What is acne?

Acne is a very common condition that will affect most men at some time in their lives. I see many men with acne in my clinic and in my experience it is not uncommon for men to delay seeking treatment and to present after many years of struggling with their skin leading to scarring and loss of confidence.

Whilst acne affects both sexes equally during the teenage years, men are more likely to develop severe acne and to have longer lasting acne that continues as an adult. Male acne may also affect areas such as the back and chest. The good news is that in almost all cases even severe acne can be effectively treated. and where scarring has already occurred significant improvements can be achieved.

Acne is caused by blockage of hair follicle openings 'pores'. The different types of skin 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. examples
• 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. examples
• Inflammatory acne: When the hair follicle becomes inflamed or infected it appears red, this is the classic acne spot. examples
• 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. examples

Which conditions can be confused with acne?

Whilst the diagnosis of acne is generally straightforward, there are a number of conditions that can be confused with acne and for which the treatment is very different. During an acne consultation, I will examine your skin to verify that the diagnosis of acne is correct and to ensure that there are no other co-existing conditions are also present. Conditions that can be confused with acne include:-

• Perioral dermatitis: This is a common condition that causes clusters of reddish spots on the chin, around the nostrils and sometimes around the eyes. examples
• Papular rosacea: This is another common condition causing redness of the face. Some forms of rosacea cause predominantly red spots on the face that can be mistaken for inflammatory acne. examples
• Milia: These appear as small white spots on the face - particularly on the upper cheeks. They can be mistaken for acne whiteheads. They are caused by the build up of keratin beneath the skin surface. examples
• Pseudofolliculitis Barbae 'Razor bumps': This condition causes inflamed spots in the beard area. It is thought to result from short hairs irritating the skin and is far more common in men, particularly those with darker skin types. examples

What triggers breakouts in men?

Most men experience breakouts as a teenager and whilst this will often resolve with time, some men continue to experience breakouts throughout their lives and are unaware that effective treatments are available.

The following are some factors that trigger breakouts in men:-

• Testosterone: The production of sebum is increased by the increased level of testosterone that occurs at puberty.
• 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.
• Anabolic steroids are sometimes taken by bodybuilders and increasingly by recreational gym users. These can cause severe acne and patients may be understandably reluctant to inform a doctor that they are taking them.
• Moisturisers - particularly thick moisturisers or skin oils.
• Beard oils, waxes and greasy skin and haircare products.
• Sustained pressure, for example from a mask, motorcycle helmet or from a weight bench in the gym can compress the openings of hair follicles triggering acne.
• Medications: Certain tablet medicines can trigger acne flares.
• Sweating: This can make acne worse, particularly on the back.
• 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 does the treatment of acne differ for men versus women?

A lot of the information available online relates to treatment of acne or breakouts in women. Whilst some of this information does also apply to men there are important differences.

• Men may be less accustomed to applying products to the skin and may prefer a tablet rather than topical treatment.
• 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.
• Powerful tablet treatments for acne are generally simpler to administer in men compared to women since a major concern with these treatments is the risk of falling pregnant with resulting fetal abnormalities.

How can you treat acne at home?

Mild acne can often be controlled with over the counter treatments. There is no need to overcomplicate things and I generally advise starting with a cleanser in morning and evening, daily sunscreen and benzoyl peroxide once or twice daily. If this is ineffective you can trial other non-prescription treatments including salicyclic acid, alpha hydroxy acids or retinol, however at this point is usually better to see a doctor to obtain medical-grade products which are far more effective (and often less expensive). This is particularly important when you have severe acne with scarring, which is highly unlikely to respond to topical (creams/ointments/lotions) treatments alone.

Benzoyl peroxide

Benzoyl peroxide kills bacteria that contribute the formation of acne lesions and helps to prevent excessive skin cell division and clogging of hair follicles with dead skin cells. It is available in concentrations of 2.5-10%. It can cause dryness and irritation of the skin particularly when high concentrations are used.

Other 'over the counter' active ingredients

Salicylic acid removes dead skin cells preventing the openings of hair follicles ‘pores’ from becoming blocked.

Alpha hydroxy acids (AHAs) encompass a wide range of products but the most widely used are glycolic acids and lactic acids. AHAs help to remove dead skin cells and reduce inflammation.

Retinol is chemically related to retinoids, which are frequently used prescription products for acne. It works in a similar manner reducing the production of sebum and regulating the division of skin cells (keratinocytes) to reduce blockage of hair follicles.

All of these products can be irritant particularly if you have sensitive skin and it is advisable to start with lower concentrations, to test on a small area of the face and to use less frequently than daily if irritation occurs.

