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The Causes and Treatment of Adult Acne

acne

The Causes and Treatment

of Adult Acne

written by Dermatologist, Dr Kesiree Naidoo

Acne

Adult acne also known as late onset or post adolescent acne has been the anguished subject of many dermatology room consults worldwide. Its diagnosis is almost always followed by questions like ‘Why do I still have acne now? ‘or ‘Aren’t I too old to get Acne’ or sometimes statements like ‘I’ve never had acne before’ or ‘I’ve always had a perfect skin till now’.

Sadly, adult acne is a continuous challenge, especially as it is difficult to treat with an often prolonged and recurrent course. It has become increasingly more common in recent years for leading dermatologists to question whether there are different factors playing a role as opposed to those causing adolescent acne. 

Adult acne is defined as acne that affects men and women over the age of 25. It is by far more common in women than men. Adult acne may persist continuously from adolescence, recur after age 25 or in fact occur for the first time after the age of 25 years old. So, to answer those questions ‘Yes, you can still have acne beyond adolescence’ and ‘yes it can be for the first time’. Most cases of adult acne persist from adolescence and only around 20 % occurs for the first time after the age of 25. Hence the term adult acne seems more appropriate than late onset acne.

Traditionally it is believed that the main factors causing adult acne are genetic and hormonal, with predominant involvement of the lower third of the face. Flare-ups are typically premenstrual supporting the role of hormones. Most patients complain of deep seated and painful nodules with very few comedones (blackheads and whiteheads). The acne nodules are usually sparse, but can lead to significant scarring.

There are now considered to be 2 predominant forms of adult acne, inflammatory and retentional:

Inflammatory acne is the most common type accounting for 50-60% of cases. The skin is not always oily, and in fact may be normal to dry making it sensitive to topical treatments generally prescribed in adolescent acne. The acne spots can be on multiple areas and not just the lower third of the face.
Retentional acne is the other predominant subtype and is characterised by increased sebum or oily skin and multiple comedones (blackheads and whiteheads).

What causes adult acne?

The fundamental factors causing acne whether adolescent or adult are:

  1. Genetic predisposition. As many as 40% of acne sufferers have a family history of acne. This may be related to the size, number and activity of sebaceous glands which are genetically determined.
  2. Increased androgenic hormone (testosterone, dehydroepiandrosterone sulphate and dihydrotestosterone) stimulation of the sebaceous glands leading to an oily skin. The levels of the androgen need not be higher than normal. It is the sebaceous glands that are more responsive to normal levels of circulating androgens. Oestrogen inhibits the secretion of androgenic hormones and inhibits sebaceous gland activity. An age related decline in oestrogen tips the balance towards androgenic stimulation.
  3. Excessive sebum production by sebaceous glands. While this is largely driven by androgenic hormones, there are other factors that also stimulate the sebaceous glands.
  4. Abnormal follicular keratinisation leading to blocked pilosebaceous unit (hair follicle unit) and the formation of a comedones. The skin cells in the hair follicle do not shed easily. They accumulate and together with the increased sebum from the sebaceous glands block the opening of the follicle. This in turn contributes to the inflammatory response.
  5. Propionibacterium acnes or cutibacterium acnes which live normally in the sebaceous glands proliferate with increased sebum production worsening the inflammatory response and acne
  6. an inflammatory response primarily to Propionibacterium or cutibacterium acnes which release enzymes that trigger the inflammatory cascade. These cause papules and pustules in acne that we commonly refer to as  ‘pimples’.

There are however other factors or triggers that may be more significant in causing adult acne and these need to be further evaluated:

Ultraviolet light exposure- excessive sun exposure causes thickening of the stratum corneum and accumulation of dead surface skin cells. There is stimulation of the sebaceous glands producing more sebum. Both these processes lead to comedones and acne

Stress- a stressful lifestyle with poor sleep patterns can cause acne by its effects on the pituitary adrenal axis and resultant release of corticotrophin releasing hormone, neuropeptides and proinflammatory cytokines which stimulate the sebaceous glands and worsen the inflammatory response.

Obesity and insulin resistance is associated with hormonal imbalance and acne.

