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Acne vulgaris (or simply acne)
What is acne? Acne vulgaris (or simply acne) is a common human skin disease specifically referred as disease of hair follicle of the face, chest, and back, characterized by areas of seborrhea (scaly red skin), comedones (blackheads and whiteheads), papules (pinheads), nodules (large papules), pimples, occasionally as cysts (deep pimples, boils ) and possibly scarring.
Adult acne: The number of adults who have acne is growing. Photograph above taken from American Academy of Dermatology’s website.
Important notes: Its common medical conditions affect almost all teenagers during puberty affecting an estimated 80–90% of teenagers in the Western world; the only exception being members of a few primitive tribes.
In 2010 it was estimated to be the 8th most common disease globally affecting 650 million people. For most people, acne diminishes over time and tends to disappear – or at the very least decreases – by age 25. There is, however, no way to predict how long it will take to disappear entirely, and some individuals will carry this condition well into their thirties, forties, and beyond.
Aside from scarring, its main effects are psychological, such as reduced self-esteem and in very extreme cases, depression or suicide. One study has estimated the incidence of suicidal ideation in patients with acne as 7.1%

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What causes acne? Hormonal: Hormonal activity, such as menstrual cycles and puberty, may contribute to the formation of acne. During puberty, an increase in sex hormones called androgens especial testosterone, other also which can associated with are, Dihydrotestosterone (DHT) and dehydroepiandrosterone sulfate (DHEAS), as well as insulin-like growth factor 1 (IGF-I ). These hormones cause the follicular glands to grow larger and make more sebum; a similar increase in androgens occurs during pregnancy, also leading to increased sebum production. Use of anabolic steroids (mostly used by body builder) may have a similar effect.
Development of acne vulgaris in later years is uncommon, although the incidence of rosacea, which may have a similar presentation, is increased in older age groups. True acne vulgaris in adult women may be a feature of an underlying condition such as pregnancy, or disorders such as polycystic ovary syndrome, hirsutism, or Cushing's syndrome. Menopause-associated acne (known as acne climacterica) occurs as production of the natural anti-acne ovarian hormones estradiol and progesterone fail, permitting the acnegenic hormone testosterone to exert its effects unopposed
Genetic The predisposition for specific individuals to acne is likely explained by a genetic component, which has been supported by twin studies as well as studies that have looked at rates of acne among first degree relatives. The genetics of acne susceptibility is likely polygenic, as the disease does not follow classic Mendelian inheritance pattern. There are multiple candidates for genes which are possibly related to acne, including polymorphisms in TNF-alpha, IL-1 alpha, CYP1A1 among others.
Psychological While the connection between acne and stress has been debated, scientific research indicates that "increased acne severity" is "significantly associated with increased stress levels." The National Institutes of Health (USA) list stress as a factor that "can cause an acne flare”
Infectious some studies conclude that acne does not caused by bacteria, although bacteria play a role in its development. Those bacteria linked to acne are: Propionibacterium acnes (P. acnes) is the anaerobic bacterium species that is widely concluded to cause acne, though Staphylococcus aureus has been universally discovered to play some role since normal pores appear colonized only by P. acnes.
Diet Some studies conclude there is no good quality evidence the relationship between diet and acne .However, a high glycemic load diet is associated with worsening acne. There is also a positive association between the consumption of milk and a greater rate and severity of acne. Other

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associations such as chocolate and salt are not supported by the evidence. Chocolate does contain a varying amount of sugar that can lead to a high glycemic load and it can be made with or without milk. There may be a relationship between acne and insulin metabolism and one trial found a relationship between acne and obesity
Pathophysiology: Acne develops as a result of blockages in the follicles. Hyperkeratinization and formation of a plug of keratin and sebum (a microcomedo) is the earliest change. Enlargement of sebaceous glands and an increase in sebum production occur with increased androgen (DHEA-S) production at adrenarche. The microcomedo may enlarge to form an open comedo (blackhead) or closed comedo. Comedones are the direct result of sebaceous glands' becoming clogged with sebum, a naturally occurring oil, and dead skin cells. In these conditions, the naturally occurring largely commensal bacterium Propionibacterium acnes can cause inflammation, leading to inflammatory lesions (papules, infected pustules, or nodules) in the dermis around the microcomedo or comedone, which results in redness and may result in scarring or Hyperpigmentation.
What are signs and symptoms of acne? 1. Papules Papules feel hard. When many appear, as they did on this woman’s forehead, the skin can feel like sandpaper.
2. Blackheads and whiteheads Blackheads and whiteheads are pores that fill with too much oil and dead skin cells. When a blackhead forms, the pore remains open. A whitehead causes a closed pore.

