Acne is a very common condition that tends to affect teenagers and adults, mainly on the face and upper trunk where one finds oiliness of the skin and hair. This leads to multiple blackheads and whiteheads, red bumps and pustules and in the more severe form cysts on the skin.
Most teenagers develop acne but some develop it in a mild form for a short period of time, while others develop it in a more severe form for a longer period of time. The more severe forms of acne are often genetic and can start at a younger age. Unfortunately, if the acne is not treated properly it can persist into adulthood.
All acne is imminently treatable and nobody in this day and age should end up with permanent scarring or pigmentation.
There are many different ways of grading acne but I like to keep it simple:
At puberty males as well as females produce the hormone testosterone which works on their sebaceous glands causing the skin to become more oily. The top layer of the skin, the stratum corneum, becomes more sticky and the younger teenager then develops multiple, small blackheads and whiteheads. Young teenagers often present to me with what we call Comedonal Acne – in other words they just have an oily skin with multiple, small blackheads and whiteheads. It is therefore essential to start proper treatment at this stage. This would usually include a mildly foaming cleanser and a cream or gel that contains a topical Retinoid.
The next stage of acne is where the patient develops multiple, red papules (bumps) and deeper pustules. This is Papulopustular Acne. Treatment at this stage would include an oral Tetracycline antibiotic and topical Benzoyl Peroxide. In women, once the infection has settled down another treatment option is the oral contraceptive pill. This type of acne occurs when there is an overgrowth of the normal bacteria called Propionibacterium Acnes which is found in the pilosebaceous unit. It causes inflammation, pustules and sometimes deeper cysts if not treated.
If the acne has not been treated properly in the earlier stages it can progress into what we call Nodulocystic Acne. This is where the patient develops deeper red papules and deeper cysts in the skin. This type of acne unfortunately often leaves permanent scarring and on the upper back and chest it may leave keloid scarring. This is why it is imperative to rather treat acne at an early stage and never allow it to progress to this stage. The treatment of choice for this type of acne is Isotretinoin or Roaccuatane. This is the only drug that can put acne into remission and it contains a Retinoid i.e. a chemical derived from Vitamin A. It is a powerful drug and it needs to be given under supervision preferably by a Dermatologist. It does make the skin more sensitive to the sun so I often prescribe it more over the winter months.
A new type of treatment for acne that is now available in South Africa is the Acleara/Theraclear which is a laser-like device that emits a special wavelength of light that kills off the bacteria causing the infection and inflammation in acne. It also has a suction attached to it so that it is able to very effectively extract all the deeper blackheads and whiteheads. It complements the treatments discussed above but it is especially helpful in patients who are reluctant to take oral antibiotics or Isotretinoin. The two main causes of acne are genetic and hormonal:
Genetic or Hereditary
This often occurs in the most severe form of acne i.e. nodular cystic acne. In other words the affected person has inherited the tendency for this more severe form of acne from one of their parents. Unfortunately, this type of acne often starts at a younger stage even before 10 years of age and will tend to persist for much longer often into adulthood.
The affected person may use the correct products, have a perfect diet and not have any hormonal imbalances but they still get this more severe form of acne. Fortunately, many parents who have themselves suffered from this more severe form of acne, will bring their young teenagers to the doctor rather earlier than later.
All acne is hormonally linked and in most patients there will not actually be a hormonal problem as such. Most girls and young women will often get a flare of their acne just before their menstrual cycle and this is virtually regarded as normal.
There are however, a number of medical conditions such the Polycystic Ovarian Syndrome where there is a hormonal imbalance in women. As a result of this hormonal imbalance the affected patient produces too much of the male hormone, testosterone and this will cause increased oiliness of the skin, blackheads and whiteheads and a more severe form of acne. In addition, they will often have increased darker hair on the face, nipples and pubic region. It is important that this condition is diagnosed early and treated in the appropriate way. If it is not treated properly it can lead to more severe acne and scarring as well as infertility.
Other risk factors
Medications containing the hormone Progesterone:
- Oral form (Provera)
- Intramuscular injection (Depo-Provera or Nur-Isterate).
- Progesterone implanted under the skin (Implanon NXT)
- Progesterone released from intra-uterine devices (Mirena loop)
Oral & Topical Corticosteroids
I find that this is quite a common problem in my medical practice. A patient will use a potent topical corticosteroid cream on the face and this will produce a form acne.
- Anabolic Steroids
- Intramuscular Vitamin B12 especially given at a high dosage intramuscularly
- Lithium – Bipolar Affective Disorder
- Lamotrigine – Anti-Epileptic Medication & Mood Stabiliser
Acne Cosmetica or Pomade Acne
This is where a product or make-up is too rich or greasy and applied to acne-prone skin. It blocks the pores and this can aggravate the acne. It is important to always use products that are formulated for oily skins.
The skin often becomes used to certain climatic conditions and humidity. When travelling to a very hot, humid climate, people will often get a flare-up of their acne. The top layer of the skin, the stratum corneum, becomes better hydrated, plumps out and can block the pores causing a flare-up.
Dairy products and a high glycaemic index diet can make acne worse.
A Guide to follow if you suffering from Acne
• Seek treatment for acne earlier rather than later.
• Nobody should end up with severe Post Inflammatory Hyperpigmentation (PIH) or post acne scarring as this is imminently preventable with the correct treatment.
• There are different treatments for different degrees of acne.
• Treatment should be specifically tailored for the individual patient and this may require a Dermatologist’s opinion.
• Multiple factors have to be taken into account when treating acne – there is not one-size- fits-all when it comes to treating acne.
• There are some general principles for treating acne but these often have to be fine-tuned to the individual.
• Never try and scrub away the acne using harsh cleansers or scrubs as this can cause inflammation of the skin. Rather use a gentle exfoliating cleanser on the advice of your skin care professional.
We have very effective treatments for acne and no-one should suffer the psychological consequences of severe acne, or end up with permanent scarring. The take home message should be: