MANAGING
ACNE VULGARIS

Acne vulgaris

Acne, or acne vulgaris, is a common skin condition where the pores of your skin become blocked, causing various types of pimples to appear on your face, as well as other parts of the body. 

Acne peaks in adolescence and early adulthood, but can affect people of all ages. Nearly everyone will experience an acne breakout at some point in their lives. During adolescence, acne vulgaris is more common in males than in females, and in adulthood, its more common in women than in men. 

Acne pimples can heal slowly at times, and severe acne can cause permanent scarring and dyspigmentation. Acne can affect one’s self-esteem and cause emotional distress, and has been associated with anxiety and depression regardless of the severity. 

There are several treatment options available to alleviate symptoms and minimise scarring. Generally, the outlook for those with acne, is excellent, as acne clears up on its own as you grow into early adulthood. 

What is acne? 

Acne vulgaris is a chronic condition that develops when hair follicles (the small cavities from which tiny hairs grow) are clogged with oils, dead skin cells, and bacteria. It generally appears on the face, but can also spread to the neck, chest, back and the rest of the body – where the oil glands are mostly found. 

There are different types of acne: 

• Comedones are small, flesh-coloured pimples, better known as: o blackheads, which are closed plugged pores, and 

o whiteheads, which are the open plugged pores 

• Papules: small, tender red bumps 

• Pustules: pimples with pus; the white or yellow “squeezable” spots 

• Fungal acne (pityrosporum folliculitis): this develops when there is an excess of yeast in the hair follicles; they can become itchy and inflamed. 

• Nodules: large, painful red lumps 

• Cystic lesions: pus-filled lumps, which can cause scarring. 

Acne usually goes away within two weeks but the deeper pimples or lumps may take months, or even years, to clear up. Many acne patients also have oily skin (seborrhoea). 

Acne can be classified as mild, moderate, moderately severe or severe. 

• Grade 1 (mild): mostly whiteheads and blackheads, with a few papules and pustules. 

• Grade 2 (moderate/ pustular acne): multiple papules and pustules, mostly on your face. 

• Grade 3 (moderately severe/ nodulocystic acne): numerous papules and pustules, along with occasionally inflamed nodules. Your back and chest may also be affected. 

• Grade 4 (severe nodulocystic acne): numerous large, painful and inflamed pustules and nodules. 

Symptoms 

Acne is visible mainly on the face, neck, chest and back. This includes: 

Superficial lesions*

• blackheads 

• whiteheads 

• inflamed, raised bumps (papules) 

• inflamed, raised bumps with yellow or white tops, filled with pus (pustules) 

Deeper lesions

• bumps under the skin (cysts or nodules) 

*A skin lesion is a bump, lump, or sore on the skin.  

Complications 

Once acne lesions heal, there may be darkened spots on the skin (known as post-inflammatory hyperpigmentation) or some scarring (which appear as indentations, pits, or raised marks, called keloid scars) which could take months to clear up. This can have a psychological effect on the patient, especially for those dealing with painful and bleeding lesions. 

What causes acne? 

Acne is caused by four processes: 

• excess oil (sebum) production 

• hair follicles clogged by oil and dead skin cells 

• bacteria 

• inflammation 

Acne develops when the hair follicles of your skin become blocked by hair, oils, bacteria and dead skin cells. The oil (which moisturises the skin and hair) comes from the sebum secreted by the sebaceous glands that are connected to the hair follicles under the skin’s surface. The sebaceous glands are influenced by the hormones called androgens (including testosterone). Since acne is primarily a hormonal condition – at puberty, for instance – the body produces more androgens, which stimulate the sebaceous glands to produce more sebum. 

The excess sebum, along with dead skin cells (formed as part of the normal skin cells cycle) clogs the hair follicles. The plugged hair follicles can form blackheads and whiteheads. If they become inflamed, red, raised pimples develop on the skin, and as the inflammation progresses, nodules or cysts may form under the skin. The bacteria, Cutibacterium acnes or C. acnes, that normally lives on the skin also plays a role. When the sebaceous glands produce lots of sebum, C. acnes reproduces, and further clogs the hair follicles, leading to skin inflammation. 

Factors that can trigger or exacerbate acne 

The following factors that can trigger acne or exacerbate it: [CC,4] 

• hormonal changes during puberty 

• hormonal changes around the menstrual cycle, pregnancy or menopause 

• stress, which increases the hormone cortisol 

• some medications, such as oral contraceptives, corticosteroids and anabolic steroids 

• diet – some studies have shown that foods with a high glycaemic load (such as white bread, potatoes, sugary drinks), and skim milk may be linked to acne. 

• certain skin care products, such as cosmetics, sunscreens, and moisturisers 

• air pollution and certain weather conditions, especially high humidity 

• clothing and headgear, such as hats and sports helmets 

• picking at acne sores 

Risk factors 

You are more likely to get acne if: 

• you are between the ages of 12 and 24 

• you’re on your period, pregnant or going through menopause 

• you have a family history of acne (especially moderate to severe acne) 

• you have an endocrine disorder, such as polycystic ovary syndrome or congenital adrenal hyperplasia, which can raise androgen levels. 

How is it diagnosed? 

A diagnosis is made based on a medical history and physical exam, but blood tests are sometimes used to measure hormone levels (such as testosterone). 

