An overview of the causes of acne and treatment approaches for patients
Acne is one of the most prevalent skin conditions, with an estimated 650 million people affected worldwide.1 With acne appearing as either pus-filled spots (pustules) or comedones (blackheads and whiteheads) and presenting on multiple areas of the body, it can have a detrimental effect on patients’ confidence and self-esteem.2
In a survey of 2,147 UK adults who have experienced acne, 54% felt it had a negative impact on their self-confidence, whilst 22% noticed that it affected their social interactions.2
Despite the common generalisation that acne predominately affects adolescents during puberty, in recent research of 2,012 UK adults who have experienced acne at some point in their life, 72% were over the age of 24, and 25-34-year-olds were the second most affected age group – a prime cohort of potential patients presenting at aesthetic clinics.3 To see how practitioners can assist patients suffering from acne, Aesthetics spoke to consultant dermatologists Dr Angela Tewari and Dr Derrick Phillips, as well as education nurse at the British Dermatological Nursing Group Jodie Newman, to find out their approaches to treating acne patients.
Acne is characterised by a blockage and inflammation of the pilosebaceous unit comprising of the hair follicle, hair shaft and sebaceous gland.4 It therefore presents with lesions which can be non-inflammatory (blackheads/whiteheads), inflammatory (papules, cysts and nodules) or a mixture of both (Figure 1).4 Acne tends to present predominantly on the face, but can also appear on the back, shoulders and chest.5
Newman explains, “Acne can occur when there is a build-up of excessive sebum (oil) in the skin which causes the follicle to become blocked and inflamed (Figure 2). Acne severity can range from mild to moderate and severe.”
Acne can present when excess oil production is exacerbated due to numerous reasons. Dr Phillips notes, “Some people are genetically predisposed to producing more oil than the average person, but we also know that during different stages of life, like teenage years, under the influence of testosterone, there is also an increase in oil production,” he explains. Another reason can be an abnormal build-up of keratin within the pores, influenced by hormones. Dr Phillips continues, “This causes the pores to become more easily blocked by sebum which can be oxidised, causing blackheads. If the pore closes, this results in whiteheads.”
Dr Phillips adds that the combination of blocked pores, excess oil production and lack of oxygen to the skin causes acne. “This environment becomes hospitable for bacteria and proliferates, resulting in inflammatory acne. In severe cases, it can lead to a rupture of the pilosebaceous unit, and subsequent scarring.” he notes.
Some of the known factors that cause or contribute to acne can include: medications (such as lithium, steroids, anticonvulsants), excessive sun exposure, occlusive clothing, hormones and endocrine disorders like polycystic ovarian syndrome, and even pregnancy.6 Genetic factors also play a part, with one paper stating that heritability estimates range from 50-90%.6 Other lifestyle factors such as excessive stress and anxiety, diet and cosmetic use may also have an impact.7 The practitioners interviewed explain that all of these factors need to be considered when consulting patients and planning treatment approaches.
Newman notes that some contraceptives, such as the progesterone only pill, can be known to drive the development of acne, whilst Dr Phillips highlights that newer immunotherapy cancer medications can cause acne as a side effect. “I usually see two to three patients a month that are on these medications and they present with an acneiform rash localised to areas rich in sebaceous glands. The rash differs from conventional acne as inflammatory lesions (papules, pustules and nodules) predominate. Oral steroids or steroid hormone injections used to enhance athletic performance can also trigger acne, so it is important to take a thorough medical history during a patient’s consultation,” he advises.
Although research in this area is growing, there is an ongoing debate about the role of dietary habits in the development, duration and severity of acne.8-10 According to a 2022 systemic review, further randomised trials are necessary to fully characterise the potential associations.11 If a patient feels there is a link between their diet and acne severity, some dermatologists encourage them to keep a food diary for at least 12 weeks.12
Dr Tewari notes, “There are some foods which are known to be related to acne, such as dairy. Interestingly, skimmed milk can be associated more with acne than full fat, which a lot of patients don’t realise! Ensuring your patients have foods with lots of fibre helps to increase skin function, and they are therefore less likely to develop bad acne.” Newman also reiterates that diets containing a high sugar and fat content can exacerbate acne as it drives insulin levels causing a surge in hormones and inflammation. Furthermore, there has been some evidence that whey protein has acne-inducing effects, resulting in truncal acne.13 Dr Phillips explains, “It’s really difficult to prove causality as studies rely on small numbers from case studies, as well as the possibility of use of additional training enhancing medications.”14
Skincare is also a common factor contributing to acne according to Dr Phillips, who says that some of his patients are not aware that their products may be worsening their condition or that they might not complement their skin type. “Often people with acne have an increased amount of oil production, which might be localised to the t-zone, hence using products which are oil or silicone-based can aggravate acne by occluding the pores. Alcohol-based products should also be avoided as they can dry the skin, causing the oil glands to produce more sebum,” he adds.
