Acne is the most common skin disease. People of all races and ages get acne. It is most common in teenagers and young adults. An estimated 80 percent of all people between the ages of 11 and 30 have acne outbreaks at some point. That said, we see individuals with acne that may continue well into their forties and fifties, we also see those that develop acne as adults having had clear skin in their teens. There are many theories as to why people develop late on set acne. Stress is often cited as a trigger and we know that there are cortisol changes associated with stress that would fit with an exacerbation of acne. Hormonal fluctuations as we age often leads to acne, typically this is seen as acne around the lower face and jawline. As always genetics may also play a part.
Advice for acne scarring:
How to best advise patients with acne scarring
Firstly when I am consulted about acne scarring I start by carefully examining the skin. Often there is active acne and as such I need to treat the acne before attempting to improve any scarring. Secondly the acne has often left red marks knows as post- inflammatory erythema and this is mistakenly being called scarring. I can often reassure the individual that once the inflammatory process settles any subsequent redness usually clears, which as you can imagine is reassuring. For many people, a scar doesn’t just leave a physical impression on their skin, it also affects them emotionally and can have a real impact on their day-to-day life. Therefore, we think it is important that you are given some advice and support. Bio-Oil Professional has several free resources on the topic of scarring for download, including a training module ‘Managing Scarring in Primary Care’ that counts towards CPD revalidation, as well as a handy resource ‘Supporting to you to care for your wounds and minimise scarring’ for you to share with patients.
Bio-Oil helps to treat post acne scarring
I would be cautious in recommending Bio-Oil in active acne but it has been found to work very well on post acne scarring and redness. It is also good for treating dryness caused by retinoid treatments. Bio-Oil helps improve the appearance of scarring (new and old) and helps maintain elasticity of scar tissue on joints and other high mobility areas.
Deep isolated scars can be minimised
Sometimes there are deep isolated scars which may be best treated with careful excision to minimize any subsequent scar. Sometimes if there is an area of scarring that is tethering skin, a needle can be used to release this scarring, a process called subcision. Likewise a dipped scar maybe brought to the surface to improve the appearance by incising and lifting the skin. To loosen the fibrous tethering underneath the scar sometimes this is best performed immediately after a needling procedure (slight swelling makes ice pick scar more visible) In essence a 26 gauge needle is inserted underneath the ice pick scar (parallel to skin surface).‘The needle is ‘wiggled’ from left to right to cut fibrous strands.
Combine treatments to minimise ice pick scarring
If there are multiple so called ice pick scars then a combination of treatments may help. Micro-needling works by causing Inflammation, Proliferation (tissue formation) and remodeling which is ideal when trying to soften scars. If the scars are deep they can be brought to the surface by the use of a targeted chemical peel. Trichloroacetic acid (TCA) is applied with a cotton bud to the acne scars to help to resurface the skin and reduce the scar depth. This treatment is cycled with micro-needling over a period of months, treating the skin alternately with TCA and micro-needling at 4 weekly intervals. I prefer to use an automated needling process, the Dermapen as I can adjust the depth of the needles depending on the area of the face. If this technique is being used in darker skins, to reduce the risk of post inflammatory pigmentation the skin can be prepared with creams to suppress pigmentation for 3 weeks prior to starting. Both chemical peels and micro-needling can be used as standalone treatments too.
Sometimes when we age the loss of volume and skin laxity can exaggerate scarring. In this case treatments that resurface and tighten skin such as fractional laser can help to improve the appearance of scars. This can be combined with radiofrequency treatments that heat deeper tissues in skin and tighten it or once again both treatments can be used as standalone treatments.
If scars are raised they may be treated with intralesional triamcinolone, a steroid. This utilizes the effects of steroids by thinning the scar tissue. This must be used with care as there is a risk of over correcting and causing atrophic or dipped scars.
The most important role as the clinician is to manage expectations. The first step is to treat any active acne and then to look at the severity of scarring, type of scarring and to gauge likely outcomes after treatments. If the physician and patient have realistic expectations and are clear about the benefits and risks of any procedure then patients are more likely to be happy with the outcome.
