Acne on face

Acne, or acne vulgaris, is a very common skin condition which many healthy teenagers and adults find embarrassing.  Since it mainly affects the skin of the face, acne is displayed on a very prominent area of the body.  Due to this fact, it is hard to hide this condition.

This condition tends to mainly affect adolescents and young adults.

Acne, also more commonly known as pimples or zits, is a dermatological condition affecting the pores of the skin.  More specifically, acne vulgaris, affects the pilosebaceous units of the skin.

These pilosebaceous units are made up of hair follicles including their arrector pili muscle and their adjoined sebaceous gland.

Pilosebaceous Unit of the Skin

When an overproduction of, and blockage of, sebum occurs within the pilosebaceous units, whiteheads and/or blackheads can form.  The underlying cause is inflammation.

Bacteria are also believed to play a role in this skin condition.  Propionibacterium acnes (P. acnes) is the bacteria which has been implicated in the pathophysiology of acne vulgaris.

There are actually several mechanisms that are believed to play a role in the development of acne including:

  • greater than normal follicular keratinization (follicular hyperkeratinization)
  • an increase in the level of sebum production due to hyperandrogenism
  • the further spread of Propionibacterium acnes
  • inflammation


Follicular Hyperkeratinization Explained

Looking at the picture of the skin above we can see that the epidermis is the uppermost layer of the skin.  Keratinocytes are cells that make the protein keratin.  These cells make up 90% of the cells of the epidermis.  Look at your hands and face.  What you are looking at are keratinocytes.

Keratinocytes have two roles they are either a dividing cell in the basal layer of the epidermis (basal cells or stem cells) or they are cells that differentiate and migrate up through the layers of the skin.

As stated previously, keratinocytes produce a protein known as keratin.  Keratin is a fibrous structural protein.  Besides being found in the skin cells, keratin is also found in our nails and hair.  To emphasize how hard keratin can be it is important to know that it is the hard structural protein that makes up bird’s beaks and animals horns.

Hyperkeratinization is basically an overabundant production of the protein keratin which is accompanied by an unusually fast shedding of skin cells.  Folicular hyperkeratinization happens when the cells of the follicle produce more than the normal amount of keratin and become “stuck together”.  Due to this cohesion, these cells are unable to migrate normally onto the surface of the skin.

Skin cells with lots of keratin in them become less pliable than skin cells with less keratin.

Normally, sebum produced by the sebaceous gland brings dead keratinocytes from within the follicle to the surface of the skin.  Highly keratinized skin cells become very stiff and form a plug together thus blocking their journey to the surface of the skin.  This plug stops the flow of dead cells and sebum.

Hyperandrogenism and Increased Sebum Production Explained

Hyperandrogenism means that there is an increased level of androgen hormones within the body.  The most well known androgen hormone is testosterone.

Androgens are often thought of as the male sex hormone but it is important to know that they are also produced and found in females as well.

Sebum is the oily substance produced by the sebaceous glands which helps the skin to remain waterproof.

Testosterone increases the size (hypertrophy) of the sebaceous glands and boosts the production of sebum.  It can even lead to inflammation of the sebaceous gland.

Genetics also influences the degree to which we produce sebum.

Propionibacterium acnes (P. acnes)/Cutibacterium acnes (C. acnes)

Propionibacterium acnes, or P. acnes, is a bacterial species known to facilitate pathological processes in acne.  P. acnes is a gram-positive bacilli.  P. acnes is also known as Cutibacterium acnes.

Due to a recent re-classification, P. acnes is now properly referred to as Cutibacterium acnes.

Sebum is a nutritional substrate for C. acnes.  C. acnes loves the lipids found within sebum.  It uses sebum and cellular debris as its source of energy and nutrients.

There is now evidence that C. acnes can form a biofilm which can plug the pore opening of the hair follicle leading to the build up of sebum.  It is also thought that C. acnes can even modulate the differentiation of keratinocytes and increase the production of sebum.

It initiates and enhances inflammatory processes as well.  As you can see C. acnes can play a significant role in acne.

Signs and Symptoms of Acne

The common signs of acne include:

  • closed comedones (whiteheads)
  • open comedones (blackheads)
  • papules
  • pustules
  • nodules
  • cysts

The Treatment of Acne Vulgaris

The methods of treatment of acne vulgaris basically involve counteracting the biological mechanisms which lead to acne.

These methods include:

  • counteract the actions of androgens (testosterone)
  • reduce sebum production
  • stop hyperkeratinization
  • decrease the proliferation of C. acnes
  • lower inflammation

Treatments are either topical, systemic or physical.

Topical treatments include washes, gels, ointments and creams.

Systemic treatments are usually taken orally in the form of capsules and tablets.

Physical treatments are treatments that physically alter the affected skin such as microdermabrasion, chemical peels and laser treatments.

Mild cases can often be treated successfully with simple remedies.  These simple remedies include regularly washing of the affected areas with soap and water and/or treatment with over-the-counter medications such as benzoyl peroxide and salicylic acid.

More serious cases will require prescription medications, or other treatments, provided by your family physician or a skin specialist known as a dermatologist.

Topical prescription medications include tretinoin and adapalene.  Topical antibiotics may also be used.  These include topical clindamycin and erythromycin.

Oral medications may also be prescribed and include antibiotics, oral contraceptives and isotretinoin.

Caution must be used with using isotretinoin in women of child-bearing age.  Isotretinoin can cause significant teratogenic effects in babies if a woman taking tretinoin should become pregnant.  Contraceptive methods must be used by women taking isotretinoin.

It is important to treat severe acne as soon as possible as permanent scarring can occur.  A patient with severe acne who experiences scarring can be at risk of developing depression.

There are many great treatments available.  There is hope when dealing with acne.   Getting this skin condition under control is possible.

To read information about other embarrassing health issues visit our Conditions page.