With acne being a chronic skin condition, there are multiple treatment options available to help tackle the issue, from prescription medications and topical skincare to chemical peels and lasers, which are dependent on the severity of the acne presented.
Patients suffering with mild acne are usually first advised on skincare products and their usage, says Dr Phillips. “I recommend that my patients avoid sleeping in their makeup, stop using oil-based products and signpost them towards skincare which is formulated for blemish-prone skin. Some brands I recommend are the CeraVe Blemish Control range or La Roche-Posay Effaclar Duo or H,” he adds.
Non-inflammatory acne, which includes whiteheads/blackheads, can result in blocked pores. Dr Phillips, therefore, advises exfoliating treatments, such as medical-grade retinoids. “I tend to prescribe Differin (adapalene), and more recently Aklief (trifarotene). Beta hydroxy acids, such as salicylic acid (e.g. CeraVe SA Smoothing Cleanser), are also advised to stabilise acne-prone skin and further improve skin texture,” he notes. If patients have increased skin sensitivity, this might affect the strength or dosage of certain retinoids, Dr Phillips adds.
In her initial treatment approach for all acne patients, Dr Tewari prefers to start patients on a skincare routine consisting of vitamin A derivatives and actives like niacinamide. “These ingredients can help prevent clogged pores, decrease inflammation, as well as possibly reducing sebum production. Topical approaches also include peroxide gels, such as acnecide, to reduce bacteria on the skin,” she explains.
If patients are suffering with moderate acne or if it is presenting on other areas of the body, Dr Phillips recommends antibiotics alongside skincare. He explains, “NICE has guidelines on the treatment of acne which includes antibiotic recommendations and doses.15 The typical antibiotics used are tetracyclines (Oxytetracycline, Lymecycline and Doxycycline). I occasionally use trimethoprim for severe papulopustular acne that has failed to respond to conventional antibiotics. Three months is required to assess the benefits of antibiotic therapy.”
For patients suffering with severe or nodulocystic acne which has failed to respond to treatments in primary care, both Dr Phillips and Newman recommend prescribing isotretinoin under supervision in secondary care. Newman explains that it is a vitamin A derivative, used to target the over production of oil in the sebaceous glands. She continues, “Due to the side effect profile of isotretinoin, it is only available in secondary care and requires supervision from a qualified practitioner. However, in secondary care, for our cohort of female patients with underlining gynaecological issues, the use of spironolactone off-license may be beneficial as it helps suppress the production of androgens, leading to oil production and acne.”
There are other treatments commonly used in medical aesthetic clinics which may help to improve acne, particularly for those who would like alternative treatments, have not responded to other interventions or are unsuitable for medical therapy. Some of these include laser resurfacing, light-emitting dioide (LED) therapy, intense pulsed light (IPL) and chemical peels.17
Dr Phillips likes to use salicylic acid peels to help unclog pores and improve the skin’s complexion and texture. As well as exfoliation, peels can remove superficial lesions, followed by a regeneration of new epidermal and dermal tissues.18
LED can be advised for patients with mild to moderate acne as blue light may destroy acne-causing bacteria, whilst red light reduces inflammation and stimulates collagen.19 With similar benefits to LED, IPL can also reduce redness and help improve acne scars.20
Lasers are also an option, with a wide variety of choices available for technologies and brands.17 According to Dr Phillips, the new AviClear device by Cutera launching in the UK this year is a long-awaited treatment for targeting acne. “The laser targets sebum and has been licensed by the US Food and Drug Administration for treating moderate-to-severe acne. Within three treatment sessions, the results continue to improve by up to 12 months and possibly beyond.21 This is a technology that should be easily accessible for patients once it has been officially launched,” he explains.
Acne scarring is a common side effect and patients may also present to aesthetic clinics seeking help on skin quality and texture. Dr Tewari states, “Less invasive therapies such as microneedling, chemical peels and light therapy can be helpful to target acne scarring, even skin tone and improve skin quality. Personally, I use VI peels, Jessner’s peels and the mesoestetic range in-clinic, as well as Morpheus8 and Sciton’s BBL and Moxi laser therapy.” Some of these treatments might not be suitable for active acne as it may worsen the condition and create further inflammation and scarring, Dr Tewari advises.
