Wendy Lewis discusses the different acne patient groups and advises practitioners on how to grow a successful acne treatment clinic
Acne is the most common skin condition, according to the American Academy of Dermatology (AAD), and nearly 85% of all people have acne at some point in their lives, most often on the face, chest, and back.1 For some, it may just be an occasional pimple that appears. For others, acne can be severe and disfiguring. For most people affected, the condition falls somewhere between these two extremes. Acne also affects more than just a patient’s skin. It can have an impact on their entire life in many ways. Acne has a dramatic impact on self-esteem and self-confidence. Even mild breakouts can negatively affect the way people feel about themselves in social and professional situations. Acne is also not just a teenage thing. It can occur at any age, from birth through to the post-menopause years. Although it tends to start in teens, some adults continue to get acne as they age, or for the first time in their 30s or 40s. Cases of adult acne are also on the rise, which is often attributed to stress, cosmetic use, lifestyle and simply neglecting the skin. Upwards of 20% of all adults have active acne.2
There are many effective remedies and treatments that can help get acne breakouts under control for the short term and for the long term. Noninflammatory acne may be the most common variation, but inflammatory acne patients are even more motivated to seek out a treatment that works.
There are many causes of acne, including stress, hormonal fluctuations especially around menstruation, pregnancy, peri-menopause, and menopause, oral contraceptives, medication side effects, plus hair and skin care products used. According to Dr Zein Obagi, a Beverly Hills-based dermatologist, “Since the causes of acne are diffuse, including genetics, hormones, excessive oil production, diet, sleeping habits, hygiene, and stress, a successful acne treatment must be specialised to each patient.” Treating patients effectively should begin with a comprehensive history, including lifestyle, skincare habits, and also ethnic background. A thorough inquiry into what treatments the patient has used in the past, what worked or did not work, any possible side effects or allergies to topical agents, their expected outcomes, tolerance for downtime, budget, and availability to return to the clinic at regular intervals should factor into your treatment plan. Patient compliance is also a key issue when it comes to successful outcomes with acne protocols. If the patient is unwilling or unable to continue long-term therapy, results may not be satisfactory which can lead to missed appointments that waste clinic staff time, or unhappy patients who post negative reviews online. Acne can occur on the face, back, neck, chest and other parts of the body. The area that most patients will be seeking treatment for is usually the face and neck area as it is always visible. Athletes, swimmers, and men are also often concerned with back acne. The same goes for brides and girls leading up to graduations when the ability to wear low cut and backless gowns is an important consideration.
Offering a programme of monthly or bi-weekly medical extractions can be very appealing to teenagers who find it difficult to stick to a daily skincare routine. A medical grade facial with extractions will immediately improve existing active acne lesions while helping to prevent future flare-ups. Teens need detailed instructions for how to care for their skin at home in between clinic visits. Many patients cause harm by squeezing lesions that can cause scarring and spread infections. Medical grade facials to safely extract comedones are a popular service for this patient group. Peels and microdermabrasion treatments are also effective ways of improving blackheads. By removing the top layers of the skin, pores become unclogged and the dirt and oil that causes blackheads is reduced. Homecare products and prescription-grade topicals go hand in hand with clinical acne treatments. Most notably, benzoyl peroxide formulas help to reduce oil, and keratolytics in the form of glycolic and beta hydroxy acids help loosen debris and assist with cell turnover. Retinoids can decrease the production of sebum in the skin, both in an oral form (isotretinoin, Roaccutane) and topical forms (retin-A, Adapalene, Differin). Certain hormonal treatments, such as androgen inhibitor Spironolactone and oral contraceptives may also help to decrease sebum production.3 Water-based concealing products are a useful addition to the teen acne patient’s product selection.
In my experience, men tend to be the least motivated and least compliant of all acne patient sectors. It is more challenging to get them back to the clinic on a regular basis, so extra thought should be given to more aggressive therapy, such as oral medications and/or topical agents, that may deliver longer lasting results. Light-based therapy, such as blue light or Isolaz which vacuums pores and kills Propionibacterium acnes (p. acnes), the bacteria that is the primary pathogenic agent responsible for acne vulgaris, can be very helpful in treating male patients. It may be more difficult to persuade them to undergo deeper treatments when there is some downtime required. Men are frequently resistant to any procedures that require time out of work, sports, or the sun. It is important to bear in mind that some topical ingredients may come with too many side effects or sun sensitivity to be practical for long-term usage, so I would advise that you discuss with the patient how much time they spend outdoors.
