Acne

What is acne and who gets it?

Acne is the common cause of 'spots'. Most people with acne are aged between 12 and 25, but some older and younger people are affected. About 9 in 10 teenagers develop some degree of acne. Untreated acne usually lasts about 4-5 years before settling. However, it can last for many years in some cases. Acne typically affects the face, back, neck, and chest. The severity can range from mild to severe.

What causes acne?

Understanding normal skin
Many small sebaceous glands lie just under the skin surface. These glands make the 'oil' (sebum) that keeps the skin supple and smooth. Tiny pores (holes) on the skin allow the sebum to come onto the skin surface. Hairs also grow through these pores.

During the teenage years, you make much more sebum than when you were a child. This is due to the hormone changes of puberty which stimulate the sebaceous glands. As a rule, the more sebum that you make, the more greasy your skin feels, and the worse acne is likely to be. Some people make more sebum than others.

Mild to moderate acne - blackheads, whiteheads, and small pimples
Some pores become blocked ('plugged'). This is due to the skin at the top of the pores becoming thicker, combined with dead skin cells that are shed into the pores. You can see the 'plugs' that block the top of the pores as tiny spots known as blackheads and whiteheads (comedones). Note: the black of the blackheads is due to skin pigment, and is not dirt as some people think. In many cases, acne does not progress beyond this mild stage.

Some sebum may collect under blocked pores. You can see this as small spots called pimples or papules. In some cases, the acne does not progress beyond this mild-to-moderate stage when you can see a number of small pimples, blackheads, and whiteheads.

Moderate to severe acne - larger spots and inflammation
Blocked sebum is ideal for a bacterium (bug) called P.acnes to live and multiply. Small numbers of this bacterium normally live on the skin, and do no harm. However, if large numbers develop in the blocked sebum, the immune system may react and cause inflammation. If inflammation develops, it causes the surrounding skin to become red, and the spots become larger and filled with pus (pustules). In some cases the pustules become even larger and form into small cysts.

Each inflamed spot will heal eventually, but a small, pitted scar may be left.

Some other points about the cause of acne

• Acne is not caused by poor hygiene. In fact, many people with acne wash more than usual. Some people think that extra washing will help (but unfortunately it does not).
• Chocolate, fried foods, sweets, or other foods do not cause acne.
• Acne is not just a simple skin infection. You cannot 'catch' acne - it is not contagious.
• Acne cannot be cured by drinking lots of water.

What makes acne worse?

• Some contraceptive pills may make acne worse. This is due to the hormones in some pills.
• In women, the hormone changes around the monthly period may cause a flare-up of spots.
• Stress is said to make acne worse in some people, but this is difficult to prove.
• Thick or greasy make-up may, possibly, make acne worse. However, most make-up does not affect acne. You can use make-up to cover some mild spots. It is probably best to use non-greasy make-up, and not to cover your face with foundation.
• Picking and squeezing the spots may cause further inflammation and scarring.
• Sweating heavily, such as doing regular hot work, may make acne worse. The extra sweat possibly contributes to blocking pores.
• Spots may develop under tight clothes. For example, under headbands, tight bra straps, tight collars, etc. This may be due to increased sweating under tight clothing.
• Some medicines can make acne worse. For example, some medicines taken for epilepsy, and steroid creams and ointments that are used for eczema. Do not stop a prescribed medicine if you suspect it is making your acne worse, but tell your doctor. An alternative may be an option.
• Anabolic steroids (which some body-builders take illegally) can make acne worse.

What are the treatment options for acne?

The aim of treatrment is to clear spots as much as possible, and to prevent scarring. Treatment will usually clear most spots if you take it properly. However, no treatment will clear your skin perfectly.

There are different types of treatment that work in different ways. A doctor or pharmacist will advise, and the treatment they advise will often depend on the severity and type of your acne.

Topical (rub-on) treatments
There are many gels, lotions and creams that you can rub-on to affected skin. A rub-on treatment is often used alone to treat mild acne. Sometimes a rub-on is advised in addition to other treatments for moderate or severe acne. Different preparations work in different ways. For example:

• Benzoyl peroxide is a common treatment. It has three actions - kills bacteria, reduces inflammation, and helps to unplug pores. You can buy this at pharmacies without a prescription.
• There are various antibiotic rub-on preparations, but require a prescription. These kill bacteria and reduce inflammation.
• Certain rub-on preparations are good at unplugging pores. They include adapalene, tretinoin, azelaic acid, and isotretinoin. These come as various brand names. They tend to be advised if you mainly have blackheads and whiteheads, but with little inflammation.
• Some rub-on preparations contain two different ingredients which act in different ways.

Antibiotic tablets
These are commonly prescribed for moderate or severe acne. Antibiotics kill the bacteria in the spots, and reduce inflammation. A 3-6 month course will usually clear most spots. Tetracycline antibiotics are the most widely used, but other types also work well.

Isotretinoin tablets
Isotretinoin greatly reduces the amount of sebum that you make by the sebaceous glands. It works very well, and usually clears spots even in severe cases. However, it is normally used only on the advice of a specialist after other treatments have been tried first. This is because there is a risk of serious side-effects with isotretinoin.

Hormone treatment
One type of contraceptive pill (dianette) contains hormones that help to reduce acne. This may be prescribed for women with acne who also want contraception.

How long is treatment needed for?

Whatever treatment is used, it is normal to take 2-3 months for any improvement, and up to 3 to 8 months for most spots to clear. The most common reason why a treatment for acne fails is because some people think that treatment is not working after a month or so, and give up.

It takes time to un-block pores, for the inflammation to settle, and for fresh, healthy skin to grow. So, persevere with any treatment for at least 2-3 months before deciding if it is working or not. If there is no improvement after 3 months of taking a treatment regularly and correctly, do not despair. A change to a different or more powerful treatment will usually be advised, and is likely to work.

Will acne return after treatment?

Once the spots have cleared, acne commonly flares up again if you stop treatment. So, after the spots have gone, you will usually be advised to carry on with treatment to prevent acne from flaring up again. However, a lower 'maintenance' dose is usually sufficient to prevent spots from returning.

It is common to need treatment for 4-5 years to keep acne away. Most people with acne 'grow out of it' by their early 20's, and can stop treatment. However, in a small number of cases, acne persists into the 30's, or even later. In these cases, many years of treatment is needed to keep the spots away.

Some other points about acne

• Sun beds and sunbathing do not help acne.
• Wash your skin with normal soap and water. Do not wash more than normal (twice a day is usual). Do not scrub the skin harshly. Excess washing and scrubbing may cause more inflammation, and possibly make acne worse. Antiseptic washes are heavily advertised, but are unlikely to make any difference.
• You may prefer not to treat mild acne which is not inflamed (that is, if you just have blackheads, whiteheads and mild pimples). Mild acne is common, and usually goes in time without scarring. However, inflamed acne can scar. If you develop inflammation (redness, red spots, pustules, etc) then it is best to take treatment early to prevent scarring.
• Anxiety and depression are more common in people with acne. Do tell a doctor if you feel anxious or depressed about your acne.

Further help and advice

The Acne Support Group
PO Box 9, Newquay, Cornwall, TR9 6WG
Tel: 0870 870 2263   Web: www.m2w3.com/acne/ & www.stopspots.org

© EMIS and PIP 2004   Updated: September 2002   CHIQ Accredited   PRODIGY Validated