10 Journal of the Royal Society of Medicine Supplement No.
10 Volume 78 1985
Neglected aspects in the management of
B Gordon MB BS
Consultant Dermatologist, The Royal Infirmary,
New Durham Road, Sunderland SR2 7JE
Acne, 'the scourge of adolescence' -'the
commonest skin disease of adolescence', if not in
fact the commonest of all diseases of adolescence,
is possibly the most unsuccessfully treated of all
skin diseases in general practice, and not so
successfully treated in many skin clinics either.
The reason for failure is often blamed on poor
patient compliance but patient compliance can only
be expected if patient instruction is adequate.
Inadequate patient instruction is, in my belief, the
main cause of the patient not becoming fully
involved in his own management and not being
totally committed to success and is ultimately the
main cause of failure in so many cases. In this paper
I want to highlight this failure of communication
and I want to deal with it in a very practical
manner, i.e. in the words GPs would use themselves
when talking to their acne patients. I therefore
include no statistics, graphs or histograms and no
detail from the vast amount of academic research
into the aetiology of acne which has been carried
out in recent years, and is still going on.
In order to master the treatment of acne and
especially the neoalected aspects, which I intend to
emphasize, it is necessary to understand firstly the
psychology of the acne patient, and secondly the
pathophysiology of the acne lesion itself. Acne
starts at puberty and proceeds through adolescence.
Age at onset is often as young as 12 or 13 but only
tends to resolve in most cases between the ages of
20-25. It may therefore affect many adolescents
for ten years or more - more or less a seventh part
of a total lifespan - through a period when they are
subjected to considerable and stressful hormonal,
emotional and sociological changes. These young
patients are often bewildered by and apprehensive
of the pubertal changes which they are going
through. They are trying to establish and assert
themselves in an adult world and consequently tend
to reject parental and teacher authority so that
their behaviour sometimes becomes quite antisocial
or, at least, difficult to manage. Unless they
have extremely loving, caring and understanding
parents, friction and estrangement between parents
and child occurs, and despite their desire for
acne
self-assertion and independence, they probably
develop a subconscious feeling of insecurity. On
top of all this they develop acne, facial spots and
pimples, to add to their self-consciousness, shyness
and misery.
To obtain their cooperation in the treatment of
their acne it is very important to obtain their
confidence. From the outset the practitioner,
general or specialist, must present himself to patient
and parent as a caring, interested and sympathetic
counsellor. To tell the patient that 'he only has
teenage spots and he'll grow out of them' is not
only cruel and unkind, but also destroys any hiape
of patient compliance eventhougfi thedoctorwrites
out and hands to the patient a prescriiption for an
antibiotic and a peeling agent. Tem to fifteen
minutes spent with the patient and parents
explaining the nature of the disease and its long-
term management wil be time spent well and
rewardingly.
Successful therapy depends on an understanding
of what we are aiming to achieve and then how to
achieve it. I would ike to discuss the histological
structure of the pilosebaceous unit which is the
anatomical site of the acne lesion. Under the
influence of androgenic hormones at puberty the
following changes occur:
(1) The sebaceous glands enlarge and activate,
producing an abundance of sebum.
(2) There is a greatly enhanced flow of sebum along
the sebaceous duct, along the infundibulum to
the skin surface - hence the greasy skin of acne.
(3) The infundibulum becomes colonized with
Propionibacterium acnes (the acne bacillus) and
with Staphylococcus epidermidis (S. alba).
(4) The amount of keratin increases in the
pilosebaceous unit, especially in the
infundibulum and surrounding the ostium.
These changes and events lead to the formation of
the comedone: closed (the whitehead) or open (the
blackhead). The comedone is the basic lesion of
acne and all other acne lesions: the papule, pustule,
the hard lump and the fluctuant cyst all develop
from this comedone. I will therefore consider the
management of acne from these four basic changes.
 Journal of the Royal Society of Medicine Supplement No. 10 Volume 78 1985
The greasy skin
There has been much research into the composition
of sebum which need not be expanded upon here;
but acne vulgaris only occurs in a greasy skin, it
does not occur in a non-greasy skin or in an
adequately degreased skin. Dealing with the greasy
skin is therefore the most important part of the
treatment of acne. The grease on the skin may be:
(1) Endogenous: sebum and disintegrating epi-
thelium.
(2) Exogenous i.e. applied from without.
(i) Greasy cosmetics.
(ii) Cleansing creams.
(iii) Moisturizing creams.
(iv) Superfatted soaps.
