Acne or commonly known as pimples are very common skin problem in teenage and late teenage groups, though any age group from newborn to adults or sometimes older people can also have acne, usually women complains about acne but common in men too. Acne has negative effects on selfesteem due to cosmetic reason and it gives scars when goes off.
Acne is a chronic inflammation of pilosebaceous units (hair follicles and accompanying sebsceous glands) due to increased sebum production. Acne may present as various forms include seborrhea, comedones, papules, pustules, nodules, pseudocyst and after that scars when acne goes off.

Pathogenesis
There are four major pathogenic factors in the development of acne
1. Increased sebum production
2. Follicular hyperkeratinization (follicular plugging with sebum and keratinocytes)
3. Propionibacterium acne (P. acne) colonization
4. Release of multiple inflammatory mediators

Factors that may cause acne
Severity of acne depends upon sebum excretion rate which increases in puberty. There are multiple factors which can cause acne.
1. Hormonal factors – Sex hormones androgens, progesterone and testosterone increases sebum production rate. At puberty, level of these hormones increases thus cause acne formation. Estrogen reduces sebum production. But most patients have normal hormone profiles.
2. Genetic factors – sometimes if anyone in family had bad acne that may run in to family.
3. Environmental factors – high humidity, heat and sweating may also cause acne.
4. Stress and depression – Psychological stress and depression may disturb the hormonal level and may cause acne.
5. Lack of sleep – Insufficient sleep also stimulates sebum production and acne formation.
6. Certain cosmetics which contain lanolin, vegetable oils, butyl sterate or lauryl alcohol and oleic acid are another cause of acne.
7. Some products which are irritants on skin or allergic to skin also cause acne.
8. Dietary habits – High intake of dairy products, meat, sugars, junk food also cause acne.
9. Hair dandruffs also cause acne so hair washing frequently advised to prevent acne.
10.Certain medications also provoke acne.

Signs and symptoms
Local symptoms are pain tender and erythema. Acne vulgaris typically affects the areas of skin with the densest population of sebaceous follicles (eg, face, upper chest, back). Acne vulgaris may have a psychological impact on any patient, regardless of the severity or the grade of the disease.
Acne or pimples may be in different forms
Comedones are sebaceous plugs impacted within follicles. Depending on wheather follicle is closed or dilated(open) at skin suface comedones are of two types closed comedone or whiteheads and open comedones also called blackheads.
Plugs are easily extruded from open comedones but are more difficult to remove from closed comedones. Closed comedones are the precursor lesions to inflammatory acne. Whiteheads (closed comedones) are flesh-colored or whitish palpable lesions 1 to 3 mm in diameter; blackheads (open comedones) are similar in appearance but with a dark center.
Papules and pustules are inflammatory acne, usually occurs after propionibacterum acne colonization in closed comedones, these are red lesions around 2-5 mm in diameter, papules are relatively deeper and pustules are superficial.
Nodules or small eruptions which are solid and painful. Cysts are suppurative nodules.

Acne fulminans – It is rare but severe presentation usually associated with fever, joint pain and swelling. It is usually found on the trunk.
Acne Conglobate – Severe acne, characterized by multiple comedones, nodules, abscess, sinuses, cysts and marked scarring without the presence of systemic symptoms. More commonly present in adult males on the trunk and upper limb.
Acne Excorii- Self inflicted excoriation of skin due to repetitive touching , picking and pricking of preexisting acne lesions. Most commonly presents in teenage girls and people suffering with psychological stress or depression.
Pyoderma faciale (also called rosacea fulminans) – occurs suddenly on the midface of young women. The eruption consists of erythematous plaques and pustules, involving the chin, cheeks, and forehead.
Secondary acne– acne caused by either greasy or irritant cosmetics, exposure to oil and dust or some medications like corticosteroids, anticonvulsants, lithium. Polycystic ovary syndrome, menstrual irregularities and premenstrual period are usually associated with acne.

Diagnosis
Signs and symptoms along with medical history, menstrual history, any medications, psychological stress or depression and environmental history.
Local examinations of acne and scars
Laboratory tests for female menstruating patients to check hormone levels of total and/or free testosterone, dehydroepiandrosterone sulfate, luteinizing hormone (LH), and follicle-stimulating hormone (FSH).