Laser resurfacing can also help patients with mild to moderate acne scarring, improve skin texture, stimulate collagen and reduce discolouration on the skin. One literature review highlighted the benefits of combining laser with other modalities such as platelet-rich plasma and radiofrequency microneedling to treat post-inflammatory hyperpigmentation which is a side effect from acne.22
All the practitioners agree that patients should be consulted thoroughly before treatment, and all possible side effects and serious adverse events should be explained.
Some medications, such as isotretinoin, have been linked to increased risk of depression and suicidal thoughts, particularly for those with a personal or family history of mental disorders.16 Further studies are needed to identify patients who would benefit from an early referral to a mental health professional when isotretinoin is initiated.16
Newman says it is pivotal for a patient’s mental health to be explored during the consultation. She adds, “Most patients are quite in touch with their mental health, however, for those that do have pre-existing mental health conditions should seek advice from their mental health team if there are concerns about starting isotretinoin therapy and ensure that the patient has a good support network in place for when they commence therapy. This could be in the form of informing friends and relatives to monitor their moods, increasing frequency of appointments, regular mental health screening assessment tools and direct contact details of the department or practitioner involved in the care.”
Isotretinoin is an effective treatment that is licensed for the management of moderate to severe acne that has failed to respond to conventional therapies or where there is a risk of scarring, Dr Phillips explains. “It is a treatment that can only be prescribed under the supervision of a dermatologist, and has some associated but tolerable side effects.” He continues, “At some points, different treatments might need to be trialled, so it’s not a simple journey. Therefore, I also recommend spironolactone for adult female acne and if they are suitable, I try to use this medication where possible as once patients are stable on this, I can manage and maintain their skin with very few side effects.”
Both spironolactone and isotretinoin should not be prescribed to pregnant women due to the potential effects on the foetus, explains Newman. “It is also important to understand what other medications the patient is on, so we don’t contraindicate these,” she says, adding, “There are risks associated with the use of any medications, but it’s about making the patient aware of these and involving them in the treatment decision.”
Patients should also be aware that isotretinoin can exacerbate acne when first initiated on the medication. Newman adds that it is important to notify patients of this to manage expectations accordingly. She explains, “Tackling acne concerns can be a rollercoaster for patients and durations and outcomes of treatment will vary.” Dr Phillips usually tells his patients they should expect improvements after eight to 12 weeks, with patients able to judge how successful the treatment is going after this time. “This is the optimal time for treatments like spironolactone to work. Retinoids and exfoliating treatments may bring about a purge and some patients may see their acne get worse before improvements are seen. However, three months is a good point to measure response,” he explains.
All practitioners agree that patients should be applying a broad-spectrum SPF 50 or above daily as some medications can cause patients’ skin to become photosensitive. “For topical therapies, SPF is pivotal to protect the skin,” Dr Tewari advises.
Dr Phillips also recommends a simplified skincare routine to help the skin remain acne-free. He notes, “I advise a simple routine as I don’t want patients applying active ingredients which aggravate the skin, particularly when they are on treatments which may make their skin more sensitive.” Dr Phillips suggests a cleanser, an alpha hydroxy/beta hydroxy acid (if tolerated once or twice weekly), a moisturiser and SPF for the mornings, whilst the evening entails a cleanser, medical retinoid (three to five nights a week as tolerated) and moisturiser.
In terms of scar management to assist with acne side effects, Newman advises patients to wait six to 12 months to allow the skin to settle. She states, “It is important for patients to wait for this amount of time to allow collagen to renew and for the skin to completely settle down before tackling scarring. I always refer my patients to a qualified practitioner who has experience in the use of isotretinoin and scar management treatments.”
Newman advises her patients that often for scar management a robust assessment of the scars is required as a combination of treatments may be dependant on the scar types. This could be in the form of chemical peels, microneedling or laser therapy but the patient should be counselled about the benefits and risks.
In 2021, NICE changed its guidelines on the management of acne scarring regarding patients with severe psychological distress. The Integrated Care Board are statutory NHS organisations that plan, manage and arrange health services in a geographical location. They are responsible for referring patients to specialists who offer appropriate management of laser therapy in this case.23
Acne is a skin condition that affects most of the population at some point in their lives. Therefore, it is important for aesthetic practitioners to have a sound knowledge of the causes of acne, as well as appropriate treatment options available, whether this is prescription-led or cosmetic solutions.
Dr Phillips concludes that if practitioners are in doubt of the correct diagnosis or are unable to treat patients as it is outside their scope of practice, they should refer the patient to a specialist, such as a dermatologist. He says, “If you have a patient that is experiencing moderate to severe acne, then refer to a dermatologist sooner rather than later as there is an increased risk of scarring. The sooner the acne is treated, the less likely patients are to develop scars which can persist into later life.”
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