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Severe acne isn’t well understood but acne treatment can be effective

Yale Medicine Magazine, 2022 Issue 168 More than skin deep
by John Curtis

The physiological causes of acne skin lesions aren’t clear but acne treatment can go a long way to alleviate its physical and psychological toll.

Acne is a common disease—it affects about 85 percent of us—and one of the most misunderstood, says Richard Antaya, MD, director of pediatric dermatology at Yale Medicine. It emerges in tandem with the raging hormones of adolescence, and teenagers often take the blame for their disease.

“There’s a social stigma in severe acne that we attribute to behavior, which is completely untrue,” said Antaya, who’s been treating adolescent skin problems— of which the skin lesions caused by acne are the most common—for more than 20 years. “It’s at a time of life when we as humans are striving for independence from our parents, trying to develop this separate identity, and you hit them in the face with this disease that really messes things up for them.”

Acne doesn’t just hit the face. Its pimples, pustules, blackheads, and lesions also appear in the chest, shoulders, back, and arms. Although longstanding myths about diet and cleanliness have been debunked, why acne skin lesions develop remains a mystery.

What causes pimples?

“We still don’t know exactly what causes severe acne, but we break it down into three factors,” Antaya said. Among them are sticky skin cells in sebaceous follicles. “You have something causing those skin cells to be sticky.” The likely culprit is sebum, an oily substance produced by our oil glands. Sebum appears to affect these cells’ natural progression, making them stickier. The third factor is cutibacteria, which metabolizes triglycerides, thereby inducing inflammation.

Recent studies have found connections between acne and milk consumption and high-carb diets. The link between carbs and pimples, however, remains controversial and Antaya believes more research is needed. The recent surge of interest in the microbiome, he added, has suggested a link to bacteria on the skin.

Severe acne takes a psychological toll

Whatever its cause, acne affects teenagers’ social lives, self-image, and self-esteem, as well as the likelihood of their finding work, as many work in public-facing service jobs in stores and restaurants. And a 2011 study from Scandinavia found higher rates of suicidal thoughts among teens who have pimples and other types of skin lesions.

Antaya likes to quote Marion B. Sulzberger, MD, chair of dermatology at New York University from 1949 to 1960. “There is no single disease which causes more psychic trauma, more maladjustment between parent and children, more general insecurity and feelings of inferiority and greater sums of psychic suffering than does acne vulgaris.”

Although it can recur in adults, most acne usually goes away by the time people reach their 20s. It comes in three categories, mild, moderate, or severe, and the more severe forms of the skin lesions it causes can bring scarring.

“We see kids who are very, very upset about their acne,” Antaya said. “How much they open up to their dermatologists about it is not very much.I use a non-threatening way to tease this out—on a scale of one to 10 how much does your acne bother you? If it doesn’t bother them, we’re not going to treat them. If it really bothers them, we’re going to treat it.”

From pimples to severe acne, treatment helps

The arsenal of treatments includes medications, antibiotics, and anti-inflammatories, both topical and oral. Oral acne treatments are reserved for severe cases or when topicals don’t work. In general, the treatment is aligned with the type of acne and its severity.

When he sees patients for the first time, Antaya tells them three things.

“The first one is that it takes three months to see the maximum effect from topical medicine, and most of the kids who come in are going to be treated with topical medicines,” he said. “The second one is you have to use the medication every day for it to work—you’re conditioning your skin to prevent new acne. The third one is that most topical medicines are 60 to 70 percent effective if used regularly. I don’t want them to think that if they use a cream their acne is going to be completely gone. That’s not reality.”

Adherence to acne treatment is difficult across specialties, but Antaya said it’s a particular problem with acne. Almost all topical medications cause irritation, redness, scaliness, and soreness. They can also add to the risk of sunburn or windburn. Studies have shown that adherence ranges from 20 to 80 percent, and one study found that 20 percent of patients never even opened the tube. But when everything falls into place, Antaya sees a marked difference.

“When kids come in the first time, they may not say anything, but their demeanor is different,” he said. “They’re holding their head down. they’re not looking you in the eye, they’re not talking. You get them on the medication. Slowly they get better. By the end, a lot of times they’re completely different. They’re now more outgoing, gregarious. It really changes how they feel about themselves. They tell you it’s changed their lives.”