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Acne in adolescents
Kurt Gebauer

A
Background cne vulgaris (vulgaris meaning common in Latin) affects
Acne vulgaris affects more than 90% of Australian adolescents more than 90% of Australian adolescents aged 16–18
aged 16–18 years. It may have a significantly deleterious effect years. In most cases, it is a self-limiting complaint.1
on their self-esteem and emotional state. Moderate-to-severe However, it takes several years for acne to naturally resolve in this
acne can lead to scarring. There are many treatment options patient group. It has a profound impact on self-esteem, mood and
available. Most teenagers obtain information from their peers psychological status. Moderate-to-severe acne has the potential
or from the internet. to cause permanent scarring.2
The thrust of this article is inflammatory acne in young people.
Objective Although parents and most doctors consider acne to be a disease
of puberty, increasingly, comedonal acne is now seen in children
The aim of this article is to inform general practitioners (GPs)
under the age of 10 years. The reasons for this include that
of the pathogenesis, physiology and description of acne, as
children are maturing earlier and are generally of a larger size
well as therapeutic options, including topical and systemic
therapies. Skin care, diet and other factors of importance are than previous generations. The belief that acne is caused by poor
also discussed. hygiene, excessive consumption of fatty foods and chocolate has
not been validated by extensive research.3,4
Discussion It is important to realise that your patients have received
extensive information from commercial sources via the internet
The first point of contact with patients is in general practice. where cosmetic and other companies have extensively marketed
GPs effectively manage most patients with acne. Treatment products, many of which make no logical or medical sense. As
choice is guided by experience, with many clinical acne in all aspects of medicine, our patients withhold or disguise such
treatment guidelines available. The most common reason for
information. This is especially important in the atopic group,
treatment failure is insufficient duration of therapy. Successful
who already have a fragile epidermal barrier. Excessive washing,
treatments require months of topical agents and, in many
scrubbing and the use of extensive topical agents makes the use
cases, additional systemic therapies. Internationally, there is a
of prescription therapies, especially retinoids, problematic.
resurgence in the basic research of acne vulgaris, leading to new
Often in tertiary practice, quite adequate medications have been
topical and systemic treatments.
prescribed, but poor compliance by the patient has resulted in an
  equally poor outcome. Patient explanation at the first consultation,
with realistic time lines of treatment duration, is paramount. Not
infrequently, patients become confused by excessive and often
conflicting advice from pharmacists, paramedical services and,
especially, the internet. In some pharmacies, there is a tendency
to upsell non-prescription and unnecessary agents, from washes
and scrubs through to probiotics. This increases the expense
of their pharmacy experience. From clinical experience, one
result is that patients do not purchase the necessary prescribed
treatments. Acne vulgaris is readily treatable, with general
practice as the point of first contact. Most acne is ably managed
and stays in this location.

