What causes acne?
Skin has two main layers €“ the outer epidermis and the underlying dermis €“ as well as structures including hair follicles, sweat glands and cells that produce melanin. The specific part of the skin affected by acne is sometimes referred to as the pilosebaceous unit (PSU). The main component of the PSU is the sebaceous gland, a small gland connected to a hair follicle in the skin that produces an oily substance called sebum. The sebum empties onto the skin surface through the small pores of the hair follicle. PSUs are particularly common on the face, upper back and chest €“ the areas most commonly affected by acne.
Acne is associated with puberty and is therefore caused by the skin's reaction to hormonal changes. During puberty, levels of the hormone testosterone increase in both sexes. As a result, the sebaceous glands in the skin are stimulated to produce higher levels of sebum, which is why teenagers often suffer from oily skin and greasy hair.
Dead skin cells, which form the outermost layer of the skin, are constantly being formed and replaced by new skin cells. In acne, some of these dead skin cells mix with excess sebum and block the tiny pores of the skin. In addition, bacteria (usually Propionibacterium acnes), which normally occur harmlessly on the skin's surface, thrive in this excess oil and multiply. If the bacteria grow inside a clogged skin pore, that pore can become red, swollen and inflamed.
Reflective exercise
Emma, 15, comes to the pharmacy with a friend, asking for an acne treatment. Her friend mentions that she previously tried a gel, which was effective. Emma has had mild acne on her forehead since she was 13. She is going to be a bridesmaid at a family wedding in a few months time and wants her acne to have improved by then.
What questions would you ask?
As Emma has suffered with acne since she was 13, ask whether she has tried any medication in the past and if it was successful. Check whether Emma is taking medication for any other condition, as it may be inducing her acne. Non-epileptic medication in particular can cause sufferers to break out in an acne rash. Emma says she has not tried any acne treatments, and is not epileptic or taking any other medication.
What would you recommend?
Emma could start off with a product containing benzoyl peroxide. As her friend found a gel formulation to be effective, she may want to try a similar product. Show her the range of formulations and brands in stock. She should start with the lowest strength and work up to higher strengths if necessary. However, in many cases, the 2.5 per cent strength works just as well as the higher strengths and doesn't cause as much skin irritation. Advise Emma to clean her face at least 10 minutes before applying the gel. Emphasise that the gel should be used sparingly, twice a day at most, to reduce irritation. Care should be taken when applying the product near hair or clothes as it can cause bleaching.
What if:
Emma mentions that she thinks wearing make-up may be the cause of her acne. This is a common myth and although certain cosmetic products can irritate skin, they do not cause acne. Emma should use oil- and fragrance-free moisturisers, and look out for products labelled 'non-comedogenic' as these will have a light, non-greasy formula that doesn't block pores. Wearing oil-free make-up and removing it thoroughly before bed may also help to improve symptoms.
What if:
Emma returns to the pharmacy a month later saying the gel has not made any difference. The acne on her forehead is getting worse and she's becoming increasingly frustrated.
Check that Emma is using the gel as instructed. Reassure her that it can take up to eight weeks for products to have any effect and for skin to noticeably improve, so it may be worth persevering with the product for another month. If symptoms haven't improved after eight weeks, recommend trying a higher strength of benzoyl peroxide. Also ask Emma if she is happy with the gel formulation or if she'd like to try a cream or spray instead. If it appears that Emma's acne is affecting her confidence or making her very unhappy, refer to the pharmacist.