What is Acne?

• What is Acne

• Types of Acne

• Who Gets Acne

• Various Forms of Acne

What is Acne?

Acne is the common term generally to describe plugged pores (blackheads and whiteheads), pimples, and even deeper lumps (cysts or nodules) that occur on the face, neck, chest, back, shoulders and even the upper arms.  Acne affects mostly everyone particularly teenagers to some extent.  The disease is not restricted to any age group; adults in their 20s - even into their 40s - can get acne.  While not a life threatening condition, acne can be upsetting and disfiguring.  When severe, acne can lead to serious and permanent scarring. 

Types of Acne

When you read about acne or other skin diseases, you may encounter terms or phrases that may be confusing. For example, the words used to describe the lesions of acne—comedo, papule, pustule, nodule and cyst—are understandable only if you know each word’s definition. Photos are generally very helpful to have a photo that is characteristic for each type of lesion.

The following is a brief summary of definitions of words used to describe acne.

Lesion—a physical change in body tissue caused by disease or injury. A lesion may be external (e.g., acne, skin cancer, psoriatic plaque, knife cut), or internal (e.g., lung cancer, atherosclerosis in a blood vessel, cirrhosis of the liver). Thus, when you read about acne lesions you understand what is meant—a physical change in the skin caused by a disease process in the sebaceous follicle.

Acne lesions range in severity from comedones blackheads and whiteheads) to nodules and cysts. The following is a brief definition of acne lesions:

Comedo (plural comedones)—A comedo is a sebaceous follicle plugged with sebum, dead cells from inside the sebaceous follicle, tiny hairs, and sometimes bacteria. When a comedo is open, it is commonly called a blackhead because the surface of the plug in the follicle has a blackish appearance. A closed comedo is commonly called a whitehead; its appearance is that of a skin-colored or slightly inflamed "bump" in the skin. The whitehead differs in color from the blackhead because the opening of the plugged sebaceous follicle to the skin’s surface is closed or very narrow, in contrast to the distended follicular opening of the blackhead. Neither blackheads nor whiteheads should be squeezed or picked open, unless extracted by a dermatologist under sterile conditions. Tissue injured by squeezing or picking can become infected by staphylococci, streptococci and other skin bacteria. The following photos are characteristic of acne with comedones:

Papule—A papule is a small (5 millimeters or less), with a solid lesion slightly elevated above the surface of the skin. A group of very small papules and microcomedones may be almost invisible but have a "sandpaper" feel to the touch. A papule is caused by localized cellular reaction to the process of acne. This photo shows papules and comedones on the face of an acne patient:

Pustule—A dome-shaped, fragile lesion containing pus that typically consists of a mixture of white blood cells, dead skin cells, and bacteria. A pustule that forms over a sebaceous follicle usually has a hair in the center. Acne pustules that heal without progressing to cystic form usually leave no scars. This photo shows pustules, papules and comedones on the face of an acne patient:

Macule - A macule is the temporary red spot left by a healed acne lesion. It is flat, usually red or red-pink, with a well defined border. A macule may persist for days to weeks before disappearing. When a number of macules are present at one time they can contribute to the "inflamed face" appearance of acne. This photo shows the "red face" appearance of acne with macules:

Nodule—Like a papule, a nodule is a solid, dome-shaped or irregularly-shaped lesion. Unlike a papule, a nodule is characterized by inflammation, extends into deeper layers of the skin and may cause tissue destruction that results in scarring. A nodule may be very painful. Nodular acne is a severe form of acne that may not respond to therapies other than isotretinoin (Click on Acne Treatments)

Cyst—A cyst is a sac-like lesion containing liquid or semi-liquid material consisting of white blood cells, dead cells, and bacteria. It is larger than a pustule, may be severely inflamed, extends into deeper layers of the skin, may be very painful, and can result in scarring. Cysts and nodules often occur together in a severe form of acne called nodulocystic. Systemic therapy with isotretinoin is sometimes the only effective treatment for nodulocystic acne. Some acne investigators believe that true cysts rarely occur in acne, and that (1) the lesions called cysts are usually severely inflamed nodules, and (2) the term nodulocystic should be abandoned. Regardless of terminology, this is a severe form of acne that is often resistant to treatment and likely to leave scars after healing. These photos show nodular, cystic acne:

Who gets acne?

