All you need to know
The effects of acne can persist for years; with disfigurement and permanent scarring resulting in significant psychosocial consequences, including diminished self-esteem, embarrassment, social withdrawal, depression and anxiety. Acne is a condition that can be managed very successfully, so read on …
Acne is a chronic inflammatory disorder of the pilosebaceous unit – the hair follicle – that affects 85% of adolescents and young adults. Pilosebaceous units are found all over the body except the soles of the feet and palms of the hands. The number of sebaceous glands is constant for life however they can get bigger with age.
- Sebum: A mixture of fats or lipids produced by the sebaceous gland in the skin. Normally sebum acts as a barrier and has antibacterial properties protecting the skin. The production of sebum is under the control of hormones and the production peaks at age 17/18.
- Keratinocytes: These are the main types of cells in the epidermis and lining the hair follicle. At the surface of the skin, they die off and are supposed to exfoliate and shed naturally but this does not always happen.
- Proprionibacterium Acnes: These are bacteria that are normally part of the skin flora that live primarily on the sebum secreted by sebaceous glands in the follicles.
What happens when hormones set in?
Androgenic hormones secreted by the adrenal glands are male type hormones like DHEA and Testosterone. They influence both the sebum and the keratinocytes. Androgenic hormones cause an increase in sebum production. They also increase the number and stickiness of the keratinocytes, reducing their ability to shed naturally. Both dead cells and sebum then block off the hair follicle, which forms a whitehead or a blackhead depending on whether it is open and oxidised (blackhead) or closed (whitehead). Once the duct is blocked pressure builds up…
Along comes P.Acnes which loves sebum. Sebum is “manna from heaven” for P.Acnes! The digested sebum gives off waste products and enzymes which are pro-inflammatory resulting in an inflammatory response in the skin.
The inflammation caused by the digested sebum is the biggest problem not the bacteria itself, so giving an antibiotic is not always the best solution. The inflammation results in a pustule or pimple. If squeezed it ruptures through the weakened follicle wall and digested sebum flows into the dermis. It is recognised as a “foreign body” and causes a huge immune response with phagocytosis and possible scarring.
If the pustule is left alone normal healing will happen, although in some unfortunate cases the immune response overreacts and a nodule forms resulting in scarring.
The four 4 primary factors causing acne are:
- Increase in production of sebum due to hormones
- Insufficient shedding of dead skin cells causing blockage of hair follicles, also due to hormones
- Increase in growth of P Acnes due to blocked sebum
- Inflammation with rupture of hair follicle into the dermis
Classification of acne
- Comedomal (non inflammatory) ie whiteheads and blackheads
- Papulopustular (inflammatory) ie pimples
- Nodular (inflammatory) solid raised nodules over 5 mm in diameter
Treatment of acne
Proper acne prevention and management should address all four of these factors. That is why doctors often need to treat with hormones and with antibiotics and products that cause the cells to turn over faster and dry out sebum.
- Avoid oily greasy products on skin, cleanse daily pollutants and sweat off the skin.
- Don’t pick/touch the face
- Avoid a high GI diet full of white carbs and sweets. It’s not greasy food or chocolate that is the problem…its sugar.
- Stress make acne worse.
- Use a cleanser that helps exfoliate and removes oils but is calming, soothing and hydrating to protect the skin barrier.
- Use a lightweight, oil-free, fragrance-free, non-comedogenic moisturiser.
- Some acne preparations are also anti-inflammatory and anti-bacterial and may even contain a retinoid which increases cell turnover.
- Use a spot control gel or serum for active lesions to help dry them out and heal quicker.
- Use a broad-spectrum sunscreen that is lightweight, oil-free hydrating and non-comedogenic.
- Use a non-comedogenic foundation when wearing makeup.
Medical treatments include
- Suppressing sebum
Because sebum is under the control of hormones the best way to reduce sebum is to use the oral contraceptive pill (such a s Yasmin, Yas, Minerva Ginette and Diane). There are some other oral anti-androgens and cortisone which also reduce sebum production but with many more side effects.
- Increasing exfoliation and cell turnover
Retinoids are a group of Vitamin A containing products that increase cell turnover in the skin and increase exfoliation. When using a retinoid it is important to start slowly as else ones skin can become flaky and red. This is called a “retinoid reaction” and is not an allergy as some incorrectly assume. Different examples of topical retinoids include Differin gel (adaptalene) Retin A, Ilotycin A and Retacnil. Benzoyl peroxide is mainly an exfoliator but is very irritant. Anything with salicylic acid (aspirin) or azelaic acid also exfoliates.
- Antibacterial agents
Oral Antibiotics such as Tetralysal, doxyxycline and minocycline can suppress the growth of P.Acnes but only for three to four months or else resistance occurs. Antibiotics also have anti-inflammatory properties. That’s why they work so well for papulopustular acne. Remember it’s the inflammatory response that is the real problem, not the bacteria. Besides antibiotics, other products have bacterial properties such as tea tree oil, the retinoids and salicylic acid (which is aspirin) . Antibiotic creams and gels don’t work well as they lead to more rapid resistance and can cause irritation.
As mentioned above , antibiotics have anti-inflammatory properties. Doctors sometimes prescribe cortisone which is anti-inflammatory. But cortisone is mostly injected into nodules rather than given orally due to the side effects. Azelaic acid (Skinoren) also has anti inflammatory properties.
- Isotretinion (Roacutane/Acnetane/Oratane)
This is an oral medication that reduces the size of the sebaceous glands and reduces the number of sebum-producing cells. Sebum production reduces by 90%. It needs to be used for 6-12 months. About 15% of people still relapse.
Isotretinoin is teratogenic, meaning that under no circumstances can a person fall pregnant while on it. It also is known to cause depression GI upsets and sensitivity to light so it is not to be used lightly. But it works exceptionally well for nodular acne.
There are other oral supplements for acne that contain Zinc and vitamin B3 which make a big difference to mild to moderate acne. But if the acne is nodular then something like Roaccutane is needed.
- In-house treatments
At an aesthetic centre acne treatments include deep cleanse extraction facials, regular chemical peels, PDT light, micro-needling, Tixel, microdermabrasion and laser treatments. Aesthetic doctors are also able to treat the scarring and pigmentation that often goes with acne.
Doctors may need to order blood tests if there is any chance of an underlying hormonal problem