Comedonian acne: from causes to solutions

Sometimes it is a few pimples and black or white dots scattered here and there on the forehead, around the nose, on the chin or in the back area of the cheeks, towards the ears: signs, all in all, harmless, that come and go and create relative aesthetic damage.

Other times, however, juvenile acne can become a real problem because the lesions become inflamed, swell and infected, resulting not only unpleasant to see, but also painful, difficult to manage in everyday life and a source of great psychological discomfort, especially when they are located on the face or other exposed areas.

Although the disorder is more frequent and marked in adolescence and in men, it is not only boys who suffer from it: even adult women can find themselves with unwelcome signs on the face or in other parts of the body, generally, starting from 25-30 years, perhaps without ever having suffered from comedonic acne previously. In these cases, we speak of late acne.

Why does this happen? Where do comedones, papules and pustules more or less annoying come from? And above all, how to make them leave and prevent them from returning?

Comedonic acne: what is it

Acne is an inflammatory skin disease that essentially affects the hair follicle, a structure similar to an elongated, blind-bottomed bag, from which the hair is born, which then emerges to the surface through the hair duct.

Each hair follicle is associated with a sebaceous gland, housed in the dermis, which produces a viscous material formed by fatty acids (sebum) and pours its oily secretions into the rounded base of the follicle itself. From here, even the sebum, like the hair, goes up the duct of the follicle to reach the surface, where it helps to form the hydrolipidic microfilm that protects the skin from excessive dehydration and external aggressions and keeps it soft.

When, for some reason, the sebaceous gland begins to produce sebum in excessive quantities or the hair duct shrinks, fatty material begins to accumulate in the follicle, and the characteristic lesions of comedonic acne appear, namely:

• comedones (small subcutaneous humps filled with fat, also called “whiteheads” for their characteristic light or skin-like color)
• “blackheads” (open comedones on the surface, which “get dirty” due to dust, pollution or other substances entering the first part of the hair duct)
• papules (lesions of variable shape, usually less than 5 mm in diameter, more or less inflamed, usually a little swollen and reddened)
• pustules (lesions that are a little larger and more inflamed than the papules which, as a rule, contain small amounts of pus in the center, due to the presence of bacteria)
• nodules and cysts (harder and deeper formations of papules and pustules, generally inflamed and, often, infected; in some subjects, cysts can give rise to real abscesses).

In the latter case, we speak of cystic acne (also called nodular or conglobata), the form that determines the greatest aesthetic impairment, both when acute lesions are present and after their healing, due to the high tendency to leave residual scars. Fortunately, it is also the least common form. The most frequent variants are, instead, the mild-moderate ones, namely comedonic acne and vulgar acne, typical of adolescence.

Regardless of the type, acne tends to occur mainly on the skin of the face, neck, shoulders, chest and back, in areas where there is a greater number of sebaceous glands. The most severe acne forms are often linked to a familial predisposition, mainly related to hormonal factors, and tend to affect mainly boys and young adult men.

Why it is frequent in adolescents

Although it can also appear at other times of life, acne is considered a typical disorder of adolescence, since in the vast majority of cases it arises and resolves at this stage of life or at the beginning of adulthood.

Conversely, this inflammatory skin pathology practically never occurs before puberty, corresponding to the stage of sexual development that, as a rule, occurs around 10-14 years in females and 11-15 years in males. In particular, between the ages of 13 and 18, there is a real “hormonal storm” that, especially in males, has no equal throughout the rest of life.

At this stage, there is a peak in the production of androgens, which are the typical “male sex hormones”, but which are also produced to a lesser extent by the female body. One of the main functions of these hormones is to stimulate the sebaceous glands associated with hair follicles to produce significant amounts of sebum, resulting in increased skin oiliness and the risk of developing comedonic acne or more challenging forms to manage.

Of course, since not all adolescents suffer from acne and that some boys experience mild forms while others more severe, androgens cannot be held solely responsible for the problem, but they certainly play a leading role.

Causes of comedone acne

The appearance of comedone acne and other variants of acne pathology is determined by the combination of a number of unfavorable factors that lead to total or partial obstruction of hair follicles and their subsequent inflammation and infection.

As mentioned, a key role is played by the sebaceous glands and their hyper-stimulation due to the change in hormone levels typical of adolescence. In women, even physiological situations such as pregnancy and endocrine or gynecological pathologies (such as polycystic ovary syndrome, PCOS) can cause transient or persistent forms of acne. Similarly, drug therapies that directly or indirectly affect the production of androgen hormones can facilitate the onset of acne (for example, corticosteroid, testosterone or lithium treatments).

Another favorable element is represented by the excessive proliferation of skin cells (keratinocytes) that line the duct of the follicle, through which the sebum reaches the surface of the epidermis. If keratinocytes multiply too much, the duct narrows and is more likely to be occluded by sebum, which will begin to accumulate at the bottom of the follicle.

In this way, comedones are formed first and then papules, more or less inflamed. The subsequent evolution to pustules occurs when the excess of sebum recalls to the bottom of the follicle some bacteria that feed on it to survive, such as Propionibacterium acnes, and others that take advantage of the weakening of the inflamed skin to proliferate, such as Staphylococcus aureus.

More generally, all factors internal or external to the body that promote hormonal imbalances and occlusion of the hair follicle can cause the appearance of acne:

• stress
• obesity
• use of poor quality creams and cosmetics
• taking drugs that increase the activity of the sebaceous glands
• inadequate cleaning of the skin, in defect or in excess.

Remedies for comedonic acne

To effectively control acne manifestations and reduce associated aesthetic damage, over the years dermatological research has made numerous therapies available, which must be chosen according to the type of acne present (comedonic acne, vulgar, nodular acne, etc.), the severity of the skin picture (mild, moderate or severe) and the location of the lesions.

