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Feature Article

Treating acne – how to minimise physical and emotional scarring

Jo-Ann See, PHILIP TONG
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Patient concerns

Acne can cause significant psychological harm and can affect quality of life.7,8 Many studies link patients who have more severe acne and acne of a longer duration with a greater likelihood of low self-esteem and quality of life.9 People with acne can also experience lack of self-confidence, anxiety and depression. In the Global Skin Disease Study, acne ranked highly as a skin disease associated with significant disease burden.10,11 A recent Delphi survey showed that patients with acne reported:

  • being self-conscious 
  • feeling unattractive to themselves and others
  • feeling uncomfortable in their own skin 
  • not wanting pictures taken
  • feeling envious of people with clear skin 
  • that time and effort was spent concealing scarring.12 

Although previously considered a teenage concern, a recent meta-analysis found the prevalence of depression was higher among adults with acne (aged 20 years) compared with their adolescent counterparts (aged 12 to 19 years).13 

Due to the chronicity of the condition, many patients can become disheartened and disillusioned with treatments offered to them. They often seek alternative measures, some of which have very little scientific basis. Many patients are now consulting social media platforms such as YouTube and Instagram, and social media influencers for advice – the advice given is not always in keeping with recommended acne guidelines.14 

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Patient concerns should be identified and addressed so that an individual management plan can be tailored to each patient. Patients with acne often question and are concerned about the possible side effects of acne medications such as oral antibiotics and oral isotretinoin. There is also increasing global concern about the use of antibiotics and increasing antibiotic resistance of bacteria. This may lead to patients not wanting to adopt antibiotic treatment strategies. It is recommended that antibiotic courses be limited to three to six months, and that topical and oral antibiotics are not prescribed simultaneously. Patients are also concerned about the possibility of acne scarring and it is important for the clinician to realise that early effective management can lessen the risk of this.15 

The GP consultation

The GP is at the forefront of acne management, with presentations of chronic acne seen by Australian GPs at a frequency of 0.4 of every 100 consultations.16 Acne is diagnosed clinically by patient history and physical examination, which evaluates the type and severity of the acne and if there is any psychological impact. Laboratory investigations may be considered if there is a possibility of underlying hormonal factors, such as polycystic ovary syndrome, as a baseline for oral medications such as isotretinoin, or monitoring in the setting of spironolactone. Key questions to ask patients presenting with acne can be found in the Box

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Although consultation time may be limited, it can be worthwhile asking patients what they think the cause of their acne is. The four main factors contributing to acne are:

  • increased sebum
  • hyperkeratinisation of the pilosebaceous duct
  • colonisation by C. acnes (formerly known as P. acnes)
  • immune activation and release of inflammatory mediators.

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Dr See is a Dermatologist in private practice at Central Sydney Dermatology, Sydney; and is Co-Chair of the All About Acne group. Dr Tong is a Dermatologist in private practice at Central Sydney Dermatology and Visiting Medical Officer at St Vincent’s Hospital, Sydney, NSW. He is a member of the All About Acne group (www.acne.org.au).