‘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.

Getting acne....Q&A............(part 3 of 5)

I’ve started getting acne spots. How long do they last?
This depends on what type of spots they are and, even then, it can
be very difficult to predict what will happen. Some spots will
appear and then disappear during the course of a day but others
will evolve more gradually through the various stages. Comedones
can be very persistent if they don’t get inflamed. Mildly inflamed
spots will last 5–10 days before settling down, but can leave a flat
red mark (macule) for several weeks. Nodules and cysts may last
for weeks or months unless you get some treatment.

What is the difference between a whitehead and a yellow-
head spot?
These two common terms describe quite different types of spot.
A whitehead is a closed comedone where the pore is blocked and
not open to the air. There is no inflammation (redness). A yellow-
head suggests a spot with pus in it. The medical term is a ‘pustule’.
Whiteheads may become yellowheads if the blocked pore becomes
infected.

My daughter is only 9 but she seems to have developed some
blackheads around her nose. Can this be acne – like I had?

Girls seem to be starting puberty earlier and earlier, and many
9-year-olds have started to develop some hormone changes.
Blackheads are one of the types of spots that occur in acne so,
yes, this could well be the start of it. Almost all children will get
some blackheads and other spots as they start and go through
puberty, so your daughter will not necessarily get worse but this
might depend on how bad your own acne was. We don’t fully
understand the role of genes in acne but there is some inherited
factor that makes acne more likely in some families. If you had
severe acne, it is worth starting a simple treatment approach to
reduce the number of blackheads on your daughter’s nose.

I am an identical twin and I have acne but my sister
doesn’t – weird or what? Can you explain why?
Answering questions like this is always difficult. We can’t give you a
reason why your twin doesn’t have acne, because the precise cause
and triggers are not fully understood. However, studies of twins
have helped to work out that some genetic inheritance is involved,
as identical twins tend to produce similar amounts of the skin
grease called sebum. This is not the case for non-identical twins.
You don’t say how old you are – it may be that your sister will
go on to develop acne. She is certainly more likely to have acne
than if she were not your twin.

I have been having problems with my skin for about two years. Can you tell me what the difference is between spots and acne? I think that to have acne you must have at least 20 spots but my mum thinks otherwise.
There is no real difference between spots and acne, assuming
that the type of spots fits into the pattern we have described withblackheads, whiteheads, papules and pustules. What is most
important is the effect the spots have on you and whether you
have any of the more serious types of spot that might cause long-
term scars. If you are upset by the appearance of your skin, it
doesn’t really matter how many spots you have – you have a
problem that is worth seeking some treatment for.

Why am I the only one in my class who has spots? I heard
it was very common but I don’t think it is really.
The most important spots are the ones that you have, and you
will be much more aware of them than anyone else. Other
students might have spots that you can’t see – on their back or
chest – or they might be using some treatment or camouflaging
make-up. Don’t worry about them; just talk to your pharmacist or
doctor if you are not already using some creams.DBE6SCXAA5WF

How Is Acne Treated?

