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Acne Scars

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Acne Scarring

Obtaining a detailed and comprehensive discussion of acne scars starts with causes of scarring, prevention of scarring, types of scars, and treatments for scars.

Learn more about drinking green tea to clear up acne and why it works. Before talking about scars, a word about spots that may look like scars but are not scars in the sense that a permanent change has occurred. Even though they are not true scars and disappear in time, they are visible and can cause embarrassment.

Macules or “pseudo-scars” are flat, red or reddish spots that are the final stage of most inflamed acne lesions. After an inflamed acne lesion flattens, a macule may remain to “mark the spot” for up to 6 months. When the macule eventually disappears, no trace of it will remain?unlike a scar.

Post-inflammatory pigmentation is discoloration of the skin at the site of a healed or healing inflamed acne lesion. It occurs more frequently in darker-skinned people, but occasionally is seen in people with white skin. Early treatment by a dermatologist may minimize the development of post-inflammatory pigmentation. Some post-inflammatory pigmentation may persist for up to 18 months, especially with excessive sun exposure. Chemical peeling may hasten the disappearance of post-inflammatory pigmentation.

Causes of Acne Scars
In the simplest terms, scars form at the site of an injury to tissue. They are the visible reminders of injury and tissue repair. In the case of acne, the injury is caused by the body’s inflammatory response to sebum, bacteria and dead cells in the plugged sebaceous follicle. Two types of true scars exist, as discussed later: (1) depressed areas such as ice-pick scars, and (2) raised thickened tissue such as keloids.

When tissue suffers an injury, the body rushes its repair kit to the injury site. Among the elements of the repair kit are white blood cells and an array of inflammatory molecules that have the task of repairing tissue and fighting infection. However, when their job is done they may leave a somewhat messy repair site in the form of fibrous scar tissue, or eroded tissue.

White blood cells and inflammatory molecules may remain at the site of an active acne lesion for days or even weeks. In people who are susceptible to scarring, the result may be an acne scar. The occurrence and incidence of scarring is still not well understood, however. There is considerable variation in scarring between one person and another, indicating that some people are more prone to scarring than others. Scarring frequently results from severe inflammatory nodulocystic acne that occurs deep in the skin. But, scarring also may arise from more superficial inflamed lesions. Nodulocystic acne that is most likely to result in scars is seen in these photos:

(Photos used with permission of the American Academy of Dermatology
National Library of Dermatologic Teaching Slides)

The life history of scars also is not well understood. Some people bear their acne scars for a lifetime with little change in the scars, but in other people the skin undergoes some degree of remodeling and acne scars diminish in size.

People also have differing feelings about acne scars. Scars of more or less the same size that may be psychologically distressing to one person may be accepted by another person as “not too bad.” The person who is distressed by scars is more likely to seek treatment to moderate or remove the scars.

Prevention of Acne Scars
As discussed in the previous section on Causes of Acne Scars, the occurrence of scarring is different in different people. It is difficult to predict who will scar, how extensive or deep scars will be, and how long scars will persist. It is also difficult to predict how successfully scars can be prevented by effective acne treatment.

Nevertheless, the only sure method of preventing or limiting the extent of scars is to treat acne early in its course, and as long as necessary. The more that inflammation can be prevented or moderated, the more likely it is that scars can be prevented. (Click on Acne Treatments for more information about treatment of mild, moderate and severe acne). Any person with acne who has a known tendency to scar should be under the care of a dermatologist. (Click on Find a Dermatologist to locate a dermatologist in your geographic area).

Types of Acne Scars
There are two general types of acne scars, defined by tissue response to inflammation: (1) scars caused by increased tissue formation, and (2) scars caused by loss of tissue.

Scars Caused by Increased Tissue Formation
The scars caused by increased tissue formation are called keloids or hypertrophic scars. The word hypertrophy means “enlargement” or “overgrowth.” Both hypertrophic and keloid scars are associated with excessive amounts of the cell substance collagen. Overproduction of collagen is a response of skin cells to injury. The excess collagen becomes piled up in fibrous masses, resulting in a characteristic firm, smooth, usually irregularly-shaped scar. The photo shows a typical severe acne keloid:

(Photo used with permission of the American Academy of Dermatology
National Library of Dermatologic Teaching Slides)

The typical keloid or hypertrophic scar is 1 to 2 millimeters in diameter, but some may be 1 centimeter or larger. Keloid scars tend to “run in families”?that is, abnormal growth of scar tissue is more likely to occur in susceptible people, who often are people with relatives who have similar types of scars.

Hypertrophic and keloid scars persist for years, but may diminish in size over time.

Scars Caused by Loss of Tissue
Acne scars associated with loss of tissue?similar to scars that result from chicken pox?are more common than keloids and hypertrophic scars. Scars associated with loss of tissue are:

Ice-pick scars usually occur on the cheek. They are usually small, with a somewhat jagged edge and steep sides?like wounds from an ice pick. Ice-pick scars may be shallow or deep, and may be hard or soft to the touch. Soft scars can be improved by stretching the skin; hard ice-pick scars cannot be stretched out.

Depressed fibrotic scars are usually quite large, with sharp edges and steep sides. The base of these scars is firm to the touch. Ice-pick scars may evolve into depressed fibrotic scars over time.

