Acne Sue McGarrigle ND Copyright Bionutri 2021 Acne • Acne is one of the most common multifactorial chronic inflammatory diseases of the pilosebaceous follicles involving: • Androgen induced sebaceous hyperplasia • Altered follicular keratinisation • Hormonal imbalance • Immune hypersensitivity • Bacterial (Propionibacterium acnes) colonisation Acne vulgaris • Acne is a chronic skin disease, and the common form is called vulgaris which is the medical term for "common". It is given this name to distinguish it from less common variants of acne. • Acne vulgaris occurs when hair follicles as a result of obstruction and inflammation are blocked with dead skin cells, bacteria, and oil (sebum). The blocked follicles cause blemishes on the skin. • Acne vulgaris is characterized by comedones, papules, pustules, and nodules and/or cysts in a sebaceous distribution (e.g., face, upper chest, back). • A comedo, or basic acne lesion, is a hair follicle that has become clogged with oil and dead skin cells. Comedones (the plural of comedo) can develop into bumps called whiteheads and blackheads. A whitehead (closed comedone) or a blackhead (open comedone) is without any clinical signs of inflammation. • Products that may trigger comedones are called "comedogenic." • Papules and pustules are raised bumps with inflammation. Acne The 6 main types of caused by acne: • Blackheads – small black or yellowish bumps that develop on the skin; they're not filled with dirt, but are black because the inner lining of the hair follicle produces colour • Whiteheads – have a similar appearance to blackheads, but may be firmer and will not empty when squeezed • Papules – small red bumps that may feel tender or sore • Pustules – like papules, but have a white tip in the centre, caused by a build-up of pus • Nodules – large hard lumps that build up beneath the surface of the skin and can be painful • Cysts – the most severe type of spot caused by acne; they're large pus-filled lumps that look similar to boils and carry the greatest risk of causing permanent scarring Acne Acne-rarer forms • Acne conglobata: a very severe form of nodulocystic acne. (next slide) Zeichner J; Acneiform Eruptions in Dermatology: A Differential • Acne fulminans: sudden, severe inflammatory Diagnosis, 2013. reaction which causes deep ulcerations and erosions; may be associated with fever and arthralgia. Singh S, Mann BK, Tiwary NK; Acne cosmetica revisited: a case- control study shows a dose-dependent inverse association • Acne excoriée: mainly affects young women and is characterised by self-inflicted wounds associated between overall cosmetic use and post-adolescent acne. with a psychological or emotional problem. Dermatology. 2013226(4):337-41. doi: 10.1159/000350936. • Acne mechanica: caused by pressure, friction or Epub 2013 Jul 10. rubbing from clothing. • Acne cosmetica: caused by contact comedogenic Patterson AT, Kaffenberger BH, Keller RA, et al; Skin diseases products with the skin. One study found the link associated with Agent Orange and other organochlorine between acne and cosmetics was weak but exposures. J Am Acad Dermatol. 2016 Jan74(1):143-70. doi: conceded that it was possible with some products. 10.1016/j.jaad.2015.05.006. Epub 2015 Jul 22. • Chloracne: caused by occupational exposure or military exposure to halogenated hydrocarbons. It presents with many large comedones. Acne-conglobata • Acne conglobata is one of the most severe forms of acne and can affect the neck, chest, arms, and buttocks. It involves many inflamed nodules that are connected under the skin to other nodules. • Deep abscesses • Inflammation • Severe damage to the skin • Scarring • Comedones (blackheads) which are obvious and widespread, often occurring on the face, neck, trunk, upper arms and/or buttocks • Inflammatory nodules may form around multiple comedones and grow until they break down and discharge pus. Deep ulcers may form under the nodules, producing keloid-type scars, and crusts may form over deeply ulcerated nodules. Abscesses can form deep, irregular scars. • Acne conglobata may be preceded by acne cysts, papules or pustules that do not heal but instead rapidly deteriorate. Occasionally, it flares up in acne that had been dormant for many years. Acne Conglobata and Rarer Forms of Acne • This type of acne is more common in men and is Authored by Dr Laurence Knott sometimes caused by taking steroids or testosterone. Timely treatment by a dermatologist is essential. Acne-mechanica • Acne mechanica is caused by heat, friction, and pressure against the skin, often the result of wearing sports gear such as a helmet or baseball cap. It is sometimes called "sports-induced acne" because it occurs frequently in athletes. • Preventive measures include wearing an absorbent material under sports equipment and showering immediately after activity. Acne • Acne is known to run in families. If both your mother and father had acne, it's likely that you'll also have acne. • Acne is very common in teenagers and younger adults. About 95% of people aged 11 to 30 are affected by acne to some extent. • Acne is most common