WHAT IS ACNE?

Acne, also known as acne vulgaris, is a common chronic inflammatory skin condition that occurs when hair follicles become clogged with oil and dead skin cells.

WHAT AGES ARE AFFECTED BY ACNE?

It is more common in teenagers, although it can affect people of all ages.

Acne is one of the most common skin conditions in the United Kingdom and leads to around 3.5 million visits to primary care every year.

The prevalence of acne is:

• 85% in those between 12-24 years of age
• 8% in those between 25-34 years of age
• 3% in those 35-44 years of age

Most people will find that they have acne coming on and off for many years before their symptoms improve as they become older. In some cases, acne can continue into adult life.

WHAT AREAS ARE AFFECTED BY ACNE?

The most common areas affected by acne are the face, back and chest.

Nearly everyone with acne will experience spots on their face, whilst around half will experience it on their back and only around 15% will experience acne on their chest.

WHAT ARE THE SYMPTOMS OF ACNE?

Acne causes spots, oily skin and skin that may be painful or hot to touch. It can present with whiteheads and blackheads and may lead to complications such as widespread inflammation and scarring.

There are difference types of spots caused by acne, which include:

• Blackheads
• Whiteheads
• Papules
• Pustules
• Nodules
• Cysts

What are blackheads?

Blackheads typically present with small black or yellowish bumps on the skin. Blackheads are not filled with dirt, but due to the inner lining of the hair follicle it produces a black colour.

What are whiteheads?

Whiteheads have a similar appearance to blackheads, however they will not empty when squeezed and may be firmer.

What are papules?

Papules are small red bumps on the skin, which may feel tender or sore.

What are pustules?

Pustules are similar to papules, however due to a build-up of pus they have a white tip in the centre.

What are nodules?

Nodules are large hard lumps that form and build up beneath the skins surface and they can be painful.

What are cysts?

Cysts are large lumps filled with pus and look similar to boils. They are the most severe type of spot caused by acne and may cause permanent scarring.

WHAT ARE THE CAUSES OF ACNE?

Acne is caused when hair follicles become blocked. Hair follicles can become blocked when sebaceous glands next to the hair follicles product too much sebum. Sebaceous glands normally produce an oily substance known as sebum, which aims to lubricate the hair and skin to stop it from drying. However, in acne, these glands may produce too much sebum which can mix with dead skin cells and block the hair follicle.

If the blocked follicle is close to the skins surface, it can bulge outwards and form a whitehead. Whereas if the blocked follicle opens towards the skin, then it can create a blackhead. In some cases, normally harmless bacteria on the skin can infect the blocked follicles and this can cause papules, pustules, nodules or cysts.

One of the most common causes of acne is hormonal changes during puberty. This is as certain hormones can cause glands next to hair follicles to produce larger amounts of oils such as sebum. This can change the activity of skin bacterium called P. acnes. P. acnes is usually harmless, but the change in activity can cause it to become more aggressive and causes inflammation and pus. Certain hormones also thicken the inner lining of the hair follicle, which can block the pores and contribute to acne. Certain hormones that can affect the glands include testosterone or hormonal changes that occur during periods or pregnancy or other conditions such as polycystic ovary syndrome.

Acne can also be related to your family history and currently there is no clear link between diet, poor hygiene or sexual activity caused acne. Although certain cosmetic products, medications (e.g., steroids, lithium, antiepileptics), smoking or items of clothing can contribute and cause flare-ups of acne.

WHAT ARE THE POTENTIAL COMPLICATIONS OF ACNE?

One of the major complications of acne is scarring. This is as any acne spot can lead to scarring but it is more common when nodules and cysts burst and damage the surrounding skin. Scarring can also occur when you pick or squeeze spots, which is why this is not recommended.

The three main types of acne scars are:

1. Ice pick scars – these are small, deep holes in the surface of the skin
2. Rolling scars – these present as a rolling or uneven look caused by bands of scar tissue forming under the skin
3. Boxcar scars – these are round or oval depressions or craters in the skin

Other complications of acne can include post-inflammatory hyperpigmentation (PIH), which is discoloration of the skin that follows an inflammatory wound and may present as dark marks or spots left behind after a pimple heals which can be more aggravating and distressing or depigmentation, which is a loss of skin colour after the skin has healed.

Acne scarring may require cosmetic surgery which is not normally available on the NHS. However, if you plan on having cosmetic surgery, you can discuss your options with your GP. The British Association of Aesthetic Plastic Surgeons website has information about private treatments available in your area. Prices can vary quite widely and it is important to have realistic expectations and an understanding that whilst it may help the appearance, it can not get ride of all acne scars completely.

One other complication of acne is depression. This is as acne can cause people to feel self-conscious with intense feels of anxiety and stress and can lead to people becoming socially withdrawn. It is important to realise that acne is common and it is important to speak to your GP if you are feeling depressed. Symptoms of depression include feeling down, having little interest or pleasure in doing things and a lack of energy. Your GP or suitable healthcare provider may be able to suggest potential treatment options for depression including cognitive behavioural therapy (CBT) or antidepressants as suitable.

HOW IS ACNE DIAGNOSED?

