Acne

What is acne?
Acne is a disorder of the hair follicles and sebaceous glands. The glands become clogged, leading to
pimples and cysts.
Acne is very common--people of all races and ages have acne. In fact, the majority of individuals in the U.S.
between 11 and 30 years old will be affected by this condition. Even people in their forties and fifties can
have acne. However, acne most often begins in puberty. During puberty, the male sex hormones
(androgens) increase in both boys and girls, causing the sebaceous glands to become more active, resulting
in increased production of oil (sebum).

How does acne develop?

The sebaceous glands produce sebum that normally travels via hair follicles to the skin surface. However,
skin cells can plug the follicles, blocking the sebum coming from the sebaceous glands. When follicles
become plugged, skin bacteria (called Propionibacterium acnes, or P. acnes) begin to grow inside the
follicles, causing inflammation and pimples. According to the National Institute of Arthritis and
Musculoskeletal and Skin Diseases, the most common types of pimples are:

Whiteheads. These pimples stay under the skin's surface.

Blackheads. These rise to the surface of the skin. Although these pimples are black,

the color is not from dirt. It's from the process of oxidation when the sebum is exposed to
air.
Papules. These are tender, small pink bumps.
Pustules. Pimples that have pus on the top and are red on the bottom of the lesion.
Nodules. These are hard, large, painful pimples that arise deep in the skin.
Cysts. Pus-filled, deep, painful pimples that often result in scars.

The basic acne lesion is called a comedo.

Acne can be superficial (pimples without abscesses) or deep (when the inflamed pimples push down into
the skin, causing pus-filled cysts that rupture and result in larger abscesses).

What causes acne?

Rising hormone levels during puberty may cause acne. In addition, acne is often inherited. Other causes of
acne may include the following:

Hormone level changes during the menstrual cycle in women

Hormone changes during pregnancy

Starting or stopping birth control pills

Certain drugs (such as corticosteroids, lithium, and barbiturates)

Oil and grease from the scalp, mineral or cooking oil, and certain cosmetics

Acne can be aggravated by squeezing the pimples or by scrubbing the skin too hard. Skin may also become
irritated with friction or pressure from helmets, backpacks, or tight collars. Some environmental conditions
such as pollution or humid conditions can also irritate the skin.

Where does acne occur?

Acne can occur anywhere on the body. However, acne most often appears in areas where there is a high
concentration of sebaceous glands, including the following:

Face

Chest

Upper back

Shoulders

Neck

The presentation of acne may resemble other skin conditions. Always consult your doctor for a diagnosis.

Treatment of acne
Specific treatment for acne will be determined by your doctor based on:

Your age, overall health, and medical history

Severity of the acne

Your tolerance for specific medications, procedures, or therapies

Expectations for the course of the condition

Your opinion or preference

The goal of acne treatment is to minimize scarring and improve appearance. Treatment for acne will include
topical or systemic drug therapy. Depending on the severity of acne, topical medications (applied to the skin)
or systemic medications (taken orally) may be prescribed by your doctor. In some cases, a combination of
both topical and systemic medications may be recommended.

Topical medications to treat acne

Topical medications are often prescribed to treat acne. Topical medication can be in the form of a cream, gel,
lotion, or solution. Examples include:
Benzoyl
peroxide

Kills the bacteria (P. acnes)

Antibiotics

Helps stop or slow down the growth of P. acnes and reduces inflammation

Stops the development of new acne lesions (comedones) and encourages

cell turnover, unplugging pimples
Tretinoin

Decreases comedo formation

Adapalene

Systemic medications to treat acne

Systemic medications, or oral antibiotics, are often prescribed to treat moderate to severe acne, and may
include the following:

Doxycycline

Erythromycin

Tetracycline

Treatment for severe, cystic, or inflammatory acne

Isotretinoin, an oral drug, may be prescribed for individuals with severe, cystic, or inflammatory acne that
cannot be effectively treated by other methods to prevent extensive scarring. Isotretinoin reduces the size of
the sebaceous glands that produce the skin oil, increases skin cell shedding, and affects the hair follicles,
thereby reducing the development of acne lesions. Isotretinoin can clear acne in 85 percent of patients.
However, the drug has major unwanted side effects, including psychiatric side effects. It is very important to
discuss this medication with your doctor.
Isotretinoin must not be taken by women who are pregnant or who are able to become pregnant, because
there is a very high likelihood of birth defects occurring in babies whose mothers take the medication during
pregnancy. Isotretinoin can also cause miscarriage or premature birth. Because of these effects and to
minimize fetal exposure, isotretinoin is approved for marketing only under a special restricted distribution
program approved by the FDA. This program is called iPLEDGE.
The goal of the iPLEDGE program is to prevent pregnancies in females taking isotretinoin and to prevent
pregnant females from taking isotretinoin. Requirements of the iPLEDGE program include:

Isotretinoin must only be prescribed by prescribers who are registered and activated
with the iPLEDGE program.

Isotretinoin must only be dispensed by a pharmacy registered and activated with

iPLEDGE.

Isotretinoin must only be dispensed to patients who are registered with and meet all
the requirements of iPLEDGE

Female patients who can get pregnant are required to use birth control for one month
prior to treatment, during treatment, and for one month after stopping treatment.

Pregnancy tests are required before, during, and after treatment.

Treatment for acne scars

Specific dermatological procedures to minimize acne scars will be determined by your doctor based on:

Your age, overall health, and medical history

Severity of the scar

Type of scar

Your tolerance for specific medications, procedures, or therapies

Your opinion or preference

Although acne often is a chronic condition, even if it lasts only during adolescence, acne can leave lifelong
scars. Acne scars typically look like "ice pick" pit scars or crater-like scars. Although proper treatment for
acne may help minimize scarring, several dermatological procedures may help to further minimize any acne
scars, including the following:

Dermabrasion. Dermabrasion may be used to minimize small scars, minor skin

surface irregularities, surgical scars, and acne scars. As the name implies, dermabrasion
involves removing the top layers of skin with an electrical machine that "abrades" the skin.
As the skin heals from the procedure, the surface appears smoother and fresher.
Chemical peels. Chemical peels are often used to minimize sun-damaged skin,

irregular pigment, and superficial scars. The top layer of skin is removed with a chemical
application to the skin. By removing the top layer, the skin regenerates, often improving
the skin's appearance.
Derma filler injections. These are injected beneath the skin to replace the body's

natural collagen that has been lost. Injectable dermal fillers are generally used to treat
wrinkles, scars, and facial lines.
Laser resurfacing. Laser resurfacing uses high-energy light to burn away damaged

skin. Laser resurfacing may be used to minimize wrinkles and fine scars.
Phototherapy or blue light therapy. Phototherapy using a blue light source has

been shown to decrease the number of acne-causing bacteria with minimal side effects,
such as dry skin. Blue light therapy does not use ultraviolet (UV) light, so it does not
damage the skin as earlier types of light therapy did.
Pulsed light and heat energy (LHE) therapy. This type of combined light and heat

therapy is believed to work by destroying acne-causing bacteria and by shrinking the oilproducing glands in the skin. The FDA has approved an LHE system that uses green light
and heat pulses for treating mild to moderate acne.
Punch grafts. Punch grafts are small skin grafts used to replace scarred skin. A hole is
punched in the skin to remove the scar, which is then replaced with unscarred skin (often
from the back of the earlobe). Punch grafts can help treat deep acne scars.

Autologous fat transfer. An autologous fat transfer uses fat taken from another site
on your own body and it is injected into your skin. The fat is placed beneath the surface of
the skin to elevate depressed scars. This method is used to correct deep contour defects
caused by scarring from nodulocystic acne. Because the fat may be reabsorbed into the
skin over a period of months, there may be a need for the procedure to be repeated.