Soft scars, superficial or deep are soft to the touch. They have gently sloping rolled edges that merge with normal skin. They are usually small, and either circular or linear in shape.

Atrophic macules are usually fairly small when they occur on the face, but may be a centimeter or larger on the body. They are soft, often with a slightly wrinkled base, and may be bluish in appearance due to blood vessels lying just under the scar. Over time, these scars change from bluish to ivory white in color in white-skinned people, and become much less obvious.

Follicular macular atrophy is more likely to occur on the chest or back of a person with acne. These are small, white, soft lesions, often barely raised above the surface of the skin?somewhat like whiteheads that didn’t fully develop. This condition is sometimes also called “perifollicular elastolysis.” The lesions may persist for months to years.

Treatments for Acne Scars
A number of treatments are available for acne scars through dermatologic surgery. The type of treatment selected should be the one that is best for you in terms of your type of skin, the cost, what you want the treatment to accomplish, and the possibility that some types of treatment may result in more scarring if you are very susceptible to scar formation.

A decision to seek dermatologic surgical treatment for acne scars also depends on:

* The way you feel about scars. Do acne scars psychologically or emotionally affect your life? Are you willing to “live with your scars” and wait for them to fade over time? These are personal decisions only you can make.

* The severity of your scars. Is scarring substantially disfiguring, even by objective assessment?

* A dermatologist’s expert opinion as to whether scar treatment is justified in your particular case, and what scar treatment will be most effective for you.

Before committing to treatment of acne scars, you should have a frank discussion with your dermatologist regarding those questions, and any others you feel are important. You need to tell the dermatologist how you feel about your scars. The dermatologist needs to conduct a full examination and determine whether treatment can, or should, be undertaken.

The objective of scar treatment is to give the skin a more acceptable physical appearance. Total restoration of the skin, to the way it looked before you had acne, is often not possible, but scar treatment does usually improve the appearance of your skin.

The scar treatments that are currently available include:

Collagen injection. Collagen, a normal substance of the body, is injected under the skin to “stretch” and “fill out” certain types of superficial and deep soft scars. Collagen treatment usually does not work as well for ice-pick scars and keloids. Collagen derived from cows or other non-human sources cannot be used in people with autoimmune diseases. Human collagen or fascia is helpful for those allergic to cow-derived collagen. Cosmetic benefit from collagen injection usually lasts 3 to 6 months. Additional collagen injections to maintain the cosmetic benefit are done at additional cost.

Autologous fat transfer. Fat is taken from another site on your own body and prepared for injection into your skin. The fat is injected beneath the surface of the skin to elevate depressed scars. This method of autologous (from your own body) fat transfer is usually used to correct deep contour defects caused by scarring from nodulocystic acne. Because the fat is reabsorbed into the skin over a period of 6 to 18 months, the procedure usually must be repeated. Longer lasting results may be achieved with multiple fat-transfer procedures.

Dermabrasion. This is thought to be the most effective treatment for acne scars. Under local anesthetic, a high-speed brush or fraise used to remove surface skin and alter the contour of scars. Superficial scars may be removed altogether, and deeper scars may be reduced in depth. Dermabrasion does not work for all kinds of scars; for example, it may make ice-pick scars more noticeable if the scars are wider under the skin than at the surface. In darker-skinned people, dermabrasion may cause changes in pigmentation that require additional treatment.

Microdermabrasion. This new technique is a surface form of dermabrasion. Rather than a high-speed brush, microdermabrasion uses aluminum oxide crystals passing through a vacuum tube to remove surface skin. Only the very surface cells of the skin are removed, so no additional wound is created. Multiple procedures are often required but scars may not be significantly improved.

Laser Treatment. Lasers of various wavelength and intensity may be used to recontour scar tissue and reduce the redness of skin around healed acne lesions. The type of laser used is determined by the results that the laser treatment aims to accomplish. Tissue may actually be removed with more powerful instruments such as the carbon dioxide laser. In some cases, a single treatment is all that will be necessary to achieve permanent results. Because the skin absorbs powerful bursts of energy from the laser, there may be post-treatment redness for several months.

Skin Surgery. Some ice-pick scars may be removed by “punch” excision of each individual scar. In this procedure each scar is excised down to the layer of subcutaneous fat; the resulting hole in the skin may be repaired with sutures or with a small skin graft. Subcision is a technique in which a surgical probe is used to lift the scar tissue away from unscarred skin, thus elevating a depressed scar.

Skin grafting may be necessary under certain conditions?for example, sometimes dermabrasion unroofs massive and extensive tunnels (also called sinus tracts) caused by inflammatory reaction to sebum and bacteria in sebaceous follicles. Skin grafting may be needed to close the defect of the unroofed sinus tracts.

Treatment of keloids. Surgical removal is seldom if ever used to treat keloids. A person whose skin has a tendency to form keloids from acne damage may also form keloids in response to skin surgery. Sometimes keloids are treated by injecting steroid drugs into the skin around the keloid. Topical retinoic acid may be applied directly on the keloid. In some cases the best treatment for keloids in a highly susceptible person is no treatment at all.

