Our skin has pores that are connected to sebaceous glands located under the skin. These glands secrete sebum which is extracted from the body through the pores that surround the hair follicles. As sebum and dead skin clog the hair follicle, a comedo forms within the pore. There are two types of comedones: a closed comedone (whitehead) that stays below the skin’s surface or an open comedon (blackhead) which opens as it reaches the surface. Other acne-type lesions can be present on the skin. One example are papules which are the small pink bumps that are sometimes tender to the touch. When a papule becomes inflamed with a reddened base and a white or yellow pus-filled center, it is considered a pustule. A nodule is a solid, hardened lesion that develops deep below the skin’s surface. It is one of the most painful lesions caused by acne and can lead to tissue destruction. Larger, pus-filled lesions, known as cysts, can also form on the skin; they are very painful and can lead to scarring and deformity.
A 15 year old male is scheduled for a consultation. His mother made an appointment for him because she is concerned about an acne outbreak he is experiencing. During his consultation, you immediately notice that his face is clear of any acne lesions. After trying to initiate communication with the young man, his mother steps in and explains that she became concerned when she saw him wince as he put on his backpack.
As she continues to explain the situation, you notice that the client is very agitated and will not make eye contact. He is blushing and continuously rubbing the back of his neck. To draw the client into the conversation, you ask about his daily routine and if he currently plays any sports. As he talks, you find out that he does not currently take any medication; he showers every morning and evening, but not immediately after practice at school; and he has a healthy appetite which includes junk food and soft drinks. Once you have a chance to look at his back, you notice that it is inflamed and starting to carry over onto his shoulders and chest. There is evidence of papules, pustules, a few cysts, and some lesions that are very sensitive to the touch which could be nodules.
As a skin care professional, what solution do you propose to treat this case study?
Danné Montague-King, president of DMK and DMK COSMETICS international
“The young man has inflamed folliculitis – common to teenage boys of certain nationalities, but can also be seen on people of all races. Normally, however, it affects Caucasian men and women with strong German or Irish backgrounds. The skin on the face, often being finely grained, even porcelain, may experience a few breakouts while the back has copious lesions and papules surrounding the hair follicles. The testosterone levels are responsible for this, and his cortisol levels spiking at night. In addition, excessive sudoriferous secretions (sweating) exacerbates the condition. Normally the teenager tries to hide this condition from everyone, so the area does not get the attention it needs.... I frankly tell the teenager about my own experience with acne – including my back, et cetera, and how I felt – and then follow up by saying, ‘Okay, let’s take a look.’ Once I start examining the area, with visuals and touch, the client relaxes and does not feel so intimidated. At that point, it is easy to initiate treatment. When your client feels and sees a positive change in his skin, his hypothalamus gland slows down the excessive stress signals to the entire hormonal system, thus initiating an internal remission as well as a topical remission.
Following my diagnosis, I would recommend non-abrasive exfoliation to remove the back cuticle build up. A very alkaline cleansing paste is best for this – even a cleanse made of bicarb of soda. Low level acids (such as salicylic acid), any good desincrustation gel or lotion, and/or galvanic current can be used following the cleanse. The purpose is to decongest the impacted hair follicles and increase plasmatic activity at the same time (dilation of the capillaries) to increase oxygen flow through the tissues. A P. acnes killing spray is also advised and there are a few non-benzyl peroxide products out now that kill off P. acnes bacteria quickly. An enzyme-based mask left on for 45 minutes would complete the treatment – along with a final spritz of antibacterial spray and a non-oily lotion that contains zinc and Langerhans cell-stimulating beta-glucans that are the immune defense of the skin. The client can use a mild, exfoliating at-home shower gel along with a bacterial spray and lotion. Getting the client to allow a parent to help them apply these at-home products may be difficult at first but it will become easier as the client beings to see positive results.”
Dr. Charlene DeHaven, clinical director of Innovative Skincare
“This case illustrates the importance of understanding and taking in all of the client’s history prior to giving recommendations. Before treatment specifics can be discussed, time should be given to further understand the client’s condition. His agitation and reluctance to make eye contact are concerning. First of all, rapport with the client should be developed.... He might be willing to reveal more details about his skin problem that would be helpful and guide recommendations.
