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Acne is so common that one could argue that it is a normal occurrence in
human development. Its prevalence has been estimated at 95%-100% in
16-17-year-old boys and 83%-85% in 16-17-year-old
girls.1 The initial presentation is
usually comedonal acne, progressing to inflammatory lesions within
2-3 years,2 then rising in incidence and
severity to reach its most serious stage between the ages of 14 and 17
years in girls and 16 and 19 years in boys.1 Development of comedonal
acne at an early age, in girls at least, appears predictive of more
severe disease in later years.3 Acne will mostly resolve by
the age of 23-25 years; nevertheless, 1% of men and 5% of women still
bear acne lesions at 40 years of age.4
So, is acne a disease worthy of treatment, or a normal occurrence that
should be ignored, as it will eventually cease to be a problem for most
affected individuals? Concern about acne is one of the commonest
reasons for young patients to consult a medical practitioner, so the
direct cost of consultations and of the diversion of medical services
needs to be taken into account in any assessment of the value of
treating this apparently "normal" life event. Added to this, we are
seeing the development of increasing antibiotic resistance in
Propionibacterium acnes,5 a problem exacerbated by
long term and widespread use of often suboptimal doses of
antibacterial agents. So how can one justify treatment?
Firstly, acne as a condition is aesthetically and sometimes
physically unpleasant. Severe cystic acne causes pain, recurrent
bleeding and purulent discharge. In rare instances, patients with
acne develop severe systemic toxicity and require treatment in
hospital. Before isotretinoin was introduced, such
patients were extremely difficult to treat.
Secondly, it can cause great distress in adolescents at a time when
they are probably least able to deal psychologically and socially
with the unsightliness of active acne. Being so readily visible
(affecting the face in 99% of cases6), acne can reduce
employment prospects7 and create interpersonal
difficulties.8 Affected adolescents
report more social isolation and self-consciousness than their
unaffected peers8 and experience more
embarrassment, social inhibition, unhappiness, anxiety, and
dissatisfaction with their facial appearance.9
Finally, acne scarring can cause devastating long term psychic
trauma for the sufferer and it has been suggested that such scarring
may be a risk factor for suicide, particularly in men.10 As
current treatments for acne are very effective, scarring could be
avoided in many cases by adequate medical intervention early in the
course of the disease. Successful treatment of cystic acne with
isotretinoin appears to reduce anxiety and depression in
patients.11 Anti-androgen hormonal
treatments such as cyproterone acetate and spironolactone, topical
preparations such as adapalene, azelaic acid, topical antibiotics
and retinoic acid may help to replace or augment long term antibiotic
therapy, ensuring a sufficient armamentarium to keep the incidence
of acne scarring to a minimum.
Unfortunately, scarring may affect up to 95% of patients with acne.
The degree of scarring is related to the severity and duration of acne
before adequate therapy is instituted. One study found that a time
delay of up to three years between acne onset and adequate treatment
was sufficient to cause facial scarring in either sex, although
keloidal or hypertrophic truncal scarring was more common in
men.12 The same study
established that superficial inflamed papular acne and cystic acne
could both produce scarring, a finding with important implications
for our healthcare system, which subsidises isotretinoin for failed
therapy in nodulocystic disease only. If hypertrophic
scarring occurs it should be dealt with by such measures as
intralesional steroids, silicone sheeting or vascular laser
treatment, as required.
However, most scarring in acne is atrophic rather than hypertrophic
in nature, with destruction and dissolution of supporting tissues.
In the young, most scars will initially improve, the erythema will
subside and the scars mature over the first two to three years. After
this initial improvement the scarring is quiescent, but, over time,
as facial tone declines and facial fat stores are resorbed, the scars
will become more noticeable. With ageing, the facial skin starts to
sag and seems to literally hang on the scars. The inelastic strands of
scars bind the skin, giving it an uneven, cascading appearance. This
is amplified by other age-related changes such as the resorption of
skeletal and soft tissues.
Remedial approaches to acne scarring have improved over the years.
The older, less successful treatments such as dermabrasion and
chemical peeling have been replaced by the use of resurfacing
infrared lasers such as CO2 lasers13 and, more
recently, erbium lasers14 to better remove and
tighten the skin.
