Acne causes and etiology
Acne is a multifactorial disease with involvement of multitude of factors which may be introduced as acne causes. Genetic, racial, hormonal, dietary and envrionmental factors have been implicated in its development, while it is clear that its psychological implications may be severe. Although the role of heredity in acne has not been clearly denied, there is a great tendency toward more serious involvement if one or both parents had severe acne during their youth.
The sebaceous glands ( part of sebaceous follicles ) are under neuroendocrine control and so it is not surprising that sebum production shows change according to age and sex of an acne patient or university students acne exacerbations during final examinations. Sebum production in acne patients is dramatically greater than that in normal individuals with an increase in sebum generation with a peak at about age 40. Sebum composition and skin surface lipids are also subject to change in acne patients. Any approach to control androgens appear to be relevant to adult acne since the sebaceous follicle is an organ targeted by androgens. Similarly, sebaceous glands and corresponding lipids are influenced by surrounding bacteria and role of propionibacterium acnes in increase sebum production has been recognized by multitude of studies.
Steroidogenesis in the skin, hormonal factors and acne : Hormones and its related enzymes obviously play an important role in development of acne. Sebaceous glands ( part of sebaceous follicles ) are extremely sensitive to androgenic stimulation, and their enlargement usually precedes other obvious signs of puberty even before any sign of acne. They are under endocrine control and so it is not surprising that sebum production varies with age and sex. Increase in sebum production and change in skin lipids is associated with increase in free fatty acids rather than an increase in essential fatty acids. Males have a significantly greater sebum production than females. Men’s skin in many other respects is different than female’s. For example it is under influence of different hormones. Production of sebum continues to increase after puberty, reaching a peak in both sexes between 30 and 40 years, and thereafter there is a gradual decline. It is evident that the sebaceous gland is an androgen target organ and any measure pharmacologically to control androgens is a logical approach to treatment of acne.
Emotional factors and stress: As with any disease whose course is prolonged and capricious, the importance of stress and psychological factors in treatment of breakouts has been repeatedly stressed and should be seriously taken into account when using topical treatments. There seems to be no doubt that stress such as final examinations regularly cause exacerbations in patients. Negative impact on self confidence, acne causes increased glucocorticoid secretion by the adrenal glands that seem to potentiate the effect of androgens.
Environmental factors and acne : Environmental factors also play a major role in determining the severity and extent of acne and affect topical treatments. In most cases the manifestations are worse in winter and improves during the summer, suggesting a salutary effect of sunlight. However, in some cases exposure to sunlight worsens the disease, which may be explained by generation of reactive oxygen species, ROS, which may contribute to inflammation, known in pathogenesis of acne vulgaris. The constant friction caused by protective devices such as a helmet, shoulder pads or pillows will make its management futile.