Acne vulgaris (commonly called acne) is a skin disease caused by changes in the pilosebaceous units
(skin structures consisting of a hair follicle and its associated sebaceous gland).
Severe acne is inflammatory,
but acne can also manifest in noninflammatory forms.[1] Acne lesions are
commonly referred to as pimples, spots, or zits.
Acne is most common during adolescence, affecting more than 85% of teenagers,
and frequently continues into adulthood. [2] For most people, acne diminishes over
time and tends to disappear—or at the very least decrease—after one reaches his
or her early twenties. There is, however, no way to predict how long it will
take to disappear entirely, and some individuals will continue to suffer well
into their thirties, forties and beyond.[3]
The term acne comes from a corruption of the Greek άκμή (acme in the sense of a skin
eruption) in the writings of Aëtius Amidenus. The most common form of
acne is known as "acne vulgaris", meaning "common acne". Many teenagers
get this type of acne.
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]
Aside from scarring, its main effects are psychological, such as reduced self-esteem[5]
and, according to at least one study, depression or
suicide.[6] 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.[5]
[edit]
Causes of acne
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 comedo (blackhead) or closed comedo (whitehead). In these
conditions the naturally occurring largely commensual bacteria Propionibacterium acnes can cause
inflammation, leading to
inflammatory lesions (papules, infected
pustules, or nodules) in the dermis
around the microcomedo or comedo, which results in redness and may result in scarring or hyperpigmentation.[7]
[edit]
Primary causes
Exactly why some people get acne and some do not is not fully known. It is
known to be partly hereditary. Several factors are known to be linked to
acne:
- Family/Genetic history. 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. [8] - Hormonal activity, such as menstrual cycles and puberty. During puberty, an increase in male sex
hormones called androgens cause the glands to get larger and make more sebum.
[9] - Stress, through increased output of hormones from the adrenal (stress) glands,
although modern tests have said otherwise and point to this not being a cause. - Hyperactive sebaceous glands, secondary to the three
hormone sources above. - Accumulation of dead skin cells.
- 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. [10] - Skin irritation or scratching of any sort will activate inflammation.
- Use of anabolic
steroids. - Any medication containing halogens (iodides, chlorides, bromides), lithium, barbiturates, or androgens.
- Exposure to certain chemical compounds. Chloracne is particularly linked to toxic exposure to
dioxins, namely Chlorinated dioxins.
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). In addition, acne-prone skin has been shown to be insulin resistant[citation
needed].
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 adults 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).
[edit]
Diet
[edit]
Milk
A recent study, based on a survey of 47,335 women, did find a positive
epidemiological association between acne and consumption of partially skimmed milk, instant breakfast drink, sherbet, cottage cheese, and cream cheese.[11] The researchers
hypothesize that the association may be caused by hormones (such as several sex
hormones and bovine IGF-I) present in cow milk. Though
there is evidence of an association between milk and acne, the exact cause is
unclear. Most dermatologists are awaiting confirmatory research linking diet and
acne but some support the idea that acne sufferers should experiment with their
diets, and refrain from consuming such fare if they find such food affects the
severity of their acne.[12]
[edit]
High carbohydrates/High GI
It has also been suggested that there is a link between diets high in refined
sugars and processed foods and acne. The hypothesis is that rapidly digested
carbohydrate foods, such as white bread and refined sugars, produces an overload
in metabolic glucose that is rapidly converted into the types of fat that can
build up in sebaceous glands. According to this hypothesis, the startling
absence of acne in non-westernized societies could be explained by the low glycemic index of these
cultures' diets. Others have cited possible genetic reasons for there being no
acne in these populations, but similar populations shifting to these diets do
develop acne.[citation needed]
Note also that the populations studied consumed no milk or other dairy
products.[13] Further research is
necessary to establish whether a reduced consumption of high-glycemic foods
(such as soft drinks, sweets, white bread) can significantly alleviate acne,
though consumption of high-glycemic foods should in any case be kept to a
minimum, for general health reasons.[14] Avoidance of 'junk
food' with its high fat and sugar content is also recommended.[15]
The University of Pennsylvania and the
US
Naval Academy conducted experiments that fed subjects chocolate or a bar
with similar amounts of macronutrients (fat, sugar etc.) and found that
consumption of chocolate, frequent or not, had no effect on the developing of
acne. [16]
A 2005 systematic
review found "surprisingly little evidence exists for the efficacy or lack
of efficacy of dietary factors, face-washing and sunlight exposure in the
management of acne."[17] A study in November 2006 in
Australia gave a 50% reduction in 12 weeks in mild-moderate facial acne by
introducing its subjects to a high protein, low GI diet. [18]
The American Medical Association says chocolate does not contribute to acne.
