Two dermatologists on exactly what to do to treat acne properly.
Is there a skin condition more prevalent than acne? Acne vulgaris (as it’s formally known) affects around 9.4 per cent of the global population, and will strike regardless of gender, age or race, which explains why the term “acne” has nearly 23 billion views on TikTok—with a further 28.5 million views on the term “adult acne.” Recent research also suggests that its unwanted appearance in our lives—and on our skin—has only increased, too.
“Genetics play a huge role in why someone will break out,” says dermatologist Dr Alexis Granite. “And then combining that with all the elements of the Western lifestyle: processed foods, high stress, pollution… This is just my take on it, but I’m sure it’s all the little things we’re exposed to, including endocrine disruptors and micro-plastics. It’s impossible to eliminate all of these things, and they’re probably why there is a big uptick in acne, particularly in adults.” She also notes that puberty happens much earlier in children nowadays, which subsequently means that acne presents itself much earlier, too.
The psychological toll
Suffering from acne isn’t just a case of dealing with bad skin and getting on with it; often it’s accompanied by mental health issues—and they can be extreme. Anecdotally, many of us can confirm that our self-esteem drops when breakouts surface, but the scientific research also backs this up. Studies show that high rates (up to 40 percent) of patients with acne suffer from depression and anxiety, with six to seven percent feeling suicidal. If you belong in either camp, seek professional help.
Menopause and acne
“There’s been so much chatter about the menopause—which is obviously great—over the past few months. But the one thing that nobody is talking about is the fact that if lots of women go on HRT—in particular, progesterone and testosterone—they’re going to get acne,” says dermatologist Dr Anjali Mahto. “I am now seeing a massive spike in postmenopausal women, who started HRT in the past month or two, that are getting acne for the first time.”
Naturally, this can be really stressful—especially if you thought your acne days were long gone. Dr. Mahto says that a low dosage of isotretinoin (or roaccutane) works really well to treat acne in this instance. “The side effects of roaccutane are dose-dependent—the higher the dose you’re on, the more likely you are to get side effects—so giving these women a very low dose actually means they dodge them.”
Treating acne properly
Of course, acne has been around forever, and Dr Granite notes that the treatment plan hasn’t changed all that much from days gone by. “I have a lot of mums bringing their daughters in who expect that the treatments have evolved, but really we’re still using a lot of the same prescriptions,” she says. That’s if you go to a dermatologist—more on which later.
With the rise of social media and the internet as a whole, many consumers have begun taking their skin health into their own hands—often with detrimental effects. With so many active ingredients available over the counter, dermatologists have noted an increase in patients with acne-presenting problems that are actually a result of an impaired skin barrier due to excessive use of active ingredients and stripping formulas.
Not to mention the birth of skincare communities on platforms like Facebook (where users post their skin issues to glean advice from other users), which can be positive places, but often also lead to misdiagnoses. “What I see a lot of is people who think they have acne, when actually they have rosacea,” says Dr Mahto. “Then they start using a whole load of really active, high-strength, prescription retinoids, and that makes the rosacea worse.”
The other issue is that, without a proper consultation with an expert (and preferably a dermatologist), many acne sufferers mistakenly think they need a prescription topical product, such as a retinoid, when “it’s obvious that what they need is oral medication”, explains Dr Mahto. “The reason why things like laser facials, chemical peels and topical retinoids don’t work for everyone is because if you have got deep acne—nodular or cystic—that inflammation is sitting quite deep in the layers of the skin,” she says. “And all of these treatments are superficial and don’t penetrate to where the problem actually is.”
Dr. Mahto, who incidentally suffered from acne herself, regularly sees clients in clinic who have been “prescribed” a series of (expensive) treatments by someone who isn’t a dermatologist, and not seen the results they expected—or, worse, their skin has gotten more reactive. “They’ve had six sessions of IPL, three rounds of microneedling and been sold a whole load of medical skincare to sort their acne and acne scarring, and things aren’t better,” she explains. “That’s thousands of pounds worth of treatment—and it took me two minutes to see that what needed to happen was to sort the acne out first, and then treat the skin afterwards. It’s not fair on any patient.”
