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Acne
What is acne, what triggers breakouts and how can I help?
BY DR MAGNUS LYNCH

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What is acne?

Acne is a very common condition that will affect most of us at some time in our lives. It is often mild and does not require any treatment, however it can be disfiguring with significant psychological and social consequences. The good news is that in almost all cases even severe acne can be effectively treated.

The causes of acne are complex and multifactorial, however fundamentally acne results from blockage of the hair follicle. The hair follicle is a blind-ended tunnel within which the hair grows. At the top of the follicle, close to the skin surface, a gland known as a sebaceous gland secretes sebum into each hair follicle. The lining of the hair follicle is made from modified skin cells that are shed through the opening of the follicle at the skin surface. The earliest abnormality in acne is an accumulation of dead skin cells within the opening of the hair follicle. Subsequent blockage of the follicle results in an acne lesion.

What are the different types of acne?

The different types of lesion seen in acne reflect stages in the evolution of blockage of the hair follicle:

  • Whitehead (closed comedome): This is caused by blockage of the neck of the hair follicle and appears as a whitish bump.
  • Blackhead (open comedome): This is similar to a whitehead, however in this case the opening of the hair follicle is clogged with debris and appears black.
  • Inflammatory acne: When the hair follicle becomes inflammed or infected it appears red, this is the classic acne spot.
  • Acne nodules and cysts: Further inflammation can lead to the development of large lumps (nodules/cysts) that can persist for a long time and lead to significant scarring.

What are the causes of acne?

There is no one specific cause for acne, however the following factors are relevant:

  • Age: Acne is most common in the teenage years and early 20s. It becomes less common with age but can come on for the first time in older individuals.
  • Hormonal factors: The production of sebum is increased by hormonal changes that occur at puberty and this is an important factor in the development of acne. Most patients with acne do not have a hormonal abnormality, however for women suffering from acne that also have irregular periods and/or excessive hair growth the diagnosis of polycystic ovary syndrome (PCOS) should be considered and this can be investigated by your GP with an ultrasound scan and blood tests.
  • Propionibacterium acnes: This is a common, harmless bacteria found on healthy skin, however in individuals prone to acne it can cause infection of hair follicles and worsen the condition.
  • Genetic factors: Acne and severe acne is more common when other family members have been affected. This reflects an inherited tendency rather than a specific acne gene.
  • Drugs: Certain medications including the progesterone only pill 'minipill', steroids and certain novel targeted cancer treatments can trigger the development of acne so it is important to tell your dermatologist about all medications that you are taking. The use of topical steroids, for example for the treatment of eczema on the face can also worsen acne.
  • Thick or greasy moisturisers or make up can block the opening of the hair follicle triggering the development of acne.
  • Sustained pressure, for example from a motorcycle helmet or from a weight bench in the gym can compress the openings of hair follicles triggering acne.
  • Diet: In most cases, diet does not play a significant role in the development of acne however some studies have shown an association between a diet high in milk or high glycaemic index foods.

What triggers breakouts?

  • Age: Acne is most common in the teenage years and early 20s. It becomes less common with age but can come on for the first time in older individuals.
  • Genetic factors: Acne and severe acne is more common when other family members have been affected. This reflects an inherited tendency rather than a specific acne gene.
  • Hormonal changes: The production of sebum is increased by hormonal changes that occur at puberty and this is an important factor in the development of acne. Medical conditions that cause hormonal changes such as polycystic ovary syndrome (PCOS) can also trigger acne.
  • A change in hormonal contraception, for example stopping the combined oral contraceptive pill, changing to a new brand or starting progesterone only contraception can trigger an outbreak.
  • Moisturisers and make up can block the openings of the hair follicle triggering the development of acne.
  • Sustained pressure, for example from a mask, motorcycle helmet or in the gym can compress the openings of hair follicles triggering acne.
  • Medications: For example corticosteroids prescribed for the treatment of eczema can trigger acne flares.
  • Diet: In most cases, diet does not play a significant role in the development of acne however some studies have shown an association between a diet high in milk or high glycaemic index foods.

How is acne diagnosed?

The diagnosis of acne is usually straightforward and can be made by examination of the skin. During your consultation I will establish whether your acne is mild, moderate or severe and whether it is comedomal or inflammatory. There are a few other conditions that can appear similar to acne but these are simple for a dermatologist to distinguish.

How does the treatment of acne differ for men versus women?

There are some important differences in the triggers and treatments for acne in men and women. In particular, whilst acne can be hormonally driven in both women and men, however tablet treatments which block the action of the male sex hormone (testosterone) are only suitable for females. For this reason I have written separate articles on the treatment of male and female acne.

What treatments are available?

Treatments for acne can broadly be divided into topical treatments, antibiotics, the contraceptive pill and other tablet treatments.

Topical treatments

Topical treatments (creams, gels and lotions) are usually the first line of treatment for mild acne. They include benzoyl peroxide, antibiotics (Duac, Zineryt ,Dalacin T), topical retinoids (isotrex gel, differin gel) and combinations of the above such as epiduo (benzoyl peroxide + retinoid). These treatments can be effective for mild acne, however they are unlikely to work for more severe disease. In most cases, by the time of consulting with a dermatologist patients will have already tried one or more topical treatments in addition to multiple over-the-counter (non-prescription) topical treatments.

Antibiotics

Antibiotic tablets are thought to work by reducing infection with Propionibacterium acnes although they likely have additional anti-inflammatory effects. Usually they will be taken for a course of a few months of treatment. Several different classes of antibiotic may be used. Tetracyclines, for example, lymecycline are usually well tolerated. Other antibiotics that can be used include erythromycin or trimethoprim.

