ACNE – JUST A SPOT OF BOTHER? by Dr. Stephanie Hughes

Acne (acne vulgaris – the medical name for “teenage spots”) is no laughing matter. As the owner of a face that bore a striking resemblance to a pizza throughout my adolescence, I allowed no photographs of myself aged between 13 and 16 and empathise entirely with my patients who are experiencing this cruel skin problem. It’s common as well as cruel – 60-70% of people will have symptoms of acne at some point in their lives, with 20% of sufferers being classified as having a “severe” form of the condition – that’s a lot of spots! I use the word “cruel” to describe acne because it tends to afflict young people just at the point in their lives when they most strive for acceptance from their peers, (see our blog on Teenage Health & Wellbeing) and sexual desirability from those whom they “fancy” (acne affects girls usually in the mid teens,  and boys in the late teens – although it can affect younger children and adults too). Although most (70%) teenagers will be over their acne within 5 years of it starting, living with spots is not easy – and 5 years is a third of your life when you’re 15. 

Acne requires a practitioner with both expertise and empathy
I view acne as a serious condition. Not “serious” in that it represents a rare (we know it’s very common) or difficult-to-diagnose (it’s one of the easiest skin problems to diagnose) problem, but “serious” because it frequently causes significant debility in its sufferers, some of whom go on to experience real issues with low self-esteem, anxiety and depression – this can be seemingly out of proportion to the so-called severity of the condition, and the effect of even “mild” acne on a person’s overall wellbeing should not be under-estimated. No, I view it as serious because it is notoriously difficult to treat well. The vast majority of cases of acne are managed by GPs, and most are dealt with competently – but permanent scarring is a real possibility if the treatment is not early or adequate enough, and sometimes prompt referral onto a dermatological consultant is critical if specialist therapies are needed to get on top of the condition once and for all. Personally, I would urge patients with acne to find a GP who is not only comfortable and experienced in its management, but also able to understand the distress it is causing and is willing to act accordingly.

How acne occurs, or the 'troublesome trio'
So, what is happening when a person develops acne? Well, there are three main processes which seem to coincide in the unlucky ones’ skin. Firstly, comedones (blackheads and whiteheads) form in the skin due to over-proliferation of the skin cells in the ducts which produce sebum (oil) – this over-production of skin cells blocks the so-called pilosebaceous duct (a bit of skin containing a hair and a sebaceous gland) and causes the little lumps to form. Contrary to popular belief, blackheads are not formed due to dirt, but are merely comedones which are open to the air (rather than whiteheads, which are closed), and no amount of scrubbing or exfoliating will get rid of either. In fact, excessive scrubbing can make acne treatments less effective later on. It is possible, however, to lessen the formation of blackheads and whiteheads by avoiding comedogenic cosmetics and other skin products (coconut butter, for example, causes comedones) – by looking for packaging labels which specifically state that the contents are non-comedogenic.

The second process implicated in acne is the effect of the hormone testosterone, which is present in both sexes but which surges in adolescence, and which causes the increased production of the sebum (oil) produced by the pilosebaceous duct. Sebum builds up in the duct, which is already blocked with skin cells, and is a perfect breeding ground for a bug called P. acnes, which is present on everyone’s skin but which causes particular problems for those prone to acne. Infection of the pilosebaceous duct by this pesky bug is the third process causing acne, and is responsible for the characteristic red bumps (papules), squeezable spots (pustles – please don’t squeeze them, by the way!) and large red lumps (nodules) due to the inflammatory effect the infection has on the skin. Spots infected with P. acnes can be very sore, and can get quite big and burst – this may eventually lead to scarring. Not surprisingly, spots are more often seen in areas of the skin where there are many pilosebaceous ducts, such as the face, back and chest. True acne vulgaris will always have more than one type of spot visible (comedones and papules, for example) – if there is only one type of spot on the skin, your doctor may want to think about whether a medication such as steroids might be at fault instead.

Acne should be treated comprehensively and promptly
Treatment for acne is most effective if it is started swiftly, and if it tackles all three of the processes which lead to the spots forming. Perhaps surprisingly, so-called “topical” treatments (those which are applied directly to the skin – remembering to apply it to the whole affected area, not individual spots, as there may well be P. acnes infection or comedones that can’t be seen with the naked eye) are very highly effective. Benzoyl peroxide acts as an anti-inflammatory and anti-microbial preparation, is very good at tackling blackheads/whiteheads and should really be used as part of every anti-acne regimen. Take care though – it will bleach clothes! Another excellent topical treatment is a retinoid such as adapalene – this stops the over-production of skin cells that can block the ducts, and also has anti-inflammatory effects. Adapalene commonly causes a low-grade irritant dermatitis (a bit like sunburn) in the initial stages, which is made much worse by scrubbing. Try to persevere though – these side effects often lessen with time. Benzoyl peroxide is available in combination with adapalene, to make application less bothersome.

