TOP 5 THINGS ABOUT ACNE
- Acne is the commonest skin problem and apart from cosmetic concerns can have a significant psychosocial impact as well as result in permanent scarring.
- Treatment needs to be individualised and early treatment can stop progression and minimise complications but results take time and management needs regular review.
- Treatment is aimed at overcoming the main causative factors of increased oil production, blocked oil glands, overgrowth of bacteria and inflammatory products
- Topical treatments and attention to skincare and diet can very effectively control milder forms of acne and prevent progression to more severe acne
- Severe acne may require medication but great results can also be obtained with lasers especially in combination with PDT (Photo Dynamic Therapy).
Over the counter topical agents include topical antiseptic washes such as Triclosan (eg PHISOHEX), antimicrobials such as Benzoyl Peroxide (eg BENZAC) and exfoliants to unplug follicles such as Salicylic acid. Azelaic acid preparations (eg FINACEA) have comedolytic and antimicrobial actions and are less irritating to the skin and can be used in darker skinned patients.
Topical antibiotics (erythromycin and clindamycin) are effective in mild and moderate acne but less effective than oral antibiotics and should not be used alone due to antibiotic resistance. Combination of benzoyl peroxide with topical antibiotic ( eg DUAC gel) reduces the chance of resistant strains of acne bacteria developing.
Topical Vitamin A (retinoids) are very effective in both non inflammatory and inflammatory acne. All retinoids cause some skin irritation but this can be minimised with appropriate skin care regime. Adapalene is a newer retinoid that is photostable and can be applied during daytime as it doesn’t cause photosensitivity. Benefits from topical retinoids can take up to 12 weeks and these products have to be avoided in pregnancy. Combination of benzoyl peroxide and retinoid (eg EPIDUO) works more effectively than retinoids alone (eg DIFFERIN, ISOTREX) as multiple causative factors can be targeted with the one preparation.
Oral antibiotics suppress acne bacteria but also have anti-inflammatory actions. Doxycycline is first line (eg DORYX) usually 100mg/day. Cannot use in children younger than 12 or in pregnancy. In these situations use erythromycin 500mg twice a day.
Hormonal therapy can be very effective in women with acne by decreasing androgen activity. The combined oral contraceptive pill can improve acne in 50-90% of patients but may take 6-9 months to take full effect.
Oral isoretinoin (ROACCUTANE) is reserved for the most severe cases of acne. This can only be prescribed by a dermatologist and because of possible toxic effects blood tests are needed regarding liver function and cholesterol levels before this medication can be started. There is a high risk of birth deformities and ROACCUTANE must be avoided during pregnancy. There are also concerns about mood changes and a link to depression whilst on this medication and referral to a psychiatrist may be needed before starting.
Dermal treatments with chemical peels, microdermabrasion and extractions all have a place. Superficial peels such as Salicylic acid can be helpful in superficial open comedonal acne. Prescription peels such as Retinoic acid peels can more specifically target acne. Extraction of closed large comedones with a needle can be useful.
Lasers and light sources especially in the blue light spectrum can be effective in targeting acne bacteria. LED light especially red light can help with reducing acne inflammation and controlling sebum production. The REVLITE laser and Laser GENESIS can also be effective depending on the grade and severity of the acne.
Photodynamic therapy for acne is where a photosensitiser (called ALA) is applied to the skin and left for 60 minutes during which it is absorbed by the sebaceous glands. A light source is then applied to the skin to target these now light sensitive glands. Typically 3 treatments spaced 4 weeks apart are needed followed by maintenance every 6-12 months if necessary. Many doctors feel results as good as Roaccutane can be achieved with Photodynamic therapy.
The treatment of choice for scars resulting from past acne damage (i.e. acne scars) will depend on the type and severity of the acne scars. Treatment options range from surface treatments for superficial scars such as peels and microdermabrasion to treatments for deeper scars using advanced medical lasers such as the latest fractional laser technology (FRAXEL) and fractional radiofrequency microneedling (INFINI). For more information visit our page on Acne Scarring
ACNE IN PREGNANCY
If a patient is pregnant or trying to conceive then they should not be using topical or oral reinoids because of the high risk of birth defects. Tetracycline antibiotics should also be avoided as they can result in yellow staining of the baby’s teeth.
Treatment options for acne during pregnancy are limited to topical antibiotics, azelaic acid,salicylic acid and lactic acid. LED light treatments can be used but Photodynamic Therapy is not recommended.
