The Making of a Pimple

Acne is the most common skin disorder in the United States, affecting up to 50 million persons of all ages regardless of race or gender.  Acne is also a chronic skin disease that results from inflammation. This inflammation typically begins within the areas of the skin where the hair and oil glands combine (medically known as pilosebaceous units).

There are two kinds of acne-related lesions:

  1. Non- inflammatory lesions, such as blackheads and whiteheads (medically known as open and closed comedones)
  2. Inflammatory lesions, such as superficial pimples or deeper infected cysts.

Acne lesions commonly occur in  areas with the highest concentration of sebaceous or oil glands.  These include the face, neck, chest and back.

Even though we all have areas of hair and sweat glands, several other factors intersect to cause the formation of acne lesions.  One of the most powerful factors is hormonal changes, with the androgen hormone playing the most powerful role. This explains why teenagers, especially teenage boys, struggle with acne.  Other fluctuations in hormone levels, such as those experienced by women in the later stages of their reproductive life, can also cause acne flareups.

As much as we would all like acne pimples or zits to go away immediately,  the formation of a comedone (or pimple) is the result of a complex series of events that can be broken down into 5 steps:

  1. Initially, stimulated by hormonal changes, the sebaceous or oil glands increase their production.
  2. The thickening of skin cells within the pore and on the hair follicle itself, known as hyperkeratinization.
  3. These thickened cells combine with the increased sebum, or oil production, resulting in a partial blockage of the pore. At this point, skin begins to appear bumpy and irregular. The thickened cells within the pore show up as dark specks commonly known as blackheads.
  4. Through a process known as colonization, skin bacteria invades the hair follicle- oil gland unit.  From the point of view of skin bacteria, the thickened cell and sebum combination within the skin pores is a virtual buffet of protein.
  5. Finally, an inflammatory reaction occurs that is caused by the buildup of thickened skin cells, sebum and bacteria. This toxic soup under the skin attracts immune cells which try to fight off the perceived infection.  Unfortunately, the results of this microscopic fight include redness, swelling, pain, and eventually scarring.

The bacteria most commonly associated with these types of flare-ups is called Propionibacterium acne, or P. Acne for short.  P. acne is an anaerobe, meaning that it can survive and grow without air. The growth of this bacteria within a pore that is partly or completely blocked can cause simple pimples, but can also result in cystic acne when unchecked.

Treatment of acne involves disrupting one or more of the major factors that cause the formation of these lesions.  Goals for treatment certainly depend on the extent and  the severity of the acne itself.  Ultimately the prevention of scarring is the top priority in the inflammatory phase of treatment.

In a later post, I will outline many of the different types of treatment available at this time. In my experience, many people will respond to one treatment and not another.  Many others will also require combinations of treatment.

About Dr. John Burke

John Burke M.D. has practiced medicine for over 25 years, and is the founding partner of MidMaine Internal Medicine. He established Maine Laser Skin Care in 2004 after devoting years to learning the latest in laser and dermatologic technology. Dr. Burke has treated patients from all over the United States. He is one of Maine's busiest practitioners in laser treatments, and in the use of Botox for upper facial lines and excessive sweating.
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