Acne

Skin condition: Acne

What is it?

Acne is essentially a blockage of the oil glands. To understand acne you need to know a number of facts

1. We all have oil glands which are mainly located on the face, chest and back.
2. Oil glands normally empty into the end of hair follicles.
3. Skin cells can grow across the end of hair follicles and debris can accumulate leading to blockages
4. These blockages appear on the skin as black heads (open comedones) or small hard white lumps (closed comedones)
5. Our skin is covered in bacteria which under normal conditions keep us healthy. One of these bacteria is propionebacterium acnes .
6. When the structure of the skin is altered the levels of bacteria can increase.
7. The immune system in the skin detects changes in bacteria numbers. If the number of bacteria increase, an immune response is started that leads to red skin. When this occurs around a hair follicle a red spot is produced.

Acne occurs at puberty because the increase in male sex hormones such as testosterone which occurs in boys and girls. This leads to an increase in oil production and can also lead to the skin cells around follicles growing and blocking the follicles. Once the follicles are blocked, the oil builds up, the bacteria thrive with the increased oil and this triggers inflammation leading to acne. Not all blocked follicles become inflamed so acne often presents as a mixture of blocked non inflamed follicles (comedones) and inflamed follicles (papules or spots).

If inflammation occurs deeper down at the bottom of a hair follicle and lasts for some time the risk of scarring arises. Acne scarring results when an area of deep inflammation heals. As part of the healing process the tissue contracts pulling down the overlying skin. This produces a pitted acne scar or pock mark. Acne scars are difficult to treat and every effort must be made to prevent them from occurring.

Why have I got it?

Everyone gets acne at puberty, some very mildly and some severely. There are number of factors which determine how bad the acne is including the amount of oil production, the tendency for follicle blockage and the size of the immune response against the bacteria. Theses things are to some extent determined by genetic factors and up to 40% of patients with severe acne will report a family history.

Since everyone gets acne there has been a tendency with some doctors to  regard it as a normal process. This is reasonable in mild cases where the acne does not last beyond puberty and no scarring develops. In more severe cases and when longer lasting  acne needs proper treatment. Acne is well known to cause significant mental health problems including anxiety and depression. In any patients where acne is affecting normal socialising and mental health it needs to be sorted out promptly.

Acne is often divided into 2 groups; teenage and adult

Teenage acne

Everyone is affected by teenage acne. At puberty the rising testosterone triggers sebaceous (oil) gland growth. The oil needs to move onto the skin surface along ducts. In the pre-adolescent skin these ducts are covered by normal skin cells (keratinocytes). The growth of these keratinocytes gradually changes so that the oil ducts are not blocked. Acne occurs from when the oil production starts until the keratinocytes stop blocking the oil ducts. This process is very rapid in some individuals and very slow in others. Other factors that influence acne are the skin bacteria which multiply in the blocked oil ducts and the immune response to these bacteria. These 3 factors which are largely determined by genetic variations combine to determine the severity of teenage acne. External factors such as stress and diet are far less important.

Adult acne

Adult acne generally occurs in women. Some reports suggest that up to 40% of women can develop chronic acne, This is  thought to occur because of the fluctuations in hormone levels associated with the menstrual cycle. The relative increase  in male hormones at some stages in the cycle, when oestrogen levels are lower,  stimulates the skin cells around the oil glands  to grow, leading to blockages. Another possible explanation is that the hormonal fluctuations lead to an increase in sebum production triggering bacterial growth which then triggers inflammation which manifests as spots.

Many women find the combined oral contraceptive pill improves acne ; this is due to the fluctuations in hormone levels being less whilst on the combined pill.

Comparing the treatment options

The first issue is to decide how much it is bothering you. As mentioned above, everyone gets acne during puberty and mild acne without scarring during this time is probably nothing to worry about. If the acne gets more severe or if as an individual it is affecting your mental health then it needs to be sorted.

Self-treatment

Mild acne will be helped by face washes which will remove dead skin cells and help to reduce superficial blockages. Some over the counter face washes also have anti-inflammatory properties which will help to reduce redness.  You may need to try a few different ones until you find one that suits your skin.  General advice would be to wash the affected areas twice per day and apply any stay on treatments overnight.

Benzoyl peroxide products can be bought from a pharmacist. These act to both kill bacteria and to reduce the excess skin cells growing around the oil ducts. The main side effects are drying of the skin and bleaching of clothes and bedding. Products include quinoderm,  panoxyl and benzoyl peroxide gel. These are also available on prescription from a GP.

Freederm gel is available over the counter. It contains an anti-inflammatory product called nicotinamide and can help with mild to moderate inflammatory acne.

Help from the GP or family doctor.

