Severe acne can cause permanent damage to the skin. At this stage, acne requires aggressive treatment. Find out the kinds of drugs used in the treatment of this serious form of acne.
by Brad Chase
Acne vulgaris is a common skin condition which affects most people at least once. For most people, acne starts during puberty and starts to clear out after a decade. However, some people do experience recurrent acne well into their adulthood.
When left untreated or if treatment fails, acne worsens and it progresses from mild and moderate acne to severe acne. Severe acne is the last stage of acne and it needs aggressive treatment.
Severe acne is easy to diagnose and difficult to treat. It requires consultation with and care under a dermatologist.
It is also the most serious form of acne vulgaris and it involves extensive inflammation on the skin.
Severe acne is also called cystic acne, nodulocystic acne, and nodular acne. This is because it is at the stage that nodules and cysts appear. These are new and deep acne lesions on the skin.
Severe acne can affect adolescents as well as adults. In some cases, severe acne extends beyond mere skin disease and can present as part of larger disease complexes.
Severe acne does not occur spontaneously but it is a progression of present acne.
When moderate acne is poorly controlled, it develops into severe acne. Therefore, severe acne is caused by all the other actors that cause mild and moderate acne. These include genetics, stress, diet, hormones and infections.
Genetics: Even though acne affects most of the population, the severity of acne is an inheritable trait. In some families, mild acne quickly progresses to severe acne in multiple members of such families.
For people with genetic predisposition to severe acne, the acne can last well into adulthood and it may occur as a component of other inheritable autoimmune diseases.
Stress: Emotional stress can very well worsen a present acne breakout. Stress triggers vary and they can be positive (weddings), negative (a death in the family) or neutral (examinations). Whatever the trigger, stress can turn a mild or moderate case of acne into severe acne.
Stress-induced severe acne should be treated with a combination of acne medications and stress relief exercises.
Diet: Some foods do worsen acne. Such foods include milk and dairy products as well as foods with high glycemic loads such as sugary drinks and snacks.
These foods either introduce growth hormones into the body or stimulate their secretions.
Hormones: Growth hormones are some of the strongest root causes of acne. This is why the first acne breakouts coincide with the start of puberty.
Androgens such as testosterone and dihydrotestosterone (or DHT) are produced in higher amounts during this phase of rapid growth. Another hormone of importance is insulin-like growth factor 1 or IGF-1.
These hormones stimulate increased production of sebum from the sebaceous glands.
Androgens specifically increase the proliferation of sebocytes which causes the enlargement of the sebaceous glands and the production of more sebum.
As the excess sebum is pushed to the skin surface, some of it clog the pores along with dead skin cells and bacteria. This is directly responsible for the appearance of comedones and the deep infection in the dermis that produces inflammatory acne lesions observed in severe acne.
Infections: The excess sebum that reaches the skin surface serves as food source for acne-causing bacteria such as Propionibacterium acnes and Staphylococcus epidermis.
This dramatically increases the population of these bacteria colonizing the skin and also changes the sensitivity of the skin to the effects of these bacteria. Therefore, P. acnes and S. epidermis cause extensively damage to the dermis which triggers an abnormal cycle of inflammation that produces inflammatory acne lesions.
Both superficial and deep acne lesions appear during severe acne and in greater numbers than during mild and moderate acne.
In addition, the lesions spread beyond the face during severe acne. They can be observed on the neck, upper arm, upper chest, shoulders, back and even thighs and buttocks in some cases.
Therefore, severe acne can be identified by these signs:
Whiteheads & Blackheads – These are called comedones. Whiteheads are called closed comedones or pimples while blackheads are called open comedones.
Both types of comedones are caused by the blockage of skin pores by dead skin cells, bacteria and sebum. However, the pores are partially blocked for blackheads and fully blocked for whiteheads.
Whiteheads appear as white specks on the skin. They do not last as long as blackheads which appear as dark colors on the skin. The dark coloration of blackheads is partially caused by the oxidation of sebum in the air and partially by the mixture of melanin, the skin pigment, with the content of the partially blocked pores.
