ACNE - a patient's guide
Dr Stephen Helander - Dermatologist

Overview

Acne is a common skin complaint
It mainly affects teenagers but many adults also suffer from acne
Acne is not an infection, but bacteria and hormone levels play a role
Acne ranges in severity from mild to severe
Acne can cause scarring and psychological problems
There are several treatments available, depending on severity
There is no evidence that acne is related to diet
The drug isotretinoin (Roaccutane) is effective for severe acne

Introduction

Acne is one of the most common skin complaints. It affects most people during teenage years but not infrequently extends into adult life. Severity ranges from a few spots that settle without any treatment to a severe scarring process. Acne causes not only physical but psychological scars. Fortunately effective treatment is available for acne of all severity.

What causes acne?

This is still not fully understood. Hair follicles on the face and trunk have sebaceous (oil) glands that are under the control of androgenic (male) hormones. Normal females produce small amounts of androgenic hormones from ovaries and adrenal glands. If production of these hormones is too high or if the hair follicles are too sensitive, excess oil is produced. This blocks and stagnates in the follicles causing whiteheads and blackheads. Bacteria that live on the skin grow in these oils and produce waste products that cause inflammation with red spots (papules) and pustules. In the worst cases, severe inflammation results in rupture of the follicles and large deep blind nodules and cysts that can cause severe and permanent scarring.

Because androgenic hormone production is high at puberty, teenagers often have acne.

There seems to be genetic factors at work in some cases, with families tending to have bad scarring acne.

Heavy cosmetic use does not help, although it often becomes a vicious cycle applying more makeup to worsening acne.

Popular misconceptions

There is no need to treat teenage acne as they will grow out of it.

Acne can persist into adult life. 5% of women over 25 years have significant acne. If acne is scarring or causing psychological distress, waiting is seldom a good option.

Acne is due to poor diet, lack of vitamins or not drinking enough water.

There is no evidence that acne is linked to any dietary factor or deficiency of vitamins or zinc. Drinking more water will not help.

It is important to squeeze pimples.

This can cause increased inflammation, making the acne look even worse and worsen scarring.

Treatments

General Skin Care

Washing the face twice daily with a mild soap can be remarkably effective in mild cases. Cleansers can be used instead particularly for removal of makeup, but offer little additional benefit. Use makeup as little as possible and ensure it is thoroughly removed at night.

Topical (externally applied) treatments

These can be very helpful for mild to moderate acne (blackheads, whiteheads, smaller spots) but not for scarring lumpy acne. Several products are available.

Benzoyl Peroxide: (Panoxyl,Oxy, Benoxyl) kills bacteria and dries skin. Can be irritating on sensitive skin and cause white patches on darker skin.

Antibiotics: (Dalacin-T, Eryacne, Stiemycin) kill bacteria.

Retinoids: (Retin-A, Differin, Isotrex) are the most effective topical agents. Derived from vitamin A, they are related to Isotretinoin (see below) and have powerful effects on the skin. They are only available on prescription and must not be used in pregnancy. They increase sensitivity to sunburn and can irritate sensitive skin.

Oral medications

These are a better choice for denser more widespread acne or if there are more inflamed spots. They are essential if there are deeper nodules cysts or scars.

There are 3 types of oral acne treatment.

1. Antibiotics

Antibiotics (Minocycline, minotabs, doxycycline, erythromycin) work by killing bacteria. They also have an anti-inflammatory effect and are particularly effective in inflammatory pustular acne. They need to be used for at least 3-6 months. Side effects are usually few but may include thrush and nausea. Extra may be needed if using oral contraceptives at the same time.

2. Diane 35 and other hormone treatments

These are only available for females. Acne is generally improved with any combined oestrogen/progestogen contraceptive pill, but Diane 35 contains a progestogen cyproterone that is particularly effective at reducing androgenic hormone levels. It also helps control irregular periods and is the best treatment if blood tests show abnormally high levels of androgenic hormones. It can take 6-12 months to see an improvement with Diane 35. There are some alternatives to Diane 35 if this is not tolerated.

3. Isotretinoin (Roaccutane)

This vitamin A derivative has revolutionised the treatment of severe acne. Although an expensive drug, it is fully funded if prescribed by a dermatologist. The course lasts 4-6 months and offers clearance rates approaching 100% and long term cure rates of up to 85% even in the most severe cases. Isotretinoin seems to work by breaking the acne cycle so effectively that in most cases it never starts again. It cuts down production of oils in the skin and promotes unblocking of the follicle as well as having anti-inflammatory actions. It has no effects on hormones or the immune system. It does not accumulate in the body and is totally gone within one month of stopping. Side effects include dry skin, lips and nose, sun sensitivity and some minor tiredness and muscle aches especially with exercise. Blood test monitoring of liver function and lipids is routine, with serious side effects being very rare. Pregnancy must be avoided on the medication and for one month afterwards but there are definitely no long-term problems with having children. Isotretinoin has been available for over 15 years and there have been no signs of problems on long-term follow up studies.

Treatment of Acne Scars

It is important to ensure that the acne has been properly treated, if necessary with Isotretinoin (Roaccutane) prior to any treatment of scars. Treatment of scars varies depending on whether the scars are raised or depressed (sunken). Raised scars and cysts can be reduced in size with injections of steroids. These have no internal effects. Excision (surgical removal) is best for stubborn cysts.

Depressed scars need to be removed down to normal skin. If they are isolated, excision is a good option. If they are multiple, laser resurfacing is the best option, with chemical peels and dermabrasion as alternatives. Over the counter and mail order hydroxy acids will not peel deeply enough to be of any benefit.

Comedonal acne - topical treatment appropriate:

Pustular - an oral antibiotic would be best:

Severe acne treated with Isotretinoin: A) Before treatment:

B) After 5 months:

Summary

Acne ranges enormously in severity. The psychological effects should not be underestimated. Fortunately effective treatment is available for all types of acne. While the aim is to treat before scarring occurs, good treatments are available for this aspect too.