Contents Chapter 1. All About Acne 1 What is acne and how is it caused? 1 Who gets acne? 2 Types of acne 2. Foreword

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1 In this booklet you will find: Information on the various types of acne Lifestyle advice for acne sufferers Treatment options to assist with managing acne Expert feedback and compelling real-life stories Tips on where to get help Science For A Better Life Bayer Australia Limited 875 Pacific Highway Pymble NSW 2073 Australia Ph: ABN L.AU.WH All About Acne This booklet has been developed by All About Acne and Bayer Australia Limited

2 Foreword Acne is so common in teenagers and, while it can be distressing, it s certainly not a surprise - teens expect to get pimples. Some women find they continue to battle with pimples, spots and zits in their 20s, 30s and beyond. At a time when they are becoming confident in their careers and relationships, or even planning a family of their own, they re hit with this teen issue. Adult acne sounds like an oxymoron - It can be a bit of a shock and seen as a hindrance. As a dermatologist, my colleagues and I see women who are experiencing acne for the first time in their 30s, while others who have had it since their teen years are wondering if and when it will ever end. All of them have questions and this booklet has been specifically developed with these women in mind. All About Acne, a voluntary group of Australian health professionals working in acne, has worked in conjunction with Bayer Australia to provide this comprehensive look at adult acne. This booklet not only explains the different types of acne, but also busts common acne myths and misconceptions, outlines the range of treatments available, and helps to identify who to speak to, and where to seek help. You won t just hear it from the medical experts; we ve also spoken to women to get their personal insights into acne and more than 1,500 women have taken part in our survey the results of which we re sharing with you. We hope this booklet assists in answering many of your questions regarding adult acne. More information can be found at and, as with all general medical information, it is essential to see a healthcare professional for personal advice. Adult acne can be many things, but most importantly, it s treatable. Professor Kurt Gebauer Dermatologist Co-chair, All About Acne Contents Chapter 1. All About Acne 1 What is acne and how is it caused? 1 Who gets acne? 2 Types of acne 2 Chapter 2. Acne and Your Life 9 Acne s impact on your quality of life 9 Lifestyle advice for acne sufferers 10 Chapter 3. Treatment Options for Acne 15 Skin cleansers 15 Topical therapies 16 Antibiotics 18 Retinoids 18 Combined Oral Contraceptive Pill 20 Natural remedies 21 Treatments for scarring 21 Chapter 4. What do you need to know about your acne 23 Acne FAQs 23 The role of the dermatologist in acne treatment 27 Useful sites for more information 28 Chapter 5. Where to get help 29 General Practitioners (GPs) 29 Specialists 32 Pharmacists 32

3 1 All about acne What is acne and how is it caused? Acne is a common skin disorder distinguished by whiteheads, blackheads and pus-filled spots on the face, neck, back and chest. The condition may appear for short spans of time in some adolescents, although it can persist for years in others. In fact, acne might only develop for the first time in some people in their late 20s or early 30s. Hair Skin surface Sebum Follicle Sebaceous gland DID YOU KNOW...? Whilst a lot of women (62%) consider their acne to be mild, Gen Y women were more likely to consider their acne as moderate (40%) compared to older women from Gen X (27%) Acne usually rears its red head at puberty when an increase in sex hormones, some of which are called androgens, results in a surge in oil production. This spike in oil production causes blockages in the skin s pores leading to blackheads and whiteheads. The oil produced by the sebaceous glands is called sebum. It is meant to help keep the skin supple and healthy. This oil usually drains naturally to the surface of the skin, although when it becomes blocked at the opening of the oil gland, the sebum builds up allowing bacteria to multiply. This causes inflammation which is seen as redness, swelling and tender pimples. Some areas of the body, particularly the face, are more prone to acne because they have a higher concentration of oil glands than other parts of the body. The main acne bacterium (known as Propionibacterium acnes) exists on everyone s skin, however it doesn t usually cause problems, except for those prone to acne. When oil builds up, the bacteria have the perfect conditions to multiply and trigger inflammation. Who gets acne? Eighty-five per cent of Australians develop acne at some stage in their life, with five per cent experiencing very serious forms of the condition. People suffering persistent acne may experience both physical and emotional effects. Teenage boys and young men have higher levels of androgens than women do. Because of this, they are more prone to acne during puberty and it is likely to be more severe. Acne in men usually settles during their early 20s. Females, unfortunately, are more likely to suffer from ongoing acne. In some instances, women can develop acne for the first time after puberty. Acne can run in the family, though in most instances its occurrence is sporadic. Types of acne There are various types of acne. All are defined according to the severity of the condition as well as when the acne occurs. There are non-inflammatory acne (whiteheads and blackheads) and inflammatory acne (papules and pustules). " Research shows that in the later years, hormones play a bigger part in causing acne. Stress and diet can also be factors in worsening acne in 20 to 40 year olds." Dr Mei Tam, Dermatologist, VIC Non-inflammatory acne Whiteheads, named for the white spot they form on the skin s surface, appear when trapped oil Whiteheads remains below the surface of the skin. Whiteheads may be so small that they are invisible to the naked eye. A blackhead Blackheads occurs when the pore opens to the surface and the sebum, containing the skin pigment melanin, oxidises and turns a brown/ black colour. Many people think blackheads are dark in colour because they contain dirt, which is not true. Blackheads cannot be washed away. The oil that becomes blocked in pores takes quite some time to drain to the surface of the skin and because of this, blackheads can be quite persistent. A whitehead or blackhead can heal by releasing its contents to the surface of the skin. When this doesn t happen, the pore s wall ruptures which may result in inflammatory acne. 1 2