In summary, acne scars are caused by the body’s inflammatory response to acne lesions. The best way to prevent scars is to treat acne early, and as long as necessary. If scars form, a number of effective treatments are available. Dermatologic surgery treatments should be discussed with a dermatologist.

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Acne Medications

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There may be new info on acne medications. Learn more about drinking green tea to clear up acne and why it works. This information presented here does not take the place of talking with your prescriber (doctor or other health care provider).
What is the most important information I should know about Accutane?

Accutane is used to treat a type of severe acne (nodular acne) that has not been helped by other treatments, including antibiotics. However, Accutane can cause serious side effects. Before starting Accutane, discuss with your prescriber how bad your acne is, the possible benefits of Accutane, and its possible side effects, to decide if Accutane is right for you. Your prescriber will ask you to read and sign a form or forms indicating you understand some of the serious risks of Accutane.
Possible serious side effects of taking Accutane include birth defects and mental disorders.

1. Birth defects. Accutane can cause birth defects (deformed babies) if taken by a pregnant woman. It can also cause miscarriage (losing the baby before birth), premature (early) birth, or death of the baby. Do not take Accutane if you are pregnant or plan to become pregnant while you are taking Accutane. Do not get pregnant for 1 month after you stop taking Accutane. Also, if you get pregnant while taking Accutane, stop taking it right away and call your prescriber.

All females should read the section in this Medication Guide “What are the important warnings for females taking Accutane?”

2. Mental problems and suicide. Some patients, while taking Accutane or soon after stopping Accutane, have become depressed or developed other serious mental problems. Symptoms of these problems include sad, “anxious” or empty mood, irritability, anger, loss of pleasure or interest in social or sports activities, sleeping too much or too little, changes in weight or appetite, school or work performance going down, or trouble concentrating. Some patients taking Accutane have had thoughts about hurting themselves or putting an end to their own lives (suicidal thoughts). Some people tried to end their own lives. And some people have ended their own lives. There were reports that some of these people did not appear depressed. No one knows if Accutane caused these behaviors or if they would have happened even if the person did not take Accutane.

All patients should read the section in this Medication Guide “What are the signs of mental problems?”

For other possible serious side effects of Accutane, see “What are the possible side effects of Accutane?” in this Medication Guide.

What are the important warnings for females taking Accutane?

You must not become pregnant while taking Accutane, or for 1 month after you stop taking Accutane. Accutane can cause severe birth defects in babies of women who take it while they are pregnant, even if they take Accutane for only a short time. There is an extremely high risk that your baby will be deformed or will die if you are pregnant while taking Accutane. Taking Accutane also increases the chance of miscarriage and premature births.

Female patients will not get their first prescription for Accutane unless there is proof they have had 2 negative pregnancy tests. The first test must be done when your prescriber decides to prescribe Accutane. The second pregnancy test must be done during the first 5 days of the menstrual period right before starting Accutane therapy, or as instructed by your prescriber. Each month of treatment, you must have a negative result from a urine or serum pregnancy test. Female patients cannot get another prescription for Accutane unless there is proof that they have had a negative pregnancy test.

A yellow self-adhesive Accutane Qualification Sticker on your prescription indicates to the pharmacist that you are qualified by your prescriber to get Accutane.

While you are taking Accutane, you must use effective birth control. You must use 2 separate effective forms of birth control at the same time for at least 1 month before starting Accutane, while you take it, and for 1 month after you stop taking it. You can either discuss effective birth control methods with your prescriber or go for a free visit to discuss birth control with another physician or family planning expert. Your prescriber can arrange this free visit, which will be paid for by the manufacturer.

You must use 2 separate forms of effective birth control because any method, including birth control pills and sterilization, can fail. There are only 2 reasons you would not need to use 2 separate methods of effective birth control:

1. You have had your womb removed by surgery (a hysterectomy).
2. You are absolutely certain you will not have genital-to-genital sexual contact with a male before, during, and for 1 month after Accutane treatment.

If you have sex at any time without using 2 forms of effective birth control, get pregnant, or miss your period, stop using Accutane and call your prescriber right away.

All patients should read the rest of this Medication Guide.
What are the signs of mental problems?

Tell your prescriber if, to the best of your knowledge, you or someone in your family has ever had any mental illness, including depression, suicidal behavior, or psychosis. Psychosis means a loss of contact with reality, such as hearing voices or seeing things that are not there. Also, tell your prescriber if you take medicines for any of these problems.

Stop using Accutane and tell your provider right away if you:

? Start to feel sad or have crying spells

? Lose interest in activities you once enjoyed

? Sleep too much or have trouble sleeping

? Become more irritable than usual

? Have a change in your appetite or body weight

? Have trouble concentrating

? Withdraw from your friends or family

? Feel like you have no energy

? Have feelings of worthlessness or inappropriate guilt

? Start having thoughts about hurting yourself or taking your own life (suicidal thoughts)
What is Accutane?

Accutane is used to treat the most severe form of acne (nodular acne) that cannot be cleared up by any other acne treatments, including antibiotics. In severe nodular acne, many red, swollen, tender lumps form in the skin. These can be the size of pencil erasers or larger. If untreated, nodular acne can lead to permanent scars. However, because Accutane can have serious side effects, you should talk with your prescriber about all of the possible treatments for your acne, and whether Accutane?s possible benefits outweigh its possible risks.
Who should not take Accutane?

