Acne vulgaris causes

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Ogheneochuko Ajari, MB.BS, MS [3] Tayyaba Ali, M.D.[4]

Causes

Common Causes

Acne develops because of occlusion of follicles. The earliest change in acne development is hyperkeratinization and formation of a plug of keratin and sebum (a micro-comedo). Sebaceous glands enlarge, and sebum production increases with increased androgen (DHEA-S) production at the adrenarche. The micro-comedo may enlarge to form an open comedo (blackhead) or closed comedo (whitehead). Increased sebum production provides an environment for the overgrowth of Propionibacterium acnes. Bacterial overgrowth of Propionibacterium acnes can cause inflammation, leading to inflammatory lesions (papules, pustules, or nodules) in the dermis around the micro-comedo or comedo, which may cause scarring or hyperpigmentation.

There are many misconceptions and myths about acne.

Primary Causes

Exactly why some people get acne and some do not is not fully known. It is known to be partly hereditary. Several factors are known to be linked to acne:

• Family/Genetic history: The tendency to develop acne runs in families. For example, school-age boys with acne have other members of their family with acne. I associate a family history of acne with an earlier acne occurrence and increased acne lesions.
• Hormonal activity, such as menstrual cycles and puberty: During puberty, increased male sex hormones called androgens, cause the glands to get larger and make more sebum.
• Stress: The increased output of hormones from the adrenal (stress) glands.
• Hyperactive sebaceous glands, secondary to the three hormone sources above.
• Accumulation of dead skin cells.
• Bacteria in the pores, to which the body becomes 'allergic.': Propionibacterium acnes (P. acnes) is the anaerobic bacterium that causes acne. In-vitro resistance of P. acnes to commonly used antibiotics has been increasing.
• Skin irritation or scratching of any sort will activate inflammation.
• Use of anabolic steroids.
• Any medication containing halogens (iodides, chlorides, bromides), lithium, barbiturates, or androgens.
• Exposure to high levels of chlorine compounds, particularly chlorinated dioxins, can cause severe, long-lasting acne, known as Chloracne.
• Exposure to certain drugs and chemical compounds, including narcotics (opiates and opioids), especially when taken intravenously

Several hormones have been linked to acne: the androgens testosterone, dihydrotestosterone (DHT) and dehydroepiandrosterone sulfate (DHEAS), 17-hydroxyprogesterone, and insulin-like growth factor 1 (IGF-I). Besides, acne-prone skin is insulin resistant.

In later years, the development of acne vulgaris is uncommon, although this is the age group for Rosacea, which may have similar appearances. True acne vulgaris in adults may be a feature of an underlying condition such as pregnancy and disorders such as polycystic ovary syndrome or the rare Cushing's syndrome. Menopause-associated acne occurs as the production of the natural anti-acne ovarian hormone estradiol fails at menopause. The lack of estradiol also causes thinning hair, hot flashes, thin skin, wrinkles, vaginal dryness, predisposes to osteopenia and osteoporosis, and triggering acne (known as acne climacteric in this situation).

Diet

Milk

A recent study, based on a survey of 47,335 women, did find a positive epidemiological association between acne and consumption of partially skimmed milk, instant breakfast drink, sherbet, cottage cheese and cream cheese. The researchers hypothesize that the association may be caused by hormones (such as several sex hormones and bovine IGF-I) present in cow milk. Though there is evidence of an association between milk and acne, the exact cause is unclear. Most dermatologists are awaiting confirmatory research linking diet and acne but some support the idea that acne sufferers should experiment with their diets, and refrain from consuming such fare if they find such food affects the severity of their acne.

Seafood

Seafood often contains relatively high levels of iodine. Iodine is known to make existing acne worse but there is probably not enough to cause an acne outbreak. Still, people who are prone to acne may want to avoid excessive consumption of foods high in iodine.

High Carbohydrates/High GI

It has also been suggested that there is a link between a diet high in refined sugars and other processed foods and acne. The theory is that rapidly digested carbohydrate food such as white bread and refined sugars produces an overload in metabolic glucose that is rapidly converted into the types of fat that can build up in sebaceous glands. According to this hypothesis, the startling absence of acne in non-westernized societies could be explained by the low glycemic index of these cultures' diets. Others have cited possible genetic reasons for there being no acne in these populations, but similar populations shifting to these diets do develop acne. Note also that the populations studied consumed no milk or other dairy products. Further research is necessary to establish whether a reduced consumption of high-glycemic foods (such as soft drinks, sweets, white bread) can significantly alleviate acne, though consumption of high-glycemic foods should in any case be kept to a minimum, for general health reasons. Avoidance of 'junk food' with its high fat and sugar content is also recommended. On the other hand there is no evidence that fat alone makes skin oilier or acne worse.

