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.
The different types of lesion seen in acne reflect stages in the evolution of blockage of the hair follicle:
There is no one specific cause for acne, however the following factors are relevant:
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.
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.
Treatments for acne can broadly be divided into topical treatments, antibiotics, the contraceptive pill and other tablet 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.
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.
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.
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:
Rare side effects include:
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.
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.
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:
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.