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3. Blackheads and pimples Blackheads are pores that fill with oil and dead skin cells.
4. Acne nodules Acne nodules are large, hard bumps under the surface of the skin. When a nodule heals, it leaves an acne scar.
Acne cyst An acne cyst forms when the pore fills with dead skin cells, oil, and bacteria. A cyst goes deep into the skin and can hurt.

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Above photograph were taken from: www.aad.org/dermatology-a-to-z/disease-and-treatment.
Acne signs Many people think that acne is just pimples. But a person who has acne can have any of these blemishes:
 Blackheads.
 Whiteheads.
 Papules.
 Pustules (what many people call pimples).
 Cysts.
 Nodules.
Acne appears on the face in all of the photographs above, but it can appear on other areas of the body. Acne can appear on the back, chest, neck, shoulders, upper arms and buttocks.
Acne symptoms Acne can cause more than blemishes. Studies show that people who have acne can have:
 Low self-esteem: Many people who have acne say that their acne makes them feel bad about themselves. Because of their acne, they do not want to be with friends. They miss school and work. Grades can slide, and absenteeism can become a problem because of their acne.
 Depression: Many people who have acne suffer from more than low self-esteem. Acne can lead to a medical condition called depression. The depression can be so bad that people think about what it would be like to commit suicide. Many studies have found that teens who believe that they have “bad” acne were likely to think about committing suicide.
 Dark spots on the skin: These spots appear when the acne heals. It can take months or years for dark spots to disappear.
 Scars (permanent): People who get acne cysts and nodules often see scars when the acne clears. You can prevent these scars. Be sure to see a dermatologist for treatment if you get acne early — between 8 and 12 years old. If someone in your family had acne cysts and nodules, you also should see a dermatologist if you get acne. Treating acne before cysts and nodules appear can prevent scars.
What other skin conditions can mimic acne?
 Rosacea: This condition is characterized by pimples but not comedones and occurs in the middle third of the face, along with redness, flushing, and superficial blood vessels. It generally affects people in their 30s and 40s and older.
 Pseudofolliculitis: This is sometimes called "razor bumps" or "razor rash." When cut too close to the skin, growing hairs twist into the skin and produce tender bumps. This is a

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mechanical problem, and treatment involves shaving less (growing a beard, laser hair removal). Pseudofolliculitis can, of course, occur in patients who have acne, too.
 Folliculitis: Pimples can occur on other parts of the body, such as the abdomen, buttocks, or legs. These represent not acne but inflamed follicles. If these don't go away on their own, doctors can prescribe oral or external antibiotics, generally not the same ones used for acne.
 Gram-negative folliculitis: Some patients who have been treated with oral antibiotics for long periods develop pustules filled with bacteria resistant to the antibiotics that were previously used. Bacterial culture tests can identify these germs, leading the doctor to prescribe different antibiotics or other forms of treatment
 Other :keratosis pilaris, perioral dermatitis, and angiofibromas among others
When should you start acne treatment? Since everyone gets acne at some time, the right time to treat it is when it bothers you or when the potential for scarring develops. This can be when severe acne flares suddenly, for mild acne that just won't go away, or even when a single pimple decides to show up the week before your prom or wedding. The decision is yours.
But remember: Dermatologists know that letting acne runs its course is not always the best advice. Here's why:
 Without treatment, dark spots and permanent scars can appear on the skin as acne clears.
 Treating acne often boosts a person’s self-esteem.
 Many effective treatments are available.
Diagnosis There are multiple scales for grading the severity of acne vulgaris, three of these being:
 Leeds acne grading technique: Counts and categorizes lesions into inflammatory and non-inflammatory (ranges from 0–10.0).
 Cook's acne grading scale: Uses photographs to grade severity from 0 to 8 (0 being the least severe and 8 being the most severe).
 Pillsbury scale: Simply classifies the severity of the acne from 1 (least severe) to 4 (most severe).
Medications
Benzoyl peroxide Benzoyl peroxide is a first-line treatment for mild and moderate acne due to its effectiveness and mild side-effects (mainly irritant dermatitis). It works against P. acnes, helps prevent formation of comedones, and has anti-inflammatory properties. Benzoyl peroxide normally causes dryness of the skin, slight redness, and occasional peeling when side effects occur. This topical does increase sensitivity to the sun as indicated on the package, so sunscreen use is often advised during the treatment to prevent sunburn. Benzoyl peroxide has been found to be nearly as effective as antibiotics with all concentrations being equally effective. Unlike antibiotics,

