Acne and Rosacea
Our Acne Management Guidelines published in the Journal of Clinical and Aesthetic Dermatology may be viewed via this link. (Note to patients: These guidelines are not meant for personal diagnosis or to supersede your existing treatment plan. Please consult your medical doctor for assessment and management on an individualised basis.)
What is Acne?
The word acne and pimples are used interchangeably and both refer to the same condition.
Acne is a disease of the pilo-sebaceous unit (the hair follicle and the oil glands that surround them ) that can occur on any part of the body. However it commonly affects the skin of the face, back and chest.
Acne is largely a disease of adolescence, affecting up to 85% or more of individuals in this age group. Although the duration and severity varies in each individual, studies have shown that the condition can persist in up to 12% of women and 3% of men, right until the age of 44.
What does acne look like?
Acne consists of whiteheads and blackheads in the early stages of formation. Subsequently, red lumps and spots with pus develop (papules and pustules). Sometimes painful red lumps called cysts and nodules develop and these can result in scarring.
What causes acne?
The following 3 factors are important in the formation of acne /pimples:
- Increased sebum (oil) production – this occurs in all adolescents as a result of hormonal changes during puberty Those with higher sebum production tend to get more severe pimples.
- Abnormal hair follicle keratinisation – this refers to the excessive activity of the cells lining the opening to the sebaceous gland, resulting in a blocked pore. This, coupled with the increased oil production, results in the formation of the earliest pimple spot . a whitehead or blackhead.
- Bacteria and its products – once the pore is blocked, bacteria in the deeper parts of the hair follicle release chemicals that act on the sebum and this results in the production of other chemicals. The resultant inflammation that these chemicals cause produce the red or yellow spots commonly found in acne. If inflammation or swelling involves a large area or is more severe, then nodules or cysts develop.
There are some documented aggravating factors and these include menstruation (pre-menstrual flare), certain occupations (for example those working in a hot, humid environment), application of certain hair oils and certain medications or drugs used to treat other medical conditions. Stress may aggravate acne in some individuals.
What about diet and acne?
A wealth of folklore has blamed acne on certain foods, in particular chocolates and fried or fatty foods but strong scientific evidence is lacking. There is also no proven connection between having oily skin and eating fried or fatty foods.
What happens if acne is left untreated?
Acne can result in scars. These range from temporary pigmented marks to permanent deep pits (pitted scars) and hard swellings (hypertrophic scars) . Untreated bad pimples and permanent acne scars often result in negative psychosocial effects on the sufferers such as lowered self-esteem, reduced self-confidence and social withdrawal .
What should I do when I have acne?
Consult your doctor early since treatment results in improved appearance and prevent the development of permanent scarring. Waiting to “outgrow” pimples is not advised.
How is acne treated?
Treatment is aimed at correcting the causative factors and it can either topical (creams applied to the skin) or oral therapy. Topical therapy is the first-line of treatment in those with mild acne and is combined with oral therapy in those with more severe grades of acne.
Sulphur /resorcinol preparations have been around for a long time and can be useful in mild acne.
Benzoyl peroxide available in several preparations either as a gel/lotion or a wash. It helps eradicate the bacteria found in acne and may also loosen blackheads and whiteheads. Some redness and peeling may be expected. It is not suitable for severe acne. It can bleach hair and clothes.
Retinoids – these are medicated creams related to vitamin A (note: these are not vitamin A creams). Examples of retinoids include tretinoin, isotretinoin and adapalene. These are available in various strengths and are very effective in reducing whiteheads and blackheads. But side effects of redness and peeling skin can occur in some individuals. It can also make the skin somewhat sensitive to sunlight.
Topical antibiotics – antibiotic applications containing erythromycin or clindamycin are useful in killing the bacteria in acne. These medicines are available as a water-based gel, moisturising lotion and alcohol-based solution.
Oral Antibiotics – antibiotics have been used for acne treatment since the 1960’s and have been shown to be safe and effective against bacteria and the associated inflammation. Tetracycline or its related compounds (doxycycline, minocycline) and erythromycin are the antibiotics commonly prescribed. Acne is a slowly responsive disease and antibiotics must be given for weeks before its effects are seen. It has to be taken for a sufficient length of time (usually about 6 months), so stopping it prematurely may result in a relapse. In fact, one of the most common causes of failure of treatment is non-adherence to treatment.
