Teenage Acne (Pimples): Types, Causes, Treatments, Scar Removal

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Introduction

  • Teenage acne is an extremely common skin condition where there is a chronic inflammation of the pilosebaceous gland during puberty that affects over 90% of adolescents, particularly in females causing whiteheads, blackheads, or pimples, that usually appears on the face, forehead and often trunk.
  • It is associated with emotional distress and scarring depending on the severity of the disease.

Epidemiology

Incidence: Affects 50 million people in the USA and 85% of them are teenagers. Almost 10% of the world population and 3 in every 4 people aged 11 to 30 years are affected by acne.

Age: most common between the ages of 12 and 20 years, but it can occur at any age; may last for 5-10 years and usually resolves by age 20–25 years. It usually becomes most severe in the late teenage years.

Sex: Both genders are equally affected, the onset is slightly earlier in female.

Pathogenesis

The key components are 

  1. Increased sebum production: The severity of acne is related to sebum excretion rate, which increases at puberty due to hormonal change. Both androgens and progesterone increase sebum excretion and estrogens reduce it
  2. Basal keratinocyte proliferation in pilosebaceous follicles causing occlusion of pilosebaceous ducts
  3. Colonization of pilosebaceous ducts by propionibacterium acnes, which in turn causes inflammation.
  4. Comedones formation that blocks secretions, hence papules, nodules, cysts and scars formation

Risk factors of teenage acne

    • Age- most common in teenagers but people of all ages can get acne.
    • The onset of menstruation – some teenagers experience acne outbreaks just before menstruation.
    • Hyperandrogenism – testosterone secreted into the body, enters the sebaceous gland and increases sebum production.
    • Greasy oily substances– Exposure to oils, tars or chlorinated aromatic hydrocarbons cause the oil to stick to the skin and block the follicles.
    • Excessive sweating and humidity.
    • Family history – There may be a positive family history indicating that genetic factors are important, but the exact responsible genes are poorly defined.
    • Pressure or friction on the skin – acne may develop when the skin comes in contact with telephones/helmets/tight collars for too long.
    • Medications – systemic or topical glucocorticoids, oral contraceptives, anticonvulsants, lithium, or antineoplastic drugs, such as the epidermal growth factor receptor (EGFR) inhibitors.
    • Polycystic ovary syndrome– Acne is a common feature of polycystic ovary syndrome associated with hirsutism and menstrual irregularities. 

Aggravating factors of teenage acne

  • Stress
  • Smoking
  • Diet- Diet is not believed to play a major role in acne development but milk products and food containing high-glycemic diets can exacerbate the existing acne
  • Exposure to sunlight

Types of acne according to the presence of inflammation

  1. Inflammatory (papules, pustules and nodules)
  2. Non-inflammatory (open and closed comedones)

Clinical features of teenage acne

  • Inflammatory Papules (Small red and tender bumps)
  • Pimples (papules with pus)
  • Nodules (Large, solid, and painful lumps beneath the surface of the skin) 
  • Cysts
  • Seborrhea – Excessive oil production by the sebaceous glands causing the skin to become greasy. 
  • Comedone is the hallmark 
    • blackheads (open comedones)  are enlarged keratin-filled follicles. It becomes black due to keratin deposition. 
    • whiteheads (closed comedones) have no visibly open follicle and are caused by the accumulation of sebum and keratin deeper in the skin (pilosebaceous ducts).
  • Scarring due to deep-seated or superficial acne 
  • Keloid or hypertrophic scar
  • Emotional effects: 
    • Depression and suicidal tendency may occur due to embarrassment 
    • school avoidance 
    • life-long effects on the ability to form friendships or attract partners

Differential diagnosis

  • Milia
  • Keratosis piliaris
  • Hidradenitis suppurativa
  • Acne Keloidalis nuchae
  • Acneiform eruptions
  • Folliculitis
  • Perioral Dermatitis
  • Rosacea
  • Sebaceous Hyperplasia
  • Syringoma
  • Tuberous Sclerosis

Complications

  • Scar
  • Keloids
  • Anxiety
  • Depression
  • Social withdrawal
  • Poor facial aesthetics
  • Low self-esteem

Investigations

  • Investigations are not usually required for the diagnosis of typical acne vulgaris. 
  • If secondary causes of acne are suspected then underlying endocrine disease, PCOS or virilization should be investigated.

