Monday, December 27, 2010

Why should pimples be a cause for concern?

When I was about 10 years of age my skin began to change. I started having bumps on my face. I begged my father to bring me to a doctor. But people back then didn’t believe that pimples need to be treated. They adhere to the belief that it would disappear on its own upon reaching adulthood. Until now some people still think that way about pimples or acne. But why do we need to seek medical care for it?
First of all, acne is a cause of embarrassment for most teenagers and even adults. Their once smooth skin becomes rough and bumpy. They could not even look straight into other people’s faces anymore.  They were afraid of being stared at or laughed at. These people experience impaired self esteem, anxiety and clinical depression as a direct consequence of acne, which can lead to social isolation, interpersonal difficulties and even suicidal ideation. In a study of 60 adult patients with acne, Lasek et al. found that patients reported emotional effects as a consequence of their skin condition that were similar in magnitude to those reported by patients with psoriasis, which is traditionally regarded as a condition causing significant psychological disability. According to the results of a retrospective Swedish cohort study it was observed that the risk for attempted suicide was increased in patients with severe acne 6 months before and after treatment.  Even mild/moderate acne can be associated with significant depression and suicidal ideation.

Secondly, acne can leave scars which are permanent. It would be there for life even after the pimples are long gone. Patients who scar have an even higher prevalence of psychological morbidity when compared with non-scarring acne sufferers. Scars are difficult to remove even with the advent of dermabrasion and laser resurfacing.

What is Acne Vulgaris?

Acne vulgaris refers to the inflammation of a pilosebaceous unit in areas rich in sebaceous or oil glands, such as the face, neck, chest or back. It is the medical term for pimples. Most people call the huge zits on the face acne. It is a common misconception. Acne is characterized by a combination of lesions, such as blackheads (open comedones) and whiteheads (closed comedones), inflammatory papules and pustules and the nodulocystic lesions. Severe cystic acne affecting other areas aside from the face is called acne conglobata.

open comedones

Acne occurs at the onset of puberty due to the complex interaction of gonadotrophic hormones and bacteria (Propionibacterium acnes) in genetically predisposed individuals. Androgens stimulate increased sebum production by sebaceous glands. On the other hand, bacteria secrete lipase which converts lipids to fatty acids. The combination of sebum and fatty acids causes a sterile inflammatory reaction in the pilosebaceous unit with resultant hyperkeratinization of the lining of the follicle and its subsequent plugging. This is how comedones are being formed.  When comedones rupture into the dermis it resembles a foreign body, giving rise to an inflammatory response with pustule and abscess formation. Destruction of the surrounding tissue leads to scar formation.

multiple erythematous papules and comedone

The tendency to develop acne runs in families. It can be triggered by certain factors such as exposure to acnegenic mineral oils, intake of drugs (lithium, hydantoin, topical and systemic corticosteroids  and oral contraceptives),  endocrine factors (polycystic ovary syndrome), emotional stress, lack of sleep, occlusion and pressure on the skin by leaning face on hands or telephones and improper care of the skin.

Population-based and migration studies have suggested a correlation between diet and acne. Large, well-controlled, observational studies have demonstrated that diets high in dairy products are associated with an increase in the risk for and severity of acne. The relationship between milk and acne severity may be explained by the presence in dairy of normal reproductive steroid hormones or the enhanced production of polypeptide hormones such as IGF-1, which can increase androgen exposure, and thus, acne risk. Recent findings also describe an association between a high-glycemic-index (i.e., carbohydrates that break down quickly during digestion and release glucose rapidly into the bloodstream) diet and longer acne duration. No study has established a positive association between acne and chocolate, saturated fat, or salt intake.

Treatment measures to be carried out by the patient

  • .     Wash your face with soap twice a day. Do not scrub too roughly.
  •      Do not use greasy cream on the face.
  •      Avoid pancake-type makeup which may contain oil, grease or wax.
  •     Boys should not use oils, greases, pomades or hair tonics. Shave regularly.
  •     Have at least 8 hours of sleep each night.
  •     When getting out in the sun do not use oily or greasy suntan preparations.
  •      Don’t prick pimples on your own as this may lead to scarring.

The choice of acne therapy is largely determined by the severity and extent of the disease, but should be influenced by a number of other factors including disease duration, response to previous treatments, predisposition to scarring and post-inflammatory hyperpigmentation, as well as patient preference and economics. Patients with mild acne usually require topical treatment alone. Those with more extensive acne should be prescribed topical agents in conjunction with appropriate oral therapy. 
Many topical preparations for acne are available. These are:

  •  topical retinoids
  •  benzoyl peroxide
  •  azelaic acid 
  •  topical antibiotics
Most of the time a combination of these agents is necessary for a successful outcome. Antibiotics and/or hormonal treatments are employed for more severe or treatment-resistant disease. Systemic retinoids provide extremely efficacious therapy for severe disease that has not responded to combination therapy.
Your dermatologist should guide you on the step-by-step approach to treatment of acne. Bear in mind that resolution of pimples doesn't happen overnight. Response to treatment might be slow and there could even be a flare-up of acne on the onset of treatment. Any local preparation that was prescribed should be continued for months or even  years if you continue to have complexion problems.

You may experience occasional flare-ups and when this happens it is imperative that you begin active medical therapy with your dermatologist to avoid scarring of the skin.


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