It may not be strictly true, but it forms a good
working hypothesis, that the severity of acne is
proportional to the amount of grease on the skin.
Endogenous grease alone may be sufficiently
excessive to produce acne but in many cases the
natural grease of the skin is insufficient to cause
acne until some extraneous grease is added and I
believe this is why many girls only develop acne
when they begin using cosmetics, even if only
occasionally, at about the age of fifteen. Most
cosmetics are grease based. Acne is a non-specific
reaction to grease and any grease applied to the
skin, adding to the natural sebum, can cause acne.
Other examples of this are well known.
(1) In days gone by when camphorated oil was
commonly applied to the chests and backs of
babies with chesty colds and coughs, it
frequently caused infantile acne.
(2) Oil acne on the thighs of industrial workers
whose dungarees become oil sodden is well
recognized.
(3) Severe acne and its resultant scarring is often
evident in TV close-ups of actors and actresses
who are subject to regular applications of heavy
grease paint. Such cosmetics and grease paints
are then removed by the use of cleansing creams
which simply replaces one grease with another.
(4) The use of widely advertised superfatted soaps,
such as Camay, Knight's Castille, Palmolive,
Imperial Leather, leave a thin film of fat on the
skin and so add to the natural greasiness of the
skin and can precipitate and aggravate acne
vulgaris. A superfatted soap has 6-7% free fatty
acids as opposed to 1 % or less in ordinary
soap.)
The avoidance of all exogenous grease is a very
important aspect in the management of acne.
The aggravation of greasiness by handling
Most teenageers with acne are students, either still
at school or at college. Often when studying,
especially at home, they will sit reading or writing
with one hand firmly pressed to their forehead or
their chin. This grease present on the hand is added
11
to the grease already on the face and often explains,
in some patients, the localized concentration of
acne lesions on one or other site. An attempt to
hide acne on the forehead by wearing a fringe will
often aggravate the acne because the grease from
the hair adds to the grease on the forehead. Apart
from this, one should dispel the mistaken belief that
greasy hair is the cause of the acne; even doctors
will sometimes refer a patient with a letter stating
that the acne has not improved despite the use of
this or the other shampoo!
How then in practical terms does one deal
with greasy skin? Lowering the level of sebum
production with anti-androgens or by the use of
the vitamin A derivative, the retinoid 13-cis retinoic
acid or Roaccutane, is certainly not a first line
treatment and, at present, is not licensed for use
in general practice. Neither should the oral
contraceptive type of pill Diane be used as a first
line treatment of acne, but should only be
considered if basic treatment, which is dealt with
below, is not entirely satisfactory. Diane should,
of course, be considered for the acne patient who
is already taking or wishes to start the pill for
contraceptive purposes.
Therefore, endeavours to deal with greasy skin
must be aimed at degreasing the skin by the use
of suitable soaps or other degreasing agents and
peeling agents. Once achieved, peeling will, in lay
terms, unblock the pores and prevent further
blockage, thus avoiding the development of
blackheads and subsequent papules, pustules, etc.
Degreasing the face is best achieved by washing the
face at least three times a day using Neutrogena
acne cleansing soap (not available on FP1O), Acne
Aid Bar, pHiso-Med or similar products and, after
each wash, applying a peeling agent. In the past,
sulphur and resorcin were commonly used as
peeling agents but the most commonly used today,
and probably the most effective, is benzoyl
peroxide in 2.5%, 50o or 1007o strengths. It is
sometimes combined with sulphur, as in Benoxyl
or with hydroxyquinoline, as in Quinoderm. The
use of a gel formulation makes most of these
preparations aesthetically acceptable to patients for
daytime use.
It is advisable to start with a weak preparation,
i.e. 2.5%, and, if well tolerated, to step up to 5%
or 10%o, which will produce a mild but evident
peeling. It is very important to explain to patient
and parent what they are trying to achieve. With
gentle peeling the skin will feel dry and a little tight;
this is not only to be expected but should be
encouraged and maintained. Such dryness and
peeling, provided it does not become excessive, is
not a reason for stopping treatment and on no
account should moisturizing creams be used to
counteract the dryness.
