ACNE
Acne is a common inflammatory skin disease due to infections of blocked hair follicles. Each hair follicle is associated with a sebaceous gland which secretes a conditioning oil (sebum) into the follicle. This normally travels along the pilosebaceous duct to reach the skin surface.
During adolescence, sebaceous glands in the skin activate under the influence of androgen hormones and excessive oil (sebum) is secreted. This produces the oily skin often associated with puberty. Skin cells rapidly divide and often produce so many cells that the opening (punctum) of a hair follicle gets blocked. This traps freshly produced sebum inside and results in the formation of the classic enlarging blackhead (comedone). The blackness is due to a dissolved skin pigment, melanin, rather than dirt as is commonly believed. These open blackheads do not usually progress to form spots. It is the closed comedone (white head) that tends to explode into a spot.
Changes in skin acid levels at puberty encourage bacterial overgrowth, particularly of a bacterium called Propionibacterium acnes. Another common causative bacterium is Staphylococcus aureus and Pityrosporum ovale. Bacteria become trapped in hair follicles to produce pustules (superficial microabscesses) and papules raised pimples due to underlying deeper infection.
It is important not to pick or scratch spots and blackheads as this can make scarring worse.
In some people, inflammatory changes occur due to the bacterial overgrowth, or because of leakage of sebum into surrounding tissues. This may be due in part to an allergic reaction. White cells are attracted into the area to release potent chemicals that exacerbate the problem. Nodules, cysts and scarring result.
Acne usually affects areas rich in sebaceous glands such as the face, hairline, upper chest and upper back. In severe cases, acne may spread down the arms, lower trunk, buttock and even the upper legs.
Androgenic Acne Vulgaris
The secretion of sebum is controlled in part by androgen hormones. As puberty is a time of rapid hormonal fluctuations, acne affects 80 per cent of teenage males. Spots start to appear at around 15 years of age (two years earlier in girls) and reach maximum severity at 1617 years. Around 1 per cent of males continue to suffer with acne into their twenties and thirties.
Hereditary factors seem to play a role. There is little scientific evidence that fatty foods, dairy products and chocolate contribute to acne, but a low-fat diet full of fresh fruit and vegetables does appear subjectively to improve skin clarity.
Acne Conglobata
This form of acne is a severe, long-term, painful disease that is also more common in males. It is characterized by the formation of large, inflammatory cysts and nodules on the face and upper trunk. These lesions heal to produce severe, disfiguring scarring.
Occupational Acne
Some males continue to suffer acne in later years due to occupational exposure to oils, tars and halogenated hydrocarbons. This is usually easily diagnosed because the site of the acne corresponds to the areas of skin exposed to the chemicals.
Drug-induced Acne
True drug-induced acne lacks blackheads (comedones) and is solely characterized by pustules. Drugs that can trigger it include corticosteroids (topical or systemic), progestogens (sometimes prescribed to males with hormone-dependent illnesses), anabolic steroids and isoniazid a drug used to treat tuberculosis.
Cosmetic Acne
This is occasionally seen in males who use cheap, greasy lotions and creams marketed as moisturizers for men. The greases block the pilosebaceous ducts to cause blackheads, and can trigger acne. More expensive agents described as non-comedogenic will not cause this problem.
Acne Treatments
When acne is severe, prompt diagnosis and treatment are needed to prevent scarring so never be afraid to consult your doctor if your skin starts to flare up.
Unfortunately, acne treatments need extreme patience, as often no benefits are seen for six to eight weeks after starting therapy. It is important to keep up with the treatment, however, as after two months of continued and regular use, improvements of around 20 per cent per month are common. Treatment is usually needed for at least six months.
Abrasive Agents
such as aluminium oxide, polyethylene granules in detergent or soaps help to remove excess sebum and comedones and reduce the number of bacterial colonies on the skin. They can irritate the eyes and skin and are of limited value. They are suitable for use in mild acne.
