Several factors contribute to the development of acne. The primary problem is that the abnormal flaking of cells inside the hair follicle leads to the formation of a plug. The plug can enlarge and even rupture the hair follicle. A ruptured hair follicle spills its contents of oil and debris into the skin where it leads to swelling and causes redness (inflammation).
Bacteria that normally live on the skin also play a role in acne development. The bacteria known as Propionibacterium acnes are responsible for causing acne. These bacteria produce substances that cause redness and irritation (inflammation). They also make enzymes, which dissolve the sebum (oil from oil glands in the skin) into irritating substances. These substances also make the inflammation worse.
Certain hormones called androgens are an additional factor in causing acne. Androgens are male hormones that are present in both men and women, but are higher in men. Androgens do two things: First, they enlarge the sebaceous glands in the skin. Second, they cause these glands to increase sebum (oil) production. The increased sebum leads to plug formation and serves as more "food" for the bacteria. Androgens surge at puberty, which is why teens develop armpit and pubic hair, and why boys develop facial hair and deeper voices. This hormonal surge also contributes to the development of acne in teens.
Estrogens, which are the female hormones, actually can help to improve acne in girls. A woman's monthly menstrual cycle is due to changes in the estrogen levels in her body. This is why acne in a female may get better and then get worse as she goes through her monthly cycle. A doctor may recommend acne treatment with birth control pills, which contain the helpful estrogens.
We also now believe that acne can run in some families. This may be due to some genetic factor that has not yet been discovered.
Anatomy of the hair follicle: Hair follicles exist on virtually all skin except for the palms of the hands and soles of the feet. Inside the follicle, the hair extends up from the deep layers of the skin and comes out of a pore. Near the surface, the oil gland (sebaceous gland) enters the hair follicle where it empties oil (sebum) at a relatively constant rate. The sebum lubricates the skin and provides a protective barrier to prevent drying. Skin on the face, chest, and back has an especially large number of sebaceous glands. These are the areas where acne occurs.
Acne lesions: There are 2 major types of acne lesions: noninflammatory and inflammatory. Noninflammatory acne lesions include blackheads (open comedones) and whiteheads (closed comedones). Open and closed comedones along with papules and pustules are referred to as papulopustular acne—a form of inflammatory acne. Nodular acne is the most severe form of inflammatory acne.
Noninflammatory acne: Open comedones result from the enlargement and dilation of a plug that forms from oil and flakes of skin inside the hair follicle.
The hair follicle pore remains open exposing a black plug (known as a blackhead). The dark color is not dirt inside the pore. Instead it is the oil inside the pore, which has become exposed from the outside air.
A closed comedo forms if the hair follicle pore remains closed. The plug in a closed comedo or whitehead is therefore not exposed to the outside air, and no black color develops. The closed comedo simply appears as a tiny, sometimes pink bump in the skin.
Inflammatory acne: Inflammatory acne lesions consist of red blemishes, pimples also called zits (papules, pustules), and larger, deeper swollen tender lesions (nodules).
Papules are closed comedos, which have become red, swollen, and inflamed.
Pustules are closed comedos, which become inflamed and begin to rupture into the skin forming pustular heads of various sizes.
Nodules represent large, tender, swollen acne lesions, which have become intensely inflamed and rupture under the skin. If untreated, these can produce deep scarring
The pathogenesis of acne vulgaris is multifactorial. Four key factors are responsible for the development of an acne lesion. These factors are follicular epidermal hyperproliferation with subsequent plugging of the follicle, excess sebum, the presence and activity of Propionibacterium acnes, and inflammation.
Follicular epidermal hyperproliferation is the first recognized event in the development of acne. The exact underlying cause of this hyperproliferation is not known. Currently, the 3 leading hypotheses have been proposed to explain why the follicular epithelium is hyperproliferative in individuals with acne.
First, androgen hormones have been implicated as the initial trigger. Comedones, the clinical lesion that results from follicular plugging, begin to appear around adrenarche in persons with acne. Furthermore, the degree of comedonal acne in prepubertal girls correlates with circulating levels of the adrenal androgen dehydroepiandrosterone sulfate (DHEA-S). Additionally, androgen hormone receptors are present in the portion of the follicle where the comedone forms; individuals with malfunctioning androgen receptors do not develop acne.
Second, changes in lipid composition have been implicated in the development of acne vulgaris. Persons with acne frequently have excess sebum production and oily skin. This excess sebum may dilute the normal epidermal lipids and result in a change in the relative concentrations of the various lipids. Diminished concentrations of linoleic acid have been demonstrated in individuals with acne and, interestingly, these levels normalize after successful treatment with isotretinoin. This relative decrease in linoleic acid may be what initiates comedone formation.
Inflammation is the third hypothesized factor incriminated in comedone formation. Interleukin (IL)–1–alpha is a proinflammatory cytokine. It has been used in a tissue model to induce follicular epidermal hyperproliferation and comedone formation. Although inflammation is not apparent microscopically or clinically in early lesions of acne, it may still play a pivotal role in the development of acne vulgaris and the comedones.
Excess sebum is another key factor in the development of acne vulgaris. Sebum production and excretion are regulated by a number of different hormones and mediators. Androgen hormones, in particular, promote sebum production and release. Still, most men and women with acne have normal circulating levels of androgen hormones. An end-organ hyperresponsiveness to androgen hormones has been hypothesized. Androgen hormones are not the only regulators of the human sebaceous gland. Numerous other agents, including growth hormone and insulinlike growth factor, also regulate the sebaceous gland and may contribute to the development of acne.
P acnes is a microaerophilic organism present in many acne lesions. Although, it has not been shown to be present in the earliest lesions of acne, the microcomedo, its presence in later lesions is almost certain. The presence of P acnes promotes inflammation through a variety of mechanisms. P acnes stimulates inflammation by producing proinflammatory mediators that diffuse through the follicle wall. Recent studies have shown that P acnes binds to the toll-like receptor 2 on monocytes and neutrophils. Binding of the toll-like receptor 2 then leads to the production of multiple proinflammatory cytokines, including IL-12, IL-8, and tumor necrosis factor. Hypersensitivity to P acnes may also explain why some individuals develop inflammatory acne vulgaris while others do not.
Inflammation may be a primary phenomenon or a secondary phenomenon. Most of the evidence to date suggests a secondary inflammatory response to P acnes as mentioned above. However, IL-1-alpha expression has been identified in the microcomedone, and it may play a role in the develop