Furthermore, the presence of lesions on his back and not his face raises a red flag. Certainly, acne can be present solely on the back, but the complete absence of facial lesions raises the possibility that this is more than or different from usual acne. Certainly acne is a probable cause of this client’s rash but there are other possibilities to consider in a young athlete. Acne mechanica is a type of acne that can be epidemic among teenage athletes. In addition to the usual teenage hormonal influences, skin occlusion under protective gear encourages lesion development. Showers immediately after events and practices are helpful as well as wearing moisture-wicking clothing under pads and protective gear. Furunculosis also relates to sweating under protective gear and lessening sweat contact with skin with immediate cleansing/showering as well as use of wicking clothing under gear can be helpful. The resultant blockage of the hair follicle causes the follicle to enlarge and become infected, resulting in folliculitis. Local measures including careful skin cleansing and removal of sweaty clothing as soon as possible are advisable. Impetigo is a skin infection that can mimic acne caused by bacteria (Strep and Staph species) present on the skin. Impetigo develops when these surface organisms penetrate the normal skin barrier. This can occur with excessive sweating, abrasive clothing, or skin abrasion from contact sports. Treatment of impetigo is different from acne and requires topical and/or oral antibiotics. Herpes gladiatorum can spread throughout an entire athletic team by skin contact. This skin infection caused by the cold sore virus Herpes Type I also requires treatment different from acne with antiviral medication. The rash of Herpes gladiatorum is vesicular (composed of small blisters in different stages of development) and is not the typical initial comedone or resulting pustule of acne vulgaris. Tinea corporis gladiatorum is a fungal skin infection, the development of which is encouraged under wet occlusive clothing. However, its appearance would probably not be mistaken for acne.
After all possibilities have been explored by talking with the client, and if acne is the most likely cause of this rash, recommendations appropriate for treating acne should be made. Since this client participates in athletics and may wear protective occlusive clothing predisposing to acne, careful skin hygiene is also very important. Many previous dietary recommendations used for acne have not been proven with scientific research. However, a diet high in carbohydrates (sugars) and carbonated drinks has been shown to worsen acne. This client’s diet of junk food and soft drinks could likely contribute to acne development.”
Heather Owens, L.M.E. and owner of Self Nurture, LLC
“Addressing acne problems in teenage boys poses a greater challenge than simply treating the skin condition. Most teenaged boys are very self-conscious about their changing bodies. The presence of severe acne and going to a spa for treatments only adds to their embarrassment. The aesthetician must be cognizant of this and proceed accordingly. The first step would be to address the client’s diet and lifestyle. Be realistic. Most teenaged boys will not give up soda or junk food; however, urging him to shower after sports practice and increase his water intake are attainable suggestions. For treatment, a gentle, non-invasive approach is best. Blue LED has shown to be very effective for acne. A series of at least eight treatments, twice a week, and an application of a vitamin A serum will produce excellent results. Only after the inflammation has subsided should extraction be considered. At-home use of salicylic cleanser and a gentle back brush will help exfoliate and prevent further exacerbation of the condition.”
Gül Ç. Zone, president of ECOZONE, INC. and DERMAWARE Bio-Targeted Skin Care
“There are several considerations for this 15 year old male.... On a clinical level, we would recommend starting him on an acne control home care regimen, not only on the affected areas but on the face as well. This can be combined with an acne control professional treatment schedule. The professional treatments would consist of a series of six weekly treatments alternating between an acne control peel and an anti-inflammatory back facial. In consideration of his lifestyle, we would make sure to discuss cleansing directly after exercise at school and improving his daily nutrition. We would limit his starting home care regimen to three products at first since he is young and we want be sure that he complies with his treatment schedule. Once we have established a system we would bump up our home care recommendations to allow for more aggressive daily skin care maintenance.”
Sharon Boes, senior education manager of the North region for Murad, Inc.
“I would initially discuss that acne presents itself in many ways. Typically thought of as a facial concern, it is commonly found on the back and chest. Due to the sensitive nature of this topic, and the emotional toll it takes on those suffering from acne, I would make sure he felt that his was not a unique situation. My solution would be to treat his condition topically, internally and emotionally. I would recommend a healthy well-balanced diet, a proper day, evening and post-exercise skin care regimen, and suggest activities that may help to boost his self-confidence and insecurity. Back facials would improve his condition by minimizing painful discomfort and boosting his self-image while providing him much needed self-care. Overtime, proper skin care, healthy dietary habits and confidence-boosting activities would have a very positive impact on him and many aspects of his life.”