Skincare Regimen - a note on oily, acne prone and sensitive skin

Acne is a prevalent skin condition primarily affecting the seborrheic area of the face, and is caused by the blockage of follicles leading to inflammation. Until the age of around 25, the majority of sufferers are male. Thereafter this changes to affect principally females, almost 1 in 2 of those in their 20's (50%!), 1 in 3 of those in their 30's, and 1 in 4 of those in their 40's - it is a very common issue!

Nodulocystic acne gives a combination of papules, pustules and comedones indicating the diagnosis of acne compared to scaly with a greasy appearance in seborrhoeic dermatitis. 

While proper face cleansing plays a crucial role in improving and preventing acne, excessive washing can compromise the skin barrier and result in dryness, particularly in individuals with sensitive skin. There are four major components of a complete acne management that is formed due to fundamental understanding of both acne prone skin and acne-treated skin with the biological basis of maintaining structural and functional integrity of the epidermal (i.e. skin) barrier:

1. Cleansing - with a non stripping clenser

2. Medicating - where required

3. Moisturising - with a non comedogenic moisturiser

4. UV photo-protection - a mineral rather than chemical sunscreen could be trialled but may not suit all

Many such treatments despite reported effectiveness may  cause epidermal barrier impairment as evidenced by increased transepidermal water loss and decreased stratum corneum) water content which can generate inflammation, increase skin sensitivity when skin is exposed to cosmetic washing products, certain and topical medications. Some treatment will predispose photosensitivity (i.e., tetracyclines), including products containing benzoyl peroxide and topical retinoids, therefore it is recommended to use sunscreens and to avoid sun and sunlamp exposure. Even some over the counter products can cause skin irritation and exacerbate or induce acneiform eruptions. Anabolic steroids are well known exacerbating factor in acne as well as causing aggression and mood change. Creatine supplements have also been implicated as a cause of acne.

It is important to note that some sunscreens can induce skin irritation and some moisturisers and sunscreens can be acnegenic and comedogenic in some patients. New treatment should be introduced gradually, one at a time, ideally.

Surgical management of acne scarring involves using techniques such as Subcision (with or without a Taylor Liberator), Punch or surgical excision, and Fully Ablative Laser surgery to help to regenerate and remodel the scarred skin thereby giving it a more normal structure and contour.

Important notes on Isotretinoin

• Some manufacturers of isotretinoin use soya oil as an ingredient which can cross react with peanuts and cause an allergic reaction.
• Adjuvant vitamin A supplements are contraindicated in isotretinoin treatment as it increases the toxic side effects.
• Isotretinoin therapy enhances photosensitivity.
• Isotretinoin has been implicated in depression, mood change and rarely suicide, especially in susceptible individuals or those with a family history of mental illness.
• Patients must have a baseline fasting lipid profile and LFT check prior to commencing isotretinoin as there can be a significant affect on lipid and liver metabolism whilst taking it. This must also be checked during the course of treatment.
• Patients must be fully informed about the side effects and rare complications of taking isotretinoin, especially - dry lips and mucous membranes, headaches, muscle aches, photosensitivity mood change, depression and suicide. Women must be counselled on pregnancy prevention as isotretinoin is associated with teratogenicity. They must use 2 methods of contraception and sign a pregnancy prevention contract form.
• Usually at least 6 months each of 2 different antibiotics need to have been tried before considering isotretinoin. However, in severe acne with scarring this is not necessary.

Often commencing as a dose of 20mg and increased to 40mg,  usually one course of isotretinoin treatment is adequate. However some people may require an additional course, but this cannot be given until at least 6 months after the last course.

British Association of Dermatology paper on isotretanoin: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2133.2010.09836.x

You must tell the people close to you that you are taking the tablet and to let you know of your mood changes or you become depressed and withdrawn.