? Do not take Accutane if you are pregnant, plan to become pregnant, or become pregnant during Accutane treatment. Accutane causes severe birth defects. All females should read the section “What are the important warnings for females taking Accutane?” for more information and warnings about Accutane and pregnancy.

? Do not take Accutane unless you completely understand its possible risks and are willing to follow all of the instructions in this Medication Guide.

Tell your prescriber if you or someone in your family has had any kind of mental problems, asthma, liver disease, diabetes, heart disease, osteoporosis (bone loss), weak bones, anorexia nervosa (an eating disorder where people eat too little), or any other important health problems. Tell your prescriber about any food or drug allergies you have had in the past. These problems do not necessarily mean you cannot take Accutane, but your prescriber needs this information to discuss if Accutane is right for you.
How should I take Accutane?

? You will get no more than a 30-day supply of Accutane at a time, to be sure you check in with your prescriber each month to discuss side effects.

? Your prescription should have a special yellow self-adhesive sticker attached to it. The sticker is YELLOW. If your prescription does not have this yellow self-adhesive sticker, call your prescriber. The pharmacy should not fill your prescription unless it has the yellow self-adhesive sticker.

? The amount of Accutane you take has been specially chosen for you and may change during treatment.

? You will take Accutane 2 times a day with a meal, unless your prescriber tells you otherwise. Swallow your Accutane capsules with a full glass of liquid. This will help prevent the medication inside the capsule from irritating the lining of your esophagus (connection between mouth and stomach). For the same reason, do not chew or suck on the capsule.

? If you miss a dose, just skip that dose. Do not take 2 doses the next time.

? You should return to your prescriber as directed to make sure you don?t have signs of serious side effects. Because some of Accutane?s serious side effects show up in blood tests, some of these visits may involve blood tests (monthly visits for female patients should always include a urine or serum pregnancy test).
What should I avoid while taking Accutane?

? Do not get pregnant while taking Accutane. See “What is the most important information I should know about Accutane?” and “What are the important warnings for females taking Accutane?”

? Do not breast feed while taking Accutane and for 1 month after stopping Accutane. We do not know if Accutane can pass through your milk and harm the baby.

? Do not give blood while you take Accutane and for 1 month after stopping Accutane. If someone who is pregnant gets your donated blood, her baby may be exposed to Accutane and may be born with birth defects.

? Do not take vitamin A supplements. Vitamin A in high doses has many of the same side effects as Accutane. Taking both together may increase your chance of getting side effects.

? Do not have cosmetic procedures to smooth your skin, including waxing, dermabrasion, or laser procedures, while you are using Accutane and for at least 6 months after you stop. Accutane can increase your chance of scarring from these procedures. Check with your prescriber for advice about when you can have cosmetic procedures.

? Avoid sunlight and ultraviolet lights as much as possible. Tanning machines use ultraviolet lights. Accutane may make your skin more sensitive to light.

? Do not use birth control pills that do not contain estrogen (“minipills”). They may not work while you take Accutane. Ask your prescriber or pharmacist if you are not sure what type you are using.

? Talk with your doctor if you plan to take other drugs or herbal products. This is especially important for patients using birth control pills and other hormonal types of birth control because the birth control may not work as effectively if you are taking certain drugs or herbal products. You should not take the herbal supplement St. John?s Wort because this herbal supplement may make birth control pills not work as effectively.

? Talk with your doctor if you are currently taking an oral or injected corticosteroid or anticonvulsant (seizure) medication prior to using Accutane. These drugs may weaken your bones.

? Do not share Accutane with other people. It can cause birth defects and other serious health problems.

? Do not take Accutane with antibiotics unless you talk to your prescriber. For some antibiotics, you may have to stop taking Accutane until the antibiotic treatment is finished. Use of both drugs together can increase the chances of getting increased pressure in the brain.
What are the possible side effects of Accutane?

Accutane has possible serious side effects

? Accutane can cause birth defects, premature births, and death in babies whose mothers took Accutane while they were pregnant. See “What is the most important information I should know about Accutane?” and “What are the important warnings for females taking Accutane?”

? Serious mental health problems. See “What is the most important information I should know about Accutane?”

? Serious brain problems. Accutane can increase the pressure in your brain. This can lead to permanent loss of sight, or in rare cases, death. Stop taking Accutane and call your prescriber right away if you get any of these signs of increased brain pressure: bad headache, blurred vision, dizziness, nausea, or vomiting. Also, some patients taking Accutane have had seizures (convulsions) or stroke.

? Abdomen (stomach area) problems. Certain symptoms may mean that your internal organs are being damaged. These organs include the liver, pancreas, bowel (intestines), and esophagus (connection between mouth and stomach). If your organs are damaged, they may not get better even after you stop taking Accutane. Stop taking Accutane and call your prescriber if you get severe stomach, chest or bowel pain, trouble swallowing or painful swallowing, new or worsening heartburn, diarrhea, rectal bleeding, yellowing of your skin or eyes, or dark urine.