Sunscreen

Sunscreen does not treat acne per se, however it is important to help prevent pigmentation occurring from acne spots in those with darker skin types and of course plays a key role in protecting your skin from premature wrinkling and skin cancer.

It is important to use a non-greasy sunscreen. I like the following products:-

• Anthelios XL 50+ ultra light fluid (La Roche Posay)
• Products from the Heliocare 360 range
• SkinCeuticals skin brightening SPF 30

Moisturiser

If you have acne-prone skin that is also dry than finding the right moisturiser can be challenging. You should look for non-oily, non-acnegeneic, non-comedogenic products. If you do not have dry skin at all then you most likely do not need to use a moisturiser and daily sunscreen will likely be sufficient.

You don’t need to spend a huge amount to find effective products. I like the following products:-

• Effaclar H (La Roche Posay)
• CeraVe moisturizing lotion
• Cetraben lotion
• SkinCeuticals Daily moisture

Shaving

Shaving with acne can be painful and uncomfortable. Be careful that you do not shave the tops of acne spots. If a razor is irritating your skin then try using an electric shaver. Sometimes, when you have severe acne, any form of razor causes discomfort and you may try a beard trimmer instead which does not remove hairs but keeps them short.

Some men develop a condition called pseudofolliculitis barbae 'razor bumps'. This can look like acne but is actually caused by ingrown hairs in the beard area causing skin irritation. It is more common in those with curly hair in the beard area and in those with darker skin types.

What about back acne?

Breakouts on the back often occur due to excessive sweating and can be triggered by exercise and warm weather. Some men continue to suffer from acne on the back even after acne on the face has been treated.

There are several things that you can do to minimize breakouts on the back:

• Wash with dermol 500 rather than soap or shower gel
• Use benzoyl peroxide
• Wear light cotton clothing next to the skin rather than tight compression garments
• Try to minimize pressure on the back - for example from benches in the gym

Despite these measures it can be difficult to treat acne on the back with topical products (creams/ointments/lotions) since it is hard to access and it is a large area. For this reason patients with back acne will benefit from consultation with a doctor to consider tablet treatment options.

When should acne scarring be treated?

Untreated moderate and severe acne will often lead to scarring of the skin. Men will sometimes come to me for treatment of acne scarring when they still have active acne lesions. In this scenario it is essential to get control of the acne - with powerful tablet treatments if necessary - before commencing treatments for acne scarring such as laser resurfacing. Indeed such treatments are futile without controlling acne since new acne scars will continue to appear!

After acne has been controlled scars will often improve significantly in appearance over time due to the natural remodeling of collagen that occurs with skin healing. For this reason it is usually advisable to wait for a minimum of 6 months and usually a year after completing treatment of acne before performing invasive procedures for treatment of acne scars. Another reason to delay treatment is that certain powerful tablet treatments for acne can impair wound healing and increase the risk of poor healing.

How can I help?

During an acne consultation, I will ask you how long you have been suffering from acne, what treatments you have tried, how it is affecting your life, what your current skincare routine entails and whether you have any other skin concerns. I will also ask you about your general health and any previous treatments that you have used.

Next, I carefully carefully examine your skin ensuring that the diagnosis of acne is correct, that there are not other co-existing conditions. I will also determine the types of acne lesions that are present, the severity of your acne and whether the distribution of the acne lesions gives any clue as to the causes.

At this point I will discuss with you the treatment options. This will be influenced by the following considerations:

• The types of acne lesions that are present (see above).
• The severity of the acne and whether there is scarring.
• How long your acne has been present.
• Previous treatments that you have tried for your acne.
• Other health issues that you may have.
• Any concerns that you might have regarding side effects of treatment.

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.

Mild acne can usually be treated with topical treatments (i.e. creams and lotions). Where topical treatments are not effective I will move on to tablet treatments. With moderate acne there are more numerous acne lesions and early scarring can be present. Topical treatments are less effective and a tablet treatment is often required.

With severe acne there are widespread lesions and it is important to treat promptly and effectively to minimize scarring. This will almost always require a systemic (tablet) treatment.

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:

• Make a list of the treatments that you have tried previously, how long you used them for and whether they were effective.
• Make a list of questions that you have for me.
• Take some photographs in the weeks before your appointment as the severity of acne can fluctuate
• Do some research as to what treatment options are available and which of these might be suitable for you.

Many patients prefer to come in person for an initial visit, however with clear photographs acne can be effectively assessed and treated remotely. Acne scarring is better assessed in person as an evaluation of the 3-dimensional morphology of the skin is required as well as dynamic assessment for tethering of the skin surface to deeper structures.