Acne

1 - JUVENILE ACNE (Chosidow O, Dreno B. Acné. Des conseils pour votre quotidien. Dialogue Médecin-Malade. John Libbey Eurotext Ed 2003.)

Acne is a common condition in teenagers, affecting 80% of this age group. Most cases are mild or moderate but some teenagers can be severely affected. It is therefore almost normal for teenagers to have some degree of acne.

It is a chronic condition, arising at the same time as all the hormonal changes that take place during adolescence and lasting several years. Even when treated properly, it does not disappear as quickly and permanently as patients would like. Acne can flare up again after an initial successful course of treatment and some patients will require other courses.

2 - HOW DOES ACNE DEVELOP?

Acne develops in three stages:

1 - it is triggered at puberty under the effects of androgen hormones (male hormones), which males obviously have but which are also present in women, but to a lesser degree. Most often, acne arises when the sebaceous glands are genetically too sensitive to the effects of androgens (and there is often a family history of acne in one or other or even both parents)/ More rarely, these androgens can be over-produced by a woman’s ovaries or adrenal glands or she can be exposed to them in her contraceptive pill. In all these cases, the androgens stimulate the sebaceous glands to produce too much sebum: this creates what is known as seborrhea.

2 - During the next stage, comedones (blackheads) and microcysts (whiteheads) develop. These are caused by retention of the excess sebum in clogged pores. The blocked follicles are located under the surface of the skin. Patients can’t remove them themselves because they may burst in the dermis and create more spots. Some topical products, especially those that contain acid vitamin A, can help get rid of these blackheads and whiteheads. Otherwise, they should be removed by a dermatologist through a micro-incision that does not leave a scar, and not by the patient or a beautician.

3 - Finally, spots form. These are not caused by infection, but by inflammation around the blackheads and whiteheads. An anaerobic bacterium, Propionibacterium Acnes, which is also found in the skin of people who do not have acne, grows and multiplies in the clogged pore and releases several substances which cause inflammation. Despite being a bacterium, it causes inflammation rather than infection. Acne is not an infectious disease and, except in very rare cases, there is therefore no point in taking repeated acne samples from patients to test for other germs. The spots should not be scratched or squeezed as this could cause unsightly scabs, redness, dark spots and even actual scars.

3 - HOW TO TREAT ACNE?

3.1 - FIRST OF ALL, SHOULD IT ACTUALLY BE TREATED?

Yes of course it should be treated. Any teenager will tell you that having spots is unpleasant and unsightly. Acne has a negative impact on teenagers’ quality of life, their relationships (friendships and other) and self-esteem at an age where they strive for physical perfection (particularly girls).

In addition, the permanent scarring left by certain types of acne, even when relatively mild, can be avoided by prompt and appropriate treatment. Patients, their parents and doctors should bear in mind that scars are for life and even the most sophisticated treatments will only help them fade, not get rid of them completely. Acne should not therefore be ignored on the premise that it is normal during adolescence and will go away during adulthood. The unsightly scars it can cause should always be borne in mind

3.2 - WHO PRESCRIBES WHAT TREATMENT?

Anti-acne preparations seen on the TV, bought in a supermarket or even recommended by a pharmacist are often ineffective, except for very mild cases, and expensive compared to real anti-acne treatments. Teenagers should see a doctor, either their GP if he or she is willing to prescribe treatment for acne, or a dermatologist who knows and understands acne and the treatment options available.

3.3 - TREATMENTS THAT WORK ARE AVAILABLE

— But the results are not immediate. Treatment must be pursued for several weeks before a result is obtained.

— The patient’s full cooperation is required for the treatment to work. Following the doctor’s orders is the key to success which is why patients must understand the aims of treatment and be given the chance to ask any questions they may have during their first and subsequent appointments.

— Patients should not be discouraged by the initial irritant effect of local treatment. This is not an allergic reaction and treatment will not have to be stopped. The irritation will disappear if a longer interval is allowed between applications. The doctor may also prescribe a moisturizer to soothe the skin.

— Local treatments should be applied to all the areas usually affected, even when they are spot-free, as the primary goal is to prevent new spots from developing.

— With the exception of mild gastrointestinal effects, oral tetracyclines and zinc are well tolerated. Some tetracyclines may make patients more sensitive to the sun and the doctor must be informed about holiday plans and exposure to the sunlight.

— Oral isotretinoin (Contracné^®, Curacné^®, Isotrétinoïne Teva^® and Procuta^®) is a potent and highly effective treatment prescribed for severe acne and after the failure of other treatments. As it can cause a variety of side effects, certain precautions are required when prescribing it and the patients treated must be monitored closely. It dries out the skin and mucous membranes and a moisturizer and lip balm must be used. Contact lens wearers should revert to glasses throughout treatment (about 6 months). It may cause muscle and joint pain which is why it is not suitable for athletes. Although rare in this age group, isotretinoin may also cause changes in blood lipid and cholesterol levels and in liver function test results which should therefore be checked before and during treatment. Above all, isotretinoin is teratogenic, which means that it can cause foetal malformations if taken during pregnancy. It can only be prescribed for women if they understand and accept the mandatory contraceptive measures (contraception started before prescription, maintained throughout treatment and for one month afterwards, with regular pregnancy tests during this period). The pharmacist may only supply the medicine if these conditions (which can be checked in the patient’s monthly monitoring notebook) are met. Depressive patients with acne require particularly close monitoring if they are to be treated with isotretinoin as a link between this drug and depression/suicide attempts has been suggested. This link remains controversial since it is widely acknowledged that depression is more common in people with acne than in the rest of the population.

