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Understanding Acne

Contact Author Lydia Sarfati February 2009 issue of Skin Inc. magazine

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Nearly 85% of people will experience some form of acne during their lifetimes. According to the American Academy of Dermatology (AAD), acne is the most common skin disorder in the United States, affecting 40–50 million Americans at one time.1 When people think of acne, they think of teenagers, but acne can affect many people throughout adulthood, as well. Some estimate as many as half of all adult women experience some form of acne due to an increase in androgen and a decrease in estrogen during perimenopause.

Looking good and feeling good go hand in hand—this is why it can be so difficult for clients who suffer from acneic skin. Acne can have a devastating effect on self-esteem and confidence, and many acne sufferers withdraw socially and even experience depression. The good news is that most acne can be treated with outstanding results. Treating acne can be one of the most rewarding experiences for you as an esthetician

Acne is an inflammatory lesion of the sebaceous glands and the first signs usually show up during puberty when there is an increase in the hormone androgen, which is especially active in stimulating the amount of oil produced by the sebaceous glands in the skin. This results in the extra production of sebum that combines with dead skin cells and other debris and becomes trapped, creating a plug that blocks the hair follicle. As the ducts of these glands become plugged with the waxy oil, comedones (blackheads) and milia (whiteheads) form. They are frequently infected with bacteria, causing welts, deeper lumps and pimples.

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Sebaceous glands are the glands situated at the root of the hair follicle in the dermis. They can be found all over the body, except on the palms of the hands and the soles of the feet. These glands secrete sebum or oil. When the oil is mixed with perspiration, the skin’s surface becomes slightly acidic. This keeps some bacteria and fungi from embedding in the skin and, at the same time, helps to retain water in the tissue by slowing down evaporation from the skin. When the sebaceous glands are stimulated, a process known as retention hyperkeratosis occurs. This may be triggered by the onset of puberty, hormonal fluctuations, pharmaceutical agents, stress, heat and humidity.

In acne, the dead cells stick together, along with excess sebum and bacteria, to form an impaction plug. This first stage impacted follicle is often referred to as a microcomedone. As the bacteria digest the sebum, they produce fatty acid waste products that irritate the lining of the follicle, causing a proliferation of cells to accumulate in the impacted follicle. At this point, the disease may result in noninflammatory lesions, and simply produce closed comedones. When they eventually turn into open comedones and expel their contents, inflamed lesions may also result, whereby the follicle wall ruptures forming a papule. White blood cells invade the area and inflammation ensues. If the break is close to the surface of the skin, a pustule results—if it is deeper, a nodule forms. In some cases, a membrane entraps the infection and a cyst forms.

There are three factors that cause acne: sebum, bacteria and enclosure. When you encounter these factors together, it creates an environment for inflamed, irritated and congested skin.

Treatments for acne

Today, acne can be treated without the harshness and discomfort of traditional treatments that leave the skin red and irritated. First, to treat any form of acne, you have to deal with the three main factors—sebum, bacteria and enclosure. This can be done by using a three-tiered approach of professional esthetic treatments, a home care program and a healthy diet that includes nutritional supplements. Acne-prone skin can be addressed by controlling the excess sebum production and maintaining a proper moisture level.

Prevention often is not enough to avoid the mainfestation of acne, however, so when it does occur, there are several methods that can be used to remove acne lesions. Desincrustation is the process of softening the keratinaceous horny plug that allows extractions to proceed easily with minimal trauma to the surrounding tissue.

Manual extractions using vinyl gloves and wrapped index fingers are a very effective measure in removing comedones. If they don’t remove immediately when using slight pressure from side to side, use alternating angles to gently lift the comedone. Another gentle and effective way to remove a comedone is with sterile cotton swabs. If the contents are not expelling, simply go to another section and leave it for the next treatment. Remember that comedones did not occur in one day and, many times, it will take more than one treatment to clear up all of them.

Estheticians also can remove closed and open comedones and milia with the use of lancets. The use of lancets, however, is not approved in all states, so check with your local state board to confirm whether it is permissible. However, cysts and nodules must be treated by dermatologists. As an esthetician you can still administer acne treatments that will help cystic skin, but you won’t be able to remove those lesions. (Editor’s note: The contact information for each state board can be found at

High frequency is an excellent and versatile tool for the esthetician to use when dealing with acne. This electrical unit contains an electrode that uses UVC germicidal rays and has antibacterial properties. The machine also decreases inflammation, allows for faster healing time for lesions and helps prevent secondary infections. Although high frequency is a great tool, it should not be used on clients who are pregnant, who have high blood pressure or a heart condition, who have epilepsy or asthma, or those with braces, metal implants or heavy dental work. See How-to: Acne Skin Treatment for step-by-step instructions about how to offer this service in your spa.

Educating your clients

Knowledge is the key to treating acne. Educate your client about the importance of in-spa treatments, as well as following a home care program designed especially for them. Inform clients that picking and squeezing pustules will only make their acne worse because picking can spread acne-causing bacteria and squeezing can result in pushing infected material deeper into the skin, causing more inflammation and even scarring.

