Question: My son is 17 and has had a problematic skin since starting high school. He has tried numerous “wonder cures” and skin ranges but with poor results. He is hygienic and active. His confidence has taken a huge knock.
Answer: Your son’s situation is a tough one. Acne vulgaris is a common skin disease, characterised by areas of skin with seborrhoea (scaly red skin), comedones (blackheads and whiteheads), papules (pinheads), pustules (pimples), nodules (large papules) and possibly scarring.
It is not easy to manage, but can be treated according to its stage of severity with different medications and adjuncts.
Central to successful treatment lies a good understanding of the mechanisms of the disease as well as the areas targeted with specific interventions – treatment decisions should be clear and specific and progression monitored.
Who is at risk?
Acne occurs most commonly during adolescence and often continues into adulthood. In adolescence, it is usually caused by an increase in testosterone. Acne is not limited to teenagers. Although rare, babies are born with acne and some people get acne for the first time during adulthood.
There is certainly a genetic predisposition to developing it and skin type may also predispose a person.
Where are the most common sites?
Acne affects mostly skin with the densest population of sebaceous follicles, including the face, the upper part of the chest and the back.
What causes the condition?
The sebaceous (oil-secreting) glands in the skin and along hair shafts become clogged, inflamed and infected by bacteria. The lesions are caused by changes in pilosebaceous units, skin structures consisting of a hair follicle and its associated sebaceous gland. These changes require androgen stimulation.
Key features of the disease:
1. Increased production of oil stimulated by androgenic (male sex) hormones.
2. Obstruction of the opening of the follicle caused by increased production of scales (keratin).
3. Infection by a bacterium, namely Propionibacterium acnes. The bacteria P acnes and Staphylococcus epidermis occur naturally in hair follicles.
4. Rupture (breakage of the follicle leading to inflammation).
What is the course of the disease?
Acne diminishes over time in most individuals and tends to disappear by mid-twenties. There is no way to predict how long it will take for complete resolution, as some people carry this condition well into their thirties, forties and beyond.
Large nodules and the term nodulocystic have been used to describe severe cases of inflammatory acne. The “cysts” or boils that accompany cystic acne, can appear on the buttocks, groin and armpit area, and anywhere else where sweat collects. Cystic acne affects deeper skin tissue than does common acne.
Medical treatment of acne
Topical retinoids are effective in the treatment of comedonal acne. They can be used as monotherapy in individuals with exclusively comedonal acne. However, patients with an inflammatory component often benefit from the addition of concomitant antimicrobial therapies (for example, benzoyl peroxide or topical antibiotics) that reduce the number of pro-inflammatory P acnes colonising the skin.
Patients with moderate to severe inflammatory acne often warrant more aggressive treatment with oral antibiotics. Antibiotics in the tetracycline class are most frequently used and appear to have both antibacterial and anti-inflammatory properties. The use of benzoyl peroxide with topical or oral antibiotics decreases the emergence of antibiotic resistant bacteria
Acne typically recurs over years and maintenance therapy is an important component of acne management.
Androgens stimulate increased sebum production, which contributes to the formation of acne. Hormonal therapy may benefit women with moderate to severe acne.
Oral isotretinoin, a retinoid, decreases sebum production, reduces P acnes colonisation, and normalises follicular keratinisation. It is an option for patients with severe acne that cures or improves acne in the majority of patients who complete a full course of treatment.
Oral isotretinoin is used as monotherapy; a typical treatment course is 20 weeks.
Adjunctive therapies
Light-based and laser therapies, chemical peels, comedo extraction and intralesional glucocorticoids have also been used.
Tips for dealing with acne
External factors that contribute to acne – soaps, detergents and astringents remove sebum from the skin surface but do not alter sebum production. Repetitive mechanical trauma caused by scrubbing with these agents may worsen the disorder and promote the development of inflammatory lesions. Patients with acne should refrain from rubbing their faces or picking their skin.
Turtlenecks, bra straps, shoulder pads, orthopaedic casts, and sports helmets may all cause acne mechanica (a form of acne common in athletes), in which occlusion of pilosebaceous follicles leads to comedone formation. Pomade acne is associated with the use of occlusive, oil-based hair products.
The latest on diet
The potential role for diet in acne is controversial. A study of 47 355 women in the Nurses’ Health Study that used retrospective data collection to determine diet during high school found an association between acne and intake of milk. The authors suggested natural hormonal components of milk or other bioactive molecules in milk could exacerbate acne.
What are the long-term side effects ?
The main effects are devastating – psychological, such as reduced self-esteem and in extreme cases even depression and suicide. The psychological effects of embarrassment and anxiety can impact the social lives and employment of affected individuals. Scars can be disfiguring and lifelong. Acne usually appears during adolescence when most young people already tend to be most socially insecure.
Early and aggressive treatment is therefore advocated by some to lessen the overall long-term impact on individuals.