Washes and Soap Substitutes
are useful for cleansing the skin, removing excess grease and maintaining the correct level of skin acidity. Some are mildly antiseptic.
Benzoyl peroxide
has been available for over 20 years and is often teamed up with other agents such as antiseptics. It is applied as a cream, lotion or gel once per day and has an antibacterial effect against Propionibacterium. Studies show it can reduce the number of surface bacteria on the skin by 100 fold. Benzoyl peroxide also reduces the number and size of comedones and damps down inflammation, so that the number and size of inflammatory nodules is reduced. Studies show that it produces a 60 per cent reduction in the number of acne lesions after two months' treatment.
Side effects: 40 per cent of users notice redness and scaling of their skin after the first few days' treatment. This effect is a necessary part of benzoyl peroxide's action and generally settles down after a couple of weeks. Irritation can be reduced by decreasing the strength of solution used, by decreasing the frequency of application and by applying a non-comedogenic moisturizer. Benzoyl peroxide will bleach hair and clothes, so wear an old vest or T-shirt under your clothes after treating the back and chest.
If you are using prescribed tretinoin (see below), you can alternate this with benzoyl peroxide, using one in the morning and the other in the evening. Benzoyl peroxide may also be used with aqueous solutions of topical antibiotics, but not with ones in alcoholic solutions.
Azelaic Acid
is a new acne treatment applied as a cream once or twice per day for a maximum of six months. It is used to treat mild to moderate acne and has both an antibacterial and an anti-comedone action. It is as effective as benzoyl peroxide, erythromycin cream or oral tetracycline.
Side-effects: mild, transient redness and irritation in 510 per cent of users. It is better tolerated than benzoyl peroxide or tretinoin.
Topical Antibiotics
are used in cases of mild to moderate acne that mainly affect the face. They contain either erythromycin (plus or minus zinc acetate), clindamycin or tetracycline and are applied twice daily as a solution or lotion to reduce the numbers of Propionibacterium on the skin. These antibiotics have a similar overall efficacy to benzoyl peroxide, although some Propioni- bacterium infections may become resistant to them.
Side effects: topical antibiotics are less irritating than benzoyl peroxide. One or two preparations fluoresce under ultraviolet light, and thus should not be worn if you are going out to a disco or anywhere you might encounter UV lights.
Systemic Antibiotics
Four oral antibiotic treatments are available: tetracycline, doxycycline, minocycline and erythromycin. Very occasionally, trimethoprim may be used. Systemic antibiotics are useful for mild to moderate acne that affects a large area such as the face, back and chest. Studies show that these antibiotics reduce the number of Propionibacterium by around 10 fold. They must be taken regularly for prolonged lengths of time, however at least three to six months.
Minocycline has several advantages over the other antibiotics used to treat acne. It:
• can be given once per day
• can be taken with food but not milk, which binds it
• is less likely to induce bacterial resistance
• has an anti-inflammatory action.
Side effects: long-term administration of antibiotics affects bacterial balances in the intestinal tract and can lead to oral thrush, nausea, abdominal pain or diarrhoea in around 5 per cent of patients.
In 1976, researchers found no Propionibacterium acnes resistant to antibiotics. In 1991, surveys found 38 per cent of acne patients carried bacterial strains resistant to one or more antibiotics, 26.5 per cent carried erythromycin-resistant strains, and 13 per cent carried tetracycline-resistant strains. Resistance to minocycline was less than 1 per cent. If your antibiotic (topical or systemic) no longer seems to be working, it is worth asking your doctor for a different treatment.
Tretinoin
(topical retinoic acid) is an analogue of vitamin A. A cream or gel is applied once or twice daily for a minimum of two months. Tretinoin works by stimulating the division of fibro-blast cells deep within the skin. This proliferation helps push spots up and out, to such an extent that initially skin may appear worse lumpy and inflamed before improving dramati-cally. It also reduces the number of horny skin cells around the mouth of the hair follicle, allowing discharge of the comedone and restoring the free flow of sebum. Tretinoin is used when comedones, papules and pustules predominate. The majority of users show a 70 per cent response over three to six months of treatment.