The lesson is always to see a dermatologist to ensure skin issues are diagnosed properly. It may seem expensive at first, but in the long run it will save you cash.
What to expect when seeing a dermatologist for acne
A dermatologist’s first port of call upon seeing a new client is to take a detailed history of their skin and lifestyle, from how long their acne has been there to any treatments tried. “I want to know about their periods, any previous medical issues, diet—whether they are vegetarian, vegan or cutting out loads of food groups—whether they smoke and drink,” says Dr. Mahto. “I ask a lot of questions at the beginning.”
Once she’s done that, she examines the skin and looks for severity, scarring and mental health impact, and whether the patient feels self-conscious in their skin, and so on. Then it’s on to the plan of action. “I see acne treatment in three phases,” she explains. “Phase one is getting the acne switched off—that might be an oral medication. Once you’ve got the acne switched off and the bumps have gone, the next step is acne maintenance. That’s reducing the likelihood of the acne coming back in the future, so keeping pores decongested, and a decent skincare routine that’s geared towards acne-prone skin.” The third phase is treating the scarring, which is what treatments like microneedling, laser and peels are for—it’s just crucial to have the acne itself under control first.
Retinoids and what works for acne-prone skin
“Prescription-wise, you can use creams, hormonal treatments, antibiotics, and roaccutane and, similarly to aesthetic treatments, we often combine them because that tends to work best,” says Dr Granite, who adds that over-the-counter products—often a patient’s first port of call—have gotten much better in recent years. What used to be a stripping formula or tea tree oil has been replaced with ingredients like salicylic acid, benzoyl peroxide, AHAs, BHAs and PHAs, which help treat inflammation, unclog pores and dry out some of the oil in the skin.
Crucially, skincare brands are now switched on to the fact that, in the past couple of years, consumers have fallen into the habit of throwing every acne-busting ingredient and formula they can at the problem, in a bid to clear it up as quickly as possible—only to disrupt the skin barrier. “High-strength blemish treatments can be really alluring to those with vulnerable skin,” agrees Daniel Isaacs, chief product officer at Medik8. “They combine the awe of high-percentage actives with promises of fast, decongesting results—but at what cost? Overloading the skin, in particular, sensitive, blemish-prone skin, can result in an impaired skin barrier which in turn can leave skin susceptible to damage, inflammation and further breakouts.”
The brand’s new Press & Clear formula harnesses the power of BHA salicylic acid (two per cent), which is oil soluble and able to penetrate deep into the pores to break down the blockages which lead to congestion. The formula contains technology which slowly releases the salicylic acid to prevent discomfort while maintaining power and efficacy. “It has a very skin-friendly pH of around 5.5,” adds Isaacs. “Alongside the brightening active tranexamic acid, sake extract and aloe vera soothe, hydrate and offset any dryness. The skin barrier is nourished, supported and resilient to future breakouts.”
Retinoids, whether prescription strength or bought over the counter, are the gold standard to treat acne-prone skin. “Retinoids are very good applied topically if you’ve got comedonal acne, lots of blackheads or blocked pores beneath the skin,” says Dr. Mahto. “But they’re quite strong, so if you’re using one, I recommend combining with a cleanser and/or moisturizer that’s geared towards sensitive skin to prevent disruption to the skin barrier.” Avoid ingredients like drying alcohols and fragrances, too.
One thing worth noting about retinoid use is that, because they accelerate skin turnover, sometimes they can initially cause the skin to purge, meaning it can look worse for a time, advises Dr Granite. “Everything that was lurking under the skin surface comes out at once,” she says. “And for some people that can be really, really discouraging.” Play the long game—and expect an improvement after 12 weeks.
This article was originally published on British Vogue.