The scourge of the teen years...
Zits, spots, pimples…call them what you will, they are the enemy of every teenager.
Eight out of 10 adolescents experience some degree of acne. Trying every antiseptic soap and lotion available, many spend hours squishing out blackheads and looking with horror on every new eruption.
However, teenagers don’t have a monopoly on acne. To their dismay many adults develop it for the first time in their 20s or 30s. Worse again, just when they thought they had left the ‘pimply youth’ stage behind them, many see acne breaking out again in their maturity.
Root of the problem
To understand how acne occurs, you need to have some understanding of skin. Skin consists of two thin layers — an outer layer called the epidermis and a deeper layer called the dermis. The dermis contains blood vessels and fibres which give the skin its elasticity.
The epidermis contains a hard protein called keratin, which helps protect the skin. Hairs are present everywhere on the skin’s surface apart from the soles of the feet, the palms of the hands and parts of the genitalia. Each hair has a root and a shaft. Small glands called sebaceous glands near the root secrete a fatty substance called sebum, which also gives the skin a protective covering. It is this area of hair and sebaceous glands that is affected when acne develops. And the substances keratin and sebum are major players in the development of acne. Bacteria at the site of a blocked gland aggravates the condition.
Acne affects areas of the skin that have a lot of sebaceous glands, such as the face, centre of the chest, the back above the waistline, shoulders and the neck.
A black and white issue
The primary defect in acne is thought to be that there is too much keratin produced at the exit of the hair shaft. This blocks the surface and doesn’t allow the sebum out. Too much sebum is also being produced. Consequently the sebum builds up underneath and a plug of keratin and sebum then forms. If the upper portion of this plug is at the surface it becomes dark in colour from pigment (melanin) produced by surrounding cells in the epidermis. The result is a blackhead. If the plug remains under the surface it is referred to as a whitehead.
Sometimes sebum will continue to be produced under the blackhead or whitehead and because it has no means of escape the sebaceous gland itself begins to swell and eventually bursts into the dermis underneath. Because sebum is not normally present in the dermis it causes irritation. Redness and inflammation occur and pus is formed. Occasionally, in severe cases the dermis reacts by trying to ‘wall off’ the sebum and acne cysts are formed during this process. Scarring is also a rare feature of severe cases.
Like many medical conditions there are many influencing factors. More sebum than usual is being produced but this alone does not necessarily cause acne. The sebum produced by people with acne contains an excess of substances called free fatty acids, which in some way affect the process. This excess production of sebum is also influenced by hormones and usually acne begins during puberty.
Many girls notice that their acne flares up pre-menstrually. This is because fluid retention which occurs coming up to a period causes keratin to swell and this aggravates the problem. Sometimes infants have acne spots in the first few months of life which simply disappear. These are thought to be caused by the mother’s hormones during pregnancy.
Like skin during acne, its exact cause is still unclear. One reason might be the increased presence during acne of a certain bacteria that is found on healthy skin. Some families also seem to be more prone to acne, but how it is inherited is not clearcut.
But one thing that seems fairly certain is that acne is not the result of poor hygiene. All the experts state that acne is not affected by diet; however, many people are convinced of the contrary.
While lack of washing does not cause acne, frequent washing with soap and water will help by removing some of the excess keratin and sebum, and lessen the likelihood of blackhead formation. Removing blackheads with an extractor after soaking with a hot towel is useful.
There are preparations which break up keratin and allow drainage of sebum. It is best to start with the weakest strength and gradually move on to a higher strength if a response is occurring and the skin is not getting too sore. It is best to apply these at night.
Ultraviolet light often helps because of the peeling effect it has on the skin. Unfortunately relapse afterwards is high. If sunlight is associated with excessive heat and humidity it makes acne worse.
However, if the scrubbing isn’t working, the blackhead extractor is suffering metal fatigue and your mounting frustration is generating enough steam to make the bowl of boiling water redundant, do not despair…see your GP for help.
How can your GP help?
If in spite of your nightly ablutions, the infernal spots have not been banished, your friendly family doctor may be your answer.
- After discussion and assessment your GP may prescribe a course of antibiotics for you. Antibiotics are effective in about 70% of patients. Unfortunately response to treatment is a slow process. Expect a 10% improvement per month at best and it may be at least three months before a significant difference is seen. The usual length of treatment is six months.
- You will need to go back to your GP after about four weeks to have your response assessed. You may need a higher dose or a different antibiotic if your response is not satisfactory. If you do respond well after a completed course it is important not to stop treatment suddenly. You may need a small maintenance dose for a short period before tailing the dose off gradually.
- Antibiotics are also available in lotion for those with mild acne. Vitamin A-based gels are also useful and your GP will advise you on their use.
- For patients who don’t improve with antibiotics there are alternatives. For women, one of the contraceptive pills has an agent in it which improves acne. There are also stronger drugs which are generally prescribed by specialists for more severe cases.
Dr Sinead Cotter, general practitioner, Cork
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