Who Has Acne & Where?

Acne is a very common skin problem in adolescents. You and your friends probably have had this trouble in the past or even now. Girls reach their puberty earlier and have the peak around age 14 - 17, while boys around age 16 - 19. Actually, lots of adults are troubled by acne too, and believe it or not, even people around the age of 40 still come to the doctors seeking treatments for acne. Their acne is also more difficult to treat than those in youngsters.

Acne distributes mainly in areas where there are lots of oily secreting glands called sebaceous glands. Apart from the face, it is frequently seen on the chest, back and shoulders. Among the sufferers, 99% have it on their face, 90% on their back, 78% on their chest, and 75% in all 3 areas.

Not uncommonly acne happens only on the shoulder or the chest, and patients are puzzled to learn that it is acne rather than some skin allergy they have in mind.

Acne on Chest	Acne on Back

What Causes Acne?

• The sebaceous glands secret oil into the follicles, and the oil then flow onto the skin surface. During puberty, the sebaceous glands are stimulated by the surge of male hormones that escalate the oil production. Sometimes it may be over sensitivity to a normal amount of male hormone.

• The cells in the follicles grow abnormally, and cause thickening. Together with excess oil, this blocks the pores and leads to whiteheads and blackheads, referred to as pimples, or medically non-inflammatory acne.

• The thickened and enlarged follicles encourage growth of bacteria, which break down the oily content into some harmful chemicals. These chemicals cause inflammation, with redness, swelling, and pus formation, the inflammatory acne.

Mild Acne
There are mainly features of blockage, with few whiteheads and blackheads. There may be some small inflammed acne.

Moderate Acne
The number of inflamed acne and the degree of inflammation increase, but mostly in the superficial level. There may some deep pustules.

Severe AcneThere are lots of large inflamed acne and deep pustules. The chest and back may be affected too. This can lead to scarring easily.

Mild	Moderate

Moderate to Severe	Severe

Treatments For Acne

Some people may think that acne is only a mild skin problem that would burn itself out after a while, and ignore proper treatments. This could lead to long-term deep-seated inflammation and leave permanent scars. This is totally preventable these days with very effective medications, and so early treatment is warranted.

Cleansers

There are numerous of them around, and you can find from very cheap one to very expensive cosmetic brands in the chemists. Even the expensive ones are not necessarily good. All of them are helpful only to the mild acne.

They contain too many different ingredients that cannot be all listed out here. The more effective ones are glycolic acid, salicylic acid, and benzoyl peroxide.

Glycolic and salicylic acid can improve the dead skin layer and reduce blockage. Benzoyl peroxide can inhibit the growth of bacteria and prevent the pimples from becoming inflamed acne.

External Preparations

1. Benzoyl Peroxide
Concentration from 2.5% to 10%. There are solution, gel, and cream available. It can inhibit bacterial growth and has inflammatory property. It has the advantage of not causing bacterial resistance. The side effects include irritation with red, dry and itchy skin.

2. Antibiotics
There are Erythromycin and Clindamycin, again with solution, gel and cream. They are anti-bacterial, but the incidence of resistance is mounting. To avoid this and to increase the anti-inflammatory effect, it is commonly used together with benzoyl peroxide.

3. Retinoids
They are vitamin A derivatives. There are Tretinoin 0.025%, 0.05% and 0.1%; Isotretinoin 0.05% and 0.1%; Adapalene 0.1%. They work by reducing the oily secretion and normalise the cell growth inside the follicles. They are particularly effective for non-inflammatory acne, but the effect is slow and usually takes several months. Sometimes they can make the acne slightly worse.

To the first-users, there may be irritation in the initial period, with dryness and flaky skin. This usually subsides after getting adapted to it. This is best avoided during pregnancy because there is uncertainty regarding their absorption into the system and safety to the babies.

4. Azelaic Acid
This is a natural chemical acid, which is present on our body. It has many different functions:

• Inhibit the bacteria inside the follicles

• Inhibit the free radicals causing the inflammation

• Normalise the cell growth inside the follicles

• Inhibit abnormal growth of melanocytes

• Inhibit the enzyme tyrosinase, which is essential in making melanin

Therefore azelaic acid is very effective against both non-inflammatory and inflammatory acne. It can soften the deep pustules and make them smaller. Like others, significant improvement takes 3 - 4 months.

The main side effect is irritation and dryness. Because of its effect on melanin, it can also be used in lightening melasma.

5. Fruit Acid
There is glycolic acid, which is an Alpha Hydroxyl Acid, and salicylic acid, which is a Beta Hydroxyl Acid. They can clear the blockage by loosening the dead skin cells. They are prepared as cleansers as well as lotions, but the concentrations over the counters are usually quite low.

