Acne is a chronic skin condition that affects skin follicles resulting in their blockage and expansion. It results in open and closed comedones (blackheads and white heads) which can become inflamed and infected. The inflammation can lead to increased pigmentation and scarring.
It typically affects the face but can also affect the trunk, chest and back.
There are many factors in play. The skin is dotted with millions of pilosebaceous follicles, commonly known as pores. These act to house or encapsulate the hair follicle, which is embedded in the skin. The follicle secretes something called sebum which is a thick sticky substance that acts to moisturize and protect the skin.
There are thought to be four main contributing factors to acne. (1)
The exact sequence of events and precisely how these factors interact is not fully understood but they all play their part.
It is primarily a condition affecting teenagers, mainly 13-16 years, but is becoming increasingly common in adulthood with 1% of men and 5% of women being affected. (2)
Acne is classified into mild, moderate, or severe depending on the number of comedones, and the presence of cysts and inflammation.
The following types of acne have also been noted:
Occurs from birth up until one year. The exact cause is not known but usually, it resolves spontaneously within a few months. The same treatments that are used for adults can be considered if symptoms persist, but it is always better to consult with a doctor. Acne in children between 2-6 years of age is rare and needs to be investigated to rule out an underlying cause.
Hormones have a significant role to play in skin function. Testosterone is an important hormone as it stimulates sebum production which can lead to clogging of pores that can culminate in acne. This can be a contributing factor in cyclical acne, which often becomes more obvious at certain times in the menstrual cycle.
Testosterone is the essence of what makes men male, but females also produce testosterone albeit in much smaller amounts. The natural fluctuation of hormones that occurs during the menstrual cycle affect the delicate balance between female and male hormones, tipping it in the favour of testosterone and triggering breakouts around the time of menstruation.
Hormonal imbalances also occur in the perimenopause and post menopause. As Oestrogen levels fall, Testosterone can exert its influence on the pilosebaceous units resulting in acne in later life. In an American survey 15% of women reported acne in their 50s or even later (3)
However, there are other contributing factors with one study of 280 patients with adult acne showing that sunlight was a trigger in 33.2% of patients, cosmetics in 14.3% and stress in 25.7%. (4) 6.4 % of patients were also obese which also had an impact.
Obesity can result a condition known as insulin resistance whereby circulating levels of insulin rise, this is turn can stimulate the production or more testosterone further exacerbating the problem. (5)
Acne is more common around puberty. There are a few reasons why this may be the case.
There are higher levels of sex hormones around puberty, these are converted to Dihydrotestosterone which acts on the sebaceous glands at the base of hair follicles. The increased sebum production can cause the skin to become oilier, leading to breakouts. The sebaceous glands also secrete inflammatory factors, these mix with sebum, causing debris from dead skin cells to get caught up and block pores causing the comedones (white heads). If inflammation builds up the comedone can rupture.
Exposure to sunlight, stress, smoking, sleep deprivation, dietary factors and cosmetics can all trigger or contribute to adult acne. (6)
Increased environmental stress causes the release of a certain hormone, CRH from higher centres in the brain. This acts directly on the sebaceous glands causing the skin to become oilier and more prone to acne. CRH also increases testosterone production, further compounding the problem.
Cigarette smoke alters the composition of sebum, by removing antioxidants from it and increasing the levels of certain lipids that leads to overgrowth of skin cells and comedone formation. (7)
Cosmetics especially certain moisturisers, foundation, and pomades (wax-based substances used to style hair) can trigger acne, particularly if they are oil based. Avoid products that contain lanolin, petrolatum, vegetable oils, butyl stearate, lauryl alcohol, and oleic acid.
Acne usually improves in the first trimester of pregnancy but can worsen during the third trimester due to the increase in maternal androgens (male hormones such as testosterone). If you are pregnant and experiencing symptoms, its best to speak to a pharmacist who can discuss safe treatment options.
Conditions such as polycystic ovarian syndrome (PCOS) are associated with increased levels of androgens, as a result, acne can be a common presenting complaint. Other endocrine causes include Cushing’s syndrome and androgen secreting tumours. If you have acne that doesn’t respond to conventional treatment or have other features of excess testosterone e.g., excess facial hair, that are new, you should see your GP for hormone tests.
Yes, the food you eat can impact acne. Some foods are beneficial, others can be causative factors.
