The Acne Practice

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The Basics:
Acne is a disease of the pilosebaceous unit or "pores". (i.e. the structure containing the hair follicle, the hair, and the oil glands.
Acne affects males and females at any age but occurs more frequently in the teenage years. The disease may present as a mild nuisance with occasional pimples and plugged pores or severe, with massive inflammation and scarring. The most severe forms of acne occur more frequently in males but the disease tends to persist more frequently in females. Acne usually occurs on the face, chest, arms, and back. It may be short lived or persistent for decades. The psychological effects of Acne range from mild to complete incapacitation.

Acne Lesions:
Non-Inflammatory Lesions:
Open Comedone- "blackhead" A small blocked pore with a dilated orifice. (some believe the black color comes from oxidation of tyrosine contained in the follicular orifice, to melanin)

Closed Comedone- "whitehead" A small blocked pore with a closed orifice.

Inflamed Lesions:
Papule - raised lesion less than 5mm

Pustule - raised lesion with a visible central core of purulent material (pus)

Nodules - raised lesion greater than 5mm

Cysts - A name given to acne Nodules that are highly inflamed and/or draining. (name given because of their resemblance to inflamed epidermal cysts)

Pathogenesis of Acne (the process of Acne formation):

1) Increased production of sebum in predisposed individuals is the starting point of acne. (Sebum is an oily substance released by the Sebaceous glands in the skin which helps to maintain hair and skin's moisture and elasticity at normal levels. The sebaceous glands are largest and most numerous on the face, back, chest, and upper outer arms)

2) As a result of the increase in sebum, a normal skin bacterium called Propionibacterium acnes proliferates and begins to alter the sebum's content and the lining of the follicle.

3) This alteration of the lining of the follicle makes the follicular canal more adherant and also causes the cells of the follicle to increase their production of Keratin. (Keratin is a structural protein that is found in hair, skin, and nails)

4) The mixture of excess keratin and newly changed sebum adhere to the walls of the altered canal and form a plug, known as a microcomedo.

5) All other acne lesions are a consequence of the initial plugging of the follicular canal. Highly inflammatory lesions like pustules, nodules, and cysts result from rupture of the follicular canal with release of it's contents into the deeper layers of skin and subsequently causing an intense foreign body reaction.

Causes of Acne:
Acne is an inherited disease.


Hormones have been shown to influence oil gland secretion. Other causative factors such as stress and diet have been suspected and debated over for decades but no clear consensus among the literature has been universally accepted. (see Dr. Neal's opinion on stress and diet)

Hormone secreting tumors or measurably overactive glands are less common causes of severe acne. These causes can be ruled out quickly by bloodwork and imaging studies.

Classification of Acne:
For decades, Acne has been classified based on many factors including size of lesions, number of lesions, scarring, drainage, hemorrhage, pain, psychosocial impact, and the failure of previous treatment. This classification has helped physicians decide how quickly they should begin oral antiobiotics, hormonal therapy, or oral isotretinoin.

Mild: Few to Several papules and pustules without Nodules.
Moderate: Several to many papules and pustules with few to several Nodules.
Severe: Numerous to extensive papules and pustules with many Nodules.

We're not going to dive further into the details of this historical classification system because in our new breakthrough practice, it will not be dictating our treatment. Acne can be equally as stubborn whether it presents as sand paper-like bumps or massive cysts.

Definition of Terms:
Pilosebaceous unit = "pore"
Follicular canal = part of "pore"
Sebaceous gland = "oil gland"
Microcomedo = "plugged pore"
Closed comedones / papules / pustules / nodules / cysts = "pimples"
Open comedone = "blackhead"
Closed comedone = "whitehead"

This information is a tribute to the knowledge gathered in the field of Acne over many generations of study. As a breakthrough practice, this knowledge will not be guiding our treatment, but rather give us a platform to introduce a new program that is safe, effective and proven through high resolution video.

Dr. Neal's Basics:
The first important change to this historical perspective is that we will be discussing acne as a chronic condition rather than a disease.

Although it's only a subtle difference of semantics, it will significantly help us with the psychological challenges of acne. Disregarding the strict definition of both disease and condition, we will be working with commonly held perceptions in our culture.