Endocrine disorders – There are numerous endocrine diseases that cause acne by increasing the activity of androgens, stimulating the sebaceous glands or inducing abnormal keratinization. The most common cause is polycystic ovarian syndrome aka PCOS. Other conditions include congenital adrenal hyperplasia, hypothyroidism, Cushings syndrome and various other adrenal and ovarian tumours. Acne also occurs in menopause due to the decline in oestrogen and resultant increasing effects of male hormones.

Smoking – causes acne by stimulating the sebaceous glands and inducing abnormal keratinization. The acne associated with smoking is typically a non-inflammatory, comedomal acne. There are mainly blackheads and whiteheads without significant papules and pustules.

Diet -does diet worsen acne? There is not much scientific evidence, but studies have shown that high glycaemic index foods increase insulin and insulin like growth factor 1(IGF1) which stimulate the production of androgens and sebum.

In addition, diets rich in dairy products and muscle building supplements with whey protein have also been found to worsen acne. Anabolic steroids used by weight lifters and body builders can cause a severe scarring acne affecting the face and body.


Damage to the skin barrier – Over washing of the skin leading to a damaged epidermal skin barrier which in turn causes water loss through the skin and worsens the inflammatory cascade.

Greasy cosmetics – Occlusive makeup, Vaseline and other thick greasy creams block the follicles and cause acne in those that are susceptible. This problem is sometimes seen in actors and models or those requiring heavy make up as part of their job. Hair products that spreads onto the hairline can cause acne in the affected areas.

Medication- Some drugs can cause acne as a side effect. Examples of these drugs are progesterone only contraception (includes commonly used injectable contraception) benzodiazepines, mood stabilisers like lithium and blood pressure medication like ramipril. There is also some speculation as to whether hormone releasing intrauterine contraceptive devices and contraceptive implants possibly trigger acne in some women who are predisposed. Anabolic steroids used by weight lifters and body builders can cause a severe scarring acne affecting the face and body.

Are there any tests needed to diagnose adult acne?

Acne is a clinical diagnosis and lab tests are not needed to make the diagnosis. Even though androgenic (male) hormones are one of the main pathogenetic factors causing acne there is usually no increase in hormone levels. It is rather the balance between androgenic hormones and oestrogen that causes acne.
Investigations may be required if endocrine disorders associated with acne are suspected, though these conditions will usually have other signs and symptoms to warrant further investigation.
Polycystic ovarian syndrome (PCOS) commonly presents with acne as well as other signs of hyperandrogenism (increased male hormones). It is the most commonly suspected cause of adult female acne. PCOS will need laboratory investigations and abdominal imaging and a visit to the gynaecologist or endocrinologist.

How is acne treated?

This is the most difficult part.

Adult acne is challenging as it typically responds to treatment, but frequently recurs once treatment is stopped. Acne is also of varying severity and is sometimes not even present at the time of the dermatology consult. This is frustrating for both the patient and the dermatologist. Prolonged courses of treatment are often needed as well as rotating different treatment options, and off course maintenance treatment is essential, which often involves a good skincare regimen. We also have to take into account the possibility of pregnancy and breastfeeding which decreases treatment options. Adult patients tend to have a drier skin compared to adolescents which does not always tolerate topical prescription acne medication. There is really no one size fits all approach and each person needs to be evaluated individually and treated accordingly.  
I am often asked for ‘the best treatment ‘or the ‘strongest treatment’. Patients are sometimes under the impression that it is possible to ‘treat acne and get it right the first time’. Sadly, the truth is there is no quick fix for adult acne. If there were.

  1. You would probably know about it
  2. Doctors would give it to you and there would not be more than that 1 treatment option
  3. You would not see so many people walking around with adult acne

Treatment options can be broadly divided into topical, systemic treatments, skincare and procedures.

Topical Acne Treatments

Topical treatments are best suited to mild to moderate acne and sporadic lesions. In this case they can be used as a spot treatment as needed. Topical treatments are also an important part of maintenance treatment.

Retinoids

Retinoids used for topical treatment include 0.1% adapalene gel( Differin, Dapta), and tretinoin( Retin -A, Ilotycin -A,Retacnyl) 0.05% cream and 0.025% gel.

These treatments are also fundamental to adolescent acne. Gradual introduction is recommended. Interestingly retinoids are also anti-ageing and prevent skin cancer. As mentioned, these topical treatments cause dryness and irritation of the skin in the first few weeks of use. They also cause photosensitivity. They must be used with a good moisturiser for skin hydration and comfort and with sunscreen over moisturiser in the daytime. Retinoids are not suitable during pregnancy and breastfeeding.