In milder forms of comedone acne, characterized by comedones and non-inflamed papules, self-care can be carried out using over-the-counter anti-acne products to be applied locally on the lesions, identified with the help of the pharmacist.

Among these, creams, gels and solutions based on benzoyl peroxide (or benzoyl peroxide) or retinoids derived from vitamin A can be proposed in the first instance.

All these substances have keratolytic action, which means that they are able to reduce the amount of cells of the epidermis that lines the duct of the hair follicle, preventing its closure and / or facilitating the opening and leakage of excess sebum.

Some substances used to combat acne also have antibacterial activity, thus also reducing the risk of infection and the consequent formation of inflamed pustules with pus and abscesses.

If only non-inflamed comedones are present, a chemical peeling can also be carried out with solutions of salicylic acid and glycolic acid that can be purchased in pharmacies, simply by passing a small amount on the skin affected by blackheads and whiteheads. The keratolytic and antiseptic action of these compounds allows to free the ducts of the clogged follicles, facilitating the escape of sebum and improving the appearance of the skin. This approach can be associated with photodynamic therapy, based on exposure to light with calibrated wavelength and intensities.

To improve acne control, the use of preparations to be applied and left to act on the skin is combined with that of specific antiseptic cleansers for acne skin. In addition to promoting the disappearance of lesions, these products allow to reduce the appearance of sensitization, skin dryness, redness and discomfort (feeling of “skin pulling”) that typically arise during topical acne treatment.

To obtain a real benefit, it is important to use specific detergents correctly, ie no more than 1-2 times a day, massaging them gently and without rubbing, after diluting them in a little water, and letting them act for a few minutes. In this regard, it should be emphasized that a thorough cleansing of acne skin is a fundamental complement to therapies, but it must not be excessive: vice versa, there is a risk of inducing a worsening of the disorder.

If comedones and papules are not too numerous, but have a certain tendency to become infected and turn into pustules, the topical remedies already mentioned can be used in combination with antibiotics also to be applied topically, on prescription and for short periods.

When, on the other hand, the lesions are localized on the face or extended over large surfaces and appear characterized by important inflammation, infection and formation of nodules or cysts, before intervening in any way it is advisable to undergo the evaluation of a specialist in dermatology to receive the most appropriate treatment indications and practical management advice in different cases.

A targeted specialist approach is essential in severe forms of acne because if you use inadequate drugs, creams or cleansers or use them incorrectly, you risk not only promoting the worsening of lesions and facilitating the development of residual scars, but also compromising the integrity and appearance of the surrounding healthy skin.

The most severe acne variants (acne with pustules and cystic acne), not adequately controlled by topical treatment, require the use of systemic therapies, including mainly oral antibiotics (often, combined with belzoyl-topical peroxide) or, in a minority of subjects, oral retinoids (especially in the presence of acne with nodules).

Against comedone acne that affects the female population in adulthood, in addition to topical products to be applied on the skin, it may be useful to provide hormonal treatment, especially in forms associated with gynecological or endocrinological problems, such as PCOS.

For example, if there are signs of hyper-androgenism, such as thinning, brittleness and hair loss or hypertrichosis (increased body hair growth), treatment with anti-androgen drugs (which antagonize the action of androgen hormones) or with estroprogestin birth control pills (with this second option, 1-2 months may pass before observing an improvement in the appearance of the skin).

In these cases, to obtain effective control of both the skin problem and the underlying pathology and avoid pharmacological interference, acne treatment must be planned in agreement between dermatologist, gynecologist and endocrinologist, after formulating a precise diagnosis, also taking into account the age and characteristics of the patient.

How to prevent comedonic acne

Given that at the origin of the majority of acne cases there is the physiological oscillation of hormonal levels, a 100% effective prevention of the disorder is not feasible even by adopting all possible lifestyle strategies and skin care.

This does not mean that there are some useful tips to follow to support the topical and systemic therapies already seen, which help to improve clinical outcomes and reduce the risk of acne recurring after obtaining an initial improvement in the appearance of the skin and the disappearance of most of the lesions. The main ones consist of:

• follow a healthy and balanced diet, based on fresh foods and rich in fruits and vegetables, which are an important source of antioxidant vitamins and mineral salts useful for maintaining healthy and luminous skin
• drink at least 1.5-2 liters of water a day, because the skin must be hydrated especially “from the inside”, avoiding drinks containing sugars and additives and alcohol
• There are no foods that cause acne, but sweets, fatty foods, sausages, chocolate and junk-food in general should be consumed in moderation as they are unhealthy for the body and can promote unfavorable weight gains that affect hormonal balances and skin health.
• In case of strong tendency to acne, try to eliminate milk from the diet for a few weeks to assess if the skin situation improves
• Never touch lesions, except for the necessary procedures of washing and applying topical products, and do so only after washing your hands
• Do not apply disinfectants that are not specific for acne skin (for example, common alcohol) to lesions.
• in the presence of lesions, do not apply cosmetics; Even after healing, limit the use of cosmetics as much as possible and resort only to products of excellent quality, designed for skin with acne
• apply only moisturizing creams of excellent quality or designed for skin with acne, avoiding any other type of formulation (masks, peelings, sunscreens, etc.) without first consulting your doctor
• Also for skin cleansing use only specific cleansers for skin with acne and avoid too frequent washing, which destabilizes the skin barrier, promotes dehydration and sensitization and stimulates the production of sebum by the sebaceous glands
• do not expose yourself to the sun during acne therapies because drugs can induce photosensitization reactions; In addition, the treated skin is dehydrated and weakened, therefore easily damaged by ultraviolet rays
• Even if you are not applying anti-acne products, limit sun exposure because the sun tends to favor the appearance of acne (even when it seems to induce an initial improvement).