Acne, without a doubt, is a teenager's most despised problem. Acne pimples, cysts, blackheads and whiteheads can ravage a young person's skin and destroy self-esteem. The best time to begin acne treatment is as soon as it becomes evident. Acne usually progressively worsens if untreated. Prevention and control is preferred - before acne has had a chance to take over and cause scarring and psychological damage.

NOTE: Acne is the most common skin condition in the United States. Though common, accurate information about acne can be scarce. This can make it difficult to get clearer skin.

Acne affects approximately 80% of the population. It's an inherited skin condition that is controlled by prescription medications, hormone therapy, topical products, light therapy such as Blue Light and in the more difficult cases, the use of Photo Dynamic Therapy.

Types of Acne

Most people aren’t sure about this, but it’s important so you get the right treatment. If you’ve got severe acne, using a treatment for mild acne isn’t going to give you the results you want.

A clogged pore becomes infected by bacteria, causing a red, raised bump on your skin.

A doctor or dermatologist can usually tell you what type of acne you have by simply observing the number, type and depth of the acne spots. A suitable course of action can then be made, based on the doctor’s observation.

Acne Treatment

Not just teens have acne. A growing number of women have acne in their 30s, 40s, 50s, and beyond. Dermatologists are not sure why this is happening. But dermatologists understand that adult acne can be particularly frustrating.

There are a few key steps to good skin care, which is important for everyone with acne.

Using the right skin care products can make a big difference in your acne control, promote skin health and help keep your skin looking young. With the huge number of skin care products and ranges available, choosing the best products for your acne and skin can be confusing.

Start by getting information from someone you can trust; someone who is trained in this area. Your pharmacist, general practitioner or dermatologist are good people to speak to for guidance in choosing the right skin care products to help control your acne, plus avoid treatment related problems.

Don’t base your skin care only on how good the skin of a well-paid, Photoshop edited model or celebrity appears in an acne product advertisement.

The best skin care routine for acne-prone skin is to:

• Cleanse
• Treat
• Protect

Follow these skin care steps and recommendations - unless your health professional says otherwise. They'll help you to achieve greater benefits and avoid acne treatment problems.

Mild Acne

f your acne condition is limited mainly to whiteheads and blackheads, you probably have mild acne, especially if the lesions do not cover large areas of the face or body.

A whitehead occurs when the opening to the pore is closed off and the hair follicle fills with oil and dead skin cells.

A blackhead occurs when the opening to the pore is blocked by a dark plug of oil and dead skin cells. A chemical reaction causes the surface to darken and form a blackhead.

Early treatment and regular preventive skincare can reduce mild cases of acne.

Anti-acne treatments available without a prescription at pharmacies or on supermarket shelves can help control mild acne.

Moderate Acne

If you have papules (raised reddish bumps) or pustules (the same raised reddish bumps but with white centers) you may have moderate acne, especially if the lesions are widespread across the face or body.

Breakouts last longer than in mild acne and often do not go away.

If over the counter products are not working and you think you have moderate acne, you should visit your doctor who can decide if you need a different treatment or if you should be referred to a dermatologist.

When moderate acne is not treated early enough, it can leave a permanent scar on the skin, so it’s good to get in early with the right advice.

Severe Acne

If you have large, deep, solid and painful lumps or cysts under your skin, you may have severe acne.

The breakouts cover large areas of the face or body and last longer than in moderate acne, often not going away for months or years. It can have a huge impact on self-confidence and self-esteem, leading to anxiety and depression.

Severe cystic acne will not usually respond to over the counter skincare products available at pharmacies or from supermarket shelves. However, people with severe cystic acne should still follow general advice for managing acne.

Untreated, severe acne can cause permanent and disfiguring scars.

If you have severe acne, your doctor may refer you to a dermatologist for assessment and further treatment.

Severe acne can prevent a person from doing many things they usually enjoy because of a concern about their appearance and the opinion of others.

Pregnancy Acne

Not all pregnancies have an impact on acne but if you have hormonal acne, it is likely to flare during the first trimester (three months) of your pregnancy. Fortunately, your acne will probably then improve and may even disappear during the last trimester. Breast-feeding is also an excellent way of keeping acne away. Many females with persistent acne also notice that their acne is progressively less severe or disappears with subsequent pregnancies.

