Physiology of Acne
Two types of acne exist: inflammatory and non-inflammatory.
Non-inflammatory acne lesions are not painful; they are merely collections of dead cells and oil that clog the follicles. Comedogenic products can cause clogging similar to clogging caused by other environmental factors. The follicle is open (blackhead) or closed (no head or a white head), but is not inflamed or sore.
Inflammatory acne is caused by an imbalance of androgen and estrogen hormones, specifically in the pilosebaceous unit. The normal pilosebaceous unit is composed of a sebaceous gland, a rudimentary hair, and a wide follicular canal lined with stratified squamous epithelium. During the skin’s normal turnover process, desquamated cells from the follicular epithelium are carried up the follicular canal by sebum secreted from the sebaceous glands. In an imbalanced environment, such as an overabundance of male hormones (androgens) around the sebaceous gland or reduction in female hormones (estrogens), the aggressive androgens cause a surge in the production of sebum, which is deposited into the follicle. They also stimulate dead cells to increase desquamation (shedding) from the walls of the follicles.
This condition of increased sebum and debris in the follicle provides an excellent environment for propioni bacterium acnes bacteria (P. acnes) in the follicle to proliferate in the papillary area of the follicle. This produces an imbalance in the flora of the follicle. The resulting inflammation instigates a white cell response from the lymphatic system as well as a collection of dirt and cellular debris due to the imbalance, which results in a pimple. Inflammatory acne lesions are always sore because of the inflammation. The white suppuration (pus) is a mixture of inflammatory response materials from the surrounding cells and lymphatic system, cellular debris, and oil.
Anatomy of Acne - Non-inflammatory
Clogged pore impactions grow from microscopic proportions to visible size. The purpose of anti-acne skincare products is to prevent these impactions from becoming visible.
A microcomedo is a small impaction of dead cells, bacteria, and fatty acids from sebum and debris in a follicle, not visible without magnification.
Sebaceous Filaments are the small filaments that form a “worm-like” exudate upon extraction. They usually appear around the nose and in oily areas.
Comedones are visibly obstructed follicles. They are non-inflammatory, but can become inflammatory under certain conditions.
Milia is a pearly-white closed comedone which usually occurs around the eye, nose and cheek area in adults. This type of comedone is difficult to extract and usually requires an incision in the skin in order to remove the impaction. Removal of milia must be performed by a skilled professional, for improper removal can lead to tissue damage.
Whiteheads are a type of closed comedone, formed by deposits of sebum just below the very small opening of the follicle.
Open comedones are classic “blackheads” with distinctly dilated follicle openings. They are a mix of keratinized cells and solidified sebum. The black appearance is caused by oxidation of the keratinized sebum at the opening of the follicle and melanin.
Anatomy of Acne – Inflammatory
This is the acne which millions of dollars are spent every year to com- bat. The lesions are classified according to their placement in, above, or surrounding the follicle.
A papule is a red, sore bump caused by the beginning of a lesion - the collection of sebum and debris in the mid or lower follicular channel. No pus has developed yet, but the follicle is tender to the touch due to the surge of sebum and the collection of debris.
A pustule is a raised, inflammatory acne lesion with pus in the higher portion of the follicle, including above the surface, and a head filled with pus. It is a mature papule with developed infection through the entire length of the follicle.
A nodule is similar to a papule, but much deeper, very solid and very sore. If the inflammation stops due to cessation of the sebum surge, this sore bump beneath the skin will disappear. Nodules cannot be extracted and should not be manipulated in any way.
A cyst is a closed sac with a deep encapsulated infection, and a massive invasion of white blood cells, possibly the full length of the follicle. It exhibits a shiny, slick covering on the surface of the skin. It can also be described as a swelled, hardened, deep infection. A nodule has burst out of the wall of the follicle, spilling infection into the surrounding area. The body’s defences have encapsulated the infection, and it is now a cyst. Cysts destroy the surrounding dermal tissue, leaving pock marks and scarring when they heal.
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