Acne vulgaris is an inflammatory lesion of the pilo-sebaceous unit (skin structure consisting of the hair, hair follicle and sebaceous gland). The characteristic lesions can be open (dark) or closed (light) comedones, inflammatory papules, pustules, nodules or cysts that can lead to permanent scarring and changes in skin pigmentation. The lesions occur mainly on the face, neck, back and thoracic region.
Although it is more prevalent in adolescence, it can occur at any stage of life in both sexes. Among adolescents, the frequency and severity of acne, as well as the tendency to scarring, are higher in males. Adult acne, on the other hand, is more frequent in females. Acne has a significant impact on the patient’s quality of life, affecting both self-esteem and psychosocial development. Clinical evaluation is essential to establish the cause of acne and indicate the best treatment.
There are four main factors involved in the origin of acne: sebaceous hypersecretion, changes in the keratinization process of the skin, bacterial proliferation (Propionibacterium acnes) and inflammation.
Hormonal causes of acne include all situations that result from increased androgen secretion (hyperandrogenism, that is, the increase in male hormones) in both men and women.
Thus, the presence of acne in the puberty phase is normal in both sexes, being caused by the hormonal changes inherent to this stage of development. However, acne that appears earlier or later deserves detailed investigation.
In addition to acne, hyperandrogenism causes seborrhea, increased hair (hirsutism) and hair loss (alopecia). Among the causes of hyperandrogenism in females, we can mention: polycystic ovary syndrome, adrenal gland diseases and use of drugs that contain hormones. In women over 25-30 years old with acne of recent onset and in the presence of other signs of hyperandrogenism, they must undergo a thorough hormonal evaluation, as well as ultrasound examinations of the ovaries and adrenal glands. On the other hand, the appearance of acne in children before the age of normal puberty also requires hormonal investigation, as it may be sexual precocity in both sexes.
Several acne treatments are available and aim to reduce the severity and recurrence of skin lesions, as well as to improve the aesthetic aspect. However, identifying the cause is essential to establish the best therapeutic option that will depend on the severity, age of the patient, preferences and history of previous treatments. Treatments can act on all factors that cause acne.
Treatment can be topical (external, only on site) or systemic (use of medications) Thus, some modalities include topical treatment (in mild or moderate cases) with retinoids and antimicrobials. Some dermatological products such as soaps, gels, scrubs are useful for oily skin and on the contrary, moisturizers, ointments, creams can help in cases of dry skin. The indiscriminate use of over the counter products from pharmacies is also very common and patients should avoid using them without medical advice. Some creams and sunscreens, for example, may, instead of assist in treatment, worsen the clinical picture. Moderate and severe acne requires systemic treatment that includes oral antibiotic therapy, hormonal therapies such as the use of oral contraceptives that contain estrogens, anti-androgenic medications and finally isotretinoin (which interferes in all the processes that cause acne. Treatment with isotretinoin must be closely monitored by the specialist due to the possibility of producing side effects.
There are several cosmetic treatments, including manual extraction of comedones, chemical peels, local injection of corticosteroids, photodynamic therapy, laser therapy for scars, among others, but the scientific evidence to indicate them is limited. Contrary to what lay people think, diet and hygiene seem to be factors with little influence on the origin of acne.
Successful treatment of acne depends on interaction between the dermatologist and the endocrinologist.