Dr Philip Hampton
Head of Dermatology, Royal Victoria Infirmary Newcastle

A while back we met with Dr Philip Hampton, head of dermatology at the Royal Victoria Infirmary in Newcastle, to get some answers to our burning questions about acne! He was kind enough to let us publish the answers we’ve been searching for, so let’s get geeky!

What are acne lesions? How do they form?

Acne is due to blockages in oil glands, called sebaceous glands. The blockage is in the ducts that the oil travels through to get to the surface of the skin which are found most commonly on the face, back and chest. You can get an increase in skin cells at the top end of the oil duct, and these can then block the oil duct. This is called a microcomedone. Following this, open and closed comedones develop.
Open comedones are what we’d call blackheads, whereas closed comedones are small white bumps. From there, you can then go on to get inflammatory acne, when – due to the blockage of the oil duct – you get increased growth of Priopionibacterum acnes, which are bacteria that are resident in the skin. Where there is a change in skin structure, these bacteria grow abnormally, which then triggers inflammation that triggers a red spot. Persistent inflammation can progress to form a papule, nodule or cyst. Cyst rupture with subsequent healing leads to pitted acne scarring.
So it’s a progressive process – but most people will only go up to the earlier stages, whilst only a few will go on to develop nodules and cysts that can leave permanent acne scars.

Why do we start getting spots in our teens?

Levels of androgens, such as testosterone, increase during puberty and this causes more oil to be produced due to the maturation of the sebaceous glands. Because the maturation of the gland and the duct itself isn’t quite matched, the ducts may not have matured enough to accommodate for the increased oil production, which can start the acne process. The large variation in severity of acne is due to many factors, including how quickly the oil ducts mature and how much oil is being produced. Twin and family studies have shown that genetics also plays a role.

How many of us are affected by acne?

95% of adolescents will get acne to some degree. Some studies now indicate that up to 40% of women can go on to develop chronic acne which, without treatment, can last up until the menopause. For men acne is generally limited to adolescence and early adulthood. This difference is thought to be linked to hormone cycle differences between men and women: women may have periodic cycles of acne, as the balance between male and female hormones varies between different points in their menstrual cycle.
Hormonal products, such as progesterone-only female oral contraceptives may also contribute to this.

How does our diet affect our skin and skin conditions such as acne?

Diet doesn’t affect acne. Many studies have focussed on the effects of dairy products on acne, but there has been no real convincing evidence of diet having any effect on acne whatsoever. (Wooh bring on the chocolate!)

Do other environmental factors affect our skin?

Very few environmental factors really contribute to acne, other than oral contraceptives: the progesterone-only contraceptive pill has acne as a side effect, because the progesterone can be converted into androgens. However, the combined contraceptive pill often has anti-acne effects. Heavy makeup use has been linked to acne, as has the use of oil-based hair lacquers and straightening oils.

Are there any of associated health problems with acne?

There are significant associations between bad acne and depression. Acne has been shown to have a major negative impact on self-esteem and even chances of employment. Acne can be a far more damaging disease than is commonly acknowledged. It is odd in many ways that whilst eczema affects only around 20% of children, it’s more likely for a child to be taken to the doctor about their eczema than about acne. Acne is often completely normal, but there is a failure to identify when acne is abnormal: people often brush it off, but if it’s serious enough to leave significant scarring then that scarring can be very psychologically damaging to the person.

Is there any way to easily get rid of scars from acne?

There are no good treatments for acne scarring. In severe cases, carbon dioxide laser resurfacing can be used to essentially burn away the scars and tighten up the collagen but this only works in selective cases. For isolated deep-pitted scars, surgical excision may be an option, but there would then be scarring associated with that surgery and so it may or may not improve skin appearance.

What can we do to help prevent acne?

The first thing to do is decide what level of acne you’re happy to live with. A lot of people will have mild temporary acne, which you might use a light exfoliator to try and improve – but it’s generally not a problem.
People with comedonal acne can be treated with benzoyl peroxide creams or retinoid creams. With inflammatory acne you need to use the anti-comedonal treatment along with an antibiotic. If they then don’t respond to that treatment, the next step would be systemic retinoids, such as isotretinoin. In very severe cases, patients may be put straight on isotretinoin. It all depends on the type and severity of acne.
It’s also worth noting that the suspected link between isotretinoin use and depression has been largely discredited by a major study from Sweden published in the British Medical Journal in 2012. There is a major correlation between severe acne and depression. The study showed that patients with bad acne were getting worsening depression in the 3 years prior to receiving isotretinoin and that depressive symptoms improved in the years following a successful course of isotretinioin. Even with this new data any patient with severe acne embarking on a course of isotretinoin still needs careful assessment for mental health issues as severe acne itself is a risk factor for depression and these patients remain a vulnerable group.

Do face masks and other anti-acne products work? How do they work?

Most of them work by having anti-inflammatory effects, but many do not tackle the underlying blockages in the skin, and so the relief is only temporary. You need to be tackling the comedones to have a prolonged effect on the condition, which is done through the use of retinoid creams or isotretinoin.

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