ACNE

Frequency

Many adolescents will at some time have a few acne spots (often called zits): some 15% have more troublesome spots referred to as acne. Its treatment may require the help of a general practitioner and, at tines, of a skin specialist (dermatologist).

Onset and duration

Acne usually starts in the early teens and, without effective treatment, reaches its peak between 17-21 years. Most patients then improve and are spot free by 25 years; in a few people, acne may persist to the age of 40 or even beyond.

What are acne spots?

Acne is a disease based on the grease glands in the skin (sebaceous glands) and their channels (ducts) through which the grease (sebum) passes to the surface. These glands occur mainly on the face, back and chest, which are therefore the main sites for acne.

Acne is associated with increased grease production, and people with acne often notice and complain of the greasiness of their skin.

Those who have acne will recognise several different spots. Most know what a blackhead looks like. White heads are skin-coloured spots of roughly the same size as blackheads and often outnumber them.

The small red lumps seen in acne are called papules and the yellow spots are pustules. Depending upon the degree of inflammation, spots may become big and, at times, tender. Such large spots are called nodules and may lead to scars of which there are two types. Scars may be raised from the skin surface (keloid scars) or depressed (atrophic scars).

The spots of some patients with black skin become dark and this pigmentation can last for months.

It is therefore important that such patients are treated early.

The reason for spots

Grease glands are controlled by the sex hormones and this is why acne arises at puberty. In males, these hormones are produced mainly in the testicles and, in females, by the ovaries and adrenal glands. However, acne is seldom due to an excess of these hormones; usually, it is due to an excessive response of the grease glands to normal hormone levels.

It is still not clear why and how blackheads and whiteheads develop. But some components of the grease secreted by the sebaceous glands probably play a part in their formation.

Skin bacteria are important too in the formation of the red and yellow spots. After puberty, the skin of the face and upper trunk, with or without acne, contains bacteria. The most important bacteria in acne are called Propionibacterium acnes; these get into the ducts of the grease glands where they make chemicals which eventually escape into the deeper parts of the skin. This does not mean acne is infectious: it is not. It is due to the action of normal skin bacteria on the abnormal quantity and quality of grease produced by acne sufferers. Washing, or the lack of it, does not influence acne.

Factors which aggravate acne

A flare of acne is common just before the monthly period. Pregnancy does not usually influence acne. Sunshine may help acne, but sunbeds give little benefit. Diet has probably no role in acne and poor personal hygiene does not worsen it. Squeezing spots usually aggravates the problem. Stress may also aggravate the problem.

Acne may start later than usual: for example, in women aged more than 25 years. However, the facts which apply to ordinary spots apply to this age group also.

Treatment of acne

Acne can be treated effectively only of the following rules are understood by patients, pharmacists and doctors.

General principles

It is important to remember that acne lasts for many years but that, despite this, the spots can usually be kept under excellent control: 90% of patients show a 50% improvement in 3 months and an 80% improvement within 6 months, but continuous treatment is necessary for many years. Those who require treatment by mouth, usually in the form of antibiotics, may need repeat courses, each lasting at least six months.

Treatment applied to the skin (topical treatment)

Most patients with mild acne will respond reasonably well to treatment applied to the skin (topical treatment).

Types of topical treatment

Some can be brought direct from a chemist's shop; others require a doctor's prescription. The most effective topical preparations which can be brought over the counter contain benzoyl peroxide. These are also available from your doctor, who may also prescribe topical retinoic acid or its derivatives (a vitamin A treatment) or topical antimicrobial agents. These include benzoyl peroxide, antibiotics and azelaic acid. Topical treatment has to be applied not just to the spots but to the whole of the affected areas and should be continued as acne improves, to keep the posts under control.

Side effects of topical treatment

Mild irritation with some scaling and redness occurs frequently and can easily be controlled by cutting down the number of applications from two to one a day, or even less often, and applying them to less irritated parts of the face only. Moisturisers will help to control dryness and, with continued treatment, these problems usually settle.

Treatment by mouth (oral treatment)

There are three types of oral therapy: antibiotics, hormones, and retinoids. All are available and, with the exception of retinoids, should be combined with topical therapy.

Oral antibiotics

The most frequent oral treatments are antibiotics. Initially, the most commonly prescribed ones are tetracycline or oxytetracycline which should be taken twice daily for six months. It is important to take them 30-40 minutes before food with water to get the greatest benefit. Alternative antibiotics include erythromycin, doxycycline, trimethoprim and minocycline. Occasionally the skin bacteria may be resistant to the antibiotic and changing the antibiotic may be helpful.

Antibiotics act in two ways: they reduce the number of skin bacteria and also reduce inflammation.

Side effects of antibiotic therapy

Antibiotics have proved to be very safe. Rarely, however, a widespread itchy rash may appear and therapy has to be stopped. Minimal sickness or abdominal pain (colic) may occasionally occur, sometimes with mild diarrhoea. This usually stops after a few days or may need other treatment for a few days. Antibiotics taken by mouth may also slightly increase the risk of contraceptive pill failure. So if you are on the pill - use additional contraceptive methods, such as the condom. Other mild side effects can included sensitivity to the sun (doxycycline) and darkening of scars (minocycline)

Hormonal treatment

Ordinary contraceptive pills have little or no effect on acne. However, your doctor can prescribe one particular pill (Dianette) which is often helpful. Its action is to reduce excessive grease production. It is usually taken for 12-36 months.

Side effects of hormonal regimes

The side effects of Dianette are the same as those of an ordinary contraceptive pill; ask your doctor to explain these to you if you want further information.

Isotretinoin

Oral isotretinoin is very effective but can only be prescribed by a dermatologist whose instructions must be strictly followed.

If you have severe acne, and do not respond to other treatments, you may be given this drug which is neither a hormone nor an antibiotic. It is related to vitamin A.

A four-month course is usually needed, after which, most patients' acne will be virtually clear.

Side effects of Isotretinoin

All patients develop considerable drying of their lips and skin (especially of the face); some have mild aches and pains of their joints, and headaches. However, all these side effects can be easily and well controlled, such as by using a simple analgesic, like paracetamol. It is very rare to have to stop treatment. BUT - the drug will harm an unborn baby and pregnancy is totally forbidden while on treatment and for one month after the course has finished.

Treatment of scars

Patients with severe acne often develop scars, and scars are difficult to treat. Many with slight scaring accept it, and, with time, the scars tend to improve. Topical retinoids used long term may be helpful. Carefully selected patients with bad scarring may be considered for an operation called dermabrasion. This is performed usually by plastic surgeons, under a local or general anaesthetic. The success rate is about 25-70%. Only patients who are strongly motivated to have the operation should be recommended for it. If in doubt, surgery should be avoided. Collagen injections help a small number of patients.

How successful is treatment for Acne?

Acne is usually one of the easiest of the persistent skin conditions to treat, but it must be treated sooner rather than later. Early treatment minimises the risk of scarring. It is important for you not to give up your treatment since doctors can now offer therapies which can guarantee a satisfactory result in virtually everyone.