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Dr.

Tinny Ho,
Specialist in Dermatology
June 29, 2004
Acne
Causes & Treatment
Acne is one of the most common skin
diseases, there are about 17,000,000
Americans affected by acne.
According to the data in US research, close to
100% of people between the ages of 12 to 17
have acne. After the age of 15, around 40% of
adolescents have acne severe enough to
require treatment by a physician.
Half Respondents Suffer From
Acne At Least Twice A Month
31%
16%
9%
3%
24%
19%
0% 10% 20% 30% 40%
don't know/hard to tell
once in quarter year or less
once in 2-3 months
once a month
2-3 times a month
once a week
valid sample:506
Frequency of having acne:
47%
Nearly 50% Respondents Thinks The
Cleanliness Of Skin Is The Major Cause of
Acne
30%
34%
40%
48%
12%
5%
14%
6%
0% 10% 20% 30% 40% 50%
don't know/hard to tell
others
oil secretion
pressure/mood
daily habit (not enough rest)
hormone secretion
food
cleanliness of skin
valid sample:503 (multiple responses)
What are the causes of having acne?
Causes of Acne
Acne is caused by the plugging of follicles, which is
mostly due to excessive sebum production by
sebaceous glands stimulated by the influence of
androgens (male sex hormones).
Skin keratinization and plugging of follicles speed up
the formation of acne.
A normal skin bacteria called P. acnes, produces
irritating substance that can cause inflammation.
Androgens & Acne
Androgens (male hormones) are present in females as
well as males, but in higher amounts in males.
Androgens cause the sebaceous (oil) glands of the
skin to produce more sebum (oil), excess androgens
will cause excess sebum production.
If excess production of sebum plugs the opening of
the follicles, it may increase the amount of bacteria
which cause inflammatory acne.
Despite having normal level of androgen, if the
sebaceous glands are over-sensitive to androgens,
excess sebum is thus produced, acne results.

Types of Acne
Whitehead:
a closed
comedo is a
sebaceous
follicle plugged
with sebum.
Its
appearance
is that of skin-
colored or
slightly
inflamed
bump
in the skin.
Blackhead:
a comedo is
open.






The surface of
the plug in the
follicle has
blackish
appearance.
Papules
Pustules
Types of Acne
Papules:
a small, solid
lesion slightly
elevated above
the surface of
the skin. It is
caused by
localized
cellular
reaction to the
process of
acne.
Pustules:
a dome-
shaped,
fragile lesion
containing pus
that typically
consists of
mixture of
white blood
cells, dead
skin cells and
bacteria.
Papules
Pustules
Nodules
Cysts
Types of Acne
Nodule:
is characterized by
inflammation, extends
into deeper layers of the
skin and may cause
tissue destruction that
results in scarring.
It may be very painful.




Cyst:
It may be severely
inflamed, extends
into deeper layers
of the skin, may be
very
painful, and can
result in scarring.





Cysts
Variation of Acne
Characterized by
whiteheads,
blackheads, papules,
pustules.
Inflammatory
increases and
becomes more
serious. It usually
happens on surface
but sometimes have
deeper pustules.
Characterized by
cysts and nodules,
many are in the body,
scars are easily
formed.
Severe Moderate Light
valid sample:506 (multiple
responses)
Where is the acne you usually having
50% Of Respondents Have
Acnes On Forehead
28%
31%
51%
1%
4%
26%
6%
0% 20% 40% 60%
don't know/hard to tell
others
near the mouth
nose
chin
cheek
forehead
Normal Distribution of Acne
Acnes lesions are most common areas with
sebaceous (oil) glands, mainly on the face, but
they can also occur on the upper back and
chest.
Upper back
Face
Causes of Excess Sebum
Production & Increase of
Androgen
Hormonal secretion becomes higher during puberty,
which causes the sebaceous glands becoming larger
and producing more sebum.
Womens menstrual cycle, being pregnant, starting or
ending to take contraceptive pill will cause hormonal
changes.
Others causes:
Heredity
Taking drugs containing androgens and lithium
Facts about Causes of Acne...
1. Eat chocolate and greasy food (e.g. French Fries) will
case acne
No scientific proof on the correlation between the
formation of acne and food.
2. Will dirty skin cause acne?
Acne is caused by the excess production of sebum
from skin.
3. Stress causes acne!
Some studies have demonstrated there is no
relationship between acne and stress. However, recent
studies show that corticosteroids (which are increased
during times of stress) may stimulate sebum
production, hence worsen the acne. A 2003 study
targeting medical students also shows patients with
acne may experience worsening of the disease during
examinations, suggesting stress may have a significant
influence.
1. I wash my face several times a day. Why do I still get
acne?
Too much washing will only irritate the skin further and worsen
their acne. Gently wash your face daily with mild cleanser or
soap, pat dry and use appropriate acne treatment.
2. Just let acne run its course!
Some acne scar will remain permanent, so patients should use
appropriate acne treatment as soon as possible.
3. Is it essential to squeeze the acne?
Squeezing forces infected material deeper into skin, causing
additional inflammation and possible scarring. If you have
severe acne problem, consult the doctor as soon as possible.
4. If the acne cannot be cured in a month, then should try other
drugs.
Give acne products enough time to do their job. Some
medicines might take a few months to take effect. Ask your
doctor how much time is needed for each particular product to
work.
Facts about Treatment of
Acne...
Acne Treatment
Purposes of Acne Treatment
Decrease sebum production
Reduce P. acnes (bacteria)
Reduce keratinization
Eliminate inflammation

A dermatologist may combine two or more
treatment options to create effective therapy
and prevent new lesions from forming.
Treatment for Mild Acne
Topical Treatment
External keratolytics may reduce
keratinization. Treatment such as:
Salicylic acid
Alpha hydrosy acids (AHA)
Benzoyl peroxide (cannot eliminate
inflammation)
Retinoids
Anti-inflammatory drugs to inhibit P. acnes
(bacteria)
Treatment for Severe Acne
The Common rationale of some of the treatment
method
1. Use anti-androgen (e.g. oral contraceptive pills) to
regulate androgen, to prevent excess sebum production.
This method is only suitable for women.
2. Use anti-biotic to curb the growth of bacteria.
3. Use retinoids, derivative of vitamin A (e.g. isotretinoin)
to reduce sebum production and keratinization. Patients
may experience side effects.

Beside the above treatment methods, other non-
medical treatment may be introduced, for example
to keep the skin clean by using skincare products
correctly.
Treatment for Severe Acne
Oral Anti-biotic
Use anti-biotic, for example tetracycline,
erythromycin or co-trimoxazole etc. to curb
the growth of bacteria and reduce
inflammation.
Use with care and prolonged treatment may be
necessary to achieve the desire results.
Treatment for Severe Acne
Oral Retinoids (isotretinoin)
To reduce sebum production and help skin cells inside
follicles to return to normal. Effective but takes 4-5
months before beginning to see an improvement.
Early use will cause dryness and shedding of skin, and
even cracking around the mouth.
Might cause foetal abnormality, hence not suitable for
pregnant women or women planning to have babies.
Studies show it might cause suicidal attempt.
Physician follow-up is required.
Treatment for Severe Acne
Anti-androgen
Androgens stimulate sebum production. To
tackle of root cause of acne, women should
find ways to tackle androgens.
Oral contraceptives works by regulating the
hormones (estrogen, progestogen and
androgen), blocking the effect of androgen on
the skin, and thus reducing sebum production.
It is effective in acne treatment and sebum
control among women.
Antiandrogenic Effect of Different
Oral Contraceptives
Source: Pharmacological profiles of progesterone, drospirenone and other synthetic progestogens.
Foldert et al. Eur J Contracept Reprod Health Care 2000; 5: 124-34
Antiandrogenic
Effect
Synthetic Progesterones (active
ingredients of most oral contraceptives)
e.g: Levonorgestrel, Norgestimate,
Desogestrel, Gestodene
-
Drospirenone (Brand name: Yasmin)
+
Cyproterone acetate (Brand name: Diane)
++
CPA synthetic hormone
effective in reducing androgen
CPA (cyproterone acetate) was developed in
1961.
CPA attaches itself to androgen receptors in
the skin and then blocks the receptors (like
the wrong key jammed in a lock). The
androgens then cannot affect the skin.
Additionally, it also reduces the activity of the
ovaries, so it also works as a contraceptive
pill.
Diane-35 is the only oral contraceptive that
contains CPA.
Treatment for Severe Acne
Anti-androgen: Diane-35 Acne
Treatment with Contraceptive
As oral contraceptive pill effective on acne treatment and
skin improvement.
Clinical studies show:
1. After 3 cycles (months): improvement/healing for 35-50% of
patients
2. After 12 cycles (months): improvement/healing rate of acne
for 90% of patients
The only oral contraceptive approved by the Hong Kong
Department of Health for the indication of acne treatment.
Oral contraceptives not suitable for pregnant women and
cigarette smokers.