Acne

Development

Acne, or 'Acne vulgaris', is a chronic inflammatory disorder of the sebaceous glands, which occurs almost universally in adolescents. Onset is generally in line with puberty. Acne appears as a mixture of comedones, papules, pustules, nodules, cysts and scars on the face, neck, chest and back, sites where the greatest density of sebaceous glands are found. The severity and extent of the condition are extremely variable. Remission usually follows the end of puberty; however, up to 5% of women and 1% of men may continue to suffer from acne as adults, and may still require treatment in their forties.

To best treat the condition, it is important to understand the effect acne is having on the skin. Sebaceous glands are found in association with a hair follicle. The glands secrete sebum, a fatty fluid which lubricates the hair and spreads over the adjacent skin. In both males and females, puberty is accompanied by an increase in circulating androgens which stimulate the sebaceous glands to undergo enlargement and increase sebum production. The pores become noticeably enlarged. The skin thickens inside the follicle lining, the duct becomes blocked and this results in swelling due to the pressure of sebum production. At first the follicle is only partially blocked, and a trace of white can be seen through the hole. Melanin secretion into the sebum turns this whitehead into a blackhead. When the entrance is completely blocked, swelling leads to an inflammatory reaction and pustule formation. This may progress to rupture of the follicle and cyst formation. Bacteria and opportunistic yeast play an important role in the inflammatory reaction, increasing irritation, swelling and redness.

In addition to the androgenic sex hormones, other factors can adversely influence the course of acne. These include certain drugs, stress, humidity, sweating and occlusive clothing, along with generally poor hygiene and health. Though not scientifically proven, diet may be a factor in acne control. Acne is often improved by sunlight.

Management

The aim of treating acne is to prevent the emotional and, in some patients, the physical scarring associated with the disorder.
Patients with mild acne (mainly whiteheads and blackheads with few papules or pustules) can be treated by the community pharmacist. Those with moderate acne (frequent pustules and papules and mild scarring) or severe disease (nodules/cysts which will cause more extensive scarring) should consult their GP. In these latter groups, oral treatment started at an early stage may minimise scarring.

The main active treatments for acne either help to prevent the cause of the condition (antibacterials) or alleviate the symptoms (anti-inflammatories). Keratolytics are abrasive agents which break up the blocked follicles and increase skin turnover.

Anti-bacterials/Keratolytics:

Regular washing, at least twice daily, with water and an antibacterial is important in controlling acne. A number of gels containing detergents, antibacterials and keratolytics are available; these may be applied after cleansing. The most effective for mild acne are those containing benzoyl peroxide alone (eg. 'Panoxyl') or in combination with potassium hydroxyquinolone sulphate (eg. 'Quinoderm'). Both of these agents have both antimicrobial and keratolytic properties. Benzoyl peroxide is a skin irritant and your pharmacist should be asked for advice on its appropriate use.

Prescription-only Products for Application:

With all prescription products, it is imperative that the advice of the doctor and pharmacist be heeded. Some products are not suitable for use alongside over-the-counter preparations, such as some benzoyl peroxide products, or in certain patient groups, such as women of child-bearing potential. Also, exposure to sunlight may need to be avoided when using certain products.

Azelaic acid is suitable for patients with mild-to-moderate acne. It has antibacterial and anticomedonal properties. It causes less skin irritation than the retinoids or benzoyl peroxide.
Adapalene is a retinoid-like agent, appropriate for mild-to-moderate acne on the face, chest and back. It can also be used in combination with oral medicines for more severe cases of acne.
Tretinoin, and the similar agent Isotretinoin, are retinoids, or vitamin A derivatives. They act by modifying the thickening process of the skin and reducing sebum secretion. During the first 1-2 weeks of treatment, acne can actually worsen. Their main value is in reducing the formation of comedones.
Antibiotic applications are often used in patients who are unable to tolerate other preparations.

Oral Prescription-only Products:

Oral antibiotics are generally used for moderate acne in combination with a topical therapy, often benzoyl peroxide. It may take some 2-3 months for an effect to be seen, and certain antibiotics are not suitable for certain patient groups. The doctor should be informed if you are pregnant, breast-feeding, at risk of becoming pregnant, or on oral contraceptives.
For women who also wish to use oral contraception, a hormonal product containing an antiandrogen, which reduces sebum excretion rates, may be useful.
Oral Isotretinoin is reserved for cystic, severe acne which has failed to respond to an adequate course of a systemic antibiotic. It can only be prescribed by or under the supervision of a consultant dermatologist. It requires careful contraceptive cover and is not without side effects.

Other Points for Management of Acne:

Enjoy a nutritious, varied diet, including 'live' acidophilus yoghurt or acidophilus as a supplement to promote a healthy internal flora. Acne may be the result of too many acid-producing foods, such as sugar and chocolate, fats and greasy foods. Fruits (even citrus fruits) and vegetables help to alkalise the body. One's intake of whole-grains should also be increased.
Foods rich in vitamin A, beta-carotene, zinc and fish oils may promote healing of the skin. Essential fatty acids found in fish oils, evening primrose oil or seeds, such as sunflower seeds and flaxseed, may also reduce the inflammatory process involved in acne.
Drink at least 6 to 8 glasses of fresh water a day to help cleanse the body and prevent dehydration.
Smoking can be a contributory factor for acne. If you require assistance in quitting, talk to your pharmacist.
Use a light, water-based moisturiser as opposed to a thicker, oil-based cream which may block pores and promote the formation of more pimples. Exfoliating three times a week will help keep the skin clean and free from blackheads. Clay-based masks may also be used twice weekly to gently draw out impurities and improve the appearance of the skin. If your skin is sensitive, avoid using highly perfumed products. Ask your pharmacist or beauty consultant about hypo-allergenic skin care ranges, such as La Roche Posay.
Ask your pharmacist about Zeno, a portable, electronic, medical device that is available, without a prescription, in Ireland. Zeno is clinically proven to make pimples disappear fast. It applies a precisely controlled heat dose directly to the pimple through a metal pad, causing the acne bacteria to self-destruct.
Avoid picking at pimples which delays skin healing and can lead to scarring.
There are a number of techniques which help to reduce the visible signs of scarring. A beauty therapist will use techniques such as glycolic peels. A cosmetic surgeon can also offer a number of options to improve the appearance of scarring, such as laser resurfacing.

Other Variants of Acne

A number of other variants of acne are recognised:

Infantile acne - acne lesions may appear on the face during the first months of life. They clear spontaneously.
Late-onset acne - occurs mainly in women. Nodules and cysts predominate and occur mainly on the chin. Patients should consult their doctor.
Exogenous/occupational acne - long-term use of oily cosmetics, or exposure to oils, tars and hydrocarbons, can cause acne. Comedones tend to predominate. A careful history will usually reveal the causative agent, which should then be avoided.

Acne fulminans - in which severe acne affecting the trunk and limbs as well as the face is accompanied by fever, malaise and joint pains. Patients should see their doctor.