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benzoyl peroxide does not appear to generate bacterial resistance. Benzoyl peroxide is often combined with antibiotics.
Antibiotics Antibiotics are reserved for more severe cases and decrease acne due to their antimicrobial activity against P. acnes in conjunction with anti-inflammatory properties. With increasing resistance of P. acnes worldwide, they are becoming less effective. Commonly used antibiotics, either applied topically or taken orally, include erythromycin (category B), clindamycin (category B), Metronidazole (category B), and tetracyclines such as doxycycline and minocycline. Topical erythromycin and clindamycin are considered safe to use as acne treatment during pregnancy (category B) due to negligible systemic absorption. Nadifloxacin (category N), and dapsone (category C) are other topical antibiotics that may be used to treat acne in pregnant women, but have received less extensive study.
Salicylic acid Salicylic acid (category C) helps to lessen acne due to its bacteriostatic and keratolytic properties. Additionally, salicylic acid can open obstructed skin pores and promotes shedding of epithelial skin cells. Hyperpigmentation of the skin has been observed in individuals with darker skin types who use salicylic acid.
Hormones In females, acne can be improved with the use of any combined oral contraceptive. The combinations that contain third or fourth generation progestins such as desogestrel, norgestimate or drospirenone may theoretically be more beneficial. Anti-androgen agents including androgen receptor blockers such as cyproterone or spironolactone have also been used successfully to treat acne. Hormonal therapies should not be used to treat during pregnancy or lactation as they have been associated with certain birth defects such as hypospadias and feminization of the male fetus.
Topical retinoids Topical retinoids are medications that possess anti-inflammatory properties and work by normalizing the follicle cell life cycle. This class includes tretinoin (category C), adapalene (category C), and tazarotene (category X). Like isotretinoin, they are related to vitamin A, but are administered topically and generally have much milder side effects. They can, however, cause significant irritation of the skin. The retinoids appear to influence the cell life cycle in the follicle lining. This helps prevent the hyperkeratinization of these cells that can create a blockage. Retinol, a form of vitamin A, has similar, but milder, effects and is used in many over- the-counter moisturizers and other topical products. Topical retinoids often cause an initial flare- up of acne and facial flushing.
Oral retinoids Isotretinoin is very effective for severe acne as well as moderate acne refractory to other treatments. Improvement is typically seen after one to two months of use. After a single course, about 80% of people report an improvement with more than 50% reporting complete remission. About 20% of people require a second course. A number of adverse effects may occur including: dry skin, nose bleeds, muscle pains, increased liver enzymes, and increased lipid levels in the