GENERAL ADVICE AND MYTHS
CLEANSER: Use a mild cleanser daily with water or an antiseptic wash. If have dry sensitive skin use once a day and if have oily thicker skin cleanse twice a day. Choose a cleanser for sensitive skin. Avoid soap, harsh cleansers and scrubs.
MOISTURISER: Use an oil free non-comedogenic moisturiser without additives (eg CETAPHIL). Use immediately after washing your face and try to mositurise twice a day. Moisturiser is important as if the sebaceous glands sense the skin is drying out it can stimulate more oil production and also moisturising helps cope with skin dryness from acne treatments.
MAKE UP: Try not to use too much make up and try not to wear make up too often. Use good quality mineral make up such as LYCOGEL. Avoid oil based make-up that can clog pores. Use cleanser to remove make up.
EXFOLIANTS: Do not use strong exfoliants, alcohol wipes, toners, scrubs, masks. These can make your skin more sensitive to topical treatments. A blend of AHA and BHA can be used.
SUNSCREENS: Some acne treatments leave skin sun sensitive so if outside sunscreen is important. Use an oil free formulation. Some sunscreens can aggravate acne so may need to trial a few.
SUNLIGHT: Patients often report acne can improve over summer however UV (Ultraviolet) light is not a treatment for acne. Controlled laser light treatment in a clinic is a much safer and more effective option. Many acne treatments also make the skin more susceptible to sunburn.
HUMIDITY: Where possible avoid excessively humid conditions such as using saunas and tropical holidays.
DIET: Low GI (Glycaemic index) diet is best as foods that raise blood sugar quickly can trigger acne more than anything else. In particular avoid high sugar content, carbohydrate rich and processed foods. Eat plenty of fresh fruit and vegetables. Low dairy diet can help as hormones in dairy products can stimulate oil glands.
SUPPLEMENTS: Avoid protein supplements and shakes. Whey supplements, which are derived from milk, are worst. Amino acid supplements especially Leucine can stimulate oil production. Some studies suggest Zinc supplementation (30mg elemental zinc /day) can be beneficial in some patients. Probiotic supplements (Lactobacillus rhamnosus) may help reduce acne by suppressing inflammation in some patients.
SMOKING: Stop smoking as nicotine increases oil retention and skin debris contributing to comedones.
SQUEEZING: Picking and squeezing of acne lesions can increase inflammation and increase the risk of scarring.
STRESS: Can play a role in acne exacerbations.
WASHING: Blackheads are not due to dirt. Excessive washing can be counter productive. The depth of pore blockage causing blackheads is deeper than affected by washing. Avoid washing your face directly under the shower head as this can contribute to dryness and redness. Leaving hair long, greasy and over the face is not advisable. Wash face before going to bed.
SEX: Although Acne is related to hormones in particular androgen activity this is at the cellular level and there is no evidence of a link between sexual activity and acne.
EXERCISE: Exercise is beneficial as sweating helps clean out pores and increase blood flow to the face.
LINEN: Change the pillowcase every other day and/or turn pillow over. Change face cloths after each use.
Frequently Asked Questions
How common is acne?
Why is acne a concern?
Acne can have a significant negative impact on an individual’s quality of life and can have profound psychosocial consequences especially in adolescents such as depression, social isolation, anxiety and lowered self esteem.
Poorly treated or severe acne can result in permanent scarring of the skin whilst early effective acne treatment can prevent such complications.
What causes acne?
1. Enlargement of the oil producing glands in the skin and excessive oil (sebum) production resulting in greasy skin and large pores.
2. Blockage of the tiny pathway (duct) that takes the sebum from the sebaceous gland to the skins surface.
3. An overgrowth of acne bacteria inside the sebaceous glands. This bacterium is called Proprionibacterium acnes.
4. Production of inflammatory products by the acne bacteria.
Successful acne treatment requires addressing all four factors in what is termed combination therapy.
How is acne graded?
MILD ACNE: Primarily non inflammatory lesions called comedones. These result from a plug of sebum clogging up pores and are white in colour if not exposed to air (called closed comedones or whiteheads) or when exposed to air oxidation causes darkening (called open comedones or blackheads). In mild acne there may be some papules (red Pimples).
MODERATE ACNE: Both non inflammatory comedones as well as multiple inflammatory papules (red pimples) and pustules (pimples with a white top). The term Pimples refers to small raised spots on the skin that are usually red as they are inflamed and can be infected (called pustules).
SEVERE ACNE: Also numerous deep inflammatory nodules and cysts on the face, neck and trunk.
Patients especially those with darker skin types can have skin colour changes associated with acne notably post inflammatory redness or pigmentation.