Foods with a high glycaemic index are starchy foods such as white bread, pasta, and potatoes. These cause a surge in our blood sugar levels and stimulate the release of insulin and IGF1. Insulin stimulates the growth of sebaceous glands and acts directly on the adrenal glands and reproductive organs to trigger testosterone production. Sugary foods such as chocolate also have this effect.
Milk contains amino acids that when combined with carbohydrates stimulate insulin production. In addition, milk contains hormones such as progesterone and androgens that can increase sebum production. In studies milk and whey proteins have been linked to acne flares. (8)
Studies support that Omega 3 fatty acids and Y linolenic acid act to reduce acne lesions by having an anti-inflammatory effect and reducing the effect of IGF1. (9)
There is little evidence from studies that a vegan or vegetarian diet is beneficial in preventing or treating Acne.
There is emerging evidence that probiotics may improve acne by having an anti-inflammatory effect and reducing insulin levels. (10)
Topical treatments (applied to the skin) are usually first line for mild to moderate acne.
Epiduo is a combination of adapelene, a retinoid and benzoyl peroxide. It is one of the first line treatments recommended by NICE (National Institute for Health and Care Excellence) for the treatment of mild to moderate acne. Adapalene regulates the maturation of keratinocytes to prevent their overgrowth and comedone formation. It also has an anti-inflammatory effect. Benzoyl peroxide acts to kill certain bacteria that are present in the pilosebaceous unity and that may contribute to infection. It also helps break down dead skin cells and helps prevent clogging of pores.
It comes in a gel form and there are two strengths depending on the severity of acne.
A pea size amount should be applied to all the areas affected by acne, taking care to avoid the eyes and lips. Hands should be washed afterwards.
Duac daily is also recommended by NICE as a possible first line treatment option. It consists of benzoyl peroxide again but this time in combination with an antibiotic, clindamycin. It may be worth using if the acne is particularly inflamed or there are signs of infection. The application process is similar to Epiduo.
Skinoren cream contains the active ingredient azelaic acid. It acts to reduce the number of certain types of bacteria such as C. acnes, these are commonly found in the follicles of people suffering from acne. It also prevents the proliferation of keratinocytes that contribute to come done formation. Ideally, it should be used in combination with an antibiotic such as Lymecycline for the treatment of moderate to severe acne.
Lymecycline is an antibiotic and part of the group of antibiotics known as tetracyclines. They prevent the growth of bacteria such as C. acnes by blocking the production of essential proteins needed for their survival.
It is taken in the form of a capsule, once daily and should be continued for at least 8 weeks.
The active ingredient in Differin gel is again adapalene, but this time in isolation. It can be used to treat mild to moderate acne.
This depends on the severity of the acne and the treatment in question. Generally speaking, topical treatments applied to the skin need to be used for at least 4 weeks before the full effects are seen and oral antibiotics for up to 8 weeks.
If it’s a cream or gel, reduce the number of times you apply. For example, if you use it twice a day reduce to once a day or if you use once a day use it alternate days. If the reaction is severe, it may be best to stop altogether for a few days and use a non-oily moisturiser until the reaction settles. If you have reacted to an oral antibiotic, its best to seek medical advice from your GP.
Some people note an improvement in acne when they follow a low GI diet i.e., reduce their carbohydrate and sugar intake, together with their intake of dairy. Its best to eat plenty of fresh fruits, vegetables, legumes, drink plenty of water and eat fish that’s high in omega 3 oils such as herring, mackerel, salmon or tuna. There are also plenty of vegetarian sources such as chia seeds, flaxseeds, and edamame.
Harsh exfoliators and repeated washing can damage the skin barrier and are not recommended. Its best to use a gentle cleanser with a PH of around 5.5 (higher PH products may cause skin barrier dysfunction). Oil free make up can be used and an oil free sunscreen is essential to prevent skin damage and prevent flare ups of acne.
Poor sleep can increase stress levels and the release of the stress hormone CRH from the hypothalamus of the brain. CRH increases sebum production and stimulates testosterone release both of which result in an oilier complexion, which can trigger acne.
The appearance will be that of typical acne – open and closed comedones, redness, inflammation leading to sometimes cysts and scarring. However, the pattern will be more obvious, perhaps being triggered by a stressful life event, e.g., starting a new job or sitting for exams.
If you have any more questions about Acne, its causes and treatment, speak to one of our pharmacy team today.
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