4 Inflammatory acne When the wall of a blocked pore ruptures, the broken wall allows white blood cells to enter the pore and this causes inflammation. A few days later, once the white blood cells have made their way to the surface of the skin, a spot appears. This is commonly referred to as a pimple or a zit. Pimple Inflamed acne lesions can sometimes collapse as a result of the follicle breaking along the bottom. When this happens, the surrounding skin becomes inflamed, sometimes engulfing neighbouring follicles. This is called a nodule. When very severe inflammation occurs, the result is a very large, pus filled pore. These lesions are referred to as cysts. " A common myth is that patients see their acne as a product of dirt. Patients try to wash the 'dirt' out, which leads to drying of the skin. The skin then compensates by producing more oil." Dr Mei Tam, Dermatologist, VIC Mild acne Mild acne does not cover large areas of the face or body and is limited mainly to whiteheads and blackheads. This type of acne may be controlled with regular, appropriate skin care. Treatment for mild acne includes products that are available without a prescription from supermarkets and pharmacies. 3 Nodule Cyst DID YOU KNOW...? Eight out of ten (82%) women who have experienced acne in the past five years stated that their period aggravated the condition. Some women also believed emotional stress (67%), work-related stress (34%) and an unclean face (36%) contributed to the worsening of their acne condition. 4

5 Moderate acne Unlike mild acne, moderate acne is more widespread across the face and body. It is characterised by inflammatory lesions (papules and pustules). Moderate acne breakouts can be persistent and should be treated early to avoid the possibility of permanent scarring. If over-the-counter products are not improving your acne, you should visit your doctor to discuss different treatment options or for a referral to a dermatologist. Severe acne Severe acne is mainly characterised by large, deep, solid and painful lumps or cysts. Severe acne breakouts cover large areas of the face and body, lasting for a long time. They often don t subside for months or even years. Typically, severe cystic acne does not respond to over-the-counter skin treatments from pharmacies and supermarkets. Instead, anyone with "To camouflage acne, dermatologists suggest patients use make-up that is oil-free and non-comedogenic. Mineral makeups often do a good job because they are lighter on the skin and also offer coverage." Dr Mei Tam, Dermatologist, VIC severe acne should see their doctor for a referral to a dermatologist who will conduct a full assessment and make further recommendations. Severe acne can prevent people from doing many things they enjoy because of concerns about their appearance and the opinions of others. It may affect self-confidence and some people will experience anxiety and depression. Severe acne in particular may lead to scarring if left untreated. Hormonal acne Hormonal acne is thought to result from the interplay of sex hormones, other hormones and chemical substances produced by the body in times of stress or illness. It is common for hormonal acne to begin in the 20s, or even early 30s, and can affect individuals who were blemish free during their teenage years. It is important to note that hormonal acne differs from teenage acne. Teenage acne is usually more severe in the oily T-zone of the face, whereas hormonal acne is more prominent on the jaw line, chin, lower face and neck as these areas are sensitive and easily irritated. Androgenic hormones, including androstenedione and testosterone, have male-like effects on the female body. While androgenic hormones help maintain muscle and stimulate the libido, they also increase oil production in the skin. Hormonal acne can range from mild cases before your periods, especially if you are stressed, to more severe cases which appear at any time during the menstrual cycle. Women who have polycystic ovary syndrome (PCOS), a common reproductive syndrome, are likely to battle with hormonal acne more than others, especially at times of stress, illness, weight gain, and pregnancy. DID YOU KNOW...? The most prominent area for acne to appear is on the face, with 98% of the women surveyed saying they had experienced acne on their face, followed by 51% on the back, 35% on the chest and 32% on the neck. Pregnancy acne Women who are prone to outbreaks of hormonal acne may find that they have flares of acne during the first trimester (three months) of their pregnancy. Usually those who do experience acne during their pregnancy find that it improves and may even disappear towards their last trimester. Breastfeeding can often keep outbreaks of acne at bay. Women who suffer persistent acne may notice that their acne is progressively less severe or that it disappears with subsequent pregnancies. 5 6

