What is acne?

Acne is a common skin condition that mainly affects the face, but can affect the back, chest, and buttocks as well. It causes spots: whiteheads, blackheads, red bumps (papules) and pustules. It is very common in teenagers, triggered by hormone changes, and mostly resolves after a few years. Sometimes it can last several decades. Rarely it can start later in life, usually before the age of 40. It is not serious physically, but can be very distressing and impacts the quality of life.

What causes acne?

Acne is often triggered by hormonal changes especially at puberty. Oil-producing sebaceous glands at the base of hairs in the skin are sensitive to hormone balance. The oily secretions (sebum) naturally moisturise the hair and skin. In acne too much sebum is produced. It combines with shed skin cells and blocks pores, leading to blackheads and whiteheads developing. The acne bacteria (cutibacterium acnes) grow in the blocked pores and cause inflammation, pustules, often leading to cysts and nodules as well.

Is acne hereditary?

Acne does run in families. If your parents had acne, it increases the chance that you will, but most acne occurs sporadically, for no obvious reason.

How is acne treated?

Minimal acne

Greasy skin on the forehead, nose and chin (T zone) and a few black or white heads with or without occasional papules.

Use benzoyl peroxide, an over the counter medication available from your chemist. The full effects of acne treatments often take 4-6 months.

If benzoyl peroxide has no effect after 6-8 weeks, or if you have many spots (comedones or inflammatory papules or pustules), a prescription medication is more likely to help.

Mild acne

If there are mainly comedones (blackheads or whiteheads pictured below), then retinoids like Differin are particularly effective.

If rather than comedones you have angry red spots: pustules and papules (pictured below), try an antibiotic preparation. This can be topical (applied to the skin) for example Zineryt or more effectively systemic (taken by mouth) for example lymecycline. Other more effective options are combination products such as Duac gel (benzoyl peroxide 3% and clindamycin 1%) or Epiduo (benzoyl peroxide 2.5% and adapalene 0.1%).

Moderate acne

For moderate acne (more than 30 spots) systemic medication (taken by mouth) is likely to be required whilst continuing topical treatment. Antibiotics are used, such as lymecycline, erythromycin, clarithromycin, or trimethoprim. In addition, in women, hormonal treatments, usually as combined contraceptive pills or Dianette (an antiandrogen treatment), are an option. Continue to use Epiduo (benzoyl peroxide and adapalene) daily.

Severe acne

If you have many spots (more than 125), cysts or scarring (pictured below) your acne is severe. In this case please see your GP, you may benefit from referral to a dermatologist for treatment such as Roaccutane (isotretinoin).

See the Dr Fox stepwise acne treatment plan.

What is the difference between 'topical' and 'oral' acne treatment?

Topical treatment means any medical treatment that is applied straight onto the skin. Topical treatments for acne can be creams, gels or lotions and can include antibiotics as well as other treatments to reduce skin cell shedding and pore blocking.

Oral treatment refers to any medical treatment swallowed as tablets or capsules. Another medical phrase sometimes used instead of 'oral' treatment is 'taken by mouth'. Oral treatments for acne include antibiotics, Roaccutane (isotretinoin), and in women the combined contraceptive pill.

I keep dabbing my spots with lotion, but I still keep getting new ones, why?

Topical treatment is more preventative rather than curative in that it is to stop lesions developing rather than getting rid of the spots you already have. You should treat the whole acne prone area, not just individual spots. Treatment takes approximately 4 months to be fully effective and you may not see much improvement in the first few weeks.

What is the best acne treatment?

The best treatment is the one which works for you. Always start with the most simple treatments first. Try each treatment for at least 8 weeks before moving onto the next step in the Dr Fox acne treatment plan, if the acne has not improved.

How quickly does acne treatment work?

Using acne treatment requires patience! Treatments can take 8-12 weeks to have their best effects, as skin grows and turns over very slowly. If there is no response at all after 8 weeks then try a different treatment.

Will I grow out of acne?