— Careful attention should be given to the contraceptive pill prescribed for young women with acne; this should contain a nonandrogenic progestin which will not make her acne worse. Some pills may even be selected for their mild antiandrogen effect which may have a positive impact on the acne. Most of these pills are not reimbursed by the national healthcare system and are rather expensive. Women with more severe hormone imbalances should see a gynaecologist-endocrinologist who will offer a more potent antiandrogenic treatment (cyproterone acetate or spironolactone).

3.4 - WHAT ABOUT SCARS?

Getting rid of scars is not an easy task which is why the best idea is to treat the acne promptly to prevent them from developing in the first place.

If a patient has already got scars and continues to have acne, the first step is to treat the acne to prevent more scars from developing. The support of a dermatologist is indispensible at this stage.

When the acne has been controlled and all that remains are scars, patients should be referred to a dermatologist for surgical/laser treatment. Several treatments are possible and often a combination is required. Acne microsurgery involves raising the base of deep scars up to the level of the surrounding skin or covering them with micrografts; chemical peels applied to the whole face or just the scarred areas and fractional laser treatments may also be offered. Patients seeking acne scar correction treatment must be extremely determined since these procedures are complex and often carried out in several stages. In addition, some of the treatments are not reimbursed by the national healthcare system and the dermatologist must draw up a treatment plan and quote to be submitted to the patient.

4 - DEBUNKING SOME MISCONCEPTIONS

• About sexual practices, which have no impact on acne, forget the old saying "no point in treating acne, it’ll go when you get married". This is mere coincidence, as acne does sometimes (but not always) disappear after the age of 25. Masturbation is common in teenagers exploring their sexuality and is not a cause of acne – no point in feeling guilty about it.
• About diets. There is no point in giving up chocolate, cold meats, confectionary (in moderation) or fast food meals as diet has very little impact on acne. A healthy, balanced diet is recommended. Milk and milk products have recently been accused of encouraging acne but there is currently insufficient proof to support this.
• About personal hygiene. No, it’s not because parents feel that their teenager (especially boys) doesn’t wash enough that he or she has acne. Daily hygiene measures are recommended but cleansing should be gentle because, contrary to popular belief, acne-prone skin is delicate and easily irritated. A gentle soap or soap-free gel or bar is therefore recommended for the face. For patients with extremely delicate skin, a lotion can be used or one of the product lines specially designed for greasy and acne-prone skins sold in pharmacies. A moisturizer is useful in the morning, especially if irritating local anti-acne treatments are prescribed. Highly detergent, acidic and/or antiseptic soaps are ineffective and even harmful and many teenagers have dry skin as a result of their use.
• What about make-up? it is often accused of causing acne. Most good brands are subjected to comedogenicity testing and can be used by acne patients to camouflage unsightly spots. There is therefore no reason to prevent girls from wearing make-up but they must be told to apply a moisturizer first and to remove make-up before going to bed. They must also understand that priority is to be given to the local treatments prescribed by their doctor (these can be applied at bedtime).
• the sun is a double-edged sword in acne. It brings about a transient improvement in inflammatory lesions, especially on the back, but increases retention of sebum and therefore encourages flares in the autumn especially if the patient has stopped or been lax about treatment during the summer.
• Does smoking make acne worse? Probably not as far as teenagers are concerned, but no doubt yes in adult women with acne of the open and closed comedone type.

5 - ADULT ACNE

5.1 - IN WOMEN

Acne is common since almost half of the female population has it. In most cases, a woman will already have had juvenile acne, but it may also start for the first time after the age of 25. The acne is generally slight with a limited number of inflammatory rather than retentional lesions (papules and papulopustules or deeper nodules) located on the lower half of the face, but sometimes the spots are more numerous, excoriated and extend down the neck and under the jaw line. Some of these women have hormone imbalances and/or are taking an excessively androgenic contraceptive pill.

Even when slight, women find this type of acne extremely difficult to bear from a psychological standpoint, especially when their professions bring them into regular contact with the general public.

The treatments are the same as for teenagers, with a few slight differences in the way they are employed: local treatments are less well tolerated because, as skin ages, it becomes more fragile. An oral treatment is often prescribed instead, i.e. tetracycline or zinc, isotretinoin and often an anti-androgen hormonal treatment, especially if the acne extends down into the neck. Smokers are advised to stop or at least reduce their consumption.

5.2 - IN MEN

Male acne tends to affect the back and is less immediately visible which is one of the reasons men seek medical help for the condition less often than women. However, the face may also be affected, becoming seborrheic and presenting a few lesions. However, men also present with the exceptionally rare and severe forms of acne such as acne conglobata, with deep-seated suppuration and large, multichanneled comedones. Oral isotretinoin is often required.

6 - LINKS

European Academy of Dermatology and Venereology (EADV) leaflets published in 2019, produced by the EADV Acne Task Force:

- Acne: production, evolution and diagnosis

- Acne: how to treat it

American Acne and Rosacea Society

MedlinePlus: Acne

WebMD: Understanding Acne Basics