Skin Problems


What are the symptoms of this condition?

Acne is a skin condition characterised by the appearance of whiteheads, spots and blackheads. They can be sore and painful as well as being unsightly. They are most commonly located on the face, but may also appear on the chest and the back.

Acne affects young adults of either sex. While it is occasionally seen in young children or mature adults, it is most common between the ages of 17 and 23. There is a great deal of individual variation in the age at which acne starts, its severity, and its duration; generally, the condition improves through the mid to late twenties, although in some people, acne may persist well into adulthood.

What is the cause of the condition?

Acne is the result of a change in the activities of the sebaceous (oil producing) glands in the skin.

Human skin is divided into two layers; a thin, outer layer called the epidermis, and a deeper layer called the dermis. The dermis is much thicker than the outer epidermis and contains all of the nerves and blood vessels that the skin requires.

The dermis also contains the hair roots (‘follicles’). Associated with each hair root is a sebaceous gland. The oily liquid that the sebaceous glands produce is called sebum, which passes out of the follicle to the outer surface of the skin. Here it functions to lubricate the skin and keep it flexible.

The classic symptoms of acne are the result of an overproduction of sebum by the sebaceous glands, which often starts around the time of puberty. As the body starts the transition from child to adult, the levels of certain hormones in the blood rises. Whilst there are many hormones in the body, the hormones that are thought to be involved in the development of acne are androgens – masculinising hormones which are present both in men and women.

Sebaceous glands are very sensitive to androgens, and respond by producing more sebum; the glands also increase in size. When the sebum reaches the surface of the skin, it reacts with the atmosphere and becomes thicker. With the exit from the follicle now partly obstructed by the thickened sebum, the flow from the gland slows down; bacteria from the skin can then infect the stagnating sebum left in the gland. As the sebaceous glands are often enlarged, sebum can escape from the gland into the surrounding dermis where it causes localised irritation and inflammation.

Whiteheads or blackheads (‘comedones’) are seen when the opening from the hair follicle finally becomes blocked by the thickened sebum, skin bacteria and cellular debris from inside the follicle. Red, inflamed spots may be seen and are probably the result of the leaking sebum irritating the dermis. Sometimes small pus-filled blisters develop in the inflamed spot. These usually settle down in a few days. The dark tip of a blackhead is caused by an accumulation of melanin, a natural skin pigment.

While these symptoms are mostly seen in teenagers, they can occasionally be seen in mature adults as well. Women make up the majority of these mature cases; here the acne may be due to an increased sensitivity to androgens.

There are many myths and facts about acne and spots, some of which are discussed below:

Common myths about acne

“Spots are caused by a lack of cleanliness” – Having spots does not mean you’re dirty. (The dark tips of blackheads are not dirt – they’re an accumulation of melanin, a normal skin pigment.)

“Acne is contagious” – You can’t catch acne by touching or even kissing someone who has the symptoms.

“Acne only occurs on the face” – Spots are most common on the face, but in severe cases they may also spread down the shoulders, upper back and chest.

“Acne is caused or made worse by eating unhealthy foods” – This is one of the most common myths about acne and spots. Although it is not true, a healthy diet will obviously help you stay healthy and feel well.

“Acne is caused by stress” – There is no evidence that stress is a direct cause of acne or spots, or makes them worse. However, people do tend to touch their spots more when they are anxious, and this can aggravate them.

Facts about acne

“Acne gets worse just before a period” – Most women find their spots are worse in the week before their period, because of the hormone changes which occur at that time.

“Taking the Pill can make acne worse” – The contraceptive pill does not actually cause acne, but it can influence the severity of your spots. If you have spots, ask your doctor to prescribe a contraceptive pill which will not make your acne worse.

“Acne can be affected by pregnancy” – Pregnancy can have an effect, but it is unpredictable. In some women, spots virtually disappear during pregnancy, though they may recur afterwards; if you are less lucky, you may find pregnancy causes acne to flare up.

“Acne can be aggravated by cosmetics” – Make-up can conceal spots very effectively, but you need to choose good quality, non-greasy products, or you may block the skin pores and make your spots worse. Products described as “non-comedogenic” are specially designed not to block skin pores.

“My job aggravates my acne” – Certain jobs which involve working in hot, humid environments, such as kitchens or laundries, can make the spots worse, as excessive sweating can block the skin pores.

What complications might occur?

Most teenagers suffer from acne or spots to some extent; it usually starts in adolescence and clears up by the early twenties, though it can last longer. For the majority of individuals, it is a nuisance and can be unsightly, however in severe cases, untreated acne can result in permanent scarring of the skin. These cases represent only a small percentage of the total number of sufferers. Otherwise, there are no major complications resulting from acne.

