ACNE - MORE THAN SKIN DEEP

Acne is more than skin deep. Having suffered acne as a teenager and now working in healthcare I can say that the general consensus amongst professionals tends to be that acne is an irritation but not altogether that serious. If a patient wants to pursue treatment they can but it’s viewed almost as an ‘elective therapy.’ To be fair, acne is self-limiting and unlike other disease processes won’t lead to systemic, serious illnesses if left untreated (for example, high blood pressure or untreated chlamydia). However acne is more than a simple skin condition. The link between acne and mental health is well-established. Given acne generally starts around puberty, which is already a difficult time emotionally and psychologically, greater weight should be given to identifying and treating acne. 

When I was teenager I had severe acne on my face and back and the effect on me was two-fold. Physically it was extremely uncomfortable; these are literally open sores, some of which get infected or bruise. Occasionally I would throw my school backpack over my shoulder and if it hit a pimple in a certain way it could wind me with pain. Beyond this, acne shook my confidence and self-esteem to the core. It’s confronting to not feel in control of your own body and through no fault of your own have your skin continually break-out; it felt like body-betrayal! Every person I spoke to, or crush I flirted with, I always assumed they were staring at my acne. To remain confident took regular hard-work and even then I still struggled. 

The current literature shows that people who have acne suffer higher rates of depression, anxiety and social isolation. This in part is due to the lack of control characterising acne, but also due to the cosmetic effect. In Australia, our mass-media is heavily image-focused and pimples don’t feature on the beach-babes. While I don’t think that our self-worth can ever come from something external, like clear skin or big muscles, I do think that the wide range of options for treating acne should be made common-knowledge. 

What is acne?

Acne is a skin condition that is characterised by pimples, blackheads, whiteheads and/or cysts. There are different classifications of acne depending on severity. How severe your acne classes is due in part to appearance, quantity and what type of lesion (e.g. cysts are classed as more severe than whiteheads). If following correct guidelines these classifications will determine which treatment your doctor uses. 

For most, acne starts during our teenage years and can sometimes continue throughout adulthood. When we reach puberty our body produces a hormone known as androgens. One effect of this hormone is to cause the hair follicles of our face, neck, chest and back to enlarge and produce more oil, known as sebum. As our body reabsorbs this oil a by-product is produced which can irritate the skin, block pores and cause acne in its various forms. Other causes of acne can include menstruation, hormone imbalances, stress, certain medications and some disease processes as well. 

Is chocolate giving me pimples?!?

There is a lot of contention about whether lifestyle factors like exercise and diet play a role in acne. Anecdotally the support is strong; people swear that chocolate causes pimples, that fried food makes them breakout and that lots of water clears skin. The evidence surrounding this topic is limited but generally supports the view that there is no definitive link between food/ exercise and acne and that if there is it is most likely dairy that impacts our skin. I don’t pretend to know definitively whether this is true but we are all individuals; if you know that certain foods impact your skin then avoid those but don’t assume it will have the same impact on somebody else. Personally, after a recent unrelated cut-back of dairy, I perceived an overall nicer quality to my skin. Of course, this could absolutely be psychosomatic. Similarly some people claim exercise reduces their breakouts and some say the sweating from working out causes pimples. The research in this area needs further investigation. 

Treatment

Understanding acne goes a long way to reducing its stigma and impact, so let’s talk about treatment! How you manage your acne is going to depend on how severe it is, or what class it is. People use the term acne quite broadly when in actual fact they are talking about an occasional breakout or an isolated pimple. For these people, pharmacy treatments and specialised skin care may be of benefit. Given that beginning medication will always come with inherent risk and potential side-effects a doctor may be reluctant to prescribe for people who are experiencing mild, transient skin problems. 

If you are suffering from acne the first step is to visit your doctor. The General Practitioner has a lot to offer in the way of acne treatments that most people don’t realise. Mild-moderate acne can be managed with GP treatments. Your doctor might consider a topical gel, knowns as retinoids, or an extended course of certain oral antibiotics. These work to remove existing pimples and prevent the onset of new lesions. The oral contraceptive pill can also be considered for female patients. This of course is less straight-forward as for some women this pill has strong side-effects and can actually worsen acne; it has a highly individualised response. Have an open conversation with your doctor about what the best course of treatment for you will be. 

If your acne is too severe to be managed by your GP, or if routine treatments haven’t worked, you may need a referral to a dermatologist for a stronger medication known as an isotretinoin. The brand name for this in Australia is generally Roacutane or Accutane. This is the only medication deemed to be able to ‘cure’ acne. After one course around 80% of individuals will not need a repeat dosing, and for those who do have a relapse of acne in the future a second course is often more effective than the initial dosing. However isotretinoins come with serious side-effects. Most are dermatological, including photosensitivity (or increased sensitivity to light and UV, dramatically increasing the chance for sunburn) and excessive dryness (leading to cracked lips, nose bleeds, dry eyes, etc). In writing these don’t sound too bad, but from my personal experience I can assure you it is a very uncomfortable period. Furthermore Isotretinoins have also been linked in some rare cases to psychiatric side-effects, including severe depression, which thankfully I did not experience. Before commencing this medication a proper assessment with the dermatologist is necessary, including a blood-test to assess liver function and a history of any mental health issues. 

For me, Roacutane cured my acne. After about 3 years of clear skin I had a small relapse and needed lower dose repeat and since then I have been acne-free. However this medication is not for everyone; what's important is starting the conversation with your doctor! With any acne treatment you are not going to see overnight success. Treatment will often span over months and it can take at least several weeks to notice any change. Be persistent and consistent with treatment; there are so many great management options and if you are willing to persevere with them it will be worth it. 

Other tips: makeup, squeezing pimples

If you wear makeup and know that you are prone to acne, health experts recommend using water-based products and ensuring that all makeup is removed at the end of the day. Leaving makeup on will clog pores and irritate the skin, potentially leading to breakouts. Also while it is very tempting to attack our skin and pop our pimples, it is also recommended not to squeeze acne. Squeezing acne can lead to burst blood vessels underneath the skin, bruising and scarring. Of course, the cosmetic effect of leaving a huge whitehead on your skin and the effect this will have on self-esteem is also an important consideration. I’d be a hypocrite if I said I wasn’t guilty of this but it is important to consider and also to be gentle with our skin. 

 

It’s very easy to wonder why, with all the health problems that exist, we should focus on acne at all. It is a self-limiting skin condition and not a potentially lethal epidemic like obesity. Obviously my personal experience has made me want to shed light on this condition. More than this, acne is the perfect example of Hot on Health’s self-care philosophy. It requires motivation to see the doctor and discipline with continuing treatment. When people see the effect on something external, like acne, it might give them pause to consider how focusing self-care on something internal or more complicated can lead to overall positive health impacts. 

“There is no healthcare without self-care.” 

-Nurse Robbie. 


Resources / Further Reading:

Ayer, J. & Burrows, N. 2006, ‘Acne: more than skin deep’, Postgrad Medical Journal, vol. 82, pp. 500 - 506. 

Better Health Channel 2016, ‘Acne’, Better Health Channel, Victoria, accessed 01 October 2016, < https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/acne>. 

Smith, E. V., Grindlay, D. J. C. & Williams, H. C. 2010, ‘What’s new in acne? An analysis of systematic reviews published in 2009-2010’, Clinical and Experimental Dermatology, vol. 39, pp. 119-123.