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blood. If used during pregnancy there is a high risk of abnormalities in the baby and thus women of child bearing age are required to use effective birth control. There is no clear evidence that use of oral retinoids increases the risk of psychiatric side effects such as depression and suicidality.
Combination therapy Combination therapy using medications of different classes together, each with a different mechanism of action, has been demonstrated to be a more efficacious approach to acne treatment than monotherapy. Frequently used combinations include the following: antibiotic + benzoyl peroxide, antibiotic + topical retinoid, or topical retinoid + benzoyl peroxide.
What can you do about acne on your own? Think back to the basic causes of acne and you can understand why the focus of both home treatment and prescription therapy is to (1) unclog pores, (2) reduce bacteria, and (3) minimize oil. But first a word about...
Lifestyle: You can, however, still control your acne even if your routine is frantic and unpredictable. Probably the most useful lifestyle changes you can make are to never to pick or squeeze pimples. Playing with or popping pimples, no matter how careful and clean you are, nearly always makes bumps stay redder and bumpier longer. People often refer to redness as "scarring," but fortunately it usually isn't in the permanent sense. It's just a mark that takes months to fade if left entirely alone.
Open the pores Cleansing and skin care: Despite what you read in popular style and fashion magazines, there is no magic product or regimen that is right for every person and situation.
 Mild cleansers: Washing once or twice a day with a mild cleansing bar or liquid (for example, Dove, Neutrogena, Basis, Purpose, and Cetaphil are all inexpensive and popular) will keep the skin clean and minimize sensitivity and irritation.
 Exfoliating cleansers and masks: A variety of mild scrubs, exfoliants, and masks can be used. These products may contain salicylic acid in a concentration that makes it a very mild peeling agent. These products remove the outer layer of the skin and thus open pores. Products containing glycolic or alpha hydroxyl acids are also gentle skin exfoliants.
 Retinol: Not to be confused with the prescription medication Retin-A, this derivative of vitamin A can help promote skin peeling.
Kill the bacteria
 Antibacterial cleansers: The most popular ingredient in over-the-counter antibacterial cleansers is benzoyl peroxide.
 Topical (external) applications: These products come in the form of gels, creams, and lotions, which are applied to the affected area. The active ingredients that kill surface bacteria include benzoyl peroxide, sulfur, and resorcinol. Some brands promoted on the Internet and cable TV (such as ProActiv) is much more costly than identical and sometimes more potent products you can buy in the drugstore.

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Benzoyl peroxide causes red and scaly skin irritation in a small number of people, which goes away as soon as you stop using the product. Keep in mind that benzoyl peroxide is a bleach, so do not let products containing benzoyl peroxide come into contact with fabrics, leaving unsightly white spots on colored clothes, shirts, towels, and carpets.
Reduce the oil You cannot stop your oil glands from producing oil (unless you mess with your hormones or metabolism in ways you shouldn't). Even isotretinoin (Accutane, see below) only slows down oil glands for a while; they come back to life later. What you can do is to get rid of oil on the surface of the skin and reduce the embarrassing shine.
 Use a gentle astringent/toner to wipe away oil. (There are many brands available in pharmacies, as well as from manufacturers of cosmetic lines.)
 Products containing glycolic acid or one of the other alpha hydroxyl acids are also mildly helpful in clearing the skin by causing the superficial layer of the skin to peel (exfoliate).
 Masks containing sulfur and other ingredients draw out facial oil.
 Antibacterial pads containing benzoyl peroxide have the additional benefit of helping you wipe away oil.
What are other things you can do for acne? Are there any home remedies for acne?
 Cosmetics: Don't be afraid to hide blemishes with flesh-tinted cover-ups or even foundation, as long as it is water-based (which makes it noncomedogenic). There are many quality products available.
 Facials: While not absolutely essential, steaming and “deep-cleaning” pores are useful, both alone and in addition to medical treatment, especially for people with "whiteheads" or "blackheads." Having these pores unclogged by a professional also reduces the temptation to do it yourself.
 Pore strips: Pharmacies now carry, under a variety of brand names, strips which you put on your nose, forehead, chin, etc., to "pull out" oil from your pores. These are, in effect, a do-it-yourself facial. They are inexpensive, safe, and work reasonably well if used properly.
 Toothpaste? One popular home remedy is to put toothpaste on zits. There is no medical basis for this. Ditto for vinegar.
But remember: Despite the claims, acne treatment does not work overnight. At-home treatment requires 4-8 weeks to see improvement. Once acne clears, you must continue to treat the skin to prevent breakouts.
What is a good basic skin regimen? These are all good basic skin regimens that may help with the acne battle:
1. Cleanse twice daily with a 5% benzoyl peroxide wash. An alternative for those who are allergic to benzoyl peroxide is 2% salicylic acid.
2. Apply a gel or cream containing 5% benzoyl peroxide; an alternative is sulfur or resorcinol.

