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Pimples. Nearly everyone has suffered through them--some more than others. They are an almost universal affliction of adolescence. Even one or two "zits" can cause much posturing and worrying in front of a mirror. A handful may cause panic. And a face full can result in permanent scarring--both of the skin and the psyche.
Describing 17-year-old acne sufferer Pimples Carson in his book The Wayward Bus, John Steinbeck wrote that the boy's face was "rivuleted and rotted and eroded with acne," and medicines sold to treat it "do no good whatsoever."
While acne today looks the same as it did in the 1930s, Steinbeck's assessment of the usefulness of acne medicine no longer holds true.
Although acne can't be cured, it can be treated successfully in the vast majority of people. Some cases, especially the mild types, can be cleared up completely. Vigorous treatment of more severe types of acne can help prevent facial scarring.
Technically called acne vulgaris, this skin disease affects millions of Americans annually. It can vary from quite mild to extremely severe. About 80 percent of all teenagers develop acne, but the disease may also start as late as age 25 or 30, particularly in women.
What Causes Acne?
No one knows for sure exactly what causes acne, or why it usually begins in adolescence. But a number of factors, most importantly heredity, play a role. If one of your parents had acne, there's a good chance you will, too. If both had it, "the gun is pointed directly at you," says FDA dermatologist Carnot Evans, M.D.
Acne develops when the sebaceous glands and the lining of the skin duct begin to work overtime, as they do in adolescence. The glands produce more sebum, making the skin more oily. Normally the lining of the duct sheds cells that are carried to the surface of the skin by the sebum.
When the duct is blocked, cells and sebum accumulate, forming a plug comedo). If the plug stays below the surface of the skin, it is called a "closed" comedo or whitehead. If the plug enlarges and pops out of the duct, it is called an "open" comedo or blackhead because the tip is dark. This is not dirt and will not wash away. The discoloration is due to a buildup of melanin, the dark pigment in the skin. Pilosebaceous units are found all over the body, but there are more on the face, upper chest, and back, which explains why acne usually occurs in these places.
There are two main types of acne: non-inflammatory and inflammatory.
In non-inflammatory acne, there are usually just a few whiteheads and blackheads on the face. A relatively mild type of acne, it can be treated with nonprescription medicines or, in the case of blackheads, with the prescription drug Retin-A. The majority of people with acne have this type.
With inflammatory acne, the whiteheads become inflamed, and pimples and pustules develop. In its most severe form, it can cause disfiguring cysts & deep, pitting scars of the face, neck, back, chest, and groin. Prescription drugs and sometimes surgery are needed to treat inflammatory acne.
Advent of Adolescence
Acne almost always starts when the body begins to mature--at about age 11 for girls and 13 for boys. Acne tends to be more severe among boys because their bodies begin increased production of male hormones called androgens that, among other things, stimulate the activity of the sebaceous gland. Girls also produce these hormones, but only one-tenth as much. The exact role hormones play in the development of acne is not known.
However, studies have found that many teenage girls and women with acne have higher than normal androgen levels. These findings suggest that acne in women may be associated with increased androgen production.
In addition to puberty, a number of other factors can cause, trigger or contribute to the development of acne.
- Some drugs--including certain hormones, epilepsy drugs, and anti-tuberculosis medicines--can cause acne.
- Exposure to industrial oils and grease and chemicals, such as PCBs, can cause acne.
- The bacteria Corynebacterium acnes can indirectly contribute to the development of acne by causing skin fats to break down into irritating chemicals.
- Stress and strong emotions,such as guilt, anxiety and fear,can trigger acne in people who have a predisposition to the disease.
- The onset of the menstrual period each month can trigger or worsen acne. Some 60 to 70 percent of women notice that acne gets worse the week before menstruation.
- Birth control pills appear to have an effect on acne in some women. Perplexingly, they cause acne in some cases and clear it up in others.
- Some oily cosmetics and shampoos can, on rare occasion, trigger acne in people who have a predisposition to it.
Dispelling the Myths
Contrary to earlier belief, there is no scientific evidence that foods such as chocolate, nuts, cola drinks, potato chips, French fries, and other fatty "junk food" cause acne or make it worse. Nonetheless, some people do notice that certain things they eat or drink do seem to trigger their acne, says FDA's Evans.
Oily skin and hair do not cause acne either. Although there is an association between the severity of acne and the amount of oil produced by the skin, not all people with oily skin have acne--and some people with dry skin do.