6 Myth busters Myth 1: Acne is caused by bad hygiene Acne occurs when pores in the skin become blocked with the skin s natural oils. While acne is not caused by poor hygiene, maintaining clean skin may help control the condition. Myth 2: Blackheads are just dirt; you can wash acne away Blackheads are caused when the skin s natural oil reaches the skin s surface and oxidises. They are not caused by dirt and cannot be washed away. In fact, too much scrubbing will further irritate your skin. Myth 3: Picking and squeezing pimples is okay Picking and squeezing pimples will visibly worsen your acne by causing increased and deeper inflammation, bringing with it the risk of permanent scarring. Myth 4: Makeup and moisturisers won t make acne any worse Oil-based make-up and some moisturisers can worsen acne. Choose products that are oil-free/ non-comedogenic (won t block pores). Siliconebased foundation is also a better option for those prone to acne. Heavy make-up use requires proper cleansing to reduce the chance of acne breakouts. Myth 5: Too little or too much sex can make acne worse There is no connection between acne and the frequency of sex. Myth 6: Using lots of over-the-counter acne treatments containing benzoyl peroxide and salicylic acid will improve acne This is not true. In fact, using too much of these acne treatments can worsen your acne as it causes dryness, irritation and blemishes. Myth 7: Sunlight, sunbaking and solariums will improve my acne While some people do notice some improvement in their acne in summer, overall this is not true. Sun exposure can cause inflamed acne to turn dark brown, in addition to potentially causing premature wrinkling, skin growths, skin cancers and other signs of aging skin. Myth 8: Sweat from exercise causes acne It is always a good idea to clean your face thoroughly after hot sweaty activities, however acne is not caused by sweat. Myth 9: Acne is caused by allergies There is no scientific research to suggest a connection between allergies and acne. Myth 10: Acne is contagious Acne is not contagious; it cannot be caught or passed from one person to another. Touching a pimple and then touching someone else s or your own skin will not increase the chances of developing a pimple. Myth 11: Acne outbreaks cannot be blamed on a woman s period This is false; many women notice a worsening of their acne shortly before their period. This can be attributed to changes in female sex hormones which contribute to the blockage and inflammation of the skin s pores. Myth 12: Acne is not hereditary Studies have shown that those with a history of acne in their family are more likely to develop acne themselves. Myth 13: Prescribed medications won t make acne worse Some prescription medication may trigger or aggravate acne. Your doctor or pharmacist can advise you on which medications may affect your acne. 7 8

7 2 Acne and your life Acne s impact on your quality of life We live in a world that places strong emphasis on appearance, so it comes as no surprise that acne may cause embarrassment and self-consciousness. When acne sufferers were asked what affected them most about their condition, appearance was a common concern! In some studies acne has been noted to lead to social withdrawal. In some patients, this is to the extent that they feel uncomfortable in public situations, particularly when meeting new people and socialising with members of the opposite sex. The good news is that when acne improves, usually these feelings of anxiety and depression lessen and confidence grows. Acne and depression Depression is common in young adults and adolescents, with up to one in four females and one in six males suffering depression at some time in their lives. Studies have linked acne as a cause of depression. Young men are at increased risk of depression and are more commonly affected by severe acne scarring. However, social researchers have found that women with acne find the condition more embarrassing than their male counterparts. Those with acne report that emotional stress can exacerbate their acne. Sufferers may also develop emotional problems such as social phobias, low self-esteem or depression as a result of their skin condition. Friends and family of acne sufferers can help by keeping an eye out for poor coping ability and signs of depression, and encourage the person to seek medical advice if concerned. Remember, if you are feeling down, you can access excellent services and helplines to answer your questions or get advice. Some support lines for people suffering depression include: Beyond Blue Lifeline Sane Anyone who thinks he/she might be suffering from depression should speak to a healthcare professional for advice and help. Acne s relationship with stress Research has shown links between high stress levels and the severity of acne, as well as completely new outbreaks. A number of mechanisms have been suggested to explain why increased stress levels may aggravate acne. Some reports focus on chemical reactions and changing levels of hormones in the body. In times of emotional stress, hormones called androgens and glucocorticoids are released. These hormones increase oil production by the skin and can make acne worse. Also, a corticotropinreleasing hormone, which is used by the body to coordinate the stress response, increases the conversion of androgens to testosterone, which will have an effect on acne. Not all theories are related to hormonal activity. Some scientists believe that stress causes the skin to release a substance which produces inflammation. Others say stress can slow wound healing by up to 40 per cent, which could explain why acne lesions are slower to repair in times of stress. It is difficult to eliminate stress from everyday life, but by learning to manage stress, you can reduce the impact it has on your physical and emotional wellbeing. Lifestyle advice for acne sufferers Diet The relationship between diet and acne is a controversial subject and many myths exist on the topic. Some of these suggest chocolate, soft drinks and other junk foods can possibly aggravate acne. A healthy, balanced diet might assist with acne improvement in some people, but it is not a cure for acne. There is now evidence supporting the benefits of a low GI (glycaemic index) diet to help achieve better skin. A low GI diet is one which includes plenty of protein-rich foods, such as nuts, fish, lamb, beef and legumes, in addition to a variety of fruits and vegetables. These low GI foods are recommended because they improve insulin metabolism and may improve the symptoms of acne. Insulin is an important hormone in the body because it has a controlling effect on all of our other hormones, including androgens. It is believed fluctuations in hormonal levels, particularly these androgens, will cause acne breakouts. Insulin also impacts on growth hormones and it is suggested that because of this, insulin may be related to acne formation at a cellular level. 9 10

