What causes acne?
- Too much oil (sebum)
- Acne-causing bacteria on the skin
The above can be aggravated by hormonal influences, especially around the teenage years.
How can acne impact a person?
Acne affects quality of life and has considerable psychological, social and emotional impact. Important research findings include:
- The psychological impact of acne affects several aspects of daily life, including ability to socialise, and occupational opportunities.
- 1/5 acne patients have psychiatric disorders in one study
- Other effects are embarrassment (females experience this more than males), body dissatisfaction, poor emotional health, anxiety and depression, social phobia, suicide.
- Older people with acne (>20-years-old) have more appearance-related concerns than younger acne patients.
- Women with acne are more self-conscious about it than men, they also feel worse about themselves. Acne on the body makes people more self-conscious when entering intimate/physical relationships.
- More severe acne is associated with an increased risk of anxiety, depression and thoughts about suicide
- Feeling stressed can have an impact on sebum (oil) production that can in turn, cause or aggravate acne.
But people tell me “you’ll grow out of it!” or “it’s just your skin”
Please do not allow your skin condition to be trivialised by others. Speak up and ask to be seen by an expert. The severity of your skin condition is not always proportional to how you feel, for example, mild acne can be as devastating to some people as those with severe acne. This is something we are trained to deal with in psychodermatology. Psychological health is as important as physical health.
How can I deal with acne?
Acne can be confused with other conditions (e.g. rosacea, perioral dermatitis), so the first step is to have the correct diagnosis made and, following that, appropriate treatment. Acne is usually a very treatable condition, the best approach is to start effective treatment early to avoid long-term skin changes (e.g. scars) and psychological distress (e.g. social anxiety or lack of self-confidence). People with acne and emotional symptoms usually feel some improvement of these when their skin is treated. It is also helpful to discuss with your GP or dermatologist how you are feeling so these issues can be recognised early.
What about my acne scars?
Treatment options for acne scars can be limited on the NHS, but it is good to get appropriate advice on what type of scarring you have and what treatments have been shown to work. Most important is to treat any ongoing acne activity as this can cause further scarring. Treatment options for acne scars include retinol/retinoid containing creams or gels, or physical treatments such as micro-needling, steroid injection, chemical acid application, lasers or surgical excision of certain types of scar. Again, coping with scarring is important, and looking into strategies or interventions to enhance this is also helpful. For example, cognitive behavioural therapy-based interventions can help deal with negative thoughts associated with acne or acne scarring. People with acne also have a higher chance of body dissatisfaction, identifying and then treating this can be beneficial.
I have acne, what should I do?
The usual NHS pathway is to first see your GP, who should be able to prescribe appropriate treatment. These can include:
- Topical preparations – to reduce acne causing bacteria, pore-clogging, oil production and improve skin turnover
- Antibiotics – fight acne-causing bacteria and reduce inflammation
- Hormonal treatments – there are some hormonal drivers to acne that can be addressed with medication
- Combination treatments of the above
If your acne is having a large impact on your quality of life and causing emotional distress and/or despite appropriate treatment your acne is not improving, then your GP can refer you to a dermatologist. Treatments offered by a dermatologist that are not available from your GP include oral Isotretinoin (Roaccutane/Accutane).
What about side effects?
I have heard about Roaccutane/Accutane, but I got put off because I read it affects mental health?
The evidence is this area is inconsistent as different studies report different things. A review of 17 studies showed that use of Roaccutane improved depressive symptoms in acne patients. There are however some studies that suggest an increased risk of depressive symptoms in patients that take Roaccutane. This is why the evidence is conflicting. I usually advise that if you are worried about the mental health effects of Roaccutane, you can be monitored closely throughout treatment. Having a history of a mental health condition in you or your family does not mean that you cannot have this treatment. You may just require more frequent assessments to monitor your emotional health.
Can I do anything about my skincare?
Establish a good base regime including a mild acid face wash (to remove dead skin cells and clear out pores). Salicylic acid face washes are better for acne-prone skin. These can be irritating at first so introduce slowly. An antioxidant product is also helpful to protect skin from the harmful effects of pollution and UV rays from the sun. You should use sunscreen regularly (especially if using facial acids/chemical exfoliants) and consider hyaluronic acid to improve hydration. Always remove makeup effectively and consider a topical retinoid before bed. Serums designed to reduce redness and colour-correcting products can be useful.
Does it have anything to do with my diet?
The links between acne and diet have not been evaluated enough to make any clear associations. I usually advocate a balanced diet that takes into account the major food groups and incorporates 2-2.5L of fluid a day. It is not uncommon for people to make dietary exclusions, and this is good way to evaluate if something in your diet is aggravating your skin. However, I would do this with caution, so you are not excluding too many things at once (potentially doing more harm than good). Avoiding one food group at a time (e.g. dairy) and trying this for maximum 8 weeks to 3 months may give you a good idea of whether your skin is being impacted. Keep an accurate food diary (including good and bad days for your skin) and reintroduce foods for which exclusion has had no impact.
What will happen in my Acne consultation?
When seeing a patient with acne I usually cover:
- Full medical history
- Assessment of psychological health
- Overview of lifestyle factors (e.g. sleep, diet, exercise) and triggers (e.g. stress)
- Detailed gynaecological history (for women with ‘hormonal’ acne or polycystic ovarian syndrome)
- Skincare review and bespoke recommendations
- Detailed management plan (including medical treatments, lifestyle recommendations, skincare plan)
- If appropriate I will offer treatment that may not be available from your GP, for example isotretinoin (Roaccutane/Accutane), spironolactone, or specialised topical treatments
I would encourage anyone with symptoms of psychological distress associated with having a skin condition to seek appropriate support via their GP, dermatologist or psychodermatologist.