By the time many people consult a doctor for their acne, they usually have
tried a drawerful of over-the-counter (OTC) medications. Acne is often
treated by a dermatologist, a doctor who specializes in diseases and
disorders of the skin. Dermatologists treat all kinds of acne, particularly
severe cases. Doctors who are general or family practitioners, pediatricians,
or internists may treat patients with milder cases of acne.
The main goal of acne treatment is to prevent scarring. Additional goals are
to reduce the number of painful lesions and to minimize the psychological
stress and embarrassment caused by this disease. Doctors often use drug
therapy as the first choice for treating acne. Drug therapy is aimed at
reducing several problems that play a part in causing acne: abnormal
clumping of cells in the follicles, increased oil production, the bacterium P.
acnes, and inflammation. Depending on the severity of the person’s acne, the
doctor will recommend one of several OTC or prescription topical
medications (medication applied to the skin) or a prescription systemic
medication (medication taken by mouth). The doctor may suggest using
more than one topical medication or using both an oral medication and a
topical medication at the same time.
Common Over-the-Counter Topical Medications Used to Treat
Acne
Benzoyl peroxide cream, gel, lotion, or soap:
Clearasil
Fostex
PanOxyl
Dryox
Persa-Gel
Salicylic acid:
PROPApH, Stridex
Oxy Night Watch
Clearasil Clearstick Maximum Strength
Sulfur:
Sulpho-Lac Acne Medication
Liquimat
Therac Lotion
Sulmasque
Benzoyl peroxide and sulfur:
Dryox 10S
Dryox 20S 10
Sulfoxyl
Sulfur and resorcinol:
Sulforcin Lotion
Rezamid Lotion
Acnomel Cream
Treatment for Blackheads, Whiteheads, and Mild Inflammatory
Acne
Doctors usually recommend an OTC or prescription topical medication for
people with blackheads, whiteheads, and mild inflammatory acne.
Depending on the type of medication, a topical drug is applied directly to
the acne lesions or to the entire area of skin affected. The medication helps
limit the formation of new blackheads and whiteheads and decrease
inflammation.

