Post by Dr. Herman
A rather embarrassing skin condition. In my former years of clinical practice, both in Outpatient and Pathology department, I often handled cases of psychological depression from patients who suffered one form of skin condition to another. Indeed the psychological sequel of acne includes higher rates of clinical depression with elevated levels of anxiety, anger, and even suicidal thoughts among adults.
Simply put, the root cause of acne is Oil: Acne starts when oil glands located deep in our skin (also known as sebaceous glands) produce greasy secretions (known as sebum) and end up clogging the pores of the skin. When this sebum clogs the tiny pores of the skin, increased cutaneous and systemic oxidative stress-caused by lipid peroxidation-starts off an inflammatory cascade leading to acne development. Therefore Acne is worse in people with oily skin. Some particular oils used in cosmetics and soaps have tendency to clog skin pores, worsening acne.
In women, Acne lesions are most common on the face, but in male population, they occur on areas with more hair follicles such as the neck, chest, back, shoulders, and upper arms. In men, it is the second disturbing skin condition after pruritus ani, a curable skin condition characterized by chronic itch around the anal region.
Acne occurs in both sexes, although teenage boys tend to have the most severe cases. Women are more likely than men to have mild to moderate forms into their 30s and beyond. 20% of all acne cases occur in male adults.
Plugged pores can develop into swollen, tender inflammations or ugly pimples or deeper lumps or nodules. Nodules associated with severe form of acne (cystic acne) clinically present as firm swellings below the skin’s surface that become inflamed, tender, and sometimes infected.
If the clogged openings are large, the clogs take the form of blackheads: (presenting as small, flat spots with dark centers). If the openings stay small, the clogs take the form of whiteheads: (presenting as small, flesh-colored bumps).
How Acne Develops
A triad of cascade comes into play: Hormones, Clogged pores and Bacteria are largely responsible for acne eruption;
Stress can aggravate acne-but clearly does not cause it. Stress leads the body to produce a stress hormone called Cortisol which leads to more inflammatory processes worsening acne.
Testosterone, a hormone produced in both sexes, signals the body to make more sebum. It is this excess sebum that clogs the openings to hair follicles.
Presence of bacteria known as Propionibacterium acnes bacteria often get trapped into the blocked pores, causing blackheads or whiteheads (also known as comedones ) on the skin’s surface. When sebum clogs the pores it may leak into nearby tissues and form a pustule or a papule, causing what is called inflammatory acne. Larger, tender pustules are called nodules.
Other factors associated with acne development, though not common are diet, contraceptives and steroids-that are taken by body builders.
Acne may be made worse-even when on treatment- by scratching and touching the itchy pimples with dirty or oily hands. Affected people whose profession exposes them to frequent contact with oily soils and detergents e.g. Mechanics and Salonists, can attest of the incidence at which acne bounces back despite sustained efforts in treatment of the same.
Effective Management of Acne
Pharmaceutical companies have taken advantage of, and like the false prophets littered in social media, devised a way of cashing in big time from the suffers of Acne by making products that purport to cure acne. These medicaments are poorly compounded and passed off as OTC products. Often, the users of such ‘medicines’ change from one product to another when the previous one has not worked out as anticipated, spending quite some amount of their income on the condition. In USA alone, topical drugs which are used to treat mild acne, accounted for an estimated 2.1 billion U.S. dollars in 2016 and within the same period, many pharmaceutical companies hiked the prices of the anti-acne drugs by over 1000%
Like I said earlier, some oils used in skin care preparations, (including soap) have the tendency to plug the skin pores. These oils are known as comedogenic oils. Not only do they worsen, but initiate acne development (especially to Acne-prone persons). It is imperative, therefore to know the types of oils used in cosmetics and soaps when it comes to managing acne. It often becomes a major undoing trying to cure acne while using products that are made of ingredients known to plug the pores.