8 DID YOU KNOW...? The vast majority (96%) of female acne sufferers felt that their acne had adversely affected their self-confidence, with half of all Gen Y women (50%) stating that their acne had stopped them from going out. There is no reason why you can t treat yourself to high GI foods, although they should be eaten in moderation. A diet of high GI foods, which includes processed and refined foods (white bread, sweets and biscuits) causes a rapid increase in blood sugar levels. This increase in sugar levels triggers the production of insulin and may lead to worsening of acne. While there are many reasons to eat a balanced diet, medical treatments may still be necessary for improving moderate to severe acne and a general practitioner or dermatologist is best placed to assist with this. Weight The likelihood of developing acne may be reduced by maintaining an appropriate healthy body weight. This may also help reduce the severity of acne. Weight is essentially determined by the balance of kilojoule intake from food and the amount of energy used each day; if more kilojoules (4.184 kilojoules = 1 Calorie) are consumed than expended, you will gain weight as the excess kilojoules are stored as body fat. While it is important to have some fat, too much of it can interfere with your overall health. For females, fat converts good hormones oestrogens into other hormones, which have similar effects as testosterone. These hormonal changes will contribute to acne. This doesn t mean only overweight people have acne; rather, maintaining a healthy weight will minimise your chance of developing the condition and reducing its severity. Acne sufferers will be pleased to learn that even modest weight loss may bring improvements in your skin. General Lifestyle A number of factors in everyday life may have an impact on acne including exercise, time spent outdoors, smoking and alcohol. Exercise Daily exercise is important to overall health and wellbeing, including healthy skin. Moderate exercise might help reduce acne in a number of ways. This can be by lowering stress levels, which have an impact on the body s hormones that are responsible for acne, such as insulin or the growth hormone corticotropin. Also, exercise promotes circulation, which helps remove toxins from the body, which would otherwise aggravate acne. CASE STUDY Age: 34 Sex: Female Occupation: Police woman Sun Appropriate sun protection is highly important for all Australians, particularly those who are being treated for acne. For those who are acne prone, look for products labelled non-comedogenic. These products are lighter and spread more easily on the skin so they will not clog pores, which may contribute to the worsening of acne. Cosmetics The excessive use of make-up, coverup or other techniques to reduce the I have had acne as long as I can remember. I have tried numerous products oral antibiotics prescribed by my GP, products that I bought off the internet, over-the-counter chemist products, treatments that my friends and pharmacists recommended none of these made a difference. I am now taking an oral retinoid, which is intense but the benefits make it worthwhile. My acne is not under control yet but is very much improved and for this, I am grateful. My advice to acne sufferers is to seek professional advice. I have got satisfaction from seeing my GP and a lot of satisfaction from my dermatologist

9 visibility of acne lesions can be a doubleedge sword. It may camouflage the acne but the wrong type of cosmetics will block pores. Again, look for noncomedogenic products. Mineral makeup is also an option for acne prone skin. Being overly vigorous or using strong cleansers to remove make-up can further irritate skin and cause acne to become inflamed. Gentle cleansing with gentle products are recommended. Some people with acne complain of their skin being excessively oily or greasy, in these cases, it is advisable not to use a moisturiser. Smoking Clinical experience suggests there is a relationship between smoking and acne. A recent study found there was a higher incidence of adult acne in those who smoked versus those who did not. Smoking has been found to cause harm to the skin by constricting the outer skin s blood vessels. It also severely impairs collagen production, leading to wrinkling and premature aging. Smoking also stimulates inflammatory reactions in the body resulting in poor wound healing and reduced repair of inflammatory acne lesions. Alcohol DID YOU KNOW...? Acne was shown to be linked to embarrassment and decreased self-confidence, with 96% reporting that acne had an effect on these two selfperceptions. Furthermore, one in five (21%) women described their embarrassment caused by acne as 'extreme' and 17% described the effect on their self-esteem as 'extreme'. All in all, 92% of women surveyed reported acne as having an impact on their lives. Research into the effects of alcohol show a trend towards alcohol affecting hormone balances. Excessive alcohol consumption also leads to increased weight. This is worth noting as hormonal fluctuations caused by weight gain in females are an important factor in acne development