[19]
A recent study[20] shows that a diet high enough in sugars
triggers the liver to convert these sugars into lipid; as a side-effect this
stops production of Sex hormone binding globulin, a
chemical that reduces the level of testosterone in the blood. Since high
testosterone levels generally trigger acne, the researchers believe this can be
a cause.
[edit]
Vitamins A and E
Studies have shown that newly diagnosed acne patients tend to have lower
levels of vitamin A circulating
in their bloodstream than those that are acne free.[21] In addition
people with severe acne also tend to have lower blood levels of vitamin E.[22]
[edit]
Hygiene
Acne is not caused by dirt. This misconception probably comes from the fact
that blackheads look like dirt
stuck in the openings of pores. The black color is not dirt but simply oxidised
keratin. In fact, the blockages of keratin that cause acne occur deep within the narrow
follicle channel, where it is impossible to wash them away. These plugs are
formed by the failure of the cells lining the duct to separate and flow to the
surface in the sebum created there by the body. Built up oil of the skin can
block the passages of these pores, so standard washing of the face could wash
off old oil and help unblock the pores.
[edit]
Treatments
[edit]
Available treatments
There are many products available for the treatment of acne, many of which
are without any scientifically-proven effects. Generally speaking, successful
treatments show little improvement within the first two weeks, instead taking a
period of approximately three months to improve and start flattening out. Many
treatments that promise big improvements within two weeks are likely to be
largely disappointing. However, short bursts of cortisone can give very quick
results, and other treatments can rapidly improve some active spots, but usually
not all active spots.
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 P.
acnes - antinflammatory effects
- hormonal manipulation
A combination of treatments can greatly reduce the amount and severity of
acne in many cases. Those treatments that are most effective tend to have
greater potential for side effects and need a greater degree of monitoring, so a
step-wise approach is often taken. Many people consult with doctors when
deciding which treatments to use, especially when considering using any
treatments in combination. There are a number of treatments that have been
proven effective:
[edit]
Topical bactericidals
Widely available OTC bactericidal products containing benzoyl peroxide may
be used in mild to moderate acne. The gel or cream containing benzoyl peroxide
is rubbed, twice daily, into the pores over the affected region. Bar soaps or
washes may also be used and vary from 2 to 10% in strength. In addition to its
therapeutic effect as a keratolytic (a chemical that dissolves the keratin
plugging the pores) benzoyl peroxide also prevents new lesions by killing P.acnes. In one study, roughly 70%
of participants using a 10% benzoyl peroxide solution experienced a reduction in
acne lesions after 6 weeks.[23]Unlike antibiotics, benzoyl peroxide has the
advantage of being a strong oxidizer (essentially a mild bleach) and thus does
not appear to generate bacterial resistance. However, it routinely causes
dryness, local irritation and redness. A sensible regimen may include the daily
use of low-concentration (2.5%) benzoyl peroxide preparations, combined with
suitable non-comedogenic moisturisers to help avoid overdrying
the skin.
Care must be taken when using benzoyl peroxide, as it can very easily bleach
any fabric or hair it comes in contact with.
Other antibacterials that have been used include triclosan, or chlorhexidine gluconate but these are
often less effective, but also give less side-effects.
Prescription-strength benzoyl peroxide preparations do not necessarily differ
with regard to the maximum concentration of the active ingredient (10%), but the
drug is made available dissolved in a vehicle that more deeply penetrates the
pores of the skin.