In the majority of people, acne begins with the hormone changes of puberty sometimes from as young as 10 and it then lasts 5 to 10 years settling by their early 20s. However there are a few where it unfortunately continues into and through adult life.

My doctor diagnosed me with acne - I'm 30!

Acne is mostly a teenage condition, but adults can be affected too. It usually starts in adolescence and persists; however onset can also be later. Women are more commonly affected than men. This might be due to hormonal factors - acne varies with the menstrual cycle and pregnancy. Acne can be a feature of polycystic ovarian syndrome. The treatment is the same as for younger sufferers.

I'm 50, can these spots be acne?

Acne can start as a teen and persist for decades. It can also be a side-effect of medication. Steroids, lithium (a mood stabiliser) and ciclosporin (an immunosuppressant) can cause acne.

Will sunbathing improve my acne?

Sunbathing is not recommended, as sun damage is the major risk factor for getting skin cancer. However many people do notice improvement in their acne in the sun. This is because some wavelengths of light kill the C. acnes bacteria, thus treating acne.

UV light has been used as an acne treatment in the past, but is not common now due to concerns about skin cancer risk. Several studies show blue light treatment is effective. It is not widely used as there are more cost and time effective options. Lasers and photo dynamic light therapy are two other forms of light that can be used in acne management.

Sunlight contains all light wavelengths - those that help as well as damaging ones. Sunlight filtered through window glass is safer and may help with acne.

Also note that some commonly used medications for acne (retinoids such as Differin, adapalene in Epiduo, and lymecycline) make your skin more sensitive to light, making burning and damage more likely. If using them it is important to also apply a high protection factor sun cream, preferably non-oily, if sunbathing.

Does heat/hot weather improve acne?

Although sunshine (see Will sunbathing improve my acne?) can help, hot and humid conditions like tropical holidays, saunas, and hot steamy kitchens usually make acne worse.

Can I treat acne with toothpaste?

Although toothpaste does contain some substances which reduce bacteria, it also contains ingredients which will dry and inflame skin so it should not be used on acne.

Is acne infectious?

No. Acne cannot be transmitted to others. There can be a bacterial component to acne, but the organisms involved are already found on healthy skin as part of the normal skin flora. In acne, the bacteria grow excessively causing inflammation and infection in pores.

Should I stop eating chocolate?

Research in the 1960s compared acne in subjects who ate chocolate with those who ate other sweets of the same calorific value. There was no difference in acne, but there was no comparison to a low sugar diet. There is now increasing evidence that high intake of refined sugars in sweets, biscuits, cakes, etc can make acne worse, so it may help to stop eating sugary things like chocolate.

What is the best diet to help acne?

There is an increasing body of evidence that a low GI diet is beneficial in acne. Acne in teenagers is not a universal phenomenon, rather one of the developed world - populations in Papua New Guinea and hunter-gatherers of Paraguay show no teenage acne. It is thought that diet is the main reason for this difference.

See NHS - What is the glycaemic index (GI)?

Do hair products/cosmetics cause acne?

Acne is partly caused by excess oily sebum blocking the pores on the skin. Greasy and waxy hair products can further block pores, aggravating acne-prone skin. They should be avoided as they can worsen forehead and facial acne.

It makes sense to also avoid anything which increases the greasiness of skin, so choose non-oily cosmetics and skin products labelled as non-acnegenic or non-comedogenic.

Are there any medicines that make acne worse?

Yes. The medicines listed below are known to make acne worse:

• Lithium
• Ciclosporin
• Topical and oral corticosteroids
• Phenytoin and carbamazepine
• Isoniazid
• Progesterone in female contraceptives
• Vitamins B1, B6, and B12
• Anabolic steroids
• Iodides taken orally, which may be part of some homoeopathic therapies.

Can acne be caused by another medical condition?

Yes. There are a few conditions which cause a hormone imbalance which can cause acne. These include polycystic ovary syndrome, Cushing's syndrome, and other rarer conditions of excess male hormone. But in fact most acne is caused by natural (physiological) hormone changes.

