Beginning acne

General aspects
Acne is a frequent disorder which affects approximately 80% of adolescents in varying degrees. On the whole it is a benine disorder, however its psychological impact can be important and is not necessarily correlated with the objective severity of the lesions, especially as acne develops at an age when the childʼs personality is developing.
Acne can last for a long time, there can be very severe cases and there is a risk of permanent scarring.
For all these reasons acne must be carefully managed. The current treatments provide improvements in all patients. If the treatment is initiated as the acne starts this will limit its evolution and the consequences.

Pathophysiological factors

Acne is an inflammatory disorder of the pilo-sebaceous follicles of the face and trunk.
Its pathophysiology associates three mechanisms:

Hyperseborrhea
The follicles in areas affected by acne have highly developed sebaceous glands. The secretion of sebum is dependent on androgenous hormones (testosterone, delta-4 androstenedione, DHA sulphate), in men as well as in women. Patients with acne have normal circulating hormone levels, but their sebaceous glands react in an excessive
manner. It is important to know that hyperandrogeny syndromes can include acne but are also associated with other anomalies (hirsutism, alopecia, menstruation problems, hypertrophy of the clitoris, changes in voice and musculature, signs of hypercorticism). In the presence of isolated acne, no endocrine (or any other) follow-up is indicated.

Anomalies of the keratinisation of sebaceous canals
In acne follicles, there is an increase in the keratinisation of the epithelium which leads to the obstruction of the excretory channel and a sebaceous retention. This retention can
manifest itself as a closed comedon (white head or microcyst), or a widening of the canal forming an open comedon (black head). At the stage of beginning acne,
hyperkeratinisation is involved.

Inflammation
We use the term beginning acne when the lesions are not significantly inflammed.

What needs to be done!

Be sure of the diagnosis as every eruption of the face is not acne
Acne starts before the onset of adolescence (sometimes at the age of 8-9 years), or a little later on. The first lesions appear on the upper part of the face, forehead, temples and nose. These lesions, that are characteristic of beginning acne are the direct clinical translation of sebaceous retention: Which involve comedons:

  • True comedons or open comedons or black heads. They can vary in size, can be a simple increase in the size of follicular orifices or a dilation which holds a black keratin plug (oxidated). The presence of comedons leads to a diagnosis of acne.
  • Microcysts, or closed comedons. These are small raised mounds like a white or yellowish pinhead under the skin. The follicular orifice is barely or not at all visible.

At the stage of beginning acne, there are hardly no inflammatory lesions (papules or pustules).

Setting up the treatment, which is mainly local
Usually the treatment includes the association of a keratolytic agent and an anti-infectious agent:

  • Keratolytic (or comedolytic) agent: These are retinoids (vitamin A derivatives) and mainly retinoic acid. It is usually applied as a cream at 0.05%. Retinoids are often slightly irritant.
  • Anti-infectious agent: benzoyl peroxyde, in gel form at 5% or 10% and antibiotics: erythromycine and clindamycine.

 

It is common practice to prescribe retinoids in the evening and the anti-infectious agent in the morning. Some treatments contain both active agents in one product.
The local treatment alone is often sufficient in beginning retentional acne. In inflammatory acne, it is often necessary to add an oral antibiotic.
Oral isotretinoin, a treatment for severe acne, is not recommended in these cases.
If a contraceptive method is requested by the patient, this must include non-androgenous progesterone.
If the retentional lesions are numerous, dermatological cleansing of the skin, which involves removing the comedons, can be of great help.

What needs to be said

Reassure against distressing false beliefs
It is necessary to listen to the adolescents and their parents to know what they think of the acne and to reassure them on a number of issues:

  • Acne is not linked to sexual activity. Of course it is a disorder which affects adolescents and adults, but they are going through a perfectly normal puberty and their potential sexual activity will not affect their acne.
  • Acne is not linked to the food we eat. However, it is probably better to eat a balanced diet with no excess sugar or fats.

Provide support and guidance during the treatment
The treatment is long and keeping to it can be difficult. The patients must be encouraged and we must explain to them that a regular treatment is necessary. It must become a habit just like brushing our teeth.
A consultation before the end of the first month will ensure that the treatment is well tolerated and applied, is an opportunity to answer questions and to detect any tolerance problems. Anti-acne treatments especially retinoids can cause irritations. It is rarely an important problem, but we can suggest spreading out the applications, every other day for example, and to calm the irritation with a specific moisturising cream for patients with acne.
Add some good advice
Remind the patients that they must not manipulate the spots because this will considerably increase the risk of scarring.
We can provide advice on cosmetic products: gentle washing, with non-irritant products, and if necessary recommend the use of moisturising creams designed for oily, hyperseborrheic skins. Young girls are allowed to wear make-up if they wish too because this will improve their moral and hide the lesions. This make- up however must be light, and specific for oily skins with acne.
Sun exposure is authorised with moderation. Sun creams, like any other cosmetic products designed for patients with acne, must be specific for oily skins so as not to form comedons.
Know when to move on to a more effective treatment if necessary
After three months of local treatment, the lesions should have decreased by half or three quarters, sometimes more. If the result is insufficient despite this treatment then you must move on to the next stage which is the oral treatment. It is important to see the patient to give them the new prescription and to not give them the impression that we are no longer interested in their acne.
However, if the treatment is effective, it should be prolonged over a couple of months, explaining to the patient that the tendency to acne lasts a long time, always longer than we would wish for. It is difficult to determine an age when the acne will stop without being discredited by its natural evolution. It is better to advise an efficient long-term treatment.

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