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The earliest pathologic change is the formation of a plug (a microcomedone), which is driven primarily by excessive growth, reproduction, and accumulation of skin cells in the hair follicle. In normal skin, the skin cells that have died come up to the surface and exit the pore of the hair follicle. However, increased production of oily sebum in those with acne causes the dead skin cells to stick together. The accumulation of dead skin cell debris and oily sebum blocks the pore of the hair follicle, thus forming the microcomedone. This is further exacerbated by the biofilm created by C. acnes within the hair follicle. If the microcomedone is superficial within the hair follicle, the skin pigment melanin is exposed to air, resulting in its oxidation and dark appearance (known as a blackhead or open comedo). In contrast, if the microcomedone occurs deep within the hair follicle, this causes the formation of a whitehead (known as a closed comedo).
But Accutane has mixed reviews for a reason. It makes the skin super dry and sensitive, which means it’s important to keep moisturizers and lip balm nearby while you’re on the treatment. Oh, and don’t even think about waxing your eyebrows (just imagine your skin ripping off). There’s another downside to Accutane: It requires a lot of paperwork and office visits. Since isotretinoin can cause birth defects, you have to come into the dermatologist once a month to get a pregnancy test and take a lengthy survey with embarrassing questions about your sex life to prove that you are using sufficient birth control. These precautions are intense, but dermatologists agree that the final results for Accutane are like no other. “This is one of the few medicines that I can look [patients] in the eye and guarantee them it will work,” says Friedman.
Antiandrogens such as cyproterone acetate and spironolactone have been used successfully to treat acne, especially in women with signs of excessive androgen production such as increased hairiness or skin production of sebum, or baldness. Spironolactone is an effective treatment for acne in adult women, but unlike combined birth control pills, is not approved by the United States Food and Drug Administration for this purpose. The medication is primarily used as an aldosterone antagonist and is thought to be a useful acne treatment due to its ability to additionally block the androgen receptor at higher doses. Alone or in combination with a birth control pill, spironolactone has shown a 33 to 85% reduction in acne lesions in women. The effectiveness of spironolactone for acne appears to be dose-dependent. High-dose cyproterone acetate alone has been found to decrease symptoms of acne in women by 75 to 90% within 3 months. It is usually combined with an estrogen to avoid menstrual irregularities and estrogen deficiency. The medication has also been found to be effective in the treatment of acne in males, with one study finding that a high dosage reduced inflammatory acne lesions by 73%. However, the side effects of cyproterone acetate in males, such as gynecomastia, sexual dysfunction, and decreased bone mineral density, make its use for acne in this sex impractical in most cases. Hormonal therapies should not be used to treat acne during pregnancy or lactation as they have been associated with birth disorders such as hypospadias, and feminization of the male babies. In addition, women who are sexually active and who can or may become pregnant should use an effective method of contraception to prevent pregnancy while taking an antiandrogen. Antiandrogens are often combined with birth control pills for this reason, which can result in additive efficacy.
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Whereas blackheads are open, whiteheads are closed comedones. They appear as small, white, round bumps on the skin’s surface. Whiteheads form when a clogged pore is trapped by a thin layer of skin leading to a buildup of pus. They range in size – from virtually invisible to large, noticeable blemishes – and can appear on the face or all over the body. Whiteheads are generally painless and non-inflammatory, so they don’t exhibit redness or swelling. Although they are unsightly, this type of pimple is generally considered a mild form acne.