WHAT IS ACNE?
Acne is a chronic inflammatory skin condition. The majority of cases affect the face (99%), back (60% of cases) and chest (15% of cases).
WHAT CAUSES ACNE?
Acne breakouts occur due to a combination of factors involving the skin’s oil glands, hair follicles, bacteria, hormones, and inflammation. The primary factors involved in the development of acne are:-
Excess oil production (sebum)
The sebaceous glands in the skin produce an oily substance called sebum, which helps lubricate the skin. However, in individuals with acne, these glands can produce excessive amounts of sebum. The excess sebum can mix with dead skin cells and clog the hair follicles. This can lead to the formation of a plug called a comedo.
Clogged pores
When the hair follicles become blocked with a combination of excess sebum and dead skin cells, it can create an ideal environment for acne-causing bacteria to thrive.
Bacterial activity
Propionibacterium acnes (P. acnes) is a type of bacteria that naturally resides on the skin. However, when hair follicles become clogged, P. acnes can multiply rapidly, leading to inflammation and the formation of pimples.
Inflammation
The presence of clogged pores and bacterial activity can lead to inflammation in the surrounding skin. This results in redness, swelling, and the formation of acne lesions.
ARE THERE ANY OTHER FACTORS THAT CAN CONTRIBUTE TO IT?
Genetic factors
There is a high concordance between twins and an increased likelihood of severe acne if you have close family members with it
Racial and ethnic factors
While acne can affect people of all races and ethnicities, there are some notable differences. Acne is common among Caucasians, and studies have shown that they tend to have higher rates of acne compared to other ethnic groups. They may also experience more severe forms of acne, including inflammatory lesions such as nodules and cysts.
Studies suggest that Asians tend to have a lower prevalence of acne compared to Caucasians. However, when acne does occur in Asians, it often manifests as inflammatory acne with a higher likelihood of post-inflammatory hyperpigmentation (dark spots) or scarring.
African Americans have a lower prevalence of acne compared to Caucasians. However, when acne occurs in individuals with darker skin tones, it can be more persistent and may lead to post-inflammatory hyperpigmentation, keloid formation, or hypertrophic scars.
Hormonal factors: Hormonal fluctuations, particularly during puberty, can trigger acne breakouts. Androgens, such as testosterone, stimulate the sebaceous glands to produce more oil, leading to increased acne development. Hormonal changes can also occur during the menstrual cycle, pregnancy, or during the menopause.
CAN LIFESTYLE FACTORS AFFECT ITS DEVELOPMENT?
Lifestyle factors can indeed influence the occurrence and severity of acne breakouts. These include:-
Diet
We do not fully understand the link between diet and acne. Some studies suggest that certain foods with a high glycemic index (e.g., sugary and processed foods) and dairy products may contribute to acne breakouts in some individuals. We would generally recommend you maintain a balanced diet rich in fruits, vegetables, whole grains, and lean proteins.
Overzealous skincare
Good skincare practices are essential for managing acne. Over-washing the face or using harsh cleansers can strip the skin of its natural oils, leading to dryness and potential irritation. On the other hand, inadequate cleansing can allow the build up of dirt, oil, and dead skin cells, contributing to clogged pores. It’s important to find a gentle cleanser suitable for your skin type and to avoid excessive scrubbing or touching the face with dirty hands. If you need help choosing the right skin care then click here to book a skin care consultation with our skin care expert Dr Randhawa at our clinics in Harborne and Quinton, Birmingham.
Stress
Stress can trigger or worsen acne breakouts. When you’re under stress, your body releases hormones like cortisol, which can increase oil production and inflammation in the skin. Finding healthy ways to manage stress, such as exercise, meditation, or engaging in hobbies, can help reduce the impact of stress on acne.
Sleep
Poor sleep or inadequate sleep can disrupt the body’s hormonal balance, including those related to acne. Aim for a consistent sleep routine, ensuring you get enough restful sleep each night.
Makeup and skincare products
Certain makeup and skincare products, especially those that are heavy or comedogenic (pore-clogging), can exacerbate acne. Look for non-comedogenic or oil-free products labeled as “acne-friendly” or “non-acnegenic” to minimize the risk of breakouts. If you need advice on managing your acne-prone skin then click here to book a skin care consultation with our skin care expert Dr Randhawa at our clinics in Harborne and Quinton, Birmingham.
Environmental factors
Environmental factors like pollution and humidity can affect the skin and potentially contribute to acne. Protecting your skin from excessive sun exposure and using non-comedogenic sunscreen is important. Additionally, regularly cleansing the skin to remove dirt and pollutants can help prevent pore congestion.
HOW DOES ACNE PRESENT?
It presents with spots which can be inflammatory, non-inflammatory or both. Non-inflamed lesions, also known as comedones present as blackheads and whiteheads. Inflamed lesions include pustules, nodules or cysts. Most people have a mixture of lesions.
