Acne treatment

Many people suffer from acne, a skin condition which occurs mainly in teenagers and adolescents but which can also affect adults. It occurs in both mild and very severe forms, and while it is not contagious, it can be cosmetically disruptive due to the acne marks it leaves, and have a considerable impact on the social and psychological wellbeing of those who suffer from it.

Acne is a skin condition in which the sebaceous gland follicle becomes inflamed. The condition manifests itself mainly where the most active sebaceous glands are located, namely on the face in the so-called T-zone (forehead, nose and chin), back, neck, throat and shoulders.

During puberty, the body produces more hormones, including androgens, which are responsible for the growth of the sebaceous glands and the production of more and thicker sebum. Every sebaceous gland has an opening called a pore, from which sebum can escape. Sebum, which keeps the skin and hair supple and oily, is water-repellent, protects against dehydration and moisture loss of the skin and increases its resistance.

Thicker sebum combined with dead skin cells can clog the pores, however, and this can cause blackheads. A blackhead, or comedo, can have a black or a white spot. Those with a white spot are deeper and can close off the entire pore. In addition, there is a keratosis (scaling over) of the excretory duct of the sebaceous gland, which further clogs up the pore. The sebaceous glands contain bacteria that convert the sebum into fatty acids. Due to the accumulated sebum and the irritating fatty acids, the clogged sebaceous gland follicle expands further and further and eventually bursts open. The irritants enter the adjacent skin and cause inflammation, resulting in acne, i.e. spots and pimples.

The occurrence of acne or its worsening can also be influenced by:

• Genetic factors (it runs in the family);
• Hormonal factors (menstruation and pregnancy);
• Polycystic ovarian syndrome or cysts on the ovaries;
• Stress;
• Cosmetics;
• Friction with clothing;
• Strong climate change.

Acne occurs in many different forms. Common ones include:

• Acne vulgaris (the most frequent):
  Comedones, spots and pustules occur simultaneously and to varying degrees.
• Acne comedonica:
  Mild acne in which comedones rather than inflammations or blackheads are the main focus.
• Acne conglobata:
  This type is accompanied by very severe inflammations with giant and double comedones, nodules and cysts, usually creating acne scars. This occurs mainly in young men and can continue into their adult lives.
• Acne excoriée:
  In this form, acne is exacerbated by scratching or squeezing out each pimple or comedo, resulting in acne scars on the face or back.
• Acne tarda:
  This is the same as acne vulgaris except that it affects adults and acne vulgaris does not go away after puberty.
• Acne ectopia or hidradenitis supperativa:
  A type in which pimples in the groin or armpits are caused by an inflammation of the hair follicles as opposed to the sebaceous glands.
• Acne fulminans:
  A rare severe and acute outbreak of acne accompanied by a general feeling of illness. It includes inflamed pustules that develop very quickly into open wounds and sores accompanied by fever, malaise, blood disorders and muscle and joint pains in the limbs.

Acne is usually found in the face in what is known as the T-zone (the forehead, around the nose and the chin), but also on the back, chest, shoulders, neck and throat. It can manifest itself as follows:

• Blackheads or comedones: 
  Open black comedones with a black clot of dried secretion in the pore or closed white comedones with a white spot
• Pimples or spots: 
  A sharply defined solid elevation of the skin.
• Pustules: 
  A visible cavity in the skin with purulent moisture (pus).
• Subcutaneous inflammation, nodules and cysts: 
  A nodule is a sharply limited tangible resistance in the skin or in the subcutaneous tissue, which may or may not be elevated above the skin and generally heals with scarring (an acne mark). A cyst is a closed cavity filled with fluid, cells or cell products.

These symptoms occur in varying combinations and in different degrees of severity depending on the form of acne. When acne is no longer actively present, side effects such as acne scars and stains may be visible.

If treated properly, acne can decrease or disappear. Clean your skin once or twice a day with lukewarm water – do not use soap, or rub or exfoliate your skin. Do not squeeze your blackheads, pimples or spots: this will only exacerbate the condition and may also cause acne scars. Do not smoke as this has a detrimental effect on your skin. Although healthy eating, drinking enough water and moderate alcohol consumption will not directly affect acne, it will certainly not exacerbate it. Be careful with make-up, as some products clog up the sebaceous glands and aggravate or cause acne. Take a lukewarm shower after exercise, as sweating combined with friction with clothing can exacerbate acne. Moisturising cream can also help.

Despite all of the measures mentioned above, more thorough acne treatment may be required. The treatment of acne depends on the severity of the condition.

