May 2009, Volume 59, Issue 5

Editorial

Dispelling the Myths and Misconceptions of Acne

Zohra Zaidi   ( UKDCTN Nottingham, UK )

In this modern world today, acne is still shrouded by myths. It is time to look into these myths and scientifically remove the hurdle surrounding one of the most treatable skin disorders. These myths are passed down from one family member to another, mentioned by a friend and occasionally published in a fashion magazine. It is often said 'What is the harm in a little folk wisdom? For people who suffer from acne these seeds of misfortune blossom into bigger skin problems, leading to complications of acne like scarring, which then persist as a stigma for the rest of the patients life. It is a common old wives saying, 'Acne is a sign of adolescence and will wear out with time'. It is true that acne occurs at adolescence and gradually wears out, but this is no reason for not instituting treatment. Acne is due to an upsurge of androgens occuring at puberty. These androgens stimulate the sebaceous glands to produce sebum; which together with hyperkeratinisation of the pilosebaceous follicle, results in the formation of comedones, the first lesion of acne vulgaris. A comedone is the precursor for the formation of inflammatory lesions, the papules and pustules.1-3 Acne does clear in the early twenties; this is because the pilosebaceous duct does not react by hyperkeratinisation to androgens after a certain age. An alternative explanation is a change in the host response to various inflammatory stimuli.3,4 But acne patients should not wait till natural clearing takes place, because the acne might end up with scarring. If acne is not treated, then nodules and cysts form. The healing of these deeper lesions, result in scar formation.5 Nodules, cysts, and scars are a source of great psychological stress to the young acne patient. They are depressed, avoid social outings, some even have suicidal tendencies. Acne should be treated as soon as it occurs, and not when complications set in. Acne lesions should not be squeezed. Popping of acne spots does make acne less visible temporarily but it is followed by more severe inflammatory lesions in a few days. Squeezing acne spots results in the rupture of the pilosebaceous duct and the contents of the gland and duct are passed into the dermis. Here they incite an inflammatory reaction, resulting in a deeper and more severe reaction.6 So the temptation to squeeze acne lesions should be curbed. Acne is not due to dirt. The black colour of the comedone is due to oxidation of keratin, it is not dirt as commonly thought.5 There is no need to wash the face several times a day. Frequent washing strips the skin of the oil that makes the skin soft and pliable; it also makes the skin dry which results in further irritation.  Another myth that sunlight and tanning helps acne, needs to be addressed. Tanning is harmful to the skin and should be avoided. Throughout the world emphasis is laid on the harmful effects of ultraviolet light. Ultraviolet light not only causes ageing of the skin, but also results in cutaneous malignancy.7 Tanning makes the acne spots less visible, but it is not justified to use it for a harmless condition like acne.  Acne patients should not be tempted by advertisements for overnight cure. Acne needs at least 4-6 months of active treatment as it is a slow responding disorder and often needs a long period to produce reasonable improvement.5,8 Treatment should start as early as possible and reassessed every 2-3 months. The patients are reluctant to take antibiotics for this period of time, and stop the treatment after a few days. This is the most common cause of therapeutic failure.5 Isotretinoin is a mainstay in the dermatologist's armamentarium for severe and recalcitrant acne.9 It acts on all the areas of pathogenesis of acne, but unfortunately there is so much scare about it in the public especially about its teratogenic effects, that people are afraid to use this marvel drug. Isotretinoin should only be prescribed by a dermatologist, who can weigh its benefits and prescribe the drug according to the patients need. Another misconception about the therapy for acne is that medication should be applied topically only on acne spots. In fact the cream or ointment should be applied to the entire affected area. The microcomedones are not visible and these should be treated to prevent them from developing into the active visible lesions.10 An important question asked by acne patients is that should cosmetics be applied on the face. A negative answer could have been true about half a decade ago, but today there are water based make up creams, which do not block the pores and are not comedogenic as were the previous greasy based products. Some cosmetic products also contain anti-acne medicaments such as benzoyl peroxide. Primarily all cosmetic products should be non- comedogenic, oil free and hypoallergic. Stress can have an effect on hormones and theoretically can promote acne. However an effective acne treatment is more powerful than a bout of stress. Some psychiatric medicines can cause acne as its side effects.11 Acne is not contagious. This myth could have originated and spread in the bygone days, when parents wanted their daughters to stay away from boys with acne! Acne is not caused by a contagion, and so it cannot be transferred from one person to another. A wrong diet is often blamed for causing acne and often chocolates and greasy foods are attributed as causative factors for acne. This does not hold true and more research is required to prove this hypothesis. It is also known that people in some indigenous societies do not develop acne. This is in stark contrast to the widespread presence of acne throughout the world. This is a point to contemplate on whether the diet of indigenous people, contribute to their acne free skin. Discovering a dietary way of preventing acne may be a future reality. If an acne patient feels that he/she have cleared their skin by using a particular diet, or else eating a particular food increases their acne, they should report their findings to the Nutrition and Holistic Message Board. Studies are underway,12 but to date there is not enough scientific based evidence of a relationship of diet to acne.  The young acne patient is surrounded by these myths and misconceptions about acne. It is time that they sort through fact and fiction, bury these myths and uncover the truth about acne. Acne awareness is much needed in a country like ours.

References

1.Thiboutot D, Gilliland K, Light J, Lookingbill D. Androgen metabolism in Sebaceous Glands from subjects with and without Acne. Arch. Dermatol 1999; 135: 1041-5.
2.Carmina E and Lobo RA. Evidence for increased androsterone metabolism in some normoandrogenic women with acne. J Cl Endocrinol Metabol 1993; 76:1111-4.
3.Thiboutot D, Chen W. Update and Future of Hormonal Therapy in Acne. Arch. Dermatol 2003; 206: 57-67.
4.Cunliffe JW. Pathogenesis of acne: summary. Chapter 15. In Acne. Cunliffe JW. Published by Martin Dunitz Ltd. London UK 1989; pp 250-1.
5.Cunliffe JW, Clayden DA, Gould D and Simpson NB. Acne Vulgaris-its aetiology and treatment. Clin and Exp Dermatol 1981; 6: 461-9.
6.Leyden JJ. Therapy for Acne Vulgaris. N Engl J Med 1997; 336: 115-62. 
7.Sterry W, Paus R, Burgdof. Sunburn. In Thieme Clinical Companions-Dermatology. International Edition 2007. Printed by Saurabh Printers Ltd. New Dehli, India. 296-300. 
8.Simonart T, Dramaix M, Maertelaer De V. Efficacy of Tetracycline's in the treatment of Acne Vulgaris: a review. Br J Dermatol 2008; 158:208-16.
9.Thiboutot D. Acne and Rosacea. New and Emerging Therapies. Dermatol Clinics 2000; 18: 63-71.
10.Leyden JJ. Advances of Acne therapy. Chapter 3. In Dermatologic Therapy in Current Practice. Marks R and Leyden JJ. Published by Martin Dunitz Ltd. London UK 2002; pp 35-43.
11.Sterry W, Paus R, Burgdof. Acne. In Thieme Clinical Companions-Dermatology. International Edition 2007. Printed by Saurabh Printers Ltd. New Dehli, India 2007; pp 530-5.
12.Smith RN, Mann NJ, Braue A, Makelainen H, Varigos GA. A low- glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial. Am J Clin Nutr 2007; 86:107-15.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: