What are the implications of acne on back? (part1)

The invisible and inaccessible back

The back is that part of the body behind the chest or the posterior portion of the trunk region between the neck and the pelvis.
In the dictionary the back as a noun is also defined as the part opposite to or behind that adapted for view or use and the part or area farthest from the front. As an adjective the term back is used to describe the part distant from a center of activity; remote. In technical terms, it may also be a synonym to the unseen or the less important part of a structure or an object.
All these meanings have their relevance when acne on back is to be considered.
The most important of these descriptive terms that concerns our subject are the unseen and the remote back.
As the back is the part opposite to that adapted for view or use, it is practically invisible and inaccessible.
When we recall the definition of a symptom i.e. the visual perception of a change in the perceived appearance of a normal structure; we immediately grasp the idea. The back is beyond the limits of the normal human visual field and therefore, any changes in its appearance as caused by disease are not recognizable. That also means, whenever an abnormality develops in the back, it is not detected and is not complained of as a symptom.
That particularly applies to changes in appearance of the skin surface of the back and to add most of the abnormalities resulting from acne i.e. comedones which are only visually detected. Accordingly acne on back projects into consciousness mainly, when pain and or itching is associated with the comedones.
The consequences of this simple fact are:
Late discovery of the lesions of acne on back (usually when severe or complicated) and therefore its treatment.
Inability of the sufferer to precisely recognize the progress of lesions or follow them up during the course of disease or its treatment.
This also applies to other lesions which are either neglected or misinterpreted as an acne lesion.
The remote back or the area farthest from the front is partially beyond the the range of movements of the upper limb and the reach of the fingers. Our hands are anatomically configured to perform visually monitored manipulations that are therefore in front of the body. Such a functional organization has its own significance. Failure to touch lesions of acne on back would hinder perception of changes in their density or their being raised above the skin surface as in nodules and cysts, again late discovery of abnormalities and complications.
The other disadvantage of the remote back is the difficulty or inability to apply topical medications specified for acne on back lesions. The sufferer is always in need for the help of a family member and that is a drawback in both treatment and compliance.
To mention, one good point for the inaccessible back is preventing the sufferer from picking or squeezing lesions of acne on back. That mechanical hindrance is a favorable factor in the course of disease as it diminishes the complications of such a bad habit practiced by most acne sufferers.

What are the implications of acne on back? (part2)

Biological characteristics of the back skin

The back skin, has certain biological characteristics that have many implications upon the causation, course, presentation and treatment of acne on back.
With the large surface area of the back having thousands of sebaceous glands with their pores producing an oily substance called sebum; there is a higher risk of blockage of these pores.
Such a predisposition, is augmented when coupled with the same quantitative factor of the anatomically associated increased sweat glands and the fact that increased perspiration is important in the causation of acne on back.
The skin of the back is thicker than anywhere else in the body; accordingly ducts of sebaceous glands need to penetrate it for a longer distance to reach the pores located at the skin surface.
This feature promotes relative stagnation and clogging of the sebum inside the ducts. It also favors the development of nodules and deeply seated cysts commonly encountered in acne on back.
The bacterial element (p.acnes), a normal inhabitant of the skin surface and known to contribute to the disease process is also enhanced; simply due to the large surface area, the humidity resulting from sweating and the difficulties associated with the personal hygienic approaches to the back.
Another factor is that blood supply of the back region is relatively diminished in comparison to the face, consequently acne lesions on the face heal better than those on the back.
It is well known that stress does not worsen acne on back, again this feature would be linked to the differences in blood supply of back in comparison to the face; as the chemical mediators of stress mainly corticosteroid hormones which aggravate acne reach their receptors in sebaceous glands via circulation and that means more steroids will be delivered to the face which has a much better blood supply. The back is also unseen and judgment by the back acne sufferer upon any response to stress is not practical.
This rule applies also to changes of back acne in relation to certain diets.
It has been suggested that hereditary contribution in the development of acne operates through the genetically determined size of pores in different individuals; some having relatively smaller pores would have the problem just as their parents did. Since the pores on the human back are larger than the face, such a hereditary role is not played in the causation of acne on back.
The large pores of sebaceous glands on the human back are also responsible for the more severe-looking appearance of some back acne lesions.
Since the back has much tougher skin than the face, topical treatment used for facial acne may not be sufficient, it can therefore tolerate stronger solutions of up to10 percent benzoyl peroxide.
At times it is more resistant to treatment and some dermatologists may recommend using benzoyl peroxide 2.5% in conjunction with another form of back acne treatment, such as glycolic acid or salicylic acid.

What are the implications of acne on back? (part3)

The covered back

There are two general issues related to the consequences of back coverage. The first, though less important is that it hinders moderate exposure to ultraviolet rays of sunlight which helps in drying of acne on back lesions.
The second and most important, is concerned with the sweaty covered back.
In contrast to the face, the back is not exposed as it is always covered up with clothes. This fact is coupled with the inherent abundance of sweat glands and their excessive sweating activity in the back region. Consequently, sweat is not cleared up and allowed to stay on the back for periods of time. There are many factors related to the sweaty back that are also considerable. These anatomical factors include: 1- The flat regular surface area of the back which favors Spreadability of sweat. 2- The presence of hair in the back region, which further increases the back's surface area and the entanglement of sweat favors the readily deposition of its salts.
In addition to these factors is the fact that the back has lots of oil glands which produce a large amount of oil on the back. As a result of that, sweat with its content of excreted salts is entrapped between clothes and skin surface especially in hairy backs where it can get deposited easily. The interaction between the increased amount of oil, being mixed with excessive sweat and allowed to stay on the back for periods of time, increases the chance that pores of hair follicles will become blocked producing acne.
The situation is further complicated by the humidity medium associated with sweating that favors invasion of pores with p.acnes bacteria.
Another factor related to the sweaty covered back is the practical inconvenience to wash the back many times a day especially when the acne on back sufferer is in outdoor site during day time.

Clothing factors
Everyone has to wear clothing and the clothes we wear could be important factors in the causation of acne on back. There are many mechanisms involved in the injurious effects of clothing acting upon the regular large surface area of the back with its abundant sweat and sebaceous glands. This interaction may further contribute to the initiation or worsening of acne on back.
The following mechanisms are significant:
Direct effects (primary) related to clothing, which are either organic skin damage or functional stimulation of sweat gland activity.
Indirect effects (secondary) related to the increased production of sweat and its entrapment between the clothing and skin. The causes of trapping sweat in between clothing and skin are either failure of the absorptive capacitance of the clothes or failure of its evaporation due to the barrier effect of clothing.
Consequences of these events (tertiary effects), including excessive oil production by the skin as a protective mechanism in response to the retained sweat and clogging of pores as a result of mixing sweat, sebum and debris. This eventually results in acne breakouts on the back.
The triggers of there effects are:
* Direct contact of clothing to the skin and lesions which may be associated with mechanical, thermal and electrostatic effects producing: 1. direct trauma, 2. increased sweat secretion and 3. eroding and oozing of lesions.
* Direct contact of the skin to retained harmful irritants such as sweat, skin debris and pus i.e. factors related to failure of absorption and evaporation of these irritants.

The sequence of events would be simplified as follows:
* Increased sweat secretion: local heat produced by clothing stimulates the increased production of sweat.
* Direct trauma: clothing rubs against the skin of the back and cause skin irritation and shedding of its superficial surface layers in the form of debris especially when the skin is rinsed in sweat for a long time.
* Eroding and oozing of existing acne lesions: mechanical irritation resulting from the rubbing of clothes against acne lesions may induce ulceration of these lesions and release of pus.
---------> accumulation of Sweat, Debris and Pus.
* Trapping of these harmful irritants due to to clothing related failure of absorption and evaporation of these substances: in between clothing and skin for a long time.
--------->
* Excessive oil (sebum) production by the skin: as a protective mechanism in response to prolonged contact with these retained irritants.
--------->
* Clogging of pores: as a result of the mixing of Sweat, Debris, Pus and Sebum.
--------->
* This eventually results in new acne breakouts on the back.
Specific clothing effects:
Tight clothing:
The wearing of tight clothing, especially on hot days, has increased mechanical damaging effect and heat retention with increased sweating. Clothes that fit close to the body can result in significant rubbing and leads to irritation or even excoriation of the skin. Tightness also favors mixing of the retained harmful substances and forcing them into the pores resulting in their clogging and the formation of new acne lesions.
Athletic gear, bra straps and tight fitting uniforms are known examples of tight clothing.
Rough clothing:
Rough clothing is more injurious and traumatic to the skin of the back. It can irritate existing acne and cause new breakouts.
Thick clothing:
By virtue of its weight: it has more mechanical effect producing direct damage and injuring lesions, it also increases sweat secretion.
By acting as a barrier: it prevents evaporation of sweat.
By virtue of its absorptive capacitance: it retains a lot of harmful irritants and if unchanged for a longer interval it becomes soaked with sweat, debris, pus and sebum and maintains them in contact with the skin.
Polyester clothing:
These fabrics may be associated with mechanical and electrostatic effects producing direct trauma and increased sweat secretion. They have no absorptive capacitance, and have an insulating barrier effect preventing evaporation of sweat, consequently trapping sweat and other irritants in between clothing and skin. These features are in contrast with cotton and other natural fibers which help to clear up perspiration away from the body.
The ideal solution is to wear undershirts that are made with "moisture-wicking" fabric, that keep the sweat away from the skin or to quickly change out the sweat-soaked shirt immediately after working out.

Benzoyl peroxide bleaches clothing
Many acne medications contain benzoyl peroxide, which is very effective for fighting acne. Using benzoyl peroxide may stain clothing, much like bleach.
Wearing white is advised immediately after applying Benzoyl peroxide for the treatment of acne. Another option is to use benzoyl peroxide 2.5% in conjunction with another form such as glycolic acid of salicylic acid.
A good practice is to allow the medication to fully absorb and dry before putting on any clothes. Another alternative is using other acne treatments that are formulated with salicylic acid, which does not stain clothes.

Some good , Some bad news
The back is hidden from the public eye due to clothing, consequently, back acne cause less worry.
In general, it's not quite so serious as getting facial acne because it's usually not as visible.
It's much easier to hide back pimples under the clothing we wear most of the time. Of course, the exceptions are the times one is in a bathing suit or being shirtless. Under these conditions acne on back can be as much of a cosmetic problem as the facial variety of acne.
For a female the decision that involves choosing between a dress with a low back or one that comes to the neckline, is obvious. Acne sufferers are usually terrified of having to wear a low-backed dress.
The fact that back acne limits wearing a special dress, changing in the locker room or spending the summer in your bathing suit has its own psychological consequences .
In severe cases of back acne, it might even make it difficult for the person to keep clothing on the body and this might make the person’s movement handicapped.
It is also noteworthy that overexposure to the sun dries out the skin activating the sebaceous glands to produce more sebum. Covering the back would thus be a favorable protection especially in hot climates.

What are the implications of acne on back? (part4)

The mechanically stressed back

There are many daily activities that would aggravate acne on back. These practices are considered irritative as they inflict local repetitive minor trauma to the back on a daily basis. Examples of these mechanical stresses include: sitting in a chair for a long time, such as when driving or while working. Also when carrying a heavy backpack, the straps of which would cause friction by rubbing the back region therefore contributing to the condition of back acne.
The back is also in constant contact with clothes and especially when tight, might irritate the skin, which can further aggravate the condition. Tight clothing badly interact with the mechanics of breathing in such a way that when the chest expands involuntarily against the tight non expanding especially synthetic clothes, it results in friction that irritates the back and initiates outbreaks of acne.
Some of these factors are inevitable because we all must sit down such as sitting while working or driving. However, such measures as changing posture and moving around to avoid prolonged sitting and driving for short distances and having some rest before resuming driving in long journeys would help. Another non preventable factor is the effect of contact with clothing as everyone has to wear clothing, this can be diminished by avoiding tight or heavy clothing or wearing a cotton T-shirt underneath. It's clear that all these factors comprise reasons for why acne on back is more difficult to treat than facial acne.
Other alternatives for carrying heavy packs include trying a hand held bag or a shoulder bag.
This type of acne on back caused by these friction mechanisms is sometimes called acne mechanica.