Acne is primarily an inflammatory disorder of the skin. It occurs when hair follicles become clogged, usually with skin and skin oils. It is not usually a problem with dirty skin, although those who find themselves working in greasy environments may experience a worsening of acne.

The skin renews itself approximately every 4 weeks. During this time, a cell on the bottom layer of the skin moves toward the outside world and is eventually sloughed off. Acne seems to be caused primarily by poor sloughing of the skin cells lining hair follicles. For some reason these skin cells are sticky. If they don’t slough properly, they can occlude the follicle (plug up the hair follicle). This is a problem because of the nature of hair follicles. At the root of the hair are oil glands, which produce oil to nourish the hair and keep it healthy. When we have a hair follicle that is producing oil and plugged up, there is no way for the oil to get out to the hair shaft or the outside world in general. The oil begins to accumulate. This produces the smallest zit. You may not even call it a zit yet.

The next problem is that the oil is good food for a bacteria called P. acne. (we all have this and other bacteria living on our skin) Now that the follicle is plugged and the oils are accumulating, the bacteria have a feast and begin to multiply. (Normally, excess bacteria are washed out with the oil through an open hair follicle.) This is what is called a whitehead. (Just a small white zit)

As the oil and bacteria accumulate, they get too big for the hair follicle area. When this happens, it is like popping a balloon filled with gunk. Often, the balloon doesn’t pop through to the skin surface but rather through the bottom of the follicle into the tissue below. This is when the zit first turns red. (still small).

Oh no! Now we have oils and bacteria where they are not supposed to be under the skin in the tissue. The body is not happy. It sends an army of white cells (WBCs) to attack and clean up the gunk. This is when puss starts to form. (Puss is WBCs, and garbage, and bacteria that the WBCs are trying to clean up.) Sadly, this is all happening just under the skin. If this process continues, you get a larger white head, or if it is really bad, a large pocket of puss and bacteria that when they rupture produce scars. An active zit picker can cause scars too.

Here are what cause zits:
#1. Blocked Hair Follicles caused by sticky skin cells
#2. Trapped oil and bacteria
#3 The body reacting to oil and bacteria that get under the skin (inflammation)

Things that may make zits worse:
Greasy work environment, poor skin hygiene (both too much cleaning, and too little), hormonal changes, stress (as it affect hormonal milieu).

Not shown to contribute. Dirt and foods.

Treating Acne

From a physician’s perspective, the first place to attack zits is at the blocked hair follicle. We only have one type of medicine that does this well. These are the retinoids: Differin, Retin-A, Tazorac, Accutane etc. These work to make the skin cells less sticky, preventing the initial blockage of the hair follicle. They also serve to reduce inflammation. These tend to be irritating to the skin and need to be used appropriately to make things better and not worse. A pea-sized amount of most of the topical retinoids is all you need for your entire face when you apply it. Some of the medicines are more irritating than others. As a general rule, liquids are more irritating than gels, which are more irritating than creams. If irritation occurs, you may decrease the frequency from once a day to once ever other day or even every third day. You may also wash your skin after 30 minutes to reduce irritation. Retinoids do not treat existing zits… they prevent them. Do not spot treat with them.

What can you do to prevent blocked hair follicles. DON’T IRRITATE YOUR SKIN WITH HARSH SOAPS AND CLEANSERS. Find a gentle cleanser like Cetaphil cleanser. Cleanse your face only with your fingers, not with a wash cloth or abrasive pads. Irritating your face causes the skin to thicken, makes the skin cells more sticky, and will make your problem worse. Wash your face one or two times per day.

Once the hair follicle is clogged, what can we do? Use an anti-bacterial and/or anti-inflammatory.

The most effective anti-bacterial/anti-inflammatory is Benzoyl Peroxide (BP), available in both over-the-counter and as prescription. Strengths >5% are irritating and not any more effective. BP is both irritating and drying to the skin and may need to be started and increased slowly to help reduce irritation. Over-the-counter products that have BP include: Clear Skin Regimen Gel, Neutrogena On-the-Spot, Clearasil, Oxy-10, Fostex, Clear by Design, Persa-Gel.

Again, these actually help prevent progression and should by-and-large not be used as spot treatment, but as overall prevention. The major drawback of BP is again irritation. If you get irritation, use less, less frequently, or a different type (gel, cream, etc.). Over time (weeks) irritation gets better. BP cannot be used at the same time of day as a retinoid (destroys the retinoid).

Topical antibiotics work as well targeting both inflammation and the bacteria, but should be used in combination with BP to prevent antibiotic resistance. (When the BP also is working to kill bacteria, anything that escapes the antibiotic gets killed by the BP).

Oral antibiotics are mostly for moderate to severe cases and should only be used for about 2 months to get acne under control. Target both bacteria and inflammation.

Oral contraceptives. (When used for acne, I refer to them as “hormone cycle control”) may help reduce some of the hormones that increase oil production and consequently help acne. (sadly not an option for guys)

My preferred over-the-counter regimen (no doctor involved):

1. Gentle cleanser 1-2x per day. (Remember use only your fingers or hands to clean your face)

2. BP product in 2.5% one to two times per day. Adjust to minimize irritation.

3. Moisturizer as needed.

4. If makeup is desired look for makeup that says “Non-Comedogenic” or does not cause acne.

If you see me in my office:

1. Gentle cleanser twice daily.

2. Differin, either gel or cream depending on tolerance. Apply once every third day for a week, then once every other day for a week, then once daily. Apply at night before bed. Only a pea-sized amount for the entire face.

3. Benzoyl peroxide 5%, Apply every other day in the morning after cleansing face. Increase to daily if tolerated.

4. * Cleocin T (clindamycin topical) Apply daily either in the morning or evening.

5. * Minocin (Oral antibiotic)

   * only in more moderate to severe cases.

No acne regimen gets rid of all acne. The best will reduce acne lesions by 50% or more in 75% of patients.

Remember that it takes a full four weeks for a skin cell at the bottom of the skin layer to be sloughed off. Consequently, it may take at least four weeks to see improvement in an acne treatment. Sometimes it can take up to eight weeks. Often, acne will get worse before it gets better (because the medicines can be initially irritating). If you see no improvement by eight weeks, either you are doing something wrong, or you need to go back to the doctor.

Most people see acne improve over time (late adolescence into young hood).

Posted by Lee Brock on Sunday, January 7th, 2007 at 9:47 pm.