…that is exactly how i exclaim each time I see another pimple pop up, considering I never had them in my 30+ years until now.

 Acne a k a pimples a k a zits are an enigma to many. No matter what some of us seem to do they just never stop popping up. Unfortunately many of us just dont understand them. This write-up will try to demystify this condition.

 Acne is one of the commonest skin conditions on the planet. Commoner in adolescents and more severe in teenage boys. In typical cases that start at puberty, it starts to wane by the time the affected individual gets into thier 20s, in some cases it is carried on into the 30s and even the 40s and 50s. There is no known cause of acne per say but it has been associated with hormononal surges- hence its being common in puberty and in hormone altering conditions like polycystic ovarian syndrome and the XXY genotype. It has a genetic component to it as it runs in families. Acne is mainly distributed on the face but can erupt on the chest, shoulders and upper back too.

 How a pimple forms is however easy to understand and this forms the basis of treatment.

 Our skin is in layers and has organelles within it that help it function normally and properly. One of these is the pilosebaceous unit which consists of a hair follicle, sebaceous glands and arector pili muscle. The sebaceous gland is like a sac and it produces sebum/oils that flows to the surface of the skin through a duct to help lubricate the skin. This same sebum also has fungicidal (fungus killing) properties. Under the influence of hormones at puberty, this sebaceous gland grows 4 to 9 times larger producing more sebum/oils within it and also more cells within the follicular duct. These are produced at a faster rate than they exit the gland and the duct, you therefore get an accumulation. The accumulated cells and sebum form comedones – the tiny swelling on a red base which may be a whitehead (white and closed) or blackhead( black colored and open). These comedones are non-inflammatory. The whitehead has higher chances of even more accumulation and inflammation(since it is closed). As accumulation continues and turgidity increases, the walls of the canal give way spilling its contents- both cells and sebum/oils into the dermis(a deeper skin layer). As these are foreign to the dermis, an inflammatrory reaction is mounted at that level and bacteria (propionebacterium acnes) take advantage of this situation to multipy and form pus. The inflammed lesions range from pustules to nodules to cysts depending on how large and deep the inflammation gets.


(Photo courtesy gidifab.com) Showing non-inflammed acne with several blackheads and fewer whiteheads.
(Photo courtesy gidifab.com) Showing non-inflammed acne with several blackheads and fewer whiteheads.


 (Photo courtesy womensderm.org) Showing inflammed acneic lesions of various sizes- pustules, nodules and cysts.  This patient also has atrophic scars(the visible holes in the skin), post inflammatory hyperpigmentation(the spots)and very few raised scars.
(Photo courtesy womensderm.org) Showing inflammed acneic lesions of various sizes- pustules, nodules and cysts.
This patient also has atrophic scars(the visible holes in the skin), post inflammatory hyperpigmentation(the spots)and very few raised scars.

Acne can worsen around a menstrual period and during pregnancy. It can be aggravated or even triggered in patients with no prior history of acne by the use of topical steriods (contained in tube creams, herbal creams, chinese creams etc), in people that work in factories where they come in contact with coal tar, chlorinated hydrocarbons etc, drugs like systemic corticosteroids, androgens, lithium, iodides and phenytoin.

The stage ot which the acne is determines the type of treatment instituted. This is where many people get it wrong. Many over the counter medication are only helpful if used for the proper stage of acne. And seeing that the problems with acne are multi-faceted, the management has to be multi-pronged. These all have to be addresed:

  1. Excess cell production and accumulation within the follicle, which is best managed with things like azelaic acid and topical retinoids.
  2. Excess sebum/oil production, also well managed by azelaic acid, topical retinoids, salicylic acid, glycolic acid and many other plant acids.
  3. Infection by Propionebacterium acnes, in which case benzoyl peroxide, topical and systemic antibiotics help immensely
  4. Inflammation caused by rupture of follicles. Here a topical or systemic anti-inflammatory agent will need to be used.

For most of my patients with non-inflammatory acne- mostly blackheads & whiteheads, I start with a cleansing agent containing at least 2% salicylic acid used twice daily, with topical retinoids used at night. If mildly infected and inflammed i add benzyl peroxide and with profuse inflammation analgesics and systemic anti-inflammatory medictaion is institued. The treatment of acne is “designer treatment” and highly individualized. Every patient is treated according to thier specific needs and the above might not serve the needs and bring relief to every patient. Some patients may need hormonal therapy or oral isotretionion depending on severity and the recalcitrant nature of the acne.

Depending on other accompanying problems and complications like spots (pigmenation), deep scarring, keloids etc other treatments may be needed like depigmenting agents, chemical peels, micro dermabrasions, microneedling and even laser treatment.

Acne unfortunately doesnt have a cure but thankfully it can be managed easily with great results. If you have acne prone skin you must always look out for products made for acne prone skin. Heavy moisturizers, concealers, foundations can aggravate or even trigger acne. Heavy Hair oils melting down to the forehead can trigger acne on that area.

I will need to specifically speak about a type of acne we see very commonly in our practice nowadays -STEROID ACNE! This variant of acne is caused exclusively by the use of products that contain steroids in them. These steroids are seen in tube creams, spot removers, 7 day action lightening creams, many of those creams that have no active ingredients and lighten many shades in a few weeks, herbal creams, chinese creams, mixed creams etc etc… the list is endless! This type of acne is extremely difficult to treat and just does’nt behave like regular acne. Best to stay clear of these. Please.

Also minimize complications by not picking, preesing or squeezing the pimples. If you are using the right products, the pimples flatten out on thier own. Picking makes inflammation worse and spots darker and can even cause scarring which are way more difficult to treat than the active pimples themselves.

Also don’t overwash and scrub, stripping your skin of oils sometimes makes your skin produce more oils to compensate. Using the right products will gently achieve the reduction of oils for you.

In conclusion, if the basic over the counter medication dont help, please seek a QUALIFIED SKIN DOCTOR. Dont guess, avoid trial and error. Proper information and management will help you win your acne war.

I am open to answering any questions you may have… thanks for reading!


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