Acne Vulgaris

How common is acne?

• Acne is the most common skin problem among adolescents.
• In Singapore, it affects up to 88% of adolescents, with half having moderate or severe acne.
• Although most commonly occuring in teenagers, acne can persist or occur for the first time in adulthood.
• Acne may lead to permanent scarring.
• Acne can lead to poor self-esteem and psychosocial problems.

Why does acne occur?

• Patients with acne often have a family history of acne.
• Four factors lead to acne:
1. Hormonal stimulation
2. Abnormal keratinisation (shedding of dead skin cells)
3. Bacterial infection (Propionibacterium acnes)
4. Inflammation

How does acne present?

• Earliest signs of acne include white heads (closed comedones) and black heads (open comedones).
• Inflammatory acne presents as reddish bumps (papules) and pus bumps (pustules).
• More severe acne presents with cysts and nodules.
• Acne can occur on the face, chest or upper back.
• When acne heals, it can leave scars which may be atrophic (punched-out) or hypertrophic/ keloid (thickened).
• Pigmentation (dark spots) can also occur when acne lesions heal. This is more common in darker skin types and if lesions are picked at.

What can trigger acne?

• Stress
• Skin occlusion eg. cosmetics, sportsgear, chin straps
• Medications eg. anabolic steroids, progestins, lithium, isoniazid and phenytoin.
• Menstruation (in girls)

Treatment of acne

General measures:

• Wash your face two to three times daily with an anti-acne facial wash.
• Avoid heavy make-up
• Have at least seven to eight hours of sleep every night. Avoid irregular sleep schedules.
• Minimise stress
• Do not pick, squeeze or scratch acne.

Topical treatments:

• These are used alone in patients with mild acne, but are also very useful when combined with oral therapies in moderate or severe acne.
• Examples include benzoyl peroxide, adapalene (Differin), tretinoin and topical antibiotics.
• Combination fixed-dose topicals may also be prescribed.
• Your doctor may prescribe different topicals for the day and for the night. It is important to follow the instructions of your doctor.
• Some patients may develop skin irritation when using acne creams. If this occurs, stop the topicals for a few days and use a thin moisturiser on the affected areas. Re-start the topicals when the irritation improves but use it on alternate days instead. Inform your doctor if this side effect occurs.

Oral antibiotics:

• Oral antibiotics (eg. doxycycline, erythromycin and minocycline) are first line treatment in patients with moderate or severe acne.
• Oral antibiotics are taken once or twice daily, as instructed by your doctor. It is important to follow these instructions for best results.
• Oral antibiotics take six to eight weeks to achieve results, and are usually required to be taken for several months thereafter.

Oral contraceptives:

• This is an option for treatment of acne in female patients.

Oral lsotretinoin:

• This is the strongest oral treatment for acne and is used for patients with severe acne or patients who do not respond to other treatments.
• Results are seen within a few weeks, but treatment is required for at least six months to one year.
• Blood tests are required before and during treatment, to monitor for liver and cholesterol problems.
• Pregnancy tests are required for females before and during treatment.
• Common side effects include dry skin, dry eyes and dry mouth.
• Less common side effects include nose bleeds, hair loss, headache and muscle pain.
• lsotretinoin can cause severe developmental defects in unborn babies. It is important that female patients taking isotretinoin do not get pregnant. Your doctor will discuss effective birth control with you. If you suspect that you are pregnant while on isotretinoin, you must stop taking isotretinoin and inform your doctor immediately.