Acne

What is acne? 

Acne vulgaris is a chronic inflammatory skin disorder that primarily affects the[5]:

• Face – 99% of cases 

• Back – 60% of cases 

• Chest – 15% of cases 

It causes different types of spots, including[6]:

• Non-inflammatory lesions – blackheads (small black or yellowish bumps) and whiteheads (similar to blackheads but they’re firmer and do not empty when squeezed) 

• Inflammatory lesions – papules (small red bumps that may feel tender or sore) and pustules (similar to papules, but filled with pus)  

• Nodules – large, painful lumps under your skin  

• Cysts – large, pus-filled lumps under your skin 

Cysts are the most severe type of spot caused by acne and carry the greatest risk of causing permanent scarring if they burst[7]. Picking or squeezing papules and pustules can also lead to scarring, so it’s important to leave your spots alone.   

How is acne diagnosed? 

A GP can diagnose acne by looking at and examining your skin to assess which types of spots you have[8]. They will then make treatment recommendations based on how severe your acne is.  

The severity of acne is typically categorised as:

• Mild – mostly non-inflammatory whiteheads and blackheads, with a few inflammatory papules and pustules 

• Moderate – a greater number of non-inflammatory whiteheads and blackheads, with a lot of inflammatory papules and pustules 

• Severe – lots of large, painful inflammatory papules and pustules, as well as nodules and/or cysts; you may also have some scarring 

If you have mild acne, you do not need to speak to a GP and can speak to a pharmacist about how to treat the condition. However, if you have moderate or severe acne that is affecting your quality of life and/or causing you to develop nodules or cysts, you should speak to a GP.  

What causes acne? 

Acne is caused when the tiny holes in your skin that individual hairs grow out of, known as hair follicles, become blocked. The underlying causes of these blockages can vary[9]:

• Excess oil (sebum) – hormonal fluctuations can increase the amount of sebum your skin produces. In people born male, this is due to increased levels of testosterone. Whereas, in people born female, this tends to relate to their menstrual cycle or having a condition such as polycystic ovary syndrome (PCOS). Excess sebum can interact with the bacteria in your hair follicles and cause blockages. This is known as hormonal acne and leads to non-inflammatory lesions, inflammatory lesions and cysts. Hormonal acne treatment tends to involve using a retinoid cream and an oral or topical (cream, lotion or gel) antibiotic  

• Oil and dead skin cells – these can clog your pores and interact with bacteria to cause a reaction in your skin. This is known as cystic acne and causes acne cysts. Cystic acne treatment often involves taking oral antibiotics and using a topical cream or gel  

• Fungus – your hair follicles can become infected with a fungus called Malassezia yeast. This lives on your body naturally but can get out of hand, for example, if you have a weakened immune system. This is known as fungal acne and causes small painful spots that may have a red ring around them and might itch. Fungal acne treatment tends to involve using topical or oral anti-fungal acne medications 

As well as these underlying causes and types of acne, other factors can contribute to the development of acne, such as: 

• Some cosmetic products – these used to be a common contributor to acne but are less common these days as most cosmetic products are now formulated not to cause spots (non-comedogenic). The best skincare treatments for acne are oil free 

• Certain medications – drugs containing steroids (e.g. hydrocortisone), lithium (used to treat depression and bipolar disorder), and some medications used to treat epilepsy can contribute to the development of acne 

• Smoking – research has found a correlation between smoking and acne; the more cigarettes smoked the more severe the acne. However, the causal link between the two is unclear, meaning that while smoking is a risk factor for acne, it does not necessarily cause the condition  

• Diet – studies have identified a correlation between acne and diets with a high glycaemic index as well as food items such as dairy, whey proteins, and meat products high in leucine. However, diets including sufficient levels of omega-3 fatty acids and γ-linoleic acid have been associated with reduced acne lesions 

• Genetic factors — twin studies have found a high concordance (similarity) in acne between identical twins. Additionally, people with a family history of acne tend to have more severe acne  

• Stress – stress doesn't cause acne, but it has been found to exacerbate it if you already have it  

• Pressure on your skin – friction on your skin, caused by items such as phones, helmets, tight collars and backpacks, has been found to contribute to acne 

Importantly, acne isn't caused by dirty skin or poor hygiene[10]. In fact, washing your face more than twice a day has only been found to aggravate your skin and can make acne worse. 

How can acne be treated? 

It can take several months of acne spot treatment to see any changes in your acne, so whichever treatment path is right for you, it’s important to stick with it.  

Face, chest and back acne treatments are split into topical treatments, oral tablets and non-pharmaceutical treatments.

Topical treatments 

• Benzoyl peroxide – if you have mild acne, speak to a pharmacist about trying an over-the-counter cream or gel that contains benzoyl peroxide. This is an antiseptic which can reduce the number of bacteria on the surface of the skin and has an anti-inflammatory effect 

• Topical retinoids – these remove dead skin cells from the surface of the skin to prevent them building up within hair follicles. Topical retinoids include tretinoin and adapalene 

• Topical antibiotics – these help kill the bacteria on the skin that can react with oil and dead skin cells and cause a reaction. Topical antibiotics should not be used for longer than the course of treatment (usually six to eight weeks) due to the risk of antibiotic resistance 

• Azelaic acid – used as an alternative acne treatment if topical retinoids and antibiotics cause too many side effects. Azelaic acid gets rid of dead skin cells and kills bacteria on your skin 

Oral treatments 

• Oral antibiotics – antibiotics are usually used in combination with a topical treatment to treat more severe acne. In most cases, tetracyclines are prescribed, unless you're pregnant or breastfeeding, in which case you’re more likely to be advised to take erythromycin, which is considered to be safer  

• Hormonal therapies – the combined oral contraceptive pill (containing both oestrogen and progesterone) is often prescribed to people born female with acne. These help reduce the high levels of androgens (e.g. testosterone) produced during puberty that are linked to acne development 

• Co-cyprindiol – a hormonal treatment used for more severe acne that does not respond to antibiotics. Co-cyprindiol helps to reduce the production of sebum  

• Isotretinoin – a treatment for severe acne that has not responded to other treatments. Isotretinoin helps to regulate the production of sebum, prevent hair follicles from becoming clogged, reduce the amount of bacteria on the skin and reduce redness and swelling 

Non-pharmaceutical treatments 

• Photodynamic therapy – laser and light therapy is the best treatment for acne scar removal. It works by delivering heat to the scarred collagen under your skin. This acne scar treatment promotes your body’s wound healing response to create new, healthy collagen and grow new skin 

• Comedone extractor – a small pen-shaped instrument that can be used to manually extract the dead skin and sebum clogging a pore 

• Chemical peels – a chemical solution is applied to the face, which causes the top layer of skin to peel off so it can be replaced by a new layer of skin 

Self-care techniques  

There are also plenty of good habits you can get into to avoid making your symptoms worse. For example:

• Wash your face every day with warm water and a gentle cleanser. If you’re looking for a baby acne treatment, you should also wash your baby’s face every day 

• Do not wash your face more than twice a day, as this can irritate your skin  

• Wash your skin after you sweat  

• Avoid popping, picking or squeezing your acne spots, as this can make them worse and cause permanent scarring 

• Avoid oil-based make-up and skincare products and stick to water-based products, as they’re less likely to block the pores in your skin 

• Avoid skincare products with alcohol, astringents, toners and exfoliants, as these can irritate your skin 

• Completely remove your makeup before going to bed 

• Use a fragrance-free water-based emollient 

• Wash your hair regularly and try to avoid letting your hair fall across your face 

Sources 

1. https://cks.nice.org.uk/topics/acne-vulgaris/background-information/prevalence/ 
2. https://cks.nice.org.uk/topics/acne-vulgaris/background-information/definition/ 
3. https://www.nhsinform.scot/illnesses-and-conditions/skin-hair-and-nails/acne/ 
4. https://www.ncbi.nlm.nih.gov/books/NBK459173/  
5. https://my.clevelandclinic.org/health/diseases/12233-acne 
6. https://www.nhs.uk/conditions/acne/complications/  
7. https://www.nhs.uk/conditions/acne/diagnosis/  
8. https://www.nhs.uk/conditions/acne/causes/ 
9. https://www.mayoclinic.org/diseases-conditions/acne/symptoms-causes/syc-20368047 
10. https://www.nhs.uk/conditions/acne/treatment/