If over the counter treatments are not helping or if you are very bothered by your acne you should consult your GP. There are 3 groups of treatments that GPs can provide

 

1. Creams to help unblock the oil ducts . These include benzoyl peroxide based creams such as quinoderm and panoxyl,  retinoid creams such as adapalene  and combinations of the two such as epiduo . These creams work by reducing the skin cells around the oil ducts. If the blockages can be cleared the bacteria do not grow excessively and the skin immune system is not triggered. All patients being prescribed treatment for acne by their GP should receive one of these creams.
2. Creams to reduce inflammation. These are either antibiotics which reduce the bacteria and thereby prevent triggering of the immune system or anti-inflammatory substances that reduce the activity of the skin immune system
   1. Antibiotic creams.
   2. Anti – inflammatory creams
3. Systemic antibiotics. There are a number of different antibiotics that can help to treat acne. These include oxytetracycline, doxycycline, lymecycline, erythromycin and trimethoprim. They work by reducing levels of bacteria and some also have other anti-inflammatory effects on the skin immune system. It is generally clear if they are working after 8 to 12 weeks. Three different antibiotics should be tried before referral to a Dermatologist.
4. For female patients- oral contraceptive. There are essentially 3 options for oral contraception and they have different effects on the skin. As discussed in the 'What is it' section , the hormone testosterone is involved in the development of acne. Oral contraceptives that contain oestrogen are often beneficial for acne since they oppose the effect of testosterone and reduce the fluctuations in the oestrogen levels. This is why the combined oral contraceptive often improves acne. Progesterone only contraceptives (e.g., cerazette)  may make acne worse due to the fact that progesterone can be converted to male hormones (androgens) which have testosterone like effects. The oral contraceptive Dianette contains oestrogen and a medicine called cyproterone acetate which reduces the activity of testosterone. Dianette can be very effective in treating acne. There have been some concerns regarding a very small increased risk of blood clots with Dianette so it is now less widely prescribed

Help from a Dermatologist

A referral to A Dermatologist is needed if

1. The diagnosis is unclear
2. There is  any scarring
3. The acne is not settling with standard treatment

If you have tried standard therapy or have any scarring a Dermatologist will probably discuss treatment with a drug called isotretinoin (Roaccutane©). Isotretinoin is a highly effective drug for the treatment of acne and in a high proportion of cases can cure acne.

Other issues

What if I have developed acne scarring

It is much easier to prevent acne scarring than it is to treat it. In general once the inflammatory acne has been treated and the skin is no longer red, mild acne scarring is often not that obvious. It is important to remember that real faces are not flawless. Faces in magazines are often either photo-shopped or covered in foundation or both.

Acne scarring can either be large pitted scars or more superficial ice pick scars or a combination. Larger deeper scars can be removed  surgically . You will swap a deep pitted scar for a small flat one but a subtle flat scar will be less noticeable. For more wide spread scarring laser re-surfacing can be tried. Not everyone is suitable for this and the process is relatively traumatic. The whole of the affected area is treated. The laser burns off the top layer of skin, the epidermis, and then heats up the top layer of the dermis where the scars are. This process tightens up the dermis and flattens out the scars. The top layer,the epidermis, then grows back again over 3 to 4 weeks.  This treatment should only be done by suitably trained Dermatologists or Plastic Surgeons or well qualified technicians under the supervision of Consultants.

Should I visit a beauty clinic for acne?

You need to think carefully about what you are wanting to achieve. Beauty clinics offer a wide range of treatments, many of unproven benefit. Numerous ‘treatments’ will give your skin a good clean and make it feel nice for a period of time but these have no proven benefit over the long term.  Various acne beauty parlour regimes will reduce inflammation for a period of time but the effects will be temporary. If you accept that many of the treatments only produce a short term benefit that will need repeating then it can be an option and may be beneficial.  There also other benefits from a visit to a salon such as the relaxation, which customers may enjoy.

Laser treatment for acne is now a very popular option offered by beauty clinics. Does it work? Studies in the Lancet have shown that lasers can produce a modest improvement in moderate acne. They work by reducing the levels of pro-inflammatory bacteria and thus reducing redness and papules. The problem with this strategy is that it does nothing for the root cause of the acne which is blockages of the oil ducts. The inflammation therefore returns after a certain period requiring more treatments.  If you are happy to pay for laser treatment until you grow out of your acne or you are not keen on systemic drugs  then maybe laser is a good option but for most people it is a bit of a waste of time and money.

One final thing to be aware of are the numerous skin products in beautiful packaging which are not necessarily any better than much cheaper products.  The “Because I’m worth it” campaign by L’Oréal summed up expensive beauty products.  It was almost an admission that the products were no better than the cheaper alternatives but you bought L’Oréal because you could afford it, because you the consumer were wonderful and because you were worth it.  The reality is that there are no double blind randomised controlled trials to demonstrate that these expensive products are better than the cheaper ones. So, buy them if you want to, and feel good about it, but don’t expect any miracle results and don't be surprised if you get the same effects from much cheaper brands.