We need your help to treat your acne, and we have found that it is much easier to enlist a patient's help to treat their condition when they understand something about the problem. So let's talk about the causes of acne.

Practically all acne has a hormonal basis. Children, with junk diets and poor face-washing habits, don't get acne because they have very low hormone levels. And as we get older and our hormonal levels fall, the tendency to acne subsides (and hormone replacement therapy with testosterone, even with physiological doses, can bring about a return of acne in middle age).

Testosterone and DHEA stimulate sebaceous glands in acne-prone areas of the skin. These glands then produce an oversupply of an oily substance called sebum, which is then secreted onto the surface of the skin with a tendency to keep surface dead skin cells sticking to the surface instead of shedding normally. So, you end up with a lot of extra dead skin cells floating in extra sebum on the surface of the skin. These dead cells will then tend to congregate in any depressions of the surface of the skin: such as "pores"; which are the openings of the sebaceous glands we were just mentioning. They then obstruct these "pores", and so the sebum being produced by the sebaceous glands has more difficulty getting out, and so tends to accumulate within the sebaceous gland. This stretches the gland neck, which dilates the pore, which in turn will get even more obstructed with more dead skin cells, and so the cycle goes on, until you have a "comedone".

Meanwhile, sooner or later a germ will come along and get into the sebum sitting static within the sebaceous gland, will multiply and cause a little local infection: causing a "pustule". If the neck of a sebacoues gland is seriously obstructed and the gland keeps trying to produce sebum, then the gland will start to strech further and further and you'll end up with a "cyst". Hence: "cystic acne".

There are several points along the above sequence of events at which we can intervene to reduce acne.

1) Anti-hormone treatment. Certain medications, including some forms of the oral contraceptive, can be used to reduce effective hormone levesl and therby reduce the tendency to acne. They are used with success, but some patients get much better results than others. However, male patients can't use these treatments.

 2) Diet. Patients try to reduce the oil production on their skin by improving their diet. Dermatologists tell them over and over that there is no evidence that diet makes a difference in acne, but most acne sufferers know from their own experience that certain foods tend to make them "break out".

The University of Queensland recently published a review of the scientific medical literature on this topic, and found that there really wasn't enough evidence to say either way whether diet is important or not. It seemed the dermatological community had confused "lack of evidence of effect" with "evidence of lack of effect".

Diet improvement probably helps more in some than others. There are so many reasons to have a good diet that it is probably moot as to whether acne is another one.

3) Vitamin A. Adequate Vitamin A to the sebaceous gland will reduce sebum production, cutting off the first step of the acne process. But it is not practically possible or desireable to achieve this through oral supplementation, as excessive oral Vitamin A is dangerous. The Vitamin A has to be applied directly to the skin.

Many people have heard of a drug (we can't name it here) that has a profound effect on acne. This powerful drug, available only through registered dermatologists for the treatment of cystic acne, works because it is a synthetic, modified form of Vitamin A, and works by stimulating Vitamin A receptors.

4) Glycolic acid and salicylic acid. Glycolic acid is proven to loosen and remove surface dead skin cells, leading to a smoother skin surface and to there being fewer dead cells available to produce obstructions of sebaceous glands. Salicylic acid works by penetrating into the obstructed "pores" to loosen the plugs of sebum and dead cells within them, an action unique to salicylic acid.

5) Surface treatments, such as microdermabrasion and chemical peels, work by reducing the numbers of dead skin cells lying on the skin surface. Microdermabrasion also has a drying effect, reducing surface oils, and the suction action of microdermabrasion helps pull plugs of dead cells out of obstructed pores. So it works in several ways to reduce your acne.

6) Collagen stimulation. Once dilated pores have been emptied of their obstructing contents, then any process that stimulates collagen formation will help to lay new collagen around the necks of these newly-emptied pores, helping them to narrow. This is a gradual process, as new collagen takes months to develop. Microdermabrasion, IPL treatments, Omnilux and laser treatments are examples of such treatment processes.

 7) Antibiotics. When sebum has been sitting in obstructed glands long enough, an infection will supervene. Long term low dose antibiotics will kill off a lot of these bacteria and will have an additional anti-inflammatory effect.

 8) Photodynamic therapy. In patients with deep active sebaceous glands, cysts, and acneic lesions that are resistant to simpler therapies, photodynamic therapy can have a substantial effect by specifically targeting and reducing sebaceous gland cell numbers. However, it causes days to weeks of redness, even peeling, as side effects. Consequently, its role is in the management of difficult and substantial acne where dermatologist drug treatment has failed or where the patient refuses to take such medication.

The various treatment forms here can be used in combination to get the fastest and best results, targeting different parts of the acne process. Our view is that acne requires urgent and comprehensive management, generally warranting a multi-pronged approach. The alternative, of trying one treatment for six months then another for six months, etc, etc, seems to just waste time, and risks further development of scarring whilst active acne remains.

Having said that, acne will present in a range of different patterns, and treatment programs have to be tailored. Some need to focus on surface treatments, others on anti-hormone treatments, etc. A consultation will help us subclassify your acne and design a treatment program.

Acne scarring

Acne scarring is not easy to manage, and so the first task must be to ensure active acne is brought under control as efficiently as possible whilst avoiding side effects and risks.

As an acne spot heals, there is often a red then purple mark left present. This is not a scar, and will settle with time. Antioxidant and anti-inflammatory skin care will help hasten resolution, as will light therapies such as IPL and Omnilux.

People with olive and darker skin, and especially Asian skin, may develop a dark mark after an acne spot has healed. This is post-inflammatory hyperpigmentation, not scarring. Fading creams will help these. Gentle light therapies may also help, but the energy doses have to be gentle and the treatment not rushed, because excessive light treatment will worsen post-inflammatory hyperpigmentation.

True acne scars consist of a thinning of the dermis and generally a tethering of the thinned dermis to underlying tissue. There is often a loss of pigment.

Acne scars come in a range of shapes and sizes. Three common shapes are "icepick" scars, "boxcar" scars and "rolling" scars.

Rolling scars generally improve well with a minor surgical procedure called "subcision". This involves a few drops of anaesthetic followed by the use of a common hypodermic needle to divide those fibrous tethers under the dermis that are holding down the centre of the scar. The scar thus becomes shallower, and thus less noticeable.

This process of elevation to the base of a scar can be augmented with injection of a dermal filler under the scar. Agent R and Agent A are commonly used for this purpose, bringing about faster and better results.

Subcision can be applied to boxcar scars as well, but less success results.

Often a better approach for boxcar scars, and most icepick scars, is to simply excise the scar and suture closed the resulting wound. One might think that this would just replace one scar for another, but these excision lines generally heal very very well with a practically invisible result. In particular, the new flat scar casts no shadows (unlike the acne scar it replaces) and so is not noticeable in ordinary light. Quite often a punch biopsy tool is used to make the incision, and so the wound is only 3 or 4 mm long.

Excision and subcision strategies are not practical when a patient has very many scattered small scars. At the simplest level such patients can be treated with microdermabrasion, and microdermabrasion is helpful for superficial scars, but those with moderate or deep scars need to consider a treatment with a deeper focus, such as laser resurfacing and roll-CIT.

The managment of acne scars at any location is an involved process. A detailed assessment is required; available with a consultation.