June is designated as Acne Awareness Month, and this gives a great opportunity for community pharmacists to engage with patients either seeking advice and/or treatment for the condition, as well as those already using an anti-acne product.
Patients have also expressed their dissatisfaction with GP consultations, who are perceived as “ignoring the emotional and psychological impact of acne”, as well as providing a “lack of information on how to use treatments effectively”, and it seems that community pharmacist’s knowledge may also be inadequate, according to some research.
Despite apparent failures of knowledge and understanding among health professionals, pharmacists continue to be used as a source of advice and treatment for acne. In a European study of over 10,000 people with acne, 28.7% reported being more likely to be using a topical anti-acne cosmetic product recommended by their pharmacist, and in the UK, just over a third of patients have sought advice and help from a pharmacist.
Acne is a an extremely common skin condition that is estimated to affect up to 90% of teenagers (aged 13 to 18 years) at some point. However, you will know that this is not simply a teenage problem, and research has highlighted how the condition can persist into adult life, affecting just over a quarter of women aged 40 to 49.
The impact of this common condition should never be underestimated. The visible nature of acne can have a negative impact on quality of life and even result in suicidal thoughts. A further compounding issue that that several surveys demonstrate that patient’s knowledge of acne is suboptimal, with one recent study noting “a gross lack of knowledge about acne amongst our younger population”.
This makes all consultations about acne, and even quick advice about product choice, extremely important.
What causes acne?
Acne is a disease of the pilosebaceous follicles (PSF), which are hair follicles with an attached sebaceous gland that produces sebum. The PSFs are present all over the surface of the skin with a much higher concentration in the T-zone of the face (forehead and cheeks), as well as the chest and back.
While the precise cause of acne remains to be determined, four key factors have been strongly implicated: the release of inflammatory mediators in the skin; an increased production of altered sebum; abnormal keratinocyte proliferation which leads to plugging of the PSF, and finally proliferation of Cutibacterium acnes (C. acnes), which is a bacterium present on the surface of the skin. The blocked follicle is termed a microcomedone and represents the initial acne lesion from which all other lesions evolve.
How can pharmacy teams help?
It is important to treat acne to minimise the risk of scarring, which is much more difficult to manage. Ideally, pharmacist’s advice to patients should include a discussion of the cause, as well as helping to dispel many of the myths surrounding the condition.
For instance, it is commonly believed that dietary and lifestyle factors such as stress negatively affect acne though further work is needed to clarify these associations. Pharmacists should therefore advise patients to adopt a healthy diet, although it would seem sensible to avoid any foods that an individual patient finds worsens their acne.
In primary care, acne severity is categorised as either mild (mainly comedones, aka blackheads and whiteheads), moderate (a mixture of comedones and inflamed lesions, i.e. the papules and pustules), or severe (more widespread) with nodules and cysts. Pharmacy treatments are appropriate for those with mild to moderate disease although if the acne has spread to the back and chest, topical treatment alone is often not practical and hence it is important to refer these patients.
One of the most effective over-the-counter treatment options is benzoyl peroxide, but it is often discarded by patients due to the common side-effects of irritation and skin dryness. These adverse effects can be easily minimised through use of emollients, particularly those labelled as ‘non-comedogenic’ or ‘oil-free’.
The ‘black’ colour of open comedones is incorrectly perceived as dirt, prompting many to assume that acne caused by inadequate hygiene and hence the popularity of facial washes. Unfortunately, there is a lack of good quality evidence to support the use of these products in acne.
Patients with more widespread acne are normally prescribed oral antibiotics, which have both anti-inflammatory and anti-bacterial effects. Topical therapy can be used in combination with oral agents, and current guidance indicates that all patients should also use a topical retinoid, which corrects the abnormal keratinocyte proliferation seen in acne. Unfortunately, topical retinoids are under-utilised in the UK, which might reflect a lack of understanding of the importance of this class of groups among health professions. As with benzoyl peroxide, retinoids can lead to skin irritation, and patients should be advised to practice short-contact therapy, i.e. applying the drug and washing off after about 30 minutes to minimise the adverse effects. In addition to their potency irritancy, both benzoyl peroxide and topical retinoids can cause photosensitivity reactions and it is advisable that patients use a sunscreen. It makes sense therefore to recommend the use a commercial moisturiser designed for acne-prone skin with an added sun protection factor (at least SPF 30).
Patients need to persevere with treatments. Acne responds slowly to treatment, as witnessed in a large primary care trial which showed that most improvement occurred within the first six weeks of treatment. If there are not been a response within this time-frame, then ask the patient to come back, rather than just referring to the GP. Recheck that they have been using the treatment correctly and offer alternative treatments, e.g. nicotinamide gel, particularly if they have inflammatory acne. It is also important to warn patients that there is often an initial “flare-up” or worsening of their acne (especially with topical retinoids) which settles down after about two weeks.
It is important that pharmacists are aware of the criteria for GP referral. Clearly patients who have failed to respond to over-the-counter treatments should be referred – provided that the use of these treatments has been optimal. Other patient groups who need referral include:
- Those with more widespread disease (which is difficult to manage with topical agents alone)
- Evidence of nodules and cysts
- Psychological distress, i.e. where the patient is clearly disturbed by their acne.
Acne is a potentially socially disabling disease which can be easily treated provided that the patients are appropriate assessed and treated.
While much attention has currently focused on Covid-19, we should not forget that a huge number of our teenage patients will want to treat their acne. Hopefully this month, pharmacy teams will take a proactive stance on the condition and demonstrate that we have much to offer our acne patients.