Acne
What is it?
Acne, the most common of all skin problems, is an inflammatory disease of the oil-producing glands in the skin. It usually affects teenagers, although about 20 per cent of cases occur in adults. There are many types of acne, with acne vulgaris being the most common.
Symptoms of acne
Acne is usually divided into two main types, superficial and deep. Superficial acne consists of persistent, recurrent red spots or swellings on the skin. These are known as pimples and they usually occur on the face; but the back, chest, shoulders and neck can also be affected. Spots that bulge under the skin and have no opening are known as whiteheads, while dark pimples with open pores at the center are known as blackheads. Inflamed, fluid-filled lumps known as nodules and cysts can occur occasionally. In deep acne, deep inflamed nodules and pus-filled cysts occur, and these may become abscesses. Scarring becomes more likely as the lesions get deeper.
Causes of acne
There are small glands at the base of hair follicles, known as sebaceous glands, which secrete an oily material called sebum. During puberty, hormonal changes cause these glands to grow larger and produce excess sebum. The cells that line the hair shaft canal are also stimulated to produce more keratin, a fibrous protein which is found in skin and hair.
Acne begins when the openings of these sebaceous glands become plugged with dead skin cells, debris, bacteria and sebum. As the plug grows, it may become visible on the surface of the skin as a whitehead. Contact with air can cause the plug to darken and become a blackhead. When the gland opening is blocked, certain types of bacteria can overgrow and release enzymes which break down sebum and cause inflammation.
Acne is more common in males because they have higher levels of the hormones that stimulate oil and keratin production. Genetic factors may make certain people more susceptible to acne and it is possible that sufferers have higher levels of an enzyme which converts the male hormone testosterone to a more active form. Acne sufferers may also be more susceptible to the increase in sebum production. Acne does not occur because of excessively oily skin or improper cleaning, although these may worsen the symptoms. Another relatively common misconception is that acne is related to sexual activity. This is not the case.
Allergic reactions to certain foods, heat and humidity may make the symptoms of acne worse. In some women who develop acne in their 20s and 30s, aggravation by skin cosmetics may be the cause. Some medications, including anticonvulsants, lithium, anabolic steroids and some types of contraceptive pill, may also exacerbate acne. Acne is usually worse in winter and better in summer due to the beneficial effect of sunlight.
Sudden appearance of acne in adults appears to be on the increase and may be linked to hormonal imbalances. In some women, acne is worse before menstruation, possibly due to increased progesterone secretion. In some cases, acne may become clear or worsen during pregnancy.
While teenage acne almost always heals spontaneously in early adulthood, appropriate treatment can reduce the duration and severity of the disease, and help to avoid complications such as scarring.
Treatment of acne
Acne treatment depends on the severity of the lesions. Washing skin properly with warm water and nonperfumed soap, avoiding oily cosmetics and abrasive scrubs, and regular shampooing of hair to stop it becoming too oily can help to control acne. It is important to minimize the effects of pressure from tight collars or helmets, perspiration and touching, scrubbing and rubbing affected areas. Stress also causes an increase in certain hormones which can affect the severity of acne, and relaxation techniques may be useful in improving symptoms.
Picking and squeezing pimples can result in infection and scarring and should be avoided. There is no instant or permanent cure for acne, although it can be controlled and proper treatment will prevent scarring.
Medications
Mild cases of acne may be treated with various medicated creams and solutions, both prescription and nonprescription. Benzoyl peroxide, which is used on all acne-prone areas of the skin, can prevent as well as treat acne, and is used even when the face is clear. Side effects include burning, excessive drying and redness. Other treatments include clindamycin solution, tretinoin cream and azelaic acid cream.
Oral antibiotics such as tetracycline and minocycline are sometimes prescribed for moderate or severe cases, especially when there is a lot of acne on the back or chest. They reduce the bacteria in the hair follicles. It is usually found that acne symptoms recur after short periods of antibiotic treatment and long-term therapy may be necessary. However there are adverse side effects associated with long term antibiotic use.
Vitamin A-derivative drugs
Synthetic vitamin A-derivative drugs known as retinoids are used to treat cases of severe acne which have not responded to other treatment or which have only shown partial response to antibiotic therapy. There are topical and oral forms of these drugs and they are available on prescription. Visits to a doctor or dermatologist are necessary to monitor the side effects which include dryness and inflammation of the lips, conjunctivitis, photosensitivity, arthritis, bone abnormalities and depression. These drugs can cause birth defects if taken during pregnancy and should also be avoided by breastfeeding women.
