Acne - aka Acne Vulgaris - is a pathology affecting the oil glands of the skin.

Your first encounter with acne occurs typically during puberty - hormonal flux stimulates oil production by the sebaceous glands of the skin, resulting in sebum build up and acne formation. These oil glands are located just under the skin where one’s pores are seen. This oil is intended to carry dead cells to the surface of the skin via the hair follicles, as well as to lubricate the hair and skin externally. It is when this pore gets blocked that the trouble starts.

In general, acne forms when:
1. Pores are blocked
2. Sebum production rate exceeds its rate of release through the blocked pore
3. Bacteria feeds on the collected sebum and multiply
4. Inflammation from the resultant infection exacerbates the problem

This produces:
1. Non-inflammatory comedones: Whiteheads and blackheads, which can later form
2. Inflammatory acne: Papules, pustules, nodules and cystic acne

While acne is itself is not dangerous, its presence can be distressing. On top of the pesky bumps and persisting red marks, acne can leave more permanent sequelae - scars. As such, acne should be managed as early as possible, and understanding how acne forms is the first step to compliance to treatment measures.

Why Does Acne Keep Returning?

Think of the structure of the hair follicle like that of a tree - the hair follicle feeds on nutrients (and is affected by hormones) that are brought to it by the blood - like a tree feeds on the water in the ground through its roots. This is the body’s (systemic) effect on the single hair follicle; hormonal changes during puberty or menstrual periods affect change to the follicles at this level, and is one of the methods in which acne can effectively be controlled.

Once it receives its nutrients and signals, the hair follicle produces sebum at the sebaceous gland, much like a tree photosynthesising and growing on its own. For some reason or other, pores through which the hair sprouts in the skin gets blocked by dead skin and the sebum accumulates within the follicle. This is the next area that can be targeted in acne treatment - managing the tree itself.

As can be seen, the organ that is the skin is itself a living organ - it is in constant growth and renewal and as such, acne is too. Most treatments center around controlling and preventing further acne outbreaks, while some harsher forms of systemic therapies can permanently destroy sebaceous glands and eliminate acne.

this is a diagrammatic description of acne formation

NON-INFLAMMATORY ACNE - COMEDONES

The early stages of acne occur as excess sebum accumulates within a hair follicle.

If the follicle’s pore is blocked, a whitehead is formed.

If the follicle’s pore is unblocked, a blackhead is formed

INFLAMMATORY ACNE

The next stage involves the introduction of bacteria - specifically Propionibacterium Acnes. This produces a local inflammatory response that results in increasing redness and swelling of the hair follicle.

As the infection and resultant inflammation goes unchecked, swelling increases and cysts may form. This is where scarring is most likely after the acne subsides.

How Can We Tackle This Problem?

Many factors are considered when management plans are formulated for acne control:
1. Severity of acne
2. Previous failed therapies
3. Sex of patient and intention for pregnancy during treatment
4. Sensitivity of skin
5. Acceptance of possible underlying side effects of medications used for treatment

An ideal plan would:
1. Have an effective outcome in as quick a time as possible
2. Allow the patient to continue with their regular lifestyle
3. Have as minimal side effects as possible

As your tolerance for any of the above factors might differ from another’s, plans should also be adjusted to suit expectations.

A holistic plan would involve:
1. A systemic treatment, if necessary, to quickly and more permanently effect change on the oil glands
2. Interval clinical treatments to stun oil glands and kill P. Acne
3. Continued topical therapy to re-acclimatise the skin
4. Subsequent scar treatments to smoothen out the skin

What Are My options?

TOPICAL TREATMENTS:

1. Differin/Retins:
- Increase skin cell turnover, preventing pore blockage and maintaining skin health
- Helps in breakdown and removal of pigmentation formed by previous acne

2. Salicylic acid toner:
- Increases exfoliation, reducing pore blockage
- Binds to and inactivates sebum glands

3. Benzyl Peroxide creams:
- Kill P. Acne
- Dry out existing sebum collections

4. Clindamycin gels:
- Kill P. Acne
- Does not dry skin out as much as Benzyl Peroxide

ORAL THERAPY

1. Antibiotics:

   - Reduces inflammation and breaks a cycle of acne eruption

   - Taken for a period of several weeks

   - Does not solve the issue but helps with controlling breakouts

2. Isotretinoin:
   - A form of oral retin, this treatment effectively dries out and eliminates acne for good in up to 70% of patients

   - Requires daily consumption for 7 to 12 months at low doses

   - Can affect the liver, increase cholesterol levels, affect one’s mood, and have severe negative effects on babies if pregnant. As such, close monitoring and strict contraception (in females) is necessary

3. Oral contraceptives or other hormonal pills:
   - Control acne in ladies with uncontrollable hormonally-related acne

CLINICAL TREATMENTS

1. Chemical Peels:
   - Much stronger than acid toners, chemical peels exfoliate, dry out, and inactivate sebum glands
   - Are performed once every two weeks for 4-6 sessions under acne is controlled, then maintained at once every 4-8 weeks as necessary
   

2. Carbon-lotion Spectra Laser:
   - Dries out sebum collections
   - Kills P. Acne
   - Shrinks pores
   - Breaks down pigmentation left by acne
   - Schedule is similar to chemical peels
   

3. AGNES Radio-frequency Micro-needling:
   - Using a small needle and radio-frequency heating, this permanently and selectively destroys each individual sebaceous gland

   - Can require several sessions to completely eliminate recurrent and stubborn acne
   

4. Medical Grade BBL and Omnilux LED Therapy:
   - Uses intense light to kill P. Acne
   - Reduces skin redness and pigmentation
   

5. Microdermabrasion:
   - Physical exfoliation to remove debris and prevent pores from blocking up

Clearly, acne management can be a daunting affair for many of us; the choices are many and compliance to a plan can be difficult. A thorough and detailed consult, as well as close follow-up is essential to an effective and safe outcome. Other new treatments are under clinical trails, but until they pass the stringent safety and efficacy tests, we will have to make the most of the current arsenal of tools. To find out more on these treatments, click here to read more.

If you are struggling with post-acne scarring, find out more about scars and how you can be free of them!