Who gets acne?
It is a common condition we associate with adolescence, but did you know that it can develop in adults in their 30s to 50s?
Why do you get acne?
The skin is our barrier from the environment and has an important function of preventing water loss from the surface. In normal skin, a fine balance exists between water, lipids and proteins and any disruption results in the skin unable to maintain a good barrier function and losing water (Trans Epidermal Water Loss). If there is TEWL, the skin produces more keratin (the hard substance found on nails) in an attempt to slow down the water loss. This leads to the skin cells appearing thicker and more ‘hornier’ than normal.
Each hair follicle in the skin is attached to a sebaceous gland which produces sebum (oil). If there is excess water loss from the surface, the skin reacts by producing excess oil.
In those with acne, there is increased or abnormal ‘keratinisation’ and overactivity in the sebaceous gland causing excess sebum production.
What does acne look like?
Whiteheads and blackheads are clogged pores. Normally dead skin rises to the surface of the pore and is shed by the skin. When there is excess sebum, the dead cells stick together inside the pores and instead of rising to the surface, they get trapped inside the pore.
A whitehead is a closed comedone, where the pore is blocked, and the sebum is trapped under the skin.
A blackhead (open comedone) occurs in a clogged pore where the sebum gets exposed to air and changes colour to appear black as a result of oxidization and it is not dirt! Some people only get white or blackheads but sometimes it may progress.
There is usually an immune reaction to the blocked pore by the body as sebum is powerful at triggering inflammation. This may result in blemishes and papules which are raised red bumps that are tender to touch.
Our normal skin contains a bacteria known as Propionibacterium acnes (P.acne) which does not do any harm. In skin with clogged pores, the bacteria can get inside the pores where the environment is perfect for the bacterium to multiply quickly and flourish. The proliferation of these bacteria triggers an immune reaction in the skin. The resulting pus formation leads to pustules on the skin which appear as yellow pus-filled bumps on the skin.
In more severe forms, cysts or nodules may develop. These are larger, harder tender bumps which may burst or heal without bursting. They may or may not contain pus and may last for weeks or months. Scarring is very likely following cyst or nodule formation. Scarring can be permanent, and this is likely to cause pigmentary changes.
Commonest sites of acne correspond to the highest density of sebaceous glands which includes the face, back and chest. Uncommon, but possible sites for acne include shoulders, upper arms and buttocks.
Is acne different in adults?
In adolescence, boys are more often affected than girls but in adulthood, women are more likely to suffer from acne than men. Just as adult skin is different from teenage skin, acne is also different in these groups and requires different management.
What causes acne?
The sebaceous glands are sensitive to hormones, especially to androgens like testosterone. This stimulates sebum(oil) production in males and to a lesser degree in females. The fluctuation in hormone levels that occur during the menstrual cycle affects women. At menopause, the declining female hormone oestrogen creates a relatively stronger testosterone presence causing excess sebum. Some hormonal contraception methods, as well as conditions which cause hormonal abnormality like polycystic ovarian syndrome, affect hormonal balance.
Some people are genetically more susceptible than others, and it may run in families.
When we are stressed, we produce more cortisol which can subsequently increase androgen levels which increase sebum production.
Skin and hair care products
Any of these can affect the normal functioning of the skin, weaken it or cause clogging of the pores and predispose to acne.
Food that has a high glycaemic index causes spikes in sugar levels and this is thought to increase sebum production.
How can acne be managed?
Despite many claims, acne cannot be treated overnight. It is a chronic condition and needs commitment and regular treatment so be patient.
Treatment aims include:
Repair skin barrier to optimise healthy skin function
Reduce sebaceous gland activity and sebum production
Reduce bacteria level
Improve exfoliation to reduce blockage of pores
Improve skin texture
Maintain results and prevent relapse
It can often take 6-8 weeks for improvement of acne to be seen.
Skincare for acne
Here are some key ingredients used in medical skincare:
A cleanser containing salicylic acid is preferred. Salicylic acid is oil-loving (lipophilic) therefore reaches into the pores and breaks down the sebum. It also promotes cell turnover, therefore, gets rid of dead cells and has anti-inflammatory properties.
Vitamin A serum is a super serum that aims to normalise the skin. It reduces comedone forming by preventing dead cells clogging the pores, block inflammatory pathways which would normally lead to papules or even cysts. However, the higher the dose the better the effect but also expect to get some side effects. These include redness, peeling, skin irritation and dryness but this subsides with continued use as the skin adjusts and changes for the better. It can take 12 weeks for retinoid serums to show optimal results.
In the long term, retinoids have collagen remodelling properties which help with scarring from the acne. Retinoids also lighten pigmentation by inhibiting melanocytes distributing melanin into the skin cells.
This has 2 actions in acne management. It reduces the bacteria P.acnes by releasing oxygen into the follicles and oxygen is toxic to these bacteria. It also has a weak comedone breaking activity. Although it can work very fast at improving acne, staining is a problem as it can bleach bedding, towels and clothes.
Topical antibiotics used for acne are mainly used for their anti-inflammatory properties, but antibiotic-resistance is a high risk.
Combination therapies are preferred for their cumulative effect.
Oral medication for Acne
Antibiotics are used for their antibacterial and anti-inflammatory properties, but again resistance is likely, and results can take up to 6 weeks.
Oestrogen-containing contraceptive pills can be used to decrease the level of free androgens, but this can take 3-6 months to work and acne may return on discontinuation.
This is a specialist prescribed medication that is effective for acne. Due to potential side effects and the requirement for close monitoring with blood tests for adverse effects, it is normally reserved for severe scarring acne.
In-clinic treatments with energy-based devices (light therapy, laser) have been used to manage acne. These treatments reduce the pores and or reduce inflammation. Chemical skin peels exfoliate the skin allowing active products to penetrate and treat the acne while increasing cellular turnover. This is a very effective treatment to achieve proigressive results.
When do you need to seek help for acne?
As soon as possible!
What can you do if you have acne?
Don’t wash your skin too often or use harsh agents as irritation prompts the skin to produce more sebum.
Cleanse your face twice daily with an appropriate cleanser to clean the skin.
Avoid picking or squeezing the spots as trauma causes more inflammation and can lead to permanent scarring.
Avoid pore-blocking make-up.
Wear sun protection.