Hi everyone. I'm back for my weekly VLOG and today I'm going talk to you about
acne. And this time, not because I've got any personal experience of acne,
because I'm lucky I've never had it. However I see enough patients in GP and
more worryingly more in my aesthetics clinic who are coming to me either
terribly distressed by their acne or terribly distressed by their scars, and
looking for solutions for the scars when the damage has already been done. So
let's get going!
So what is acne? Well it's a really common skin condition and
it's caused by a combination of three things;
blocked hair follicles, the overproduction of sebum (which is like an
oil in your skin) and a bacteria. It affects all races ages and sexes, so for
once it's not a disease of one particular type of person. It affects
mainly the face but can also spread onto the back, the chest, the buttocks and
thighs. And it primarily is made up of six particular spot types. So blackheads,
called open comedones. Whiteheads, called closed comedones. Pustules which have pus
pus inside. Nodules, which are hard lumps under the skin. Papules which are red
lamps under the skin and cysts which are pockets that form within the skin and
contain a combination of sebum, bacteria and pus essentially. So any combination
of those can be seen and the most important thing to know is that it's a
really distressing and stigmatising disease. And we'll come on to why that's
so important in acne later. So who gets acne? Well it is the most
common skin disorder which I found surprising because I would have thought
it was eczema, but it's acne! Almost everybody will have suffered from acne
at some point in their life, but obviously some suffer more than others.
It's a disease of the young and generally we see it between teenage
years and about the age of 30. However, even though we see 80% of acne
in that age bracket there are people that have acne that extends into
adulthood. The good news is that less than 3% of men and 12% of women, keep
their acne into adulthood. That's still a lot of people though that
do keep it. So what are the causes? Well again, as with so many things in medicine,
we don't absolutely know. We do know there's a genetic risk. We know that we
it's hormonally mediated in some people; obviously testosterone in men, but other
hormones in women, including testosterone. We know that pregnancy can aggravate it.
So it can either get better or worse in pregnancy, so again hormones playing a
role. Some medications can cause it. And some products and face washes makeups
etc can actually aggravate it. We also see it in puberty, that's the most common
place to see acne. So looking at the hormones, the main villain in the hormone
list, is testosterone and that's in both men and women. So obviously at puberty.
Boys get a massive surge in testosterone and girls sometimes get a surge but
there's other reasons that for quite often. So testosterone. In both men and women
testosterone it's thought to blame in acne and obviously you see a rise of
that in puberty, more in boys than girls but still there. You see it in diseases
like PCOS in women. And it's thought that testosterone encourages sebum
production or overproduction and that's how actually triggers acne. So genetics..
Well you're certainly more likely to get acne if your mother, father or siblings
get acne. But studies have shown that if both your mother and your father have
acne, your acne is likely to be more severe... so thanks mum and dad... again! And
also if your mum and dad have had acne you are more likely to get adult acne. So
it's not good news if both of your parents have had acne. So in women, as I've
mentioned, we know that hormones often trigger acne or cause it.
And 80% of adult acne is in women. So we see that more likely because of hormones.
We know that pregnancy can trigger it, periods can trigger it, so women get
acne once a month for certain periods of time as their period comes and goes.
And we know that women with polycystic ovaries ,where their hormones are
deranged, and they've got increased testosterone, get acne. So let's just bust
some myths about causes of acne. So firstly there's no evidence that diet
causes acne, so if you want to have that chocolate bar go ahead and have it! We
know that it's not because you're dirty. So actually being over clean and
cleaning too much can actually be detrimental for people with acne. So it's
nothing to do with being unclean. It's nothing to do with sexual activity, it's
just coincidence that it happens around puberty. Because puberty increases your
hormones you then become sexually active and your acne kicks in at the same time.
But one isn't causing the other; sexual activity is not causing acne. Sunbathing
doesn't help acne, but it does cause wrinkles; 80% of wrinkles are sun damage
and it can cause skin cancer. So don't resort to sun beds or sun to clear your
acne, because it's not helping and it has other dangers. It's not infectious, so you
can't catch it from anyone and no one else can catch it from you.
So don't let anyone tell you that. Squeezing and picking spots doesn't help. In fact
it probably makes it worse and it increases scarring. And stress doesn't
cause acne, we don't think so anyway. We do know that acne causes stress. So it's
difficult again to unpick those two things and what's causing one or the
other but the general view is is that actually acne causes the stress and not
the other way round. So how do you get diagnosed with acne? Well you and see your
GP and you need to go early because the sooner we can actually work with you to
try and help, the less risk there is of scarring in the long-term. So please
don't delay, don't think it's trivial, go and see your GP. The GP will
examine you, have a look at where your spots are, how many different types there
are and what types there are. There are grading systems for acne.