Close to 100% of people between the ages of twelve and seventeen have at least an occasional whitehead, blackhead or pimple, regardless of race or ethnicity? Many of these young people are able to manage their acne with over-the-counter (nonprescription) treatments. For some, however, acne is more serious. In fact, by their mid-teens, more than 40% of adolescents have acne severe enough to require some treatment by a physician.

In most cases, acne starts between the ages of ten and thirteen and usually lasts for five to ten years. It normally goes away on its own sometime in the early twenties. However, acne can persist into the late twenties or thirties or even beyond. Some people get acne for the first time as adults.

Acne affects young men and young women about equally, but there are differences. Young men are more likely than young women to have more severe, longer lasting forms of acne. Despite this fact, young men are less likely than young women to visit a dermatologist for their acne. In contrast, young women are more likely to have intermittent acne due to hormonal changes associated with their menstrual cycle and acne caused by cosmetics. These kinds of acne may afflict young women well into adulthood.

Acne lesions are most common on the face, but they can also occur on the neck, chest, back, shoulders, scalp, and upper arms and legs.

Acne also has significant economic impact. Americans spend well over a hundred million dollars a year for nonprescription acne treatments, not even taking into account special soaps and cleansers. But there are also the costs of prescription therapies, visits to physicians and time lost from school or work.

Various Forms of Acne

Acne Mechanica

After removing his football helmet, Walt, a high school football player, notices acne developing on his forehead and chin where his helmet rubs his face. Jim, a twenty-year-old soldier, is getting acne on his shoulders and back. Sharon, a professional violin player, is bothered by acne on her neck that appears just below her ear, where she tucks her violin against her neck when playing.

What all of these people have in common is acne mechanica, a form of acne caused or aggravated by heat, covered skin, constant pressure and repetitive friction against the skin.

Causes

Common sports-related causes of acne mechanica are:

• Helmets and helmet straps, especially those worn by football and hockey players and motorcycle riders

• Shoulder pads and straps worn by football players

• Tight uniforms made of synthetic fabric

• Tight headbands worn by soccer players and runners

• Straps and packs on backpacks

Other common causes of acne mechanica are:

• Straps used by soldiers for weapons and equipment

• Headbands worn for long periods of time

• Musical instruments, such as the violin, tucked against the neck for hours

• Tight fur caps worn for long periods of time

• Tight clothing, such as jeans and underwear made of synthetic fabric

• Snug bra straps

• Adhesive tape that remains on the skin for several days (occasionally)

Some factors that increase the likelihood of developing acne mechanica are:

Having sandpaper acne. Small, undeveloped lesions (microcomedones) on the skin that are nearly invisible but feel rough to the touch are called sandpaper acne. When aggravated, sandpaper acne can quickly become the more active and inflamed acne of acne mechanica.

Predisposition for non-facial acne. Teens and people in their 20s who have a predisposition for developing acne on the shoulders, back and buttocks have an increased risk for developing acne mechanica when factors, such as constant friction, are present.

Being a soldier in the tropics. The heat and humidity of the tropics can also aggravate the skin, especially for soldiers in their teens and 20s. When heat and humidity are combined with the pressure and friction caused by packs and weapon straps, this creates what is called “double whammy” and greatly increases the likelihood of a soldier developing acne mechanica.

Prevention

The good news is that there are measures that may help prevent acne mechanica. These include:

• Wear a clean cotton T-shirt under a sports uniform. Cotton absorbs perspiration and reduces friction against the skin from the uniform.

