Thursday, July 1, 2010
vulgaris (commonly called acne) is a common human skin disease, characterized by areas of skin with multiple noninflammatory follicular papules or comedones and by inflammatory papules, pustules, and nodules in its more severe forms. Acne vulgaris mostly affects the areas of skin with the densest population of sebaceous follicles; these areas include the face, the upper part of the chest, and the back. Severe acne is inflammatory, but acne can also manifest in noninflammatory forms.[1] Acne lesions are commonly referred to as pimples, blemishes, spots, zits, or simply acne. Acne lesions are caused by changes in pilosebaceous units, skin structures consisting of a hair follicle and its associated sebaceous gland, changes which require androgen stimulation.
Acne occurs most commonly during adolescence, affecting more than 96% of teenagers, and often continues into adulthood. In adolescence, acne is usually caused by an increase in male sex hormones, which people of both genders accrue during puberty.[2] For most people, acne diminishes over time and tends to disappear—or at the very least decrease—after one reaches one's early twenties. There is, however, no way to predict how long it will take to disappear entirely, and some individuals will carry this condition well into their thirties, forties and beyond.[3]
The face and upper neck are the most commonly affected, but the chest, back and shoulders may have acne as well. The upper arms can also have acne, but lesions found there are often keratosis pilaris, not acne. Typical acne lesions are comedones, inflammatory papules, pustules and nodules.
Some of the large nodules were previously called "cysts" and the term nodulocystic has been used to describe severe cases of inflammatory acne.[4] The "cysts," or boils that accompany cystic acne, can appear on the buttocks, groin, and armpit area, and anywhere else where sweat collects in hair follicles and perspiration ducts.[5] Cystic acne affects deeper skin tissue than does common acne.[6]
Aside from scarring, its main effects are psychological, such as reduced self-esteem[7] and, according to at least one study, depression or suicide.[8] Acne usually appears during adolescence, when people already tend to be most socially insecure. Early and aggressive treatment is therefore advocated by some to lessen the overall impact to individuals.[7]
The term acne comes from a corruption of the Greek άκμή (acne in the sense of a skin eruption) in the writings of Aëtius Amidenus. Used by itself, the term "acne" refers to the presence of pustules and papules.[9] The most common form of acne is known as "acne vulgaris", meaning "common acne". Many teenagers get this type of acne. Use of the term "acne vulgaris" implies the presence of comedones.[10]
The term "acne rosacea" is a synonym for rosacea, however some individuals may have almost no acne comedones associated with their rosacea and prefer therefore the term rosacea.[11] Chloracne is associated with exposure to polyhalogenated compounds.
Signs and symptoms
Acne often leaves small scars where the skin gets a "volcanic" shape.
Physical acne scars are often referred to as "Icepick" scars. This is because the scars tend to cause an indentation in the skin's surface. There are a range of treatments available. Although quite rare, the medical condition Atrophia Maculosa Varioliformis Cutis also results in "acne like" depressed scars on the face.Ice pick scars: Deep pits, that are the most common and a classic sign of acne scarring. Box car scars: Angular scars that usually occur on the temple and cheeks, and can be either superficial or deep, these are similar to chickenpox scars. Rolling scars: Scars that give the skin a wave-like appearance. Hypertrophic scars: Thickened, or keloid scars.
Pigmented scars is a slightly misleading term as it suggests a change in the skin's pigmentation and that they are true scars; however, neither is true. Pigmented scars are usually the result of nodular or cystic acne (the painful 'bumps' lying under the skin). They often leave behind an inflamed red mark. Often, the pigmentation scars can be avoided simply by avoiding aggravation of the nodule or cyst. When sufferers try to 'pop' cysts or nodules, pigmentation scarring becomes significantly worse[citation needed], and may even bruise the affected area. Pigmentation scars nearly always fade with time taking between three months to two years to do so, although rarely can persist.
On the other hand, some people—particularly those with naturally tanned skin—do develop brown hyperpigmentation scars due to increased production of the pigment melanin. These too typically fade over time.