Topical antibiotics

Topical antibiotic treatments include clindamycin and erythromycin which are both safe to use in pregnancy. These work by reducing Propionibacterium/cutibacterium acnes as well as having a direct anti-inflammatory effect.
Antibiotics used alone whether topical or oral can create resistant strains of Propionibacterium/cutibacterium. For this reason, it is important to use antibiotics with either topical retinoids or benzyl peroxide to prevent antibiotic resistance.

Benzoyl peroxide

Benzoyl peroxide has been used for decades and is especially beneficial to an oily skin type as it causes further dryness and irritation with normal to dry skin. It also makes skin sun sensitive and bleaches clothing and towels. Benzoyl peroxide (5%) is recommended as first line therapy in mild adolescent acne and is safe to use in pregnancy.

Azelaic acid

20% Azeleic ( Skinoren) twice daily is effective in mild to moderate acne and especially suited to a dry skin as it is not irritating. Azeleic acid is also effective in reducing post inflammatory hyperpigmentation caused by acne lesions. It is safe to use during pregnancy and breastfeeding.

Topical combination treatments

Adapalene0.1% combined with 2.5% benzoyl peroxide (Epiduo) is an effective treatment for mild to moderate acne. It needs gradual introduction to minimise skin irritation. I recommend initiation of treatment twice a week for the first week, 3 times per week for second week and then every day once tolerated.  It should be used at night with a good moisturiser to relieve dryness and sunscreen in the day.

This combination is also good for oily skin and excellent at reducing post inflammatory hyper-pigmentation.

Benzoyl peroxide 5% and clindamycin1% (Clindoxyl) is a topical treatment combining an antibiotic with benzoyl peroxide. This gel can therefore be used alone without resistance developing. It is suitable to treat both inflammatory lesion (papules and pustules) and non-inflammatory lesions (blackheads and whiteheads)

Systemic treatments

Systemic or oral medication is best for moderate to severe acne and widespread acne where it is difficult to treat all affected skin with topical medication.

Antibiotics

Adult facial acne responds very well to oral antibiotic treatments, but the problem is recurrence once the course is completed. Antibiotics should always be used in combination with a topical retinoid or benzoyl peroxide as the combined treatment prevents resistance, and has a synergistic effect which speeds up the response to treatment.

First line antibiotics for adolescent or adult acne are the tetracyclines. Commonly used in this class are lymecycline (Tetralysal ) and doxycycline. The once daily acne dosage greatly improves compliance.
Other antibiotics that can be used are erythromycin and sulfamethoxazole/trimethoprim combination (Purbac)

Hormones

Hormonal treatments are highly effective in treating adult female acne (they cannot be used in men).

As mentioned earlier they work even when there is no measured androgen excess and
have the added benefit of being suitable for long periods of use. For this reason, they are also a very good maintenance treatment.

When would I choose to prescribe a hormonal treatment?

First of all, the patient must not be pregnant, attempting to fall pregnant or breastfeeding and must be willing to take hormonal treatments. They work best when there is skin oiliness and premenstrual flare ups of acne and should ideally be combined with a topical retinoid, benzoyl peroxide, azelaic acid or antibiotic.

Cyproterone acetate

Cyproterone acetate is an anti-androgenic progesterone found either combined with oestrogen in the oral contraceptive pill (Diane -35, Minerva, Ginette) or alone at varying doses (Androcur).
It works by blocking the androgen receptor on the sebaceous glands preventing excessive sebum production. Side effects include mood swings, breast tenderness, fluid retention, nausea and vomiting.

Spironolactone

This potassium sparing diuretic also works by blocking the androgen receptors on sebaceous glands. It may cause increased potassium levels in those susceptible eg renal failure. It is however safe to use in young healthy women. It may be combined with the oral contraceptive pill, with the intrauterine contraceptive device or topical retinoids for added benefit.