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Pathophysiology of inflammatory acne aspects because of a longer relationship with the patients and/or
Four main factors are involved in the development of acne: their family. It is very difficult for a specialist to make a detailed
1. Abnormal follicular keratinocyte hyperproliferation, leading assessment of the psychological effects and emotional impact of
to the formation of a follicular plug acne. There are clinical office tools that some dermatologists use
2. Increased sebum production within sebaceous follicles as a way of recording the emotional aspects of patients’ acne.6
3. Proliferation of microorganisms (eg Propionibacterium acnes) There are still many misconceptions about acne.1 In nearly all
in the retained sebum teenage patients, it is not caused by abnormal hormone levels.
4. Inflammation There is a separate subset in mature adult females known as
There is a strong genetic element in many patients. All acne, ‘hormonal acne’. This is a steadily increasing group presenting
including comedonal acne, has an inflammatory basis. to medical practitioners. The majority of patients in this subset
have developed acne in their second or later decades of life. This
Clinical features has a much more chronic and clinically low-grade appearance
Acne lesions are clinically classified as comedones, pustules, that persists for many years. The reasons for this have not been
nodules, cysts and scars. Comedones are the distinguishing elucidated and are presently the subject of much research.7
features between acne rosacea and acne vulgaris. They are
keratin-filled plugs that can be described as open or closed. Skin care
Open comedones are commonly referred to as blackheads; the Generally, heavy cleansing, milder cheaper soaps and washes,
black appearance is due to oxidisation of keratin plugs. Closed scrubbing/exfoliating cause further irritation to the epidermis
comedones are whiteheads. Pustules occur when follicular and blockage of sebaceous glands by causing damage and
inflammation is such that large collections of neutrophils collect. inflammation of the epidermal barrier. Patients with acne
Cysts are follicular-lined keratin-filled structures that dilate. Nodules complain of being excessively oily. Therefore, moisturisers are not
occur when there is further inflammation. These are clinically red, routinely needed in this group. Squeezing and picking at lesions
tender, palpable lesions. This is where the follicular structures have only leads to follicular rupture and more nodular inflammatory
ruptured. Scarring can be the final outcome once healed. acne. Oil-free make-up is permitted. Oil-free sunscreen is a
requirement as sunburn causes swelling of the epidermis, which
Scars creates more blockage and more acne. The use of excessive
Many variations of scarring occur in acne. These include volumes of sunscreen and make-up will block and aggravate acne.
ice‑pick (narrow and deep), hypertrophic (heaped and smooth)
and atrophic scars (flat and slightly depressed) with a thinner Diet
epidermal surface. Finally, keloids and hypertrophic scars extend Extreme dietary programs have not been shown to be of any
well beyond the site of original inflammation. These occur in the value. A balanced, healthy diet is appropriate. Some researchers
more severe forms of acne and once present they are permanent. state that there is compelling evidence that diet may exacerbate
Physical treatment modalities may help reduce such scarring but acne.8 For others the story is not so certain.9–11 This area is still
do so poorly.5 Patients usually present with a range of clinical quite controversial and three major food classes – carbohydrates,
lesions from comedones through to cysts. Equally, when scarring milk and other dairy products, and saturated fats, including
is present there is usually a variety of different clinical scars. trans fats – as well as a deficiency of omega-3 polyunsaturated
fatty acids, are linked to the promotion of acne.8 The role
Mangement of acne of gamma‑linoleic acid (omega-6 fatty acid), dietary fibre,
In acne, we are treating two linked conditions. One is the antioxidants, vitamin A, zinc and iodine remains to be elucidated.10
physical appearance and the other is the psychological effect.2 Diet-induced insulin and insulin-like growth factor 1 (IGF-1)
Unfortunately, there is frequently no obvious link between superimpose on elevated IGF-1 levels during puberty and affect
the two. Patients with quite minimal acne may be emotionally sebaceous gland homeostasis.8,10 Some researchers believe that
devastated and considerably impaired by their perception of their patients should balance total calorie intake and restrict refined
acne. Occasionally, patients with quite severe nodular cystic acne carbohydrates, milk, dairy, protein supplements, saturated fats
and scarring appear in the consultation to be minimally affected and trans fats. They recommend a palaeolithic-style diet enriched
and have low levels of enthusiasm for treatment. Rarely, patients, in vegetables and fish.8,9
predominantly young women, present with minimal acne but
significant visible cutaneous damage from picking and scratching, Topical therapies
frequently leaving many hypopigmented scars. This type of acne Topical comedolytics are thought to unblock the pilosebaceous
is known as acne excoriee. These patients compulsively pick duct and/or act as antibacterial agents.12 These products are
at their skin, creating more damage than the original acne. The of value in very mild acne. Benzoyl peroxide is a comedolytic
general practitioner (GP) has a better chance of measuring both and antibacterial agent and available over the counter in many