Treatments

If you are pregnant or planning to conceive, you should avoid the following treatments:

Topicals

Retinoids (tretinoin, adapaline, isotretinoin, tazarotene)

It is known that taking high levels of retinoids, such as isotretinoin, by mouth carries a high risk of birth defects. As such, this has led to a broader recommendation that no one who is pregnant or planning to become pregnant should use creams containing retinoids. If you find out that you are pregnant and have been using a retinoid cream, you should stop using the cream immediately.

If you have been taking retinoids while you were pregnant do not immediately assume the worst. Findings from a study of a large number of pregnancies where the mother was exposed to topical retinoids, along with data from studies looking into the absorption of retinoids after use of topical cream on the face, suggests that you have not exposed your child to any extra risks. However, as retinoids are known to cause birth defects, it is important that you discuss this issue with your doctor.

Oral

Tetracycline antibiotics which include doxycycline and minocycline should be avoided. Isotretinoin should be avoided.

Spironolactone

If you discover you have become pregnant while taking spironolactone, you should stop the drug immediately. Reassuringly, there is no evidence of any risk of harm if it is taken inadvertently during the first few months of pregnancy. It does not cause birth defects but if taken during the last few months of pregnancy, it could interfere with the normal development of a male child, due to its effects on male hormones.

Hormonal Acne

Acne is not just a teenage problem. Many women are surprised and distressed to still be affected by acne in their 20s, 30s, occasionally their 40s and/or at the time of menopause.

This type of acne usually begins in the early 20s and can affect individuals who were blemish free during their teenage years.

Unfortunately, because acne is such a visible condition, hormonal acne can still have a detrimental affect on a person's self-confidence, mood and well-being. Even mild acne can have a big impact on older women.

Adult acne is not the same as teenage acne which is usually more severe in the oilier facial areas including the forehead and central face. Hormonal acne more prominently involves the jaw line and chin area / lower face and neck. These skin areas are more sensitive and easily irritated.

NOTE: Hormonal acne ranges in severity.

It may be confined to a few small red papules and pustules on the chin which appear during the premenstrual phase of your menstrual cycle, especially if you are stressed. Others have more severe acne with deeper, tender nodules that can appear at any stage of the menstrual cycle and can result in permanent scars. It can be on your face and neck as well as your trunk and shoulders.

Adult females with persistent oily skin will usually have normal hormone levels and skin that will age well. Testing is worthwhile in females with persistent 'seborrhoea' (the medical term for overly oily skin) as some will have hormonal changes warranting treatment.

Hormones (and stress) are also responsible for acne that flares up during the first half of pregnancy or the peri-menopausal period.

Treatment

Adult acne will usually respond to acne treatments used for teenage acne including medicated creams, gels and oral antibiotics.

If you have more severe acne, if your acne fails to respond to topical therapy or if you can't tolerate topical treatment, there are other alternatives. The combined oral contraceptive pill, plus or minus anti-androgens such as spironolactone, may help achieve longer-term acne control.

Polycystic Ovary Syndrome

If you have PCOS then acne is almost always a problem. Some times are worse than others, particularly when you have your period, times of stress and illness, excess chocolate consumption, weight gain and pregnancy.

The word 'polycystic' means lots of eggs in the ovary waiting to hatch that are in hibernation. The release of these eggs is triggered by pituitary hormones and in PCOS there is faulty triggering.

A third of people with polycystic ovaries are born with faulty luteinising hormone (produced by the pituitary gland in the brain) release. The other two-thirds are not releasing their eggs because they are too young (puberty), too old (menopause), too thin (anorexia) or too stressed (lifestyle).

The eggs (ova, hence ovulation) ripen over three months, but the follicular cyst (bag of fluid containing the ova) doesn't burst. This cyst then shrinks but the cells around the now smaller cyst release excessive amounts of male hormone - hence the hair, pimples, menstrual problem, bulking up and mood problems. Sugar and insulin issues are a result of this (insulin resistance and diabetes). As a result, there is a cumulative effect, worsening with each month, particularly if more weight is gained.

Ideally doctors like to stop the accumulating cycle as early as possible in the teenage years. Because the likely cause is a genetic defect, control is achieved by blocking the excessive male hormone with medication. Most women do well with an anti-diabetic drug called metformin.

Most oral contraceptive pills contain a hormone that breaks down to testosterone and so expert advice as to which pill is suitable is essential.

Natural therapists, despite their claims, have yet to produce any research evidence that natural therapies do help in PCOS.

The doctor is the first place to get help. He or she may then refer you to a gynaecologist or even an endocrinologist.

PCOS is manageable. A simple history taking, ultrasound and hormone blood tests provide the answer to best treatment.

Acne Scars

Scarring can be prevented with early, effective treatment of moderate to severe acne. A scar is a permanent mark left after the healing of an injury or disease process.

Damage to the surface and underlying layers of the skin can be extensive, following moderate to severe acne. This can result in flat or thick raised scars, discolouration and pitted, indented skin.

Some scars improve over time, others remain unchanged and some can continue to worsen with time.

While some scars can be disguised with makeup, scars remain a permanent reminder of previous acne.

If there is a family history of scarring acne, early treatment and review by a dermatologist should be considered.

TIP: Picking or squeezing of pimples can also be a cause of scarring.

Different scars require different treatments. Some of the treatment options for scarring include:

• Skin resurfacing and other lasers and non-laser treatments
• Injectable fillers or implants
• Steroids
• Surgery

Acne Scars Treatment

Lasers

Fraxel laser

In the future, Fraxel laser may be regarded as the "new gold standard" for treating acne scarring.

The Fraxel laser gets down very deep into the skin to stimulate a healing and smoothing response, without actually creating an open wound.

Fraxel is an erbium-glass laser that works by putting pixels of energy into the skin, rather than vaporising the surface (as traditional laser resurfacing has done).

It therefore doesn't create a wound, although there is some swelling and redness after the procedure; the majority of which goes in few days.

A series of Fraxel laser procedures is required and the skin continues to improve over at least six months afterwards.

Skin Resurfacing

Carbon dioxide or Erbium lasers are used on a variety of scars to carefully remove a controlled amount of the damaged outer layer of skin. It leads to the repair of the surface layers and can stimulate new collagen formation. Collagen provides structure and strength to our skin.

Skin resurfacing can soften the scar, even out discolouration and produce a smoother and tighter appearance

For acne scarring, lasers have largely replaced earlier resurfacing techniques such as chemical peels and dermabrasion.

New treatments using "non-ablative" lasers to stimulate new collagen production do not damage the top layer of the skin and may be used for soft, indented scars.

Plasma Resurfacing

Plasma resurfacing seems to not produce the hypopigmentation (bleaching) associated with resurfacing with lasers and deep peels.

Plasma resurfacing uses high-energy nitrogen plasma to cause the top layers of skin to shed and create a new surface for the skin.

Unlike laser resurfacing, the old skin surface stays in place until the new layer grows underneath, so no open wound is created (unless it is scratched off). The new skin continues to transform for months afterwards.

The new collagen formation has a more natural layout compared to that following laser resurfacing and peels.

To date, there has been no incidence of hypopigmentation of the skin, which had been a significant problem with the sort of deep resurfacing required to treat acne scarring.

Fractional Laser Treatment

Fractional laser treatment, sometimes also known as fractional resurfacing or "Fraxel" is a treatment for improving skin texture and blending-in imperfections such as acne scarring.

Beams of laser light penetrate pixel-fashion very deeply into the skin causing remodelling in all layers down to the depths of the scars. A series of treatments is required, each causing redness and swelling for up to a week. The skin surface is not removed, unlike previous laser resurfacing techniques, so no dressings or special ointments or skin care is required. Regional treatments are also possible as the skin is not abnormally lightened as can occur with other resurfacing techniques.

The treatment is usually conducted after anaesthetic cream has been applied for quite some time (over an hour) or local anaesthetic has been injected.

Non Laser Treatment

Photodynamic therapy

Photodynamic therapy or PDT is a treatment which is most usually employed for treating superficial skin cancers and precancerous lesions; however it may also be used for treating acne and some inflammatory skin conditions.

After a microdermabrasion treatment which removes cell build-up from the skin's surface, a solution containing a special solution or cream containing aminolevulinic acid (ALA - an amino acid - building block of protein) is applied to the skin for about an hour. This is taken up more readily by the inflammatory cells and oil-producing glands and makes them more sensitive to light.

After this incubation time, light is applied to the area. This is usually a continuous blue or red light but may be an intense pulsed light or a laser. As the acne areas will have taken up the ALA more than the normal skin, they will be selectively treated. These areas usually flare up for a week or so and then settle. A series of treatments is usually required.

The normal skin surrounding the acne areas becomes sensitive to light for the following two days, so this means that bright light needs to be kept off the area during this time. For body areas, clothing is usually sufficient to do this, however for the face, it usually means staying indoors and keeping away from TV and computer screens and windows where the sun shines in.

This procedure is quite expensive so is usually not considered as a first option.

Micordermabrasion

This is a treatment that gives the skin a "cut and polish and a vacuum clean". It has a superficial "buffing" effect which smooths the surface and the suction cleans out comedones and pustules. A series of treatments is usually performed.

For acne, it is not regarded as a stand-alone treatment but may be used in association with topical or oral medications.

For acne scarring, it would only be considered for the most minor of conditions.

Fillers/Implants

Indented scars can be plumped out with commercial products injected into the skin.

Hyaluronic acid (Restylane and Juvederm) has largely replaced collagen because of its longer lasting benefits.

Fat cells and tissue grafts can also be transferred from another part of the body.

However, these techniques do not result in a permanent improvement and may have to be repeated or touched up.

Steroids

Raised and thickened scars may be softened and flattened by the use of steroids either applied to the surface of the skin or more commonly injected into the scar. Recently, fluorouracil (an anticancer drug) has been successfully used to flatten scars by being injected into the scar.

Surgery

Deep "punched out" scars can be cut out and closed side to side with stitches, while large raised scars may be improved by surgically removing them. Surgery may be performed prior to laser resurfacing which can sometimes help blend in and hide the surgical scars.

Subcision or freeing up of an indented scar is a valuable procedure when the scar is bound down to underlying tissues. Other so called 'punch' techniques include punch grafts - where a small graft is used to replace the scar or punch elevation - where the scar is punched and lifted up to a higher position in the skin.

Blue Light Therapy

Narrow band blue light phototherapy is well known as a method of reducing jaundice in newborn babies. Now it is seen also as having a promising role in treating mild to moderate acne but from a medical and scientific viewpoint, blue light therapy remains an understudied, investigational acne treatment, ie - more research is required to demonstrate it has a proven safety track record and identify its long-term effects.

How it works

Blue light therapy involves directly exposing the entire skin area affected by acne to either a continuous or intense pulsed light which has been shown to have anti-bacterial and anti-inflammatory effects. A typical treatment requires two sessions per week over four to five weeks.

It is rare for blue light to be used in isolation and it is usually combined with either topical or oral medications. Some blue light devices also use a radiofrequency current which is thought to get a little deeper into the skin and have greater affects on the sebaceous (oil) glands.

Sometimes blue or other lights are used in conjunction with another topically applied medicine which increases the sensitivity of the acne lesions to the effects of the light. This is called photodynamic therapy (PDT). However, PDT makes the skin extremely sensitive to light for the following two days, so it means staying indoors away from bright lights for this time.

Risks and Benefits

The limited studies conducted to date for blue light therapy suggest it is more likely to have a role for controlling an acne flare in an adult with mild to moderate acne. These studies observed that by four weeks into treatment, the majority of people with mild to moderate acne noticed some degree of improvement in their acne.

Inflammatory acne lesions (red raised and/or pustular pimples) are reduced more than blackheads and whiteheads. In some cases, acne was reported to completely clear.

However, about one in five people will see no benefit from four weeks of treatment and may even see their acne worsen in severity.

Blue light therapy does not appear to produce extended acne remissions. In one study, the benefits of a topical antibiotic treatment were greater than those for blue light therapy four weeks after stopping treatment.

There is very limited safety data regarding blue light. They come from a few controlled studies which followed only a very small number of patients over a relatively short treatment course (e.g. eight treatment sessions over four weeks).

The results of one study suggest blue light therapy should be avoided in severe forms of acne because it was observed to worsen patients' acne after starting treatment.

As with any therapy, there are risks involved. Unfortunately, there is only limited information about the short-term side effects and risks with even less known about blue light's longer-term safety.

Side Effects

During treatment and in the weeks following therapy, some people will be affected briefly by:

• Redness and swelling of treated areas
• Skin dryness
• Skin pigment changes (uneven or blotchy increase in skin pigment)
• Worsening of acne (possibly more likely to occur in people with severe acne)
• Photosensitivity (sensitivity to light)
  

Long-term side effects

Sunlight is known to have a number of harmful effects on the skin which can be delayed for years or decades after excessive exposure.Although there is no data on the long-term skin effects of repeated exposure to intense blue light, potential concerns include:

• It may contribute to skin cancer risk.
• It may cause photo-ageing of the skin.
• It may suppress the skin's immune system.
  

Considerations

When choosing an acne treatment, look at what is known about the long-term safety and risks of each therapy. Acne affects 85 per cent of Australians aged 15-24 years and can continue for many years, with many females still affected in their 30s and 40s, so safety is paramount in the treatment of acne in an otherwise young and healthy individual who may need to continue treatment for many years.