Doctors will, according to individual cases, prescribe higher concentrations like 10 - 15%. Some will also use 20 - 70% solution to perform chemical peeling, which is useful in treating acne as well as the acne scars.

Oral Preparation

1. Antibiotics
This is necessary when you have moderate to severe acne. They can directly reduce the bacteria inside the follicles and have anti-inflammatory property.

You need to take them for a course of 3 - 6 months. Sometimes people stop taking them after only a short period when they see some improvement. This can cause the bacteria becoming resistant and make future treatments more difficult.

The usual antibiotics prescribed are Tetracycline and Oxytetracycline. They cannot be taken together with milk because of poor absorption. The new generations like Doxycycline and Minocycline do not have this limitation and also have less bacterial resistance. Another choice is Erythromycin.

The problem with antibiotics is the ease of bacteria becoming resistant. Also the treatment effect is short lasting, with high chance of early recurrence. Therefore you may be taking course after course of antibiotics over the years, and each time of recurrence may give you new marks and scars on the face.

Antibiotics may cause gut upset or skin allergy. Tetracycline can stain the developing teeth black, and may make the skin more sensitive to the sun with easier burn. Minocycline can rarely cause some bluish grey discolouration of the skin, and allergedly some skin features similar to those in systemic lupus.

Females can be troubled by the overgrowth of candida in the vagina, because the antibiotics disturb the balance of micro-organisms. The effectiveness of the contraceptive pills may be reduced too.

2. Hormones
Anti-male hormone treatments can shrink the sebaceous glands and reduce oily secretion. The usual preparation is Cyproterone Acetate, together with female hormone Ethinyl Estradiol in contraceptive pills. If you are a female who requires contraception, with acne flaring up during menstruation, and other external preparations fail to work, then this is suitable for you.

Like antibiotics, recurrences are common. The main side effects are gut upset and liver damage. If you cannot take the contraceptive pills for some reasons, for example migraine, then you cannot take this too.

3. Vitamin A Derivatives
The only one available on the market is Isotretinoin, which is a very effective medicine. More than 10 years ago, it was prescribed only for the most severe cases of acne, but it is now becoming more widely used. Apart for some other skin diseases, it is also used in the milder cases of acne, in order to prevent the ultimate scars.

The usual course of Isotretinoin is 4 - 6 months. On average, the dosage is 0.5mg for every kg of body weight per day. So most people would be taking 20mg - 30mg daily, although sometimes more may be needed.

It has many functions. It can shrink the sebaceous glands and reduce their oily secretion; normalise the cell growth inside the follicles, reduce the blockage and pimples; and also has anti-bacterial and anti-inflammatory effects.

Although it has to be taken for a few months as for antibiotics, it has a major significant difference. Recurrence after antibiotics is quick and common, while the improvement from Isotretinoin can last for a long time, on average 2 - 5 years, although some may be shorter or longer. Even though when the acne does recur, the degree is usually much less, with less inflammation and smaller pimples. Therefore, despite the higher initial cost, it is more economical in the long term when compared to antibiotics.

If you decide to take Isotretinoin, pay attention to the following:

• The initial improvement is slow to come, usually takes about 4 weeks to become apparent, so be patient
• The improvement occurs faster on the face than the chest and back.
• In the first few weeks, there may be a temporary mild flare up in some cases, but it will stop and improve as you continue the treatment.

The main side effect is dryness, of the skin, lips, and even insides of your eyes. This usually slowly disappears in weeks. You need to apply plenty of moisturiser.

Other side effects include mild muscle ache, and headache. Sometimes the liver enzymes and triglycerides levels may rise, so may the sugar level in diabetics. If they are too high you need to stop the medication and they will return to normal with no permanent damages.

The most important thing is that female patients should not become pregnant while they are on this medication, otherwise the baby will be abnormal. Therefore during and 4 weeks after the treatment, an effective contraception must be used.

On the whole, Isotretinoin is a very effective treatment. It should be considered before the permanent acne scars are formed, and not after everything else has failed, because it would not be useful for scars.

Severe Acne Scars

Common Mis-understanding About Acne

• Acne is not contagious!
• Acne is not going to heal automatically. Treatment can prevent the scars from forming.
• Acne is not just due to poor hygiene and cleaning. To wash your face more frequently with different cleansers will not cure acne, although this may help to reduce the oiliness.
• Acne is not going to get better in days after treatment. You need to be persistent and continue most forms of treatment for 3 months or more.
• You may think sunlight may kill the bacteria. In fact sun exposure helps only 60% of acne sufferers, while 20% has no effects, and 20% will get worse. Some sunscreens will block the follicles and cause more acne. UV lamps are definitely useless, and will cause you skin aging.
• You may think some foodstuffs will stimulate acne, and avoiding them will make acne better. Actually there is no scientific proof of this. No matter how you try, it will not help.