Oral isotretinoin – this is derived from vitamin A (not vitamin A tablet), and almost universally effective in most forms of acne. It is the drug of choice in those with severe acne or those with limited response to other therapies like antibiotics. Its use is limited by cost and its side effects, most importantly – foetal abnormalities in a woman who becomes pregnant while on the medication, excessive dryness of the lips and skin, minor nose bleeds and muscle and bone aches. It sometimes causes a temporary rise in blood cholesterol levels, and minor abnormalities in the liver function. It is therefore imperative that women on this medication use an effective method of contraception and abstain from getting pregnant during and for up to 4 weeks after stopping the medication.
Hormonal therapy – since hormones play a central role in acne development, hormonal therapy is a valuable and effective alternative to antibiotics or oral isotretinoin in some women. Oral contraceptives with a high oestrogen content and anti-androgens (e.g. cyproterone acetate) have been effective in acne management. This is obviously not suitable for males.
Should I go for a facial to clear my pimples?
Extracting whiteheads and blackheads (which generally occurs during a facial) have a limited value in treatment of pimples. The effect is temporary as new whiteheads rapidly develop. You should seek medical treatment when you suffer from pimples.
What about squeezing the pimples – is that advisable?
No. It is not necessary to squeeze pimples for them to clear – pimples will resolve just as well with topicals and/or oral therapy prescribed. Squeezing may lead to more inflammation and scars.
Can I use cosmetics when I have acne?
It is all right to use water-based or oil free cosmetics when you have acne. These help to camouflage the spots.
Can acne scars be treated?
It depends on the type of scars. Scars that are pitted or depressed may be treated by a variety of surgical procedures. Superficial scars can be treated by chemical peeling, dermabrasion and laser resurfacing.
Dermabrasion is the process of sand-papering the surface of the skin with a metal device that aims to smooth out the uneven contours. It is not uniformly successful, and may result in pigmentation especially in Asian skin.
Laser resurfacing uses laser energy to create a more even skin surface. The laser removes the damaged skin surface, creating a controlled wound on the skin, and also heats up the underlying collagen to stimulate new collagen production. The result is a smoother skin texture, tighter skin and more even skin tone. There are various types of resurfacing lasers. They can be broadly divided into ablative and non-ablative types. Ablative type lasers are more aggressive but provide better results. Because it is more aggressive, the skin usually takes at least 1 to 2 weeks to recover after the laser. Non-ablative types lasers are more gentle, allowing a faster recovery. However, the improvement that can be achieved is less impressive than an ablative type laser.
Chemical peeling is a process by which various chemicals including fruit acids such as glycolic acid and other acids like trichloroacetic acid are used to cause a controlled wounding of the skin. The main aim is to improve texture and uneven pigmentation of the skin. The end result and complications depend on the depth of peel achieved. The commonly done superficial peels are used mainly as an adjunct to therapy in active pimples, and for lightening the pigmentation that occurs after pimples have cleared and for improving mild scars. It does not really help those with deeper pits or scars.
Scars that are raised above the surface of the skin (hypertrophic scars and keloids can be treated with injections of steroids into the scars. Generally, treatment of acne scars is not easy, is expensive and the results often less than satisfactory It is therefore better, cheaper and more satisfying to have acne treated early to prevent scar formation.
What is Rosacea?
Rosacea is a condition which affects the facial skin of adults, most commonly between the ages of 30 and 50 years. Features of rosacea consist of red spots on the face, localised swelling, flushes of the face, fine broken veins and in advanced cases the nose may appear scarred and lumpy. Recurrent flushing and feeling of a stinging sensation in the face are early clues to the condition.
Is it a form of acne?
No. Rosacea is an inflammatory skin condition of unknown cause. It may be mistaken for acne but unlike acne, there are no whiteheads or blackheads and additional distinctive features are present. It may be mistaken for a skin allergy or eczema resulting in topical steroids being prescribed and these would worsen the condition.
What makes rosacea worse?
- Unprotected sun exposure
- Spicy foods
- Alcoholic beverages
- Hot liquids
- Extremes of environmental temperature
- Prolonged unsupervised use of steroid creams on the face
How is rosacea treated?
Rosacea tends to recur over many years but it can be treated. Treatment includes the use of antibiotic tablets (e.g. tetracycline, minocycline and erythromycin) and applications containing metronidazole. Isotretinoin is also effective in rosacea. It is important to recognize and avoid situations and factors which aggravate the condition. Regular use of sunscreens will help to reduce flares.