WHAT IS THE DIFFERENCE BETWEEN BLACKHEADS AND WHITEHEADS?
Blackheads, also known as open comedones, appear as small, dark bumps on the skin. They occur when hair follicles become clogged with excess oil (sebum), dead skin cells, and bacteria. The clogged pore remains open, allowing the contents to oxidize and turn black. Despite the dark colour, dirt does not cause blackheads.
Whiteheads, also known as closed comedones, appear as small, flesh-colored or white bumps on the skin’s surface. They develop when the hair follicles become clogged, similar to blackheads. However, in the case of whiteheads, the pore remains closed, preventing the contents from oxidizing and maintaining a white or flesh-colored appearance.
WHY DO I GET ACNE ON MY CHIN?
Women tend to get acne breakouts on their chin and jawline during their periods. Dr C Griffiths, a leading Dermatologist in the UK describes a ‘triangle of hormone sensitivity’ on the chin in his paper: ‘The red face – an overview and delineation of the MARSH syndrome’ published in Clinical and Experimental Dermatology in Jan 1999. In this area, there is a rich blood supply which leads to increased blood blood flow and an overabundant and continuous supply of androgens to the area. There may also be more androgen receptors in that area responding to the increased supply of androgen hormones.
HOW SEVERE IS MY ACNE?
Mild acne typically involves the presence of whiteheads and blackheads with few inflammatory lesions. Moderate acne includes a larger number of papules and pustules. We often see a high number of inflammatory lesions, including nodules and cysts, in severe acne. Scarring may also be present in severe cases.
HOW CAN I TREAT MY ACNE?
The treatment ladder for acne typically involves a stepwise approach, starting with over-the-counter (OTC) products and progressing to prescription medications if necessary. There are also some conservative measures you can put into place. Here is a general outline of the treatment ladder:-
Conservative measures
Avoid over-cleansing the skin, especially with harsh products. Avoid oil-based comedogenic skincare products such as make up and sunscreens. Try to avoid picking at spots as this can lead to scarring of the skin.
Over-the-counter (OTC) products
The first line of defense for involves the use of OTC products containing ingredients such as benzoyl peroxide and salicylic acid. These products help to reduce oil production, unclog pores, and kill bacteria on the skin’s surface. The Obagi clenziderm system is often a good place to start and Dr Randhawa can prescribe it in our Harborne clinic, Birmingham after a thorough skin consultation.
Topical prescription medications
If OTC products do not provide sufficient improvement, the next step is topical medications. These may include topical retinoids (e.g. adapalene, tretinoin), topical benzoyl peroxide to unclog pores and reduce inflammation and topical antibiotics (e.g. clindamycin, erythromycin) to kill bacteria. Combination products of a retinoid + benzoyl peroxide or a retinoid + antibiotic. We advise a 12 week course of a topical treatment before moving on to the next step. We would not advise topical retinoids when trying to conceive or if already pregnant due to possible harm to the foetus.
Oral antibiotics
If there is no response to topical treatments, we may recommend oral antibiotics alongside topical treatments. We would not use a topical anitbiotic or oral antibiotic alone nor in combination with each other. When using either a topical or oral antibiotic we would use it in combination with other topical treatments such as a retinoid, benzoyl peroxide or azelaic acid. Commonly prescribed antibiotics for acne include lymecycline and doxycycline. Oral antibiotics work by reducing the amount of acne-causing bacteria on the skin and reducing inflammation.
Oral contraceptive pill
The combined oral contraceptive pill (one that includes both progesterone and oestrogen) can be used in combination with topical treatments, as an alternative to oral antibiotics, for women with acne. Contraceptive pills with only the one hormone progesterone in it can sometimes worsen acne. If you are not able to take the combined pill, another option may be spironolactone; this is a diuretic which has an anti-androgen effect at higher doses and is a FDA-approved drug for the treatment of acne.
Isotretinoin (Roaccutane)
Isotretinoin is a powerful oral medication reserved for severe, persistent cases that have not responded to other treatments. It works by reducing oil production, inhibiting the growth of acne-causing bacteria, and preventing the formation of clogged pores. Isotretinoin can have significant side effects and requires close monitoring with regular blood tests and pregnancy tests by a specialist. It is highly teratogenic which means it can be very harmful to the foetus if you become pregnant whilst taking this medication. A reliable method of contraception such as a coil or implant is advised before starting the course. It can also affect your mood and has been linked to depression. It can only be prescribed by a Dermatologist, following a referral from your GP.
WILL CHANGING MY DIET HELP CONTROL MY ACNE?
Several studies have explored the potential relationship between acne and certain food groups.
High glycemic index food
A study published in the Journal of the American Academy of Dermatology in 2007 found that a low glycemic load diet (which includes foods with a lower glycemic index) was associated with improvement in acne lesions. Another study published in the Journal of the Academy of Nutrition and Dietetics in 2016 also indicated that a low glycemic index diet might reduce the risk of acne. High glycemic index include sugary snacks, processed carbohydrates, and sugary drinks. These foods can cause a rapid increase in blood sugar levels, leading to higher insulin levels, inflammation, and increased oil production. Choosing low glycemic index foods, such as whole grains, fruits, and vegetables, may therefore be beneficial for some individuals.
