Acne
 
Acne is a common inflammatory disease in areas where
sebaceous glands are largest , most numerous, and most
active. The process begins about the base of the follicle
and is characterized, in order of increasing severity, by
comedones, pustules, papules, inflamed nodules, infected
cysts, and, in extreme cases, canalizing inflamed and
infected sacs. 

Acne is attributable to the effect of androgenic hormones
on the pilosebaceous apparatus. Acne is so common at
puberty that it may almost be considered a physiologic
disturbance; it affects more than 80% of teenagers. Acne
comes in various grades. Grade I acne is an evanescent
disorder leaving few residual sign except possibly dilated
pores. The lesion consists of a lipokeratinous plug,
commonly known as a blackhead. In Grade II acne, the
sebaceous duct ruptures and the sebum spills into the skin.
The sebum may irritate the surrounding tissue which reacts
by isolating and containing it in the form of a superficial
or deep noninflammatory cyst. Simultaneously, a superficial
pustule usually develops around the orifice. If extension
of the inflammation is prevented, atrophy and scarring
usually do not follow. In Grade III acne, bacterial and
chemical irritation of the tissues, destruction and
displacement of epidermal cells, and scarring occur. In
Grade IV acne, the lesions are extensive, involving the
shoulders, trunk, and upper arms. 

Certain foods appear to aggravate acne in some patients.
Chocolate, nuts, cola drinks, and less frequently, milk in
large quantities have been implicated. However, prohibition
of essential foods can lead to a deficient diet, especially
for growing active adolescents. Suspected foods should
therefore be eliminated, one at a time, for 3 week trial
periods. 

Clumsy manual attempts to extrude blackheads or superficial
cysts, constant fondling or pinching of lesions, and
scratching of ruptured lesions before a crust forms - all
promote residual scars. Though it is important to keep the
skin hygienically clean, too vigorous or too frequent
washing should be avoided. 

Exacerbation of acne is often noted during the winter with
improvement during the summer. However, excessively humid
and hot weather frequently produces a flare-up. 

Disfiguring acne may induce severe psychic trauma,
particularly in girls. The tension mayincrease facial
flushing and possibly seborrhea; it leads to trauma, new
lesions, and excoriation of old ones. The adolescent is
likely to use the acne as an excuse to avoid difficult
personal adjustments and may become withdrawn and
self-pitying. Such individuals find the explanation that
their acne is but a passing annoyance difficult to accept,
and may need psychotherapy. Tension may bring out and
aggravate suppressed intra-family antagonisms, particularly
between mother and daughter. 

Treatment varies according to severity. In Grade I or II
acne, treatment should be simple, since a stringent regimen
exaggerates the importance of the eruption for some. The
affected areas should be washed witha type of soap
containing an antibacterial agent. a soft complexion brush
or a slightly abrasive soap help to eliminate blackheads,
but may be harmful if the lesions are inflamed. 

In mild acne, large comedones may be removed carefully once
or twice a week, preferably with the Schamberg loop
extractor, which a responsible member of the family may be
taught to use. Warm towels applied for 10 to 15 minutes
facilitates removal. 

Inflammatory lesions should not be opened until they have
pointed in a pustule, since too early incision leads to
extension of the inflammation and scarring. Picking the
crust covering an opened lesion may delay healing for
several weeks and produce a pitted scar. 

In Grades III and IV acne, therapy aims to decrease the
output of the sebaceous glands and to control inflammation
and cyst formation. Systemic administration of a broad
spectrum antibiotic may improve severe acne. Since relapse
ordinarily follows short periods of treatment, therapy must
be continued for weeks to months, though small daily doses
may suffice. 

Any broad-spectrum antibiotic (e.g. tetracycline,
crythromycin) may be given in the usual therapeutic doses
for 2 weeks. If it is effective, dosage is continued for an
additional 2 to 4 weeks; then the dose is decreased at 2
week intervals. Abrupt cessation of treatment is usually
followed by relapse. If, after an initial 4 week trial, one
antibiotic has not resulted in improvement, another may be
tried. The risks of antibiotic treatment and the emergence
of antibiotic-resistant staphylococci must be weighed
against the severity of the disease. The results of
antibiotic therapy are erratic, as are all topical
treatments. 

Residual scarring may be decreased appreciably by
dermabrasion. The skin is ground down to the level of the
dermal papillae; the epidermal cells of the interpapillary
ridges then regenerate a smoother epidermal layer. The
patients who may be helped must be selected by a specialist
since not all types of acne scarring are improved.