What is acne?

Acne is a common disorder of the pilosebaceous unit (hair follicle). There are two main types of acne lesions:

Inflammatory lesions consists of papules and pustules, more commonly referred to as ‘pimples’, as well as nodules and cysts which can be found in severe acne.

Non-inflammatory lesions called open and closed comedones are better known as ‘blackheads’ and ‘whiteheads’.

Acne mainly affects the face, neck, back and chest and can affect a localized area or all these areas extensively, acne can therefore vary greatly in appearance and severity.
Mild acne is characterised by comedones, while severe acne can be disfiguring with large nodules and cysts.
Rarely patients may have a systemic form of acne called Acne fulminans which can leave them feeling very unwell.

Whether mild or severe, acne can still have a huge psychological impact and lead to significant permanent scarring.

Who gets acne?

Acne is primarily a disease of adolescence and affects about 85% of the young between 12 and 24 years. However it can also affect any other age group from infants to adults. It is not uncommon for acne to develop in the 30’s and 40’s and 50’s without any prior teenage acne. We call this type of acne ‘late onset acne’ and it is particularly challenging to manage.

What causes acne ?

While there are many factors that play a role, the four main pathogenetic mechanisms are:

– A defect in keratinisation at the hair follicle opening which causes keratinocytes (skin cells) to block the opening of the hair follicle

– Androgens (male hormones) which cause the sebaceous glands to produce more sebum. Androgen production increases around puberty as the adrenal glands mature which results in oiliness of the skin, causing the higher incidence of acne at this age.

– Propionibacterium acnes proliferate in the hair follicle and contribute to triggering an inflammatory response and worsening acne.

– An inflammatory response that leads to the formation of papules and pustules in response to the blocked follicle.

Other possible contributing factors:

The use of oral or topical steroids on the face for prolonged periods can lead to steroid induced acne. Many prescription drugs can cause acne as a potential side effect. Examples are epileptic medication and injectable progesterone containing contraceptives.

Greasy face creams or hair products may further block follicles and worsen acne. We call this type of acne Pomade acne.

High humidity contributes to a kind of acne found in the tropics known as Tropical acne.

Pinching and scratching acne lesions can worsen acne, particularly acne scarring. This type of acne is called Acne excorie.

Is acne genetic?

Acne may be considered genetic as one is more likely to get acne if either parent has had severe acne. The incidence of both identical twins having acne is high, supporting a genetic link. The size, number and activity of sebaceous glands which is directly related to acne is genetically determined and can’t be altered.

What is hormonal acne?

All acne can be considered ‘hormonal’ as the major contributing factor to developing acne is androgen (male hormone) induced stimulation of sebum production from the sebaceous glands. In most case the hormone levels are normal. There are however some conditions in which there is an increase in androgen production. An example of this is Polycystic ovarian syndrome.

Late onset acne is thought to be partly because of an increased effect of androgens on the sebaceous glands even at normal blood levels.

Late onset acne is usually distributed on the lower face of women. We often refer to this as ‘hormonal acne’.

How do I treat my acne?

The acne guidelines have been developed to provide a guide to treating acne.

The guidelines divide acne into mild, moderate and severe and treatment is based on the grading of acne.

Mild acne with open and closed comedones (‘blackheads’ and ‘whiteheads’) is treated with topical benzoyl peroxide and topical retinoids.

Moderate acne is treated with antibiotics (either topical or oral) in combination with topical benzoyl peroxide or topical retinoid. It is very important to combine antibiotics with topical treatments as it prevents resistance to the antibiotic.

Severe acne usually warrants prescription of isotretinoin (Roaccuatane, Oratane, Acnetane) which is the most effective treatment for this type of acne.

In addition to this oral contraceptives can be used by women as this counteracts the effects of androgens.

In all forms of acne the first lesion is the microcomedone. For this reason no treatment regimen is complete without a topical treatment to prevent the formation of new comedones.

Some other treatments that have some success are usually recommended in combination with prescription treatment.

These include:

Chemical peels

Peels help to decrease the amount of dead keratin blocking the follicular unit, reducing the amount of blackheads and whiteheads and calming down inflammation.

Chemical peels assist with mild acne scarring and post Inflammatory hyperpigmentation which is often more emotionally disturbing than the acne.

Photodynamic therapy

Red and blue light with or without topical aminolevulinic acid can decrease the amount of propionibacterium acnes in the follicle and in this way improve acne.

Home-care

A carefully tailored home-care regimen can help reduce oiliness and moisturise skin that has been left dry and sensitive from prescription medication. Ingredients like salacylic acid, lactic acid and glycolic acid can also help shed dead surface skin cells and reduce the amount of blackheads.

Does diet affect acne?

This is still a controversial topic as there is still not much evidence available. In general dairy and high glycaemic index foods may worsen acne. This does not mean that they are causing acne, nor does it mean that you don’t need acne treatment if you control your diet.

My acne has cleared, how do I treat the scars?

In most cases untreated acne will eventually resolve. The problem with this is the resultant scarring and post inflammatory hyperpigmentation which is often permanent. It is therefore important to start treating soon and to continue treatment.

Management of the acne will prevent scarring.

Treatment of scars starts with topical retinoids in the treatment phase.

After acne has cleared options for scarring include chemical peels, dermal needling and laser therapy.

Dermal filler may also be injected to fill up pits caused by acne scarring.

General measures

Keep the skin clean by washing twice daily with a gentle cleanser suitable for your skin type.

Avoid harsh soaps or scrubs which traumatize the skin and worsen inflammation.

Very oily skins may benefit from a cleanser with added salacylic or glycolic acid.

Toners may be used to reduce oiliness after cleansing.

Use a suitable moisturiser.

Use your prescription topical treatment regularly. The results will not be quick but regular treatment helps prevent new acne and assists with maintenance of a skin condition that often fluctuates in severity for many years.

Wear sunscreen in the day as most acne treatments make the skin sun sensitive.

Sunscreen will also help reduce post inflammatory hyperpigmentation.

Avoid heavy occlusive makeup or greasy cosmetics which block the follicles and worsen acne.

Seek treatment early to avoid scarring.

Visit your doctor or dermatologist for prescription treatment, and a home care regimen that can be tailored to suit your skin.