What is acne?

Causes leading to the onset and development of acne.

The seriousness of acne depends on a number of factors (internal and external). Acne therefore belongs to a group of multi-factor diseases. The combination of internal causes in each individual will determine whether acne will be more or less severe. External causes are of minor significance with regard to the modification of the disease.

Acne belongs to a group of non-infectious chronic inflammatory diseases of sebaceous glands and hair follicles. Major factors come into play here, being associated with the anatomy and leading to the  dysfunction of this unit. This kind of follicles with an additional sebaceous gland (as mentioned above) is named the pilosebaceous unit. The largest number and size of sebaceous glands attached to hair follicles are located in the face and the back (particularly between the shoulder blades and above the sternum). They are typical of human body, and their structure predisposes them to the development of acne lesions. Internal factors, in particular, contribute to the onset and development of the disease to a different degree:

• a) The increased formation of sebum (seborrhoea) develops as a result of the increased activity of sebaceous glands that is controlled by androgens. The activity of sebaceous glands is also affected by the hormones released from the pituitary and thyroid glands as well as by the central nervous system. To some extent, the genetic susceptibility of sebaceous glands (their androgenic receptors) to sexual hormones should also be taken into account. This can also be partly influenced by a diet, mental state and some drugs. Sebaceous glands are usually enlarged and very active as a result of the action of androgenic hormones. Moreover, all important components of the sebum are comedogenic and through their pharmacological and toxicological properties they can induce inflammatory reaction. The penetration of the sebum from a follicle into the surrounding skin (the cutis) induces a severe reaction of the surrounding tissue. For example, this happens after the rupture of the wall of hair ducts as a result of unsuitable mechanical removal of comedones with the subsequent development of inflammatory lesions.

The sebum is the most important factor of the whole mosaic of causes leading to acne and is called "fuel for the fire of acne." It should be pointed out that although the skin of acne patients is more or very greasy as compared to healthy individuals, the sebum plays a major role when it is still in the outlets of sebaceous glands rather than when it is on the skin's surface. At this place, it has a major role not only for the development of comedones but also for the microbial colonization, particularly with Propionibacterium acnes.

• b) The enhanced and accelerated production of cornified cells in follicles and in the outlets of sebaceous glands. Cornified cells show increased adhesiveness which makes their separation difficult and which prevents the sebum to be released on the skin surface. Cornified cells are attached one to another; so they cannot be expelled to the upper layer of the skin in the form of individual flakes as it is seen in individuals who do not suffer from acne. Besides, these cells react very sensitively to other external and internal factors (acnegenic factors) by the increased ability of cornification and the formation of another comedones. As a result, the outlet of the follicle of the sebaceous gland is blocked with accumulated cornified cells and the increasing amount of the sebum, which is initially visible only microscopically as microcomedones. Comedones therefore result from the disorder in the maturation of the cells that form the lining in the wall of the follicle's outlet of the sebaceous gland, to the normal cornified cell. A gradually increasing number of cornified cells and the sebum results in the first symptoms on the skin's surface such as clogged pores accompanied with the greasy skin. Greasy skin looks impure, glossy with large pores.

• c) Bacterial flora is represented particularly by Propionibacterium acnes whose colonies colonize the deep parts of follicles where there is an oxygen-free, anaerobic environment. Its effect on the onset of acne's inflammatory symptoms is indirect, i.e. bacteria do not act as infectious agents at the onset of the disease. The most common symptoms such as pink pimples arise due to the antibodies produced against Propionibacterium acnes. The levels of antibodies against this microbe in the blood of acne patients are high. Only the excessive amount of sebum produces the favourable environment for a growing number of Propionibacteria which also increases the amount of the biologically active substances produced by these bacteria, contributing to the formation of comedones and inflammatory reaction. Propionibacterium acnes produces enzymes which decompose fat to fatty acids. Some of the fatty acids have an adverse effect on the follicle's wall by making it less resistant to the accumulated contents of a follicle and mechanical cleansing of the skin. As a result, the follicle wall may rupture easily. In fact, the contents from the follicle outlets of sebaceous glands is a foreign substance for the deep part of the skin (cutis) and the cells present here (white blood cells) react to this material in the same way as if it was a foreign body. This results in the formation of granuloma around the foreign body. Initially, this is not an inflammatory reaction. The individual reaction to this foreign material of the comedone is subsequently reflected in the clinical picture of acne in individual patients. The next stage is characterized by the formation of pimples and pustules in the skin which may turn into inflammatory nodes, ulcers and infiltrates at later stages. The onset and extent of inflammatory reaction depends on the degree of immunity against Propionibacterium acnes. Microbes on the skin surface are only of minor importance with regard to the etiology of acne.