Aging, Global Health, Medical Education, Patient Care, SMS Unplugged

After the rain: Experiencing illness as a medical student and granddaughter

Amrapali Maitra on April 1st, 2015 No Comments

SMS (Stanford Medical School) Unplugged is a forum for students to chronicle their experiences in medical
school. The student-penned entries appear on Scope once a week; the entire blog series can be found in
the SMS Unplugged category.

In India, when the first heavy droplets of rain

meet dry earth it releases a particular kind of smell: a dampness arising from sizzling soil that in Bengal we
call shnoda gondho. It is raining on the second day we go to visit my grandfather in the hospital.
He has been readmitted to the hospital, after spending a week recovering at home from a hospitalization for
rib fractures and bleeding into his lungs. The irony of his hospitalization is not lost on his family: that a
renowned doctor, one of the first cancer surgeons in the city of Kolkata and one who spearheaded
oncological care in this region, is now gowned and sitting in a hospital bed. This happens frequently, of
course, for doctors are not immune to being patients, even if we would like to think so. The problem is that
we are little prepared for the unstructured, unscripted nature of experiencing illness rather than treating it.
Certainly for my grandfather, a man who even recently traveled to multiple hospitals each day to supervise
surgeries and see patients in clinic, being confined to bed for respiratory treatments and being unable to
walk without support feels equivalent to being bound up, tied down, and chained to the hospital. This is the

way illness imprisons. For his family, used to seeking his wise medical advice on various things from pesky
coughs to unremitting cancers, we are unprepared to now help make decisions for him.
We never stop being medical students, and later we never stop being doctors, whether in relationships with
family members, friends, acquaintances, or strangers in emergency situations
Perhaps this reflection is too personal for a forum created for sharing medical school experiences. But I
suppose my realization is that medical school is not a place but rather a privilege we hold. We never stop
being medical students, and later we never stop being doctors, whether in relationships with family
members, friends, acquaintances while traveling, or strangers in emergency situations.
But, as I spend these three weeks with my grandfather and my family in Kolkata, I find that it is important to
play both roles: that of medical student, the one who can help translate the staccato of medical jargon into
fluid lines, and that of loved one, the one who listens not via an earpiece through the taut drum of a
stethoscope but through bare ears and naked eyes, the one who listens for and is moved by the cries of
pain, or suffering, or confusion, or desperation, of the ones they love.
In many ways the loved one is the harder role to play, for it is the role with no lines. No chest x-rays to
evaluate in the morning. No medications to re-dose for a rising creatinine. No growing charts of oxygen
saturation, or heart rate, or urine output. As someone who has recently grown used to doing these things on
the medicine wards of Stanford Hospital, I now acculturate to a more improvisational kind of care. Placing a
soothing hand on an aching back. Sitting at someones bedside while he nods in and out of sleep. Holding
down an arm so that it doesnt tremble like the string on a harp. In Indian hospitals, the family must often
arrange to bring the medications that the doctors have prescribed and may often visit the hospital multiple
times a day to bring food. We mix rice with soft, curried vegetables or boiled eggs and offer them to our
loved ones, hoping to find through these labors some connection, some solace.
As family members we grasp for metaphors. In India, these metaphors of illness are often built around ideas
of hot or cold, of water or wind. Perhaps that is why I find it so poignant that it rained today, the dense, gray
clouds releasing their water just as the water from the pleural effusion in my dadus lungs was drained.
I hope that one day soon, when this rain had cleared, my grandfather will write his own words as he has
planned to do. And then he can tell you his story, not I.
Amrapali Maitra is a fifth-year MD/PhD student working towards a PhD in Anthropology. She is interested in
the illness experience, the cultural and social basis of health, and practices of care. Amrapali grew up in
New Zealand and Texas, and she studied history and literature as an undergraduate at Harvard. She is a
2013 Paul and Daisy Soros Fellow.
- See more at: http://scopeblog.stanford.edu/2015/04/01/after-the-rain-experiencing-illness-as-a-medicalstudent-and-granddaughter/#sthash.ErHitsOg.dpuf