A first possible step in the treatment of acne can be deep cleansing, where black and white comedones are removed using a thin, small needle. The purpose of deep cleansing is to reduce inflammation and prevent scarring.

Medicines are prescribed to remedy the acne as soon as possible, with different ones depending on whether the condition is classified as mild, moderate or severe. The mild form has comedones and almost no inflammation, the moderately serious form has a mixture of comedones and inflammatory reactions in the face, while the severe form has many inflammatory reactions or a mixed pattern of comedones and inflammatory reactions on the torso, or acne congoblata, with scarring or hyperpigmentation.

For mild forms, acne treatment directly on the skin is the appropriate method. In moderate and severe cases, medication is the best form of acne treatment. Dealing with the psychosocial experience can also be part of the acne treatment (see “Psychosocial well-being” below).

Always read the leaflet carefully before you start taking any medicine. Do not use antibiotics to which you have had a previous allergic reaction, and always complete an antibiotic course unless you have allergic reactions.

Products that can be used include benzoyl peroxide gel, adapalene gel and tretinoin cream. These loosen the top layer of the skin, making the pores less likely to become clogged. A gel is more suitable for oily skin, an acne cream for drier skin.

Then there are antibiotics applied to the skin (locally) including clindamycin solution/lotion or gel, erythromycin solution, clindamycin/benzoyl peroxide gel and clindamycin/tretinoin gel. Antibiotics for acne are combined with skincare products, making the acne treatment faster and more effective while preventing or reducing the bacterial resistance.

Antibiotics for acne can also be taken orally – these are doxycycline (not recommended for pregnant or breastfeeding women) and erytromycine. The contraceptive pill can also be a solution for women wanting to use birth control. Although the pill is not a direct treatment for acne, it can have a positive effect. The results vary, and if one contraceptive pill does not help against acne, another type can be tried.

Finally, isotretinoin can be prescribed should other oral antibiotics prove not to be working against moderate acne. Any products applied directly to the skin are then no longer needed.

In combination with medication, a microdermabrasion treatment – in which the top layer of skin is removed with crystals – can be considered. Acne treatment with medication and microdermabrasion is aimed at calming, counteracting and reducing the acne. It will not disappear overnight, but may eventually heal.

Acne scars

Any kind of acne can leave acne scars. They show that the body has repaired the damage to the skin in that place, but with a different structure to ordinary skin, which makes it stand out. Over time, acne scars become less visible, and there are several methods of treatment for acne scars:

• Chemical peeling:
  The epidermis is removed by an etching liquid.
• Laser treatment:
  The epidermis is burned off layer by layer.
• A combination of sandblasting, tretinoin cream and laser:
  This has a beneficial effect on the acne scars by increasing the subcutaneous connective tissue.

Research the various acne treatments and find out the best place to have them carried out.

Having acne can greatly reduce the quality of life, as the resultant shame and grief that people feel can be enormous, making them insecure, lacking in self-confidence, dejected and even depressed. If these feelings prevail, do not hesitate to consult your doctor and if necessary, ask for a referral to a psychologist and/or dermatologist.

Always read the leaflet of the medicines you are prescribed. Do not use antibiotics to which you have previously had an allergic reaction. Always complete an antibiotic course, unless you have allergic reactions.

• Bleaching:
  Benzoyl peroxide can have a bleaching effect on clothing, bedding, metal, hair and eyebrows.
• Hyperpigmentation (dark spots in the skin):
  Benzoyl peroxide and tretinoin can irritate the skin, increasing the risk of hyperpigmentation. The risk of hyperpigmentation is greater in people with dark skin. People with sensitive or dark skin should use the acne treatment every other day and use a sunscreen with a minimum factor of 15 in the summer.

Pregnancy and breastfeeding:

Do not use the following acne treatments when pregnant or breastfeeding: adapalene, tretinoin, clindamycin/tretinoin gel, doxycycline and isotretinoin.

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Apotheek.nl (Last updated KNMP: 29-09-2017). What medications are used for acne? Consulted on 23 April 2019 from https://www.apotheek.nl/klachten-ziektes/acne#welke-medicijnen-worden-gebruikt-bij-acne

Dr. Njoo D (z.d.). Acne. Consulted on 23 April 2019 from https://www.huidarts.com/huidaandoeningen/acne/

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NHG (z.d.). Acne summary map. Consulted on 23 April 2019 from https://www.nhg.org/standaarden/samenvatting/acne

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Skin care Royale (z.d.). Acne ectopia. Consulted on 23 April 2019 from https://huidzorgroyale.nl/huidproblemen/acne/acne- ectopica/

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