An understanding that replacement of the atrophied structures in the
dermis and subcutaneous tissues is necessary in severe cases of acne
scarring has led to the development of superior dermal and
subcutaneous augmentation techniques. Dermal and subcutaneous
augmentation is possible by a number of autologous techniques,
including dermal grafting,15 lipocytic dermal
augmentation,16 fat transfer17 and, more
recently, the implantation of autologous collagen and cultured and
expanded autologous fibroblasts. Non-autologous augmentation is
also possible by way of injections of bovine collagen, fibrin foam,
hyaluronic acid or polymethylmethacrylate microspheres.
For "punched out" ("ice pick") scars, none of these methods is useful.
For these a range of punch techniques is used, involving coring out of
scars with an appropriately sized cylindrical instrument, followed
by suturing or graft application. Punch techniques can be used to
treat many scars at a single operation, and may be combined with
resurfacing techniques such as infrared laser
treatment.18 Subcision (dermal
scarification) is another helpful technique, in which dermal
undermining of scars is used to improve the scar tissue by two
mechanisms: (i) direct breaking of scar attachments, and (ii)
intentional injury of the dermis to induce laying down of new
collagen.19
All of these techniques are valuable tools for practitioners seeking
to improve the outcome of treating acne scarring, but it would be
better still if the problem never arose. A preventable condition such
as postacne scarring should be one deserving of the earliest, best and
most effective treatment.
Gregory J Goodman
President, Skin and Cancer Foundation Melbourne, VIC
- Burton JL, Cunliffe WJ, Stafford I, Shuster S. The prevalence of
acne vulgaris in adolescence. Br J Dermatol 1971; 85:
119-126.
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Lucky AW, Biro FM, Huster GA, et al. Acne vulgaris in early
adolescent boys: correlations with pubertal maturation and age.
Arch Dermatol 1991; 172: 210-216.
-
Lucky AW, Biro FM, Simbartl LA, et al. Predictors of severity of acne
vulgaris in young adolescent girls: results of a five-year
longitudinal study. J Pediatr 1997; 130: 30-39.
-
Cunliffe WJ, Gould DJ. Prevalence of facial acne vulgaris in late
adolescence and in adults. BMJ 1979; 1: 1109-1110.
-
Cooper AJ. Systematic review of Propionibacterium acnes
resistance to systemic antibiotics. Med J Aust 1998; 169:
259-261.
-
Cunliffe WJ. The acnes. London: Dunitz, 1989.
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Cunliffe WJ. Unemployment and acne. Br J Dermatol 1986;
115: 386.
-
Schachter RJ, Pantel ES, Glassman GM, Zweibelson I. Acne vulgaris
and psychologic impact on high school students. N Y State J Med
1971; 24: 2886-2890.
-
Wu SF, Kinder BN, Trunnell TN, Fulton JE. Role of anxiety and anger in
acne patients: a relationship with the severity of the disorder. J
Am Acad Dermatol 1988; 18: 325-333.
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Cotterill JA, Cunliffe WJ. Suicide in dermatological patients.
Br J Dermatol 1997; 137: 246-250.
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Rubinow DR, Peck GL, Squillace KM, Gantt GG. Reduced anxiety and
depression in cystic acne patients after successful treatment with
isotretinoin. J Am Acad Dermatol 1987; 17: 25-32.
-
Layton AM, Henderson CA, Cunliffe WJ. A clinical evaluation of
acne scarring and its incidence. Clin Exp Dermatol 1994; 19:
303-308.
-
Goodman GJ. Facial resurfacing using a high-energy, short-pulse
carbon dioxide laser. Australas J Dermatol 1996; 37:
125-131.
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Stuzin JM, Baker TJ, Baker TM. CO2 and erbium:YAG
laser resurfacing: current status and personal perspective.
Plast Reconstr Surg 1999; 103: 588-591.
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Goodman GJ. Laser assisted dermal grafting for the correction of
cutaneous contour defects. Dermatol Surg 1997; 23: 95-99.
-
Coleman WP 3d. Lipocytic dermal augmentation. In: Klein AW,
editor. Tissue augmentation in clinical practice. Procedures and
techniques. New York: Marcel Dekker, 1998: 49-62.
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Coleman SR. Long-term survival of fat transplants: controlled
demonstrations. Aesthetic Plast Surg 1995; 19: 421-425.
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Johnson WC. Treatment of pitted scars: punch transplant
technique. J Dermatol Surg Oncol 1986; 12: 260-265.
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Orentreich DS. Subcutaneous incisionless (subcision) surgery
for the correction of depressed scars and wrinkles. Dermatol
Surg 1995; 21: 543-549.
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