Novel treatments

One study (Del Rosso et al, 2015)  found: the use of a complete management approach that incorporates an acne-specific skin care regimen (specified foam wash and moisturizer SPF 30) and a single fixed-dose combination treatment topical gel containing adapalene 0.1% and benzoyl peroxide 2.5% that is applied once daily for patients with mild or moderate AV  demonstrated effective AV treatment with an early onset of therapeutic benefit; good skin tolerability with broad-spectrum SPF 30 photoprotection; safe use in patients 12 years of age or older; use of specific skin care products that do not exacerbate, worsen, or induce AV and do not interfere with medication efficacy; a convenient and complete regimen with one topical prescription product, a specific facial cleanser used twice daily, and a single moisturizer SPF 30 product applied once daily; and a high degree of overall patient satisfaction. The outcomes of this study supported that a three- component topical regimen may provide many  patients affected by mild-to-moderate acne with a complete management program that is convenient, easy to use, effective, well-tolerated, and likely to produce a high level of patient satisfaction.

Further, to address this challenge for milder acne and sensitive skin, a combination skin care regimen that combines gentle skin cleansing with intensive moisturisation including a weakly acidic foaming facial cleanser infused with a mild detergent, an aqueous lotion enriched with eucalyptus extract, and a nourishing gel containing pseudo-ceramide and eucalyptus extract was published on a group of patients. Not only did the trial lead to a significant reduction in acne, but it also resulted in improved skin hydration, a remarkable increase in the levels of endogenous ceramides within the outermost layer of the skin (stratum corneum), and an elongation of the alkyl chain length of the non-hydroxy acyl sphingosine ceramides. This combination skin care solution delivered a comprehensive approach to managing acne while addressing the specific needs of individuals with dry and sensitive skin. 

Alternative diagnoses to consider

Perioral dermatitis - Papules on the chin and lower eyelid are very suggestive of perioral dermatitis. There is often a zone of sparing adjacent to the lips in perioral dermatitis.

Acne - The absence of pustules and comedones is against a diagnosis of acne.

Rosacea - In rosacea the lesions are usually most prominent on the central chin, nose and forehead and also on the cheeks.

Seborrhoeic dermatitis - The lesions tend to be scaly and have a greasy appearance in seborrhoeic dermatitis.

Lupus erythematosus - The absence of photosensitivity makes this diagnosis less likely. Lesions of LE are usually plaques, show follicular plugging and atrophy. Papular LE does occur but is very rare.

Allergic contact dermatitis - The absence of pruritus is against a diagnosis of dermatitis.

Sun exposure - The lack of photosensitivity makes lupus erythematosus less likely. Rosacea and perioral dermatitis can be exacerbated by adverse weather.

Cosmetics allergy -  raises the possibility of an allergic contact dermatitis. Heavy cosmetics including thick sunscreens can exacerbate or cause perioral dermatitis.

Allergies - Tetracycline allergy may influence the choice of treatment. Erythromycin is a suitable alternative to tetracycline in the treatment of perioral dermatitis.

Steroid creams - The use of a potent steroid on the face could cause perioral dermatitis. Rosacea is less likely in the absence of flushing with Dermatitis typically being itchy. For eruptions due to steroid induced perioral dermatitis the strength of topical steroid should be reduced from mometasone to 2.5% hydrocortisone cream.

Peri Oral Dermatitis 

Inhaled or intranasal steroid use as this can accidentally contaminate the skin and exacerbate or cause POD. Topical steroid induced POD may remit permanently once the initiating steroid use is discontinued. However, spontaneous disease may remit and relapse, and may need intermittent treatment to control it.

• Potent steroids need to be weaned down to prevent a steroid withdrawal rebound
• Oral antibiotics are usually required as topical agents are often not tolerated. Topical antibiotics and pimecrolimus have been successfully used
• Tetracyclines, erythromycin and metronidazole are the most effective oral antibiotics
• Occasionally, oral isotretinoin may be required
• An oral antibiotic is often required to control the condition
• Idiopathic perioral dermatitis may have a long relapsing course

Remember, consistency is key when it comes to skincare. The above should be combined with a good cleansing regimen, and once or twice weekly exfoliation. Following a  morning and evening routine consistently,  over time you should notice improvements in the overall appearance and health of your skin.