So grade one is mild and you'll have some blackheads and whiteheads, a few
papules and pustules, definitely no scarring, no cysts and no pain. Grade two
is moderate acne and you'll have multiple papules and pustules, generally just to
your face. Grade three is moderately severe and this is where it starts to
spread. So you'll have a large number of papules and pustules, one or two of them will
be inflamed, in terms of nodules, and it will be spreading onto your back and
chest. And then severe acne; you'll see a combination of all of those things but
also painful inflamed cysts and nodules. And likely scarring as well by time you
get to these latter two stages. And that's really important part of the
diagnosis. So lets look at treatment. As with everything, first there's some self
care that you can do; creams and gels; antibiotics; tablets in terms of
antibiotics and other tablets like Roaccutane and
contraceptive pills or pills that can lower your testosterone if you're a
woman with PCOS. So let's have a look at those. Self-care: So as I mentioned, it's
nothing to do with being dirty so we recommend that you don't wash your face
more than twice a day. And when you do, you use a very mild soap or cleanser or
facial wash it's water-based and use lukewarm water, it's really important not
to use hot water. Don't exfoliate and scrub because you're then stripping your
skin of the oils that it actually needs and you might be spreading the bacteria
around. Try and use non (and here's one of those words I can never pronounce) comedogenic
and water-based makeups. So they do exist, you can google them, and it's
really important because they actually make sure that what you're using isn't
encouraging your acne. Use fragrance free water-based emollients if you've got dry
skin and you need to moisturise. So again, it's really important that you do those
things. But that's often not the answer on it own,
but it helps support whatever treatments you might get further down the line. So,
you've gone to your GP and they've looked at your acne. So then there are lots
of different treatments and you can mix and match all of these treatments so
there's no particular order. So one of the creams that you can apply it's a
cream or gel is benzoyl peroxide. It is a bleach, so it can bleach your clothes or
your pillows and you put it on at night. So be careful of dark towels/pillows/sheets
etc. You can get gels of all different strengths, you can get creams
and you can get solutions to wash with. So that's one solution. Then you get
antibiotics but again in a cream. And these can be combined with the benzoyl
peroxide. So the first line is usually Clindamycin and that's at
1% topical solution (Dalacin). And that's what we use for most people but some
people can't use clindamycin, pregnant women for example. So then we use
Erythromycin 2%. And as I said you combine that with them benzoyl peroxide, so the
most common one I know of is DUAC. You only use these at night by the way and
that's really important. Then there are retinoids, in cream or
gel form. And these help with scarring as well as helping with the acne so this
is an isotretinoin gel and 0.05%. Something like isotrex, is common.
Or Adapalene, which is 0.1%. Again you only
use these at night. You can get very dry with all of these creams I mentioned. So
I always say to patients when I'm prescribing this; initially use it at
night every third night until you start to tolerate the dryness, when you have
move up to every other night and then again once you've tolerated the dryness
then you can use it every night. Otherwise you'll just stop using it
because you'll become too dry, and I see it all the time, so please ease in gently to
the retinoids, and the Benzoyl Peroxides - all of those creams can cause dryness.
You can combine the retinoid creams with an antibiotic, so isotrexin, for
example, has got an antibiotic in it as well.
And you shouldn't use if you're planning pregnancy or you are pregnant. Not that
we know that it causes any difficulties but because it's a retinoid
we would never risk it. So make sure you tell your doctor if you're planning to
get pregnant. Then there's oral antibiotics and these you have to take
for at least three months because it takes that long to work. So do persevere.
First-line antibiotics are things like doxycycline100mg once
a day, Lymecycline 408mg once a day or oxytetracycline
500 milligrams twice a day. So there's lots of different options in the first
line antibiotics. And if for any reason you can't take those first-line
antibiotics there are other options as well. So second line is erythromycin
which you can use if you're pregnant, because you can't use the tetracyclines
if you're pregnant, and that's a twice a day tablet. And if you can't use that, and
some people can't, then you can use trimethoprim. That's a tablet that we
usually use for a urine infection ,but just to let you know it's not licensed, that's
fine but you need to know as a patient. If you've got hormonal acne; so it's
coming with your periods or you've got PCOS, there are some specialist
contraceptive pills that we can use. So one that's licensed just for acne, not
for contraception, is dianette, and it's otherwise known as co-cyprindiol.
And it can be used for up to a year but it's not
licensed for contraception. Another very similar one is Yasmin. That is licensed
for contraception as well. But these can help with acne that's mediated by
hormones. If you've got PCOS and you don't fancy using the combined
contraceptive pills and your testosterone is high, there's a blood
pressure tablet called spironolactone that can lower your testosterone and
that can sometimes help. These all need to be done with specialist guidance,
but certainly they're important. Now on that note of specialist guidance... when
should you be referred to dermatology? Because lots of people with acne see GP's
for a long time and they try lots of treatments and they don't get referred.