[edit]
Topical antibiotics
Externally applied antibiotics such as erythromycin, clindamycin, Stiemycin, or tetracycline aim to kill the bacteria that are
harbored in the blocked follicles. While topical use of antibiotics is equally
as effective as oral use, this method avoids possible side effects including
upset stomach and drug interactions (e.g. it will not affect use of the oral
contraceptive pill), but may prove awkward to apply over larger areas than just
the face alone.
[edit]
Oral antibiotics
Oral antibiotics used to treat acne include erythromycin or one of the tetracycline antibiotics (tetracycline, the better
absorbed oxytetracycline, or one of the once daily doxycycline, minocycline, or lymecycline). Trimethoprim is also sometimes used (off-label use in UK).
However, reducing the P. acnes bacteria will not, in itself, do anything
to reduce the oil secretion and abnormal cell behaviour that is the initial
cause of the blocked follicles. Additionally the antibiotics are becoming less
and less useful as resistant P. acnes are becoming more common. Acne will
generally reappear quite soon after the end of treatment—days later in the case
of topical applications, and weeks
later in the case of oral antibiotics.
It has been found that sub-antimicrobial doses of antibiotics such as
minocycline also improve acne. It is believed that minocycline's
anti-inflammatory effect also prevents acne. These low doses do not kill
bacteria and hence cannot induce resistance.
[edit]
Hormonal treatments
In females, acne can be improved with hormonal treatments. The common combined oestrogen/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.
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 are minimal, but may include a temporary
whitening of the skin around the injection point; and occasionally a small
depression forms, which may persist, although often fills eventually. This
method also carries a much smaller risk of scarring than surgical removal.
[edit]
Biological Treatment
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A number of biological treatments available when suffering from this skin
condition contain mucin from the snail Helix aspersa
müller. This substance contains glycoconjugates (complex glycan or sugar
molecules bound to proteins, enzymes, co-enzymes, peptides, and oligoelements).
The enzymes unclog pores and get rid of debris and dead cells, the peptides act
as antimicrobials and the glycomolecules are skin repairing substances that
prevent and heal acne breakouts and acne skin lesions and scarring. The
secretion from the Helix aspersa müller regulates the skin healing and
how acne is formed.[citation needed]
These topical treatments focus on the creation of skin cells instead of
aggravating the body´s inflammatory immune system response. The ingredients can
saturate deep into the skin and promote cellular turnover.[citation needed] The
waste material is removed from the skin lesions so as to reduce inflammation,
speed up the healing process and encourage regeneration of new tissue.
Biological ingredients with active parts like antioxidants, anti-inflammatory,
proteins, peptides, and enzymes can with rather little effort stimulate the
speed in which the body heals the acne outbursts.[citation needed]
[edit]
Topical retinoids
A group of medications for normalizing the follicle cell lifecycle are topical retinoids such as tretinoin (brand name Retin-A), adapalene (brand name Differin), and tazarotene (brand name 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 lifecycle 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 Accutane, Amnesteem,
Sotret, Claravis) 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.[24] This has occasioned widespread
editorial comment.[25]
[It has long been known that short term improvement can be achieved with
sunlight. However, studies have shown that sunlight worsens acne long-term. More
recently, visible light has been successfully employed to treat acne (phototherapy)
- in particular intense violet light (405-420nm) 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%;[26] 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 420nm and shorter wavelengths of light.[27] Particularly when
applied over several days, these free radicals ultimately kill the bacteria.[28] 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.[29] The treatment apparently works
even better if used with red visible light (660 nanometer) resulting in a 76%
reduction of lesions after 3 months of daily treatment for 80% of the
patients;[30] 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, moisturiser, 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 4 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.