in girls from the ages of 14 to 17, and in boys from the ages of 16 to 19. • Most people have acne on and off for several years before their symptoms start to improve as they get older. • Acne often disappears when a person is in their mid-20s. • In some cases, acne can continue into adult life. About 3% of adults have acne over the age of 35. NHS Acne-hormone links • Acne is commonly linked to the changes in hormone levels during puberty but can start at any age. Can occur in PCOS. • Acne during puberty is often associated more with growth hormone (GH) than with testosterone and oestrogens. GH goes from the brain to the liver and triggers the release of Insulin Like Growth Factor-1 (IGF-1). IGF-1 promotes skin cell growth/division, sebum production, efficacy of luteinizing hormone (LH) and the production of oestrogens. • During times of hormonal fluctuation (like puberty) excess sebum production likely occurs to protect hair follicle growth. • Acne severity doesn’t seem to correlate with total androgen levels in the body. Rather, androgens play a permissive role in priming or initiating acne such as women with PCOS or someone starting a cycle of anabolic/androgenic steroids. People can experience a surge of circulating androgens and IGF-1, along with lower levels of sex hormone binding proteins. • This can cause the grease-producing glands next to hair follicles in the skin to produce larger amounts of abnormal sebum. • This abnormal sebum changes the activity of a usually harmless skin bacterium called Propionibacterium acnes, which becomes more aggressive and causes inflammation and pus. • The hormones also thicken the inner lining of the hair follicle, causing blockage of the pores. Cleaning the skin does not help to remove this blockage. • Environmental pollution can increase IGF-1 Propionibacterium acnes • Propionibacterium acnes is the relatively slow- growing, typically aerotolerant anaerobic, Gram- positive bacterium (rod) linked to acne; it can also cause chronic blepharitis and endophthalmitis, the latter particularly following intraocular surgery. • Chronic inflammatory acne cannot be defined as an infectious disease, since the bacteria are normally present on the skin of a vast majority of individuals, irrespective of the presence of acne lesions. • P. acnes apparently only triggers the disease when it meets favourable dermatophysiological terrain. • The 4 major recognized pathophysiological features of acne include androgen stimulated seborrhea, hyperkeratinization and obstruction of the follicular epithelium, proliferation of P. acnes, and then inflammation. Propionibacterium acnes • Comedogenesis, the transformation of the follicle into the primary acne lesion, the comedone, is the product of abnormal follicular keratinization related to excessive sebum secretion. During this process, P. acnes often gets trapped in layers of corneocytes and sebum and rapidly colonizes the comedonal kernel, resulting in a microcomedone, a structure invisible to the naked eye (Plewig and Kligman, 2000). A microcomedone can develop into larger structures, the comedones. • Closed comedones cannot evacuate the thread- looking conglomerate of cell debris, sebum, P. acnes and its products to the skin surface, and this makes them more prone to inflammation and rupture. In inflammatory acne, comedones rupture and the follicular material becomes dispersed in the dermis rather than on the skin surface. Depending on the extent of the damage to the comedone wall, various types of inflammatory lesions are produced, and these are classified as the papules, pustules, or nodules. • P. acnes are directly involved in the rupture the comedone epithelial lining (Holland et al., 1981). Propionibacterium acnes • The chronic inflammatory condition of the pilosebaceous follicle caused by P. acnes is generally considered non-pathogenic. However, there is a growing body of evidence that point to the bacterium as being a low virulence pathogen in several types of postoperative infections and other chronic conditions. • A preliminary study from Japan (Ishige et al., 1999) has shown that P. acnes DNA can be detected in lymph nodes of Japanese individuals with sarcoidosis. Sarcoidosis is a granulomatous disease that results in the inflammation of lymph nodes, lungs, eyes, liver, and other tissues. P. acnes have also been implicated in sciatica, a chronic inflammatory condition of the lower back. • It also appears to be significant that P. acnes have been isolated from several orthopaedic infections, silicone breast prosthesis, and prosthetic joint infections (Yu et al., 1997; Tunney et al., 1999). PROPIONIBACTERIUM ACNES AND CHRONIC DISEASES Ajay Bhatia, Ph.D., Jean-Francoise Maisonneuve, Ph.D., and David H. Persing, M.D., Ph.D. Acne • Comedones that stay closed at the surface of the skin are called whiteheads. This happens when oil and skin cells prevent a clogged hair follicle from opening. Acne • Blackheads are comedones that are open at the surface of the skin. They are filled with excess oil and dead skin cells. • It's not dirt that causes the comedone to turn black.