Acne is a very common skin pathology (disease), mainly affecting adolescents and young adults of both sexes.
- more than 3 out of 4 adolescents (according to studies, between 75 and 95%)
and between 25 and 58 years old, 12% of women and 3% of men
- In 20% of cases, it is moderate to very severe acne.
What is acne?
Acne is a chronic skin disease that occurs during hormonal changes, especially during adolescence. It affects the glands that secrete sebum at the root of the hair, called “pilosebaceous follicles”.
The functioning of these follicles is impaired: the secretion of sebum (whose function is to protect the skin) becomes excessive and the synthesis of keratin malfunctions.
This causes the clogging of the pores of the skin and the appearance:
- Blackheads (open comedones) or whiteheads (closed comedones or “microcysts”).
- These whiteheads can become inflamed due to bacteria (Propionibacterium acnes) and become non-purulent (papules), purulent (pustules) red “pimples” or generally larger “pimples” painful and embedded deep in the skin (nodules).
These different manifestations – found mainly on the face, back, shoulders and the front of the thorax – can coexist in the same patient.
Acne is a disease that can have real psychological repercussions and alter the quality of life: mood disorders, depression, altered self-image, relationship difficulties… In severe cases, acne can also lead to the formation of scarring lesions causing in the most serious cases a pockmarked appearance of the face.
We can differentiate 6 different degrees of severity in acne, depending on the surface of the skin affected (and more particularly the face) and the nature of the “pimples” present.
Degree of severity
|0. No lesion (wound)||Residual pigmentation and redness (erythema) may be present|
|1. Virtually no lesion||Rare scattered blackheads or whiteheads (comedones) and rare non-purulent “pimples” (papules)|
|2. Mild||Less than half of the face is affected
A few blackheads or whiteheads (comedones) and a few “pimples” (papulo-pustules)
|3. Moderate||More than half of the surface of the face is affected
Numerous “pimples” (papulo-pustules) and blackheads or whiteheads (comedones).
A larger “pimple” embedded under the skin (nodule) may be present
|4. Severe||The whole face is affected
It is covered with numerous lesions (papulo-pustules), with blackheads or whiteheads (comedones) and rare larger “pimples” embedded under the skin (nodules)
|5. Very severe||Severely inflamed acne covering the face with larger “pimples” embedded under the skin (nodules)|
The elements that particularly encourage to treat acne are:
- the severity of acne
- the risk of scarring (mostly caused by nodules);
- the psychosocial impact, if acne affects the quality of life or if it interferes with relationships with others.
Degree of severity
The first-line attack treatment will be local (creams or gels). Benzoyl peroxide and retinoids are the two main types of molecules offered in local treatment.
|Moderate to severe acne||
We can start immediately with local treatment combined with antibiotic therapy (doxycycline or lymecycline) orally.
|Very severe acne||
If there is a significant risk of scarring, the doctor may prescribe first-line isotretinoin (better known under one of its former marketing names Roaccutane®, see question above).
Patient preferences should also be taken into account in order to promote good treatment follow-up.
FOCUS: the specificities of acne treatments
- Treatments do not cure acne (except in some cases after oral isotretinoin treatment). They alleviate the symptoms and it is necessary to continue local treatment after obtaining a remission to avoid or at least delay the occurrence of a recurrence.
- No treatment is immediately effective, it takes a few weeks before obtaining an improvement.
- The good follow-up of an acne treatment is a guarantee of its success. However, only 32 to 50% of patients follow it correctly.
In case of failure
First of all, it is necessary to ensure that the prescribed treatment has been followed by the patient, because this is not the case in almost half of the situations.
If the treatment was followed correctly, the modifications of treatment depend on the stage of severity and the possible difficulties encountered by the patient with his treatment.
In all cases, the objective is to achieve remission as long as possible only through local treatment with benzoyl peroxide and/or local retinoids in order to limit the use of antibiotics.
In case of failure of local treatment in the case of mild acne
When there is a failure at 3 months despite well-monitored local treatment, this treatment can be modified, increased (for example, increase in the dose of the cream, concentration, number of applications, etc.) or antibiotic therapy with oral route can be introduced in addition to the local treatment.
In the event of failure of a treatment combining both local treatment and oral antibiotic therapy in the case of moderate or severe acne
In this case, treatment with isotretinoin (better known under one of its former marketing names Roaccutane®) will be considered.
Precautions to take
1. Concerning local treatments
Topical treatments frequently have irritating effects related to their mode of action which can be reduced by the use of mild cleansers and emollient creams.
2. Regarding antibiotics
As is the case in the treatment of other diseases, their use should be limited to situations where they are needed due to the increase in resistant bacterial strains.
3. About isotretinoin (better known under one of its former trade names Roaccutane®)
In pregnant women: the use of isotretinoin is prohibited, as it causes serious malformations for the foetus. Women should therefore under no circumstances become pregnant during treatment with this medicine or in the month following its discontinuation. It is thus requested to follow an effective contraception and to carry out a pregnancy test before the prescription of isotretinoin, test to be repeated monthly throughout the treatment and 5 weeks after the stop.
The prescription can only be made within 3 days of the pregnancy test and delivery by the pharmacist within 7 days. All these steps are followed and annotated in a notebook given by the doctor.
In the general population: even if studies on large population samples have not shown an increased risk of depressive disorders, the fact that such disorders have been exceptionally observed in patients undergoing treatment with isotretinoin justifies taking all necessary precautions against this risk. It is therefore recommended that the patient communicate to his doctor before the start of treatment, all possible personal and family history of psychological and psychiatric disorders.
Precautions for pregnant women
If the treatment of acne cannot be postponed, the use of the following molecules is possible during pregnancy and in a breastfeeding woman:
- benzoyl peroxide regardless of the term of pregnancy;
- zinc from the 2nd trimester, taking into account other possible zinc intakes (in particular “polyvitamins and trace elements” supplements) so as not to be in overdose.
In general, there are no associated diseases to look for in isolated acne. However, in the event of menstrual cycle disorders or hirsutism or early onset acne, a hormonal assessment as well as treatment by an endocrinologist or a gynecologist should be offered.
In addition, acne can have a sometimes major psychological impact to which attention must be paid and which may require specific specialized care.
Information: Cleverly Smart is not a substitute for a doctor. Always consult a doctor to treat your health condition.