? Bone and muscle problems. Accutane may affect bones, muscles, and ligaments and cause pain in your joints or muscles. Tell your prescriber if you plan vigorous physical activity during treatment with Accutane. Tell your prescriber if you develop pain, particularly back pain or joint pain. There are reports that some patients have had stunted growth after taking Accutane for acne as directed. There are also some reports of broken bones or reduced healing of broken bones after taking Accutane for acne as directed. No one knows if taking Accutane for acne will affect your bones. If you have a broken bone, tell your provider that you are taking Accutane. Muscle weakness with or without pain can be a sign of serious muscle damage. If this happens, stop taking Accutane and call your prescriber right away.

? Hearing problems. Some people taking Accutane have developed hearing problems. It is possible that hearing loss can be permanent. Stop using Accutane and call your prescriber if your hearing gets worse or if you have ringing in your ears.

? Vision problems. While taking Accutane you may develop a sudden inability to see in the dark, so driving at night can be dangerous. This condition usually clears up after you stop taking Accutane, but it may be permanent. Other serious eye effects can occur. Stop taking Accutane and call your prescriber right away if you have any problems with your vision or dryness of the eyes that is painful or constant.

? Lipid (fats and cholesterol in blood) problems. Many people taking Accutane develop high levels of cholesterol and other fats in their blood. This can be a serious problem. Return to your prescriber for blood tests to check your lipids and to get any needed treatment. These problems generally go away when Accutane treatment is finished.

? Allergic reactions. In some people, Accutane can cause serious allergic reactions. Stop taking Accutane and get emergency care right away if you develop hives, a swollen face or mouth, or have trouble breathing. Stop taking Accutane and call your prescriber if you develop a fever, rash, or red patches or bruises on your legs.

? Signs of other possibly serious problems. Accutane may cause other problems. Tell your prescriber if you have trouble breathing (shortness of breath), are fainting, are very thirsty or urinate a lot, feel weak, have leg swelling, convulsions, slurred speech, problems moving, or any other serious or unusual problems. Frequent urination and thirst can be signs of blood sugar problems.

Serious permanent problems do not happen often. However, because the symptoms listed above may be signs of serious problems, if you get these symptoms, stop taking Accutane and call your prescriber. If not treated, they could lead to serious health problems. Even if these problems are treated, they may not clear up after you stop taking Accutane.
Accutane has less serious possible side effects

The common less serious side effects of Accutane are dry skin, chapped lips, dry eyes, and dry nose that may lead to nosebleeds. People who wear contact lenses may have trouble wearing them while taking Accutane and after therapy. Sometimes, people?s acne may get worse for a while. They should continue taking Accutane unless told to stop by their prescriber.

These are not all of Accutane?s possible side effects. Your prescriber or pharmacist can give you more detailed information that is written for health care professionals.

This Medication Guide is only a summary of some important information about Accutane. Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. If you have any concerns or questions about Accutane, ask your prescriber. Do not use Accutane for a condition for which it was not prescribed.
Active Ingredient: Isotretinoin.

Inactive Ingredients: beeswax, butylated hydroxyanisole, edetate disodium, hydrogenated soybean oil flakes, hydrogenated vegetable oil, and soybean oil. Gelatin capsules contain glycerin and parabens (methyl and propyl), with the following dye systems: 10 mg ? iron oxide (red) and titanium dioxide; 20 mg ? FD&C Red No. 3, FD&C Blue No. 1, and titanium dioxide; 40 mg ? FD&C Yellow No. 6, D&C Yellow No. 10, and titanium dioxide.

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Frequent Questions Raised About Acne

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Acne is a very common disease. People who have it tend to have similar kinds of questions about it and its treatment. Learn more about drinking green tea to clear up acne and why it works. This section addresses some of the common questions asked by people with acne. Please remember that your dermatologist is always the best source of specific information about your individual health issues, including acne.

Questions and Answer does follows:

1. What causes acne?

The causes of acne are linked to the changes that take place as young people mature from childhood to adolescence (puberty). The hormones that cause physical maturation also cause the sebaceous (oil) glands of the skin to produce more sebum (oil). The hormones with the greatest effect on sebaceous glands are androgens (male hormones), which are present in females as well as males, but in higher amounts in males.

Sebaceous glands are found together with a hair shaft in a unit called a sebaceous follicle. During puberty, the cells of the skin that line the follicle begin to shed more rapidly. In people who develop acne, cells shed and stick together more so than in people who do not develop acne. When cells mix with the increased amount of sebum being produced, they can plug the opening of the follicle. Meanwhile, the sebaceous glands continue to produce sebum, and the follicle swells up with sebum.

In addition, a normal skin bacteria called P. acnes, begins to multiply rapidly in the clogged hair follicle. In the process, these bacteria produce irritating substances that can cause inflammation. Sometimes, the wall of the follicle bursts, spreading inflammation to the surrounding skin. This is the process by which acne lesions, from blackheads to pimples to nodules, are formed.

2. I wash my face several times a day. Why do I still get acne?

Many people still believe that acne is caused by dirty skin. The truth is, washing alone will not clear up or prevent acne. Washing does, however, help remove excess surface oils and dead skin cells. Many people use all kinds of products, including alcohol-based cleansers, and scrub vigorously, only to irritate the skin further and worsen their acne. Washing the skin twice a day gently with water and a mild soap is usually all that is required. However, acne is actually caused by a variety of biologic factors that are beyond the control of washing. For that reason, you should use appropriate acne treatments for the acne.