Treatment for Moderate to Severe Inflammatory Acne
Patients with moderate to severe inflammatory acne may be treated with an
OTC or prescription topical medication, a prescription oral medication, or a
combination of these.
Topical OTC Medications
Benzoyl peroxide, resorcinol, salicylic acid, and sulfur are the most common
topical OTC medications used to treat acne. Each works a little differently.
Benzoyl peroxide is best at killing P. acnes and may reduce oil production.
Resorcinol, salicylic acid, and sulfur help break down blackheads and
whiteheads. Salicylic acid also helps cut down the shedding of cells lining
the follicles of the oil glands. Topical OTC medications are available in many
forms, such as gel, lotion, cream, soap, or pad.
In some patients, OTC acne medications may cause side effects such as skin
irritation, burning, or redness. Some people find that the side effects lessen
or go away with continued use of the medication. Severe or prolonged side
effects should be reported to the doctor.
OTC topical medications are usually moderately effective in treating acne
when used regularly. Patients must keep in mind that it can take between 4
and 8 weeks before they notice an improvement in their skin.
Prescription Topical Medications
Several types of prescription topical medications are used to treat acne,
including benzoyl peroxide, antibiotics, tretinoin, adapalene, and azelaic
acid. Prescription and OTC benzoyl peroxide work in the same way. Many
doctors prescribe benzoyl peroxide instead of recommending OTC versions
to make sure patients get the most desirable formulation (cream, gel, or
lotion).
Common prescription topical medications used to treat acne:
Benzoyl peroxide
Adapalene gel (Differin)
Clindamycin phosphate (Cleocin T)
Azelic acid (Azelex)
Erythromycin
Benzoyl peroxide and sulfur
Tetracycline HCL
Erythromycin and benzoyl peroxide
Tretinoin (Retin-A, Avita)
Sulfur and resorcinol
Antibiotics and azelaic acid help stop or slow the growth of P. acnes and
reduce inflammation. Tretinoin, a type of drug called a retinoid that contains
vitamin A, is the most effective topical medication for stopping the
development of new comedones. It also fights acne by increasing cell
turnover, which helps unplug existing comedones, and thereby allows other
topical medications, such as antibiotics, to penetrate the follicles better. The
doctor may also prescribe a newer drug called adapalene gel, a retinoidlike
compound that helps decrease microcomedone formation.
Prescription topical medications come in a variety of products. The doctor
will consider the patient’s skin type when prescribing a product. Creams and
lotions are moisturizing and tend to be good for people with dry skin. Gels
and solutions are generally alcohol based and tend to dry the skin, so
patients with excessively oily skin or those who live in hot, humid climates
may prefer a gel. The doctor will tell the patient how to apply the medication
and how often to use it.
Some people develop side effects from using prescription topical
medications. Common side effects include stinging, burning, redness,
peeling, scaling, or discoloration of the skin. With retinoids, these side effects
usually decrease or go away after the medication is used for a period of time.
Patients should report prolonged or severe side effects to their doctor.
Between 4 and 8 weeks will most likely pass before patients see
improvement in their skin.
Prescription Oral Medications
For patients with moderate to severe acne, the doctor often prescribes oral
antibiotics (taken by mouth) in addition to topical medication. Oral
antibiotics are thought to help control acne by curbing the growth of P. acnes
and decreasing inflammation. Common antibiotics used to treat acne are
tetracycline, minocycline, doxycycline, and erythromycin. Some people have
side effects when taking these antibiotics, such as photosensitivity (higher
risk of sunburn), upset stomach, dizziness or lightheadedness, and skin
discoloration. Tetracycline is not given to pregnant women or children under
12 years of age because it can discolor developing teeth. Tetracycline and
minocycline also decrease the effectiveness of birth control pills, so a backup
or alternative form of birth control must be used. Patients usually must take
oral antibiotics for as long as 4 to 6 months to effectively treat acne.
Treatment for Severe Nodular or Cystic Acne
People with severe nodular or cystic acne should be treated by a
dermatologist. For patients with severe inflammatory acne that does not
improve with other medications, such as those described above, isotretinoin
(Accutane), a retinoid, may be needed. Isotretinoin is an oral drug and is
usually taken once or twice a day for 16 to 20 weeks. It is believed to
markedly reduce the size of the oil glands so that much less oil is produced.
As a result, the growth of P. acnes is decreased. Isotretinoin also reduces cell
shedding and the stickiness of cells in the follicles, which helps prevent the
development of comedones.
Advantages of Isotretinoin
Isotretinoin is a very effective medication that can help prevent extensive
scarring in patients. After 16 to 20 weeks of treatment with isotretinoin, acne
completely or almost completely goes away in most patients (up to 90
percent). For some people, however, the acne will come back, and they will
need additional treatment with isotretinoin.
Disadvantages of Isotretinoin
Patients should carefully consider the several disadvantages of isotretinoin.
The drug is not only expensive but is also linked to some adverse effects that
can be severe. Possible side effects include inflammation of the lip and
mucous membrane of the eye; dry mouth, nose, or skin; itching; nosebleeds;
muscle aches; photosensitivity; and, rarely, decreased night vision. Other
more serious side effects include increased blood cholesterol, lipid, and
triglyceride levels and abnormal liver enzymes. To make sure isotretinoin is
stopped if these side effects occur, the doctor usually monitors a patient’s
complete blood count, blood chemistries, cholesterol, triglycerides, and liver
enzymes before therapy is started and periodically during treatment. All of