10 3 Treatment options There are many safe and effective treatment options available for women who suffer from acne, ranging from topical treatments to a multitude of oral medications. This booklet will cover some acne treatment options; however you will need to speak with your GP or dermatologist to identify the best treatment option for you. Skin cleansers While acne is not caused by poor hygiene, maintaining clean and healthy skin may help control the condition. Mild soap free facial cleansers, which are acid and/or ph balanced and free of alcohol and abrasives, can be used as part of your skin care routine. For women with oily skin, cleansers that are easily rinsed off the surface of the skin are recommended. Women with combination, dry, sensitive or easily irritated skin, or women using topical medication for their acne should use liquid cleansers that are gentle, oil-free plus moisturising. More highly moisturised cleansers should generally be avoided. Specially formulated cleansers, specifically those with salicylic acid, are particularly good for acne sufferers. They work by helping to unblock pores by targeting sebum. The salicylic acid dissolves, removes and prevents the substances that block the pores. Because of this, salicylic acid helps speed up the clearing of pimples and also helps improve the skin s condition in the long-term. Mild acne sufferers may not need anything more than a cleanser for the everyday control of their acne. However, it is important to remember to speak with your doctor before combining this with prescription topical treatments. Some people use toners after cleansing, however they can irritate the skin and therefore are not always recommended. " Dermatologists generally recommend two over-the-counter treatments: peeling agents for people who suffer from rough and bumpy skin, and treatments that are benzoyl peroxide based. These treatments have been shown to be the most effective over-the-counter options for milder forms of acne." Prof Kurt Gebauer, Dermatologist, WA Topical therapies Topical treatments are usually the first choice for those suffering mild to moderate acne. These treatments include agents such as benzoyl peroxide, antibiotics, retinoids, azelaic acids and keratolytics. Combination therapies are also available and include benzoyl peroxide and a retinoid or benzoyl peroxide and an antibiotic. Some of these products can be purchased over the counter, while others will require a prescription from a medical professional. Topical creams are best applied after cleansing, once your skin has dried. This is because topical treatments may cause irritation if applied to moist skin. Unless otherwise specified by your healthcare professional, creams/gels and lotions should be applied to the entire area of your face where acne usually develops. These treatments may help prevent new pimples from forming, in addition to treating those that have already appeared. When applying topical treatments, it is important to take care around sensitive areas, including the skin around the eyes, lips and nostrils. Also, you should make sure to follow all instructions for applying these treatments in order to maximise their effect. For example, some treatments should be used sparingly. Applying more than the DID YOU KNOW...? Over three-quarters of female acne sufferers (77%) are aware of benefits of the oral contraceptive pill in treating acne and the majority of these women (65%) were informed of this benefit by their GPs. In addition, 75% of women who were prescribed the oral contraceptive pill specifically for the treatment of their acne reported the treatment as moderately to extremely effective. recommended amount will not help your skin improve any faster, in fact, it may lead to irritation and make your acne worse. Treatments will usually take time to have an effect on your acne. You should see improvements along the way but it is important to allow enough time for them to take maximum effect before deciding if the treatment is appropriate for you

11 DID YOU KNOW...? An oral retinoid prescribed by dermatologists was described as having 'moderate to high effectiveness' by 9 in 10 (89%) of the users. Antibiotics Antibiotics have long been prescribed for inflammatory acne. In addition to helping to reduce the bacteria on the skin s surface and in follicles, antibiotics have an anti-inflammatory action to reduce the swelling, pain and redness of inflammatory acne. Antibiotic gels and lotions may have limited side effects compared to oral antibiotics, however they do take longer to be effective. Topical antibiotics should be applied directly onto the affected skin. A variety of antibiotics are currently available and your GP or dermatologist will prescribe the best option for you. Your doctor may choose to change your prescription if an antibiotic proves ineffective, however this will only become clear after a trial of four to six weeks. In many cases, antibiotics are effective. You should be seeing an improvement within eight to twelve weeks. If this is not the case, it s time to speak with your doctor. Your pharmacist can also provide helpful tips if needed, such as advice on when is the best time to take your antibiotic and whether it should be taken with or without food. Retinoids Retinoids are vitamin A derivatives that are prescribed as either topical or oral formulations. They are effective at both unblocking acne pores as well as preventing the development of new pimples. Retinoid gels and creams help suppress mild to moderate acne. They can be combined with an antibiotic in the early stages of use to speed up the improvement and control of acne. The combination of topical retinoids and an antibiotic can minimise acne causing bacteria and thus help reduce inflammation. Additionally, the combinations can help prevent problems with irritation, which may affect per cent of people in the early stages of their topical retinoid use. Women using hormonal treatments such as the oral contraceptive pill to manage their acne are advised to combine this with topical retinoid treatment to provide better long-term acne control. Topical retinoids can be used for several years as maintenance. These topical retinoid treatments unblock pores to prevent further blockages, decrease oil production and also soothe the redness of inflamed acne. They also make the oil glands less hospitable to acne causing bacteria. Oral retinoid treatments are the most potent treatment for severe acne as they deal with all the known causes of severe cystic acne. Up to 85 per cent of people with severe cystic acne experience longterm remissions from the use of an oral retinoid. A single course of treatment, which usually takes five to six months, is typically sufficient to help clear acne