Side-effects: excessive use results in thin, shiny, red skin with soreness and peeling. There may be occasional photo-irritation when the skin is exposed to ultraviolet light.
Systemic Retinoids
oral isotretinoin (also an analogue of vitamin A) is only prescribable by hospital specialists and has revolutionized the treatment of severe acne. It is reserved for patients with severe cystic or conglobate acne, and for those who have not responded to several courses of antibiotics because of bacterial resistance.
Isotretinoin is given in capsule form once or twice per day for one to four months. The dose used is dependent upon body weight and repeat courses are not normally recommended. It works by reducing bacterial numbers, preventing comedone formation, damping down inflammation and reducing sebum secretion. Within two weeks of starting treatment, sebaceous follicles have shrunk significantly in size and there is a rapid reduction in the amount of sebum secreted. The production and sloughing of skin cells within the hair follicle also decreases, which discourages blocking of pilosebaceous ducts. There is also a rapid drop in the numbers of Propionibacterium on the skin, a decline which persists after treatment is stopped. As isotretinoin does not have an antibiotic action, this effect may be related to the lessening of sebum production.
Side-effects of treatment with systemic retinoids are unfortunately common:
• facial redness in 66 per cent of patients
• conjunctivitis in 33 per cent of patients
• eczema in 30 per cent of patients
• muscle and joint aches (35 per cent)
• headaches (16 per cent)
• dry mucous membranes, cracked lips and nose bleeds
• raised blood cholesterol and triglyceride levels
• raised blood levels of some liver enzymes
• seizures, abnormal blood clotting (from low platelet count) and hearing problems (these side-effects are rare).
Despite this long list of possible complications, treatment under close hospital supervision is safe and can transform the appearance and emotional state of patients with severe acne. Monthly blood tests and supervision are necessary throughout therapy.
Cosmetic Treatment of Acne Scars
There are three types of acne scars:
1. superficial, violet coloured ice-pick scars (small pits)
2. thick, palpable scars from deeper lesions
3. ugly, excessively thickened (keloid) scars, most commonly on the shoulders, chest and back.
In severe cases of acne where scarring has already occurred, treatments are available to improve cosmetic appearance. These include using skin-peeling agents, skin abrasives, laser therapy and collagen injections to plump up and even out pits. Collagen injections need repeating every six months or so. Alternatively, cysts and scars may be surgically removed or injected with steroids.
ECZEMA
Eczema (dermatitis) is a common skin condition affecting millions of adult males. It is named after the Greek word for boil, as in severe cases inflamed skin erupts with blisters that ooze exudate or pus. Dermatitis is commonly work-related from exposure to irritant chemicals (e.g. acids, alkalis, solvents, detergents) or to allergenic substances (e.g. cement, dyes, oils, coal tar, resins, insecticides, photographic/printing chemicals, nickel, plants).
Where eczema is due to an allergy to particular foods, chemicals, detergents or metals it can be difficult to work out what you are allergic to though skin patch-testing may help. Avoiding certain chemicals or excluding foods such as yeast or eggs until symptoms have settled down may help. The suspect item can then be reintroduced to see if symptoms return.
Eczema is often mild consisting of a few areas of itchy, red skin usually on the hands, inside the elbows or behind the knees. In severe cases, the whole body is affected and the skin feels thickened, scaly and dry.
Itching is one of the worst symptoms of eczema and the inevitable scratching unfortunately makes the condition worse.
Nummular eczema is common in adults. This takes the form of circular, itchy scaly patches on the body that look very similar to ringworm. This is not serious and often comes and goes throughout life.
There are several ways in which you can help your eczema:
• Wear white cotton gloves under rubber gloves when handling substances such as washing-up detergents or work chemicals that may irritate your skin.
