Acne is a disease of the hair follicle, caused by a  combination of both internal and external factors, like heredity, hormones, diet, stress, products used on the face and scalp, and others.

The first step in acne lesion formation involves an abnormal build-up of skin cells at the opening of the hair follicle, creating a clogged pore (microcomedo).

The clogged pore accumulates keratin, oil (sebum) and bacteria until it ruptures, releasing this mixture into the skin and causing inflammation. This inflammation can lead to painful cyst/abscess formation and  scarring.

Trying to squeeze out a pimple or cyst creates more even more inflammation. The lining of the hair follicle is thin.  It is stretched and thinned further by the accumulation of oil, keratin and bacteria below the plugged opening.  Squeezing the pimple partially releases the contents onto the surface of the skin, but also ruptures the lining of the hair follicle and lets this mixture spill out into the dermis, where the cells of the immune system mount an attack to remove it.  This deep inflammation promotes scarring even more.

In general, acne is characterized by the presence of whiteheads and  blackheads (comedones), papules, pustules and inflamed nodules and cysts,  usually on the face, chest and back.   Occasionally the inflammation is severe

enough to cause scarring, a  permanent change in the structure of the skin.

Mild to Moderate acne  consists of the following:

• Whiteheads  (Closed comedones) Whiteheads result when a pore is completely  blocked, trapping sebum (oil), bacteria, and dead skin cells, causing a white  appearance on the surface.

• Blackheads  (Open comedones):  Blackheads result when a pore is only partially blocked, allowing some of the trapped  sebum (oil), bacteria, and dead skin cells to slowly drain to the surface. The  black color is not caused by dirt.  When  the contents of the pore come in contact with air, they turn dark.

• Papules: Papules are inflamed, red, tender bumps with no head.

• Pustules: A pustule is inflamed, and appears as a red circle with a white or

• yellow  center, which contains pus. Pustules are garden variety pimples.

Severe acne consists of the  following, usually in combination with comedones, papules and pustules:

• Nodules: As opposed to the lesions mentioned above, nodular acne consists of acne spots  which are much larger, can be quite painful, and can

• sometimes last for months.  Nodules are large, hard bumps under the skin’s surface. Scarring is common.  Unresolved nodules can sometimes leave an impaction behind, which can flare again and again.

• Cysts: An acne cyst can appear similar to a nodule, but is pus-filled, and is described as having a diameter of 5mm or more across. They can be painful.  Again, scarring is common with cystic acne.

Treatments for acne:

Diet and hormones

• There are multiple androgenic, anabolic and growth hormones present in cow’s milk. Consumption of milk and dairy products leads to worsening of acne, as there is no such thing as hormone-free cow’s milk. Discontinuing consumption of milk and dairy products, such as cheese, yogurt, butter, ice cream, sour cream and even milk chocolate, and eating a diet of lean proteins, unsaturated fats and complex carbohydrates will be helpful in acne control.

• High glycemic index foods can also contribute to acne breakouts, as one of the mechanisms of triggering acne is related to insulin-like growth factor-1 (IGF-1)

• For women taking birth control pills, many of those preparations have androgenic (male hormone-like) properties and can contribute to significant acne eruptions.  Progestins in these medications, depot injections and intrauterine devices are the most likely to cause acne.

Acne surgery

Superficial chemical peels or cortisone injections are  sufficient treatments for many patients if they have just a few lesions.


Most of these medications are prescribed by a dermatologist after a thorough evaluation of the skin, medical history, hormonal status, allergies and other factors that go into the decision about acne treatment choices.  There are some over-the-counter options that can be tried first, like benzoyl peroxide washes or gels.

Acne sometimes flares during pregnancy.  There are very limited choices for acne treatment in pregnant women.  Most acne medications are contraindicated in pregnancy or we just don’t have information on how they could affect the baby.  If you are pregnant and seeking acne treatment, please consult with a dermatologist first, before starting any acne treatment regimen.

For mild to moderate acne:

• Benzoyl peroxide

• Topical retinoids, like Retin A, Differin, Tazorac

• Topical antibiotics, like clindamycin, erythromycin, sulfur/sulfacetamide combinations.

For nodular, cystic or scarring acne:

• Systemic antibiotics

• Antiandrogens, like spironolactone.

• Isotretinoin may be needed  for more severe or resistant cases.

Laser and Light Treatments

• Intense Pulsed Light (IPL)

• MicroLaserPeel

• Fractional Laser treatments.

These  therapies can be used alone or in combination with acne medications in order to  achieve the best results in acne treatment.

Source : Emily Altman MD

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