Acne vulgaris is a chronic inflammatory disease of the skin structure called pilosebaceous. It can be seen at almost all ages, but it is usually the sign of the transition to adolescence.

Acne Vulgaris

Acne is a chronic inflammatory disease of the skin structure called pilosebaceous. It can be seen at almost all ages, but it is usually the sign of the transition to adolescence.

The pilosebaceous consists of a hair follicle and associated sebaceous glands (sebaceous glands) and the erector pili muscle (the muscle that raises the hair). Sebaceous glands open into the hair follicle channel and discharge their secretion into the follicle channel.

Hair follicles are found throughout the human body, except for the palms, soles, and parts of the external genitalia. It is thought that there are approximately 5 million hair follicles in the human body. These have different functions such as balancing body temperature, collecting sensory information, and supporting social communication.



Sebaceous glands (sebaceous glands) can be found on all skin surfaces except the palms and soles. They produce a secretion called sebum. Apart from sebum production, sebaceous glands contribute to the immune system, act as a barrier, and play a role in oil and hormone production.

Sebum is an oily and waxy secretion. Sebum content varies with age. It supports the barrier function of the skin. It contributes to the immune system.

Acne, an inflammatory disease of the pilosebaceous unit, often occurs in adolescence and on the face. It can also be seen on the scalp, back, breastbone. It can cause cosmetic problems, especially in adolescents. It can leave permanent scars on the face. This can sometimes lead to psychological problems. There are studies showing that the incidence in adolescence is 90% and approximately 30% of these are serious cases. The incidence of acne over the age of 35 is 3%.

It is more common in boys than girls. Studies have shown that acne is most common in girls aged 14-17 and boys aged 16-19. Acne is not transmitted from person to person.

Acne development process: 

The acne development process consists of four stages.



There are four well-defined pathogenetic mechanisms in acne development. These;

  • Enlargement of sebaceous glands and increased sebum secretion,
  • Cell growth in the follicular layer of the skin,
  • Bacteria (Propionibacterium acnes / P. acnes) proliferation in the pilosebaceous unit,
  • It is the stage of inflammation.

Causes of acne: 

  • Genetic predisposition: Acne is more common in those with a family history of acne, suggesting familial transmission. Although various genetic studies have been carried out in recent years, a gene responsible for genetic transition has not been revealed yet.
  • Smoking (not the cause of acne, but increases the development of acne, some studies claim that it increases the severity of acne),
  • Nutritional habits: Due to its effects such as hormone secretion and fat accumulation, it is thought that especially feeding with foods with a high glycemic index increases the development of acne. Foods such as chocolate, fatty milk and dairy products can be effective in the development of acne.
  • Low exposure to sun rays: Studies have shown that acne is more common in winter months when exposure to sun rays is reduced.
  • Hormones: There are studies showing that hormones can be effective in both acne formation and acne treatment. In particular, sex hormones such as androgens, estrogens, progesterone, as well as some hormones such as growth hormone, melanocortins, glucocorticoids, corticotropin-releasing hormone can play a role in this area.
  • Soaps: Skin cleansing with alkaline soaps can increase the growth of bacteria by changing the pH of the skin.
  • Cosmetic products: Especially oil-based skin concealers or oily sunscreens can be effective.
  • Environmental factors:
    • Air pollution,
    • Water pollution,
    • Stress,
    • Irregular sleep,

Symptoms of acne vulgaris :  

Symptoms are usually grouped into primary and secondary lesions.

