Broadly speaking, acne begins with overactive sebaceous glands. Too much sebum, mixing with dead skin cells, plugs up follicles. You’ll see the plug, if it’s close to the surface of the skin, as a bulging whitehead. If the plug is deeper, or half-formed, you’ll see a blackhead, what’s called a ‘comedone’. The black is an oxidized form of a skin protein called melanin. (It’s not dirt, and you can’t wash it away.) Ordinarily harmless bacteria that live on the skin, usually Propionebacterium acnes, like to proliferate in these plugged follicles, and that’s what causes papules, pustules, nodules or cysts.
We define acne as comedonal, inflammatory, nodular, or nodulocystic. Extreme acne, untreated, can leave scars or darkened patches of ‘hyperpigmentation’.
Acne is largely hormone-driven, which is why teenagers get it, and particularly boys. There seems to be a hereditary component too – it runs in families. Generally speaking, it’s gone for everybody by about age 25.
Treatment depends on the type and severity of acne.
Some of it you can do yourself, like keep your skin clean, with a gentle soap (pH about 6.5). Wash twice daily, and every time you’ve been sweating. Avoid scratching or squeezing your pimples. Avoid wearing makeup, especially if it’s oil-based. Don’t be afraid of a little sunlight. It can help keep your acne down. And stay off the sweets if you can. There’s a little bit of evidence that fast-acting sugars might boost sebum production and possibly modulate inflammatory response as well.
Beyond this, your doctor may recommend topical treatment, with benzoyl peroxide, a retinoid, azelaic acid, or a topical antibiotic.
There are oral antibiotics as well, and women can benefit from the hormone-modifying effect of oral contraceptives. Really severe acne may warrant a drug called isotretinoin. Isotretinoin absolutely must be managed by a physician, especially in women.
For badly clustered acne, cortisone injections often help. For scarring, there is cosmetic treatment, like chemical skin scaling, cryotherapy, collagen injections, and laser contouring. Sometimes these can be counter-productive, however, so caution is wise.
Whatever the treatment, it takes time, usually on the order of months. It often requires some adjusting, too. You’ll need to work closely with your doctor, and be patient with it.
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