• Make sure your hands are thoroughly dry after washing wetness will macerate eczematous skin.
• Use an unscented hand cream several times a day to act as a barrier and keep moisture in.
• Add soya or almond oil products to your bath water. Some products (e.g. Balneum Plus) also contain an anti-itch substance which soothes itchy, inflamed skin.
• Use aqueous cream instead of soap for cleansing. This does not lather but acts like cold cream to dissolve away grease and dirt.
• Apply a non-scented cream such as E45 to moisturize delicate skin on your face. A stronger cream such as Unguentum will help dryness elsewhere on your body.
• Buy 100 per cent cotton clothing to wear next to the skin and avoid perfumed products such as aftershave or deodorant.
Oil of Evening Primrose contains gammalinolenic acid a fatty acid which feeds into metabolic pathways in your skin. This is particularly helpful for itchiness as well as dryness but needs to be taken in large doses (around 240 mg twice a day). Some men apply it directly to patches of affected skin.
Mild eczema can be melted away with a weak steroid cream such as 1 per cent hydrocortisone cream. This should be used sparingly and should never be applied to the face except under medical supervision. Excessive use of steroid creams can thin the skin, causing stretch marks or discolouration. Stronger steroid creams are sometimes necessary and are only available on prescription. Many people have found orthodox medical treatments unhelpful, but have been cured with herbs prescribed by doctors trained in Chinese medicine.
Perhaps the most useful thing you can do to help damp down severe eczema is to avoid highly stressful situations, which usually make symptoms worse.
FUNGAL SKIN INFECTIONS
Fungal skin infections are common. They include conditions such as ringworm, athlete's foot and infections of the skin folds (see Chapter 2).
Ringworm
Ringworm is the common name for a fungal skin infection that can affect any part of the body, including the feet, arms, groin, scalp, nails or trunk. It is named after the ring-shaped red, scaly lesions which slowly spread leaving a pale central area which often itches.
Ringworm is easily treated using an anti-fungal cream, lotion or ointment (e.g. clotrimazole, miconazole). If the infection is in a skin fold and has become macerated and inflamed, treatment is sometimes combined with an anti-inflammatory agent such as 1 per cent hydrocortisone (a steroid) cream. Steroid creams should not be used on the lesions without an anti-fungal agent as this can make the infection spread quite rapidly. This occasionally occurs where a patch of fungal infection has been confused with eczema (see eczema above).
Athlete's Foot
Athlete's foot is a fungal infection that causes soreness, slitting and itching of the skin between the toes. This commonly occurs in athletes who have worn hot, sweaty training shoes for hours at a time. Fungal and yeast cells love warm, hot, moist places sweaty feet are their dream environment.
Athlete's foot is best treated with anti-fungal creams or, preferably, a powder that helps to keep the area dry. It is important to continue treating the area for at least 10 days after all visible signs of infection have gone. The fungus burrows deep into the skin and can be reactivated if not thoroughly eradicated. If infection has spread beyond the toe cleft, for example onto the nail, oral treatments or medicated nail paints may be recommended.
Shoes should always be treated with anti-fungal sprays or powders as well, for they usually harbour the infection. If shoes smell rotten they should be thrown away and replaced.
Good foot hygiene can prevent reinfection:
• Wash your feet at least once per day, and after every sports activity. This does not mean just soaking them in the bath or standing them in the shower. The feet need to be soaped and excess skin gently pared away with tools specially designed for the job (e.g. a pumice stone, abrasive massage creams, metal parers). After washing, the feet should be dried thoroughly, particularly the spaces between the toes, using tissue or even a hairdryer.
• Clean, cotton socks should be worn every day, and your feet and shoes regularly sprayed or dusted with deodorant anti-fungal preparations. The area underneath the ends of the toenail should be regularly cleaned using a nail file. This is where dead skin builds up to harbour fungal spores.
These measures will also reduce the problem of smelly feet associated with decaying, sloughed skin and microbial infection.
