Acne is a common skin condition that affects teenagers and adults. Conventional treatments usually consist of antibiotics, prescription medications and topical treatments, but you will find that your acne stubbornly returns when the prescriptions are discontinued.
There are many organ system disruptions that may affect your acne such as a hormonal imbalances, digestive conditions, stress, dehydration, use of certain skincare and cosmetic products and even certain food allergies and sensitivities.
What is acne?
As far as skin conditions go in terms of public awareness, acne is much different than psoriasis, eczema, seborrhea and other common skin conditions in that almost everyone knows how to recognize acne. It is seen as a rite of passage for adolescents and teenagers that they experience as they enter and go through puberty, with varying degrees of severity. Severe cases can lead to scarring, particularly if flare-ups continue for years.
The difficulty with acne occurs when it is disfiguring in adolescent years or when it continues well into adult years. We see patients who are in their 20s, 30s, 40s and even 50s or older still struggling with acne, when it should have been a long distant memory.
Other cases include patients who had relatively clear skin during their youth, but have adult onset acne that can start years or decades after puberty.
Acne in a nutshell
Acne is an inflammatory skin condition that effects the upper layers of skin. As a result of the inflammation the skin may appear to have a reddened or pinkish base. The lesions that form are the result of blocked pores (sebaceous glands) that overproduce oily substances and can trap bacteria creating small pockets of pus under the skin. This creates the classic “whitehead” pimple.
There are varying degrees to which this can present. There are the isolated small whiteheads that are most common. Often times it is hard to resist picking at or popping these blocked pustules, and it is tempting to squeeze them to release the contents. This creates to an opening in the skin, which subsequently triggers a normal mechanism of skin repair, which unfortunately can lead to hyperpigmented (darkened) skin and scarring.
Other times, when pimples present at a faster rate and in a higher concentration, they can coalesce into much larger and more visible pustules that can be quite noticeable and would be classified as severe acne.
Cystic acne is a form of acne that present deeper in the skin and are slow to heal. These can be quite tender and painful and last for a longer period of time than would classic acne. Due to its deeper penetration, cystic acne can create scarring as it heals, which can affect the texture of the skin and lead to cratering or “pock marks.” This would also be a severe form of acne.
Black heads are another form of acne that are actually opened pores that collect secretions (sebum) and dead skin cells and as such appear as black dots on the skin. These can be extracted without breaking the surface of the skin, but return due to their “open” nature, and they simply start filling up again, eventually leading to more black heads.
Another hallmark feature of acne is there is an increased cell turnover in the epidermis (uppermost layer of skin). An increased cell turnover means that the cells in the epidermis are being regenerated at a faster rate than normal, which can result in an increased propensity to block ducts and pores. Blocked ducts trap material that would normally be secreted onto the surface of the skin, and lead to acne.
Types of acne
This is the best known and most common presentation associated with what we know as “acne.” It is often a mixture of the various forms of skin lesions that can comprise acne including pimples (whiteheads or blackheads), papules (small skin-coloured bumps) or nodules (larger skin-coloured bumps). This is the type of acne that is associated with hormonal changes related to puberty. It affects about 85% of the population at some point between 12-24 years old. Intensity is usually mild, but may present with a prevalence of moderate to severe in 15%-20% of those affected.
This form of acne occurs in people who are acne-prone as a result of pressure, heat and sweat. As the name suggests, it is an aggravation of a mechanical nature; that is, it is aggravated by physical exacerbation. This typically presents while exercising or playing sports, particularly when wearing tight synthetic clothing (eg. Sports bras, compression wear). This combines pressure on areas leading to heat and perspiration, which triggers a break out.
This is a presentation of acne that is related to the proliferation of a yeast in hair follicles near the surface of the skin. The yeast, called malassezia, grows on the skin normally, but in this condition it leads to tiny raised lesions that are either pink or skin-coloured and create a bumpy appearance to the skin. The regions where this presents may be itchy and worsened by perspiration. It can present on the face, neck, chest, shoulders and arms.
This form of acne differs from typical acne vulgaris since it consist of deeper lesions called nodules and cysts. Is may also more commonly be referred to simply as, “cystic acne.” Nodules are hard lesions, whereas cysts are fluid-filled lesions; these can present in isolation or in groupings and can be quite painful and slow to heal. When nodules and cysts manifest in close proximity, they can coalesce to larger lesions that can be deep under the skin and cause scarring, that looks “pitted.”