Acne develops as a result of blockages in follicles. Hyperkeratinization and formation of a plug of keratin and sebum (a microcomedo) is the earliest change. Enlargement of sebaceous glands and an increase in sebum production occur with increased androgen (DHEA-S) production at adrenarche. The microcomedo may enlarge to form an open comedone (blackhead) or closed comedone (milia). Comedones are the direct result of sebaceous glands becoming clogged with sebum, a naturally occurring oil, and dead skin cells. In these conditions, the naturally occurring largely commensal bacterium Propionibacterium acnes can cause inflammation, leading to inflammatory lesions (papules, infected pustules, or nodules) in the dermis around the microcomedo or comedone, which results in redness and may result in scarring or hyperpigmentation.[12]
Hormonal activity, such as menstrual cycles and puberty, may contribute to the formation of acne. During puberty, an increase in male sex hormones called androgens cause the follicular glands to grow larger and make more sebum.[13] Use of anabolic steroids may have a similar effect.[14] Several hormones have been linked to acne: the androgens testosterone, dihydrotestosterone (DHT) and dehydroepiandrosterone sulfate (DHEAS), as well as insulin-like growth factor 1 (IGF-I).
Development of acne vulgaris in later years is uncommon, although this is the age group for rosacea, which may have similar appearances. True acne vulgaris in adult women 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 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, and predisposes to osteopenia and osteoporosis as well as triggering acne (known as acne climacterica in this situation).
The tendency to develop acne runs in families. For example, school-age boys with acne often have other members in their family with acne as well. A family history of acne is associated with an earlier occurrence of acne and an increased number of retentional acne lesions.[15]
While the connection between acne and stress has been debated, scientific research indicates that "increased acne severity" is "significantly associated with increased stress levels."[16] The National Institutes of Health (USA) list stress as a factor that "can cause an acne flare."[17] A study of adolescents in Singapore "observed a statistically significant positive correlation […] between stress levels and severity of acne."[18]
Bacteria in the pores. Propionibacterium acnes (P. acnes) is the anaerobic bacterium that causes acne. In vitro resistance of P. acnes to commonly used antibiotics has been increasing.[19]
A high glycemic load diet and cow's milk have been associated with worsening acne.[20] Other associations such as chocolate and salt are not supported by the evidence.[20]
There are multiple grading scales for grading the severity of acne vulgaris,[21] three of these being:Leeds acne grading technique: Counts and categorises lesions into inflammatory and non-inflammatory (ranges from 0-10.0). 'Cook's acne grading scale: Uses photographs to grade severity from 0 to 8 (0 being the least severe and 8 being the most severe). Pillsbury scale: Simply classifies the severity of the acne from 1 (least severe) to 4 (most severe).

Benzoyl peroxide cream.
Modes of improvement are not necessarily fully understood but in general treatments are believed to work in at least 4 different ways (with many of the best treatments providing multiple simultaneous effects):normalising shedding into the pore to prevent blockage killing Propionibacterium acnes anti-inflammatory effects hormonal manipulation
Many different treatments exist for acne including benzoyl peroxide, antibiotics, retinoids, antiseborrheic medications, salicylic acid, alpha hydroxy acid, azelaic acid, nicotinamide, and kera-tolytic soaps.[22]
Benzoyl peroxide
Benzoyl peroxide a first line treatment for mild and moderate acne vulgarus due to its effectiveness and mild side effects (primarily an irritant dermatitis).[23] It has been found to be nearly as effective as antibiotics with all concentrations 2.5%, 5.0%, and 10% equally effective.[23] Unlike antibiotics, benzoyl peroxide does not appear to generate bacterial resistance.[23]
Antibiotics are reserved for more severe cases.[23] With increasing resistance of P. acnes worldwide they are becoming less effective.[23] Commonly used antibiotics, either applied topically or taken orally, include erythromycin, clindamycin and tetracyclines such as minocycline.
Hormonal treatments
In females, acne can be improved with hormonal treatments. The common combined estrogen/progestogen methods of hormonal contraception have some effect, but the antiandrogen, cyproterone, in combination with an oestrogen (Diane 35) is particularly effective at reducing androgenic hormone levels. Diane-35 is not available in the USA, but a newer oral contraceptive containing the progestin drospirenone is now available with fewer side effects than Diane 35 / Dianette. Both can be used where blood tests show abnormally high levels of androgens, but are effective even when this is not the case. Along with this, treatment with low dose spironolactone can have anti-androgenetic properties, especially in patients with polycystic ovarian syndrome.
