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30 ASCP Skin Deep Winter 2022 COMEDONAL ACNE The epithelial cells lining the sebaceous duct naturally proliferate, which causes sebum production to increase. Comedones form when there is a blockage and the sebum cannot follow the natural processes and becomes trapped. Comedonal acne is a noninflammatory condition and can present itself in two different ways: open or closed. Open comedones are commonly referred to as blackheads because oxidized surface pigment turns the substance in the follicle black. Blackheads result when the pore is only partially blocked, allowing some of the trapped sebum, bacteria, and dead skin cells to slowly drain to the surface. Also, the open comedone tends to be a stable structure that can take time to clear. On the other hand, closed comedones are referred to as whiteheads because this type of impaction is not exposed to oxygen and will not darken in color. Closed comedones form when there is a cap of skin over the follicle trapping the buildup of dead cells and sebum under a layer of skin. The main culprits to be aware of when discussing causes of comedonal acne are inadequate desquamation and lack of free water in the skin. PAPULAR ACNE Papular acne falls within the category of inflammatory acne. Inflammation is a defense mechanism in the body that helps localize injury, infection, and pain. However, inflammation in the skin can contribute to and result from different types of acne. Papular acne causes lesions (papules) that can be a result of inflammation in the pore's walls where P. acnes converts triglycerides into free fatty acids in the follicle. Free fatty acids and sebum contribute to inflammation when they penetrate a ruptured duct. Comedones can even turn into a papule following the rupturing of the wall of a closed comedone. Papules do not contain sebum or pus, and the areas affected tend to be hardened, raised, and pink due to inflammation. In addition, papules are not extractable. A strategy for targeting inflammatory acne is through the flourishment of healthy bacteria, like Cutibacterium acnes (C. acnes). 2 C. acnes has various strains that can be categorized as acneic and nonacneic. Rather than targeting both strains, advanced technology can be used to destabilize the acne- causing strains in favor of nonacneic strains for recovering homeostasis in the skin. This innovative mode of action helps return the skin to a noninflamed and healthy, blemish-free condition. PUSTULAR ACNE Pustular acne is also categorized as an inflammatory acne type. The telltale sign that pustular acne is present is an epidermal lesion containing pus, which is a material composed of inflammatory cells. Remember, closed comedones result from excess secretion of oil by the sebaceous gland that blocks the skin's pore. Over time, this can lead to infections and swelling. When an infection is present in the skin, neutrophils play an imperative role as the first line of defense for the immune system. Neutrophils are a type of leukocyte, which is part of the body's immune system. In response to the inflammatory process, neutrophils release protein-dissolving enzymes in the pore that destroy some of the follicular wall, creating a rupture that can lead to scarring. Closed comedones with bacteria living in the follicle leads to white blood cells (neutrophils) coming into the pore, creating pus and pressure that creates a pustule. Pustular acne means inflammation and bacteria are present. HORMONAL ACNE The human body is made up of 11 major organ systems. One of these systems, the endocrine system, regulates hormones within the body to provide internal communication. The three main hormones that are major players in our skin are estrogen, progesterone, and testosterone. Throughout our lives, these hormones can shift and change to affect sebum production and can alter the look of pores, elasticity, and much more. Hormonal acne may be precipitated by androgens (testosterone), which are present in both men and women. The increase in androgen levels generates higher sebum production and inflammation, and establishes a breeding ground for P. acnes. Hormonal acne tends to display itself along the jawline, which is where cysts can form. Cysts reside deep in the skin and can be very tender to the touch. Hormonal acne can affect both men and women. Acne is not curable, and a one-size-fits-all approach will not work. SKIN PHYSIOLOGY