12 A small number of sufferers may have a recurrence of less severe acne, normally following a prolonged gap after their previous episode. Depending on the severity of this recurrence, another course of oral retinoids or milder therapies can be used. Retinoids work by reducing the size of the sebaceous glands and their production of oil. Common side effects include dryness, scaliness or irritation of the skin. Simple precautions can be taken to minimise the risk or extent of these side effects. Also, in the early stages of treatment, patients may CASE STUDY Age: 34 Sex: Female experience additional acne flare ups, therefore antibiotics may be prescribed at the same time to prevent this from happening. Retinoids also increase sensitivity to sun, water and wind, so precautions should be taken to protect yourself from the elements. Combined Oral Contraceptive Pill In addition to contraceptive benefits, the combined oral contraceptive pill (or the Pill) may help treat acne by blocking the stimulatory effect that androgens (male hormones) have on oil glands. Occupation: HR Business Partner in the fashion retail industry I have suffered with skin problems for many years. Last year I decided I didn't want to put up with it any longer. I was tired of rejecting offers to go out socially whenever I had a bad breakout. Before I was referred to a dermatologist, I used a number of 'off the shelf' options, but they provided no improvement. After visiting my dermatologists, I was provided with other treatment options, which included an oral contraceptive pill and two topical creams, one of which is a benzoyl peroxide based cream. It has been five months since I started treatment, and it is making a world of difference not only my skin, but the confidence I have in myself. I would recommend anyone suffering from skin problems to speak to their GP. Lowered levels of stimulation decrease sebum and oil production. Some pill formulations containing low doses of oestrogen, referred to as low dose pills, are indicated for mild to moderate acne. These types of the Pill work by inhibiting ovulation, which in turn alters the levels of sex hormones in your body. Some formulations of the Pill include an anti-androgenic progestogen that have been proven to be effective in treating moderate to severe acne. These Pills stop androgens from binding to their receptors resulting in less oil being produced and acne being minimised. Your doctor will determine if an anti-androgenic Pill is appropriate for you. It is worth remembering that the minipill (also known as a progesterone-only pill) and contraceptive implants are more likely to worsen acne, because they boost sebum production. When taking the Pill for acne benefits, there are a few things to remember: " Some patients don't understand why or how acne treatments work and expect immediate results. Acne treatments take time and it's best that patients work with their GP or dermatologist to find the most appropriate treatment option for them." Prof Kurt Gebauer, Dermatologist, WA DID YOU KNOW...? Prescription topical creams and antibiotics were rated as highly effective, 11% and 12% respectively by users of these treatment options. The Pill will need to be taken for at least six months to get a good response if it is being used as an acne treatment Some common side effects from the Pill include nausea, vomiting, abdominal pain, headaches or migraines, breast tenderness/ enlargement, thrush and vaginitis You should continue with your normal daily skin cleansing routine while using the Pill You may notice a visible improvement in your skin after taking the Pill for eight to twelve weeks. Further improvements can be seen from three to twelve months 19 20

13 The Pill can be taken for as long as an acne treatment and contraception are required. If acne does return with the cessation of the Pill, it may not be as severe and the likelihood of it returning will reduce as you get older All combined oral contraceptive pills carry an increased risk of developing blood clots, depending on a number of risk factors. Your doctor will assess whether the Pill is appropriate for you depending on whether you are overweight, smoke, suffer migraines, have epilepsy, have high blood pressure and/or have a family history of breast cancer. Make sure you ask your doctor about the side effects of taking an oral contraceptive. The Pill may also help to regulate and lessen problems with your menstrual cycle. Natural remedies Research has been conducted into the effects of Vitamin A and tea tree oil on mild forms of acne. It is important to be wary when using natural therapies as variations exist between products. For example, poorly purified or processed tea tree oil can cause allergies or irritation. A study has demonstrated that Vitamin A in high doses can be an effective treatment for acne, however most doctors would not recommend this because of the serious health risks associated with excessive Vitamin A intake. A comparison between tea tree oil and benzoyl peroxide lotion found the tea tree oil was effective in reducing acne and with few side effects, however it took longer than benzoyl peroxide to take effect. Facials are often believed to have therapeutic benefits, but they are not a proven acne treatment. While facials may provide some improvement for mild acne, you should avoid facials if you are using medicated acne creams as they may contribute to irritation. Treatments for scarring Moderate to severe acne in which there are papular/nodular lesions that have caused damage to the surface and the underlying layers of the skin may cause scarring. Scarring can be reduced by a variety of therapies including: Steroids (topical or injectable; not oral) Once scars have matured, skin resurfacing and other lasers and nonlaser treatments can be used. This may include: Injectable fillers or implants Surgery If you would like more information about treatments to reduce scarring, speak with your doctor. DID YOU KNOW...? Self-selected pharmacy/ supermarket/department store/ beauty salon cleansers and topical creams and lotions are the most commonly used treatment options for women suffering from acne

