Changes inside the follicle
As androgen production increases and sebaceous glands enlarge,
the inner lining of skin in the hair follicle also changes. Normally,
dead cells inside the follicle shed gradually and get expelled
onto the surface. However, during puberty these cells are shed
more rapidly and tend to stick together. When they mix with sebum,
they can clog the follicle--the cells and sebum form a plug in
the follicle.
Bacteria
The clogged follicle becomes a breeding ground for bacteria.
One type of bacteria specifically involved is Propionibacterium
acnes or
P. acnes for short. P. acnes ingests sebum and is a normal
resident on skin even in people who don't have acne. However,
when the sebaceous gland gets clogged, and sebum builds up inside
the follicle, P. acnes multiplies rapidly. Chemicals produced
by the bacteria can cause inflammation in the follicle and surrounding
skin.
Can I be Genetically Predisposed to Acne?
While virtually everyone gets acne to some degree, some people
are born with a predisposition to certain types of acne. There
seem to be similarities in acne among family members regarding
patterns of acne lesions, duration of acne, severity and so on.
Acne occurs in all races, but there are ethnic variations that
suggest genetic influences; Caucasian Americans, for instance,
tend to be more affected than African Americans or people of Asian
heritage. From a scientific standpoint, not much is known yet
about the specific genetics involved in acne, but there seems
to be a connection.
If a teenager's parents or older siblings have had severe acne,
that teenager is likely to have severe acne, too. It is all the
more critical for such teenagers to consider seeing a dermatologist
before the acne becomes severe.
Can Cosmetics Give Me Acne?
Yes, comedones from certain cosmetics and toiletries may clog
pores. Such products, which include makeup, foundations, night
creams and moisturizers, are called comedogenic. People should
look for "noncomedogenic" cosmetics and toiletries.
Cosmetic acne is usually minor and usually does not cause scarring.
It: can be persistent, however, sometimes lasting for decades.
Aggravating the problem, some young women try to cover up the
pimples with even more makeup. Plus, normal teenage acne can occur
at the same time.
Can the Environment Induce My Acne?
Yes. Acne may also be due to (or aggravated by) contact with
a large variety of comedogenic substances. For example, the airborne
grease in a fast food restaurant can be comedogenic, as can motor
oil, which someone may be exposed to regularly at a job.
In fact, anything that can irritate acne-prone areas of the skin
may make acne worse, including rubbing and friction from clothing,
hair, sporting equipment and so on. Your dermatologist can best
identify and treat these types of acne.
Why Do Adult Women Get Acne?
Hormonal Acne
Acne in females may be influenced by hormonal changes associated
with menstruation, pregnancy, stress, ovarian disease or endocrine
imbalance. Most of the hormonal changes are temporary. Sometimes
they are caused by a condition that requires medical treatment.
When a female has acne that (1) appears for the first time in
adulthood or reappears in adulthood after clearing up earlier,
(2) is unresponsive to acne treatments, (3) gets worse during
pregnancy or menstruation, or (4) is associated with "masculine"
patterns of hair growth or hair loss, darkening of skin in armpits
or body folds, or central body obesity, she should be examined
by a dermatologist. Indications of hormonal imbalance may require
examination for adrenal, ovarian or pituitary abnormalities.
The hormones that have the most influence on acne are the androgens—so-called
"male" hormones although they are present in both males
and females. The androgens are a causative factor in acne because
they have a stimulating effect on sebaceous follicles where acne
lesions have their origin.
Androgens tend to be present in relatively large amounts during
adolescence as the teenager matures. The androgenic influence
on sebaceous follicles is substantial at this time—a reason
that acne is often thought of as a "teenage condition."
As the body matures and androgen levels stabilize in adulthood,
acne clears in the majority of cases.
Adult women can be unpleasantly surprised when acne reappears
in their 20s or 30s—or appears for the first time. While
the acne is often mild to moderate, it may not respond to tried-and-true
acne treatments that worked when the woman was a teenager. The
cause of this adult acne is probably a hormonal change. The required
treatment will be one that takes hormones into account. This type
of treatment cannot be purchased over-the-counter at the pharmacy.
It is a medical treatment prescribed by a dermatologist after
appropriate medical examination.
Typical examples of hormonal acne in healthy adult women are:
- Acne comes and goes during the menstrual cycle as hormonal
balances go through many changes in the body.
- Acne "flares" during pregnancy as the body’s
hormonal balances shift to accommodate changing physiologic
needs.
- Acne may be associated with chronic emotional or physiologic
stress. Stress may cause physiologic changes that affect hormone
production.
Treatment of Hormonal Acne in the Healthy Female
Hormonal acne in a healthy female can be effectively treated
by a dermatologist. An underlying disease of ovaries, adrenals
or pituitary, or diabetes, should be treated by an appropriate
specialist physician.
A variety of treatments are available for hormonal acne in the
healthy female. The dermatologist selects the treatment best suited
to the needs of the patient, based upon the patient’s medical
history and examination. Treatment options include:
Oral contraceptive pills are estrogen-progestin combinations
formulated to alter the female hormone pattern. Because of their
effects in altering androgen production, low-dose oral contraceptives
have been prescribed by dermatologists for many years in the treatment
of hormonal acne. The Food and Drug Administration recently approved
an oral contraceptive specifically for the treatment of mild to
moderate hormonal acne. Oral contraceptives can be taken for extended
periods of time to control hormonal acne if the woman has no plans
to become pregnant. Side effects of low-dose oral contraceptives
can include nausea, weight gain, menstrual spotting and breast
tenderness.
Oral corticosteroids are anti-inflammatory drugs that belong
to a class of drugs produced by the adrenal glands. When adrenal
glands are overactive in producing androgens, oral corticosteroids
such as prednisone and dexamethasone can be prescribed to suppress
androgen production. Oral corticosteroids are also prescribed
to suppress inflammation in severe acne. Side effects of oral
corticosteroids can include weight gain and bone thinning.
Antiandrogens are a class of drugs that (1) reduce androgen production
in ovaries and adrenal glands, and (2) block androgen reception
by cells in sebaceous follicles. Reduction of excess androgen
and reduction of androgen available in the sebaceous follicle
are anti-acne effects. Antiandrogens used in the treatment of
hormonal acne include spironolactone and, less commonly, flutamide.
Side effects of irregular menstruation and breast tenderness may
be eased by taking the drug together with an oral contraceptive.
References
AAD Press Release "Women and Acne:
The Hormonal Connection (March 3, 2001)
Strauss JS et al. Diseases of the sebaceous glands. In: Freedberg
IM et al (Eds.). Fitzpatrick’s Dermatology in General Medicine,
5th ed. New York: McGraw-hill; 1999:769-784.
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