Intralesional steroid
If a pimple is large and/or does not seem to be affected by other treatments, a dermatologist may administer an injection of cortisone directly into it, which will usually reduce redness and inflammation almost immediately. This has the effect of flattening the pimple, thereby making it easier to cover up with makeup, and can also aid in the healing process. Side effects include hypopigmentation (lightening of the skin color), fat and dermal atrophy (depression of the skin at the point of injection), bacterial infection (from either introduced bacteria or intrinsic bacteria of the pore), and recurrence of the acne. While utilized by many dermatologists and family doctors, intralesional steroid should be discouraged as the sole method for the treatment of acne. Systemic and topical steroid are both known for inducing "steroid induced acne" or "steroid rosaceae"; therefore, long term consequences of such treatment should not be ignored. Rarely, intralesional steroid can induce permanent fat atrophy, and litigation has been filed and on record. Injected steroid can cause local immunosuppression, and can encourage the formation of local abcesses. If utilized, the dose of the steroid should be minimal, and other methods of treatment should be concurrently utilized. Steroid injection alone does not address the cause of acne, the occlusion of the pore, overgrowth of microorganisms, or the over-production of sebum.
Topical retinoids
A group of medications for normalizing the follicle cell life cycle are topical retinoids such as tretinoin (Retin-A), adapalene (Differin), and tazarotene (Tazorac). Like isotretinoin, they are related to vitamin A, but they are administered as topicals and generally have much milder side effects. They can, however, cause significant irritation of the skin. The retinoids appear to influence the cell creation and death life cycle of cells in the follicle lining. This helps prevent the hyperkeratinization of these cells that can create a blockage. Retinol, a form of vitamin A, has similar, but milder, effects and is used in many over-the-counter moisturizers and other topical products. Effective topical retinoids have been in use over 30 years, but are available only on prescription, so are not as widely used as the other topical treatments. Topical retinoids often cause an initial flare up of acne and facial flushing.
Oral retinoids
A daily oral intake of vitamin A derivative isotretinoin (marketed as Roaccutane, Accutane, Amnesteem, Sotret, Claravis, Clarus) over a period of 4–6 months can cause long-term resolution or reduction of acne. It is believed that isotretinoin works primarily by reducing the secretion of oils from the glands, however some studies suggest that it affects other acne-related factors as well. Isotretinoin has been shown to be very effective in treating severe acne and can either improve or clear well over 80% of patients. The drug has a much longer effect than anti-bacterial treatments and will often cure acne for good. The treatment requires close medical supervision by a dermatologist because the drug has many known side effects (many of which can be severe). About 25% of patients may relapse after one treatment. In those cases, a second treatment for another 4–6 months may be indicated to obtain desired results. It is often recommended that one lets a few months pass between the two treatments, because the condition can actually improve somewhat in the time after stopping the treatment and waiting a few months also gives the body a chance to recover. Occasionally a third or even a fourth course is used, but the benefits are often less substantial. The most common side effects are dry skin and occasional nosebleeds (secondary to dry nasal mucosa). Oral retinoids also often cause an initial flare up of acne within a month or so, which can be severe. There are reports that the drug has damaged the liver of patients. For this reason, it is recommended that patients have blood samples taken and examined before and during treatment. In some cases, treatment is terminated or reduced due to elevated liver enzymes in the blood, which might be related to liver damage. Others claim that the reports of permanent damage to the liver are unsubstantiated, and routine testing is considered unnecessary by some dermatologists. Blood triglycerides also need to be monitored. However, routine testing are part of the official guidelines for the use of the drug in many countries. Some press reports suggest that isotretinoin may cause depression but as of September 2005 there is no agreement in the medical literature as to the risk. The drug also causes birth defects if women become pregnant while taking it or take it while pregnant. For this reason, female patients are required to use two separate forms of birth control or vow abstinence while on the drug. Because of this, the drug is supposed to be given to females as a last resort after milder treatments have proven insufficient. Restrictive rules (see iPledge program) for use were put into force in the USA beginning in March 2006 to prevent misuse, causing occasioned widespread editorial comment.[24]
Nicotinamide, (vitamin B3) used topically in the form of a gel, has been shown in a 1995 study to be of comparable efficacy to topical clindamycin used for comparison.[25] Topical nicotinamide is available both on prescription and over-the-counter. The property of topical nicotinamide's benefit in treating acne seems to be its anti-inflammatory nature. It is also purported to result in increased synthesis of collagen, keratin, involucrin and flaggrin, and may also, according to a cosmetic company, be useful for reducing skin hyperpigmentation (acne scars), increasing skin moisture and reducing fine wrinkles.[26]
Rofecoxib was shown to improve premenstrual acne vulgaris in a placebo-controlled study, although this drug has since been withdrawn.[27]
Naproxen or ibuprofen[28] are used for some moderate acne cases for their anti-inflammatory effects.