Acne is not therefore a contagious infectious disease because it is not primarily caused by microbes. An inflammatory complication caused by accompanying bacterial agents arises secondarily.

• d) Genetic predisposition plays an important role in acne patients. Genetic factors determine the size and activity of sebaceous glands, the sensitivity and number of androgenic receptors for androgenic hormones, and therefore the predisposition to acne. To some extent, the role of genetics is also reflected in the clinical picture and the duration of acne.

• e) A number of different parameters come into play at the onset of acne, some of which are more important than the others. Psychosomatic conditions were also found to play an important role as different kinds of stress always make acne worse. Conditions such as digestion problems, particularly chronic constipation, various infections (dental sac, untreated teeth, chronic inflammations of cervical tonsils,upper airways, gynaecological problems) or diseases accompanied with fever with excessive swelling. Some foods may also contribute to the deterioration of acne symptoms (for example nuts, fat foods, hot spicy food), solar radiation, hot, sultry or dusty environment, mechanical irritation (for example hair, headband, scratching and the intensive treatment of acne symptoms (squeezing). External factors which may impair acne or cause the onset of the disease include chemical substances such as mineral oils, vaseline, tar, cooling mixtures, solid chlorinated hydrocarbons. Similarly, some of the cosmetic creams, particularly those containing vaseline, lanoline, laurylalcohol, may also contribute to the development or progression of acne.

• f) Some drugs - particularly their side-effects - are also among the factors that may induce acne. Iodides, bromides and chlorides may induce acne symptoms and are not therefore used in acne patients. Furthermore, vitamin B12, steroid hormones (for example hydrocortisone, prednisone), some antiepileptics, psychopharmaceuticals (lithium, etc.) may also contribute to the development of acne.

Acne symptoms

As described above, initial changes manifested on the skin proceed unobserved since they proceed in the deeper parts of the skin. The outlets of a follicle of sebaceous glands become blocked due to the adhesion of cornified cells and the increased release of the sebum, resulting in the formation of microcomedones (i.e. primary pathological change) which gives rise to all acne symptoms that develop during the next stages of the disease. We call them precursors of all other acne lesions. An increase and accumulation of the contents gradually give rise to the first symptoms of acne such as closed comedones on the skin, i.e. "white heads". This name is derived from the whitish tiny formations which stand slightly out of the skin's surface, representing the still unextended orifice of the outlets of the follicles of sebaceous glands. Since the cornified cells and sebum are not being released, the orifice extends as a result of filling, and the open comedones appear on the skin surface; comedones are called blackheads because they look as dark brown or black widened pores. Colouration is caused by the oxidation of melanin rather than by the presence of impurities. The appearance of closed and open comedones is the first visible symptom of acne.

Any other inflammatory symptoms of acne which are usually present in acne patients such as pimples, pustules, nodes, ulcers, infiltrates occur in the next stage of the disease.

In the outlets of follicles of sebaceous glands closed by comedones, there are suitable conditions for the multiplication of some bacteria, particularly anaerobic bacteria Propionibacterium acnes, yeast and Staphylococcus. Such microorganisms very often cause inflammation in sebaceous glands which affects the whole gland. This is accompanied with damage to the wall of the sebaceous gland and the inflammation will spread into the surrounding tissue. If the inflammation is severe, it will damage the whole sebaceous gland resulting in a scar in this location. The appearance of scars depends on the individual ability of healing. As a result, there are atrophic scars where the skin is thin and folded, and the affected site is below the surrounding skin. When a larger amount of collagen tissue is formed, the scars may stand out over the surrounding tissue (i.e. hypertrophic scars) or extend the original inflammatory process (i.e. red-purple keloid scars). This kind of scars is usually very sensitive and painful.

Types and forms of acne

The complexity and variety of acne is due to the existence of many different types of acne rather than due to the mild and severe form of acne. They may look very similar at first sight which is due to the affecting of the same site - the follicle of the sebaceous gland. However, the cause depends on the ratio of the involved factors leading to the development of acne whose effects combine and lead to acne symptoms.  Causative factors act in individual types of acne with different importance, they have therefore different significance with regard to the development and duration of the disease. In practice, such differences lead to different acne, for example acne with the overproduction of comedones or with increased sensitivity to acnegenic substances or acne with significantly increased seborrhoea.

