Acne Can Sometimes Scar, Psychologically and Physically

One of the most difficult parts of living with a chronic condition like acne is that it is so visible. Since outbreaks - technically called lesions but more commonly referred to as pimples or zits - often occur on the face, they can be difficult to conceal. They can also occur on the neck, back, chest and shoulders. Severe acne can lead to permanent scarring.

Although acne is predominantly a disease of adolescents and young adults, it does occur among people 25 and older, and even in those in their 40s and 50s, says Priya K. Young, MD, an Assistant Professor of Dermatology at the Medical College of Wisconsin, who sees patients 17 and older at Froedtert & The Medical College clinics.

It's estimated that 80% of all people between the ages of 11 and 30 have acne outbreaks at some point. Among those under 25, acne affects men and boys more than women and girls, Dr. Young says. For those in their mid-20s and older, however, about 12% of women have acne, compared with just 5% of men. About 5% of the population continues to have acne in their mid-40s and beyond, with patients in this group evenly divided between men and women. Of these older patients, some have a history of acne in their teens, but not all. What causes acne? "We don't know," says Dr. Young. "It's a disease of unknown pathology, although there are several theories. It seems to be multifactorial, stemming from a number of genetic or environmental factors or from a combination of them."

Hormones Might Play a Role
One reason more boys and young men experience acne seems to be the role played by androgens, male hormones that are at peak levels among adolescents and young men. That could also explain why more young women 25 and older have acne than men the same age. Women's hormones - which include androgens - are at their peak when women are in their late 20s and 30s. And it's not uncommon for adolescent girls and adult women to have acne outbreaks two to seven days before their menstrual period starts.

Years ago, it was thought that eating chocolate and greasy foods like french fries caused acne. Not true, says Dr. Young, except perhaps for certain patients whose acne results from sensitivity to some foods. "Normally, we don't recommend any specific diet except a healthful balanced diet," she says. But environmental grease can play a role. "Patients who use cosmetics with a heavy oil base can clog their pores, and that can trigger lesions," she says. Also at risk are people who work in an environment where their skin is exposed to grease, such as a fry kitchen.

Another myth about acne, especially for people with blackheads, is that it is the result of not keeping the skin clean. "Acne is not a hygiene issue," says Dr. Young. "It's a disease." In fact, harsh scrubbing of the skin can irritate it or make it too dry. She recommends patients follow a regimen of cleansing their skin once or twice a day with mild soap and use a moisturizer that's labeled noncomedogenic (meaning it doesn't promote the formation of closed pores). She advises her patients to avoid rubbing and touching their lesions. Squeezing, pinching or picking blemishes can promote the development of scars or dark blotches.

Care, But No Cure, for Acne
For most patients, acne cannot be "cured," Dr. Young says. "Most dermatologists and researchers agree on that. The goal of treatment is to heal existing lesions, stop new lesions from forming, prevent scarring, and eliminate the embarrassment and stress that can accompany acne - and which can lead to a debilitated lifestyle in the most severe cases."

Many cases of mild acne can be treated with over-the-counter products. Dr. Young describes "mild" as relatively few lesions, minimal redness and soreness, and little scarring. For these cases, she suggests topical creams, lotions or gels containing benzoyl peroxide or salicylic acid. "Both peel the top layer of skin and prevent hair follicles from becoming plugged, which can cause a lesion to develop. Benzoyl peroxide helps reduce oil production; salicylic acid helps break down blackheads and whiteheads, and helps cut down the shedding of cells lining the hair follicles. Older remedies containing resorcinol or sulfur may also be effective," she says.

It may take up to two months before patients see results from these treatments. If there is no improvement, patients might want to consult a physician for a prescription. "Many over-the-counter products are available in prescription form," Dr. Young says. "Sometimes they are the same strength as drugstore products but they are better formulated, have a longer shelf life and are more efficacious."

Drug and Surgical Treatments
"Patients with severe inflammatory acne, or acne with nodules or cysts, should be treated by a dermatologist," she says, "as well as patients with scarring or textural changes in the skin." For patients with acne that does not improve with medicines such as those described above, a dermatologist may prescribe drugs such as antibiotics, birth control pills, or anti-androgen drugs, she says. Certain drugs to treat acne may cause skin inflammation or sensitivity to sunlight, she cautions.

For severe, disfiguring acne, dermatologists might prescribe a stronger prescription drug such as Accutane (isotretinoin), a vitamin A derivative. Isotretinoin is an oral drug that is usually taken once or twice a day with food for 15 to 20 weeks. It markedly reduces the size of the oil glands so that much less oil is produced. As a result, the growth of bacteria is decreased. For girls and women, the drug is linked to severe birth defects, so they should always use two forms of contraceptives or avoid sexual relations when on the drug.

The earlier acne is treated, the better the outcome. For patients with comedonal acne - whiteheads and blackheads - dermatologists can use a variety of procedures, in the office, to remove the comedones, Dr. Young says. For patients with scarring, the doctor may suggest a medical or surgical procedure to help reduce the scars, such as microdermabrasion, which "sands down" scars. "We have found that this procedure is most successful if done in a series of five treatments, six to eight weeks apart," she says.

"Dermatologists recognize the considerable social impact acne can have on some patients," Dr. Young says. "It can cause them considerable anxiety, self-consciousness and even depression. Although acne is usually not a serious health threat, it can be a source of significant emotional distress affecting their lifestyles. Today we can offer more treatment options than ever before."

Barbara Abel
HealthLink Contributing Writer

This article includes information from the National Institute of Arthritis and Musculoskeletal and Skin Diseases, part of the National Institutes of Health.

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.