these side effects usually go away after the medication is stopped. Patients
who experience side effects while using isotretinoin should tell their doctor.
The doctor may be able to reduce the dose of the drug so that the side effects
are decreased or stopped.
The most serious potential adverse effect of isotretinoin is that it is
teratogenic: it can cause birth defects in the developing fetus of pregnant
women who take the drug. Therefore, it is crucial that women of
childbearing age are not pregnant and do not get pregnant while taking
isotretinoin. Women must use an appropriate birth control method for 1
month before therapy begins, during the entire course of therapy, and for 1
full month after therapy stops. Women should talk to their doctor about
when it is safe to get pregnant after therapy with isotretinoin has stopped.
Treatments for Hormonally Influenced Acne
For some female patients, treatment-resistant acne is caused by excessive
production of hormones called androgens. Clues that help the doctor
diagnose hormonally influenced acne are adult-onset acne, hirsutism
(excessive growth of hair or hair in unusual places), premenstrual acne
flares, irregular menstrual cycles, and elevated blood levels of certain
androgens.
The doctor may prescribe one of several drugs to treat women with this type
of acne. Low-dose estrogen birth control pills help suppress the androgen
produced by the ovaries. Low-dose corticosteroid drugs, such as prednisone
or dexamethasone, may have an anti-inflammatory effect and suppress the
androgen produced by the adrenal glands. Finally, the doctor may prescribe
an antiandrogen drug, such as spironolactone, which helps prevent
androgens from causing excessive oil production. Spironolactone also stops
androgen production in the ovaries and adrenal glands. Side effects of
antiandrogen drugs may include menstrual irregularities, breast tenderness,
headache, and fatigue.
Other Treatments for Acne
Doctors may use other types of procedures in addition to drug therapy to
treat patients with acne. The doctor may remove the patient’s comedones
during office visits. Sometimes the doctor will inject a corticosteroid drug
directly into lesions to help reduce the size and symptoms of tender and
inflamed cysts and nodules. Other patients may benefit from light skinpeeling
agents that are prescribed by a doctor or applied in the doctor’s
office. For some patients, the doctor may suggest a minor surgical or medical
procedure to help reduce scarring caused by acne.
How Should People with Acne Care for Their Skin?
Clean Skin Gently
People with acne may try to stop outbreaks and oil production by scrubbing
their skin and using strong detergent soaps. However, scrubbing will not
improve acne; in fact, it can make the problem worse. Most doctors
recommend that people with acne gently wash their skin with a mild
cleanser, once in the morning and once in the evening. Patients should ask
their doctor or another health professional for advice on the best type of
cleanser to use. The skin should also be washed after heavy exercise. Patients
should wash their face from under the jaw to the hairline; rough scrubs or
pads should not be used. It is important that patients thoroughly rinse their
skin after washing it. Astringents are not recommended unless the skin is
very oily, and then they should be used only on oily spots. Doctors also
recommend that patients regularly shampoo their hair. Those with oily hair
may want to shampoo it every day.
Avoid Frequent Handling of the Skin
People who squeeze, pinch, or pick their blemishes risk developing scars.
Acne lesions can form in areas where pressure is frequently applied to the
skin. Frequent rubbing and touching of skin lesions should be avoided.
Shave Carefully
Men who shave and who have acne can try electric and safety razors to see
which is more comfortable. Men who use a safety razor should use a sharp
blade and soften their beard thoroughly with soap and water before
applying shaving cream. Nicking blemishes can be avoided by shaving
lightly and only when necessary.
Avoid Suntanning
A suntan or sunburn that reddens the skin can make blemishes less visible
and make the skin feel drier for a little while. But the benefits are only
temporary. The sun can seriously damage skin, promote aging of skin, and
cause skin cancer. Furthermore, many of the medications used to treat acne
make a person more prone to sunburn.
Choose Cosmetics Carefully
People being treated for acne often need to change some of the cosmetics
they use. All cosmetics, such as foundation, blush, eye shadow, and
moisturizers, should be oil free. Patients may find it difficult to apply
foundation evenly during the first few weeks of treatment because skin may
be red or scaly, particularly with the use of topical tretinoin or benzoyl
peroxide. Lip products that contain moisturizers may cause small, open and
closed comedones to form. Hairstyling products that come in contact with
the skin along the hairline can cause burning or stinging in people with acne.
Products that are labeled as noncomedogenic (do not promote the formation
of blemishes) should be used; in some people, however, even these products
may cause acne.

What Research Is Being Done on Acne?
Medical researchers are working to develop new topical antibiotics for
treating acne to replace some of those in current use. As with many other
types of bacterial infections, doctors are finding that, over time, the bacteria
that cause acne are becoming resistant to treatment with certain antibiotics.
A different type of antibiotic or a stronger one is needed to kill diseasecausing
bacteria once they become resistant to existing antibiotics.
Research is being conducted on lipophilic compounds, a class of drugs that
are potent in decreasing inflammation and killing P. acnes. Additional research is also being conducted on the potential side effects of isotretinoin
and the long-term use of medications used for treating acne.
Other researchers are attempting to determine the factors in girls during
early puberty that might predict the development of severe acne later.
Finally, some researchers are studying how acne affects certain aspects of
patients’ lives, including psychological health and quality of life.