Acne is a distressing condition, but pharmacists can offer effective treatments and counselling that can make all the difference to a patient’s wellbeing, writes Dr Rod Tucker
Key learning points
• Acne is a common condition that has a negative impact on quality of life
• Patient education on self-care and how to use topical treatments is vital to ensure the condition is managed effectively
• Many patients have mild to moderate disease, which can be easily managed in pharmacies
Acne is a very common skin problem, affecting 80% of teenagers (aged 13 to 18 years) at some point and each year accounts for some 3.5 million GP appointments. Although predominately
a teenage problem, acne can persist into adult life, affecting roughly 12% of women and 5% of men aged 40 or over.[3,4]
Although acne is considered by many as a trivial disease that adolescents grow out of, research suggests that the impairment in quality of life is comparable to the impact of other chronic diseases such as asthma, epilepsy and arthritis. Pharmacists have an important role to play in facilitating effective self-care for those with mild to moderate-severity acne because over-the-counter topical treatments are licensed for the management of this level of disease.
Cause of acne
The precise cause of acne remains unclear, though there are at least four factors: altered sebum excretion; abnormal keratinocyte proliferation and differentiation (comedogenesis); proliferation of Propionibacterium acnes (P. acnes) in functionally blocked follicles; and a host-induced inflammatory response.
Acne is a disease of the pilosebaceous follicle and during adolescence there is an increase in the production of sex hormones (mainly androgens) that cause sebaceous gland hyperplasia with a corresponding increase in the output of sebum. This gives the skin a greasy appearance, which is the first sign in the development of acne.
There is also an increase in the production and desquamation (shedding) of the keratinocyte cells lining the pilosebaceous follicle. These cells become unusually cohesive and block the follicular opening.
If the blockage occurs close to the surface of the skin, pigment in the desquamated cells reacts with the atmosphere and turns black. This produces an open comedone or blackhead; if the blockage occurs further down the lumen of the canal, the increased pressure from sebum trying to escape raises the skin to produce a flesh-coloured lump, which is known as a closed comedone or whitehead.
Once comedones are formed, P. acnes thrives in the oxygen-deficient and sealed environment and hydrolyses the sebum into glycerol and free fatty acids. These are released into the surrounding epidermis and provoke an immune response that leads to the formation of inflammatory lesions.
Types of acne lesions
Typically, a patient with acne presents with the following lesions:
• Open comedones (blackheads).
• Closed comedones (whiteheads).
• Papules – small, pink or red inflamed lesions that can be tender to touch.
• Pustules – inflamed papules with white or yellow pus-filled tops.
More severe forms of acne will be more widespread with lots of inflammatory lesions as well as:
• Nodules – large and painful solid lesions deep within the skin.
• Cysts – like nodules but filled with pus, which can lead to scarring.
Classification of acne
While there are various grading systems for acne, none have been universally accepted.
In primary care, the following classification is used:
• Mild acne – a limited number of non-inflammatory comedones.
• Moderate acne – a mixture of both inflamed and non-inflamed lesions.
• Severe acne – widespread and extensive, affecting the face, chest and back and characterised by a larger number of both non-inflamed and inflamed lesions together with nodules and cysts.
Treatment options in the pharmacy
The majority of patients have facial acne and a smaller subset have chest and back involvement. Nevertheless, if acne affects the chest and back, unless it is mild, referral to the GP is advisable, since treating these areas with topical agents is more difficult. Patients who have evidence of scarring should also be referred.
An important caveat is that acne responds very slowly to treatment and all products should be used for at least six weeks before giving up. It is vital that this is communicated to patients who want an instant cure. Furthermore, topical agents should be applied to all acne-prone areas of the skin rather than to individual lesions, as most drugs target emerging rather than existing lesions.
There is a wide range of facial washes available and such products are commonly used. In addition, there is a vast array of ingredients in these washes including lipo-hydroxy acids, glycolic acid, linoleic acid and alpha-hydroxy acids. While small-scale studies suggest these ingredients might help, further work is needed to provide more convincing evidence. One agent used in facial washes is salicylic acid, which is a keratolytic and is of benefit in comedonal acne.
The most commonly used topical anti-acne drug is benzoyl peroxide (BPO) and its clinical efficacy has been demonstrated in many studies.
BPO has both comedolytic (breaking down blackheads and whiteheads) and a powerful bactericidal effect. In fact, twice daily application of 5% BPO gel can reduce the population of P. acnes by more than 95% after five days – a feat that no antibiotic can match – and there is currently no known resistance to BPO. This is due to its mode of action. Once in the skin, BPO degrades
to benzoic acid and hydrogen peroxide, generating free radicals, which destroy P. acnes.
The two main problems with BPO are, first, that it is a powerful bleaching agent that will discolour clothes, pillows, bedding etc. Also, it is potentially irritant. One way to reduce the irritancy is to initially apply BPO products for limited periods of time (say, 15 minutes) before washing off and to gradually increase the contact time.
This vitamin B3 compound has anti-inflammatory and bacteriostatic properties and there is evidence that it can reduce the rate of sebum excretion. Although there are few studies, randomised trials suggest that nicotinamide can significantly improve acne and that the improvement is comparable to the topical antibiotic clindamycin.
Acne products are available in gels and creams and there is little evidence that either is more effective. While some authorities argue that patients with greasy skin benefit from using a gel (because of the drying effect) and those with dry skin are better with a cream, there is little evidence to support this.
It is more important that the patient finds a formulation they are happy to use. Both dryness and irritation are common with all topical therapies and patients should be advised to use non-comedogenic (oil-free) moisturisers to combat these adverse effects. If the active topical agent such as BPO is used at night, an oil-free moisturiser can be used in the morning after washing or showering.
Lifestyle factors affecting acne
One factor that has attracted a great deal of attention in acne is diet. In a recent survey of acne sufferers, 92% believed diet could affect their condition. Moreover, 71% mentioned fried, greasy foods, 53% chocolate and 47% dairy products as factors that aggravated their acne. In recent years, there has been much speculation on the influence of diet in acne, especially as studies of native non-westernised populations in Papua New Guinea and Paraguay reveal a virtual absence of the condition.
This has led to the idea that the Western diet with a high glycaemic load (highly refined carbohydrates such as white bread and cakes) leads to an increased production of androgens, which then worsens acne. In fact, a randomised, controlled, low glycaemic index dietary trial, emphasising fresh fruits and vegetables and avoiding refined carbohydrates, did show a significant reduction in acne lesions after three months. But the role of diet in managing acne remains controversial and if anything, patients should be advised to adopt a healthy diet.
Hygiene and sunlight
Poor hygiene (lack of washing) as a causative agent and lack of exposure to sunlight are often cited as lifestyle factors in acne. However, there is little evidence that either has a noticeable effect. Patients also like to use facial washes that contain particulates (exfoliants) and believe that these unclog the pores. However, vigorous scrubbing is more likely to irritate the skin and worsen acne.
People with acne who wish to use make-up should look for the term non-comedogenic (oil free) on the label. Heavy make-up products can block pilosebaceous follicles, exacerbating acne.
Other factors that appear to aggravate acne include emotional stress, smoking and picking at lesions.
Talking to patients
According to a recent survey by the British Skin Foundation of more than 2,000 people with acne, 95% said it had an impact on their daily lives and 63% reported a drop in self-confidence because of their acne.
If a patient is browsing facial washes, approaching them and inviting them into the consultation room for a private discussion should signal that you are sensitive to their possible embarrassment.
It is also important not to undermine their perception of acne severity. While your perception might be that their acne is mild, the effect on them might be profound.
Pharmacists should discuss the treatment options available in the pharmacy and how each therapy should be used. The importance of perseverance should be emphasised because treatments are slow to work. Likely side-effects, such as dryness and irritation, and how these can be managed should also be explained to the patient.
Pharmacists should understand that acne can have a huge psychological impact on sufferers, who are likely to be embarrassed when seeking help. Nevertheless, pharmacists should reassure patients that acne is very treatable, if therapies are used correctly.
The retinoid adapalene has recently been approved for over-the-counter use and is likely to become an additional treatment option for UK pharmacists.
Dr Rod Tucker is a community pharmacist and researcher at Robert Gordon University, Aberdeen
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