Other combined oral contraceptive pills with antiandrogenic progesterone(drospirenone) eg Yaz, Yasmin. It is important to exclude risk of thromboembolism ie heart attacks and strokes when prescribing the oral contraceptive pill

Isotretinoin

Isotretinoin (roaccutane, oratane, acnetane, acnetret) is usually reserved for severe or resistant acne where other treatments have failed. It is also used in acne with significant scarring which deserves a more aggressive treatment approach. Isotretinoin works by reducing the size and activity of the sebaceous glands, improving keratinocyte shedding and reducing inflammation. Even though the results are undeniable, isotretinoin has many side effects which make many patients reluctant to take it unless absolutely necessary. The biggest problem with prescribing it in females is the risk of teratogenicity, which makes contraception essential in females at least while on the medication and 2-3 months after stopping treatment. Isotretinoin does not affect fertility. Other side effects include dryness of the lips, eyes, nose and other mucous membranes, dermatitis, joint and muscle pains. Isotretinoin can cause raised liver enzymes and raised cholesterol and triglycerides so baseline blood tests are needed before treatment and during the treatment period. Isotretinoin may also be associated with depressed moods. Despite all this it is still used frequently in adult acne especially after repeated courses of antibiotics and topical treatments prove to be unsuccessful. As with all other treatments of adult acne there is frequent relapse once treatment is discontinued. There are therefore many off label low doses used which are effective in treating acne while the patient is on the medication.

Cosmeceutical skincare

Acne treatments frequently cause dryness and skin irritation and may damage the epidermal skin barrier. This leads to increased transepidermal water loss (TEWL) and worsening of inflammation through triggering of the skin’s innate immunity. It is important to moisturise the skin and maintain the integrity of the epidermal barrier so that the treatment can be continued and the skin is comfortable without burning and peeling.

In addition to this cosmeceutical skincare has many ingredients that can help in the treatment of the acne. Ingredients like salicylic acid, lactic acid and glycolic acid help shed dead surface skin cells unblocking the opening of the hair follicle unit. This reduces the earliest lesion of acne, the microcomedone. Acne facewashes and toners can help reduce oiliness of the skin. Ingredients in skincare will also assist with reducing and treating post inflammatory hyperpigmentation and scarring which often remains long after the acne has been treated. Sunscreens protect against post inflammatory hyperpigmentation and counteract the sun sensitivity caused by many acne treatments.

 It is important to note that skincare is ideally used together with prescription treatment in the case of active acne or plays a role in maintenance once the course of treatment is complete. A supportive skincare regimen is especially important in adult acne as the skin is not generally oily and thus more in need of hydration.  Visit a dermatologist early for skin assessment and advice as delay in starting treatment can cause scarring to develop.

Procedures

Steroid injection of acne nodules is used for resistant painful inflammatory nodules or scarring nodules that fail to subside despite treatment. Injections can be carried out even during the course of treatment.

Comedone (blackhead and whiteheads) extraction may be necessary to speed up response to treatment. Open comedones(blackheads) are easier to remove, while closed comedones (whiteheads) may sometimes need very careful light cautery to open up the lesions. This will reduce the amount of inflammatory acne lesions forming and prevent trauma to the skin caused by picking if the patient is impatient and wants quicker results.

Chemical peels

Superficial chemical peels aid in superficial exfoliation and removal of dead surface skin cells which contribute to forming acne lesions. They are useful for acne with multiple comedones ( blackheads and whiteheads), to reduce inflammation in mild inflammatory acne and to improve post inflammatory hyperpigmentation and scarring. Glycolic, lactic, salicylic and pyruvic acid peels have been used.

Photodynamic therapy (PDT)

PDT has been used as an alternative treatment for acne. Amino levulanic acid (ALA) in a 10- 20% concentration is applied to the skin and red or blue light is shone on the skin to activate it. This treatment works as it’s anti-inflammatory. ALA penetrates into the follicular unit and on activation destroys Propionibacterium / cutibacterium acnes.

Dermal needling

This treatment is effective at remodelling the dermis and treating acne scarring and post inflammatory pigmentation effectively. It is best to start after active treatment is complete with a course of 6-8 sessions.

Conclusion

Adult acne is a challenge because its chronicity and significant impact on the quality of life of those that suffer from it. It perhaps becoming more and more prevalent. We don’t fully understand what causes it, though it seems the same pathogenetic mechanisms causing adolescent acne are at the root of it, with a whole range of contributing factors. It is critical to consult with your dermatologist sooner than later to discuss what treatment course is best suited to you. The management of adult acne is complex and there is no one size fits all perfect treatment, but acne can be controlled and managed with the correct guidance and tools.