Acne sufferers often report that their acne improves in the summer,leading to the belief that the sun has a modifying effect. A recent Swedish study on the influence of sunlight on skin found that the majority of people with acne experienced improvement after exposure to sun.
However, medical opinion on the value of sunlight varies. "It's hard to say whether it's the sun or psyche that has an effect on acne," says Evans. "The sun may have a modest effect in some people, but the relaxation usually associated with summer is also probably a factor."
One thing is certain, though. The idea that the sun improves acne by drying out greasy skin is incorrect. Sun increases oil production, which is why people tend to have oilier skin in the summer.
Clearing Up Acne
What can you do to clear up mild acne? Evans advises the following
- Get a nonprescription acne medicine and apply regularly. Over-the-counter drugs containing sulfur, resorcinol, salicylic acid, and benzoyl peroxide are all effective for treating mild acne.
- Use ordinary hygiene on affected areas, washing your face once or twice daily with your usual soap or cleanser. Deodorant soaps may be used, but they are of no particular value for acne.
- Avoid any food or drink you know is a trigger.
- If these measures don't work, Evans advises, see a dermatologist. While it might be tempting to pick at pimples and squeeze blackheads, this can injure the skin and underlying tissues. Doctors advise patients not to pick pimples. Medical instruments called comedo extractors are used to remove blackheads. Some doctors may suggest that their patients use such an instrument themselves. Other doctors would rather remove the blackheads in their office or clinic because of a risk of scarring.
Treating Serious Acne
One drug dermatologists sometimes prescribe for serious acne is tretinoin, commonly known as Retin-A. A derivative of vitamin A, Retin-A comes in cream, gel and liquid forms and is rubbed onto the skin once nightly. It is highly effective for treating blackhead acne and modestly effective for treating pimples and pustules. Retin-A usually begins to clear up acne in two to three weeks, although in some cases it's more than six weeks before any improvement is noticed.
Scientists do not know exactly how Retin-A works, but research suggests that it both pushes out the comedo plugs beneath the skin and helps prevent their re-formation. One of the main side effects of Retin-A--one that occurs in all users--is a heightened susceptibility to sunlight. Therefore, those who use Retin-A should stay out of the sun as much as possible, and when in the sun should minimize its effects with sunscreens and protective clothing.
Retin-A users should also avoid sun lamps because their ultraviolet rays mimic those of the sun.
Another common side effect of Retin-A is drying, irritation or peeling of the skin. When this occurs, the doctor may suggest patients cut back use to two or three times a week.
Some antibiotics are effective for treating and preventing pustules and cysts of severe acne. Tetracyclines and erythromycin are the most commonly prescribed.
Treating Severe Cystic Acne
For very severe, disfiguring acne unresponsive to the treatments mentioned, the doctor may prescribe isotretinoin, commonly known as Accutane. Also a vitamin A derivative, Accutane is taken orally in capsule form. It is highly effective for treating severe cystic acne and preventing the deep pits and scars that result.
Scientists do not know exactly how Accutane works, but evidence suggests that it reduces the size of the sebaceous gland and the amount of sebum secreted. In any case, it completely clears up the disease in many people.
Women should use Accutane with extreme caution, however, because it can cause miscarriage and birth defects. If a woman becomes pregnant while taking the drug, there is a great possibility her baby will be born deformed. Therefore, Accutane's use is tightly regulated by FDA. Doctors may only prescribe it for a woman who has had a negative pregnancy test and does not intend to become pregnant while taking it, and who has signed a consent form that she has been fully informed of its side effects.
In addition to the danger of fetal malformation and miscarriage, there are a number of minor side effects associated with Accutane.
Ninety percent of those who take the drug experience inflammation of the lips (and less frequently of the eyes), and 80 percent experience drying of the skin, nose or mouth.
In severe cases of acne, the dermatologist may surgically drain large pustules or abscesses.
In addition, plastic surgery is sometimes used to smooth over deeply pitted and scarred skin. Dermabrasion--a technique to remove scars that is like sandpapering the skin--is being used less frequently. Dermabrasion has become less popular because it can discolor the face and because new acne medicines have made it increasingly less necessary.
However unpleasant and embarrassing acne is, it usually begins, peaks, and runs its course in adolescence, slowly fading away in early adulthood.
During those critical teen years, modern medicines and treatment can do much to ease the discomfort and embarrassment of the acne sufferer.
Sharon Snider is a staff writer for FDA Consumer.
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