Acne

Overview

Acne happens when hair follicles in the skin become clogged with oil and dead skin cells, and bacteria that live on the skin can then affect the blocked follicles. Changes in hormones are a major factor, and acne tends to run in families. It can range from mild, with a few spots, to severe, with deep and painful lumps under the skin. It can also affect mental health. Treatment is available from pharmacists and GPs, and some people are referred to a skin specialist.

Symptoms

What a clinician may find

• Blackheads and whiteheads.
• Inflammatory papules and pustules.
• Nodules and cysts in more severe acne.
• Spots mainly on the face, chest and back.
• Scarring, which can follow acne.

Complications

• Permanent scarring, especially if spots are squeezed or picked.
• Persistent psychological distress or a mental health disorder, which NICE says can accompany acne of any severity.
• Signs of skin infection in affected spots.

Diagnosis

The NHS grades acne by the types of spot present. Mild acne is mostly whiteheads and blackheads with a few papules and pustules, and severe acne has lots of large, painful papules, pustules, nodules or cysts, sometimes with some scarring. NICE describes acne severity as a continuum, graded as mild to moderate or moderate to severe.

Treatment

For a few blackheads, whiteheads and spots, a pharmacist can advise on gels or creams that can be bought without a prescription. These include products containing benzoyl peroxide. Prescription treatments include topical retinoids, topical antibiotics, azelaic acid and antibiotic tablets. The combined contraceptive pill is another option for women. NICE lists a topical treatment used together with an antibiotic tablet as an option for moderate to severe acne. Isotretinoin is a capsule treatment for severe acne that has not responded to other treatments, and the NHS says it can only be prescribed by a specialist doctor.

Prevention

The NHS describes gentle washing with a mild cleanser and lukewarm water as helpful for acne. NICE describes using a syndet cleansing product twice daily on acne-prone skin, choosing oil-free products and removing make-up at the end of the day. The NHS advises against squeezing spots, because this can cause permanent scarring.

Key facts

What does acne look like?

Acne can range from mild, with a few spots, to severe, with deep and painful lumps under the skin. It usually affects the face, chest and back. The NHS lists six main types of spot: blackheads, whiteheads, papules, pustules, nodules and cysts. NICE describes acne severity as a continuum, graded as mild to moderate or moderate to severe.

Blackheads are small and black or yellow in colour. Whiteheads are similar to blackheads but do not empty when squeezed. Papules are small red bumps that may feel sore, and pustules are small red bumps filled with pus. Nodules are hard lumps beneath the skin that are sometimes painful. Cysts are the most severe type, being large lumps filled with pus, and they carry the greatest risk of permanent scarring.

The NHS grades severity by the types of spot. Mild acne is mostly whiteheads and blackheads, with a few papules and pustules. Severe acne involves lots of large, painful papules, pustules, nodules or cysts, and there may be some scarring.

What causes acne?

Acne starts when hair follicles become clogged with oil and dead skin cells, and bacteria that live on the skin can then affect the blocked follicles. Hormone changes are a major factor, and acne also tends to run in families. The BAD leaflet says the oil glands can be sensitive to hormones even when hormone levels are normal. It also names polycystic ovary syndrome and anabolic steroids as possible triggers.

The NHS lists some medicines, such as steroids, and skin or hair products that make the skin greasy among the things that can contribute. The NHS says that cleaning the skin does not remove the blockage in the follicles. It also says there is no evidence that poor hygiene or sexual activity cause acne, and that acne cannot be passed on to other people. On diet, the BAD leaflet says a healthy, well-balanced diet is advisable, and NICE says there is little evidence to support recommending dietary changes.

How does skin care help with acne?

The NHS describes gentle washing with a mild cleanser and lukewarm water as helpful for acne. NICE advises a syndet (non-alkaline synthetic detergent) cleansing product twice daily on acne-prone skin, oil-free products, and removing make-up at the end of the day. The NHS advises against squeezing spots, because this can cause permanent scarring. NICE gives similar advice, noting that persistent picking or scratching of lesions can increase the risk of scarring.

For a few blackheads, whiteheads and spots, a pharmacist can advise on gels or creams that can be bought over the counter. The BAD leaflet lists benzoyl peroxide, azelaic acid and nicotinamide as active topical treatments that are available without a prescription. It says most treatments take 2 to 4 months to have their full effect, while the NHS says many take 2 to 3 months before they start to work.

How is acne treated?

The NHS says a GP can offer prescription treatments if pharmacy products have not worked or acne is more severe. These include topical retinoids, topical antibiotics, azelaic acid and antibiotic tablets, and for women the combined contraceptive pill. NICE lists a topical treatment used together with an antibiotic tablet as an option for moderate to severe acne. It found oral antibiotics used on their own to be less clinically effective and less cost-effective than the recommended options.

NICE recommends a structured follow-up 12 weeks after treatment starts, to monitor the response and discuss options for ongoing management. The NHS says many of these treatments can take 2 to 3 months before they start to work.

Isotretinoin is a treatment for severe acne that comes as capsules. NICE says it is considered for severe acne that has resisted adequate courses of standard treatment. Because of the risk of side effects, the NHS says isotretinoin can only be prescribed by a specialist doctor. The NHS lists dry or itchy skin among its possible side effects, and mental health problems as rare but serious ones. The NHS also says it is very important not to become pregnant while taking isotretinoin capsules and for at least one month after stopping.

When should someone see a doctor about acne?

The NHS advises seeing a GP if self-treatment is not helping, if there are many spots, or if spots are deep, painful or leave scars. A GP appointment is also advised if there are signs of skin infection, such as hot, swollen and red skin, or if acne is affecting mental health. A GP can refer a person to a dermatologist, a doctor who specialises in skin.

NICE lists reasons to consider referral to a dermatologist-led team, including mild to moderate acne that has not responded to two completed courses of treatment, severe acne-related scarring that persists a year after the acne has cleared, and acne of any severity that is causing or contributing to persistent psychological distress or a mental health disorder. NHS 111 Wales advises an urgent GP appointment or a call to NHS 111 for clusters of large, hard or pus-filled lumps, or if a person starts to feel very ill. In an emergency, such as someone in immediate danger, call 999.

What is the outlook for acne?

The BAD leaflet says acne usually fades by the early to mid-twenties, though it can last longer or start later in adult life. It says there is currently no cure, but effective treatment can prevent new spots and reduce scarring, and that acting early helps to avoid permanent scarring. The NHS notes that acne can take several months to improve with treatment.

The NHS says a GP can refer people to a dermatologist if acne is severe or prescription medicines are not working, or if there is scarring or a risk of scarring. NICE says referral for acne-related scarring is to a consultant dermatologist-led team with expertise in managing scarring. For severe acne, the BAD leaflet describes isotretinoin as highly effective, with about 9 in 10 people seeing significant improvement from one course, although some people relapse afterwards.

Frequently asked questions