[edit]
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.[31] 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.[32][33] Also, laser
treatment being relatively new, protocols remain subject to experimentation and
revision,[34] 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.[35]
[edit]
Less widely used treatments
- Aloe vera: there are
treatments for acne mentioned in Ayurveda using herbs such as Aloe vera,[36] Aruna, Haldi (Turmeric),and Papaya.[37] There is limited evidence from
conventional medical studies on these products.[38] 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.[39] - Azelaic acid (brand
names Azelex, Finevin, Skinoren) is suitable for mild,
comedonal acne. - Heat: local heating may be used to kill
the bacteria in a developing pimple and so speed healing. [40] - Naproxen or ibuprofen are used for some moderate acne for their
anti-inflammatory effect.[41] - Nicotinamide, (Vitamin
B3) used topically in the form of a gel, has been shown in a 1995 study to be
more effective than a topical antibiotic used for comparison, as well as having
fewer side effects.[42] 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.[citation needed] - Tea Tree Oil (Melaleuca Oil)
has been used with some success, comparable to benzoyl peroxide but without
excessive drying, and has been shown to be an effective anti-inflammatory in
skin infections. [43][44][45] - Rofecoxib was shown to improve
premenstrual acne vulgaris in a placebo
controlled study.[46] - Zinc: Orally administered zinc gluconate has been shown to be effective in the
treatment of inflammatory acne, although less so than tetracyclines.[47][48] - Honey: Honey is one of the strongest
naturally occurring antibiotics. When placed on the skin like a mask for 20
minutes and washed off with hot water, the results over the next day should be
pleasing. [citation needed]
[edit]
History of some acne treatments
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The history of acne reaches back to the dawn of recorded history. In Ancient
Egypt, it is recorded that several pharaohs were acne sufferers[citation needed].
From Ancient Greece comes the English word 'acne' (meaning 'point' or 'peak').
Acne treatments are also of considerable antiquity:
- Ancient Rome[citation needed]:
bathing in hot, and often sulfurous, mineral water was one of the few available
acne treatments. One of the earliest texts to mention skin problems is De
Medicina by the Roman writer Celsus. - 1800s: Nineteenth century dermatologists used sulphur in the treatment of
acne. It was believed to dry the skin. - 1920s: Benzoyl Peroxide is used
- 1930s: Laxatives were used as a
cure for what were known as 'chastity pimples'. Radiation also was used. - 1950s: When antibiotics became available, it was discovered that they had
beneficial effects on acne. They were taken orally to begin with. Much of the
benefit was not from killing bacteria but from the anti-inflammatory effects of
tetracycline and its relatives. Topical antibiotics became available later. - 1970s: Tretinoin (original
Trade Name Retin A) was found effective for acne.[49] This preceded the development of
oral isotretinoin (sold as
Accutane and
Roaccutane) in 1980.[50] - 1980s: Accutane is introduced in America, and later found to be a teratogen, highly
likely to cause birth defects if taken during pregnancy. In the United States
more than 2,000 women became pregnant while taking the drug between 1982 and
2003, with most pregnancies ending in abortion or miscarriage. About 160 babies with birth defects
were born.[51] [52] - 1990s: Laser treatment introduced
- 2000s: Blue/red light therapy
[edit]
Future treatments
A 2007 microbiology
article reporting the first genome sequencing of a Propionibacterium acnes bacteriophage (PA6) said this
"should greatly enhance the development of a potential bacteriophage therapy to treat acne and therefore
overcome the significant problems associated with long-term antibiotic therapy
and bacterial resistance."[53]
[edit]
Preferred treatments by types of acne
vulgaris
- Comedonal
(non-inflammatory) acne: local treatment with azelaic acid, salicylic acid, topical retinoids, benzoyl peroxide. - Mild papulo-pustular (inflammatory) acne: benzoyl peroxide or
topical retinoids, topical antibiotics (such as erythromycin). - Moderate inflammatory acne: benzoyl peroxide or topical retinoids combined
with oral antibiotics (tetracyclines). Isotretinoin is an option. - Severe inflammatory acne, nodular acne, acne resistant to the above
treatments: isotretinoin
also known as Acutane, can be prescribed by a doctor, or contraceptive pills
with cyproterone for females
with virilization or drospirenone.
[edit]
Acne scars
- See Acne
scarring.
Acne often leaves small scars where the
skin gets a "volcanic" shape. Acne scars are difficult and expensive to treat,
and it is unusual for the scars to be successfully removed completely.[citation needed]
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. Most recently fractional lasers such as the Fraxel
laser are becoming widely used as an effective treatment method[54].
Although quite rare, the medical condition Atrophia Maculosa
Varioliformis Cutis 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.
[edit]
Pigmentation
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, and may even bruise the affected area.
Pigmentation scars nearly always fade with time taking between 3 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.