  • Primary lesions:
      • Non-inflammatory lesions:
        • Closed comedones (white dots): They are sebaceous gland-like lesions that are 1-2 mm in diameter and are not easily noticed, which occur due to the obstruction of hair follicles. It is mostly seen on the nose, forehead and upper cheeks. It is mostly white in color. It does not empty when squeezed. May develop into inflammatory lesions.
        • Open comedones (black dots): These are lesions that look like oil glands and have a black hair follicle opening in the middle. Black color is a color produced by the hair follicle.
      • Inflamed lesions:
        • Papule: Small pink bumps that can be seen with the naked eye. It is considered as the step of transformation of non-inflammatory lesions into inflammatory lesions. It can be tender and painful at times.
        • Pustule: Small round lesions with red base, white inside, yellowish color, resembling papules, containing pus.
        • Nodules : These are lesions similar to papules but larger in structure. It appears as bumps on the skin that can sometimes be painful.
  • Secondary lesions:
    • Scars: Even if acne is properly treated, it can sometimes leave permanent scars. It creates cosmetic problems. In addition, psychological problems, loss of self-confidence can sometimes be a reason for suicide.
    • changes in skin color ,
    • Cysts: They are large, pus-filled lesions. It is painful. It often leaves deep scars as it heals.

Diagnosis of acne vulgaris:  

Acne is a skin disease that can be easily diagnosed by physical examination. The face, chest and back area should be examined in detail. In women, if there is excessive hair growth, menstrual irregularity, etc. in the anamnesis, hormonal factors are considered.

One of the important steps in the diagnosis of acne is causal research and evaluation of other comorbidities.

Hormone tests, microbiological tests and measurement of vitamin D levels may be required in patients who do not respond to classical acne treatments.



Along with the diagnosis, acne grading is made and treatment is planned.

Rating of acne vulgaris:  

Acne is graded in 4 main groups:

  • Mild: There are closed comedones (whiteheads), open comedones (blackheads), few papules and pustules.
  • Moderate: Many papules, pustules, and extensive closed and open comedones.
  • Severe: There are many painful, large papules, pustules, few nodules or cysts. It leaves a mark.
  • Very Severe: There are lots of papules, pustules, nodules, and cyst lesions. It can leave serious and deep scars.

According to a different grading method, the face, chest and back are divided into 6 regions and acne lesions are examined in these regions. Each region is scored according to the presence of no acne lesions (0 points), open/closed comedones (1 point), papules (2 points), pustules (3 points), nodules (4 points) and multiplied by the standard coefficient to obtain a score. . Point result:

  • Value from 1-18: Mild acne,
  • 19-30 value: Moderate acne,
  • Value 31-38: Severe acne,
  • A value of 39 and above: It is considered as very severe acne.

Grading of acne severity in diagnosis is important in terms of treatment planning and course of the disease. The degree of traces left after acne can also be understood with this rating.

Treatment of acne vulgaris: 

Acne treatment is determined according to the patient’s age, skin type and color, the area of involvement of the disease, its severity, and the patient’s preference. The main purpose is to prevent the development of acne and to heal the existing ones without leaving any scars and without causing any complications.

Acne treatment options:

Topical treatment:

It can be used alone or in combination with other treatments. It is generally recommended to prefer combined treatment options. The use of the preferred treatment option in pregnant women or children should be evaluated in detail.

  • Topical retinoids: Preventing the development of acne is the first treatment option for the removal of acne lesions. It can be used alone or in combination with other treatment options. Tretinoin, adapalene and tazarotene etc. are preferred.
  • Topical antibiotics: It is not recommended to be used alone due to the risk of resistance development, it is usually used in combination with other drugs. They are effective in the treatment of mild to moderate acne. Clindamycin, erythromycin etc. may be preferred.
  • Benzoyl peroxide: It can be used alone or in combination with other drugs in the treatment of mild or moderate acne with inflammatory lesions. It can make the skin more sensitive to sunlight. It can also cause whitening of hair and clothes.
  • Combined treatments : Topical antibiotic and benzoyl peroxide combinations, combinations of topical retinoids and antibiotics, combinations of retinoids/benzoyl peroxide/topical antibiotics can be used.
  • Azelaic acid: It is used in combination with other treatments in acne lesions, especially in patients with pigmentation problems.
  • Topical dapsone: It is preferred in adult patients, especially in cases with inflammatory lesions.
  • Salicylic acid: There are few studies on its use, especially in the treatment of open or closed comedones.
Antibiotics:

Oral antibiotics may be preferred in the treatment of moderate and severe acne. It is used to prevent bacterial growth and to treat inflamed lesions. Oral antibiotics will be more effective, especially in the presence of acne lesions in a large area, since the use of topical drugs will be difficult. Tetracyclines (tetracycline, doxycycline, minocycline and limecycline), macrolides (erythromycin and azithromycin), clindamycin, trimethoprim/sulfamethoxazole and ampicillin/amoxicillin may be preferred. In terms of antibiotic resistance, especially macrolide group drugs should be careful. Combinations with topical medications can be used to reduce the risk of resistance.