Isotretinoin
Isotretinoin (Accutane) is derived from naturally occurring retinoic acid, which is related to vitamin A. It acts to reduce oil production by reducing the size of the sebaceous glands and also exerts anti-inflammatory effects. It is taken by mouth, with food. Care needs to be taken when giving isotretinoin to people with diabetes, alcoholism, inflammatory bowel disease, liver disease and obesity, or those with high blood fat levels.
Tretinoin
Tretinoin is similar to isotretinoin but is more toxic. It prevents the build-up of keratin and increases the turnover of epithelial cells. This prevents the formation of new spots. There are rare reports of nerve damage with topical tretinoin. Symptoms include headaches, depression and memory loss.
Adapalene
Adapalene is a new retinoid which is used on the skin in gel form. Studies have shown that it is as effective as tretinoin gel but is less irritating to the skin.
Hormonal treatment
In women whose acne seems to be particularly related to menstruation, oral contraceptives may relieve symptoms.
Acne and diet
While it does not seem that acne is a food-related problem, oily and sugary foods may exacerbate the symptoms. Foods such as shellfish, iodized salt and milk, which are high in iodine, may also exacerbate acne and should be avoided.1 Alcohol and tobacco should also be avoided.
Poor nutrition adversely affects the immune system and increases the likelihood of developing infections and inflammatory responses while a healthy low fat, high fiber, nutrient dense diet can boost immunity, reduce inflammation and improve symptoms. While no scientific studies have proven links with any particular food, food allergies may cause acne. Avoiding allergenic foods and improving digestive function may help relieve acne.
Vitamins, minerals and acne
Vitamin A
Dietary vitamin A may reduce sebum production by affecting sebaceous gland activity, but there is no firm evidence that vitamin A can be effective in the treatment of acne at nontoxic doses. Vitamin A supplements should not be taken with vitamin A-derivative acne drugs as this greatly increases the likelihood of toxic side effects.
B vitamins
B vitamins are important for healthy skin function. Vitamin B6 can be useful in treating premenstrual flare up of acne, possibly due to its ability to affect steroid hormone action.2 Most experts recommend taking it in the second half of the menstrual cycle, that is, one week before and during menstruation. The typical dose is 50 mg per day. Niacin may also be helpful in acne treatment as it improves blood flow to the skin. (See page 79 for more information.)
Nicotinamide (niacin) gel has been used as a topical treatment for acne and was shown in a 1995 study to have comparable effects to the antibiotic, clindamycin. Because clindamycin, like other antibiotics, is associated with the development of resistant bacteria, nicotinamide gel is a useful alternative treatment for acne.3
Zinc
Zinc supplements may be useful in the treatment of acne. Serum zinc levels are often low in adolescent boys, who are especially prone to acne.4 Zinc is involved in many functions which could affect the symptoms of acne. These include hormone activation, regulation of oil-producing gland activity, wound-healing, immune system activity, inflammation and tissue regeneration. High concentrations of zinc decrease the conversion of testosterone to its active form, thus reducing the stimulatory effects on the oil glands.
The results of studies using zinc treatment for acne are mixed. Zinc supplements have been beneficial in reducing the spots and oiliness in some acne sufferers. The inconsistency of the results may be due to the variation in the types of supplements used. Typical doses used to treat acne range from 15 to 30 mg per day.5,6
Other vitamin and mineral supplements
Antioxidants such as vitamin E, vitamin C and selenium may help to reduce inflammation and boost the effectiveness of the immune system which can help to reduce infection. It can be difficult to obtain large doses of these vitamins and minerals in the diet and supplements may be useful. Typical doses are 134 to 268 mg alpha TE (200 to 400 IU) for vitamin E, 200 to 500 mg for vitamin C, and 200 mcg for selenium. High chromium yeast has been used to treat acne with some success.7
Supplements and acne
Essential fatty acids
Some research suggests that abnormalities in fatty acid metabolism may contribute to acne.8 Because of their anti-inflammatory effects, essential fatty acids may be useful in the treatment of acne. Good sources include flaxseed oil and evening primrose oil.
Herbal medicine and acne
There are several herbal medicines which can be used to alleviate the infectious and inflammatory processes which occur in acne. These include pot marigold (Calendula officinalis) which can be used as facial wash, echinacea (Echinacea angustifolia or E. purpurea), tea tree oil (Melaleuca spp) and goldenseal (Hydrastis canadensis).
An important part of a herbal treatment program would also involve blood cleansing and improving elimination of toxins. Herbs that may be useful for this include blue flag (Iris versicolor), cleavers (Galium aparine), nettles (Urtica dioica), burdock root (Arctium lappa) and red clover (Trifolium pratense).