• Shower immediately after athletic activities. Wash the chest, back and buttocks and areas that were under straps, padding or tight uniform. Liquid cleansers containing salicylic acid are useful for removing surface oils and unclogging pores.

• Avoid covering the forehead with a headband or cap for prolonged periods

Treatment

Applying a topical (applied to the skin) acne medication that contains salicylic acid or benzoyl peroxide to the lesions as soon as they appear is often effective. Another effective method is to eliminate the cause of acne mechanica. This, of course, is not always possible. A professional violinist cannot stop playing the violin. Soldiers cannot stop carrying packs and weapon straps. A dermatologist may be able to suggest other effective treatment.

Adolescent Acne

Studies show that during adolescence close to 100% of the population has at least an occasional whitehead, blackhead or pimple—regardless of race or ethnicity. These studies also confirm that acne most frequently occurs between the ages of 12 and 20. The likelihood of developing acne is greatest during adolescence because hormone levels become elevated. Elevated hormones stimulate the sebaceous glands, glands that are attached to hair follicles, to produce greater amounts of sebum—an oily substance. An acne lesion (whitehead, blackhead or pimple) occurs when a hair follicle becomes plugged with the sebum and dead cells.

In most cases, acne begins between the ages of 10 and 13 and usually lasts for 5 to 10 years. In some adolescents, more severe acne follows the development of comedones, reaching a peak 3 to 5 years after the first comedones appear. Adolescent acne commonly disappears between the ages 20 and 25. However, severe acne, also known as nodular acne or cystic acne, may not resolve until 30-plus years of age.

Emotional Toll

Living five or more years with acne can be emotionally devastating, especially during adolescence. Between the ages of 12 and 20, the appearance of acne can seem like a social misfortune for which that person alone has been selected. To a teenager, acne can be one of the worse things that ever happened. Acne frequently makes teens feel embarrassed and lowers their self-esteem. A recent survey of British teenagers found that the emotional toll can be significant:

• 39% of teenagers with acne claimed they avoided going to school because of embarrassment

• 55% of 11- to 18-year-olds said acne prevented them from having a boyfriend or girlfriend

• 32% indicated acne stopped them from making friends

Treating acne typically alleviates the emotional effects and leads to greater self-confidence. Treatment can also prevent acne from getting worse and deter scarring.

Most mild cases of acne can be controlled at home by gently washing the affected areas and using a topical preparation, such as benzoyl peroxide. If the condition does not improve in 6 to 8 weeks, a dermatologist’s help may be required. Acne that ranges from moderate to severe typically requires the help of a dermatologist. The good news is that today virtually every case of acne can be controlled.

Excoriated Acne

“Excoriate” means to scratch or abrade the skin. When a person spends hours in front of a mirror squeezing and picking at every blemish, the condition is termed “excoriated acne.” All of this picking and squeezing often causes red marks where the skin becomes irritated and usually leads to permanent scarring.

Excoriated acne usually appears to others as a mild form of acne, without pustules or nodules. To the person with the acne, however, it may be intolerable for a variety of reasons. People with excoriated acne often wish that they could stop all that picking and squeezing, but an uncontrollable desire to get rid of their lesions compels them. This compelling urge to pick and squeeze at every blemish regardless of size is a medically recognized condition that should be discussed with a dermatologist.

Occasionally giving in to a temptation to squeeze a blackhead is not excoriated acne.

Infantile Acne

We usually associate the development of acne with adolescence, but acne and acneiform (acne-like) lesions can occur in infants.

A newborn may have an acne eruption on the nose or cheeks. This is usually caused by hormonal changes that occurred as the fetus was developing, and the outbreak typically clears in a matter of weeks, without treatment.

When to See a Physician

A physician should be consulted when:

An infant or very young child has acne that persists for more than several weeks.An infant or very young child with acne that persists for more than several weeks should be examined by the child’s pediatrician or a dermatologist. If the acne persists or becomes severe, consultation with an endocrinologist and pediatric dermatologist is recommended. Causes that may be investigated include:

• Family history. Do the infant’s parents, brothers or sisters have acne, or did they have it at some time? A close genetic connection is a high risk factor for developing acne.