Acne treatment

AIM

  • effective treatments aim to improve the condition,
  • prevent worsening (including later scarring) 
  • restore emotional well-being and self-esteem

General measures

  • Wash affected area with gentle care not more than twice a day
  • Avoid certain products, such as facial scrubs or face masks as they may irritate the skin and worsen acne. 
  • Avoid excessive washing and scrubbing
  • Sunlight protection by using sunscreen as sunlight may worsen acne in some people
  • Avoid pressure or friction over acne-prone skin
  • Avoid touching or picking at the affected areas
  • Do not pop active acne – squeezing pushes the bacteria and pus to go deeper into the skin follicles leading to follicular wall rupture and spilling of all the infected debris into the dermis of the skin causing redness, swelling, and permanent pits or scars.
  • Get enough sleep and exercise to avoid stress
  • Avoid certain home remedies 
  • Maintain good nutrition to boost the immune system for effective action against bacteria and infection
  • Psychological support as acne and acne scars can cause stress, depression and anxiety and may affect social relationships and low self-esteem. The psychological impact of acne must not be under-estimated and should be considered in management decisions

Topical therapy

  • Benzoyl peroxide has both anti comedogenic and antiseptic effects
  • Retinoids and retinoid-like drugs
    • retinoic acid (tretinoin) 
    • adapalene
  • Azelaic acid
  • Salicylic acid
  • Dapsone
  • Topical antibiotics, such as erythromycin or clindamycin

Systemic therapy 

  • Tetracycline 
  • Oxytetracycline 
  • Lymecycline 
  • Doxycycline 
  • Minocycline (less frequently, as it can cause hyperpigmentation, autoimmune hepatitis and drug-induced lupus, and monitoring are required). 
  • Erythromycin
  • Trimethoprim.
  • Combined estrogen and antiandrogen (such as cyproterone acetate) contraceptives particularly in women with acne and hirsutism, as seen in polycystic ovary syndrome
  • Isotretinoin (13-cis-retinoic acid) if there is a failure to respond adequately to 6 months of therapy with these combined systemic and topical approaches. It has multifactorial mechanisms of action, with a reduction in sebum excretion by over 90%, follicular hypercornification, P. acnes colonization, and inflammation. Oral isotretinoin is usually used at a dose of 0.5–1 mg/kg over 4 months. 

Physical therapies

  • Intralesional injections of triamcinolone acetonide may be required for inflamed acne nodules or cysts
  • Incision and drainage, or excision under local anesthetic
Teenage acne

Acne Scar treatment

  • Intralesional injection – Keloid or hypertrophic scars may respond to intralesional glucocorticoid. 
  • Temporary soft tissue fillers– Collagen or Hyaluronic acid or fat is injected under the skin into the scars to fill out or stretch the skin and make the scars less noticeable. Repeated injections are needed periodically as the results are temporary lasting for 6-18 months
  • Permanent filler– the first FDA approved dermal filler for correcting acne scar is Bellafill which is a gel containing 80% collagen and 20% polymethylmethacrylate (PMMA)
  • Microdermabrasion – this includes removal of the top layer of skin by deep exfoliating using a wire brush or wheel so that surface scars may completely be removed, and deeper acne scars become less noticeable.
  • Chemical peeling.
  • LASER (erbium Yag) –  Er: YAG lasers typically emit a wavelength (2940 nm) of high-frequency infrared light that focuses on the skin creating heat to destroy diseased cells with minimal normal skin damage.
  • Carbon dioxide laser resurfacing – it is a process where epidermal ablation and dermal damage with collagen remodeling is done to improve skin texture, promote skin rejuvenation for a more youthful appearance
  • Ablative laser is used to remove a small patch of skin around the scar to form a new and healthy-looking skin
  • UVB phototherapy or PDT can occasionally be used in patients with inflammatory acne who are unable to use conventional therapy, such as isotretinoin. 

Prognosis

  • Acne is not life-threatening but it has lifelong psychosocial effects
  • Acne vulgaris resolves spontaneously by early to mid-20s but a minority of patients particularly women may have acne till 40 years of age. 
  • Acne usually heals without scarring if it is noninflammatory and mild but Moderate to severe inflammatory acne often heals with scarring which results in huge emotional distress, anxiety, and depression among adolescents. 
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