Advice for active acne:
Simplify their skincare regime
One of the first steps I take with acne patients is to simplify a cleansing and moisturising regime. I am struck by how much cleansing, exfoliating occurs as soon as acne appears. In my view this often makes things worse. Constantly washing especially if using soaps will change the skin’s naturally acidic pH and essentially disrupt the skin barrier. Then we see increased water loss, skin irritation and redness. Interestingly if you strip the skin of oil it will often produce more to compensate exacerbating this inflammatory process. So using a gentle slightly acidic wash and applying a light moisturiser can be one of the most important changes when treating acne. I like Cetaphil. As an active topical treatment to apply during the day, I like Effaclar Duo by La Roche Posay it calms spots, reduces skin inflammation and keeps skin hydrated. It is a simple and often effective addition to start as soon blemishes appear.
Creams and masks containing salicylic acid can help to slough off dead skin cells and oil blocking pores and reduce inflammation. I do recommend introducing this slowly as at first it can make skin quite sensitive.
Antibiotics not always best course of action
There is definitely a move away from using long courses of antibiotics for acne for obvious reasons. Increasingly we are seeing antibiotic resistant P acnes. Whilst a short course of a Tetracycline may be prescribed, there is little evidence that long courses in fact confer much benefit. I favour a combination of a combination of a topical retinoid with benzoyl peroxide applied at night. This can be uncomfortable at first but if introduced slowly with a light moisturiser applied half an after application it is very successful at settling acne.
Treatments for stubborn comedonal acne
The black heads and whiteheads we see in acne, referred to as open and closed comedones respectively can be troublesome to treat. Often traditional acne treatments quickly clear the typical papules and pustules but the comedones remain. Sometimes they respond to topical retinoids or benzoyl peroxide, especially when applied in combination. But this isn’t always successful. I have started using micro needling in the last couple of years for this problem and I am getting very good results. Sometimes it can be difficult to treat closed comedones (whiteheads) and they can remain after acne has cleared. Micro-needling essentially helps to unblock the pores. I suggest between treatments applying a combination of a retinoid and benzyl peroxide to the area to reduce recurrence. The needling has the added bonus of stimulating collagen and thus reducing fine lines and giving the skin a glow.
Laser therapy should not be used alone
Whilst there is not large studies supporting the use of Intense pulse light (IPL) treatment in acne, I can often calm an outbreak with my IPL, that said I usually use it in conjunction with other topical treatments. IPL is very good at reducing the post inflammatory redness seen after an outbreak of spots. Many individuals present to me concerned about acne scarring and I can often reassure them that it is just redness or erythema that will eventually settle, as that there is no actual scarring as such. It is this redness that responds to IPL treatment.
Positive results with combined LED light therapy
There is increasing interest in the anti-inflammatory and rejuvenating properties of LED treatment. In acne this form of phototherapy is being increasingly used. Previously a lot of work was done looking at the effects of Blue light (peak 415nm) in acne. Blue light has been shown to be anti-bacterial to P Acnes in the skin. Interestingly it is a mixture of blue light and red light (peak 660nm) that seems more effective than blue alone. The red light seems to be anti-inflammatory and it seems it is this combination of anti-inflammatory and antibacterial light that is most effective. This treatment can be carried out in clinics, a course of ten treatments at 20 minutes per session is usually recommended. There are at home LED treatments, but as always they will not be as strong as a clinic treatment. If at home treatments were used for longer, however I would definitely expect improvements.
Growing evidence linking diet and acne
Whilst the arguments continue with the association between diet and acne and more studies are definitely needed; there seems to be increasing evidence that a low glycemic diet with healthy fruit and vegetables of varying colour is good for acne prone skin, which makes sense. As with all advice moderation is always the key. Keeping hydrated, eating a diet rich in anti-oxidants and maintaining a healthy skin barrier is always sound advice in my view. Increasingly there seems to be evidence that sugar can damage skin. In the case of acne it is the release of insulin and insulin-like growth factors IGF-1 that can cause the release of androgens. Androgens stimulate sebum production in skin which in turn can block pores leading to blackheads, whiteheads and pustules. As a result I recommend that patients limit simple sugars such as chocolates and also to be aware of sugar content in savoury snacks and even bread.
- How skin is cleansed matters, a gentle wash is paramount to keep skin calm and hydrated
- Topical treatments such as benzyl peroxide and a retinoid should be used as a first line treatments, as soon as acne develops if possible
- Light treatments such as IPL and LED can be a useful adjunct to treatment
- There is little evidence for the use of long term antibiotics and where possible they should be avoided
- Acne scars can be minimised with a range of treatments and the psychological impact of scars should always be considered when advising patients
Resources for healthcare professionals:
Bio-Oil Professional has several free resources on the topic of scarring for download.
Resources for your patients: