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Acne (young people)

What is acne? A medical overview

Acne is a skin condition which often affects teenagers and young adults, although it can occur at any age. The main symptoms are spots of different types, such as: blackheads, whiteheads, papules, pustules and nodules (sometimes called cysts). These spots can be painful and sore, and the skin is often oilier. Acne severity is sometimes measured as mild, moderate, moderately severe or severe. Acne sometimes leaves scars on the skin with changed colour, dents or raised marks.
 

Dr McPherson talks about the types of spots often involved in acne.

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So acne has lots of different types of spots. Some people will have mostly one type, some people will have all different types. All spots come- are focused around something called the pilosebaceous unit and that’s where the hair grows out of a follicle, with a little sebum producing gland which is called the sebaceous unit. The earliest type of spots are mostly comedones and people will know these as whiteheads and blackheads, and those are called open comedones [blackheads] and closed comedones [whiteheads]. That’s really just a build-up of sebum and other stuff within the hair follicle. The more inflammatory type of spots are pustules and that’s when you get a different type of cell, called a white cell. And those are the ones which look like squeezable spots, so they look quite pus-y and they look quite different from comedones – most people will be able to tell the difference between a whitehead and a pustule. Then you can get more problematic or larger spots, you can get cysts, abscesses. And then you can get – from spots, you can get marks and scarring. And you know some of those scars can be more lumpy, hypertrophic or keloid.
 

Dr McPherson says there are different grading systems for acne severity used by medical professionals.

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So there aren’t any, you know, very well recognised grading systems for acne. There’s lots of different types and some of them are more kind of global, so mild, moderate, severe, very severe. Some of them, for research purposes, might focus on things like spot counting. And some of them will also look at the different types of spots, so you’ve got comedones, pustules, cysts, scarring. These types of things. So, generally the kind of more global assessments are used when you’re using it sort of clinically and then decisions about treatment will be made on how severe the acne is, how much it’s affecting people, and also how likely it is to scar. So those are the most important things. Because really when you’re treating acne it’s not just for improving the acne as it is but also preventing scarring long-term because scarring can be permanent.

So, sort of terminology around mild through to severe-

Yeah.

- is that quite varied depending on-?

A lot of these grading systems are quite subjective so it depends on the doctor that’s doing it. And so people have different levels of severity. But there are certainly picture-, kind of picture grading systems which can be quite useful in terms of, you know, how much of the face is affected, how severely it’s affected, how tight together the spots are. And that will be-. So I think there is quite variable but I think there is quite close agreement for some of those grading systems between doctors and other health professionals.
 

Dr McPherson says a patient’s views about their own acne will be taken into account by medical professionals when making decisions about treatment.

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So clearly some people will have more-, classed as mild acne but it might be having a huge impact on them and some people will have more severe acne which isn’t affecting them at all. And people’s experiences are very varied. And that will have implications for treatment because some people will be much more keen to try a treatment with possible side-effects with a milder form of acne than other people. So these decisions are often made with the doctor, health professional, patient in conjunction with taking all these factors into account. I think as a health professional if you think the acne is very severe and is scarring, you’ll probably be trying to persuade someone to take treatment that they might not feel comfortable with. But on the other side, you might see people with very minimal acne who are very keen to have treatment and you’ll have a more- different conversation. But it’s always going to be a balance between the severity as judged by the activities that you see clinically and the likelihood it’s going to scar and how much impact it’s having on people.

And I think there are some types of acne which people become quite obsessive with, you might have a lower threshold for treating. So some people who become obsessed with picking and squeezing at spots, then actually treating them at a lower level is probably sensible because they, you know, you want to try and reduce all inflammatory acne and help them with those aspects of things.
Acne can affect different areas of skin on a person’s body. The face, especially the ‘T zone’ (forehead and nose), is often affected. Other parts of the body can have acne too, such as the back, neck, shoulders and chest.
 
The causes of acne are when skin pores/follicles become blocked, for example when the sebaceous glands produce too much oil. A spot develops when the blocked pore is infected by the normal bacteria living on the skin. Acne often affects the face because there are a lot of sebaceous glands located there. There can be different underlying reasons for why acne occurs, such as changes in hormones during puberty.
 

Dr McPherson talks about how common acne is and how long it tends to last for those affected

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So it depends how you define acne in terms of-, most teenagers in this country will get spots to some degree. Whether they’ll all get acne is, you know, depends on where your definition and where your line lies. So I suppose if-, just having spots is very common, having acne that needs treatment either by your GP or by a dermatologist is not so common. But I think still within, you know, 15-20% of teenagers will have severity of spots or acne that needs treatment, so it’s very common. And that will depend on thresholds as to how- how people access healthcare or access treatment.

And how often does it tend to last for people who do have some aspect of acne?

Yeah. So the evidence is that the prevalence is very high and then it slightly depends on what sex you are. So boys tend to have worse acne that lasts probably shorter and they may be more likely for it to not last beyond their teenage years. Whereas girls can have less severe acne but it can grumble on into their 20’s and particularly if they have a more hormonal type of acne or it seems to get worse around their cycle, those types can become- can carry on into their 20s and even 30s. All of these can be like modified by treatment, but there are particular patterns that tend to be a bit more chronic. So sort of jawline acne in females can be more problem- more chronic without treatment.
A ‘flare-up’ or ‘break-out’ describes a time when someone’s acne is more severe than usual. In general, anything that can make the skin produce more oils can be a trigger for an acne flare-up. A trigger for one person’s acne may not be a trigger for another person’s.
 

