A stepwise approach to supporting young people troubled by acne

The emotional impact can appear out of proportion to the physical manifestations

For those of us whose teenage years are but a distant memory, “spots” or “zits” may seem like a fairly trivial rite of passage into adulthood. But for some of the 80 per cent of young people who get acne, it can be incredibly distressing, having a huge impact on self-esteem, body image and mood, which can already be fragile at this stage of life.

The spectrum of acne severity is broad – at the milder end, people will have a small number of spots every now and then, while others will be affected so badly their face, chest and back are covered with painful lumps, resulting in scarring that will never disappear.

Interestingly, the emotional impact can appear out of proportion to the physical manifestations, so asking about and responding to the degree of emotional distress they are experiencing, as opposed to just treating the external appearance of the acne, is crucial to successful management.

Acne affects more young men than young women, and although it is most common in the 11 to 25 age group, it can start earlier than this. For some, it can persist well into adulthood – approximately 5 per cent of women and 1 per cent of men will continue to have problems beyond the age of 25. Although it can be associated with other conditions, such as polycystic ovarian syndrome or Cushing disease, the underlying cause is mostly genetic.

In terms of pathophysiology, during puberty, there is hyperkeratinisation of hair follicles, as well as an increase in the amount of sebum production. This combination leads to blockage of the follicles by keratin plugs, and the appearance of comedones – closed comedones are known as blackheads (the black appearance is oxidisation of the keratin plug) and open ones are known as whiteheads. Cutibacterium acnes (formerly Propionibacterium acnes) then colonises and proliferates in the sebum, causing an inflammatory response and the appearance of papules, pustules and inflamed nodules.

Non-inflammatory acne is that with predominately comedones and cysts, and inflammatory acne includes papules, pustules and nodules. Of course, many young people will have a mixed type with a variety of lesions present.

Although some young people will present to their GP with the aim of talking about their acne, others will be far too embarrassed to do this, so it is something I specifically ask about. There are various ways you can introduce this into the conversation:

• As part of a general health chat – “While you’re here, I’d like to ask some general questions about your health. Do you have any worries about what you eat, your mood, your skin…”
• When asking about periods or contraception – “Do you find your skin gets worse around your period? If so, how does it make you feel?”
• By using the generalisation trick – “Many young people I see find it quite distressing/upsetting to get spots. Is this something that happens for you?”

When a young person does tell you they are getting acne, the key thing is to try to assess the impact this is having on them. Even if their acne is at the mild end of the spectrum, if it is having a huge impact on their wellbeing, you will need to step up your treatment to manage this.

In terms of assessment, making the diagnosis can almost entirely be done on the history alone, providing you ask the right questions:

• When did you start getting acne?
• How often do you get it, or is it there all the time?
• Is there an obvious trigger? For young people who are menstruating, specifically ask if this is when they get a flare-up of their symptoms.
• Is your skin sensitive or dry? Determine if they have a history of atopic eczema.
• What skin products are you using? This includes cosmetics, sunscreens, moisturisers, cleansers or other things that might be occlusive and potentially exacerbating symptoms.
• Do you use any other topical products, such as steroid creams for eczema?
• What over-the-counter acne treatments have you tried, and for how long?
• Determine whether there is anything to suggest recreational steroid use.
• Are there symptoms of low mood, low self-esteem, depression, anxiety or other mental health issues?
• Are there any symptoms or signs to suggest other pathology (eg, oligomenorrhoea, hirsutism, weight gain, striae)?

I try to minimise the extent of the physical examination, largely because many young people with acne are extremely self-conscious of their body, and showing a relative stranger can be really hard for them.

If they are happy to be examined, I look at their face and trunk, and assess how widespread their acne is, whether it is largely non-inflammatory or inflammatory, and whether or not they have any scarring. If the idea of being examined is really distressing for them, I get them to describe the spots they get or to send me some pictures when they next get a flare-up.

Unless you are really concerned that there could be other pathology (particularly PCOS), or you are considering starting isotretinoin, there isn’t a huge need for any blood tests at this stage.

In terms of management, be guided by how much this is impacting them and take a stepwise approach.

Explanation and education – these are key! I try to tell all the young people I see with acne that they’re not alone and most of their peers will also have this, although they won’t all be talking about it. I also stress that they haven’t caused their acne through poor diet, bad skin hygiene or anything else – it is due to genetics and the stage of life they are at, and, with time, nearly everyone grows out of it. Lastly, I advise them that expensive cosmetics and other acne “treatments” are unlikely to be effective, and they shouldn’t believe everything they read on the packaging!

Skin care – in general, lots of cleansing, scrubbing or exfoliation can actually make acne worse by further irritating the epidermis, so it should be avoided if possible. Gently trying a face wash containing salicylic acid can be helpful. Oil-based sunscreens, make-up and other cosmetics should be avoided; water-based ones are preferable. Squeezing and picking lesions will lead to more nodules and potential scarring, so should also be discouraged. Lastly, advise them that removing all make-up before going to sleep is a good idea too.

Topical therapies – for mild acne, I try either benzoyl peroxide, topical retinoids, azelaic acid cream or lotion, or a topical antibiotic (always in combination with either benzoyl peroxide or a retinoid to reduce the risk of antibiotic resistance). The choice of topical treatment will depend on what they have used before and how they responded to it, what kind of skin they have, and whether they can afford the non-subsidised options.

Oral antibiotics – these are appropriate for young people who are more affected by their acne or who have tried topical treatments with no success. They can be used in combination with a topical retinoid or benzoyl peroxide. Doxycycline is first line, and erythromycin should be reserved for those who either get no response to doxycycline or are allergic. Most treatment trials fail due to an inadequate length of therapy, so it’s worth advising users that they probably won’t see any response before about six weeks, and that they should keep taking them for four to six months if they are working well. At that stage, I would discuss stepping down the dose and weaning off, while continuing the topical options.

Combined oral contraceptive pill – for young people who get acne flares associated with menstrual cycles, the COC pill can be highly effective. It’s also a great option for anyone requiring contraception who would also benefit from acne treatment. Although the anti-androgenic pills (ie, those containing cyproterone or drospirenone; Ginet, Yaz or Yasmin) are thought to be slightly better for people with PCOS, any COC will be effective for simple acne, but they will often take six cycles of use to get good results.

Oral isotretinoin – consider this for any young person who has failed to respond to adequate courses of the above oral agents, or who has acne that is severely affecting them and can’t trial the other options for some reason. Although very effective for most users, isotretinoin has a multitude of potential side effects, especially mucocutaneous ones. It also needs to be monitored and shouldn’t be used as a first-line agent unless there are exceptional circumstances. It’s really important to ensure any young person on isotretinoin is also on effective contraception (ideally long-acting reversible contraception) as it is highly teratogenic.

Lastly, make a plan to check in with the young person in a few weeks or months – this is a really good opportunity to see how effective the treatment has been, but also to assess how they are doing from the point of view of their wellbeing, and to provide extra support as required.

Cathy Stephenson is a specialist GP at Mauri Ora, Student Health and Counselling, Victoria University of Wellington