Acne vulgaris is one of the most common skin conditions in Singapore. It predominantly affects adolescents and young adults, and affects as many as 80% of teenagers in Singapore. Commonly referred to as ‘pimples’ or ‘zits’, its associated negative impact on our physical image often leads to much psychological distress.
Although most cases of acne occur during puberty, adult-onset acne is not uncommon. Adult-onset acne is more prevalent among females, with twelve percent of women with acne at age 25 years, and five percent of women with acne at age 45 years.
WHAT IS ACNE?
Our skin consists of numerous pilosebaceous units-- a skin structure consisting of the hair, hair follicle and sebaceous (oil) gland. (Figure 1)
Acne forms when the opening of the sebaceous gland is blocked by excess sebum and keratin (dead skin cells). This plugs up the follicle (pore) and forms a comedone. Open comedones, also known as blackheads, are ‘black’ due to the darkening from oxidation of the sebum and keratin plug.
(Figure 2 and Photo 1)
Photo 1 - 'Blackheads'
Photo 2 - 'Whiteheads'
On the other hand, the contents of closed comedones are not exposed to the skin surface, and hence do not get oxidised. Thus they appear as skin-coloured bumps and are commonly known as whiteheads.
(Figure 2 and Photo 2).
Proliferation of Cutibacterium acnes (formerly Propionibacterium acnes) bacteria in the follicle causes inflammation of the comedone and results in the formation of an acne papule, classically known as a ‘pimple’. (Figure 3 and Photo 3) When the pimple contains pus, it is referred to as an acne pustule. (Photo 4)
Photo 3 - Acne Inflammation
Photo 4 - Inflammation with Pus
In severe cases, the acne papules and pustules can enlarge to form nodules and cysts.
Cystic acne is most common in teenage boys and young men who tend to get it on the face, back, upper arms and shoulders.
Photo 5 – Severe acne with nodules and cysts
Nodular and cystic acne tend to leave acne scars such as hyperpigmentation, hypertrophic scars, atrophic indurations, box-cart and ice-pick scars.
CAUSES OF ACNE:
There are four main factors that lead to the development of acne.
Other risk factors for acne include:
Myth: Cosmetic make-up, powder, sunscreens and dirt will block pores
Fact: Comedogenic cosmetic ingredients and products stimulate sebaceous gland activity, and lead to excess sebum production. This in turn blocks the follicles (pores) and leads to acne. It is a myth that follicles can be occluded from the exterior skin surface by cosmetic “impurities”.
Myth: Fried, spicy or oily food cause the skin to be oily and trigger acne breakouts.
Fact: Current research has not shown any correlation between consuming fried, spicy and oily food and acne. However, there is increasing evidence to show that consumption of dairy products (e.g. milk, cheese, butter) and high glycemic index food (e.g. starchy food, sugary drinks) cause acne breakouts. Whey protein consumed by athletes and bodybuilders are also associated with acne.
Myth: Only teenagers get acne.
Fact: Acne is most common in teenagers but an increasing number of adults, especially women, can get acne breakouts at any age. It has been observed that adult women aged late 30’s and early 40’s are more prone to acne.
Myth: Squeezing pimples yourself is the best way to get rid of them.
Fact: Scarring can occur even in mild cases of acne. This is due to the resultant damage to surrounding skin tissues from the inflammation. Squeezing or picking at pimples may cause more inflammation and hence more skin damage. However, the ‘pattern’ of acne scarring appears to be individual and may be genetically determined.
Myth: Getting a tan helps acne.
Fact: Some believe that getting a tan helps acne. A sunburn will only irritate the skin and lead to increased acne or cause post inflammatory hyperpigmentation(PIH) or blemishes that will take a long while to heal.
Acne treatment can be divided into:
Topical treatments are prescribed for mild acne on the face. Combinations can be used for its synergistic action. Treatment is for at least 6 months. Improvement is gradual and incremental over the 6 months. Depending on the type of acne(comedonal vs. inflammatory), our doctors will prescribe the appropriate topical treatment.
1. Retinoids, e.g. tretinoin, adapalene
Retinoids are comedolytic, reduce abnormal desquamation and have some anti-inflammatory effects.
2. Benzoyl Peroxide (BPO)
BPO is antimicrobial and effective against c acnes bacteria. It also has keratolytic effects.
3. Antibiotics, e.g. clindamycin, erythromycin
Antibiotics target c acnes bacteria
When the acne condition is deemed moderate to severe, our doctors can add oral medication to the treatment. Truncal acne is usually treated with a long course of oral medication. Oral medication is usually for a period of 6 months or longer.
Systemic antibiotics are a first-line treatment of moderate-to-severe inflammatory acne vulgaris. These agents have anti-inflammatory properties, and they are effective against C acnes. There are several types of antibiotics indicated for acne treatment. Each has a different side-effect profile and resistance profile to C acne. Our doctors will prescribe after careful assessment of our patients.
These are combinations of hormones to prevent ovulation. Because of their anti-androgenic effect, they are usually prescribed when the patient wishes contraception and has signs of excess androgen (eg. acne, hair growth on the face and body).
They take at least 6 months to treat the acne.
Usually used as second-line treatment for acne when other oral treatments fail. It is very effective in the treatment of acne and if given the correct total dosage, can prevent the condition from relapsing.
However, there are several side-effects of this medication.
Oral retinoids like Isotretinoin (Acnotin, Roaccutane, Oratane) a derivative of vitamin A, work extremely well. It has an anti-inflammatory effect and can reduce oil secretion by 90% within six weeks of treatment, and reduce whiteheads and blackheads by 90% within three months.
Intralesional corticosteroid injection, or steroid shots, are used for treating inflammation, to help shrink large acne cysts or deep nodules. A very dilute corticosteroid is injected directly into the pimple – this quickly reduces inflammation, flattens and heals the breakout in just a few days.
For more stubborn cases of acne, laser therapy using devices such as Aerolase and Nd:YAG lasers are useful in reducing inflammation and the number of acne-causing bacteria on the skin.
Light therapy with LED light is also beneficial.
Studies show that lasers and other light treatments can reduce acne but these treatments alone can rarely clear acne. For best results, multiple treatments as well as multi-modality treatments, such as in conjunction with topical and/or oral medicine may be recommended.
Broadband Light - BBL
This is a cutting-edge acne treatment that uses the power of light to comfortably and effectively clear acne (in teenagers and adults).
An advanced form of Intense Pulsed Light (IPL), blue BBL light eliminates acne-causing bacteria at its source, deep down in the pores, yellow BBL light reduces the inflammation and acne-associated redness to give you healthy, luminous skin. Finally, infrared light in rapid, gentle pulses help to initiate the body’s natural healing process.
To keep acne flares under control, regular aesthetic facial treatments such as IDS Aesthetics Advanced Acne Treatment Plus (AAT+) may help. It is specially designed to help one manage and maintain acne outbreaks. This clarifying facial treatment combines ultrasonic deep cleansing and extractions to help clear clogged pores and comedones, along with IPL and a clay mask to calm and soothe inflamed skin.