In order to discuss acne properly, it will be necessary from time to time to use medical terms, which will be explained as they are used. But first there is a nonmedical word, “pimple,” which is so commonly used, as well as misused, that something should be said about it if only to explain it away.
It is neither a good descriptive word, since it means different things to different people, nor an accepted scientific term. Therefore, in its place, the correct medical term “lesion” will be used. An acne lesion is any one of the changes which occurs in the appearance of the skin. The most common lesion of acne, the one that starts all the trouble as you will soon see, is the “blackhead.”
One of the main characteristics of acne is the oiliness of the skin. Sometimes one can see an oily film over the parts of the face where the oil glands occur in greatest numbers, particularly about the sides and front of the nose, chin and forehead. If one wipes his finger over these areas, a film of oil will easily come off on it.
Some of you have probably noticed that if pressure is placed on the side of the nose, you can squeeze out a whitish creamy substance. This is the way sebum looks while it is still in the oil glands and ducts. It only becomes oily as it is secreted onto the skin.
A close inspection of the skin will sometimes show that there are numerous blackheads present. Probably you have been very conscious of your blackheads. Trying to remove them is a common pastime with young people. Sometimes they spend hours in front of a mirror trying to squeeze them out. When you do not know how to remove blackheads properly, it can be a rather painful process. Incorrectly removing these acne lesions bruises the skin and causes more damage and a more unsightly appearance than the blackhead itself.
I have seen acne patients come into the treatment room to have their blackheads removed quite certain they are going to be hurt. It is always a pleasant surprise for them to learn that, properly done, it is a painless procedure. Insignificant in size though they may be, these blackheads are at the root of many acne lesions. Therefore, you should know what blackheads are and how they are formed.
You will remember that the oil-gland secretion gets to the surface of the skin through the channels of the hair follicles, which act as ducts. The openings at the end of these ducts on the surface of the skin are called the oil-gland or follicle openings. It is in these openings that blackheads occur.
The formation of blackheads is partly due to the presence of dried and hardened oil from the glands below which makes a plug at the opening of the duct. Contrary to popular belief, the dark color of blackheads is not from dirt. That is why blackheads cannot be removed simply by washing. The black discoloration comes from chemical changes in the composition of the dried, fatty plug due to exposure to air over a period of time.
Another reason why blackheads form is that the follicle openings may become obstructed by the overgrowth of the horny-layer cells. When the layers of the skin were described, it was mentioned that in acne the horny-layer cells in and about the follicle openings reproduce at a greater rate than they die and shed. Now we see that one of the results of this is the clogging of the follicle openings. This horny-layer growth, occurring as it does in millions of these openings, gives the skin a coarse, gritty feeling and a dusky or dirty appearance. It is going to take considerably more than mere scrubbing of the skin to help your acne.
The tender inflamed lesions containing pus which are so typical of acne arise in slowly progressive stages starting with these simple blackheads. When the plugged oil-gland openings containing the blackheads and the skin immediately about them become swollen, inflamed and tender, they are called papules. As these papules get worse and enlarge into more intensely inflamed lesions containing pus, they are called pustules. By the time the inflammation of an acne lesion has gotten to the point where papules and pustules are formed, the blackhead may no longer be visible. In fact, many papules and pustules occur without a blackhead ever being seen.
Invisible plugging deep down in the oil-gland duct is the cause of many inflammatory acne lesions. If your acne eruption has been present for many months or years, most likely there will be other lesions present besides blackheads, papules and pustules. You know already that due to the formation of blackheads the oil-gland ducts become plugged.
The plugging prevents the sebum from getting to the surface of the skin, yet the gland keeps right on manufacturing and pumping out more oily material. Often there is only one thing that the gland can do with all this backed-up secretion, and that is to balloon out. Due to this injury to the gland it is very easy for a bacterial infection to get started. Eventually the infection produces an inflamed, tender, pus-containing, saclike structure under the .surface of the skin. This is called a cyst. Sometimes infection does not occur; then the cyst appears as a firm, cream-colored papule which contains fatty material but not pus.
Most cysts are about the size of a large green pea. But sometimes they can get as large as a walnut or even larger. The bigger they are, the more local damage they cause to the skin. The number of cysts that are present in an acne eruption varies. There may be only an occasional cyst in an area like the back of the ears, for example, or there may be many cysts scattered throughout the entire acne eruption. The destruction that these lesions cause to the deeper layers of the skin very often results in scarring.
Scarring is due to an overgrowth of the connective-tissue fibers of the dermis at the site of formerly active acne lesions. At first the connective tissue attempts to wall oflf the inflammation and infection to prevent them from spreading. Later it replaces the parts of the skin which have been destroyed. Scarring does not always occur in acne. Most papules and pustules and even some cysts eventually heal without leaving a scar. But certain pustules and some cysts which have been present for a long time cause a lot of damage to the deep layers of the skin and usually leave broad, flat scars.
Another type of scarring which occurs is best described as a pitting of the skin. The pitted appearance is due to the scarring and enlargement of the oil-gland openings from many months of plugging and inflammation. The inflammation destroys the elastic fibers of the dermis. When the skin loses its elasticity, the oil-gland openings cannot close. These changes in the skin are usually seen about the nose and cheeks.
In some instances, as though enough harm had not already been done, the scars themselves have a tendency to overgrow and thicken, becoming cordlike, and when they do, they are called keloids. Keloids usually occur in acne of the chest and back when there has been severe inflammation and infection for many months.