Acne

Acne is the most common skin care problem seen by doctors. It occurs when pores become clogged by a combination of an oily substance produced by the skin called sebum, dirt, and dead skin cells.

Often, bacteria called Propionibacterium acnes (P. acnes), can be present too, which can contribute to the redness, swelling and pus that can accompany lesions. The visible result is acne, which is the term used to describe blackheads, whiteheads, pimples, and cysts. Acne usually appears on the face and neck but it can include shoulders, back, and arms.

Everyone gets a pimple somewhere on their body sometime in their lifetime.

Acne often starts around puberty, and it may last about 5-10 years or it can continue into adulthood. Even some babies develop acne shortly after birth.

It can usually be treated with topical over-the counter (OTC) products if mild to moderate. For more severe, stubborn and/or widespread acne, however, it is recommended that you see your family doctor or a dermatologist, so s/he can prescribe something stronger.

What Causes Acne?

Overactive sebaceous (oil-producing) glands that start producing more sebum, usually at puberty. In some people, the excess sebum clogs pores, which leads to the inflammation (redness and swelling) often associated with acne.

Heredity (your genes) is another factor that can determine who gets acne and how severe. If either or both of your parents had acne, you are more likely to develop the skin condition too.

There are various terms that describe different forms of acne, such as comedones, papules, pustules, nodules and cysts.

There are basically three levels of severity:

  1. Mild acne consists of a few lesions that are close to the surface and not deep or inflamed.
  2. Moderate acne is marked by deeper nodular lesions that cover more of the face, and causes some redness.
  3. Severe acne involves many lesions, multiple cysts, lots of redness and inflammation over most of the face.
Acne Stages

Acne that starts during adolescence or teens can continue into adulthood in a milder or more severe form. Meanwhile, just because you made it through your teens without a blemish doesn’t always mean you’re in the clear yet. Acne can begin in adulthood too, and three quarters of adult acne occurs in women.

Sexual hormone fluctuations are usually responsible, which is why women may suffer “cyclical acne” that shows up before their menstrual periods, or acne flare-ups during pregnancy or menopause.

Most teens are affected by acne to some degree. That’s because the surge in sex hormones that happens at puberty also seems to jumpstart acne.

How? Male hormones, known as androgens, increase the size and number of sebaceous glands as well as the amount of sebum (oily substance) they produce. Some studies have shown that the earlier acne appears, the worse it can get during the teen years.

Talking about acne and treating it early, no matter how mild or invisible it may look to others, is vital to keep the condition from becoming more severe and causing permanent scarring.

Acne can even show up as early as birth, but this form is more specifically called acne neonatorum or simply “baby acne”. It is a common skin condition that affects about 20% of all newborns. Mainly affecting the cheeks and nose, lesions appear as small, red papules.

Baby acne usually appears 2 weeks after birth and lasts from a few weeks to a few months, however it usually clears by 3 months. The cause is maternal hormones that remain after delivery and stimulate the baby’s sebaceous glands. The maternal hormones cross the placenta into the baby, which cause the overactive oil glands to produce pimple-like bumps.

Baby acne can flare up and become more irritated when skin comes into contact with saliva, milk, some fabrics, or when a baby is too hot. Unlike other kinds of acne, baby acne will clear up on its own and it does not require any treatment. In severe cases, a doctor may recommend some form of topical treatment. Also, having baby acne does not predict who will develop acne as adolescents or teens.

Acne can be mild and short-lived or severe and disfiguring, but what acne looks like doesn’t matter as much as how it may feel a person feel on the inside. Long brushed off as a rite of passage and temporary condition, acne is anything but for those who experience it.

A Canadian study of nearly 500 patients with acne published in the British Journal of Dermatology found even having mild acne can bring on feelings of low self- esteem, depression and suicidal thoughts. The fact that acne often coincides with the start of puberty adds to the feelings of uncertainty about body image, self-esteem and other emotional issues that adolescents and teenagers typically experience.

The study findings showed that acne can be associated with the following psychological effects:

  • Social withdrawal
  • Decreased self-esteem
  • Reduced self-confidence
  • Poor body image
  • Embarrassment
  • Feelings of depression
  • Anger
  • Preoccupation
  • Frustration
Quick facts about acne
  • Acne affects nearly 20% or 5.6 million Canadians.
  • Acne affects about 90 per cent of adolescents and 20-30 per cent of adults aged 20 to 40 years.
  • More than 80 per cent of acne sufferers are between the ages of 12 and 24.
  • Acne affects the face in 99 per cent of cases.
  • Infant acne affects approximately 20% of newborn babies.
  • It usually starts around puberty and lasts until adulthood, although it can persist for many more years, regardless of age.
  • About 25 per cent of teens will still have acne at age 25.
  • Women make up 75 per cent of adult cases.

