Management of Acne

By Dr I Abrahams (MBChB) 

What is acne? 

Acne is a skin condition involving the pores on your skin and their associated hair follicle and oil gland. Acne is defined by a combination of comedones (white or black heads), pustules (pus pimples), cysts and scarring. In order to diagnose acne, the only necessary criteria is a comedone. Every other lump, bump or scar started out as a comedone at some point. If you don’t have black or white heads, consult your doctor, as you may not have acne. 

How acne starts 

Acne is not caused by a single factor but rather by a combination of issues that arise from interactions between sex hormones, oil glands, dead skin, hair follicles and skin bacteria. 

There are tiny openings on your skin called pores that are linked to either a hair follicle and an associated oil gland, or a sweat gland. For our discussion on acne only the oil secreting pores are relevant in causing pimples.

1. Acne starts when a pore containing a hair follicle produces too much oil and cannot get rid of dead skin fast enough to keep the pore open. This process happens often in teenage years when hormone levels rise and speed up oil production, however, adults can also get acne. 

2. Once enough material accumulates in the pore, it becomes clogged forming a closed comedone or white head. As more and more material accumulates the blockages ruptures forming an open comedone or black head. The black color comes from debris from your hair, oil and dead skin that is all packed together tightly. 

3. Naturally occurring bacteria, called Cutebacterium Acnes grow well in blocked hair follicles. The immune system responds to the bacteria causing swelling and then finally the pimples and pustules that are associated with acne. 

Photo from Science Direct: https://www.sciencedirect.com/science/article/pii/S2405580823001590

Why treat acne 

Acne should be treated because it often causes immense emotional and psychological distress to people, especially teenagers. This can lead to problems like anxiety and depression in the long-term. Also, many people end up with scars on their faces as a result of their acne and can even have significant pain from inflamed pimples. 

What do I do at home 

1. Know that diet plays no known role in the development of acne 

2. Use gentle skin cleansers instead of soaps or scrubs. Syndet or synthetic detergents have a pH of 5.5 to 7 which is close to normal skin pH which minimizes irritation and dryness that is usually caused by high pH soaps (usually between 9-10). Examples of Syndets include: Cetaphil gentle cleansing or Dove beauty bar.  

3. Avoid aggressive skin scrubbing

4.  When washing hair, try washing your hair first before your face and avoid shampoo and conditioner from getting on your face when rinsing it out 

5. Avoid using more oils on your face. Remember oil is part of the cause of your acne! For the same reason, avoid using ointments or greasy products on your skin. Products marked for “sensitive skin” or eczema may not be appropriate and can actually worsen acne. Eczematous skin needs oil to restore the normal skin barrier while you have the opposite issue in acne. So avoid products like petroleum jelly (Vaseline) and emulsifying ointments. 

6. Look for water-based skin care or make- up. Sometimes some cosmetics and shampoos even say “non-comedogenic” or “for acne-prone skin”. Look for these labels 

7. Don’t pop pimples. 

Medical treatment of Acne 

1. Hormonal treatment for women- Oral contraceptives that have anti-androgen (anti-male hormone) components can help as androgens stimulate oil production, a key component of acne development. These include Ginette, Diane-35 or Minvera- 35. These cannot be used for men. 

2. Topical or Oral antibiotics: These are used to kill excess bacteria that cause the inflammatory acne i.e the pimples and the cysts. These should not ever be used without benzac (a topical antiseptic) as Cutebacterium Acnes can quickly become resistant to these antibiotics causing recurring acne. So this works well for pimples, pustules and cysts but can’t be used alone 

3. Benzac (benzoyl peroxide 5%; Over- the-counter)- This kills bacteria causing acne and helps prevent antibiotic resistance. It also helps with inflammation. Note: can cause sun sensitivity, redness, dryness or peeling. If this occurs, use it every second day until it resolves. If the reaction is severe or you’re concerned, always contact your healthcare provider. Benzac also bleaches clothes and sometimes hair. Wear old clothes or use it at night to prevent damaging your clothes 

4. Topical retinoids (e.g Tretinoine (Retin A ® Ilotycin A) or Adapalene). These are some of the most effective anti-acne medications available. They work by: 

5.  Reducing Inflammation 

6. They prevent excessive skin cell development and promotes normal cell development

7. They disconnect desmosomes (connections between cells) of dead cells which helps prevent cells from clumping and forming comedones in the first place → so no comedones which means none of the other symptoms of acne 

8. They also help with pigmentation caused by old pimples and help with acne scars 

9. Topical retinoids are deactivated by sunlight and should never be used during the day. 

10. Apply a thin layer on your entire face and where you normally get acne. If using it with benzac, try using benzac in the morning or use Adapalene instead of tretinoin. Combinations like Epiduo exist which contain both benzac and a topical retinoid. Alternatively, apply benzac first then retin A in a thin layer, however, this may be less effective as benzac may deactivate tretinoin. 

11. Peeling or apparent worsening of acne may occur initially. Be patient as this occurs initially. If peeling or burning is excessive, use only on alternate days or consult your healthcare provider for advice. 

12. Sun sensitivity is common with retinoids. 

13. You cannot use retinoids of any kind while pregnant as they can affect your unborn baby! Always use effective contraception if at risk of unplanned pregnancy. 

5. Sunscreen (SPF-50) - This helps with some of the side effects of sun sensitivity caused by Benzoyl Peroxide and Topical Retinoids. 

6. Oral retinoids (Isotretinoin) - These are usually prescribed by specialist and are used to treat cysts, hard nodules and scarring caused by acne. This is usually a last resort as it is extremely toxic in pregnancy and can cause significant sun sensitivity and skin dryness/ peeling. Use only under specialist guidance.