If, despite concerted attempts to degrease the
12 Journal of the Royal Society of Medicine Supplement No. 10 Volume 78 1985

skin and produce peeling, the skin remains greasy, excessively greasy pilosebaceous follicles, con-
extra cleansing of the skin after washing will often verting the triglycerides of the sebum into free
succeed using a white cotton handkerchief soaked fatty acids. Possibly the presence of excess
in isopropyl alcohol. This is highly inflammable: free fatty acids in turn causes the thickening of the
the patient should be warned to keep it away from keratin layer in the follicle and on the skin surface,
a naked flame, not to smoke while applying it and leading to blockage of the follicles and the
to keep the bottle in a cool place and tightly formation of blackheads and whiteheads. It is
stoppered when not in use. After cleaning with the likely, however, that clusters of these organisms
alcohol the peeling agent is then applied. trapped in the follicle increase the degree of
If during the course of treatment, especially in inflammatory reaction leading to the formation of
the early stages, the degreasing and peeling process pustules and abscesses.
goes beyond the required slight flaking and mild Adequate degreasing and peeling by improving
tightness, the treatment could be discontinued for follicle 'drainage' probably greatly reduces the
only a very short time, perhaps 24 or 48 hours, until harmful effects of the organisms without recourse
the excessive soreness has eased; it should then be to antibiotic therapy. However, suitable antibiotics
resumed at a slightly lower level, i.e. perhaps have been shown to reduce the colonization of the
reducing to twice a day until tolerance is achieved follicle and so reduce the number of blackheads and
and then again trying thrice daily washing and pustules. But I am sure that degreasing and peeling
application, or by reducing the strength of the without antibiotics is a more effective treatment of
peeler to a lower percentage: from 1007 to 5% or acne than antibiotics alone without degreasing and
5% to 2.5%7o. Quinoderm is more likely to produce peeling. Nevertheless, it is reasonable to assume
redness of the face than other benzoyl peroxide that the combination of both is more beneficial.
preparations. This is probably due to the hydroxy- The use of antibiotics, therefore, is only a part,
quinoline content of Quinoderm and when this and a minor part at that, of the treatment of acne.
happens it is advisable to change to a different The use of antibiotics needs to be low-dose and
benzoyl peroxide preparation. long-term and patients and parents need to be
Once the finely balanced degree of peeling is reassured of the safety of such a regimen. I have
achieved the patient must strive to maintain that never been convinced of the need to start antibiotic
state by continuing regular treatment for several therapy for acne with a full-dose regimen such as
years until the early or mid-twenties when, in most one would use for an overt infection. Why risk side
patients, the tendency to acne spots will cease. effects? Why complicate the instructions you have
to give the patient more than is necessary?
Alternative peeling agents
These are rarely needed. Which antibiotics?
Sulphur lotion 6%o in calamine. Long-term safety, efficacy and cost are the main
Sulphur and resorcin paste. considerations.
Retin-A gel. Oxytetracycline is probably the most commonly
used antibiotic in acne. In low dosage it has proved
The use of antibiotics in acne to be safe for long-term use and it can be continued
May I remind you of the four pathological changes in a dose of 250 mg twice daily for two or three
which I mentioned earlier: years if necessary. It should never be given for less
(1) Overactivity of sebaceous glands. than six months. It is certainly effective and it is
(2) Excessive greasiness of the skin. relatively cheap. It is said to interfere with the
(3) Colonization of the infundibulum by P. acnes action and effectiveness of oral contraceptives, but
and S. epidermidis. I believe this has recently been strongly disputed.
(4) Increase of thickness of the keratin lining the Pregnancy and breast feeding are, of course,
infundibulum of the pilosebaceous duct, and contraindications and relevant patients should be
surrounding the ostium of the follicle at the skin so warned. However, the use of oxytetracycline is
surface. one of the most mismanaged aspects in the
I have dealt with 1, 2 and 4; 1 is presently not treatment of acne. Most doctors are aware that
controllable by ordinary basic treatment; 2 and 4 oxytetracycline is bound by calcium and serum
can both be corrected by the processes of albumin and by alkalies, so the drug loses much
degreasing and peeling if properly carried out. of its effectiveness if taken with food; the patient
This leaves us with the presence of the acne is, in any case, only taking a low dose and if most
bacillus and the S. epidermidis in the ducts. The of this is lost by binding the benefit obtained will
role of these organisms in acne is not fully be negligible. This must be carefully explained to
understood or agreed upon. It is probable that they the patient, whose compliance is likely to be much
are not primarily concerned in causing acne but, greater if he understands why he is being asked to
instead, they are 'opportunists' which thrive in the do certain things. Detailed, and preferably printed,
 Journal of the Royal Society of Medicine Supplement No. 10 Volume 78 1985
instructions should be given. Oxytetracycline
administration depends on two principles:
(1) It must be taken on an empty stomach, i.e
nothing (except water) can be taken for two
and a half to three hours before taking the
tablet.
(2) Nothing is to be eaten or drunk (except water)
for at least half an hour after taking the tablet.
