Acne

Acne Vulgaris is a chronic, hormonally influenced, inflammatory disorder of the sebaceous (oil producing) gland and hair follicle. It is a very common skin condition that research shows affects as much as 85% of the population at some point in their lives.

Although the causes of the condition are numerous and interacting, in essence it is the result of

• inflammation of the follicle
• an elevated sebum (oil) production
• dead skin cell build-up within the follicle
• over activity of the C.Acnes bacteria (a bacteria normally found on the skin surface

Sebum production is controlled by androgens (male hormones), and so it is often considered to be a condition relating to adolescence, due to the increase in the androgen hormone testosterone around the time of puberty. However, research suggests that cases of adult onset acne are increasing.

Acne varies greatly in severity, mild cases generally just exhibit blackheads and whiteheads (open and closed comedones) and the odd inflamed lesion (papules) which appear as raised pink/red bumps.

As the level of inflammation increases, the number of papules rises, with some clearly containing pus (pustules). They can become quite large in size with those over a centimetre being referred to as cysts, and where they form deep in the base of the follicle rather than towards the surface, they are described as nodules. These lesions tend to be hard to the touch and painful.

Large inflamed blemishes can remain on the skin for weeks, or even months in the case of deep nodular lesions. They can also lead to the destruction of the follicle causing scarring and potentially long-term facial disfigurement, which in turn can lead to psychological effects and social anxiety.

What causes acne – is it genetic?

It is not straightforward to say that acne is simply the result of oily skin, or genetics. 

Like many chronic skin conditions, its development and progress is often complicated being the result of the interaction of a variety of different factors and not the result of any single cause.

Factors influencing the development of acne:

Environmental 

• UV exposure
• Air pollution, 
• Humidity/temperature
• Hormonal changes & fluctuations – adolescence, menstrual cycle, menopause, pregnancy
• Diet and fluid intake
• Stress & sleep patterns

Lifestyle choices 

• Smoking
• Cosmetics 
• Diet and fluid intake

Genetics

• Whilst there does appear to be a link between genetics and the development of acne (research suggests that your risk of developing acne increases if you have a close family member who has experienced the condition), there is no single gene that causes it. Instead, the interaction of various genes can affect things like hormonal stability, or the effectiveness of your immune system to deal with bacteria, both of which influence acne development.

Acne is an inflammatory skin disease that involves a hair follicle becoming blocked with dead skin cells and excess sebum. The causes of this and the actual steps in its development are constantly being researched and reviewed. 

Traditionally the condition has been thought to develop in this way:

• Step 1 – androgens (male hormones – chiefly testosterone) levels increase, leading to 
• Step 2 – an overproduction of sebum, and an excess production and shedding of skin cells (keratinocytes) within the follicle, leading to
• Step 3 – a plug of matted dead cells and sebum in the follicle, which results in 
• Step 4 – Sebum being trapped below the blockage and this is turns causes
• Step 5 –  C.acnes bacteria living in the oil rich environment of the follicle to proliferate in the absence of oxygen, becoming pathogenic and resulting in inflammation of the area and the development of an acne lesion.

However, more recent research has revealed that inflammation of the follicle is present from the beginning and somehow initiates the development of acne rather than being the final step in the process. 

The exact mechanism of the start of this ‘bottom up’ theory to acne development isn’t yet completely clear, but researchers suspect that it is the result of a trigger to our immune system. They have discovered that all keratinocytes (the main type of skin cell) routinely produce very low levels of an inflammatory molecule called interleukin-1 as part of a ‘surveillance system’ to alert the body to a potential need for the immune system to respond. 

So somewhat in reverse of the traditional theory that suggests a hormonally driven process, the more recent hypothesis is this:

• Step 1 – one or more factors trigger an increase in the production of interleukin-1 causing the hair follicle (pore) to become inflamed. It isn’t yet clear what this might be but the most likely causes are the C.acnes bacteria, changes to sebum composition and/or stress
• Step 2 – once the follicle has become inflamed it causes an overproduction of the protein keratin, which is the substance that skin cells are made of. It also seems to change the composition of sebum making it more ‘sticky’. These changes seem to lead to a further increase in the production of the inflammatory molecules and subsequently the pore begins to become clogged.
• Step 3 – the clogged pore allows more sebum and excess skin cells to build up, encouraging the naturally occurring C.acnes bacteria, which use sebum as a food source, to increase in number. This in turn further increases the production of the inflammatory molecules. This cycle of increasing inflammation, raised sebum production and hyperkeratinisation (abnormal production of skin cells), gradually causes the formation of small plug within the pore – a comedone.
• Step 4 – as the plug continues to grow it puts pressure on the walls of the follicle. In addition, the anaerobic conditions beneath the plug allows the C.acnes bacteria to proliferate and they begin releasing proteins that further increase the pressure on the pore wall until it ruptures.
• Step 5 – once the pore wall has ruptured the contents are released into the surrounding tissue and the body’s immune system responds leading to a further rapid increase in inflammation. The result is the formation of a red and often sore acne lesion at the site of the ruptured pore.

This new research suggests that since inflammation is the root cause of acne development the main path to treating the condition lies in its reduction – the complication being that researchers are still trying to determine exactly what triggers it in the first place. 

An important point to realise is that whilst the C.acnes bacteria is found in most acne lesions, it doesn’t appear to be present in all cases, meaning that it can’t be the sole cause of initial increased production of the inflammatory molecule interleukin-1. A clear indication that there are multiple interacting causal factors. 

Although the factors involved in the development of acne are numerous and interacting, and the exact trigger is unclear, in essence it is the result of:

• Inflammation of the follicle
• An elevated sebum (oil) production
• Dead skin cell build-up within the follicle
• Over activity of the C.Acnes bacteria (part of the skin’s natural microfauna) 

As already noted, the key to treating (and preventing) acne is to control inflammation, which means targeting all of the contributing factors.  Treatments for acne are often unsuccessful because they focus on resolving a single symptom, for example using antibiotics to eliminate the C.acnes bacteria. Which simply returns (often even more resistant) once medication is stopped. 

This illustrates a very important point, effective treatment requires commitment and persistence – after all, as is the case for many chronic skin conditions, there is currently no cure for acne, but it is possible to achieve blemish-free skin. 

Treatment Options for Acne and Acne Scarring

The aim is to resolve blocked pores and blemishes so that the skin is clear and able to be maintained and any scarring addressed. The multiple causes and manifestations of acne and scarring mean that a one size fits all approach isn’t suitable, and it is necessary to understand your unique skin circumstances if we are to successfully resolve it. 

The First Step:

An initial in-depth consultation and skin health assessment is important to determine the likely causes of the blemishes and scarring and design a treatment and management plan suitable for your unique circumstances.

In-Clinic Treatments

Corrective deep cleansing facials: Galvanic therapy has a strong pedigree for unclogging pores and encouraging the circulation and lymphatic systems to encourage skin health.

LED Blue Light Therapy: Excellent at reducing the C.acnes bacteria on the skin’s surface, allowing lesions to heal.

Targeted Peel treatments: Beta Hydroxy Acid peels (BHA), offer excellent opportunities to unclog pores by dissolving the matted blockages of dead skin cells and sebum. They also have an antibacterial effect and so can help reduce bacterial activity. Where skin is sensitive or intolerance is a problem, metabolic peels which have antioxidant properties too and work by helping to rebuild the skin at the same time as exfoliating the surface are a great option.

Microneedling and Mesotherapy: whilst care is needed where acne is actively infectious, microneedling is an excellent option for strengthening the skin and breaking down pigmented lesions.

Please note it can often be beneficial to combine treatment therapies and bespoke packages attract significant discounts and savings. 

Homecare –  It is also important to remember that as a chronic condition, appropriate continuing home-care is necessary in order to prevent the condition from returning. A suitable homecare regime will be recommended for you to follow in between treatments to support the in-clinic therapies alongside dietary and lifestyle advice This will be discussed during your initial investigative consultation.