Gram negative folliculitis
This type of acne can be problematic because the causative bacteria may be resistant to antibiotic treatment. What are called “gram negative” bacteria, proliferate typically after one or more courses of antibiotics have already been implemented.
This is a severe form of acne, related to elevated androgens (male hormones, such as testosterone). As a result, this means that this form of acne presents more commonly in men than women. It consists of deeper lesions than in acne vulgaris, and may include nodules, abscesses and inflammation, which often start from blackhead. When abscesses are large and painful, they may require lancing and drainage by a physician.
The lesions often leave scarring, which can sometimes be deep, ulcerated and disfiguring. The skin appears very inflamed and red.
This is a rare and suddenly occurring severe manifestation of acne that is accompanied by a fever and joint inflammation and pain, typically in the hips and knees. The presentation for acne fulminans is very similar to acne conglobata with nodules and abscesses on a base of highly inflamed damaged skin. The difference is in the timeline and associated symptoms. Acne fulminans presents suddenly and acutely and is associated with a febrile (feverish state) and joint pains, whereas acne conglobata is a persistent chronic condition that is not accompanied by a fever.
Types of pimples
Small raised lesions that are just under the surface of the skin and are less than 5mm in diameter.
Essentially these bumps that are similar to papules, but present deeper under the surface of the skin and are larger (greater than 5mm in diameter).
These are the commonly referred to “blackheads” that accompany acne. They are termed “open” because they are open at the surface. Think of them as miniature “pits” that collect sebum (your natural protective skin oils) and dead skin cells. The “black” colour is not the result of “dirt” as people commonly think, rather it is the oxidation of your dead skin cells (when exposed to air) which contain melanin (the pigment that allows your skin to tan). Melanin darkens as it oxidizes, and therefore gives the blackhead its appearance.
These are the well-known “whiteheads” that accompany acne. They are blocked oil (sebaceous) ducts that typically present as small white pimples that can vary in size. They are called “closed” because they are enclosed by skin on their outer surface. Closed comedomes essentially have the same contents as blackheads (sebum and dead skin cells), but do not turn black because they are not exposed to air, and hence remain a lighter colour.
These are inflamed bumps under the surface of the skin. They are typically small in acne, but can also be larger as they coalesce and are tender and sometimes painful. Pustules have a characteristic white liquid (pus) that is visible under the skin, but can also contain red to pink material as well. The pustules are an enclosed region that contain inflammatory immune cells and bacteria they are targeting.
In mild to moderate cases, pustules are recommended to be left alone, rather than poked and prodded, such that your immune system can “do its thing”. Popping pustules can introduce additional bacteria is not done with sterile equipment and can cause the released bacterial contents to affect other areas of the skin that it contacts.
Cysts are pockets of material under the surface of the skin. The density of the contents can range from hard to soft to liquid and can be quite small to large. The distinguishing feature of cysts is that they are enclosed by a membranous sac.
The contents may be fluid, air or semisolid material, and feel like a tiny ball under the surface of the skin. Cysts usually do not cause pain, but if large and chronic, may be treated by sterile lancing and removal or drainage of the contents.
Milia are small plugs of a substance called keratin that gets trapped under the skin. They are typically 1-3mm is diameter and appear as tiny skin-coloured to yellowish bumps that cluster on the face. They are non-painful and hard to the touch.
Although milia present very commonly in infants (informally known as “baby acne”) and resolve on their own, they can also present in adults and can be quite persistent.
This is a bumpy skin condition that has a hereditary component. It consists of small hard lesions that present at hair follicles, and are essentially impacted keratin plugs. The most common area for this to present is on the backs of the arms (triceps) or outer upper legs. They typically do not cause any pain or discomfort but the bumps can become reddened and enlarged, making their appearance more obvious.
Dr. Makoto, ND, shares his knowledge, tips and tricks on achieving clear skin
Dr.Makoto Trotter, ND, recently authored a book on treating acne naturally. His comprehensive guide combines his clinical experience in treating acne patients along with evidence-based research to provide you with a thorough diet and lifestyle plan to target your acne.
The Complete Acne Health & Diet Guide contains comprehensive information on the anatomy, pathophysiology and psychology of acne; managing acne from conventional to natural treatments; how to deal with scarring; topical support and much more.
Dr.Makoto was also on the talk show, The Social, discussing foods that fight acne. To view this and other video clips related to skin health, please visit our media page.