3. Does stress cause acne?

Stress is commonly blamed for the development of acne. Stress can have many physiologic effects on the body, including changes in hormones that may theoretically lead to acne. In some cases the stress may actually be caused by the acne lesions, not the other way around! If the acne is being treated effectively, stress is not likely to have much impact on the majority of people.

4. I never had acne as a teenager. Why am I now getting acne as an adult?

Usually, acne begins at puberty and is gone by the early 20s. In some cases, acne may persist into adulthood. Such types of acne include severe forms that affect the body as well as the face (which afflict males more than females) and acne associated with the menstrual cycle in women. In other cases, acne may not present itself until adulthood. Such acne is more likely to affect females than males.

There are several reasons for this. As females get older, the pattern of changes in hormones may itself change, disposing sebaceous glands to develop acne. Ovarian cysts and pregnancy may also cause hormonal changes that lead to acne. Some women get acne when they discontinue birth control pills that have been keeping acne at bay. Sometimes young women may wear cosmetics that are comedogenic-that is, they can set up conditions that cause comedones to form.

5. What role does diet play in acne?

Acne is not caused by food. Following a strict diet will not, clear your skin. While some people feel that their acne is aggravated by certain foods, particularly chocolate, colas, peanuts, shellfish and some fatty foods, there is no scientific evidence that suggests food causes or influences acne. Avoid any foods which seem to worsen your acne and, for your overall health, eat a balanced diet–but diet shouldn’t really matter if the acne is being appropriately treated.

6. Does the sun help acne?

Many patients feel that sunlight improves their acne lesions and go to great lengths to find sources of ultraviolet light. There is no proven effect of sunlight on acne. In addition, ultraviolet light in sunlight increases the risk of skin cancer and early aging of the skin. It is, therefore, not a recommended technique of acne management, especially since there are many other proven forms of treatment for acne. Moreover, many acne treatments increase the skin’s sensitivity to ultraviolet light, making the risk of ultraviolet light exposure all the worse.

7. What is the best way to treat acne?

Everyone’s acne must be treated individually. If you have not gotten good results from the acne products you have tried, consider seeing a dermatologist. Your dermatologist will decide which treatments are best for you. For more information about the types of acne treatments that are available, and for basic acne treatment guidelines, please see Acne Treatments in the main part of AcneNet.

8. What kind of cosmetics and cleansers can an acne patient use?

Look for “noncomedogenic” cosmetics and toiletries. These products have been formulated so that they will not cause acne.

Some acne medications cause irritation or pronounced dryness particularly during the early weeks of therapy, and some cosmetics and cleansers can actually worsen this effect. The choice of cosmetics and cleansers should be made with your dermatologist or pharmacist.

Heavy foundation makeup should be avoided. Most acne patients should select powder blushes and eye shadow over cream products because they are less irritating and noncomedogenic. Camouflaging techniques can be used effectively by applying a green undercover cosmetic over red acne lesions to promote color blending.

9. Is it harmful to squeeze my blemishes?

Yes. In general, acne lesions should not be picked or squeezed by the patient. In particular, inflammatory acne lesions should never be squeezed. Squeezing forces infected material deeper into the skin, causing additional inflammation and possible scarring.

10. Can anything be done about scarring caused by acne?

Scarring is best prevented by getting rid of the acne. Dermatologists can use various methods to improve the scarring caused by acne. The treatment must always be individualized for the specific patient. Chemical peels may be used in some patients, while dermabrasion or laser abrasion may benefit others. It is important that the acne be well controlled before any procedure is used to alleviate scarring.

11. How long before I see a visible result from using my acne medication?

The time for improvement depends upon the product being used, but in almost all cases it is more a matter of weeks or months instead of days. Most dermatologists would recommend the use of a medication or combination of medications daily for 4 to 8 weeks before they would change the treatment. It is very important for patients to be aware of this time frame so they do not become discouraged and discontinue their medications. Conversely, if you see no change whatsoever, you might want to check with your dermatologist regarding the need to change treatments.

12. Would using my medication more frequently than prescribed speed up the clearing of my acne?

No–always use your medication exactly as your dermatologist instructed. Using topical medications more often than prescribed may actually induce more irritation of the skin, redness and follicular plugging, which can delay clearing time. If oral medications are taken more frequently than prescribed, they won’t work any better, but there is a greater chance of side effects.

13. My topical treatment seems to work on the spots I treat, but I keep getting new acne blemishes. What should I do?

Topical acne medications are made to be used on all acne-prone areas, not just individual lesions. Part of the goal is to treat the skin before lesions can form and to prevent formation, not just to treat existing lesions. Patients are generally advised to treat all of the areas (forehead, cheeks, chin and nose) that tend to break out rather than just individual lesions.

14. My face is clear! Can I stop taking my medication now?

If your dermatologist says you can stop, then stop–but follow your dermatologist’s instructions. Many times patients will stop their medication suddenly only to have their acne flare up several weeks later. If you are using multiple products, it may be advisable to discontinue one medication at a time and judge results before discontinuing them all at once. Ask your dermatologist before you stop using any of your medications.

