Acne vulgaris, or
more commonly termed ‘pimples’, is probably the most common skin disorder
occurring in mankind. It is a chronic self-limited condition but the sequelae
can be lifelong, causing scar formation with profound psychological and
emotional impact.
The prevalence of
acne among various countries differs. A recent large study in China showed the
prevalence of between 10.5% to 36% among children more than 10 years old to
those above 25 years old. There is no population based study done in Malaysia,
but there was a study done among adolescent (13-18 years old) in two small
district secondary schools showed the prevalence of 67.5%.
The causes of acne
are multi-factorial. Four mechanisms causing acne are identified, mainly
increased sebum production, the formation of comedones (white and black heads),
proliferation of the bacteria Propionibacterium
acnes and inflammation of the hair follicles.
Most patients with
acne had gradual onset of lesions around puberty. Uncommonly acne can be seen
in young babies mainly of whiteheads, which is believed to be cause by the
maternal hormone.
There is no gender
difference in the occurrence of acne, but it tends to be more severe in males.
There is also no difference in acne severity among age and ethnic groups. Acne
is mostly seen during middle-to-late teenage period. Thereafter, the incidence
steadily decreases. However, in women, acne may persist through the third
decade or even later.
There seemed to be a
genetic influence in acne. Individuals with strong family history of acne among
first degree family members are at risk. There is also a significant
association between obesity and acne in children. Other factors that have been
shown to aggravate acne include cigarette smoking, stress and facial therapy or
salon facial massage.
Diet has long
believed to exacerbate acne. Food that is high in glucose load such as white
glutinous rice, white bread, cornflakes, boiled potato, fried meehoon, among
others, may aggravate acne. However, the link between consumption of milk and
worsening of acne is weak. There is also no good evidence for oily foods, chocolate
and nuts intake in the pathogenesis of acne. The effectiveness of zinc, vitamin
A, vitamin C, vitamin E and omega-3 fatty acids is not conclusively proven.
Nevertheless, diet with high fibre and low fat content is encouraged for acne
patients.
Acne occurs mainly on
the face, to a lesser degree, the back, chest and shoulders. On the trunk,
lesions tend to be concentrated near midline. The skin lesions are of many
types. They are characterized by whiteheads, blackheads, superficial red
swelling, pus-filled lesions as well as deep red swelling termed nodules in a
more severe form. The lesions may resolved by itself. However, if it is not
treated early, especially the nodular type, severe scarring can form. Most of
the scars are depressed type. Uncommonly, especially on the trunk, the scars
may be raised and cause keloids (painful thick scars).
In general, acne can
be diagnosed and treated easily. However, medical attention should be sort
especially if the lesions are severe or if it occurs in girls who develop
features of possible abnormal increased in androgen levels as manifested by
deepened voice, menstruation irregularity and abnormal hair growth. It is also
important for doctors to differentiate other skin disorders that mimic acne
vulgaris such as folliculitis, rosacea, perioral dermatitis and drug-induced
acne.
In the past, many old
and unproven remedies were employed to treat acne such as restrictive diets,
vigorous scrubbing, steaming or washing with soap and hot water, which might
aggravate existing acne. The compulsive act of pricking or squeezing the
lesions further lead to permanent scarring. More often than not, many sales
persons start recommending certain herbal or supplements that claimed to be
able to cure acne without side effects. These over-the-counter treatments
sometimes cause a huge hole in the pocket and without improvement.
Many people are
uninformed about the availability of medical treatment, or feel reluctant or
embarrassed to see a healthcare provider.
Modern medicine has
changed the landscape of acne treatment for the past few decades where
supervised treatment by trained physicians offer various treatment modalities
that are able to not just treat but potentially cure acne. Many topical agents
are available which had proven to be effective such as topical benzoyl
peroxide, antibiotics, azaleic acid and retinoids. All these agents, except
benzoyl peroxide, are prescriptive items, which means, only doctors are allowed
to prescribe them.
Mild acne can usually
be self-treated by applying over-the-counter preparations such as benzoyl
peroxide, tea tree oil, salicylic acid or sulphur containing products. Moderate
to severe type of acne requires consultation with doctors where often treatment
requires the combination with oral antibiotics. More severe type of acne,
especially the nodular type, or when other first line treatments failed,
patients may then require oral retinoids, like Isotretinoin (Roaccutane).
Isotretinoin is
currently the most effective treatment for acne vulgaris as it targets the four
main mechanisms that cause acne. However, Isotretinoin can cause potential serious
side effects especially to the developing fetus. It is therefore
contraindicated in pregnant women or women planning to have children.
Isotretinoin prescription requires registration with the Drug Control Authority
(DCA) and currently only certified dermatologists can prescribe it in our
country.
For those people who
could not tolerate the standard treatments as mentioned above, various
alternatives are also available. Chemical peeling with glycolic acid or salicylic
acid can be used as adjuvant in the treatment of facial acne. Other treatments
that use light-based therapy such as photodynamic therapy, lasers, intense
pulse light and other visible light sources (green, red, or blue light) can
also be used. However, these modalities are only available in specialized
centres and can be quite expensive.
Complementary and
alternative medicine (CAMs) therapy are commonly used by some practitioners to
treat acne. However, currently there is insufficient evidence to recommend any
specific CAMs for the treatment of acne.
Treatment of acne
scars can be quite challenging. It is best performed by trained doctors
specialized in such procedures. Hypertrophic scar can be injected with steroid
to flatten it. Mild depressed scar can be treated with simple procedures like
chemical peeling, skin micro-needling or microdermabrasion. Deeper scars
require more invasive methods such as dermabrasion or surgical excision. Many
light-based therapies such as various lasers can also be used to treat acne
scars effectively. Currently, laser using fractional technology is most popularly
used to treat acne scars with short recovery.
In summary, acne is a
common chronic skin condition affecting many adolescents and young adults. It
presents with different spectrums of severity and every individual perceives
acne differently at various stages of life. Many effective treatment options
are currently available. It is important to seek treatment early to prevent
scar formation. As acne is a medical disease, medical treatment by healthcare
providers is therefore advisable.
For more information
about the availability of dermatologists in the country, kindly refer to
Dermatological Society of Malaysia website (http://www.dermatology.org.my/dermatologist.htm)
or the National Specialist Register website (http://www.nsr.org.my).
Prepared by,
Dr. Chong Yew Thong
Consultant
Dermatologist,
Gleneagles Penang,
1, Pangkor Road,
10050 Penang
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