• Early hormone production. Does the infant have a condition that causes very early production of sex hormones, especially the androgenic hormones associated with acne? The possibility of sexual precocity (very early sexual development) requires medical attention to prevent or moderate disabilities linked with this condition.

• Growth and developmental abnormalities. Are there any indications of problems with mental or physical development? Very early acne can also be an indication of a developmental abnormality.

• Drug-induced acne or acneiform eruption. Has the infant had any contact with a medication that can cause acne or acneiform lesions, such as corticosteroids or iodine-containing drugs?

Acne develops between the ages of 2 and 6. While acne occurs in infants, it usually subsides by age 2. If acne develops between the ages of 2 and 6, a dermatologist should be consulted as this is a stage in life known as the acne free zone.

During the acne free zone, which occurs from approximately 2 to 6 years of age, acne vulgaris rarely occurs. It is believed that acne usually does not occur between the ages of 2 and 6 because sebum production is very low. The low sebum production is probably associated with the low levels of androgenic hormones in the child’s developing body. 

Where Infantile Acne OccursIn infants and very young children, acne usually appears as rash-like comedones and papules on the cheeks and chin. There may also be the occasional small pustules. Boys are more likely than girls to have infantile or juvenile acne. (Photo used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides)

Treatment

Infantile and juvenile acne is treated in much the same way it is treated in teenagers and adults. Actual treatment usually consists of gently cleansing the skin and treating it with topical agents. Only rarely, in very severe cases, are antibiotics or isotretinoin prescribed. Therapy is required for as long as the acne persists. As in adolescent and adult acne, any underlying condition must also be treated.

Pomade Acne

When hair styles change, it is common for teenagers and young adults to adopt the new style. Sometimes a new hair style requires use of a thick, oily dressing called pomade. Pomade is generally used when a hair style requires that (1) curly hair be straightened or (2) hair be molded into various shapes. Some pomades are available in stores and shops; some are homemade.

One of the undesired effects of pomade use may be pomade acne. Pomade acne occurs on the scalp, forehead and temples where pomade comes into contact with the skin. It usually consists of comedones, with perhaps a few papules andpustules.

Pomade acne occurs on skin that comes into contact with the pomade, such as the scalp, forehead and temples.

(Photo used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides)

Most, if not all, pomades fall into the category of comedogenic (pore clogging) cosmetics and hair dressings. The heavy oils in pomades can clog skin, setting the stage for formation of comedones. In addition, some of the other chemicals in pomades may irritate the skin, contributing to inflammation. 

Treatment

For pomade acne, treatment consists of these options:

• If using pomade to decrease scalp dryness, try applying pomade one inch behind the hairline.

• Is using pomade to style or make hair more manageable, try applying pomade to the ends of the hair only to avoid contact with the scalp and hairline.

• Stop using pomade.

When pomade is no longer making contact with the skin or pomade use is discontinued, pomade acne should gradually clear. If it persists, the acne should be treated the same as any other acne—by gently cleansing the skin and using a topical preparation, such as benzoyl peroxide. If the acne does not clear after 6 – 8 weeks of treatment, contact a dermatologist.

Severe Acne: 4 types

Severe acne can affect many facets of a person’s life, causing a great deal of embarrassment and stress. Severe acne may significantly limit one’s social life and even interfere with opportunities for employment. Since this condition can be disfiguring and require years of treatment, it is important to see a specialist. Dermatologists have the most experience treating the different types of severe acne.

