Acne

Acne happens when the sebaceous (oil-producing) glands in your skin are overactive. If too much oil is produced, this combines with dead skin cells to clog up your pores, resulting in whiteheads and blackheads. The clogged pores provide a perfect breeding ground for the bacteria that live on your skin, leading to inflammation and spots.

Acne is one of the most common skin problems, affecting around eight in 10 people aged between 11 and 30, most commonly boys aged 16 to 19 and girls aged 14 to 17. Boys tend to get acne more often than girls. Acne is usually mild but around three in every 10 teenagers have severe acne that can cause scarring if left untreated. 

Acne usually comes and goes for several years, eventually resolving as you get older, usually in your mid-20s. However, around three in every 100 people still get acne after age 35.

It can cause a lot of distress if it's severe, especially as it can cause scarring. Fortunately, there are treatments that can make a big difference.

There are six types of acne-related skin blemishes, which can be mild, moderate or severe:

• Blackheads — pores clogged by dead skin cells on the skin’s surface that have turned yellow or black; this discolouration is not caused by dirt but by a chemical reaction of the melanin (pigment) in dead skin cells to the oxygen in the air
• Cysts — painful, deep, pus-filled spots that look like boils and can cause permanent scarring; this is the most severe type of acne
• Nodules — large, deep, painful, red lumps underneath your skin that are solid and do not contain any pus
• Papules — small, red or pink bumps that feel sore and tender
• Pustules — small red or pink bumps with a white spot in the centre; the white spot is a build-up of pus inside 
• Whiteheads — clogged pores just below the skin’s surface; these are similar to blackheads but feel firmer and won't empty when squeezed 

In almost all cases, these skin blemishes occur on the face. However, over half of cases of acne also cause skin blemishes on the back and in about 15% of cases, blemishes also occur on the chest. 

Your GP will look closely at your skin to assess the types of spots you have and their severity. Your acne may be classed as follows:

• Mild — whiteheads, blackheads, with some papules and pustules; this can often be treated with over-the-counter medication from a pharmacist
• Moderate — a moderate amount of whiteheads, blackheads, papules and pustules
• Severe — lots of papules and pustules, plus nodules, cysts, and possibly some scarring

Your GP may also ask you questions about other symptoms to find out if there’s an underlying medical cause. If you are a woman and suddenly develop acne, it could be caused by a hormonal imbalance, particularly if you also develop excessive body hair and irregular or light periods. You may have a condition called polycystic ovary syndrome (PCOS), which can be diagnosed with an ultrasound scan and blood tests.  

If you have severe acne, your GP may refer you to a dermatologist (a doctor specialising in treating skin problems). Symptoms of severe acne include many painful nodules, scarring or a high risk of scarring, and papules and pustules on your back, chest and face. 

The treatment recommended will depend on the severity of your acne.

Acne occurs when your hair follicles (tiny holes in your skin through which individual hairs grow, also known as pores) become blocked. This happens when the oil-producing gland (sebaceous gland) attached to the hair follicle produces too much oil (sebum). These glands produce sebum to lubricate your skin and hair but when they produce too much, the sebum mixes with dead skin cells and clogs your hair follicles. 

If the clogged hair follicle is just underneath the surface of your skin it causes a whitehead; if it is open to the surface of the skin it causes a blackhead. Bacteria that normally live on the surface of your skin — called Propionibacterium acnes — grow more in these clogged hair follicles, causing them to become red and sore. This causes cysts, nodules, papules or pustules to develop.

Acne treatments, therefore, aim to unblock the clogged hair follicles and clear the bacterial infection. 

Acne triggers

Hormonal imbalances trigger acne in teenagers, specifically increased testosterone levels during puberty in both girls and boys. In boys, testosterone promotes the growth and development of the penis and testicles and in girls, it helps maintain muscle and bone strength. Increased testosterone levels cause the sebaceous glands to produce too much sebum, which leads to acne. 

Acne can also run in families ie if one of your parents had acne, you are more likely to develop acne. If both of your parents had acne, you are more likely to develop severe acne and at a younger age. If one or both of your parents had acne as an adult, you are also more likely to develop adult acne. 