Calendula in suspension is used as an anti-inflammatory agent.[29]
Sulfur is probably the oldest acne remedy known to medicine and its origins as an anti-acne treatment date to ancient Greek, Roman, and Chinese texts citing its efficacy in balneotherapy. Sulfur formulations are effective both as a micro-exfoliant and as a mild antiseptic. Sulfur is hydrophilic and can easily penetrate sebaceous pores where its antiseptic properties can assist local immune response in rapidly eliminating infection resulting from acne proliferation. Because the growth of acne bacteria is limited naturally by the skin's slightly acidic pH, alkaline cleansers (including soaps and detergents) can have a detrimental effect on controlling acne proliferation. Sulfur-based cleansers with a balancing or neutral pH can help eliminate acne and prevent future breakouts by maintaining the hydrolipidic layer's acidity and thereby controlling acne populations on the surface of the skin. Sulfur is abundant in keratin and its use is also helpful in promoting collagen synthesis. An active ingredient in prescription and over-the-counter lotions, creams, gels, washes, and shampoos, sulfur is also very effective in controlling seborrheic dermatitis, rosacea, eczema, psoriasis, pityriasis versicolor, scabies, and lice.[30][31]
[edit] Dermabrasion
Dermabrasion is a cosmetic medical procedure in which the surface of the skin is removed by abrasion (sanding). It is used to remove sun-damaged skin and to remove or lessen scars and dark spots on the skin. The procedure is very painful and usually requires a general anaesthetic or "twilight anaesthesia", in which the patient is still partly conscious.[32] Afterward, the skin is very red and raw-looking, and it takes several months for the skin to regrow and heal. Dermabrasion is useful for scar removal when the scar is raised above the surrounding skin, but is less effective with sunken scars.
In the past, dermabrasion was done using a small, sterilized, electric sander. In the past decade, it has become more common to use a CO2 or Er:YAG laser. Laser dermabrasion is much easier to control, much easier to gauge, and is practically bloodless compared to classic dermabrasion.
Microdermabrasion comes from the above mentioned technique dermabrasion. Microdermabrasion is a more natural skin care that is a gentler, less invasive technology for doing an exfoliation on the skin. The goal of the microdermabrasion is to eliminate the superficial layer of the skin called the epidermis. If the surface of the abraded skin is touched, a roughness of the skin will be noticed. The roughness is keratinocytes, which are better hydrated than the surface corneocytes. Keratinocytes appear in the basal layer from the proliferation of keratinocyte stem cells. They are pushed up through the cells of the epidermis, experiencing gradual specialization until they reach the stratum corneum where they form a layer of dead, flattened, strongly keratinized cells called squamous cells. This layer creates an efficient barrier to the entry of foreign matter and infectious elements into the body and reduces moisture loss. Keratinocytes are shed and restored continuously from the stratum corneum.
The time of transit from basal layer to shedding is generally one month. Corneocytes are cells derived from keratinocytes in the late stages of terminal specialization of squamous epithelia. The microdermabrasion is done to eliminate some of the corneocytes. These cells are responsible for the impermeability of the skin. The minimizing or elimination of scars, skin lesions, blotchiness and stretch marks from the skin can be an easy process with the use of skin exfoliation. The result depends on how well the procedure known as "skin remodeling" works. Results are optimal and fewer treatments are needed with more recent and/or superficial scars. Still, microdermabrasion can be used on scars that showed up during puberty or many years later.
