Spotlight on Acne

As someone who had acne prone skin that needed daily management for years, I know how annoying and painful it is and how much of an impact it can have on ones confidence. If you suffer from “adult acne” you’re not alone. Acne isn’t just for adolescents; it can occur well in to our 30s and 40s. Some women may experience new acne even during peri- and post menopause.

Acne is characterised by open comedones (black heads) and closed comedones (white heads), papules, pustules and cystic acne. There are a few processes that contribute to the formation of acne; plugging of the pores due to a combination of hyperkeratinisation (high keratin) and increased sebum or oil production (seborrhoea), the presence of bacteria eg. Cutibacterium acnes, and inflammation.

Be mindful that Rosacea, another inflammatory skin condition, very common in the Irish population, is often mistaken for acne. It’s characterised by redness, flushing, pustules and papules. With that said, many people suffer from both acne and rosacea concurrently. For more info on rosacea see my blog post here Rosacea – Supplements Made Simple Women in particular are more prone to acne due to hormonal influences at various life stages which may increase oil production. Hormonal acne typically occurs on the jaw line or lower third of the face. Flares during the luteal phase (second) half of the menstrual cycle, the early stages of pregnancy and women going through peri and post- menopause are not uncommon. Women with Polycystic Ovarian Syndrome (PCOS), with high androgen levels, often suffer from acne too. Further characteristics that may point to PCOS as the underlying cause of acne include oligomenorrheoa (infrequent periods), insulin resistance (either pre-diabetes or type 2 diabetes), hair loss on the scalp, facial + body hair growth and, sometimes but not always, cysts on the ovaries. Before we get stuck in to acne treatments let’s first have a look at triggers. Identifying and eliminating these where possible may be all you need!

Triggers

• Acne Mechanica: Regularly using or wearing items that place pressure on the skin can cause localised breakouts. Think helmets, head bands or facemasks. I once had a patient who got breakouts on her chin where she rested her violin. Of course I don’t recommend not wearing or helmet or giving up your favourite musical instrument but knowing the underlying cause can help to guide treatment.
• Acne Cosmetica: Cosmetics may contribute to acne lesions. Choosing skin care and make up can be tricky when you have acne prone skin; it often requires a lot of trial and error which can be exhausting and expensive! Look out for products listed as “non-comedogenic”. Although this term isn’t really regulated, they are the best options for acne sufferers.
  - Pay careful attention to what you’re using on both your skin and your hair! Hair products can be heavy and oil based and contribute to acne as small particles of the product fall down on to the face. If your forehead is most effected by acne, could it be a hair product you’re using? Maybe some day we will see non-comedogenic hair products? That would be useful!
• Supplements look at your supplements or what may be hidden in your multivitamin! Supplements that can flare acne include Biotin and Vitamin B6. Note also that Whey Protein is a known dietary trigger for acne.
• Diet: There’s no “clear skin diet” or “acne diet” but there is an association between some dairy products, particularly skimmed milk, and acne. A high glycaemic diet i.e. a diet high in sugar, is also associated with acne flares.
• Medications that cause acne: lithium, steroids, the progesterone only pill and The Mirena coil may cause acne in some people.
• Stress worsens all skin and medical conditions, acne included. It reduces immune function, impedes skin barrier function and increases inflammation and thus worsens acne.

Treatment
Before we dive in to specifics, some good rules of thumb for acne treatment include:

• Don’t give up too soon! Acne takes times! I know it’s frustrating but give a new treatment option 6-8 weeks before assessing response.
• Don’t spot treat. You need to treat tomorrow’s acne today! Stay a step ahead.
• Don’t over do it. A pea or pearl sized amount of product will suffice.

Over the counter options:

• Start with a good face wash. This may be all you need. Look out for face washes with salicylic acid which acts as a keratolytic, unblocks pores and helps clear acne. I like the Cera Ve Blemish Control cleanser. Washing once daily is all you need. Don’t over do it and dry your skin out. Remember that acne is not caused by lack of cleanliness! Over washing will make things worse so stay steady with once daily.
• Also make sure to choose a good moisturiser. Despite the fact that high oil production is a component of acne, the skin still needs moisture to be healthy. Drying the skin out isn’t the answer to acne. Two nice acne moisturisers available over the counter are “Avene Comedomed Moisturiser” and “Acnecide Daily Moisturiser with SPF 30”.
• Don’t skip sunscreen! I like the Elta MD SPF 44 for acne and rosacea prone skin.
• Benzoyl Peroxide is one of the most effective acne treatment options. It’s available over the counter; look for “Acnecide” gel. Be mindful that benzoyl peroxide can cause yellow staining of pillows or clothing so use old ones that you don’t mind staining slightly.
• Salicylic acid: The “Cera Ve Blemish Control Gel” has salicylic acid with added glycolic acid for gentle exfoliation and soothing niacinamide; this is a good night treatment option.
• Azelaic Acid is less effective but still an option for treating acne; there are a lot of over the counter options to choose from. Both Boots and The Inkey List have an azelaic acid cream. Azelaic Acid has the added bonus of providing some skin brightening effects as well as being safe in pregnancy and breast feeding.
• Sulfur is another ingredient that works for acne. I love the Murad Sulfur mask with added Salicylic Acid. I use this on my T zone about once a week. The De La Cruz sulfur mask is also a nice option.
• Body Washes for Body Acne: I like the “Smoothing Cleanser” from Cera Ve which has Salicylic Acid or “Panoxyl” which has Benzoyl Peroxide.

Home Devices:
There is some evidence that Blue Light therapy can help with acne. A lot of the red light devices you see online also have blue light functions which you may find helpful.

Supplements:
The best supplements for acne are zinc and omegas. Omegas are particularly important for people who take Roaccutane for their acne treatment. Collagen supplements may also help.

Prescription treatment options:
Talk to your GP if you’re not having any success with over the counter options or if you see scars developing. Prescription options include:

TOPICAL treatments
Retinoids i.e. topical Vitamin A derivatives.
These include:

• Adapalene. This is the gentlest retinoid. Trade name: “Differin”. This is over the counter in The US so could be handy to pick up if you’re visiting there.
• “Epiduo” =- adapalene (retinoid) + benzoyl peroxide
• “Treclin” – tretinoin (retinoid) + clindamycin (antibiotic)
• “Epiduo” =- adapalene (retinoid) + benzoyl peroxide
• Tretinoin. A number of trade names exist eg. “RetinA” or “Ketrel”. Doses come in 0.025%, 0.05% and 0.1%.

“Duac”: benzoyl peroxide + clindamycin (antibiotic)

Azelaic acid : prescription options include “Finacea” (15% azelaic acid) and “Skinoren” (20% azelaic acid)

A lot of the above can be harsh, drying and irritating. Some tips to avoid this irritation include:

• Start low and go slow i.e. start at the lowest dose and work your way up gradually. With retinoids in particular, you may want to first use just weekly, then work your way up to every second or third night and then every night as tolerated
• Moisturise after using the product, once it’s dried in
• Some people like “short contact therapy”. This means applying the treatment for 30-60 minutes and then washing it off so it doesn’t dry and irritate the skin.

ORAL MEDICATIONS

Oral antibiotics can be useful for treating acne The one most typically used is Doxycycline. Be mindful that this can cause photosensitivity i.e. make the skin more sensitive to sun light so be extra vigilant with UV protecting measures like sunscreen hats etc.

The oral contraceptive: pills with anti-androgen properties can be very useful women who have hormonal acne.

Spironolactone – typically used as a blood pressure medication but also has anti-androgen properties that can be used for acne. This is usually prescribed by dermatologists.

Oral isotretinoin, trade names “Roaccutane” and “Accutane” are most commonly prescribed by dermatologists rather than primary care doctors (although there are some who can prescribe so it’s worth asking!). Isotretinoin is oral vitamin A; therapy leads to shrinkage of sebaceous glands and reduction of sebum secretion. Roaccutane can be a truly life changing medication. Side effects may include: Dry eyes, dry mouth, cracked lips, nose bleeds, muscle aches and pains. It’s important to note that it’s not safe in pregnancy. Women who have the potential to become pregnant need to be on contraception and have regular pregnancy tests. Blood test monitoring to check liver function and cholesterol levels whilst on treatment is also required. Duration of treatment varies (can be 6-9+ months); most people will only require one course to clear their acne.

COMPLICATIONS

Post inflammatory hyperpigmentation and scarring are the most common complications of acne. Treatment options for scars include laser therapies, microneedling and topical retinoids. Retinoids can also help pigmentation. Other topical treatment options for pigmentation include Vitamin C serums, available over the counter, and hydroquinone, on prescription.

I hope you find the above useful. Acne can have a huge impact on quality of life and confidence. I hope the above shows that there’s an abundance of treatment options available so you don’t have to suffer in silence. The profound psychological impact of acne is medically recognised; this isn’t regraded by doctors as a frivolous medical concern so please do reach out and seek help if over the counter options aren’t working.