14 4 What you need to know A number of commonly asked questions are addressed in this booklet, but the best way to get personal advice about your acne or the health of your skin, is to speak with your doctor or dermatologist. " If you are concerned about your acne, the best person to see first is your GP. Ideally you would have a great relationship with your doctor and they will understand your problem from a medical and social viewpoint." Dr Jo-Ann See, Dermatologist, NSW Acne FAQs General acne questions Can acne be cleared immediately? No. The process for improving acne, even in mild cases, takes time. You should speak with your GP about what treatment options are best for you. Your GP might also refer you on to a dermatologist. Can acne be cured permanently? Acne appears as a result of hormonal changes, which affect the amount of sebum produced by oil glands. Because hormonal changes are unpredictable, it is difficult to find a permanent cure for acne. The good news is that any acne can be improved with treatment. DID YOU KNOW...? Almost half of the women (47%) surveyed said they spent more than $100 a year on acne Who should I see if I am suffering from acne? Because acne is a medical condition, it is important to see a healthcare professional. For mild acne, start by seeing a pharmacist. If your acne is not responding to an over-the-counter treatment or you have moderate to severe acne, see a GP who is likely to commence topical and/or systemic treatments. If your skin is particularly problematic, a referral to a dermatologist is appropriate. I have acne on my chest, back and shoulders. What is the best treatment for acne that is not on my face? Treatment for acne on your body is the same as treatment for acne on your face. A dermatologist might supply you with an alcohol-based lotion containing salicylic acid, specifically designed for the upper body. These treatment options are more economical for treating larger areas of the body than the face. For more effective acne treatment of inflammatory acne, systemic antibiotics can be used in combinations with topical treatments. After my acne clears, I am left with red/ dark marks. What are these marks and how do I make them go away? The red marks that appear on your skin once acne has cleared are called erythematous macules. These marks may get temporarily darker when you exercise or when your skin gets hot. The macule is not a scar and is not permanent. It is the result of the skin s inflammation process and is far more common in people with easily tanned skin. The marks should fade within a few months, though for some, they may last for a number of years. Nonetheless, the spots will always disappear over time. Can people with acne suffer from depression? Studies have revealed acne can contribute to depression, anxiety, low self-esteem, low self-image and decreased confidence. Treatments are available which help control acne and in turn psychological symptoms. If acne is reducing your enjoyment of life, it is important to speak with your GP. Over-the-counter therapies for acne Will an acne treatment or facial wash purchased over-the-counter be an effective treatment for my acne? Some over-the-counter acne treatments contain benzoyl peroxide, salicylic acid, alpha hydroxyl and azelaic acids. Products with these active ingredients are generally effective treatments for mild acne. It is important to be gentle when using these treatments, as excessive scrubbing will cause irritation and inflammation. For more severe acne, speak with your GP or dermatologist, as systemic therapies, which are only available on prescription, will improve this type of acne. Are there inexpensive products that can be purchased to help control my mild acne? There are many economical options that are proven, effective treatments and these can be purchased from your pharmacist. treatments

15 Using a cleanser containing salicylic acid along with a light moisturiser is usually sufficient. Some light moisturising gels and creams include silicones, which won t affect your acne and protect your skin from irritation. Remember, you should select light moisturisers to follow your facial cleanser, as heavier versions may worsen your acne. What should I do if the acne treatment I am using causes my skin to become irritated? Some acne medications can cause dryness or other minor skin irritations. Usually, this will resolve itself as your skin becomes accustomed to the treatment you are using. In the meantime, you can try to alleviate the dryness by using a non-comedogenic moisturiser, which won t clog your pores. If the irritation or dryness persists, speak with your GP or pharmacist. People using topical treatments for the first time can be enthusiastic and may over apply medication, so you may try reducing the quantity and/or frequency of application. How long should I wait to see if my over-the-counter product makes a difference to my acne? You should see notable improvements within six to eight weeks and some smaller improvements along the way. Prescription treatments for acne How severe should my acne be before I go to see my doctor? If your acne is interfering with your life and causing you distress, you should see your doctor. Acne often will not only cause physical discomfort or scarring, it also can have an emotional effect on you. Early intervention with a trip to the doctor could help prevent these effects. I have been prescribed medication to control my acne. How long will it take for my medication to have an effect, and how long should I remain on the medication for? When your doctor prescribes your medication, they will also explain what you should expect from the treatment, including how long you will need to take your medication and when to expect an improvement. It is important that you follow the instructions that are included with your medication and complete the full course. In some cases, acne appears to worsen when a new medication is started. This is usually due to natural variation with flares and improvements in acne over time. However, some improvement should appear within eight to twelve weeks. Why should I continue taking/applying my medication even after my acne clears? Even though your acne clears, due to the chronic nature of acne it may be necessary to continue your treatments for some time after as maintenance. Does the oral contraceptive pill help acne? Some specific hormonal combinations in oral contraceptives help acne, while other combinations can worsen the condition. There are many factors that determine which Pill may be suitable for you and this should be discussed with your doctor. DID YOU KNOW...? Only close to a quarter of women who suffered from acne in the past five years (24%) consulted a health professional to guide their treatment of the condition. " When you see patients with acne and you help improve their skin, you often give them back their self-esteem, so they feel much better about themselves. This is extremely rewarding for me." Dr Jo-Ann See, Dermatologist, NSW Will the oral contraceptive pill treat severe acne? Pills containing low doses of oestrogen are referred to as low dose pills and some of these are indicated for moderate to severe acne. Some combination therapies can be used to treat acne for more severe cases but the most effective treatment for severe acne is an oral retinoid