Another misconception is that acne can simply be washed away, but over-washing will further irritate the skin. Educate your clients about the myths of acne, such as acne is caused by chocolate. There is no evidence to support that claim. Maintaining a healthy lifestyle, home care program, nutritional supplements and professional acne treatments will lead to healthier, more radiant skin at any age.


1. (Accessed Nov 26, 2008)

Related Content



Types of Acne Lesions

Level 1

Microcomedone. A comedone that is formed below the epidermis and can’t be seen by the naked eye. It feels like a small, hard bump and, as it grows larger, it looks like a tiny white bump just below the surface of the skin.

Closed comedo (whitehead). A firm white papule.

Open comedo (comedones). A hard plug composed of sebum and dead skin cells. This is the mildest form of acne.

Levels 2–3

Papule. An inflamed lesion that is a small, solid and slightly raised area of the skin less than half of an inch in diameter. It can have a varied appearance, such as rounded, smooth or rough, skin-colored or red, pink or brown.

Milia. Also known as epidermal cysts, these are small, firm, white papules usually found in clusters on the upper cheeks and around the eyes.

Pustule. A small pus-containing skin blister often found at the opening of hair follicles, this inflammation is more visible than a papule.

Levels 4–5

Nodule. A large, painful, solid lesion that extends deep into the skin.

Cysts. In some cases, a membrane entraps the infection and a cyst forms. Cysts are inflamed pus-filled lesions.

The Sequence of an Acne Lesion

  • A keratinized plug blocks sebum from wicking out along the hair shaft.
  • Stagnant sebum is broken down by bacterial enzymes into a short-chained fatty acid.
  • Irritation in the form of a papule is formed.
  • Increased blood flow activates the immune system.
  • White blood cells are rushed in to deal with the foreign matter.
  • Pustules are formed.

How-to: Acne Skin Treatment

Treatment duration: 60 minutes

Treatment cost: $125

Equipment needed:

Magnifying lamp


2 spatulas

High frequency machine


Sharp box container

Supplies needed:

Consultation form

Nonirritation facial cleanser

Sulfur-based facial mask


Sterile cotton swabs

Needle or lancet, where permissable by state law


Antibacterial mask

Calming and soothing mask

Mattifying moisturizer

Step 1: After greeting the client and performing a gentle, nonirritating cleansing, begin a 10–15 minute pretreatment consultation. Find out how long the client has had an acne problem and what products she has been using to treat the condition. Ask whether isotretinoin has been used and if she is pregnant. Inquire about health issues and allergies. Also, perform a thorough skin analysis using a magnifying lamp. Check for pore size, type of acne lesions, irritation and sensitivity.

Step 2: Ask the client to lie face up on the treatment table and begin the process of desincrustation, which includes opening the pores using the steamer, followed by a gentle, nonstimulating facial massage. This softens the outermost layer of the skin.

Step 3: Apply a sulfur-based mask that preps the skin for extractions. Remove the mask after 10 minutes.

Step 4: Use a magnifying lamp to locate areas that need extractions. Wrap both index fingers with cotton and use sterile cotton swabs and fingertips to exert firm pressure on the skin surrounding the blackhead, and then lift the blackhead from the follicle gently. If removing milia, where permissible by law, use a sterilized needle or lancet, to pierce the skin from a horizontal direction. When finished, dispose of needle or lancet in a sharp box container. Repeat steps as needed.

Step 5: After the extractions, apply astringent to the client’s skin, paying close attention to the areas that received extractions.

Step 6: Apply an antibacterial mask using a spatula. Keep the mask on for seven minutes and remove using damp cotton.

Step 7: Apply a calming and soothing mask using a spatula for an anti-inflammatory effect. Keep that mask on for 10 minutes and remove using damp cotton.

Step 8: After removing second mask, apply a gentle mattifying moisturizer to the client’s face.

Step 9: To complete the treatment and prevent secondary lesions, use the high frequency machine, making sure the client has removed all metal jewelry, isn’t pregnant, doesn’t have heart problems, asthma and epilepsy, and doesn’t have metal implants, heavy metal dental work or braces.

Step 10: Place index finger on electrode and apply to the client’s face starting at the chin. Remove index finger when electrode makes contact with the skin.

Step 11: In circular movements, move the electrode over the client’s face, beginning at the chin, for 3–5 minutes, sparking the skin by lifting the electrode up and down directly over the acne lesion.

Step 12: To remove the electrode from the skin, place index finger on the electrode and then lift it off the skin. Turn machine off and clean the electrode with soap and water, then spray with alcohol, dry, and place in a sterilization solution for 20 minutes.

Step 13: After the service, discuss a home care program with your client in order to maintain the results that were achieved in the treatment. This program should include the use of a gentle antibacterial cleanser and astringent, a night serum that unclogs pores and controls skin desquamation, a daytime moisturizer that heals and has antibacterial properties, a gentle antibacterial mask to be used up to three times per week and a drying lotion to reduce pustules overnight.

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