My doctor told me to stop smoking - why?

Stopping smoking can help to improve acne as nicotine in cigarettes and e-cigarettes promotes comedone (blackhead and whitehead) formation.

Can I use treatment for acne whilst pregnant/breastfeeding?

Most acne treatments are not recommended in pregnancy. Simple benzoyl peroxide cream, gel or wash is safe, and Zineryt can also be used.

There is more choice when breastfeeding but products should not be applied to the chest area.

Acne treatment	Use in pregnancy?	Use if breastfeeding?
Benzoyl peroxide (not available from Dr Fox)	yes	yes
Differin	no	yes
Epiduo	no	yes
Duac	no	no
Zineryt	yes	yes
Lymecycline	no	no

Is stress causing my acne?

This is another controversial issue. It is not so simple, but there is some research showing mechanisms linking stress and acne. We know that acne is a side effect of steroid medication. The body increases production of cortisol, a natural steroid, in response to stress.

Decreasing stress is difficult but is almost always beneficial to health.

There is a lot of documentation regarding acne as a source of distress, low self-esteem, and misery.

I keep washing my face so it is really clean - why is my acne no better?

It is a myth that acne is caused by dirt. Blackheads are not due to poor washing. Frequent washing and scrubbing too hard can irritate skin as the natural oils are stripped away and so it will actually make acne worse.

Cleanse your skin and remove make-up with a gentle, neutral or slightly acid, cleanser and water, or an oil-free soap substitute.

Can I use makeup with acne?

Yes. Wearing makeup can help to disguise acne and can help with self confidence. Avoid oily cosmetics which can further clog pores and aggravate acne. Use products which are labelled as non-acnegenic or non-comedogenic.

Make sure that all makeup is removed at night and before applying acne treatments.

How can I prevent scarring?

Treatment of scars is not easy, so that's a good question. Prevention is better than cure. Early treatment is recommended, before scarring occurs.

Also please do not pick or squeeze spots. This can cause further inflammation and damage, increasing the risk of scarring.

If acne is severe or is beginning to show signs of scarring, consult a GP to discuss referral to a dermatologist to consider prescription of Roaccutane (isotretinoin).

Why can't I get Roaccutane?

Consultant dermatologists only can prescribe Roaccutane for severe acne through hospitals. Roaccutane capsules containing isotretinoin are very effective for treating severe acne. Unfortunately isotretinoin can have severe side effects, including damage to an unborn child, sexual dysfunction, low mood, suicidal ideas, self-harm, and even in very rare cases, suicide. For this reason its use needs very careful monitoring, including blood tests and also use of extremely reliable contraception.

See NHS - Isotretinoin capsules (Roaccutane) and British Association of Dermatologists - ISOTRETINOIN.

What treatment is there for acne scarring?

Some markings due to acne will fade with time, especially residual red colouring or shallow depressions.

Scars are more likely to develop if you pick or squeeze spots, or have cysts and nodules, with the acne.

Unfortunately there are no treatments available on the NHS for severe scarring from acne.

Acne scarring is split into 3 types:

• Ice pick scars like deep holes.
• Rolling scars with bands of scarring under the skin surface.
• Boxcar scars like craters or depressions.

The different types of scar respond best to different treatments. No treatment can completely remove scarring but the appearance can be improved. There are many clinics and practitioners offering scar treatments and it is important to check their qualifications carefully and if possible look for CQC or professional body registrations.

See NHS - Choosing who will do your cosmetic procedure.

Treatments used can include:

• Laser resurfacing
• Dermabrasion
• Steroid injections
• Microneedling
• Subcision
• Punch excision, elevation or grafting for ice pick or boxcar scars.

Sometimes learning about makeup camouflage techniques can help significantly.

See also NHS - Complications, Acne.

Should I squeeze spots?

You should not squeeze spots as this can cause scarring. If you must however, there is further information here: How to properly extract a pimple.

Acne treatment