You can have a look at our FREE online skin assessment that will help you get started , if you however would like to rather book a consultation to see Dr Kesiree Naidoo or the Skinsmart medical therapist, please do not hesitate to contact us on 021 531 1107 or email us on i[email protected] or alternatively at [email protected]

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The Magic of Serums

Serums are often the ‘wonder product’ of most skincare brands, and the go-to product for most dermatology and specialist skincare clinics. With so many different options, it isn’t always easy to know which product to choose or even how these can fit into your skincare regimen.

So, let’s shed some light on the matter …

What are serums and why are they so special?
Serums are lightweight liquids or gels containing the highest quality, highest concentration of active ingredients specially formulated to enable the product to penetrate the epidermis to reach the deeper dermal layers of the skin. The sophisticated delivery systems ensure faster and efficient absorption of the product and consequently less wastage.

To be able to guarantee stability of these high quality ingredients while they are on the shelf, to ensure maximum benefit when the product is applied, is nothing short of scientific genius and the reason why serums are often more expensive.

In fact serums are generally the most expensive part of a skincare regimen and this is often the reason most patients are hesitant to use them.

It’s important to remember that very little product is required as the delivery systems are often superior to creams and lotions. With proper use and correct storage most serums actually end up lasting longer than creams or lotions and are ultimately more cost effective.

Where do serums fit in my skincare regimen?
Serums are best applied after cleansing and toning when the product can achieve maximum penetrance into the skin without being hindered by other products. There may be exceptions to this rule.

Serums may be used morning or night depending on the product.

Remember serums do not always give enough moisturise or hydration so you may still need to apply a moisturiser after the serum especially if your skin is dry.

Which serum should I choose?
Serums are often used to target specific skin types or skin concerns. A product range may have a variety of serums with different concentrations of active ingredients to suit different skin types . For example, an oily skin may benefit from a higher concentration of Vitamin C while a dry sensitive skin may only be able to tolerate a low concentration.

Serums may fall under the ‘prevent’ , ‘treat’ or ‘hydrate’ categories of a skincare brand.

Antioxidant serums containing combinations of Vitamin C, E and other ingredients will help prevent and reverse damage caused by sun exposure.

Various skin concerns like hyperpigmentation, acne, rosacea and dryness are targeted by appropriate ingredients found in different serums.

Since most serums contain superior active ingredients either alone or in power combinations, you may find a single serum effective for numerous skin concerns.

Can serums be combined?
Absolutely! Since most of us have more than one issue going on at once, it’s often necessary to treat more that one problem. So if you want an anti-ageing serum , and also a treatment for hyperpigmentation you may use more than one serum. In this case, you may apply one and wait a few minutes before applying the other or use them at different times of the day. Sometimes a single serum can fulfill all your needs.

Have a look at our Skinsmart product recommendations below where we try to help you find what you need, or complete our free online skin assessment here.

– Skinsmart Suggestions –

For hyper-pigmentation or uneven skintone:

*SkinCeuticals Discoloration Defense
*Neostrata Illuminating Serum

For skin redness and rosacea-prone skin:
*Neostrata Redness Neutralising Serum
*SkinCeuticals Phyto Corrective Serum

For hydration:
*SkinCeuticals Hydrating B5

For ageing and fine lines:
*Neostrata Tri-therapy Lifting Serum
*Neostrata Firming Collagen Booster
*SkinCeuticals HA Intensifier Serum

For prevention of free radical damage:

*Obagi C Clarifying Serum
*SkinCeuticals Phloretin CF
*SkinCeuticals C E Ferulic
*Neostrata Antioxidant Defense Serum

For skin barrier repair:
*SkinCeuticals Retexturing Activator
*Neostrata Bionic Face Serum

For mature skin prone to acne:
*SkinCeuticals Blemish + Age Defense Serum

If you are still unsure of what you need, email us at [email protected]. Our qualified medical therapist can give you the right advice for your skin concerns.

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All About Acne

 

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.

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Focus on Microneedling

 
What is microneedling?
Microneedling is a safe, minimally invasive therapeutic technique initially developed for facial rejuvenation, but now used to treat a wide range of dermatological skin conditions. It involves controlled piercing of the skin with a derma roller or more recently, automated devices with miniature fine needles. Dermal rollers are available for home use, but recently patients prefer to have their treatments done at a skin clinic with the expertise of a trained professional. Microneedling has also proven to be safe for use in all skin types, which has bolstered its popularity.