Four types of severe acne, described in detail below, are:

• Acne conglobata

• Acne fulminans

• Gram negative folliculitis

• Nodulocystic Acne

Acne Conglobata

Acne conglobata is a chronic and severe form of acne vulgaris, characterized by:

• Deep abscesses

• Inflammation

• Severe damage to the skin

• Scarring

• Blackheads (open comedones) are usually conspicuous and widespread—often occurring on the face, neck, trunk, upper arms and/or buttocks

In acne conglobata, inflammatory nodules form around multiple comedones, gradually increasing in size until they break down and discharge pus. Deep ulcers may form under the nodules, leading to keloid -type scars, and crusts may form over deeply ulcerated nodules

Burrowing abscesses commonly result in deep, irregular scarring.

Acne conglobata may be preceded by acne cysts, papules or pustules that do not heal, but instead rapidly deteriorate. Occasionally, acne conglobata flares up in acne that had been dormant for many years.

Males are more likely than females to have acne conglobata; the age of onset is usually between 18 and 30 years. The cause of the condition is not well understood.

Treatment

Isotretinoin is the usual treatment of choice for acne conglobata. Antibiotics may also be prescribed. Several courses of treatment may be necessary over a period of years. Even after effective treatment, the patient should have regular checkups by a dermatologist for any signs of recurrence. A dermatologist can also treat the scars.

Acne Fulminans

Acne fulminans is a sudden onset of highly destructive inflammation. It appears suddenly in a person with inflammatory acne and is characterized by:

• Symptoms of severe and often ulcerating acne

• Fever

• Inflammation and aching of joints, especially hips and knees

A person who develops acne fulminans may have had unsuccessful treatment for another form of severe acne, acne conglobata.

Treatment

Corticosteroids or non-steroidal anti-inflammatory medications may be given to reduce inflammation. Attacks of acne fulminans may recur, and the patient may develop acne that requires long-term treatment with isotretinoin.

Nodulocystic Acne

Cysts are relatively uncommon in acne; however, this form of severe acne is characterized by cysts, which may measure several centimeters in diameter as seen in these two photos:

Cysts may develop singly or be widespread as these photos show

(Photos used with permission of the American Academy of Dermatology National Library of Dermatologic Teaching Slides)

Cysts may occur singly, or be widespread over the face, neck, scalp, back, chest and shoulders. And, they can be painful.

The nodular cyst of acne is not a true cyst—an abnormal dilatation of a normal skin structure. Acne cysts are nodules of inflammation. The cysts may arise from a papule or nodular acne lesion, or occasionally from a type of cyst that develops in the outer layer of the skin—a type of cyst not usually associated with acne. A cyst may appear to be filled with thick, yellow pus-like fluid. This is usually an inflamed and infected cyst. If an attempt is made to drain such a cyst, it should be done in a physician’s office under sterile conditions, not in front of a bathroom mirror.

Cysts occurring close together may coalesce, producing soft areas undermined with tunnels, cell destruction and inflammation, resulting in another form of severe acne, acne conglobata.

Treatment

Nodulocystic acne usually requires an aggressive treatment regimen that may include isotretinoin and antibiotics, or intralesional corticosteroids that "melt" the cyst over a period of 3 to 5 days. Some very large follicular cysts that do not respond to medications may require drainage and surgical excision.

Gram-negative folliculitis

Gram negative folliculitis is an inflammation of follicles caused by a bacterial infection that can result from long-term antibiotic treatment. Patients who are being treated with antibiotics for severe acne may develop Gram negative folliculitis.

The word “Gram” refers to a blue stain used in laboratories to detect microscopic organisms. Certain bacteria do not stain blue and are called “Gram negative.”

Treatment

In Gram negative folliculitis, the bacteria are resistant to many antibiotics. Isotretinoin and antibiotics that are effective against Gram negative bacteria are used to treat this condition.

Anyone with severe acne should be under the care of a dermatologist as dermatologists have the experience needed to control virtually every case of acne.

It is important for patients and their families to know that severe, disfiguring forms of acne may require years of treatment and patients can experience one or more treatment failures. During treatment, the support of family and friends can greatly comfort patients. Information sources, such as AcneNet, may help family and friends to better understand what those with severe acne face every day.