The infection element of acne vulgaris can be tackled by the use of antibiotics. These can be topical, and can also be found in combination with adapalene or benzoyl peroxide. Alternatively, antibiotics can be used systemically – that is to say, taken by mouth – either method, if used long-term, can lead to the development of antibiotic-resistant bugs. Common sense would tell us that oral antibiotics shouldn’t be used “first line” until topical treatment has been tried; and we also know that topical adapalene and benzoyl peroxide speed up the rate of response to oral and topical antibiotics, so a combination approach is always recommended. Oral antibiotics are particularly effective against inflammatory skin lesions (papules, pustules and nodules) but they do take some time to work – be prepared to be taking antibiotics for at least a couple of months, in combination with topical treatments, before you see any real improvement (all acne treatments work on “tomorrow’s skin” – the skin that hasn’t yet been formed) and you will probably need to accept that treatment will last at least six months. Oral antibiotics should be stopped as soon as there is no further improvement in the skin. Please tell your doctor if you are pregnant or have a personal or family history of lupus (systemic lupus erythematosus) as this will affect which antibiotics you are able to be prescribed.

In women, hormonal forms of contraception might help acne by moderating the effects of testosterone on the skin. Progesterone-only pills (the so-called “mini-pill”) do NOT help acne, however, and can make things worse. Standard combined oestrogen and progesterone contraceptive pills can help acne by blocking the production of testosterone by the ovaries; Dianette and Yasmin are specific brands of combined pill which also directly block the effects of testosterone on the pilosebaceous ducts, however, they do carry a higher risk of causing blood clots than the other pills, and may well not be suitable for every woman, so please discuss this with your doctor. Also, please bear in mind polycystic ovarian syndrome (PCOS), which is a complicated hormonal disorder of women characterised by the effects of excessive “male” hormones, including acne, alongside period problems and excessive body/facial hair and which may well be associated with obesity – if you think this may apply to you, please discuss this with your doctor, as you may need further investigations and more involved treatment to get on top of the symptoms.

Finally, for severe acne which has not responded to combination treatments, dermatologists can prescribe Roaccutane. Roaccutane is a powerful oral treatment, in the same class as the topical retinoids mentioned earlier, and two thirds of patients who receive it will be “cured” of their acne. However, it has quite a few serious potential side effects, and patients need to be monitored very closely when taking it. Firstly, Roaccutane causes birth defects – women who take it need to be using two separate forms of contraception and will need to have regular pregnancy tests; it is safe to conceive after treatment has been stopped for five weeks, however. Secondly, Roaccutane can cause elevated liver and cholesterol blood tests, so these need to be checked before starting treatment and monitored regularly throughout treatment. Thirdly, Roaccutane causes dry, flaky skin, especially in the sun, and can cause muscles and joints to ache. Finally, Roaccutane has been associated with depression and even suicide (some may argue that the link is with severe acne, rather than with treatment, but it is still a very important consideration, especially if patients have had any mental health problems in the past).

What else can you do to help improve your acne?
There is no evidence that diet makes any difference, although eating well will help general well-being and health. Sunlight helps, probably because ultra-violet light has anti-inflammatory properties, but do make sure you use a non-comedogenic high factor sunblock and avoid sunbeds – excessive light exposure can worsen the side effects of treatments like adapalene, antibiotics and Roaccutane, and can lead to patchy pigmentation of the skin after the acne inflammation settles down. There are various specialist procedures such as laser resurfacing, chemical peels, dermabrasion and so on, which can be effective in reducing visible scars, and your GP can advise you on this after your anti-acne treatment has finished.

Living through acne can seem like a difficult and lonely journey at times, but please take heart – there are many, many ways to treat it. Please make sure you find a sympathetic GP who is willing to take the time needed to listen to your concerns, and to work with you to tailor-make the perfect treatment plan for your individual needs. Acne is not just a “spot of bother” – it can cause crippling embarrassment, wreak havoc on self-esteem and take away some of the pleasure in entering adulthood, as well as carrying the risk of permanent outward scars in addition to emotional ones. If you or your loved ones are facing acne, don’t face it alone – see your GP. In a few months’ time you could well be ready for your close-up! 

If you have enjoyed this blog on acne, please feel free to like and share on social media, and pass on to any friends you think might be interested. Wishing you well, Winchester GP