'Blue' and red light
Light exposure has long been used as a short term treatment for acne. Recently, visible light has been successfully employed to treat mild to moderate acne (phototherapy or deep penetrating light therapy) - in particular intense violet light (405-420 nm) generated by purpose-built fluorescent lighting, dichroic bulbs, LEDs or lasers. Used twice weekly, this has been shown to reduce the number of acne lesions by about 64%[33] and is even more effective when applied daily. The mechanism appears to be that a porphyrin (Coproporphyrin III) produced within P. acnes generates free radicals when irradiated by 420 nm and shorter wavelengths of light.[34] Particularly when applied over several days, these free radicals ultimately kill the bacteria.[35] Since porphyrins are not otherwise present in skin, and no UV light is employed, it appears to be safe, and has been licensed by the U.S. FDA.[36][37]
The treatment apparently works even better if used with a mixture of the violet light and red visible light (660 nanometer) resulting in a 76% reduction of lesions after three months of daily treatment for 80% of the patients;[38] and overall clearance was similar or better than benzoyl peroxide. Unlike most of the other treatments few if any negative side effects are typically experienced, and the development of bacterial resistance to the treatment seems very unlikely. After treatment, clearance can be longer lived than is typical with topical or oral antibiotic treatments; several months is not uncommon. The equipment or treatment, however, is relatively new and reasonably expensive to buy initially, although the total cost of ownership can be similar to many other treatment methods (such as the total cost of benzoyl peroxide, moisturizer, washes) over a couple of years of use.
Photodynamic therapy
In addition, basic science and clinical work by dermatologists Yoram Harth and Alan Shalita and others has produced evidence that intense blue/violet light (405-425 nanometer) can decrease the number of inflammatory acne lesion by 60-70% in four weeks of therapy, particularly when the P. acnes is pretreated with delta-aminolevulinic acid (ALA), which increases the production of porphyrins. However this photodynamic therapy is controversial and apparently not published in a peer reviewed journal. A phase II trial, while it showed improvement occurred, failed to show improved response compared to the blue/violet light alone.[39]
For patients with cystic acne, boils can be drained through surgical lancing.[6]
Laser treatment
Laser surgery has been in use for some time to reduce the scars left behind by acne, but research has been done on lasers for prevention of acne formation itself. The laser is used to produce one of the following effects:to burn away the follicle sac from which the hair grows to burn away the sebaceous gland which produces the oil to induce formation of oxygen in the bacteria, killing them
Since lasers and intense pulsed light sources cause thermal damage to the skin, there are concerns that laser or intense pulsed light treatments for acne will induce hyperpigmented macules (spots) or cause long-term dryness of the skin.
In the United States, the FDA has approved several companies, such as Candela Corp., to use a cosmetic laser for the treatment of acne. However, efficacy studies have used very small sample sizes (fewer than 100 subjects) for periods of six months or less, and have shown contradictory results.[40] Also, laser treatment being relatively new, protocols remain subject to experimentation and revision,[41] and treatment can be quite expensive. Also, some Smoothbeam laser devices had to be recalled due to coolant failure, which resulted in painful burn injuries to patients.[42]
Other Aloe vera: there are treatments for acne mentioned in Ayurveda using herbs such as Aloe vera, Neem, Haldi (Turmeric) and Papaya. There is limited evidence from medical studies on these products.[43] Products from Rubia cordifolia, Curcuma longa (commonly known as Turmeric), Hemidesmus indicus (known as ananthamoola or anantmula), and Azadirachta indica (Neem) have been shown to have anti-inflammatory effects, but not aloe vera.[44] Azelaic acid (brand names Azelex, Finevin and Skinoren) is suitable for mild, comedonal acne.[45] Heat: local heating may be used to kill the bacteria in a developing pimple and so speed healing.[46] Pantothenic acid, (high dosage vitamin B5)[47] Tea tree oil (melaleuca oil) dissolved in a carrier (5% strength) has been used with some success, where it is comparable to benzoyl peroxide but without excessive drying, kills P. acnes, and has been shown to be an effective anti-inflammatory in skin infections.[43][48][49] The reason it is a good substitution for benzoyl peroxide is because it also has the ability to kill bacteria on the surface of the skin but mostly due to fact that some people are allergic to benzoyl peroxide or have sensitive skin. Tea tree oil is a gentler and more natural solution.[50] Zinc: Orally administered zinc gluconate has been shown to be effective in the treatment of inflammatory acne, although less so than tetracyclines.[51][52]
Acne usually improves around the age of 20 but may persist into adulthood.[22]
Acne affects 40 - 50 million people in the United States, and approximately 3 - 5 million in Australia.[53]

"Wearing high heels is especially stressful on the joints of the foot because all of the body's weight rests there; the foot is then forced into a narrow, pointed toe box, compounding the problem."- source:
"The wearing of high-heeled shoes is a prime example of women inviting foot problems. Doctors of podiatric medicine see no value in high heels (generally defined as pumps with heels of more than two inches). They believe them to be biomechanically and orthopedically unsound, citing medical, postural, and safety faults of such heels.