Papules & Pustules – Papules and pustules are inflammatory acne lesions.
Papules are red, inflamed, small bumps on the skin. They are have no heads and should not be popped. Pustules on the other hand do have visible white or yellowish heads surround by red borders. They are filled with pus.
Nodules – Nodules look like larger papules. However, they are painful and can last for months.
Nodules appear as large, hard bumps under the skin surface. They are known to cause scarring and flare up every now and then. Nodules should not be aggravated or they can damage the dermis and take even longer to clear.
Cysts – Cysts resemble nodules except they are filled with pus. They are large, painful, inflamed bumps on the skin. They should also not be aggravated or they will not only cause more damage to the dermis but spread deep tissue infections that will prove very difficult to clear.
Scars – Acne scars are created as the body tries to heal the wound created by deep acne lesions such as nodules and cysts.
These scars can form with depressions on the skin that represent lost tissues. Alternatively, they can form with raised bumps on the skin which represent excess collagen produced as the body overcompensates while try to fill the scar pit.
There are 4 forms of severe acne vulgaris.
Acne conglobata affects men more than women, and it usually occurs between the ages of 18 and 30.
In acne conglobata, nodules form around clusters of comedones. These comedones quickly fill with pus and then become engorged and raw until they bust and refill again. This repeated engorging and popping of the lesions allow them to expand quickly.
Soon, the nodules and comedones connect together and fuse into larger masses with crusted centers and nodulocystic edges. As the wounds heal and break, they cause extensive scarring on the skin.
Acne conglobata is one of the two forms of severe acne (the other is acne fulminans) that contributes to an arthritis-like musculoskeletal disorder called SAPHO.
Acne fulminans results from acne conglobata that is not well controlled.
It is an even more serious form of severe acne. Acne fulminans not only produce ulcerative lesions along with all the deep lesions observed with acne conglobata but it also causes fever.
Acne fulminans has an immunological component. Both the fever and the bone lesions it causes are believed to be due to autoimmune hypersensitivity reactions to the antigens produced by the colonizing acne-causing bacteria such as P. acnes.
Besides these bacteria, testosterone and isotretinoin are known to trigger acne fulminans.
Gram-negative folliculitis is another severe form of acne. It is caused by the long-term antibiotic treatment of acne.
When broad-spectrum antibiotics are taken for a long while, they kill off all the beneficial and bad bacteria on the skin. Therefore, gram-negative bacteria that are resistant to these antibiotics face no competition and can rapidly colonize the skin.
Therefore, gram-negative folliculitis is caused by the opportunistic infection made possible by antibiotics.
Severe acne can cause permanent scarring of the skin, and it can negatively affect the psyche and confidence of its sufferers. Therefore, it needs to be aggressively treated.
The first-line drug for severe acne is oral isotretinoin.
Isotretinoin is a synthetic vitamin A analog. It is a powerful and effective anti-acne drug and it works by killing off cells of the sebaceous glands and turning off genes.
However, isotretinoin produce a number of serious side effects including birth defects (it should not be used by pregnant women; to prevent pregnancy, it is prescribed for women along with at least 2 forms of contraceptives).
When isotretinoin is unsuitable, long-term, high dose oral antibiotics are also used.
Alternatively, women can be given oral contraceptives containing estrogens and progestins. Men and women can be given anti-androgens such as spironolactone, flutamide, finasteride and oral corticosteroids.
When drugs fail or are inadequate, physical therapies are also available. These radical treatments range from freezing the lesions and surgical excision of nodules to direct injection of corticosteroids into lesions.
Lasers and other light therapies can also be used to surgically destroy lesions.
For very serious forms of severe acne especially acne conglobata and acne fulminans which involves SAPHO syndrome, specialized drugs such as sulfasalazine, methotrexate, infliximab and etanercept may be used for more aggressive treatment of autoimmune attacks.
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