Treatment 

Acne is treated with medication and lifestyle changes. Acne medications work to reduce oil production and swelling, or by treating bacterial infection. Prescription-strength medications can help you to control your acne, avoid scarring or other damage to your skin and make scars less noticeable. With most prescription acne medication, you may only see results after four to eight weeks. It can take months or years for your acne to clear up completely. 

Medication 

Acne treatment depends on your age, sex, the severity and duration of the acne and the response to previous treatments. 

1. Topical medication (creams, lotions, gels, foams, washes) 

• Benzoyl peroxide. The antibacterial agent, benzoyl peroxide kills C. acnes bacteria and helps to prevent pores from getting clogged up. 

• Antibiotics. Topical antibiotics reduce the number of acne-causing bacteria and also has anti-inflammatory properties. These include clindamycin, erythromycin, doxycycline, and tetracycline. It’s often used in combination with other medication, like benzoyl peroxide. 

• Retinoids. Retinoids are vitamin A derivatives that treat both noninflammatory acne and inflammatory acne, regardless of severity. These help to reduce the clogging of pore, as well as help reduce the pigment alterations and scarring caused by acne. Tretinoin (Retin-A) is a commonly prescribed topical retinoid. Topical retinoids increase your skin’s sun sensitivity, and can cause dry skin and redness, especially in people with darker skin. 

• Salicylic acid. Salicylic Acid helps to keep pores from clogging. 

• Azelaic acid. Azelaic acid kills bacteria involved in the formation of acne, and reduces the clogging of pores. 

• Dapsone. Dapsone is recommended for inflammatory acne, especially in women. 

2. Oral medication 

• Antibiotics. Tetracyclines, macrolides, trimethoprim/sulfamethoxazole, trimethoprim, penicillin, and cephalosporin are used to treat moderate to severe inflammatory acne and is used should be used in combination with non-antibiotic topical agents to prevent resistance and enhance effectiveness.*

• Hormonal therapy. This consists of combination birth control pills (low-dose estrogen and progesterone). They are antiandrogenic, i.e. they block the effect of male hormones at the level of the hair follicles and oil glands. 

• Anti-androgen agents. Spironolactone is used for women and adolescent girls if oral antibiotics aren’t helping. It blocks the effect of androgen hormones on the oil-producing glands. 

• Oral Isotretinoin. This oral retinoid – also a vitamin A derivative – is used to treat severe cystic and nodular acne, scarring acne, or acne that does not respond to all other conventional therapies. It stops the growth of C. acnes bacteria by decreasing sebum production, which diminishes inflammation. 

3. Other therapies 

These can be used alone or in combination with medication: 

• Steroid injections. For severe acne, corticosteroids are injected into the cysts or nodules to reduce inflammation. Oral steroids, such as prednisone, can be used along with oral isotretinoin, in the case of severe flare-ups. Side effects can include thinning of the skin, and discoloration of the treated area. 

• Light therapy. There are various light-based therapies available but require multiple visits. 

• Chemical peel. used as a treatment for mild acne, this uses repeated applications of a chemical solution (such as salicylic acid, glycolic acid or retinoic acid) to improve the appearance of the skin. 

• Drainage and extraction. Special tools are used to remove whiteheads, blackheads or cysts that haven’t cleared up with topical medications. This may cause scarring. 

Scars can be treated using a variety of techniques, including dermabrasion, laser therapy, microneedling and fillers. 

*Ogé, L.K., Broussard, A. & Marshall, M.D. (2019). Acne Vulgaris: Diagnosis and Treatment. American Family Physician. 100(8):475-484. https://www.aafp.org/pubs/afp/issues/2019/1015/p475.html  

Living and managing 

With these basic skin care and self-care techniques, you can try to control mild to moderate acne: 

• Avoid touching acne-prone areas. 

• Don’t pick. Don’t scratch any of the acne lesions, because it can cause scarring. 

• Use a gentle cleanser on your face, and don’t wash or scrub to the point where it irritates the skin. Be careful when shaving affected skin. 

• Avoid irritants. Oily cosmetics, sunscreens, hair care products, acne concealers and even certain facial scrubs and masks, tend to irritate the skin. Instead, look for water-based or noncomedogenic labelled products. 

• Protect yourself from the sun. Many acne medications increase your sensitivity to the sun, and you are more likely to sunburn. 

• Avoid friction on your skin from helmets, tight collars, underwire bras, straps, and backpacks. 

• Shower after strenuous activities, as oil and sweat on your skin can trigger breakouts. 

• Watch what you eat. Some research also suggests that cow’s milk and foods that have a high glycaemic index may cause acne to flare. Eating a balanced, nutritious diet with plenty of fresh fruits and vegetables, especially those rich with vitamin C and beta carotene, helps reduce inflammation. 

• Build regular exercise into your schedule. Exercise minimises stress and has countless other health benefits. 

• Reach out. If you or a loved one with acne is experiencing anxiety or feelings of depression, reach out to a mental health professional. 

• Offer emotional support. If you’re the parent of a child suffering from acne, empathise with your child while helping them get medical treatment. 

How can I prevent acne? 

Since acne is caused by normal hormonal changes, it can be difficult to prevent altogether. Here’s what can help: 

• Wash your face daily with warm water and a mild facial cleanser. 

• Use moisturiser regularly. 

• Try to use “non-comedogenic” skin care products which don’t clog pores. 

• Remove makeup at the end of each day. 

• Keep your hands away from your face.