The University of Pennsylvania and the US Naval Academy conducted experiments that fed subjects chocolate or a bar with similar amounts of macronutrients (fat, sugar etc.) and found that consumption of chocolate, frequent or not, had no effect on the developing of acne.

A 2005 systematic review found "surprisingly little evidence exists for the efficacy or lack of efficacy of dietary factors, face-washing and sunlight exposure in the management of acne." A study in November 2006 in Australia gave a 50% reduction in 12 weeks in mild-moderate facial acne by introducing its subjects to a high protein, low GI diet.

The American Medical Association says chocolate does not contribute to acne.

A recent study shows that a diet high enough in sugars triggers the liver to convert these sugars into lipid; as a side-effect this stops production of sex hormone binding globulin- a chemical which reduces the level of testosterone in the blood. Since high testosterone levels generally trigger acne, the researchers believe that this can be a cause.

Vitamins A and E

Studies have shown that newly diagnosed acne patients tend to have lower levels of vitamin A circulating in their bloodstream than those that are acne free. In addition people with severe acne also tend to have lower blood levels of vitamin E.

Hygiene

Acne is not caused by dirt. This misconception probably comes from the fact that blackheads look like dirt stuck in the openings of pores. The black color is simply not dirt but compact keratin. In fact, the blockages of keratin that cause acne occur deep within the narrow follicle channel, where it is impossible to wash them away. These plugs are formed by the failure of the cells lining the duct to separate and flow to the surface in the sebum created there by the body.

Sex

Common myths state that masturbation causes acne and, conversely, that celibacy or sexual intercourse can cure it. Acne has not been linked to any type of sexual activity.

Causes by Organ System

Cardiovascular	No underlying causes
Chemical / poisoning	Dioxins, Industrial exposure to halogenated hydrocarbons
Dermatologic	Chloracne, Skin irritation or scratching
Drug Side Effect	17-hydroxyprogesterone, antiepileptics, bromides, Cidofovir, Dactinomycin, dehydroepiandrosterone sulfate (DHEAS), Desogestrel and Ethinyl Estradiol, dihydrotestosterone (DHT), Eflornithine, Estradiol valerate and estradiol valerate/dienogest, Ethynodiol diacetate and ethinyl estradiol, Fluoxymesterone, gefitinib, Goserelin, iodides, isoniazid, Ivacaftor, leflunomide, lithium, low Vitamin A levels, low Vitamin E levels, methyltestosterone, nabumetone, Nafarelin, Oxandrolone, oxcarbazepine, phenytoin, pramipexole, prednisolone, steroids, testosterone, Chlorides Cosmetic agents
Ear Nose Throat	No underlying causes
Endocrine	Congenital adrenal hyperplasia, Cushing's syndrome, increased androgen production, insulin-like growth factor 1 (IGF-I), polycystic ovary syndrome, Dioxins
Environmental	Increased stress levels
Gastroenterologic	No underlying causes
Genetic	Genetic, congenital adrenal hyperplasia
Hematologic	No underlying causes
Iatrogenic	No underlying causes
Infectious Disease	Propionibacterium acnes infection, Staphylococcus epidermidis
Musculoskeletal / Ortho	No underlying causes
Neurologic	Dioxins
Nutritional / Metabolic	A diet high in glycemic index foods and dairy products, consumption of cottage cheese and cream cheese, consumption of partially skimmed milk, low Vitamin A levels, low Vitamin E levels
Obstetric/Gynecologic	Menstrual cycles, oral contraceptives, pregnancy, Dioxins
Oncologic	Dioxins
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal / Electrolyte	No underlying causes
Rheum / Immune / Allergy	Dioxins
Sexual	Puberty, Dioxins
Trauma	No underlying causes
Urologic	No underlying causes
Dental	Dioxins
Miscellaneous	No underlying causes

Causes in Alphabetical Order

• A diet high in glycemic index foods and dairy products
• 17-hydroxyprogesterone
• Antiepileptics
• Bromides
• Chloracne
• Chlorides
• Cidofovir
• Congenital adrenal hyperplasia
• Consumption of cottage cheese and cream cheese
• Consumption of partially skimmed milk
• Cosmetic agents
• Cushing's syndrome
• Dehydroepiandrosterone sulfate (DHEAS)
• Desogestrel and Ethinyl Estradiol
• Dihydrotestosterone (DHT)
• Dioxins
• Eflornithine
• Gefitinib
• Genetic
• Increased androgen production
• Increased stress levels
• Industrial exposure to halogenated hydrocarbons
• Insulin-like growth factor 1 (IGF-I)
• Iodides
• Isoniazid
• Ivacaftor
• Lithium
• Low Vitamin A levels
• Low Vitamin E levels
• Menstrual cycles
• Oral contraceptives
• Phenytoin
• Polycystic ovary syndrome
• Pregnancy
• Propionibacterium acnes infection
• Puberty
• Skin irritation or scratching
• Staphylococcus epidermidis
• Steroids
• Testosterone