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3. Combination therapy as explained above
4. At night, apply a spot cream containing sulfur to the affected areas.
5. Use a light skin moisturizer and water-based makeup.
Additional Tips for managing acne: You can reduce your acne by following these skin care tips from dermatologists.
1. Wash twice a day and after sweating. Perspiration, especially when wearing a hat or helmet, can make acne worse, so wash your skin as soon as possible after sweating.
2. Use your fingertips to apply a gentle, non-abrasive cleanser. Using a washcloth, mesh sponge or anything else can irritate the skin.
3. Be gentle with your skin. Use gentle products, such as those that are alcohol-free. Do not use products that irritate your skin, which may include astringents, toners and exfoliants. Dry, red skin makes acne appear worse.
4. Scrubbing your skin can make acne worse. Avoid the temptation to scrub your skin.
5. Rinse with lukewarm water.
6. Shampoo regularly. If you have oily hair, shampoo daily.
7. Let your skin heal naturally. If you pick, pop or squeeze your acne, your skin will take longer to clear and you increase the risk of getting acne scars.
8. Keep your hands off your face. Touching your skin throughout the day can cause flare- ups.
9. Stay out of the sun and tanning beds. Tanning damages you skin. In addition, some acne medications make the skin very sensitive to ultraviolet (UV) light, which you get from both the sun and indoor tanning devices. Using tanning beds increases your risk for melanoma, the deadliest form of skin cancer, by 75 percent.
10. Consult a dermatologist if:
 Your acne makes you shy or embarrassed.
 The products you've tried have not worked.
 Your acne is leaving scars or darkening
REFERENCES:
1) Picardi, Angelo; Mazzotti, Eva; Pasquini, Paolo (2006). "Prevalence and correlates of suicidal ideation among patients with skin disease". Journal of the American Academy of Dermatology 54 (3): 420–6. doi:10.1016/j.jaad.2005.11.1103. PMID 16488292.
2) Thappa, Devindermohan; Adityan, Balaji; Kumari, Rashmi (2009). "Scoring systems in acne vulgaris". Indian Journal of Dermatology, Venereology and Leprology 75 (3): 323– 6. doi:10.4103/0378-6323.51258. PMID 19439902.
3) Goodman, Greg (2006). "Acne and acne scarring - the case for active and early intervention". Australian family physician 35 (7): 503–4. PMID 16820822.
4) Kurokawa, Ichiro, et al. "New Developments in Our Understanding of Acne Pathogenesis and Treatment." Experimental Dermatology 18 (2009): 821-832.
5) University of Nottingham Centre of Evidence Based Dermatology (2012). "2011-2012 Annual Evidence Update on Acne vulgaris". p. 10. Retrieved 23 September 2013.

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6) Madan RK, Levitt J (April 2014). "A review of toxicity from topical salicylic acid preparations". J Am Acad Dermatol 70 (4): 788–92. doi:10.1016/j.jaad.2013.12.005. PMID 24472429.
7) Melnik, Bodo C. (2011). "Evidence for Acne-Promoting Effects of Milk and Other Insulinotropic Dairy Products". Milk and Milk Products in Human Nutrition. Nestlé Nutrition Institute Workshop Series: Pediatric Program 67. p. 131.
8) Melnik, Bodo; Jansen, Thomas; Grabbe, Stephan (2007). "Abuse of anabolic-androgenic steroids and bodybuilding acne: An underestimated health problem". JDDG 5 (2): 110–7. doi:10.1111/j.1610-0387.2007.06176.x. PMID 17274777.
9) Chiu, Annie; Chon, SY; Kimball, AB (2003). "The Response of Skin Disease to Stress". Archives of Dermatology 139 (7): 897–900. doi:10.1001/archderm.139.7.897. PMID 12873885.
10) Titus, S; Hodge, J (2012). "Diagnosis and treatment of acne". American family physician 86 (8): 734–40. PMID 23062156.
11) www.aad.org/dermatology-a-to-z/disease-and-treatment.