On the basis of these findings, acne can be divided into three basic groups:

a) The forms of acne that depend on the internal predispositions (endogenic)  which particularly include acne vulgaris with its clinical forms of different severity

• Comedone acne (acne comedonica)
• Papular pustular acne (acne papulopustulosa, Grade I, II, III, IV severity),
• Acne conglobata
• Special forms of acne (acne conclobata, complicated by further inflammatory symptoms in locations that are not typical of acne)

b) The forms of acne that depend on external factors (exogenic) when the skin comes into contact with substances that contribute to the development of acne.

c) The forms of acne, i.e. acneiform acne, which may develop as a side-effect of some of the drugs.

Acne vulgaris

The most common form of acne is acne vulgaris which occurs mainly in puberty. First symptoms usually occur at the age of 11 - 13 years, or early, for example at the age of 8 years in girls. Both genders are affected at early age at the same frequency. However, severe forms of acne due to the differences in hormonal levels of androgens develop in boys at a higher rate as compared to girls. The maximum rate of acne is at the age of 16 - 18 years. Acne recedes in girls at the age of 20-21 years and in boys at the age of 22-24 years. In a small portion (around 5 %), the symptoms persist after the age of 25 years. Over the last few years, the age limit for the occurrence of acne has shifted particularly in adult females, namely in 31 % of cases up to the age of 45-50 years.

The first symptoms of acne, i.e. closed and open comedones, appear in typical localizations (nose, forehead) followed by the chin and face while in late stages they may also appear on shoulders, the upper part of the back and the torso in the area of the neckline. However, it is quite common that only some of the above-mentioned sites are affected, for example the face or the back and the torso.  At the same time, sebum is produced at elevated level which is manifested by greasy skin, particularly in the face, and by greasy hair. In next stages, both closed and open comedones became inflamed with pimples, pustules, red subcutaneous nodes, cysts and ulcers being formed in the affected sites of the skin.

Comedone acne is characterized by predominant closed and open comedones without any significant inflammatory symptoms. This means that the number of pimples or pustules does not exceed 5 in one half of the face.

On the other hand, one typical feature of papulopustular acne is that besides comedones it also contains a significantly larger number of inflammatory pimples and pustules, depending on a degree of severity (from the lightest to the most severe, i.e. from 6 up to over 50 in one half of the face). This kind of acne is more severe, lasts longer and results in minor scars whose number depends on treatment. However, some patients develop unnecessarily scars and pigment spots due to unsuitable squeezing and scratching of comedones or inflammatory lesions.

Acne conglobata is a severe form of the disease whose clinical picture is formed not only by pimples and pustules but also by larger inflammatory nodes and infiltrates, cysts (abundant in sebaceous substances), abscesses often linked with fistulae which release bloody pus and sebum spontaneously or after opening. Acne conglobata proceeds chronically, usually for dozens of years, up to adulthood and in most cases it leads to the formation of differently formed scars. The majority of patients are men. Predisposed individuals are prone to the formation of thickened, solid and elevated scars (hypertrophic and keloid) of red/purple colour. The resultant state can also consists of scars drawn under the level of the surrounding skin with a thin folded surface - atrophic scars. Unsuitable treatment may also result in complications with the excessive deposition of pigment. All above-mentioned resultant states require longer time for alleviation and healing. This is one of the reasons why therapy using suitably selected acnetherapeutics should begin early.

Severe forms of acne

Acne inversa includes acne tetrada and acne pentoda and only affects healthy adults. It often combines with acne conglobata whose clinical picture is complicated by the formation of abscesses, fistulae, scaring, particularly in intertriginous areas where the two skin areas may touch or rub together (wet sites).  The inflammatory process affects the large sweat gland localized in the armpits and groins. Painful bumps also develop in the genital area and in the gluteal cleft around the annus. Fistulae with purulent secretion may recur below the sacral bone (acne tetrada). In some cases, this stage may deteriorate by the formation of minor ulcers in the hairy part of the head with the subsequent formation of scars and scaring (acne pentada). The disease is chronic since the treatment often fails to bring unambiguous results.

The most severe forms of acne include acne fulminans which is called „acute fever ulcerative acne conglobata with the inflammation of joints." It is characterized by the acute, often unexpected onset, symptoms of acne conglobata with the inclination to the formation of ulcers even in non-typical localities such as arms, forearm and shanks. The condition is accompanied with fever, joint inflammation and the increased number of white blood cells. The disease is rare, only affects boys usually at the age of ca 17 years. Treatment requires hospitalization.

Other common forms of acne

Acne neonatorum, Acne infantum, premenstrual acne, Acne excoriée, Acne tropicalis, acne of adult females, masculinizing syndrome, acne dependent on external factors, cosmetic acne, acne from clearing agents, Mallorca acne (acne aestivalis), oil acne, tar acne, chloracne, acne induced by physical factors, acneiform acne.