Even mild acne can produce scarring, although the more severe acne (cystic) is associated more strongly with the risk of scarring. It’s hard to tell, though, who will develop scarring and how severe it will be.

Scars are the result of injury to the skin, and what you see is the loss of skin tissue or the build-up of excess skin tissue. You can basically get one of two types of scarring: depressed (pitted) scars or elevated (thickened) scars.

Different Types of Scars
  • Ice-pick scars – these are the most commonly seen form of acne scarring, which form deep pits in skin
  • Rolling scars – less defined edges but still dip, giving wavelike appearance
  • Boxcar scars – pitted scars with defined edges with crater-like appearance
  • Hypertrophic (keloid) scars – elevated scar tissue that appear as bumps rather than dips
How to Reduce Scarring

Prevention is the best treatment for acne scars, which includes treating acne early and controlling it to prevent new lesions from forming. However, there are several ways to treat scars if you do develop them. Speak to your dermatologist about what treatment is best for you.

Tretinoin creams and gels can be used as a non-surgical way to treat superficial scarring (as opposed to deep or elevated scarring). They help with new collagen production, basically helping skin to build new, unscarred tissue.

Chemical or alphahydroxy acid (AHA) peels help even out skin tone and can smooth out slight imperfections.

Microdermabrasion, also known as a “power peel”, is recommended for superficial mild acne scars. It involves a 10-20 minute treatment that removes the uppermost damaged layers of skin.

Injectable fillers include materials such as collagen and hyaluronic acid, which are injected below the skin’s surface to plump up pitted areas from rolling scars.

Laser skin resurfacing removes a damaged surface layer, which helps to smooth out the appearance of deeper scars. It also encourages new collagen formation in the skin.

Don’t pop! Picking and squeezing leads to more bacteria being distributed and more acne.

Don’t stress out! Stress can indirectly worsen acne by affecting your hormones.

Don’t feel alone. Nearly everyone in the world gets pimples.

Don’t scrub too much! It won’t work and can irritate your skin and aggravate your acne.

Do wash your face! ONCE or twice daily with proper acne washes to help keep acne at bay.

Do apply sunscreen! Skin is much more sensitive to UV rays when you use acne products

Do use oil-free makeup. Look for noncomedogenic products – they don’t contain ingredients that clog pores.

Don’t wear makeup! Take a break to let your skin breathe and heal (at least once a week!)

Do wash your pillow case and sheets often. They absorb oil and reapply the dirt and oil on your skin.

Do wash your make-up brushes with antimicrobial soap. Makeup applicators can store bacteria.

Myth #1: Eating greasy food makes acne worse.
Certain foods such as chocolate, French fries, and other greasy foods have long been suspected of aggravating acne but scientific studies have not been able to find a connection.

Myth #2: Poor hygiene can cause acne.
Acne is not a consequence of dirty skin and isn’t a reflection of anyone’s hygiene habits. And blackheads aren’t dirt-filled pores. They’re black because the protein in them (keratin) is oxidized when it comes into contact with air. In fact, washing too often and vigorously can actually make acne worse.

Myth #3: Acne will clear up on its own in time.
It may clear up eventually but acne can get a lot worse before it gets better. And the longer you have acne, the greater the chances of permanent scarring. The most effective way to get rid of acne is not to wait and see but to treat it. Talk to your doctor about what treatment is right for you.

Myth #4: You can get acne from contact with someone who has it.
Acne may be unsightly and embarrassing for the sufferer but it is absolutely not contagious.

Myth #5: Sun exposure and tanning clear up skin.
Neither outdoor nor indoor tanning will help acne over the long run. Being in the sun can help acne initially by drying up skin lesions and surface oils a bit but the effect is just temporary. More often, people will experience an acne flare-up after UV exposure. In addition, sun exposure greatly raises the risk of skin cancer.

You should see a doctor when treating acne yourself using OTC products isn’t improving your skin condition. Your family doctor or a dermatologist can help even with mild cases of acne. That’s because even mild acne can still potentially lead to scarring, and there is no way of predicting if mild acne will progress to becoming more severe over time.

What are the Different Kinds of Treatment?

No matter how mild or brief acne can be, seeking treatment sooner rather than later is key to getting it under control and limiting the chances of permanent scarring. There’s no telling whether a mild case of acne will progress to a more severe form, continue into adulthood or disappear before you can say goodbye to your teen years.

Acne treatments are aimed at achieving a few things: decrease sebum production, kill acne bacteria (P. acnes), help to normalize skin shedding, and fight inflammation.

Non-prescription Medications (OTC)

For mild acne, you can usually try over-the-counter (OTC) acne treatments first before turning to your doctor for help. They are usually milder than prescription-strength products and are readily accessible. OTC acne treatments can include medicated cleansers and topical creams and gels.