15. Does it matter what time I use my medication?

Check with your dermatologist or pharmacist. If you were taking one dose a day of an antibiotic, you could probably take it in the morning, at midday or in the evening, although you should pick one time of day and stay with it throughout your treatment. With oral medications prescribed twice a day or three times a day, you should try your best to spread out the doses evenly. Some antibiotics should be taken on an empty or nearly empty stomach. For optimal results with topical treatments, you should strictly follow your dermatologist’s recommendations. For example, if instructed to apply benzoyl peroxide in the morning and a topical retinoid at bedtime, it is important to follow these directions strictly. If the two were applied together at bedtime, for example, you could decrease the efficacy of the treatment because of chemical reactions that make them less effective.

16. I have trouble remembering to take my oral medication every day. What’s a good way to remember? What should I do if I forget a dose?

This is a common problem. Many patients try to associate taking their medication with a routine daily event such as brushing teeth or applying makeup. It also helps to keep the medication close to the area where the reminder activity is carried out.

In most cases, if you miss a day of your oral treatment, do not double up the next day; rather, get back to your daily regimen as soon as possible–but there may be different instructions for different oral medications. Ask your dermatologist or pharmacist about what to do if you miss a dose of your particular medication.

17. I have been using topical benzoyl peroxide and an oral antibiotic for my acne and have noticed blue-black and brown marks developing on my face and some discoloration on my body. The marks are especially noticeable around acne scars and recently healed lesions. Is this a side effect of medication and is it permanent?

It is not possible to make general statements about side effects of medications that apply to individual cases. A dermatologist should be consulted. The facial marks and body discoloration described by the patient in this case do fall within the range of side effects of some antibiotics.

Unique patterns of pigmentation are sometimes seen in acne patients treated with certain oral antibiotics?particularly minocycline. The pigmentation patterns that appear may include:

* Localized blue-black or brown marks in and around acne scars and in areas of previous acne inflammation

* A “muddy skin” appearance that may cover much of the body

* Diffuse brownish pigmentation of the feet and lower legs.

The pigmentation side effect gradually disappears after the therapy is discontinued.

Any side effect of a medication should be noted by the patient and brought to the attention of the physician. While most side effects are temporary they should be discussed with the physician and monitored.

18. My doctor is prescribing a topical retinoid for my acne. He said a retinoid is a substance related to vitamin A. If the drug is related to vitamin A, shouldn’t vitamin A dietary supplements be helpful in getting rid of acne?

Dietary vitamin A is essential to good health, especially vision. It has healthful effects in the skin. Large doses of vitamin A for the treatment of acne is not recommended on grounds of safety. The retinoids and retinoid-like substances used as topical treatments for acne are prepared especially for their potent effect on the shedding of cell lining in the sebaceous follicle. Their use should be monitored by a dermatologist.

Dietary vitamin A has multiple health effects in the human body. Vitamin A is essential for good vision. Extreme vitamin A deficiency can result in blindness, usually accompanied by dry, scaly skin. Vitamin A overdose that far exceeds the Recommended Dietary Allowance (RDA) of 5,000 IU can have effects nearly as catastrophic. Extreme vitamin A overdose can cause the skin to blister and peel?an effect first seen in early North Pole explorers who nearly died after eating polar bear liver that has an extraordinarily high vitamin A content.

Topical retinoids are usually prescribed as a treatment for moderate to severe acne. Side effects are chiefly dermatologic, including redness, scaling and dryness of the skin, itching and burning. These side effects can usually be managed by adjustment of the amount and timing of retinoid applied to the skin. Dose adjustment must be discussed with the dermatologist who prescribed the treatment.

19. Are there any acne treatments specifically for people with dark skin? Are there any treatments specifically harmful to dark skin?

There are no acne treatments specifically for use on dark skin. Acne treatments are generally as safe and effective on dark skin as on light skin. Some treatments for acne scars may cause temporary lightening of dark skin.

Acne is a common skin disease that has the same causes and follows the same course in all colors of skin.

Very dark or black skin may be less well-moisturized than lighter skin. Topical anti-acne agents such as benzoyl peroxide that have a drying effect on the skin should be used under the supervision of a dermatologist. Benzoyl peroxide also is a strong bleach and therefore must be applied carefully to avoid inadvertent decolorization of a patch of hair, towels or clothing.

Darker skin has a tendency to develop post-inflammatory hyperpigmentation (excessive skin darkening at places where the skin was inflamed). Severe inflammatory acne may result in dark spots. The spots resolve over time; a dermatologist may be able to recommend cosmetic measures to make the spots less apparent until they resolve. Some acne treatments, such as topical retinoids and azelaic acid, may also help fade the discoloration.

Removal of acne scars by dermabrasion or chemical peeling may cause temporary lightening or darkening of dark skin in the areas of treatment. Scar treatment should be discussed with a dermatologist or dermatologic surgeon before it is undertaken.

Alterations of melanin (dark pigments that give the skin its color) pigmentation such as vitiligo and melasma are not related to acne, but they may be present simultaneously with acne. The diagnosis and treatment of melanin pigmentation disorders such as vitiligo requires a dermatologist with knowledge and experience in treating these conditions.