Dr McPherson talks about acne causes and triggers.

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I think it's always difficult to talk about the difference between causes and triggers. Most people, the cause of their acne is a normal part of puberty and adolescence, and it's to do with a, you know, complex mix of hormones. Particularly androgens, testosterone, which are higher during puberty. So we're not normally looking for kind of an underlying cause, because mostly it's quite well recognised that being in puberty you're kind of acne-prone. And that's partly because of the- mostly because of the hormones. And obviously because of those, the way those hormones will then increase sebum production, which in turn will make it a more favourable state for certain bugs. Particularly p. acnes to live on the skin and cause sort of more problems with acne. There are some other kind of rare causes. So you can have other reasons why you might have increased testosterone. For instance, taking anabolic steroids, or something like that. So very, very unusually there can be other causes. But mostly it's, you know, you’re more likely to have bad acne if you've got genetics or bad- family history, family history of bad acne, and then you're going through puberty. We know that boys tend to have more inflammatory acne in puberty, but girls can have more chronic acne as they get older. So, hormones are the main kind of cause. In terms of triggers, that's a bit more difficult to kind of untangle. Like any inflammatory state, stress can play a role. Which I think, you know, obviously when people find they've got a spot at an important point in their life, and you know, we know that stress can play a role in all of these processes. Other triggers are not so sort of clearly worked out. So people are often interested in diet. And it's a kind of area of increasing research. Probably some places, some places where they have very low dairy diets have very low acne, even in adolescence. So there may be some role for particularly high dairy diets, and that might have some role on the types of hormones and inflammation they have on their skin. Other triggers. So, smoking doesn't seem to make acne- so it doesn't make it better. It's not clear whether it makes it much worse. But mostly people will get acne, you know, even if they have clean skin, if they don't have kind of bad skin habits. It's just unfortunately a part of the way their genetics are and being a teenager.
 

Dr McPherson says the link between diet and acne is unclear.

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Yeah, I think there are lots of misconceptions. And it's not to do with having dirty skin or not washing your face. It's to do with the hormone levels and your sebum production and your genetics. And that's, that's normally nothing to do with, you know, your diet or how clean or dirty you are, what your food-, whether you eat junk food or not. You know, we do know that probably having a healthy diet, eating fruit and vegetables, is good for your skin generally. But the other way round it's not quite so clear. So I don't think there's a clear link between junk food and acne. And I know lots of-, I see lots of young people who have incredibly healthy diets and have acne in any case. So I think it's , it's not directly linked to the food you eat. Sunshine can help some people with acne, it can be- you know, it probably reduces inflammation and can help some, some people with acne. But you know, face washing is an important part of management, but certainly you can have very clean skin and still have acne. So I think unfortunately you can do everything right, look after your skin, eat lots of fruit and vegetables, and still get spots. And that's, you know, people mustn't feel that they're responsible for that.
There are different medical treatments available for acne. Examples include topical treatments (applied to the skin) and antibiotic tablets. Some types of treatment can be bought from a shop (‘over-the-counter’). Other treatments must be prescribed after visiting a medical professional such as a General Practitioner (GP), nurse or dermatologist. Only dermatologists can prescribe the treatment isotretinoin tablets.
 

Dr McPherson talks about when a person could seek a doctor’s help for acne.

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At what stage should a young person to go to the doctors if they are having some spots?

I think there's lots of things that can be done for acne. The key is to do things before you've got scarring. So I don't think it's worth waiting and waiting. I mean, there's lots of things that can be used over the counter quite safely, initially. So there are some quite good, you know, products which are, you know, available without seeing a doctor. But I think if you're getting ongoing lesions, if you think you've got any kind of marks or scarring, you should absolutely go and see your doctor as soon as possible. And, or even if you know that you're kind of high risk, then it might be worth going to see your doctor, just to sort of get prepared. If you know you've had an older brother or sister that's had very bad acne, or a parent who's had scarring acne. I don't think- it's not something you need to kind of wait until things are really bad, because there are things that can be done.
 

Dr McPherson explains why isotretinoin treatments (tablets and topical gels) are usually only available from dermatologists.

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So traditionally when it was a new medicine and it was found to be very effective for acne, there were concerns about its safety and its side-effects. Particularly the psychiatric side-effects and it was- when it was first being used, it had links with depression and even suicide in certain people. So I think there was quite a lot of concern about its use first of all and it was certainly being used, you know, it had quite a high threshold for use. And the other reason for care with its use is the pregnancy prevention programme. So if you’re on isotretinoin and you’re female, it’s, you know, it’s very dangerous to get pregnant and there would highly likely be a problem with the baby if you did get pregnant. So for those reasons, so partly the kind of concern about side-effects, partly the need to monitor things, particularly pregnancy side, it’s traditionally been prescribed only in hospitals by dermatologists. That may change in the future and I think as antibiotics have- have to be careful with prescribing antibiotics for their- they’re used quite a lot in primary care anti-inflammatory purposes for acne- for treating acne, but really if the side-effects of using the antibiotics is so widely more problematic than using something like isotretinoin which is a very effective treatment for acne earlier, then this may change in the future. There have been a few times when I think there- so some GPs with Special Interests can and do prescribe isotretinoin, but they have to be comfortable with monitoring the side-effects, monitoring the pregnancy prevention programme. And traditionally when that’s been kind of rolled out to General Primary Care unit, it hasn’t worked so well and they haven’t felt comfortable prescribing it. But these things are, yeah, may change in the future.
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