This is so that the tablet has time to disintegrate
in the stomach and be absorbed into the blood
stream before it has had an opportunity of
coming in contact with food in the stomach and
so becoming 'bound'.
My advice to patients is to take the first tablet each
day as soon as they wake up in the morning,
washing it down if necessary with water only, no
tea or coffee. They should place a tablet and glass
of water by their bedside when they retire to bed
the previous evening; by the time they get up, go
to the toilet, wash, dress and comb their hair, a
half hour will have elapsed and they may then have,
if they wish, a cup of tea or breakfast. The second
tablet of the day is best taken half an hour before
the evening meal, ensuring that nothing is eaten
or drunk during the afternoon, i.e. no afternoon
cups of tea and biscuits, at home or the office, no
sweets, chocolates, crisps etc. at school or on the
way home from school. The actual time of taking
the second tablet is not critical and may vary but
it must always be taken in accord with the above
principles.
The advantage of this pre-evening meal dosage
is that it leaves the whole of the evening after the
evening meal free of restriction, a time when most
people watch TV while eating crisps and chocolates
or go out for a drink, or visit socially or entertain
others and wish to eat and drink.
Alternative antibiotics
If oxytetracycline is contraindicated, i.e pregnancy
or lactation, a suitable alternative would be erythro-
mycin, 250 mg twice daily.
If the acne is rather severe and slow to respond,
despite adequate and intensive local therapy, it
might be worth changing to minocycline, 50 mg
twice daily. This may possibly be a little more
effective than oxytetracycline and it does not have
the same food restrictions, but it is very much more
expensive - an important consideration especially
in long-term use.
The third choice of antibiotics after tetracyclines
and erythromycin is co-trimoxazole, one tablet
twice daily.
Acne of the trunk
Acne of the trunk quite often occurs in association
with facial acne, but not necessarily so. Some facial
acne may have no accompanying trunk acne at all
and, less commonly, severe trunk acne will occur
13
with little or no facial acne. Trunk acne u'sually
involves the upper back and chest and shoulders,
but in some cases it may extend well down the back,
even as far as and onto the buttocks.
Trunk acne may be precipitated in patients with
facial acne by wearing wool or wool-like clothing
in direct contact with the skin, e.g. sweaters or the
fluffy inside of a sweat shirt. The skin should be
insulated from such garments by wearing a smooth
cotton blouse, shirt or T-shirt next to the skin. A
sweat shirt can be worn inside-out so that the
smooth surface is next to the skin. If acne is
accentuated around the neck, enquire if a wool
scarf or muffler is worn, or even a furry collared
overcoat.
Topical therapy of trunk acne
It is not practical to apply proprietary peeling
agents packed in tubes to the fairly extensive areas
of trunk that need to be treated. A sulphur lotion is
much more practical, and economical. I invariably
prescribe:
Sulphur precipitate 6%
Teepol 1.5%
Calamine lotion ad 100%
Mitte 500 ml
Sulphur preparations tend to have an unpleasant
smell and therefore this application is only used at
bedtime and should be dabbed on with a cotton
handkerchief. The help of a parent or friend is
needed for application to the back.
Antibiotics are, of course, beneficial for trunk
acne as well as facial acne.
Summary
Acne is the result of excessive grease on the skin.
The successful treatment of acne depends
essentially on the degreasing of the skin to an extent
which produces peeling, which is the observable
index of adequate treatment. The use of antibiotics
is supplementary to degreasing and peeling.
Degreasing is best achieved by thrice daily washing
with Neutrogena acne cleansing soap, followed by
the application of a benzoyl peroxide preparation
of a suitable strength. If necessary, further
degreasing can be achieved by cleansing with
isopropyl alcohol after washing with the
Neutrogena soap.
Avoid
Picking, squeezing or any other form of handling;
greasy cosmetics - water-based foundation lotion
may be used; cleansing creams; wearing fibrous-
surfaced garments, i.e. wool or wool-like material
next to the skin.
14 Journal of the Royal Society of Medicine Supplement No. 10 Volume 78 1985
Antibiotics
Oxytetracycline can be administered unless contra-
indicated; low dosage long-term (250mg twice
daily). Give careful instructions about taking
oxytetracycline and explain why.
Alternatives: minocycline, erythromycin, co-
trimoxazole.
Printed instructions
Name of soap:
Neutrogena acne cleansing soap, in red pack.
Instructions for taking oxytetracycline.
Follow-up
Repeated encouragement and moral support is
required; treatment must be reviewed at two or
three month intervals.