What can I do to treat myself?

There are steps which can be taken to improve the symptoms of acne, and make the condition more manageable.

Pay attention to personal hygiene
Although spots are not caused by dirt, frequent washing does help to keep down the levels of grease on your skin. It is also a good idea to use a skin cleanser regularly, to prevent a build-up of grease on the skin and to remove dead cells.

Look after your hair
If you have spots your hair may tend to be greasy, and in turn greasy hair can aggravate spots, so wash your hair frequently, and either keep it short, or wear it back off your face.

Get out in the sunshine
Acne seems to improve in the sun, although the effect does not last. Do be careful to avoid over-exposure to sun, and use a non-greasy sunscreen for protection.

If you are using prescribed medicines…
Some medicines, in particular steroid creams and tablets, and anti-epilepsy drugs, can make acne worse. If you think a medicine you are taking may be making your spots worse, consult our pharmacist or your doctor. Never stop taking prescribed medication without first seeking medical advice.

Use make-up to conceal your spots
Choose light ‘oil-free’ water-based products, which will not block the skin pores. Spot concealer sticks are useful to disguise individual spots, but should not be used over large areas. Always remove make-up thoroughly with a gentle non-greasy cleanser at night. If you need to use a moisturiser (particularly if your acne treatment makes your skin dry) choose a non-greasy one. Products described as ‘non-comedogenic’ are best, as they are specially designed not to block skin pores.

Don’t squeeze your spots
No matter how tempting it is, you should never squeeze whiteheads, or spots that are red and inflamed. The pressure can cause the infected contents of the spot to be squeezed deeper into the surrounding tissue, making a larger, angrier-looking spot. Squeezing can even lead to permanent scarring. If you really must, you can very gently squeeze superficial yellow spots to release their contents. But any spot requiring more than very gentle effort, or which is red or bleeds, must be left well alone.

Blackheads can be removed by gently stretching (not squeezing) the skin around them.

Over-the-counter treatments can be used to treat the affected areas. These are discussed in detail in the next section.

What treatments are available for me to purchase?

All acne treatments are designed to reduce the number of new spots forming rather than to treat existing spots. They will also take a number of weeks to produce an effect and so patience is important. There are three main types of treatment: keratolytics, anti-bacterials and cleansers; these are described below.

These break down keratin (a component of skin) removing dead skin cells and so unblocking skin pores. They also increase the turnover of the skin. The most effective keratolytic, and probably the most effective treatment available to buy, is benzoyl peroxide which is found in a number of products including Oxy 5 and 10, Panoxyl and Quinoderm. Benzoyl peroxide is also anti-bacterial (see below). These products can cause some redness when first used and so it is advisable to start with a lower strength product and gradually build up the length of time that they are used.

These help to reduce the number of bacteria on the skin thus preventing infection of blocked pores. There are a large number of products including the Clearasil and Oxy ranges.

Simple cleansers will remove some of the excess sebum from the skin and so help to prevent pores becoming blocked. Many of these cleansers are also anti-bacterial.

What treatments are available from my doctor? If you find that non-prescription treatments for acne are ineffective, or if you cannot tolerate them because of skin irritation, there are other treatment options available from your doctor, including antibiotic tablets and lotions.

Mild acne 
Topical retinoids (isotretinoin) or retinoid-like medications may be prescribed. Adapalene gel is an example of the retinoid-like class of product. Topical antibiotics may also be used with clindamycin being the most widely prescribed; however this should not be used in conjunction with benzoyl peroxide as the two preparations may interact. An alternative antibiotic to clindamycin is erythromycin. Moderate acne Oral antibiotics may be prescribed for moderate acne. Erythromycin and oxytetracycline are often used in a 3-6 month course, but resistance to the effects of these drugs can occur. Minocycline is a similar antibiotic to oxytetracycline, however it can rarely cause a pigmentation of the skin, which limits its usage. Anti-androgenic preparations (such as cyproterone acetate) can be used in women – this ingredient is found combined with ethinyloestradiol in the contraceptive pill, Dianette.

Severe acne
Isotretinoin is a very potent drug for the treatment of acne, but must only be used under specialist supervision because of its potential side-effects. Blood tests for cholesterol and liver function must be undertaken before beginning an initial 16-week course. Contraceptive precautions will be required in women of childbearing age before treatment starts until one month after cessation; your pharmacist or doctor will advise further about this medicine if necessary.

What additional investigations might be needed?

Severe acne that is not responding to treatment may need referral to a dermatologist; some medicines used for treating severe acne are available only from dermatologists – your doctor will refer you if he feels this is appropriate. The acne may be worsened by an allergic or sensitivity reaction to a chemical in the home or at work. This would need specialist investigation if you cannot identify the trigger factor.