Dairy products
Several studies have suggested a possible link between dairy consumption and acne. A systematic review and meta-analysis published in the Journal of the European Academy of Dermatology and Venereology in 2018 concluded that dairy intake, particularly skimmed milk which contains hormones and growth factors, was associated with a higher risk of acne. However, more research is needed to fully understand the mechanisms behind this association. If you suspect that dairy may be affecting your skin, you could consider reducing or eliminating dairy products from your diet and observing if it makes a difference.
Omega-3 fatty acids
A study published in Lipids in Health and Disease in 2012 examined the effect of omega-3 fatty acid supplementation on inflammatory acne. The study found that participants who received omega-3 supplementation experienced a reduction in inflammatory acne lesions. Sources of omega-3 fatty acids include fatty fish (e.g. salmon, mackerel), walnuts, chia seeds, and flaxseeds. Including these foods in your diet may help reduce inflammation and potentially improve acne symptoms.
Antioxidant-rich foods
Antioxidants help protect the skin from damage caused by free radicals and inflammation. Consuming a diet rich in fruits and vegetables, which are high in antioxidants, may contribute to overall skin health.
While adjusting your diet may be worth exploring as part of a holistic approach to acne management, it’s important to remember that diet alone may not be a definitive solution. The impact of diet can vary among individuals, and some people may not experience significant improvements solely through dietary changes. It is important to have a conversation with a medically qualified professional before making these changes.
HOW CAN I TREAT MY ACNE SCARS?
Acne scars can be treated through various methods depending on their severity and type. Here are some commonly used treatments for acne scars:
Topical Treatments
Over-the-counter creams, ointments, or gels containing ingredients such as retinoids, vitamin C, or hydroxy acids can help reduce the appearance of mild acne scars. These treatments promote skin cell turnover and stimulate collagen production.
Chemical Peels
Chemical peels involve the application of a chemical solution to the skin, which exfoliates the outer layer. This process removes dead skin cells and encourages the growth of new, smoother skin. We can use superficial or medium peels to treat acne scars.
Microdermabrasion
This procedure uses a handheld device to gently exfoliate the outer layer of the skin. Microdermabrasion helps improve the appearance of shallow acne scars by stimulating collagen production and revealing fresh skin.
Dermabrasion
Dermabrasion is a more intensive procedure performed by a dermatologist or plastic surgeon. It involves the use of a high-speed rotating brush or diamond wheel to remove the outer layers of the skin. Dermabrasion can effectively reduce the appearance of deep acne scars, but it requires a longer recovery time compared to other treatments and can leave your skin looking red and sore for several months.
Microneedling
Microneedling, or collagen induction therapy, involves using a device with tiny needles to create controlled micro-injuries to the skin. This process stimulates collagen production and improves the texture and appearance of acne scars over time.
Laser Therapy
Laser treatments can target specific areas of scarring by resurfacing the skin, promoting collagen production, and reducing the appearance of scars. Different types of lasers, such as fractional lasers or pulsed dye lasers, may be used depending on the type of acne scars.
Injectable Fillers
Dermal fillers, such as hyaluronic acid or collagen-based injections, can be used to temporarily fill in depressed acne scars, making them less noticeable. The results are immediate, but the effects are temporary and usually last several months.
Surgical Procedures
In cases of severe acne scarring, surgical procedures like punch excision, subcision, or skin grafting may be recommended. These procedures involve physically removing the scar tissue or transferring healthy skin to the scarred area.
HOW CAN ACNE AFFECT MY MENTAL HEALTH?
Acne can have a significant impact on a person’s mental health and well-being. It can greatly affect self-esteem and may lead to feelings of self-consciousness, embarrassment, and a negative body image. Individuals with acne may feel less confident and may avoid social situations or interactions due to concerns about their appearance. Acne can contribute to the development or exacerbation of anxiety and depression. Acne-related anxiety may manifest as social anxiety, impacting one’s ability to engage in social activities or form relationships. This can all negatively impact a person’s quality of life.
If you relate to these feelings, please reach out for support. Your GP is a good starting point but here are some other useful resources:
HOW CAN WE HELP?
Book in for a free virtual skin consultation with Dr Randhawa or see her face to face in one of our clinics in Quinton or Harborne in Birmingham or Worcester, Worcestershire. She will take a thorough history and examine your skin in order to then create a bespoke, personalised and holistic skincare plan for you. As GPs, acne is a common problem we are very experienced in managing and we would love to work with you to achieve your skincare goals.
Click here to book a skin care consultation with our skin care expert Dr Randhawa at our clinics in Harborne and Quinton, Birmingham.