‘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.

How Does Acne Develop?

Doctors describe acne as a disease of the pilosebaceous units. Found over
most of the body, pilosebaceous units consist of a sebaceous (oil) gland
connected to a hair-containing canal called a follicle (see below). These units
are largest and most numerous on the face, upper back, and chest—areas
where acne tends to occur. The sebaceous glands make an oily substance
called sebum that normally empties onto the skin surface through the
opening of the follicle.
Acne is believed to result from a change in the inner lining of the follicle that
prevents the sebum from passing through. For reasons not understood, cells
from the lining of the follicle are shed too fast and clump together. The
clumped cells plug up the follicle’s opening so sebum cannot reach the
surface of the skin. The mixture of oil and cells causes bacteria that normally
live on the skin, called Propionibacterium acnes (P. acnes), to grow in the
plugged follicles. These bacteria produce chemicals and enzymes that can
cause inflammation. (Inflammation is a characteristic reaction of tissues to
disease or injury and is marked by four signs: swelling, redness, heat, and
pain.) When the plugged follicle can no longer hold its contents, it bursts and
spills everything onto the nearby skin—sebum, shed skin cells, and bacteria.
Lesions or pimples develop as a result of the skin’s being irritated.

People with acne frequently have a variety of lesions, some of which are
shown below. The basic acne lesion, called the comedo (kom´-e-do) or
comedone, is simply an enlarged hair follicle plugged with oil and bacteria.
This lesion is often referred to as a microcomedo because it cannot be seen by
the naked eye. If the plugged follicle, or comedo, stays beneath the skin, it is
called a closed comedo or whitehead. Whiteheads usually appear on the skin
surface as small, whitish bumps. A comedo that reaches the surface of the
skin and opens up is called a blackhead because it looks black on the skin’s surface. This black discoloration is not due to dirt. Both whiteheads and
blackheads may stay in the skin for a long time.
Other troublesome acne lesions can develop, including the following:
       Papules—inflamed lesions that usually appear as small, pink bumps
on the skin and can be tender to the touch.
       Pustules (pimples)—inflamed, pus-filled lesions that can be red at the
base.
       Nodules—large, painful, solid lesions that are lodged deep within the
skin.
       Cysts—deep, inflamed, pus-filled lesions that can cause pain and
scarring.