I understand the huge impact that acne can have on your life and that you may have been living with it for many years and that this may be the first time that you are seeing a specialist to discuss treatments. I will take time to understand your concerns and answer your questions. When you come to see me in the clinic the consultation will generally include the following stages:-
The diagnosis of acne is usually straightforward and can be made by examination of the skin, however there are several other conditions that can be confused with acne:-
The treatment is different for these conditions and during an acne consultation, I will examine your skin to verify that the diagnosis of acne is correct and to assess whether co-existing conditions are also present.
Acne is caused by 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.
Whiteheads, also known as closed comedones, are formed when the neck of the hair follicle becomes blocked, manifesting as a whitish bump on the skin. Blackheads or open comedones are similar in nature, but the opening of the hair follicle is clogged with debris, giving it a black appearance. Inflammatory acne, the classic acne spot, presents as a red lesion and occurs when the hair follicle becomes inflamed or infected. Further inflammation or infection can lead to pustules, which are collections of white blood cells and acne nodules and cysts, which are large lumps that may persist for extended periods and have the potential to cause significant scarring.
During your consultation I will establish the types of acne lesions that you have, the degree of severity of your acne and I will look for features of hormonal acne which often affects the lower face and jaw and can vary in severity with the hormonal cycle.
A number of factors can trigger worsening of acne and I will ask you questions to assess whether any of the following could be relevant:-
The following factors play a role in deciding which treatment is best for your acne:-
Mild acne will often respond to topical treatments (creams, gels and lotions) including benzoyl peroxide, topical antibiotics and topical retinoids. Over the counter products containing retinol, retinoids, AHAs, azelaic acid and salicylic acid can also be of benefit. Where topical treatments are not effective the next step would often be tablet treatments.
Moderate acne will often not fully respond to topical treatments and may require tablet treatments such as antibiotics, the oral contraceptive pill (females only) spironolactone (females only) or isotretinoin (roaccutane).
Hormonal acne often affects the chin and jawline area in women and can be driven by increased levels of the male sex hormone testosterone (which is naturally present at low levels in women as well). Topical treatments tend to be less effective, however tablets which block the male sex hormone such as spironolactone or the oral contraceptive pill can be helpful.
With severe acne there are widespread inflammatory papules, pustules, nodules and cysts and it is important to treat promptly and effectively to minimize scarring. This will often require tablet treatments.
Acne treatments can broadly be classified into topical treatments (creams, lotions, gels) tablet treatments and laser/energy treatments.
Topical treatments are usually the first line of treatment for mild acne. They include benzoyl peroxide, topical antibiotics and topical retinoids. These treatments are often prescribed in combination. In many cases patients will have already tried one or more topical treatments before attending for a consultation with me.
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 and can be particularly effective for hormonal acne. It works by blocking male hormones and reducing sebum production and is usually very well tolerated. It can be taken for years if needed, however it is essential that you do not become pregnant whilst taking this treatment. Other potential side effects include breast tenderness and high blood potassium.
Retinoids are drugs with structural similarity to naturally-occurring vitamin A. They interact with retinoid receptors in cell nuclei with a wide range of effects including reducing the production of sebum by sebaceous glands. A number of retinoids are available topically including tretinoin, isotretinoin and adapalene. Retinol, whilst not technically a retinoid, has similar actions and is available without prescription in over the counter products.
Topical retinoids can be effective treatments for mild acne being particularly effective for comedomal acne which is dominated by whiteheads and blackheads. They are less likely to be effective treatments for moderate acne although can be used in combination with other treatments such as oral antibiotics.
Retinoids can also be taken in tablet form. Isotretinoin, also known as Roaccutane is one of the most effective treatment for acne with approximately 85-90% of patients seeing a long term improvement in the skin after completing a course of treatment. Isotretinoin is generally well tolerated, however there are a number of important side effects that you should be aware of. In particular it is essential not to become pregnant whilst taking the medication or for at least a month afterwards. Isotretinoin can cause mood disturbance and depression and has rarely been associated with suicide and it is essential to stop taking the medication and contact a doctor urgently if low mood arises. If you have previously suffered from significant depression or taken anti-depressants I will need you to see a psychiatrist to evaluate the safety of this medication before I am able to prescribe it.
In October 2023 the Medicines & Healthcare products Regulatory Agency (MHRA) introduced significant new regulations governing the prescription of isotretinoin. This has important implications for patients with mental health issues and for patients with the potential to become pregnant. These rules apply to all doctors prescribing isotretinoin and may mean that you need to attend for a consultation with a psychiatrist prior to starting treatment or need to attend for follow up appointments monthly during treatment. If you are considering treatment with isotretinoin then please read the following information prior to your appointment: Isotretinon regulations
A number of other treatments are available including light or laser treatments and superficial peels. Many of these treatments can be helpful for mild or possibly moderate acne, however they are unlikely to be effective for severe acne. More recently a newer laser treatment (Aviclear) has been developed which targets sebaceous glands in the skin. This can lead to a long lasting improvement in acne and will soon be available at OneWelbeck.
After your appointment you will receive a detailed letter summarising our discussions and my assessment of your skin. You can contact me by email or telephone at any time after the consultation if you have further questions or if anything was not clear.
Dr Lynch is available for acne consultations in Central London and Blackheath.