Adult acne is more common in women and is most likely due to the hormonal changes that women go through at certain times in their life or due to certain health conditions, such as: 

• Menopause
• Polycystic ovary syndrome (PCOS) — a condition caused by a hormonal imbalance; acne is one of several symptoms, including excessive hair, ovarian cysts and weight gain
• Periods — acne can flare-up just before a period
• Pregnancy — acne can develop during the first three months of pregnancy

Other triggers for acne include: 

• Certain cosmetic products — this is rare as most products in the UK are tested to ensure they do not promote acne ie they are non-comedogenic
• Certain medications — this includes: 
• Certain anti-epileptic drugs
• Lithium — this is used to treat depression and bipolar disorder
• Steroids — this includes anabolic steroids, which are sometimes taken illegally by sportspeople to improve their performance 
• Exposure to certain chemicals in the workplace eg halogenated hydrocarbons
• Smoking
• Touching your face a lot eg sitting with your hands over your cheeks — this helps spread germs from your fingers to your face
• Wearing make-up every day — to allow your skin to breathe, it is recommended to have make-up free days; if you have to wear make-up every day, use make-up with a pH close to that of your skin (the average skin pH is pH 4.7)

Acne can also be made worse by:

• Over-cleaning your skin
• Pollution or humid weather
• Regularly sweating
• Regularly wearing items that cause pressure to an affected area, such as a headband
• Squeezing spots or blackheads

Acne myths

Contrary to popular myth, acne isn’t caused by:

• Chocolate
• Poor diet — there is no evidence that certain foods trigger acne; eating a healthy, balanced diet is still recommended as this is good for your overall health
• Poor hygiene — the biological processes that cause acne occur beneath the surface of the skin; any dirt on the surface of your skin, therefore, does not cause acne
• Stress — although stress can make it worse

Acne is not infectious and it can’t be treated by: 

• Drinking lots of water
• Squeezing blackheads, whiteheads or spots — this can worsen your symptoms and cause scarring
• Sunbathing, sunbeds and sun lamps — there is no evidence to support these as effective acne treatments; certain acne medications can make your skin more sensitive to light, which means sunbathing, sunbeds and sun lamps could actually damage your skin and increase your risk of skin cancer

Acne can be effectively treated with medications. 

You can often improve mild acne at home by:

• Avoiding picking or squeezing spots
• Not scrubbing the skin too hard
• Using a mild cleanser
• Using oil-free or water-based make-up

You can also try creams and lotions for sensitive skin or alcohol-based gels for oily skin. Over-the-counter medications for mild acne can also help.

When using an acne cream, start with a low dose as some acne creams can irritate the skin, causing redness or a burning sensation when you first start using them.

For moderate to severe acne, your doctor can prescribe:

Topical medications 

Azelaic acid 

This removes dead skin cells and kills bacteria. It doesn’t make your skin more sensitive to light. It is applied twice a day for at least a month. Side effects include a burning or stinging sensation and red, itchy and/or dry skin.

Benzoyl peroxide 

This reduces the growth of bacteria, whiteheads and blackheads. It is applied one to two times a day, 20 minutes after washing your face. It makes your skin more sensitive to sunlight and UV light — you must therefore avoid too much sun and not use sunbeds or sun lamps.

You will need to use it for six weeks to clear your acne. Side effects include dry, tight skin, a burning, itching or stinging sensation, redness and skin peeling.

Topical antibiotics 

These kill bacteria and are usually applied one to two times a day for six to eight weeks. However, the bacteria causing your acne may become resistant to the antibiotics. Side effects include skin irritation and peeling, redness and a burning sensation.

Topical retinoids 

Eg tretinoin and adapalene. These remove dead skin cells and are applied once a day before bedtime for six weeks. They're not suitable if you are pregnant.

Tablets

Hormonal treatments for women 

In women, acne often flares up in response to hormonal changes. Taking the combined oral contraceptive pill can help, although it can take up to one year for it to be fully effective. 

A different version of the oral contraceptive pill called co-cyprindiol is sometimes prescribed to treat severe acne when antibiotics have not worked. Improvements occur after around two to six months of use.

Rare risks of taking co-cyprindiol include developing a blood clot and developing breast cancer later in life. It shouldn't be taken if you're pregnant or breastfeeding. Other side effects include: 

• Bleeding and spotting between your periods
• Headaches
• Mood changes
• Reduced libido
• Sore breasts
• Weight gain or weight loss

Isotretinoin 

This is a strong acne medication, given as capsules, which reduces sebum production, kills bacteria, unclogs pores and reduces inflammation.

Side effects include muscle, joint and back pain, mood changes, liver and pancreas problems and if you are pregnant, miscarriage and birth defects.

You should not take this drug if you are pregnant and while on it, you will need to use two forms of birth control during sex.

Oral antibiotics 

These are used alongside a topical treatment for severe acne. You will usually be prescribed tetracyclines. Tetracyclines can make your skin more sensitive to sunlight and UV light, so you should avoid too much sun and not use sunbeds or sun lamps.

Tetracyclines can also interfere with the oral contraceptive pill, making it less effective for the first few weeks of your treatment. 

If you are pregnant or breastfeeding, you will be prescribed erythromycin. 

You may need to take these antibiotic tablets for four to six months. You can expect to start to see improvements after around six weeks.

Skincare techniques for skin with acne

To reduce your symptoms, make sure you do not: 

• Scrub your skin too hard or use abrasive soaps, cleansers with granules or exfoliators
• Squeeze or try to clean out your blackheads and whiteheads — this can cause scarring
• Wash your face or other affected areas more than twice a day 
• Wash your face with very hot or very cold water
• Wear too much make-up or cosmetic products — if you need to wear make-up use water-based products and products labelled as non-comedogenic

Make sure you do: 

• Exercise regularly to boost your mood — however, you should shower as soon as you finish exercising to avoid sweat irritating your acne
• Let your facial skin air-dry — towels can contain bacteria
• Remove all of your make-up before bedtime
• Use a fragrance-free, water-based emollient if you have dry skin — some acne creams can dry out your skin
• Wash your face and other affected areas with a mild soap and lukewarm water
• Wash your hair regularly and keep it from falling onto your face

Other everyday tips for managing your acne include:

• Avoiding anxiety and stress — this can increase cortisol and adrenaline production, which worsen acne symptoms
• Avoiding exposure to too much sun
• Cleaning your glasses regularly — sebum and skin residue collect on glasses
• Frequently washing your hands, particularly before you apply creams, lotions or makeup
• Holding the phone away from your face when talking — sebum and skin residue collect on phones
• Softening your facial skin with warm, soapy water before shaving

Acne and toothpaste

Do not use toothpaste to treat your acne. Although it contains antibacterial substances, it also contains substances that can damage your skin. See your pharmacist or GP for medications specifically designed to treat acne. 

Acne complications

Acne scarring can happen due to damage in the deeper layers of the skin, which is caused by inflammation from the spot itself, most often with cysts and nodules. It can also be caused by squeezing or picking spots. 

There are three types of acne scars: 

• Boxcar scars — round or oval craters or dips in your skin
• Ice pick scars — small, deep holes in the surface of your skin; these scars look as if your skin has been punctured with a sharp tool
• Rolling scars — bands of scar tissue under your skin that make the skin above it uneven

Getting help for acne as soon as possible will reduce the risk of scarring. If you already have acne scars, there are treatments to minimise your scars, although they will not be able to completely remove your scars.

Treatments to reduce acne scars

Dermabrasion

The top layer of your skin is removed using lasers or a special wire brush. After dermabrasion, your skin will be red and sore for a few months. Over time, your skin will heal and your scars will look better

Laser treatment

For mild to moderate scars, there are two types of laser treatment: 

• Ablative laser treatment — lasers remove a patch of skin around your scar, allowing new, smoother skin to grow back
• Non-ablative laser treatment — lasers encourage the growth of collagen (a protein that gives your skin structure) to repair damage caused by your scars

Surgery

Surgery can remove ice pick and boxcar scars using punch techniques. There are three types of punch technique: 

• Punch elevation for boxcar scars — surgery to remove and lift up the base of the scar, so it can be reattached to the sides of the scar to create a more level surface 
• Punch excision for mild ice pick scars — surgery to remove the scar and seal the wound; as the wound heals a smoother surface is created
• Punch grafting for very deep ice pick scars — surgery to remove the scar and plug the wound with skin taken from elsewhere on your body (usually the back of your ear)

Surgery can also remove rolling scars using subcision techniques. This involves removing the upper layer of the skin above the scar tissue. This allows blood to pool here and form a clot. The blood clot helps new connective tissue form, which pushes the rolling scar up to form a more level surface 

Surgery using a subcision technique can be followed up with dermabrasion or laser treatment to further minimise the scar.