‘Grading’ your acne

My doctor talked about my acne being ‘moderate’. What
does this mean?
To assess the severity of acne, it is graded into different levels.
There are many different ways of grading acne, some very complex
ones being designed for carefully assessed research into
treatment. It is easiest to look at three or, perhaps, four degrees
of acne:
• mild – mainly comedones with perhaps a few papules and
pustules,
• moderate – papules and pustules,
• severe – deeper lesions, nodules and some cysts,
• very severe – many nodules and cysts with scarring.
These four grades take into account the numbers and types of
lesions (‘spots’) as well as looking at scarring or pigmentation
changes seen in darker skins. Each area of the body should be
graded separately, and consideration should also be given to the
degree of psychological impact. For example, if you have only
mild acne but feel very upset by it, you should be considered as
‘moderate’ because this will affect which treatment is chosen for
you.
An exception to the grading rule is in people with pigmented
skin. Acne is one of the most common skin diseases in black people
and can cause a lot of damage. There is always much more
inflammation going on under the skin than would seem likely, so
mild-looking acne in someone of Asian or African-Caribbean origin
should be treated as if it were moderate.
Your doctor or nurse might also talk to you about grading so
that you can check or compare how different treatments are
working and how good (or otherwise) they are for you.
I hate my spots and have to cover them up when I go out.
My doctor is no use as he says I only have mild acne. What
can I do?
It can be very difficult to get doctors to understand how bad you
feel your acne is but, if you always cover it up, there may not be
much for the doctor to look at. It is worth following a few simple
guidelines whenever you go to your doctor:
• Keep your hair away from your forehead so that any comedones
and other acne lesions there are clearly seen. You
could take some hairgrips with you and pin your hair back or
up once you get to the surgery.
• If you are male and shaving, don’t forget to shave on the day
you see your doctor. Stubble can cover spots and make them
difficult to see.
• Why not ask for the first appointment for the day? That way,
you won’t have to sit in a crowded waiting room, feeling selfconscious.
• If you really can’t bear the thought of going without makeup,
you must be prepared to remove it before consulting
your doctor. In order to make a clear diagnosis, he will need
to look closely at your skin. That is his job and he will have
to look at far worse things than your skin, even if you can’t
imagine this! So take make-up remover with you and gently
remove it just before going in to see your doctor.

What is acne?.....................(part 2 of 5 )

Below we outline the types of spots you can get, so you can tell whether you have a mild, moderate or severe problem. They do not all have to be present for you to have acne. Just one type will still mean you have this condition, and there are effective treatments no matter how bad your problem is.

Comedones

These are the starting point of all acne. They begin as very small blockages in the pores. At this stage a blockage is referred to as a microcomedone – the comedone is too small to be seen. Microcomedones can progress to become larger comedones, or they can burst (rupture) internally, causing different types of spots.They burst because of the build-up of pressure and the damage that the inflammatory process does to the wall of the duct.

Whiteheads (closed comedones)

Some people think of whiteheads as a type of pus-like spots, but they are not. As the microcomedone gets larger, because swelling is building up behind the blockage, it becomes visible. If the initial blockage is quite deep in the pore, the opening onto the skin will remain closed; this causes the typical whitish lump that can be seen and felt on the surface.
Blackheads (open comedones)

These are clearly visible and very annoying because they look so dark and obvious. The blockage has occurred further up the duct, so its opening is widened and the contents are visible. If you were to dissect your skin, you would see the curly sebaceous gland –which is the escape route for oil – blocked full of a hard, yellow plug. This plug is a mixture of the sebum that has solidified and
the dead lining cells that have been shed. Because these are like skin cells, they contain some of the pigment (melanin) that gives skin its colour. This pigment turns dark when it is exposed to air,so the ‘black’ in ‘blackhead’ is notdirt.

Inflamed spots

Comedones can stay quite happily in your skin for months, or even years, without changing. If they progress or burst (rupture), though, different kinds of spots result: papules, pustules, nodules and cysts.

Papules

If the comedones start to leak sebum into the surrounding tissue, this produces inflammation and a red spot results. Papules are less than 5mm across and have no pus visible. They could be
called ‘redheads’, as they are otherwise like the whiteheads. If your microcomedones rupture, you will produce papules without going through the whitehead and blackhead stage.

Pustules

A pustule is the typical pus spot or yellowhead. These occur when the bacteria present on the skin and in the duct start to multiply. These bacteria are called Propionibacterium acnes
(usually shortened to P. acnes). They prefer dark places with no air to breed. A blocked pore is ideal and soon there will be lots of bacteria producing more inflammation; this triggers the body’s
own defences as mentioned above, leading to a head of pus on a red swelling.

Nodules and cysts

Comedones, papules and pustules are nasty to look at and caus pain associated with the swelling and inflammation but will clea up without causing much scarring except in people wit
pigmented skin. (This is discussed further in Chapter 6, The physical scars.) The next two types of spot mentioned, howeve – nodules and cysts – can cause real and lasting damage.

Nodules

Nodules are solid spots; they are much bigger than papules and extend deeper into the skin. They are caused when a large comedone has ruptured, releasing lots of inflammatory contents
(white cells and bacteria) into the surrounding skin. More inflammation and pus result, leading to more pain and swelling.The nodule extends deeper into the area that contains the skin’s
structural support. Damage here leads to the scarring.

Cysts

Unlike nodules, cysts are bags of liquid that is a mixture of pus and bacteria. Cysts usually occur only with nodules, often when two or three are close together. They are even more destructive
than nodules to the structure of the skin but, luckily, are quite rare.

Who Gets Acne?

People of all ages get acne, but it is most common in adolescents. Nearly 85
percent of adolescents and young adults between the ages of 12 and 24
develop the disorder. People of all races can have acne, but it is more
common among Caucasians. For most people, acne tends to go away by the
time they reach their thirties; however, some people in their forties and fifties
continue to have the disorder.