Active ingredients usually include salicylic acid or benzoyl peroxide in various concentrations. Salicylic acid boasts anti-inflammatory and peeling action while benzoyl peroxide is known to cause drying and slight peeling, and it kills bacteria. Benzoyl peroxide-based cleansers and creams are available in concentrations of 5 per cent or less; they are available in higher concentrations (10 per cent) by prescription. Whatever you try, it’s important to stick to the treatment for one to two months before you can see a difference. Visit your doctor if you don’t notice improvement within 6-8 weeks.

What you Should Know:
  • Topical medication should be applied to the entire affected area, not just individual pimples.
  • You should also be aware that applying more won’t work better or faster, so apply a thin layer evenly.
  • Use product as directed on the label and as recommended by your doctor.
  • Products containing benzoyl peroxide can make your skin more sensitive to the sun, so reduce your sun exposure and wear sun protection.
  • Apply your acne medication first and let it dry before applying any make-up.
  • Keep using your treatment even after acne has visibly improved in order to prevent new acne from forming.
Prescription Medications

Prescription-strength acne treatments can include topical formulations, such as antibiotics and retinoids (vitamin A derivatives). Oral (or systemic) medication can include antibiotics, retinoids, or hormonal agents (i.e. birth control pill).

Topical antibiotics (i.e. erythromycin, clindamycin) can be recommended to help control the inflammation associated with the redness and swelling of acne.

Oral antibiotics (i.e. tetracycline, minocycline) are usually indicated for moderate to severe acne of the chest, back, and shoulders. They work by reducing the presence of P. acnes bacteria.

What you Should Know:
  • Generally, topical antibiotics aren’t recommended for long-term treatment, since there is a tendency for antibiotic resistance to occur with prolonged use — meaning that treatment is no longer effective in killing acne bacteria.
  • Often, your doctor may prescribe a combination product that contains both benzoyl peroxide and a topical antibiotic.

Hormonal agents such as oral contraceptives (OCs) are recommended for moderate to severe acne (e.g. cystic) after other treatments have failed. Often used for acne that begins or worsens in adulthood. Acne that responds well to OCs is the type of acne that flares up in the “premenstrual” part of the cycle and acne that occurs along the jaw line, which is usually hormonal.

What you Should Know:
  • Acne may worsen in the first one to three months of treatment.
  • You shouldn’t take this kind of medication if you are pregnant, since hormonal agents can cause birth defects.
  • Cigarette smoking increases the risk of serious adverse effects on the heart and blood vessels from use of these hormonal agents.
  • Hormonal agents and oral contraceptives are generally not recommended for women over 35.

Retinoids (vitamin A derivatives) are prescribed only to treat severe cases of acne that doe not respond well to other treatment options. They are available in both topical and oral forms. Topical retinoids (i.e. tretinoin, adapalene, tazarotene) help skin cells turn over more efficiently and reduce inflammation. Oral forms (i.e. isotretinoin) are reserved for the most stubborn cases of severe acne.

What you Should Know:
  • Isotretinoin products must not be used during pregnancy due to the risk of severe birth defects and miscarriage when used for any length of time. (Health Canada warns that taking even a single dose can affect a developing fetus.)
  • You must avoid pregnancy or breastfeeding while using isotretinoin products, since they may harm a child.
  • When treating women of childbearing age, doctors must strictly follow the manufacturer’s risk management program, including educating the patient about potential risks of this drug; information about birth control options; and having the patient sign a consent form, among other things.
  • Oral isotretinoin products have been linked to depression and even suicide in some people. They can also increase your chances of developing diabetes, liver disease or heart disease in those with a family history.
  • Isotretinoin products may also increase your skin’s sensitivity to the sun and cause reduced night vision, which can come on suddenly.
  • Topical retinoids can cause redness and peeling, so you should avoid using them near the eyes, mouth or nose.
Why it is important to stick with treatment?

Once your doctor has prescribed a treatment for you, you should use it properly and keep using it for as long as your doctor recommends. Many kinds of acne medication initially cause dryness, visible peeling, flaking, redness, irritation, and/or possibly even acne flare-ups. In some cases, acne can get worse before it gets better. Any of these unwanted effects can lead some patients to stop treatment early and even report to their doctor that it isn’t working. That’s why it’s vital to ask and understand why your doctor prescribed a certain treatment, how to use it, how long to use it, what results to expect and when you can expect to see an improvement in your skin.

Your doctor may suggest easing into a treatment regimen to allow your skin to get used to it. For example, s/he may advise you to apply a topical treatment for 15 minutes at first, then double the time daily until you get to four hours. Your skin should be used to the product by then, so you should be able to apply and leave it on all day or night without any significant irritation. An alternative approach is to alternate the days you use a product, so you would use it one night and skip it the next night until your skin gets used to it. Any skin irritation due to treatment should subside after a few days of use.