16 " Although dermatologists are experts in skin, it is often best that the GP is the first point of call. If you need further help, get a referral to a dermatologist." Dr Jo-Ann See, Dermatologist, NSW CASE STUDY Age: 53 Sex: Female Occupation: Artist Once taking the oral contraceptive Pill, how long until I notice a visible improvement in my acne? You will only notice a visible improvement in your skin after taking the Pill for eight to twelve weeks. Further improvements can be seen from three to twelve months. Is it true that applying toothpaste to a pimple can cause it to clear up? Applying toothpaste to your skin will cause dryness and irritation. Rather than using toothpaste, you should obtain a gentle cleanser that is ph balanced and soap free. If you have oily skin, avoid cleansers with significant emollient or moisturising properties. Applying a topical agent to inflamed nodules and papules only addresses the inflamed lesion. It does not stop new lesions from forming. A general whole skin approach is required to improve acne and reduce the number of new formations. Where should I go for more information about acne? This booklet provides general information for acne sufferers. You can also visit the All About Acne site, au, for additional information, however for personal medical advice, you should visit your doctor, who may refer you to a dermatologist. The role of the dermatologist in acne treatment A dermatologist is a qualified medical professional who has undergone extensive training and postgraduate qualifications enabling him/her to diagnose, treat and prevent skin diseases, including acne. You will require a referral from a GP to visit a dermatologist. Dermatologists consult generally in the community as well as in private and public hospitals. A dermatologist will decide which therapy is best for your acne based on your individual circumstances. Factors that will be considered include the extent and severity of your acne, previous scars or your risk of scarring in the future, as well as the emotional and social impact of your acne. As a trained professional, your dermatologist will also take you through the appropriate skin care products to control your acne and help avoid treatment related issues. I began to get acne at age 17 and have had bouts of the condition into my late 40's. As well as being painful, the acne was extremely embarrassing and could not be easily covered with makeup. The scarring that resulted is a constant reminder of the awkwardness and embarrassment I felt as a teenager. In my mid-30 s, my skin needed further treatment so my dermatologist prescribed spironolactone, the birth control pill, a retinoid based cream and a skin peel every six weeks or so. Useful sites for more information: There are many resources available if you are seeking information on acne and the available treatment options. We recommend visiting the following websites: All About Acne American Academy of Dermatology Australasian College of Dermatologists British Association of Dermatologists " One of the reasons why I became a dermatologist is that when I was younger I suffered from both acne and eczema." Dr Jo-Ann See, Dermatologist, NSW 27 28

17 5 Where to get help General practitioners (GPs) A GP is usually the first point of call for anyone looking for medical information. GPs can offer ways to manage your acne, including information about treatment options for acne, as well as information on how to avoid treatment related issues. Your GP may prescribe medication to treat your acne after assessing your medical history and specific needs. They can also provide a referral if you need to visit a dermatologist. It s a good idea to find a GP whom you can relate to and trust, and establish an ongoing relationship with them. By going to the same GP on a regular basis, he or she is able to get insight into your medical background and have your history on file. If you don t have a regular GP, ask your friends, family or neighbours if they can recommend someone. Different GPs have different payment schemes. Under Medicare, the government will pay most of the scheduled fee for an appointment. However, some clinics choose to include a charge on top of the Medicare rebate and you may need to pay some money out of your own pocket. Check with your GP when you make an appointment to see what the consultation fee is. If your GP bulk-bills that means he or she only charges at the Medicare rebate rate and you do not have to pay any additional fee. CASE STUDY Age: 18 Sex: Female Occupation: Student I first started getting acne when I was twelve. It affected my self-esteem and I thought I wasn't good enough for anyone. I tested different creams that were recommended by my GP, but I preferred taking pills to using creams. I am now taking an oral antibiotic twice a day, which started working about two weeks after I started taking it. I am a lot happier now and feel more comfortable in my own skin

18 Specialists When it comes to skin diseases, including acne, dermatologists are the specialists. You will require a referral from a GP to visit a dermatologist, in order to be eligible for a Medicare rebate. A GP referral generally lasts for 12 months for the specified skin condition (e.g. acne). Some dermatologists can also be consulted through public hospital outpatient clinics. As with a GP, your dermatologist will decide if therapy is recommended for your acne based on your individual circumstances. Dermatologists are able to prescribe an oral retinoid for severe acne, which is not usually prescribed by GPs, unless they are an authorised medical practitioner. Talking about it with your healthcare professional: Your GP or dermatologist is the best person to answer all your questions about acne and the different treatment options. To make sure you get the most out of your consultation with your healthcare professional, there are a number of things you can do to prepare: Give your doctor as much information as possible Always be sure to provide honest answers to the questions you are asked. This will ensure your doctor can provide the most suitable advice for you Take a list of the points you would like to discuss or the questions you would like to ask, and don t be afraid to take notes. Pharmacists Pharmacists are trained healthcare professionals who are able to provide patients with their medications and medicine information. In Australia, some acne medications can only be purchased with a prescription from a doctor or specialist, while others can simply be purchased over-the-counter. Whenever you get a prescription or pharmacist-only medicine, the pharmacist is likely to perform a number of checks to ensure the medication is right for you. You can also talk to your pharmacist if you are not sure how to take your medication properly. In addition to pharmacists, pharmacies employ pharmacy assistants. Pharmacy assistants are not usually trained healthcare professionals, though they may be able to provide you with basic information and advice on over-thecounter products. Disclaimer information: The statistical information provided within the Did you know? statements within this booklet was collected from an Australian survey conducted by McCrindle Research and commissioned by Bayer Australia Limited. The survey consisted of a sample of 1598 women between the ages of 18-46, who had suffered acne within the last 5 years. Views expressed by dermatologists and patient case studies presented within this booklet reflect the opinions of the individuals and are not intended to represent Bayer s position on the subject matter