, and blood serum--are byproducts of inflammation. Eventually, fibrous tissue is laid down to replace damaged cells, often forming a scar.

It isn't clear precisely what initiates this process. Sebum production is thought to be stimulated in puberty by androgens--hormones that in women are released by the adrenal glands--and there is some evidence that in older women acne results from a drop in estrogen levels.

Treatment
Acne treatments are usually directed at destroying P acnes and other bacteria, slowing the cellular turnover inside the follicular canal, and reducing the production of sebum. Regardless of the form of treatment, it usually takes at least 2-3 months to have any effect, and in some cases, the condition may worsen before it improves. The following techniques are commonly used.

Salicylic acid, sulfur, or resorcinol: These nonprescription lotions, creams, or gels are used to treat mild acne. Although they can't prevent new blackheads or whiteheads from springing up, they can cause existing ones to dry and peel.
Benzoyl peroxide: This is probably the most effective nonprescription topical preparation. Available in several strengths as a lotion or gel, it inhibits the growth of P acnes and slows the development of new lesions. It is sometimes used in conjunction with topical antibiotics because it helps to prevent skin bacteria from becoming resistant to their effects. Because benzoyl peroxide can irritate the skin, it's best to start with the weakest preparation and progress to stronger ones as needed.
Retin-A (tretinoin): This topical vitamin A derivative is very effective in the treatment of comedones, papules, and pustules. It increases the production of slick-surfaced cells along the follicle walls, which dislodge the impacted sebum and allow it to flow to the skin's surface. Retin-A can trigger a proliferation of blemishes, which subsides after the first few weeks of treatment. It also causes peeling, redness, and an increased sensitivity to sunlight. Because of a theoretical link with birth defects, it may not be advised for pregnant women.
Topical antibiotic solutions or lotions: Available by prescription, preparations such as clindamycin, erythromycin, or tetracycline can not only inhibit bacterial growth, but can also decrease the number of inflamed papules. A combination of topical erythromycin and benzoyl peroxide (Benzamycin gel) may be more effective than either alone.
Oral antibiotics: Tetracycline, minocycline, and doxycycline, which inhibit the growth of P acnes, are the preferred treatments for moderate acne. Because antibiotics don't slow sebum production or reduce the number of comedones, it's also necessary to use topical preparations as well. All have some side effects: they make the skin more sensitive to the sun and pave the way for vaginal yeast infections. Because they discolor forming teeth, they shouldn't be used during pregnancy. Erythromycin, another antibiotic, may be a good alternative, but it isn't as effective and can cause abdominal cramping.
Accutane (oral isotretinoin), which shrinks the sebaceous glands to curtail sebum production, is the treatment of choice for severe acne that hasn't responded to very high doses of tetracycline or erythromycin. About 40% of patients treated with Accutane are cured after one or two 4-5 month courses of treatment; another 21% require only topical medications to keep the condition under control; the rest may need oral antibiotics.
However, relief doesn't come without a price. Accutane has several noteworthy side effects. Because it has been linked with birth defects, women of childbearing age must have a negative pregnancy test before beginning treatment and use reliable contraception for a month prior to therapy, during treatment, and for 2 months afterward.

Most patients taking Accutane experience some or all of the following, most of which are reversible: conjunctivitis (pink eye), inflamed lips, nosebleeds, and abnormally dry skin, eyes, and mouth. Less common adverse reactions include difficulties with night vision, elevated blood lipids, abnormal liver function, and increased numbers of platelets, which are involved in blood clotting.

Estrogen: High doses of ethinyl estradiol can treat severe acne by suppressing sebum production.
Comedo extraction: The technical term for picking one's face, comedo extraction involves squeezing, pressing, or gouging the blemish, either with the fingernails or with commercially available instruments. Mother was right when she warned us against the practice because it can trigger inflammation, turning a relatively benign blackhead or whitehead into a pustule, which can leave a scar. Unfortunately, comedo extraction has been incorporated into many professional facials. If you're going to treat yourself to a salon session, ask the cosmetologist to skip this feature. If a lesion won't drain on its own, have a doctor do it.
Treatments for scars
While moderate acne can leave some scars, most red or brown discolorations eventually diminish without treatment in a few months to several years. However, scarring from more severe acne is usually permanent. In most cases, treatment can only reduce scars; it can't eradicate them.

The most common approach to superficial skin damage is collagen injection, which raises shallow scars to the level of the surrounding skin, and chemical peels, in which glycolic acid removes the top layer of skin to reduce pitting.

Deeper scars may require a type of plastic surgery called dermabrasion, in which the patient is sedated and the affected skin is frozen with a refrigerant spray. The skin is then planed with a hand-held device consisting of rotating wire brushes or stainless steel wheels to which industrial diamonds are bonded. If scars are very deep, the surgeon may need to remove the fibrous tissue and fill the depressions with skin taken from behind the ear. Once these skin grafts have healed, dermabrasion can be used to smooth the surface.

Caring for your skin
Medicine has yielded no sure ways to prevent acne, but these measures may help:

Washing the affected areas once or twice a day with a mild soap recommended by your dermatologist. Avoid abrasive cleansers and masks.
Reading product labels. Use only make-up and moisturizers labeled "noncomedogenic."
Shampooing. Use an antiseborrheic shampoo to wash your hair and scalp; wear hair away from your face.
Eating well. Research has not demonstrated a connection between acne and chocolate or any other food, but eating a balanced diet and eliminating any items you believe will trigger outbreaks could help.
Sunning. Some doctors recommend limited sun exposure to help clear up acne. However, those who use Retin-A or are taking Accutane or certain antibiotics should avoid it altogether.

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