Primary Care Acne Clinic (By referral only)

Acne vulgaris affects virtually everyone at some point It’s characterized by whiteheads, blackheads, small red pimples, and for some, large nodular/cystic and painful red bumps.

Most commonly, acne starts in the teenage years, but acne can persist or start in adulthood. Acne can even occur in the perimenopausal period. In adults, acne tends to appear around the chin and jawline.

Acne is caused by a combination of the following:

1. Excess production of oil from your sebaceous glands
2. Excess build up of skin cells
3. Bacterial proliferation of Cutibacterium acnes (formerly Propionibacterium acnes)

In the teenage years, sex hormones are being released at high doses causing excess release of waxy sebum in oil glands that are particularly sensitive to hormones. In addition, skin cells reproduce quickly.

During the menstrual cycle and perimenopause, fluctuations in hormones may also trigger acne flares.

Excess buildup of skin cells clog up skin pores. Clogs under the skin surface are called whiteheads or closed comedones. If the pore is open to the air, the plug turns black and is called a blackhead or open comedones. Clogged pores and excess oil production promotes bacterial growth. The bacteria stimulates inflammatory signals that cause the red, tender, and pus-filled pimples to form. The inflammation can lead to difficult to treat scars.

Food itself is not a direct cause of acne. However, there are studies that suggest that natural hormones and chemicals in milk can worsen acne. High glycemic foods can also trigger acne.

Stress can have an indirect effect on acne formation. Stress increases steroid levels in the body and can cause fluctuations in sex hormones.

In severe acne, there is often a positive family history of severe acne. May be due to genetic predilection to increased degree of skin proliferation and sebum production.

In order to prevent and/or treat acne, we have to address the underlying causes:

1. Excess build up of skin cells
2. Excess production of sebum/oil
3. Bacterial proliferation

A good skincare regimen is key to managing skin cell turnover and excess oil build-up.

Clearing Skin Buildup

Use a gentle cleanser and gentle exfoliant. Overscrubbing can stimulate oil production and worsen acne instead helping. A chemical “exfoliant” like glycolic acid (an alpha hydroxy acid AHA) or even better, salicylic acid (the only beta hydroxy acid BHA) is important to breakdown and remove skin cells.

In mild acne, in patients with sensitive skin, or as part of maintenance after acne is controlled, I often recommend starting with glycolic acid because many patients find it less drying and irritating than salicylic acid. However, salicylic acid being oil soluble does penetrate into oily pores better.

Salicylic acid It comes in various strengths from 0.5% to 2%. If your skin is sensitive, start low and increase the concentration. Choose lotions over solutions or gels which tend to be alcohol based and irritating.

Topical Vitamin A (retinols or the stronger prescription retinoids/retinoic acids) is a very important anti-acne ingredient to treat clogged pores and preventing re-clogging. However, you must be patient and bear through the dryness and redness and peeling that will almost definitely occur. Many patients stop due these side effects before they can see the benefits which occur 3 to 4 months later. If you are concerned whether the side effects are unusual or more severe than normal, it is important that you see your treating physician. You can visit our handout on how to minimize the side effects of topical vitamin A here. (click here)

Topical vitamin A’s should not be used when planning pregnancy or when pregnant.

Dryness can be countered by using a light moisturizer.

Controlling Oil Production

Oral contraceptives with estrogen and certain types of progesterone reduce the amount of circulating androgens such as testosterone. The reduction in androgens mean less sebum production and hopefully less acne.

Niacinamide (vitamin B3) is a topical skin care ingredient that may help control oil production that you can add to your skin regimen.

Treating the Bacteria

Benzoyl peroxide (BP) is a topical ingredient with antibacterial properties. This product comes in multiple strengths from 2.5 to 10 percent and in multiple forms such as soaps, washes, and cleansers. However, using strengths more than 5% is unnecessary with more side effects without more benefits.

It may be necessary to combine topical BP with a topical antibiotic to help control acne.

Some patients will need oral antibiotics, but this should only be used short term (a few months at a time) due to side effects and bacterial resistance. It is really important to have an ongoing good skin regimen and topical acne treatment during and after antibiotic treatments.

Treat the whole area. This is called field treatment. Treat the areas where acne can appear on you or where you see white or blackheads.

While there are over the counter “spot” treatments available, they really don’t work that well. The goal is really to prevent the NEXT set of acne from forming.

Having said that, steroid injections into the acne spot can help quickly settle the inflamed acne spots. Often this is done prior to special occasions or if person is likely to develop scarring. This is not routinely done because there are possible side effects like changes in coloration, thinning/ atrophy/depression of the treated skin. However, in reality, the inflamed acne nodule may also cause similar consequences.

Treat the whole area. This is called field treatment. Treat the areas where acne can appear on you or where you see white or blackheads.

For any treatment, you really have to give it 3 to 4 months. It takes time for your body to respond to the treatments and for “new” healthier skin to from. And it is not unusual for flares to happen before things improve.

Accutane is a brand name for isotretinoin. Other brands in Canada include Epuris and Clarus. Patients with severe acne, scarring acne or moderate acne not responding to other treatments may be candidates for isotretinoin.

Isotretinoin is an effective drug, but it is true that there are many possible side effects associated with isotretinoin like with any drug. One of the most important side effect is that it will most likely cause serious birth defects to a fetus if taken during pregnancy, so effective contraception must be used along with pregnancy tests before and during the course. At the Primary Care Acne Clinic, we will discuss the side effects and provide tips on how to manage them and monitor patients through the course.

Scar treatment is an important part of acne treatment. Acne should be in remission to avoid new scars before investing in scar treatment. Scars are notoriously difficult to treat and multiple types of treatment are usually required. There can be improvement but one must have realistic expectations. However, sunscreen is something that everyone should use to help the appearance of scars.