Hormone therapy:

Hormone therapy may be preferred in some female patients. Oral contraceptives, spironolaton, corticosteroids, metformin, etc. can be applied in cases of acne resistant to other treatments, especially in female patients with menstrual irregularity or hormonal problems. It may be effective in patients whose hormonal changes are considered as the cause of acne development.

Peeling:

It is the process of peeling and smoothing the skin by applying a chemical agent to the skin in patients with pigmentation changes and acne scars. It is increasingly used to assist other treatment options or to remove scars after treatment. By applying skin tests, the patient is selected for peeling. Agents such as alpha hydroxy acid, salicylic acid, lipohydroxy acid, Jessner’s solution, glycolic acid, lactic acid, rezosinol can be used for chemical peeling.

Laser application:

Although it is not the first choice in the treatment of mild and moderate acne, its use is becoming widespread. It reduces sebum production by damaging the sebaceous glands. Other light treatments can be applied with the same mechanism of action. There are publications showing that it gives effective results in the treatment of acne exacerbations and that 40-60% of the lesions are healed. However, the improvement is not permanent, it can recur.

Other treatment options:

In addition to the classical acne treatment, different treatment options can be applied to accelerate the healing. Among these, different methods such as corticosteroid injection into the lesions, evacuation of comedones, peeling of the skin can be applied.

Depression treatment:

Acne can be a cause of anxiety and stress, especially in adolescents. This can sometimes result in depression. Patients with acne and scarring lesions may also need to be evaluated for depression and treated appropriately. Cognitive behavioral therapy or selective serotonin reuptake inhibitors may be preferred in the treatment of depression.

Recommendations for acne vulgaris:  

  • Washing, rubbing and brushing the area of acne lesions frequently may irritate the skin and cause the lesions to worsen.
  • There is no direct relationship between skin cleansing and acne development. Acne is caused by pilosebaceous structures under the skin.
  • Real soaps dry out the skin, impair barrier function, and can exacerbate acne lesions. For this reason, they are not preferred as cleansers in the treatment of acne.
  • Cleaning blackheads or squeezing lesions can cause permanent scarring.
  • Synthetic detergent cleaners (syndet bar) dry the leather less than real soap. The normal flora of the skin is preserved.
  • There are studies showing that antibacterial soaps are not effective in the treatment of acne.
  • Oil-free cleansers can provide skin cleansing without irritating the skin.
  • In the treatment of acne, it is recommended to clean the skin twice a day, with cleansers suitable for the pH of the skin, in a non-aggressive manner. For this purpose, syndet bar and oil-free cleaners can be used. It is more appropriate not to use cold and hot water for skin cleaning, but to clean with warm water.
  • Water-based and oil-free moisturizers can be used to prevent skin dryness and skin burns due to acne lesions.
  • Avoid oily cosmetics.
  • Sebum-balancing agents applied on the skin can be preferred, especially in inflamed acne lesions.
  • Sunscreen creams can be used especially in patients with pigmentation problems. Protects from the harmful effects of UV rays. It can also be used in lightening cosmetic products.
  • Some cosmetic products such as concealer creams and powder can be used to cover acne lesions. Oil-free, matte foundations should be preferred. Oil-free moisturizer, then matte foundation and finally loose powder application will give effective results in closing acne lesions. However, it is necessary to avoid using too many cosmetic products and excessive make-up.
  • Before going to bed, remove your make-up, do not spend the night with make-up.
  • Don’t let your hair touch your face all the time, wash it regularly.
  • No food has been found to be directly related to acne and dietary habits.
  • Applying toothpaste on acne lesions may worsen the lesions with the effect of possible chemicals.
  • A direct link between sexual activities and the development of acne has not been determined.

 


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