Acne: a Case of Cosmetic Embarrasement

INTRODCUTION:


Acne vulgaris (acne) the bane of teenage existence occurs almost universally in both young men and women in their teens and early 20s. It is almost ubiquitous in teenage years. The peak severity is in the late teenage years but acnes may persist into the third decade and beyond especially in females who may experience flare-ups before menstruation. The hormonal changes responsible for premenenstral bouts, with acne are responsible for breakouts some women experience when taking oral contraceptives, during pregnancy or while undergoing menopausal hormone therapy.

Although acne is not dangerous, it is unsightly and can have a negative psychological impact on adolescents particularly at a time when they are most anxious about their appearance. Consequently, they seek all sorts of advice and medication so as to curb this “ugly” incidence. Being so “mirror-conscious”, they strictly follow these medications to retain their beauty. To make this situation even worse, acne is rarely cured. However, its symptoms can be controlled; acne eruptions can be reduced and scarring can be minimized with proper care.

This scourge has stolen beauty from many faces, generated undue worries and anxiety among the younger population, and presented a myriad of “unanswered questions” to health workers. Hence it is necessary to proffer solutions, on how to reduce its incidence lest it becomes a source of global worry.

DEFINITION: WHAT IS ACNE?
Acne is an eruption, predominantly of the face, upper back, shoulder and chest composed of comedones, cysts, papules and pustules on an inflammatory base. Simply put, it is an inflammatory eruption involving the pilosebaceous apparatus. The common name Pimple is usually used to denote the inflammatory lesion of acne. This condition occurs ina majority of people during puberty or adolescence due to androgenic stimulation of sebum secretion with plugging of follicles by keratinization associated with proliferation of Propionibacterium acnes.

CAUSES:
The cause if multifactorial, but there are 3 major pathogenic factors that clearly summarize its aetiology.
* Elevated sebum excretion
* Infection with Propionibacterium acnes
* Blockage or occlusion of the pilosebaceous unit.

There is a clear relation between the severity of acne and sebum excretion rate. Acne does not occur in complete absence of sebum. Therefore, sebum excretion is necessary for the development of acne but not sufficient to cause acne on its own. Androgen stimulation greatly determines sebum excretion. This accounts for the onset of acne in teenage years. Progesterone also increases sebum excretion while oestrogens reduce it. In another development, the bacterium Propionibacterium acnes colonizes the pilosebaceous ducts and acts on the lipids to produce a number of proinflammatory factors. Finally, the occlusion of the pilosebaceous unit contributes to the development of acne.

Acne can be exacerbated, or even caused by a number of factors including:-
* Genetic susceptibility leading to the hyperconification of pilosebaceous duct and its blockage.

* High humidity, frequent or prolonged sweating.

* Local irritation, friction, rough or occlusion clothing, which can be conducive to lesion formation of acneprone individuals.
* Long term use of hair-care products that contain occlusive petroleum of liquid petroleum, causing acne along the hairline (sometimes “pomade acne”)
* Drug such as corticosteroids which can sensitive hair follicles and produce “steroid acne” and other systemic drugs like androgens, some oral contraceptives, halothane and thyroid preparations known to precipitate acne eruption.

* Oil-based cosmetics can be occlusive and plug the follicles.

* Prolonged exposure to sun, prolonged stress and other emotional extremes.

CLINICAL FEATURES:
Acne presents in areas rich in sebaceous glands such as the face, back, shoulder and sternal (chest) area. The cardinal features are open comedones (black heads) due to plugging of the pilosebaceous orifice by kertain or sebum or closed comedones (white heads) due to accretions of sebum abd keratin deeper in the pilosebaceous ducts.

* Inflammatory papules circumscribed solid elevation up to 100cm diameter on the skin, which may be pedunculassted, sessile or filiform.
* Pustules circumscribed superficial elevation of the skin (about 1cm diameter) containing purulent materials.

Other clinical variants of acne include infantile acne, conglobate acne, acne fulminans, follicular occlusion traid, steroid acne and oil acne each with its distinctive features.

TREATMENT:
Self treatment should be limited to those patients who have non-inflammatory acne of mild-to-moderate severity (ie eruptions are limited to white heads and black head). The role of a detmatologist in severe cases of inflammatory acne (consisting of papules, pustules and nodules) must be south.

Treatment is aimed at decreasing sebum production, bacterial proliferation, normalizing duct keratinization or decreasing inflammation. Management starts with paying attention to exacerbating factors.

Topical agents such as:
* Benzyol peroxide (a keratolytic agent) and Fretinoin (A topical retinoid) should be used in individuals with fairly minor disease (particularly those dominated by the presence of comedones).

* Patients with anything but minor degrees acne will require therapy with antibiotics (local or systemic). Local antibiotics widely used include Clindamycin or Erythromycin. The principal oral antibiotic is Oxytetracycline. Monocycline may be used if oxytetacycline’s response is inadequate.

* If these topical and systemic agents fail to produce a sufficient clinical response within 3-6 months, treatment with Isotretinoin is considered. Remember, these drugs have their different modes of administration and side effects therefore, the physician’s role on prescription and monitoring of treatment is very essential.

Good skin care habits are essential in the treatment and management of acne. These should be emphasized by health workers. They include:
* Avoidance of prolonged exposure to the sun.
* Patient’s should be encouraged to switch from oil to water-based skin care products. If the hair is oily, frequent shampooing with water-based shampoo should minimized hairline eruptions.
* Patients should wash their faces 2-3 times daily using warm water, a mild medicated or unmedicated facial soap and a soft wash-cloth.
* Mild abrasive soaps (such as those containing pumice, polyethylene or Aluminum oxide) can be helpful in removing the outer layer of dead skin cells.

* Squeezing, pinching or picking at acne lesions can aggrevate the condition and cause permanent scarring. Avoid this!

CONLCUSION
The understanding of the basic aetiology and underlying pathology of any form of sickness is a great step in the pursuit of an effective treatment. Improper understanding may “rubbish” a good scientific treatment formular, or elicit a wide- range of side effects. With these steps for acne, the beauty and cosmetic concern of every individuals will be achieved.

REFERENCES:
1. Barbara white Sax (2000): Acne and Wrinkles: Skin care for baby boomers and their kids; Pharmacy times (Oct. 2000); P. 55-57.

2. Christopher Haslett et al (2000): Davidson’s principles and practice of medicine, Churchill Livingstone; P. 1051-1082.

3. Kumar and Clark (2000): Clinical Medicine (5th Ed.); 1320.

4. Lippoincolt, Williams, Wilkins (1998); Steadman’s Medical Dictionary. (27th Ed.) p. 15-16.