They know, for example, that high heels may contribute to knee and back problems, disabling injuries in falls, shortened calf muscles, and an awkward, unnatural gait. In time, high heels may cause enough changes in the feet to impair their proper function. Most women admit high heels make their feet hurt, but they tolerate the discomfort in order to look taller, stylish, and more professional. In a Gallup Poll, 37 percent of the women surveyed said they would continue to wear high heels, even though they did not think them comfortable."- source:
Osteoarthritis is the most common form of arthritis, and it's twice as common in women. "The use of heels is a likely reason," Kerrigan speculates.
"Just wear flats," Harvard researcher D. Casey Kerrigan, MD, an associate professor of physical medicine and rehabilitation, tells WebMD. "I am strongly against wearing heels at all," says Kerrigan, who never wears them." Throw them out," she says, adding that women shouldn't be victims of fashion. - source:
Learn more about Reflexology and your feet: Information - Websites and Articles
"Podiatrists say high heels are "biomechanically and orthopedically unsound," citing medical, postural and safety faults of such heels, according to the American Podiatric Medical Association. Among the litany of problems to which stilettos and their sister heels contribute are knee and back problems, disabling injuries in falls and shortened calf muscles, not to mention an awkward, unnatural gait.
Heels force the thigh muscles to work harder, putting extra strain on the knee joint and tendon that runs from the knee cap to the thigh bone. Compared with walking barefoot, high heels increase the pressure on the inside of the knee by 26 percent. Over time, this increased pressure on the knee can lead to osteoarthritis." - source:
"According to the American Orthopaedic Foot and Ankle Society, people take an average of 10,000 steps a day. High heels shift the force of each of those steps so that the most pressure ends up on the ball of the foot and on the bones at the base of the toes. (If you wear flats, the entire foot would absorb this impact.) A 3-inch heel -- most experts consider a heel "high" at 2 inches or more -- creates three to six times more stress on the front of the foot than a shoe with a modest one-inch heel.
As a result, heels can lead to bunions, heel pain, toe deformities, shortened Achilles tendons, and trapped nerves. In fact, women account for about 90% of the nearly 800,000 operations each year for bunions, hammertoes (a permanent deformity of the toe joint in which the toe bends up slightly and then curls downward, resting on its tip), and trapped nerves, and most of these surgeries can be linked back to their high-heeled shoe choice.
The problems can travel upward, too. The ankle, knee, and hip joints can all suffer from your footwear preferences. When you walk in flats, the muscles of the leg and thigh have an opportunity to contract as well as to stretch out. However, when wearing your high-heeled shoes, the foot is held in a downward position as you walk. This keeps the knee, hip, and low back in a somewhat flexed position, which prevents the muscles that cross the backside of these joints to stretch out as they normally would. Over time, this can lead to stiffness, pain, and injury. High heels can also cause lower back strain, because the heel causes your body to pitch forward more than normal, putting excess pressure on the back."- source:
Only a tiny percentage of people are born with foot problems. Most conditions arise from neglect or simply not knowing how to care for your feet. Women are particularly vulnerable. They have about four times as many foot problems as men do, most of which come from wearing ill-fitting shoes.
Metatarsalgia This is pain in the ball of your foot, often caused by wearing high heels. The higher the heel, the greater the pressure on the ball of your foot. A three-inch heel, for example, exerts about 76 percent more pressure than a flat shoe. You can try a metatarsal pad to help relieve the pain, but it's also a good idea to change shoe styles to low or flatter heels.- source: