Acne

What is acne?

Acne is a common skin condition that happens when hair follicles, the tiny openings your hair grows from, become clogged with oil, dead skin cells and bacteria. This causes spots, oily skin and sometimes skin that feels hot or sore to the touch.

What are the symptoms of acne?

Acne most often affects your face, but it can also appear on your back, chest, neck and shoulders. There are several types of spot, which can appear at the same time:

• Blackheads, small dark bumps where a pore is blocked but stays open at the surface
• Whiteheads, similar blocked pores that stay closed, so they look firmer and paler
• Papules, small red bumps that can feel tender or sore
• Pustules, similar to papules but with a white, pus-filled tip
• Nodules, large hard lumps beneath the skin that can be painful
• Cysts, large pus-filled lumps that carry the highest risk of permanent scarring.

Acne can also affect how you feel about yourself. It's common to feel low, anxious or self-conscious because of it, and this is worth mentioning to your GP or pharmacist alongside your physical symptoms.

What causes acne and who's at risk?

Acne is driven by hormones, particularly androgens such as testosterone, which become more active during puberty and cause the skin's oil glands to produce more sebum (an oily substance). This extra oil, combined with dead skin cells, blocks pores.

Bacteria that normally live harmlessly on your skin, called Cutibacterium acnes (C. acnes, previously known as P. acnes), then multiply in the blocked pore and trigger the redness, swelling and pus of a spot.

A number of things can cause or worsen acne:

• a family history of acne, if your parents had it, you're more likely to get it too
• hormonal changes around periods, pregnancy or hormonal contraceptives
• high-dose steroid medication, including anabolic steroids sometimes used for bodybuilding
• oily or greasy skincare, haircare or make-up products, or contact with oily substances at work
• tight clothing or headgear, humid conditions and stress
• picking or squeezing spots, which makes acne worse and increases the risk of scarring.

There's no good evidence that specific foods cause acne, and it isn't caused by poor hygiene. Some studies do link diets high in sugar to worse breakouts, so a healthy, balanced diet is still a sensible precaution.

If acne suddenly starts or worsens in adult women, especially alongside excess body hair or irregular periods, it can point to a hormonal cause. The most common of these is polyendocrine metabolic ovarian syndrome (PMOS), a condition recently renamed from polycystic ovary syndrome (PCOS), which can be diagnosed with an ultrasound scan and blood tests.

Acne is extremely common: estimates suggest somewhere between 80% and 95% of people aged 11 to 30 are affected to some degree. It's most common in girls aged 14–17 and boys aged 16–19, and it usually settles by your mid-20s, though around 3% of adults over 35 still have it.

Are there different types of acne?

Dermatologists usually grade acne as mild, moderate or severe, based on how many spots you have and what type they are. Mild acne is mostly blackheads and whiteheads with a few papules or pustules, while severe acne involves numerous painful nodules or cysts and carries the highest risk of scarring.

Two other patterns are commonly described. Cystic acne causes deep, pus-filled nodules and cysts, and is more likely to scar. Hormonal acne refers to breakouts driven by hormonal changes in adulthood, and is more common in women.

How is acne diagnosed?

A GP or pharmacist can usually diagnose acne just by looking at your skin, checking your face, chest and back for the different types of spot. Tests aren't normally needed.

They may ask about your family history, stress levels, any pattern linked to your menstrual cycle, and any medications you're taking, since these can all be relevant. How severe your acne is guides where you should go for help: a pharmacist for mild acne, or a GP for moderate or severe acne.

How is acne treated?

Treatment depends on how severe your acne is, and it can take several months of consistent use before you see the full benefit, so it's worth sticking with a treatment rather than switching too soon.

Self-care and over-the-counter treatment

For a few spots, simple self-care and pharmacy products are often enough:

• Wash the affected area no more than twice a day with a mild soap or cleanser and lukewarm water
• Avoid oil-based make-up, skincare and haircare products, choosing water-based or 'non-comedogenic' versions instead
• Remove make-up before bed, and avoid picking or squeezing spots
• Try an over-the-counter gel or cream containing benzoyl peroxide, salicylic acid or azelaic acid, usually starting with a lower strength once a day.

Benzoyl peroxide usually needs around 6 weeks of use to clear most spots, and can bleach fabric, hair and towels, so take care with clothing and bedding. A pharmacist can advise on the right product and strength.

Prescription and specialist treatment

See a GP if pharmacy treatments haven't worked, or if your acne is moderate to severe. Prescription options include:

• Topical retinoids or topical antibiotics, usually applied once or twice a day for 6–8 weeks
• Oral antibiotics (usually tetracyclines, or erythromycin if you're pregnant or breastfeeding), typically taken for 4–6 months
• Hormonal treatments for women, including the combined contraceptive pill (which can take up to a year for full benefit) or co-cyprindiol*, usually used for 2–6 months
• Isotretinoin** capsules for severe acne that hasn't responded to other treatments, prescribed only by a specialist because of the range of possible side effects.

Your GP will refer you to a dermatologist if you have widespread papules and pustules on your face, chest and back, painful nodules, scarring, or if acne is affecting your mood.

*Co-cyprindiol carries a small extra risk of breast cancer with long-term use (around 17 to 18 cases per 10,000 women by age 35, compared with 16 per 10,000 who haven't taken it) and a small risk of blood clots, at around 1 in 2,500 a year.

**Isotretinoin cannot be used in pregnancy because of the risk of birth defects, so pregnancy tests are usually required before starting it. Close monitoring is also required while on this medication due to side effects.

Non-drug options such as chemical peels, lasers or light-based treatments, or manual comedone extraction, are also available. These may not work for everyone and aren't routinely offered on the NHS.

When should you see a doctor?

Speak to a pharmacist if you have mild acne, or see a GP if pharmacy treatment isn't working, if your acne is moderate or severe, or if you develop nodules or cysts, since these need proper treatment to avoid scarring.

You should also see a GP if:

• your acne is making you feel very low, anxious or is affecting your confidence
• you're developing scars or you're worried you might
• acne starts suddenly or worsens significantly in adulthood, particularly alongside other symptoms such as excess hair growth or irregular periods.

Acne can have a real effect on mood and self-esteem, and this alone is a good reason to seek help, not just the visible spots. Support is available, so do mention it to your GP or pharmacist if it's getting you down.