How does microneedling work?
Miniature fine needles cause superficial, controlled piercing of the skin without completely damaging the epidermis. The result is minimal bleeding and skin injury which is why it is a safe procedure with virtually no downtime from work or play.
The skin ‘injury’ leads to a wound healing cascade with the release of numerous growth factors, resulting in 2 important processes- neocollagenesis and neovascularization.
Fibroblasts lay down intracellular matrix and new collagen, elastin and blood vessels are produced. The process continues for as long as 6 months after the treatment course and the results have been confirmed with biopsies and histology of the treated skin.

What can you expect?
The skin is prepared for at least a month before treatment begins with a tailored homecare regimen, generally combining vitamin C and vitamin A to optimize the treatment results.
The process is quick and relatively painless. You will need to arrive an hour early to apply a topical anaesthetic cream to numb the skin. The skin is cleaned with an antiseptic wash before the procedure.
The treatment is generally well tolerated and post procedure there is minimal pinpoint bleeding and redness. The treated skin is then cleaned with saline, and soothed with ice packs.
There is virtually no downtime and you can expect to go back to work the next day.

Derma roller versus automated microneedling device
The home care rollers have varying angles and depth of skin penetration which could give inconsistent results. The automated devices can penetrate to a maximum of 2 mm and the depth can be adjusted to suit the area treated.

What are the uses of microneedling?
Microneedling which is also known as collagen induction therapy was initially developed for skin rejuvenation, but is proving to be effective for a range of conditions. The evidence is varying and consistent efficacy hasn’t been proven in all cases.


ANTI-AGING/ SKIN REJUVENATION
Microneedling leads to breakdown and reorganization of old collagen and production of new collagen, elastin and blood vessels. The result is decreased fine lines, wrinkles and pigment spots and an overall youthful looking skin. A minimum of 6 sessions is recommended with strict sun protection and tailored homecare combining vitamin C and vitamin A.

SCARRING
Microneedling has shown great results with the treatment of scarring from various causes, including acne scars, burn scars, surgical and traumatic scars as well as chicken pox scars. There are many clinical studies supporting the benefit of needling scars. It is safe to use in all skin types with minimal downtime. Again, a minimum of 4- 6 sessions is recommended with a good homecare routine, and maintenance after treatment.

ACNE
Microneedling in mild to moderate acne targets sebaceous glands causing them to produce less sebum. The process helps to clear sebum and keratinocyte build up that block the sebaceous glands. Needling assists with acne scar management and has been reported to minimize the appearance of pores. Microneedling is not suitable for active, severe acne.

PIGMENTATION
Microneedling has shown benefit in treating melasma and periorbital pigmentation. It enhances the penetration of topically applied skin lightening agents. For best results, it must be combined with strict sun protection and a tailored home regimen. The device can be adjusted to safely treat the eye area.

SUN DAMAGE AND ACTINIC KERATOSIS
Microneedling is beneficial in the treatment of actinic keratosis and sun damage as it can be combined with photodynamic therapy to enhance penetration of the photosensitizing cream. This improves the treatment outcomes in resistant areas.

ALOPECIA
Recently microneedling has been used to treat Alopecia Areata and Androgenetic alopecia. It can be combined with conventional treatments like topical minoxidil and topical steroids. Overall there has been some promising results.

Microneedling can be combined with various treatment modalities including chemical peels, platelet rich plasma and photodynamic therapy. It can be used to enhance penetration of topical agents during the procedure, including hyaluronic acid, vitamin C and tranexamic acid.
Combination therapy is key for best overall results and a minimum of 4-6 sessions is recommended.
Your treatment plan including homecare and maintenance is tailored for your skin condition and can be adjusted depending on your response to treatment.

Please visit our rooms or contact our medical therapist Annika for a skin consultation and treatment plan on [email protected]

 

 

 

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What is Pseudofolliculitis?

Pseudofolliculitis is a common chronic skin condition which typically affects the beard area of men who shave.
It is then referred to as pseudofolliculitis barbae or more commonly called ‘shavers rash’.
It typically occurs in men with tightly curled hair and of African descent. ‘Barbae’ refers to the beard area though pseudofolliculitis can occur in any shaved area and could even affect women and other race groups. It occurs where hair is coarse and abundant and subject to shaving, waxing or plucking
In all cases it is a cosmetically disfiguring condition which is difficult to treat and often recurrent.