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different combinations and formulations. Azaleic acid is also once or twice daily. Some of the newer antibiotic therapies
available over the counter. Salicylic acid and alphahydroxy acids (azithromycin 500 mg, clarithromycin 250 mg) have also been
(eg glycolic acid) act as keratolytics that open comedones. used in patients with very resistant acne. In situations where
Topical retinoids (vitamin A derivatives) are the most effective there is a failure of therapy despite using the correct dose for
comedolytics available. They may be quite irritating to delicate skin body weight for a minimum of three months, consider using an
types and are associated with the potential for photosensitivity. alternative approach. As a guideline, treatment with antibiotics
Hence, nightly application is required. Patients need to be should be reviewed every three to six months.
instructed and counselled on how to use these agents to reduce
facial erythema and cutaneous desiccation, particularly in the Combined oral contraceptives17,18
first couple of weeks of treatment.13 Topical retinoids are not Combined oral contraceptives more likely to improve acne are
recommended during pregnancy, although there is no evidence those containing cyproterone acetate, desogesterel, dienogest,
of fetal harm. If a user becomes pregnant, it is quite safe to drospirenone or jestodene. Clinically, nearly all hormonal therapies
stop using these agents.14 Topical dapsone has been released in are effective in the long-term control of acne; however, onset of
Australia. Its mechanism of action is predominantly as an anti- visible improvement is very slow and clinical effects take at least
inflammatory agent; it is not a topical antibiotic. It works on the three months to become apparent, with best results seen over
inflammatory cascade that leads to erythema, nodules and cysts.15 six months. These therapies frequently complement oral antibiotic
Topical antibiotics are available on prescription for the treatment and topical treatments. Oral antibiotic and topical retinoid therapy
of acne. They are best used twice daily. Ideally, these agents give a faster improvement in acne at first. Then it is advisable
should be combined with benzoyl peroxide and/or topical to cease the oral antibiotic and continue with the topical and
retinoids. These combination agents increase the potency of the hormonal therapy in the long term. Many female teenagers can
clinical response. There are significant concerns about increased be maintained in the longer term with only their combined oral
antibiotic resistance with the use of topical and oral antibiotics contraceptive. The age at which patients are first prescribed a
as monotherapy in acne. By using combination products, the combined oral contraceptive is becoming lower and is a clinical
risk of antibiotic resistance is markedly reduced.12,16 Therefore, all judgement best determined by the GP.
acne guidelines aim to reduce the use of topical and/or systemic Spironolactone is a synthetic steroid and weak diuretic.19,20
antibiotic therapies.16 It can be prescribed as monotherapy or in conjunction with a
combined oral contraceptive. In Australia, it is especially used for
Systemic therapies hypertrichosis and/or seborrhoea. The usual dose is 50–100 mg
Systemic treatments are required when topical agents as daily for at least six months. In those of slight build, the dose
monotherapy are ineffective. They are usually indicated when can be reduced by 25–50 mg. Very rarely, patients become
the clinical lesions become more papular, nodular, pustular and, hypotensive and there is further academic argument whether
especially, cystic. A number of systemic antibiotics are routinely monitoring with urea and electrolytes, particularly potassium
used. It is worth stressing at this point that systemic treatments levels, is indicated. When used as monotherapy, spironolactone
take weeks to months to become effective.17 very rarely causes menstrual irregularities. Addition of the
The most popular systemic agent in Australia is doxycycline combined oral contraceptive pill in these patients will lead to
at a dose of 50 mg daily. The dose can be increased depending more regular and less troublesome periods. It takes at least two
on the size of the patient. Troublesome photosensitivity is an to three months for a clinically apparent improvement to develop.
issue, as are administration difficulties. These medications need For particularly resistant, poorly responding acne associated
to be taken one hour before or two hours after a meal. This is with mental health issues, or severe acne, the use of oral
problematic when dealing with teenage patients. Minocycline isotretinoin is the gold standard. Prescription of isotretinoin
50 mg twice daily – again higher doses are given – is often in Australia is subject to the Poisons Standard. It can only be
preferred to doxycycline as it is not so strongly photosensitising prescribed by specialist practitioners, who are predominantly
and is easier to take. Minocycline is given with food and is well dermatologists. Isotretinoin is a synthetic vitamin A derivative
tolerated. Higher doses and/or long-term therapy can lead to that is thought to reduce sebaceous gland activity. In addition,
pigmentation of teeth, oral mucosa and, very rarely, skin. Issues it is comedolytic and anti-inflammatory. A proper course of
with headache and the question of intracranial hypertension isotretinoin should bring long-term remission of acne in 80% of
still cloud the use of this medication. It is extremely rare for patients. It does, however, have multiple side effects, especially
systemic lupus erythematosus to be induced with this family mucocutaneous effects. These are frequently minor but in some
of medications. individuals can be quite problematic.
Second-line oral therapies include erythromycin 250–400 mg Of prime importance, isotretinoin is teratogenic and pregnancy
once or twice daily, trimethoprim with sulfamethoxazole must be avoided throughout treatment and for one month after
80–400 mg once or twice daily, or trimethoprim 300 mg alone cessation of therapy. The teratogenic effects predominate in very

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 ACNE IN ADOLESCENTS FOCUS

9. Smith RN, Mann NJ, Braue A, Mäkeläinen H, Varigos GA. The effect of a
early fetal development. The standard practice is for patients to
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specialists and not the remit of this article.
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Key points possible role of diet in the pathogenesis of adult female acne. Postepy
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• In teenagers, enthusiasm for, and compliance with, therapy is
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do not value the input of trained medical practitioners as highly 2010;7(4):283–96.
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as their parents.
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• Compliance with topical treatments, which should contain review and meta-analysis. Br J Dermatol 2015;173(5):1132–41.
either a retinoid or benzoyl peroxide as monotherapy or in 15. Tanghetti E, Harper JC, Oefelein MG. The efficacy and tolerability of dapsone
5% gel in female vs male patients with facial acne vulgaris: Gender as a
a combination agent, is required for several months nightly,
clinically relevant outcome variable. J Drugs Dermatol 2012;11(12):1417–21.
and this should suffice in minor early inflammatory and/or 16. Zeichner JA, Patel RV, Haddican M, Wong V. Efficacy and safety of a ceramide
comedonal acne. containing moisturizer followed by a fixed-dose clindamycin phosphate 1.2%/
benzoyl peroxide 2.5% gel in the morning in combination with a ceramide
• Once lesions become clinically more apparent, inflammatory
containing moisturizer followed by tretinoin 0.05% gel in the evening for the
and papular, a systemic agent is required. Oral antibiotics as treatment of facial acne vulgaris. J Drugs Dermatol 2012;11(6):748–52.
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systematic review. Am J Clin Dermatol 2017;18(2):169–91.
topicals with the oral contraceptive. The use of topical therapy,
particularly with a retinoid, reduces the long-term risk of
pigmentary dyschromia and/or deeper elastic tissue/collagen
damage leading to scar formation.

Authors
Kurt Gebauer MBBS, FACD, FACP, Co-Chair of ‘All About Acne’, Clinical Associate
Professor, University of Western Australia. kurt@fremantledermatology.com.au
Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.

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