Oils that do not plug the skin pores are referred to as Non-Comedogenic Oils. Comedogenic (skin plugging) ingredients include synthetic and natural oils, waxes, silicones, detergents and thickeners. Comedogenecity is usually rated on the scale of 0-5. Non-comedogenic oils are rated 0, while the mildly comedogenic oils are rated 2-3. Highly comedogenic oils are rated 4&5. Some people with Acne though, can tolerate natural oils with comedogenic rating of 2.
Getting rid of excess oil through cleansing (i.e. stripping oil off skin) is key to managing Acne. Besides other supportive treatment procedures, soaps that are mildly cleansing are the mainstay to complete elimination of acne. Soaps that have cleansing ability usually contain natural cleansing agents and not chemical surfactants, since surfactants are known to worsen acne. Care must be exercised not to use soaps that contain comedogenic oils. However expensive they are, good anti-acne soaps stay clear of Palm oil (Sodium Palmate), Coconut oil (Sodium Cocoate) and Palm Kernel (Sodium Kernelate). All the said oils are comedogenic.
A popular Anti-Acne soap in Nairobi’s pharmacy stores Elba, has Shea butter, Tea tree oil, Sodium Towlate among other ingredients that open the pores and get rid of dead skin. According to an insert in the soap packet, Elba, contains Potassium Salts– a natural cleanser, which the manufacturer says effects the mild stripping of excess oil from the affected part of the skin, thereby aiding in pore opening (which is necessary for entry of antibacterial medicaments). Glycerol, a humectant with comedogenic rating of 0 is another ingredient in the soap that prevents Anti-acne soaps from excessively drying the skin during the act of cleansing.
Tea tree oil is a naturally proven antibacterial while clindamycin is a potent synthetic antibacterial. Adaplene, found in equally expensive anti-acne gels such as Klenzit C also plays the role of opening the pores. Klenzit C is an antibiotic gels prescribed for the treatment of Acne. Clindamycin in Klenzit C targets Propionibacterium acnes bacteria which causes Acne. Other topical agents with antibacterial actives include Hydroxyl peroxide creams. Sulfur-based soaps like Roberts are also good adjuvants in managing acne. Facial Cleansing Serums and Gels are especially good alternatives to Soaps due to their convenience (can be carried and used in offices or long distance travel). Various brands e.g. AcneLiptogel are accessible over the counter in leading pharmacies across Kenya, Uganda and Tanzania.
Systemic (oral) administration of antibiotics that target elimination of P. acnes bacteria is necessary when dealing with severe form acne breakout-such as Acne-Vulgaris. Antibiotics in the class of tetracyclines are preferred for their effectiveness and low incidence of resistance over Propionibacterium acnes. But is probably the mode of working of tetracycline that makes them drugs of choice in treating Acne: Tetracyclines reduce keratinisation in the pilosebaceous units thereby lowering free fatty acid levels in the sebum and as a result, inflammatory reactions are inhibited because of decreased complement activation, reduced polymorphonuclear leucocyte chemotaxis and macrophage phagocytosis
Overall, strict dermal hygiene, timely adherence to oral medications and good control of excess sebum (frequent use of mild acne soaps) are the mainstay to getting rid of Acne for good.
Common malpractices in Managing Acne:
In my short-lived medical practice, I came across individuals who attempted treating Acne with anti-mycotics. Others, due the mere fact that salicylic acid is good at acne management, used Whitefield’s Ointments on their faces. All ointments use oils and waxes that clog pores, exacerbating acne. Acne may also be misdiagnosed for a similar but a more severe condition known as Follicular Occlusion Triad, whose causes include family history of the condition, smoking, obesity, increased humidity, high carbohydrate diet and certain bacterial infections.
Any information provided on this site is also not a substitute for the advice of a licensed medical practitioner, nor is any information included intended to diagnose, treat, or cure any disease. Products mentioned in the post are for illustration only and not endorsed by the writer