How does it occur?

 

Paeudofolliculitis is caused when hair grows parallel to the skin surface rather than perpendicular to it such that the sharp tip of the newly cut hair curls back and pierces the skin causing trauma, inflammation and ultimately an ingrown hair.

A newly cut or plucked hair shaft may pierce the follicular wall to enter the dermis without ever leaving epidermis (upper layer of the skin) once again resulting in an ingrown hair and inflammation

While this process occurs mainly in curly hair, skin folds or scarred skin may cause the condition in straight hair.

Pseudofolliculitis barbae is essentially a chronic foreign body reaction to an ingrown hair shaft.

What does it look like?

Pseudofolliculitis barbae typically presents with firm papules and pustules in the beard area. For some reason it does not occur on the moustache area. The appearance of the disorder can be cosmetically distressing for affected patients. Postinflammatory hyperpigmentation, secondary bacterial infection, scarring, and keloid formation are potential complications.

How can you prevent it?
Use good shaving techniques.
Cleanse the skin thoroughly and wet the skin and hair before shaving. Wetting the hair softens the keratin making it easier to cut. Applying a warm wet towel for a few minutes before shaving may also be helpful.
Shaving preparations provide additional hydration and cushion the blade against the skin to minimise trauma.
Use a clean,sharp blade and shave in the direction of hair growth where possible.
This may be difficult as the hair in the beard area tends to grow in different directions.
Cleanse the skin thoroughly after shaving, as residual shaving preparation left on the skin surface may cause irritation.

How do you treat Pseudofolliculitis?

Stop shaving
The first step is to stop shaving in the area till all inflammatory lesions and ingrown hairs have cleared.
You may trim the hair to a minimum length of 0.5 cm with a scissors or electric clippers

Release ingrown hairs on a daily basis
Apply a warm water compress to the affected area for 10 min to soften the epidermis ( upper layer of the skin). Then release the ingrown hairs with a sterile needle or toothpick.

Topical corticosteroid
Apply a mild topical steroid to the area to decrease the inflammation and reduce burning and itching.

Systemic antibiotics
Some patients may need an oral antibiotic for secondary infection or for anti inflammatory effect.

Other treatments
Other treatment options include topical retinoids, alphahyroxyacids and benzoyl peroxide.
Chemical depilatory creams may be used for hair removal.
Laser hair removal is sometimes recommended for those with resistant and recurrent pseudofolliculitis.

Once the condition has resolved, adopt good shaving techniques as described above, and invest in a suitable skincare regimen as recurrence is common.

Skincare recommendations for Pseudofolliculitis.

Neostrata Foaming Glycolic wash

– This is a potent, foaming facial cleanser with glycolic acid and lactobionic acid to resurface and hydrate the skin with minimal irritation. The special formulation exfoliates and unclogs congested pores.

Obagi Clenziderm pore therapy

This liquid treatment contains salicylic acid which helps unclog pores and remove dead surface skin cells.

NeoStrata Ultra Smoothing Lotion 10 AHA


– Ultra Smoothing Lotion is an antioxidant-rich, exfoliating moisturiser. This is a lightweight formulation which is suitable for use on the face and body and may be preferred by men. The exfoliating action of alphahydroxyacids removes the surface dead skin cells and helps unclog pores.

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Types of Pigmentation and treatment

Postinflammatory hyperpigmentation(PIH)


This type of hyperpigmentation occurs in all skin types but is most common in those with darker skin.

It occurs after a skin condition or skin injury that causes the skin to become inflamed with resultant damage to the melanocytes, which are the cells that produce melanin pigment. Sometimes the preceding condition is barely noticeable.
Damage to the melanocytes causes melanin to be deposited in the dermis or epidermis (upper layer of the skin). This is important as epidermal hyperpigmentation fades faster than dermal hyperpigmentation, and in fact the dermal type may be permanent.
This type of hyperpigmentation can occur at any age, and on any part of the body.

It may appear tan, various shades of brown or blue gray. A blue gray appearance points to dermal melanin and a more prolonged and difficult treatment. Sometimes a dermatologist may be able to see lesions of the preexisting condition making it easier to make a diagnosis.