20. Is acne that appears for the first time in adulthood different from acne that appears in adolescence?

Acne has a specific definition as a disease of sebaceous follicles. This definition applies to acne that occurs at any age. However, it may be important to look for an underlying cause of acne that occurs for the first time in adulthood.

Current understanding of the causes of acne vulgaris is described in the Main Text section Why and how acne happens. In brief summary, acne vulgaris develops when excessive sebum production and abnormal growth and death of cells in the sebaceous follicle result in plugging of follicles with a mixture of sebum and cellular debris and formation of comedones (blackheads and whiteheads). Bacteria in the follicles?chiefly Propionibacterium acnes, the most common bacterial colonist of sebaceous follicles?may contribute to the inflammation of acne by release of metabolic products that cause inflammatory reaction. The pathogenic events, which cause disease, in the sebaceous follicle are believed to be due in large degree to changes in levels of androgenic (male) hormones in the body?a circumstance usually associated with growth and development between ages 12 and
21. Some acne investigators believe that although this understanding is generally correct, there is more yet to be learned about the causes of acne vulgaris.

Acne that appears after the age of 25-30 years is (1) a recurrence of acne that cleared up after adolescence, (2) a flare-up of acne after a period of relative quiet?for example, during pregnancy, or (3) acne that occurs for the first time in a person who had never previously had acne.

Acne that occurs in adulthood may be difficult to treat if there are multiple recurrences. Some patients with severe recurrent acne have undergone repeated courses of treatment with the potent systemic drug isotretinoin.

Acne flares in association with pregnancy or menstruation are due to changes in hormonal patterns.

Acne that appears for the first time in adulthood should be investigated for any underlying cause. Drugs that can induce acne include anabolic steroids (sometimes used illegally by athletes to “bulk up”), some anti-epileptic drugs, the anti-tuberculosis drugs isoniazid and rifampin, lithium, and iodine-containing drugs. Chlorinated industrial chemicals may induce the occupational skin disorder known as chloracne. Chronic physical pressure on the skin?for example, by a backpack and its straps, or a violin tucked against the angle of the jaw and chin?may induce so-called acne mechanica. Some metabolic conditions may cause changes in hormonal balance that can induce acne.

Some lesions that appear to be acne may be another skin disorder such as folliculitis?infection and inflammation of hair follicles?that require different treatment than acne. Acne that appears for the first time in adulthood should be examined and treated by a dermatologist.

22. My 15-year-old daughter has what I would describe as a very mild case of acne. She has made it much worse by constant picking and squeezing. She looks in the mirror for hours, looking for some blackhead or blemish she can pick or squeeze. Does she need psychological counseling?

Excessive picking and squeezing of otherwise mild acne is a condition called excoriated acne, seen most often in young women. A dermatologist may provide effective counseling.

The typical person with excoriated acne is a person?often a young women?who is so distressed with her appearance due to acne that she literally tries to “squeeze the acne out of existence.” The acne is often very mild, but the person’s face may constantly be covered with red marks from squeezing, and open sores where lesions have been picked open.

The word excoriate means to scratch or abrade the skin. Excoriated acne is a medically recognized condition that should be discussed with a dermatologist. Occasionally giving in to a temptation to squeeze a blackhead is not defined as excoriated acne. Hours in front of a mirror, squeezing and picking every blemish, is a definition of excoriated acne. A dermatologist may be able to counsel the patient regarding a course of treatment in which the patient can participate, but keep “hands off.”

23. Can the rate of secretion or the composition of sebum be altered by diet? If it can, shouldn’t alteration of diet be considered a treatment for acne?

Diet has never been proven to have a role in the cause or treatment of acne. Dietary manipulation may have a role in the treatment of some scaling diseases of the skin, but not in the treatment of acne.

Dietary cause is one of the most persistent myths about acne. Foods, such as chocolate or greasy foods, do not cause acne, but certain foods seem to make some people’s acne worse. The following can bring on or worsen it:

* Hereditary factors

* An increase in male hormones found in both males and females

* Menstruation

* Emotional stress

* Oil and grease from cosmetics, work environment

No food has been shown to be effective in preventing or treating acne. A healthy diet is, of course, necessary for good general health.

24. Shouldn’t I just try to eliminate sebum from my body?

No. When it isn’t blocked in your pores, sebum helps keep your skin healthy.

25. Why does acne usually start at puberty?

No one knows for certain. What is known is that the sebaceous glands that produce sebum get much larger at puberty than they were before.

26. Why does the skin around a pimple turn red?

This redness is caused by the body’s inflammatory response. Inflammation is a sign that your immune system is working to fight an infection. However, the inflammatory response doesn’t always work perfectly, and can even be the cause of scarring.

27. If my skin turns red, does that mean that I’m going to have scars?

Usually, no. Even when there will be no permanent scar, the aftereffects of the inflammatory response can leave the skin red for months, sometimes for more than a year.

28. What are free radicals?

Free radicals are byproducts of oxidation in your body. We all need oxidation to occur as part of our life process, but there is concern that the buildup of unrecycled free radicals contributes to many conditions, including skin damage. Antioxidants, including several of the active ingredients in Acuzine, help prevent the buildup of free radicals.

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