Treatment of acne

We expect that treatment of acne will

• Alleviate symptoms of greasy skin
• Remove comedones and prevent their formation
• Remove inflammatory symptoms (pimples, pustules, nodes, cysts)
• Prevent the development of new inflammatory lesions

The treatment of acne should not be postponed and should start when the first symptoms of closed and open comedones are found. A negative attitude towards treatment is wrong since early consistent therapy is the only way of preventing the development of acne into more severe forms and achieving satisfactory results in terms of the improved state of the skin and healing. Therapy requires patience supported by knowledge of therapeutic options, expected beneficial and adverse effects of a topically and generally used medication and the expected duration of therapy.

The side effects of drugs may seem unimportant but the opposite is true. The unsuitably applied drug may lead to burning sensation, itching, erythema, desquamation, or the formation of tiny pimples and blisters. This often necessitates the discontinuation of the drug. The drug would not cause any negative symptoms if applied suitably for short-time application.

It is also necessary to point out that even correctly chosen therapy which leads to early improvement, the disappearance of comedones, inflamed pimples, general improvement of the skin cannot be only short-time or once-and-for-all despite such a benefit. Therapy should be long enough to ensure that causative factors of the disease have been removed or suppressed and that they are not able to induce new symptoms of acne. If the therapy was short or discontinued, it is very likely (100 %) that it will appear again. It is possible that the symptoms of the disease that occurred before therapy reappear after a break of 1-2 months. Therapy should therefore be consistent and regular, particularly if severe symptoms have occurred. If the stage characterised by inflammatory symptoms with a large number of comedones has been overcome, it is possible to reduce therapy and switch to the maintenance and preventive application which prevents the re-occurrence of acne symptoms. Of course, such procedures and combinations are in the hands of physicians who should decide on the most suitable method of treatment in a particular patient depending on the patient's current state. Regular follow-up is an important part of therapy since the physician (dermatologist) may make a sensitive choice of suitable drugs depending on the nature of the disease and skin reaction. In spite of this, it may happen that even thorough therapy would bring transient failure or the impairment of symptoms. This should not force the patient to apply various products on their face that are currently being advertised. In such a case, there will not be any improvement as expected but this would raise further doubts in a patient. In the case of transient failure or impairment, it is not recommended that the patient would switch to another physician. This usually happens when the patient is impatient and the results of the treatment that lasted several months do not match their expectations. Keep in mind that the physician should tailor the method of treatment according to the individual needs of a patient. The switching from one physician to another causes the therapy to be restarted again and again.

Local therapy

a) Local therapy

• Conventional agents
• Local (topic) retinoids
• Antibiotics
• Benzoyl peroxide
• Azelainic acid
• A group of other local agents

b) General (systemic, internal) treatment of acne

• Antibiotics
• Hormonal therapy
• Isotretinoin (13-cis-retinoic acid)

Vaccine therapy

Current vaccines are usually tablets or capsules (formerly injections or drops) and contain the strains of Propionibacterium acnes and Staphylococcus. Bacterial dry matter obtained using a special procedure is then processed to capsules in a pharmacy.

An individual undergoing vaccine therapy must adhere exactly to the schedule of the vaccine dosage. The initial dosage is more intensive with longer breaks between individual doses in later stages of use. Capsules are preferably used in the morning on an empty stomach before a meal.

Vaccines in the form of tablets and capsules are suitable for the treatment of inflammatory forms of acne, and alleviate the symptoms of acne depending on the severity of the disease. Prolonged use may also prevent the impairment of acne-related inflammatory symptoms.

If an acute infectious agent occurs during vaccine therapy, the discontinuation of the vaccine is recommended. Besides this kind of vaccines there are also commercial products which are not produced specifically for the treatment of acne.

 

ACNEVAC is an original product that was developed in cooperation with experts from the Faculty of Medicine, Palacky University in Olomouc.

It contains harmless bacterial particles originating from the bacteria that are common causative agents of skin diseases

 

ACNEVAC . . . . . for beautiful skin 

 

 

• ACNEVAC - bacterial lysate from strains of the most common causes of skin inflammatory diseases.
• ACNEVAC can be used by both men and women to enhance non-specific immunity
• One pack of ACNEVAC contains a dose for three months
• ACNEVAC is used once daily
• ACNEVAC is an OTC product available in a pharmacy without prescription
• ACNEVAC is not intended to replace a varied diet
• Ask your pharmacist for ACNEVAC