Treatment
It is important to treat acne to reduce the extent of disease, scarring, and psychological distress.

A. Naturotherapy (Natural way of treatment for simple acne and prevention of severe acne).
1. Affected areas should be cleansed daily.
2. Change dietary habits avoid oily food, reduce intake of dairy products and sugar. Food should be rich in fibers and fruits.
3. Drink plenty of water.
4. Full sleep for 6-8 hours.
5. Pranayama (deep breathing exercises) helps to reduce stress and thus acne.
6. Avoid irritant cosmetic products.
Follow healthy lifestyle and health tips.

B. Pharmacotherapy
Consultation with a specialist may be necessary. Treatment should involve educating the patient and tailoring the plan to one that is realistic for the patient. Treatment failure can frequently be attributed to lack of adherence to the plan and also to lack of follow-up.

Topical therapy is useful in mild and moderate acne, as monotherapy, in combination and also as maintenance therapy. Systemic and physical therapy depends upon severity of acne.
1. Benzoyl peroxide – Mild acne usually managed with topical therapy. Initially started with low concentration topical benzoyl peroxide for short duration then gradually increased if tolerated.
2. Topical retinoids – Topical retinoids target the microcomedo–precursor lesion of acne. Tretinoin and isotretinoin are commonly used topical retinoids.
3. Topical antibiotics – Many topical antibiotics formulations are available, either alone or in combination. They inhibit the growth of P. acne and reduce inflammation. Topical antibiotics such as erythromycin and clindamycin are the most popular in the management of acne.
4. Other topical agents – Azelaic acid, Salicylic acid, Lactic acid/Lactate lotion, Tea tree oil 5%, Picolinic acid gel 10%, Dapsone gel 5% can also be used either single agent or in combination therapy.
5. Systemic antibiotics – Oral antibiotics are indicated in mainly moderate-to-severe inflammatory acne. Tetracyclines and derivatives still remain the first choice. Macrolides, co-trimoxazole, and trimethoprim are other alternatives for acne. Gastrointestinal upset and vaginal candidiasis are most common side effects. Doxycycline can be associated with photosensitivity. Minocycline may produce pigment deposition in the skin, mucous membrane, and teeth. Autoimmune hepatitis, systemic lupus erythematosus-like syndrome, and serum sickness-like reactions occur rarely with minocycline.
6. Hormonal therapy – Used in female patients suffering with androgenic alopecia, hirsuitism, seborrhea, and proven ovarian or adrenal hyperandrogenism.
Oral contraceptives – Anti-acne effect of oral contraceptive governed by decreasing level of circulatory androgens through inhibition of luteinizing hormones (LH) and follicle stimulating hormone (FSH).
Spironolactone – functions primarily as a steroidal androgen receptor blocker.
Cyproterone acetate– it is first androgen receptor blocking agent used in combination with ethinyl estradiol to treat acne in females.
Flutamide – used to treat acne in females with hirsuitism.

7. Oral isotretinoin – used to treat modereate to severe acne which in not responsive to conventional therapy.

C. Physical treatment-
Intralesional injections of triamcinolone acetonide may be required for inflamed acne nodules or cysts, which can also be incised and drained, or excised under local anaesthetic.
UVB phototherapy or PDT can occasionally be used in patients with inflammatory acne who are unable to use conventional therapy.

Summary of treatment

• Comedones: Topical tretinoin
• Mild inflammatory acne: Topical antibiotics, benzoyl peroxide, or both
• Moderate acne: Oral antibiotics
• Severe acne: Oral isotretinoin
• Cystic acne: Intralesional triamcinolone
• Oral contraceptives are effective in treating inflammatory and noninflammatory acne in females.

Effective treatments aim to improve the condition and prevent worsening (including later scarring), and to restore emotional well-being and self-esteem. The psychological impact of acne must not be underestimated and should be considered in management decisions.

Please note: Any medical information published on this website is not intended as a substitute for informed medical advice and you should not take any action before consulting with a health care professional.

Content source –  Davidson’s Principles and Practice of Medicine(22ndedition), Indian Journal of Dermatology, http://www.merckmanuals.com, http://www.dermnetnz.org