Acne is normally diagnosed by visual inspection and from your GP looking at your skin. Typical areas that will be examined for different types of spots are your face, back and chest. Your GP will normally diagnose you with either mild, moderate or severe acne which is normally categorised by your symptoms as described below:

• Mild acne – this normally involves whiteheads and blackheads, with a few papules and pustules
• Moderate acne – this normally involves more widespread amounts of whiteheads and blackheads with many papules and pustules
• Severe acne – this normally involves a lot of larger, painful papules, pustules nodules or cysts and may include scarring

When making a diagnosis, your GP may consider other potential issues such as rosacea, perioral dermatitis, folliculitis and boils, keratosis pilaris and consider whether any medications you are taking may be contributing or causing your acne.

WHAT ARE SOME TIPS TO MANAGE ACNE?

There are some treatment options available to manage acne which you can discuss with your GP or a suitable healthcare professional. Although certain treatments may be helpful, there are also self-care measures you can take which may be useful. These include:

• Do not wash your skin too often – frequent washing can irritate the skin, which may make symptoms worse so try not to wash affected areas more than twice a day
• Use mild soap or cleanser and lukewarm water when washing affected areas – this is as very hot or cold water can make your acne worse
• Avoid trying to over clean or squeeze spots – this can lead to permanent scarring and make your acne worse
• Do not use too much make-up or cosmetics – when using such products, try to use water-based products that are non-comedogenic as they are less likely to block the pores in your skin
• Remove make-up before going to bed
• Use fragrance-fee water-based emollients on dry skin
• Exercise regularly – this will help boost your mood and help with any emotional impact of acne. You should always try to shower as soon as possible after exercising as sweat can irritate your acne
• Keep your hair out of your face – this is as it can cause spots and you should look to regularly wash your hair to keep it clean

WHAT TREATMENTS ARE AVAILABLE FOR ACNE?

Acne can not be cured, however it can be managed and controlled with treatment. Mild acne may be managed at your local pharmacy as your pharmacist should be able to provide advice and discuss treatment options such as creams, lotions and gels that may be available. Many of the over-the-counter treatment options contain benzoyl peroxide which is available in a low concentration and can be helpful in managing your acne.

WHEN SHOULD YOU SEEK MEDICAL ADVICE?

As mentioned earlier, if you have mild acne you could speak to your pharmacist for suitable options to treat it. However, if these options do not control your acne or if you have moderate to severe acne, you should see your GP or a suitable alternative healthcare service. This is as nodules or cysts will need to be treated properly to avoid scarring.

Treatments for acne can include:

• Benzoyl peroxide creams and gels
• Topical retinoids such as adapalene, which is found in products such as Differin
• Topical antibiotics
• Azelaic acid
• Antibiotic tablets
• Some women may control their acne through the combined oral contraceptive pill

In mild acne where open and closed comedones (blackheads and whiteheads) predominate, single topical treatments such as topical retinoid such as adapalene or benzoyl peroxide should be considered as first line treatment. If both topical retinoids and benzoyl peroxide are not tolerated well enough, azelaic acid can be considered.

In moderate acne where inflammatory lesions such as papules and pustules predominate and response to topical preparations alone is not successful, an additional or an oral antibiotic such as lymecycline or doxycycline can be considered. However oral antibiotics should normally only be considered for a maximum of 3 months. Generally, if not contraindicated a topical retinoid such as adapalene found in products such as Differin or benzoyl peroxide should always be prescribed with oral antibiotics to reduce the risk of resistance.

In severe cases of acne, a GP may be able to refer you to a dermatologist, who are experts in treating skin conditions.

HOW LONG DOES IT TAKE FOR TREATMENTS TO WORK?

Treatments vary in response and not all individuals will respond the same way. Treatments generally take around 3 months to work, but once they do begin to work, it can lead to effective and good results. Therefore, it is important to encourage patients to be patient and persist with the treatment.

WHAT NON-PHARMACEUITCAL TREATMENT OPTIONS ARE THERE?

Some treatment options do not involve medication, but these treatments may not work and are not routinely recommended. Such treatment options include:

• Comedone extractor – this is a small instrument that can clean out whiteheads and blackheads
• Chemical peels – this is a chemical solution, which is applied to the fact to cause the skin to peel off and be replaced by new skin
• Photodynamic therapy – this is where light is applied to the skin in an attempt to improve acne symptoms

WHAT MYTHS ARE ASSOCIATED WITH ACNE?

Some people believe that acne can be caused by a poor diet, dirty skin or poor hygiene. This is currently not true, with no research finding a clear link between these causes and acne.

Others believe that sexual activity can influence acne, but there is no clear evidence to support this.

Furthermore, many people try to manage their acne by squeezing blackheads or whiteheads, but this is not true and can make acne worse and cause scaring.

Also, people believe acne is infectious however you can not pass acne to other people and it is not infectious.

Last but not least, some people believe toothpaste can help dry up spots, however whilst toothpaste does contain antibacterial substances, it also contains other substances which may irritate and damage your skin. For this reason, using toothpastes for spots is not recommended as there are more effective, safer and proven treatments available from your pharmacy, GP or alternative suitable healthcare provider.