Common causes of post inflammatory hyperpigmentation that I see in my practice every day are acne, eczema, insect bites and skin infections. We need to treat the underlying disorder if it is still present to prevent more PIH from developing. If left untreated PIH may take years to resolve.

Melasma


Melasma or chloasma is a common disorder of hyperpigmentation that mainly involves the face. It usually affects both sides almost symmetrically and occurs in both males and females, though commoner in females. At least 90% of patients with melasma are women.
It can affect all races but is most common in darker skins where it is also the most difficult to treat.

Nevertheless melasma is a very distressing condition as it occurs somewhat out of the blue, sometimes seemingly without any precipitating factors.
Common precipitants are sunlight and hormonal influences (OCP and pregnancy). There is a genetic predisposition as in most diseases.
It may not seem fair that some of us will never get melasma even with reckless sun behavior and others will get it even with strict sun avoidance. The hyperpigmentation of melasma is due to increased melanin production by melanocytes i.e. increased activity of the melanocytes and not an increased number in the cells.

These melanocytes are called ‘reactive’ melanocytes. They produce an excess of melanin pigment, which is transferred to the skin cells called keratinocytes. Some of this pigment also ‘falls’ into the dermis where it gives a blue gray appearance to the skin. The key enzyme in the process of melanin pigment production is called tyrosinase.

Melasma is a clinical diagnosis based on a typical presentation. We do not do any tests to confirm the diagnosis. The hyperpigmentation of melasma can be described as flat coalescing brown, gray or bluish patches with irregular edges.
There are three typical patterns of distribution.

Centrofacial involves the forehead, nose, chin and cheeks. Malar pattern involves the cheeks and nose and mandibular pattern involves the area over the jawline.
Melasma may also occur on the neck and forearms i.e. extrafacial melasma.

Melasma is a common condition, but the treatment remains difficult particularly in darker skinned individuals where the condition may often either persist or recur.
Apart from classification according to distribution on the face, melasma is also classified according to where in the skin the pigment sits. As with PIH, epidermal melasma is more likely to respond to treatment than dermal melasma.

Melasma is managed with a combination of treatment modalities. Treatment needs to target various stages in the production and clearance of the excess melanin pigment.

Treatment of hyperpigmentation

Three pronged approach.
1. Avoid factors that stimulate melanocytes and cause them to produce more melanin ie avoidance of sun exposure, meticulous use of sunscreen and protective clothing. I must stress that protecting your skin from the sun is critical to the treatment and ongoing maintenance for patients with melasma. If you are on an oral contraceptive pill, consider an alternative form of contraception.

2 . Inhibit the production of melanin by melanocytes by targeting the enzyme tyrosinase.
The gold standand treatment to inhibit tyrosinase is hydroquinone. This treatment is only available by prescription. Other options are Arbutin, Kojic Acid and ellagic acid which are gentler and less likely to cause a worsening of the hyperpigmentation when discontinued.

3. Increasing the epidermal turnover will help to shed those keratinocytes which have been loaded with melanin pigment.
Topical creams and chemical peels help to remove the pigmented epidermal skin layers. Good options for accelerating epidermal turnover include glycolic acid and lactic acid

Proceed cautiously especially with darker skin types as there is no quick fix and epidermal injury from aggressive treatments could worsen hyperpigmentation

Remember that to maintain results as long as possible you will need to continue with your maintenance products.

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When to start using an antioxidant?

It is advisable to start using an antioxidant as a young adult.
Topical antioxidants serums have the added benefits of stabilising melanocytes, promoting the formation of barrier lipids, and being anti-inflammatory, thus assisting with management of acne and resultant post inflammatory pigmentation (post acne marks), while providing younger skin with comfort and hydration.
Use of an antioxidant along with a good quality broad spectrum sunscreen is the perfect way to start (and continue) taking care of your skin.

It’s not too late for those who already have sun damage and a history of skin cancers. While antioxidants cannot treat skin cancers, they can help to prevent further DNA mutations and new skin cancers and improve the appearance of dry, sun damaged skin by boosting barrier lipid production and collagen repair.

Even though many products may contain antioxidants, the efficacy of an antioxidant is only as good as the stability of the product formulation as antioxidants are unstable. The products sold on Skinsmart are of the highest quality, with proven efficacy supported by scientific research. If you are not sure about which product is suitable for you , please email us and ask for advice from our skin therapist.