QUESTION: My son is 17 years old and has been suffering with a problematic skin since starting high school. He has tried numerous “wonder cures” and skin ranges but with poor results. He is a hygienic and active sportsman with loads of potential, and highly skilled as an orator.
Since January this year he has progressively retreated into a social bubble and I can see his confidence has taken a huge knock. He doesn’t date anymore and seems to isolate himself from large parties. I feel helpless as his mom.
We have stopped chocolates, fizzy drinks and have immaculate skin routines but seem to be getting nowhere.
ANSWER: Your son’s situation is a tough one and I’m sure thousands of parents and young people can identify with you. 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 an easy condition to manage, but can be treated according to its stage of severity with different medications and adjuncts. In most cases, it is a self-limiting condition.
However, 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 immaculately.
Who is at risk?
Acne occurs most commonly during adolescence and often continues into adulthood. In adolescence, acne is usually caused by an increase in testosterone which accrues during puberty, regardless of gender. Acne is not limited to teenagers. Although rare, babies are born with acne and some people get acne for the first time during adulthood. Most people outgrow acne, but in women it may last until menopause. Five percent of women older than 40 years have acne; but only one percent of men do in that age group.
There is certainly a genetic predisposition to developing this condition and skin type may also predispose a person to acne.
Where are the most common sites?
Acne affects mostly skin with the densest population of sebaceous follicles; these areas include 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 Propionibacterium 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 usually 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. Thus the level of scarring is also worse.
Medical treatment of acne
Topical retinoids are effective in the treatment of comedonal acne due to their ability to normalise follicular hyperkeratosis and prevent formation of the microcomedo.
Topical retinoids 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. The preventive effect of topical retinoids and the concern for antibiotic resistance make topical retinoids ideal candidates.
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 essentially cures or significantly 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. This drug has multiple side effects and is US Food and Drug Administration approved only for use in patients with severe, recalcitrant, nodular acne. Oral isotretinoin is teratogenic and female patients who are potentially childbearing should use two forms of contraception.
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 by rupturing comedos and promoting 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 young 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.
Causes of raised sebum production or raised hormone levels:
* Pregnancy.
* Stress.
* Menstrual periods.
* Medicines – corticosteroids.
* Male sex hormone testosterone present in both men and women.
* Female sex hormone progesterone – only in women.
* Dr Darren Green, a trusted figure in the field of media medicine, is a University of Stellenbosch graduate who adds innovative spark to health and wellness issues.
He features on 567CapeTalk, and is a regular guest on SABC3 and the Expresso show. Dr Green works as an emergency medical practitioner at a leading Cape Town hospital and completed four years of training as a registrar in the specialisation of neurology.
If you’ve got medical problems, contact the doctor at [email protected], 021 930 0655 or Twitter @drdarrengreen. Catch him in Cape Town on 567 CapeTalk, most Fridays at 1.30pm.
The advice in this column does not replace a consultation and clinical evaluation with a doctor.
Cape Argus