Hormonal therapy

The combined oral contraceptive pill (OCP) is an option for women. It can be particularly beneficial for acne that flares prior to menstruation. Forms of the OCP, such as Yasmin, that also block male hormones (androgens) are particularly effective. Risks of the contraceptive pill include irregular periods, nausea, weight gain, breast tenderness, high blood pressure and blood clots. The progesterone only pill 'minipill' can in some cases exacerbate acne and in this situation changing to an alternative form of contraception may be advisable. All forms of contraceptive pill require ongoing monitoring and for this reason are prescribed by your GP rather than a dermatologist.

Spironolactone is another option for women. It works by blocking male hormones and reducing sebum production. It is essential that you do not become pregnant whilst taking this treatment and it must be used with effective contraception. Other potential side effects include breast tenderness and high blood potassium - the latter requires blood tests for monitoring.

Retinoids

Isotretinoin (trade name Roaccutane) is one of the most effective treatments available for acne. It has multiple effects on the skin and the production of sebum. In most cases, a course of isotretioin will lead to a longstanding improvement in acne, although some individuals may need a repeat course at some point in the future.

Isotretinoin can cause severe fetal malformation and therefore it must not be taken by pregnant women. Women at risk of pregnancy should use two independent methods of contraception for 1 month prior to treatment, throughout the course of treatment and for 3 months after completing the course of treatment.

Other common side effects include:

  • Dry lips: Almost all patients will experience this, the frequent use of a lip moisturiser - such as vaseline - is usually sufficient.
  • Dry skin: Isotretinoin will dry the skin, this can lead to the development of dermatitis. If you are getting dry skin you should use a non-greasy water based moisturiser, such as cetaphil.
  • Increased sensitivity of your skin to sunlight
  • Temporary hair thinning
  • Muscle ache and delayed recovery from exercise - this can be an issue for those competing in sports at a high level

Rare side effects include:

  • Liver inflammation (hepatitis): This is an uncommon but recognized side effect. Blood tests are performed before starting treatment and after approximately 2 months of treatment in order that it can be picked up early.
  • Disturbance of the fats (lipids) in the blood: This is rare in otherwise healthy individuals and is monitored with blood tests.
  • Mood disturbance: Isotretinoin has been associated with low mood and depression and there have been several cases of suicide whilst patients are taking isotretinoin. It is difficult to known to what extent depression and low mood are the result of the treatment with isotretinoin particularly since acne itself can cause low mood, however if you have suffered from depression you will be required to see a psychiatrist who can assess the safety of isotretinoin prior to commencing treatment. If you experience low mood whilst taking isotretinoin you must immediately stop taking it and seek advice from a doctor.
  • Inflammatory bowel disease: A link has been proposed between treatment with isotretinoin and the development of inflammatory bowel diseases such as ulcerative colitis and Chron's disease, however the evidence in this area remains inconclusive.

The British association of Dermatologists has produced a very helpful information leaflet that lists some additional rare side effects that may occur and provides additional information relating to treatment with isotretinoin and it is very important that you have read this and discussed any questions that you might have with your dermatologist prior to starting treatment.

It is important to appreciate that despite the possible side effects listed above, the majority of patients tolerate treatment with isotretinoin well experiencing only dry skin and lips and find it to be a safe and effective treatment. Nevertheless, due to this potential for side effects it can only be prescried under the supervision of a consultant dermatologist.

Isotretinoin is taken as a course of treatment with the total amount required to complete the course determined by your body weight. The minimum duration of treatment is typically 4-6 months. You will start with a relatively low dose since there can be a temporary flare in your acne at the beginning of treatment and to allow you to get used to any side effects. After the first month or so the dose is typically increased since a higher dose will shorten the duration of treatment, although it may worsen side effects.

All patients (male or female) will need to attend for follow up appointments every 2-3 months whilst on treatment with isotretinoin. Blood tests will be performed before starting treatment and then repeated after 1-2 months. Women of childbearing age are invited to participate in a pregnancy prevention program that requires monthly visits for a pregnancy test. This is not compulsary, however if you prefer not to participate you will have need to sign a disclaimer stating that you are willing to take responsibilty for not becoming pregnant.

Other treatments

A number of other treatments are available including light or laser treatemnts (such as the N-Lite laser) and superficial peels. There is some evidence that these treatments can be helpful for mild or possibly moderate acne, however there have been few rigourous studies comparing the benefits with the more established treatments described above. They are unlikely to be effective for severe acne.

How should I prepare for my consultation?

In order to get the most from your consultation and ensure that all of your concerns are addressed there are a few things that you can do in advance:

  1. Make a list of the treatments that you have tried previously, how long you used them for and whether they were effective.
  2. Make a list of questions that you have for the dermatologist.
  3. Take some photographs in the weeks before your appointment as the severity of acne can fluctuate.
  4. Ideally do not wear make up to the consultation in order that the dermatologist can carefully assess you skin. If you are not comfortable traveling to the appointment without make up then plan to remove at least some of the make up prior to your consutlation and re-apply afterwards.
  5. Do some research as to what treatment options are available and think about which of these might be suitable for you.

What will happen during my consultation?

I understand the huge impact that acne can have on your life and that you may have been living with it for many years. I will take the time to understand all of your concerns and answer any questions that you might have. I will begin by asking you questions about your skin and any previous treatments that you have used. I will also ask about any other medical conditions that you might have. I will then make a careful examination of your skin to assess the type of acne that you have and to look for any other conditions that might also be present.

According to the type and severity of your acne, I will discuss the treatment options with you. It may be that there is more than one possible treatment that is suitable for you and a significant part of the consultation will be spent in weighing up the advantages and disadvantages of these different options and helping you to decide on a treatment plan that suits you.

Dr Lynch is available for acne consultations at 55 Harley Street within the Skin55 clinic book a consultation.

Sources of additional information

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