And this is one of the messages I want to get across today. I want you to have the
information to be able to set your GP "I need to be referred". So what the guidance
says is: if you've got scarring acne you should be referred straight away to
dermatology, because they have other tools in their toolbox that we don't
have as GPs. If you have tried antibiotics, two different types for at least three
months, and it hasn't worked and other treatments are failing you should be
with referred to dermatology. Or if your acne is causing you such stigma and
distress, which is so often is - I can't tell you how often I see people they
just cry because they are so damaged by it -
you should be referred to dermatology. So that's what the guidelines say, the NICE
Guidelines. So please don't forget that. In the meantime while your referral is
going through you should be treated with one of those treatments that I talked to
you about to try and obviously keep things under control or help before you
get there. So what do Dermatology do that's different to us. Well they can
use spironolactone for example, which we wouldn't normally do in GP as a
first-line and without specialist input. But more importantly they can use roaccutane.
So roaccutane is a retinoid but it's one that you actually swallow, it's an
oral tablet. And it is an amazing drug but it needs to be done with their
guidance and there are reasons for that. It is a very effective treatment for
active acne and for scarring and that's important. 85% of people
who use roaccutane will have clear skin within four to five months. BUT it
cannot be given to people that are pregnant or planning to become pregnant.
So if you go on roaccutane you usually have to have monthly pregnancy
tests and/or a long-acting reversible contraception, so for example subdermal
implants or a mirena coil or the pill, but with the regular tests. And it's
really important, because if you were to get pregnant
taking roaccutance, it is devastatingly damaging to the fetus. You get very very
very dry skin. I mean your lips almost fall off in the first few days so you
need Vaseline by the bucketload and you just need to be prepared for these
side-effects. But it does work and you have to check your
liver function because sometimes roaccutane can affect your liver and we have
to be careful if you suffer from depression. Now obviously lots of people
with acne or depressed by their acne but you just need to be aware that some
people react even more so when they take roaccutane. So if you have got
depression or you have suffered or you are suffering, make sure that you speak
to your dermatologist about it. It's really important, and if you are on
roaccutane and your mood suddenly changes or you have suicidal thoughts
that you've never had before - straight back to dermatology. Don't waste any time,
speak to them on the phone and let them know how you're feeling. But otherwise
it's a fabulous drug and that's why we carry on using it.
So are there cosmetic solutions for acne scarring? Yes there are, and I
mentioned that I've seen people in my clinic and this is what prompted me to
do the VLOG today. When I see people in my cosmetic clinic they have actually
been through the mill a hundred times over come out the other end,
spent a fortune of money and not always got a solution. And it's really sad and
my aim with this video today is to get people to GP's earlier then they would normally
go so that we can try and prevent the scarring, which we can do sometimes with
roaccutane if it's an early enough, and stop them coming to me. I'd rather not
see people because I want their scarring be sorted out so they don't get it to
start with. But if they have got scarring and they're looking for solutions there
are various things that can be done. So dermaroller is a very researched and
scientifically proven solution for scarring and pigment. Lasers have been
known to be to be used and to have been successful. I don't do them so I can't
give you too much information, but there are lots of different laser solutions.
Subcision is when we put a needle into the skin and break down the scar tissue
with the tip of a very sharp needle. And I do that in my clinic when I'm doing
other things and lots of dermatologists do that as well.
Chemical peels that actually take off the top layer of skin can help and then
fillers can help. So there are different fillers and not all
practitioners do it but I do do it and we can have
really good success with it, but it's unpredictable. And we never know how it's
going turn out until we get in there and see how much scar tissue there is
underneath. But generally there is an improvement. The thing to know about
cosmetic solutions is you are never going to get your skin back to perfect
sadly. And I really do hope that we get to the point where we stop people
scarring in the first place. So that's my message today; acne is so stigmatising it
destroys people's self-confidence, self-esteem and self-worth. It makes them
want to hide away, not go out, and they feel so conscious all the time; they feel
people are looking at them, even if they aren't, that's how they feel and it's
important. So we have to try and nip that in the bud as early as possible. When
people say to someone with acne "it really isn't that bad', "I can't see it", don't say
it's irrelevant. If someone is feeling that their acne is visible and causing
them distress we need to jump on that and support them and show them a way
through. Please listen to the guidelines I've given you about when your GP should
refer you to a dermatologist. I refer scarring as soon as I see it, no question,
and that's what should happen. And then we get you there earlier to prevent more
scars forming. So if you have scarring, get to your GP and get a referral. And if
you've got new acne that looks like it's going to be scarring or it's looking
like it's worsening, get to your GP early so that we can actually get you the
right treatments. And lots of those treatments I mentioned work really well.
Not everybody needs to go to see a dermatologist but if you do, you need to
get early. I really hope that's helped and as always ask me any
questions you want in the comments after the VLOG, suggest any new topics in
the future and thanks for watching! And I'll see you in a couple of weeks
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