Adult acne is potentially more upsetting for patients as most people expect to grow out of it past their university years. Adults also need to be treated more gently without harsh ingredients that cause dryness, redness and peeling. In female patients, it is important to manage their acne effectively so they are able to wear foundation and non-comedogenic cosmetics. An overly aggressive regime that causes roughness and flaking may be a problem for adult women, and interfere with compliance. New York City dermatologist Dr Judith Hellman has developed a large acne practice that serves a wide variety of patients. She attracts patients from young to mature, and gets referrals from local hotels when visitors need to see a doctor for an emergency steroid injection or facial to unclog their pores. “It’s important to emphasise with adult acne patients that a haphazard approach won’t work,” she explains. “They may expect that after one session with Pulsed Dye Laser (PDL) they won’t break out again. I always explain that acne requires the right treatments and the right products, and some tough love. I tell patients that we’re going to be together for a long time, but I will improve their skin substantially,” says Dr. Hellman. Female patients with acne and rosacea do well with mineral makeup that offers superior coverage yet is lighter and easier to tolerate. Professional mineral makeup brands are true multi-taskers for acne prone patients. They are a hybrid of makeup and skin care, and camouflage blemishes, conceal hyperpigmentation, and protect sensitive skin from environmental damage, without clogging pores. If your clinic treats women with these conditions, concealing cosmetics should be an essential component of your product selection.
When you are successful in helping acne patients achieve clear, radiant, even toned skin, they will be yours forever
Most practitioners agree that acne responds well to combination therapies. The ideal regime may include a customised plan of peels, microdermabrasion, light- based treatments, as well as lasers, coupled with extractions, intralesional steroid injections for cysts and nodules, and topical skincare. Among the wavelengths currently indicated for acne, diode, pulsed dye, fractional, infrared, radiofrequency, photodynamic therapy, blue light, are commonly used. Some of these energies target p.acnes bacteria, such as blue light, while others, such as pulse dye lasers, shrink sebaceous glands and cystic acne.
If you are building an acne clinic, also consider technologies that can diminish acne scarring, which is an all too common consequence of not getting treated properly soon enough to prevent post inflammatory hyperpigmentation and scar formation. The typical protocol recommended is to first get active acne under control, and then deal with the main issues for the patient. Areas of post inflammatory hyperpigmentation can be treated with a series of peels, IPL and lasers that target pigment. Acne scarring can be effectively improved with RF, as well as fractionated non-ablative or ablative technology. “Treating acne scars typically requires a combination of subcision, excision of scars, laser resurfacing and filler injections or dermal grafting,” says oculoplastic surgeon Brian Biesman in Nashville, Tennessee. “Laser skin resurfacing also plays a pivotal role in the treatment of acne scars today. Numerous types of laser resurfacing procedures have been used to treat acne scars: traditional laser resurfacing (CO2 laser), Er;YAG skin resurfacing, noninvasive laser treatments, fractional laser resurfacing,” he says. “Choosing the best laser for each patient requires consideration of the extent of scarring, downtime or recovery time the patient is willing to endure, and relative safety profile. In most cases, I feel that ablative fractional resurfacing is the best option for patients with acne scars. I typically advise that more than one resurfacing treatment will be needed to achieve the desired outcome.”
THE ACNE OPPORTUNITYWhile very treatable, of those who suffer from acne, only 11% actually get to a doctor’s clinic, and over 40% do not seek treatment at all.
SOURCE: The Acne Resource Centre Online
As acne is chronic, in all cases, a home care regime of some form of topical therapy and/or oral prescription medications may be required to maintain clearance long term. Among the most widely used topical acne medications, retinoids, antibiotics, and benzoyl peroxide rank supreme. Oral medications for acne include oral antibiotics, anti-androgen medications and retinoids, such as Roaccutane. “Drug store and prescription treatments that claim to treat acne can actually perpetuate the problem,” says Dr. Obagi. “From synthetic oils in cleansers claiming to be ‘oil-free’ to pore-clogging agents in moisturisers, unnecessary ingredients can aggravate acne, leaving people afflicted with the condition to assume that their skin issues are incurable. The fact is, with the right regimen, many people can clear up their skin without a prescription.” An appropriately selected home care regime is vital for the acne patient to keep breakouts under control in between clinic visits. There are many professionally dispensed brands that offer a wide selection of cleansers, exfoliants, body scrubs, light gel moisturisers, oil-free sunscreens, concealers, powders, and foundations that are ideally suited for acne prone skin. When you are successful in helping acne patients achieve clear, radiant, even toned skin, they will be yours forever. As this patient segment tends to be more vocal and open to sharing their experience and advice with friends, family and online, happy acne patients can become true brand advocates for your clinic.