Skin school : Adult acne

I’m sure you’ve all been in a treatment room with a stressed-out client who wants to know “why do I have acne as an adult?”. While it’s common for around nine in 10 teenagers and young adults (20s) to have acne at some point in their lives, according to Bupa UK stats, more people in their 30s, 40s and 50s are now suffering with the inflammatory skin condition.

Adult acne is one of the most challenging issues to treat, which is why, for therapists, knowledge really is power. “Speaking as somebody who suffered from acne for a long time, there needs to be much more awareness. When you ask people what acne is, most refer to the spots, but this is just the physical symptom,” says facialist Andy Millward, who is based in Birmingham.

“There is a lot going on within the skin before the spots even start to appear. If you’ve got a spot and you’re working hard to freeze it in its tracks, but you’re not considering what’s gone on underneath to get the skin to that point, then you are merely firefighting.”

Understanding the causes of acne will enable you to effectively treat the condition and, hopefully, reverse the damage it has done to your client’s complexion and their self-esteem.

This is your ultimate guide to adult acne:

What causes adult acne?

Acne (acne vulgaris) is a skin barrier disorder that is categorised into five grades, which range from mild to moderate and severe. Non-inflammatory acne falls under grades one and two, while inflammatory acne is grades three, four and five.

“Acne vulgaris is a chronic inflammatory disorder of the pilosebaceous unit, which consists of the hair shaft, follicle, sebaceous gland and the arrector pili muscle, and can vary from mild to severe,” explains Martine Jarman, founder of SkinGenius clinic in Stockton Heath, Warrington.

“Down within the hair follicle, you’ll find abnormal follicular hyperkeratinisation – a build-up of dead skin cells which are all working towards blocking the infundibulum of the sebaceous gland.” This is considered a crucial event in the development of acne lesions. Another big factor is the stimulation of androgens – a group of male hormones – which can trigger inflammation and a change in cell activity. “Stimulating androgens within the body causes the growth of the sebaceous glands and sebum production within the skin,” says facialist Kate Kerr, who is based in London.

However, C. acne bacteria (Cutibacterium), formerly known as P. acne bacteria (Propionibacterium), can also exacerbate the issue. C.acne is a gram-positive, anaerobic bacterium that lives on the skin, but can grow inside hair follicles and sebaceous glands contributing to inflammation and some swelling.

“When acne bacteria is buried deep into the pilosebaceous unit, it hydrolyses any triglycerides within the sebaceous glands, creating a further release of fatty acids, which contributes to oil on the skin and more bacteria,” explains Jarman.

When stressed, our adrenal glands pump out a group of steroid hormones called catecholamines, which are shown to exacerbate acne

Acne can cause six different types of spots on the skin: blackheads (open comedones); whiteheads (closed comedones); papules (red bumps); pustules (similar to papules but with a yellow tip in the centre); nodules (hard lumps beneath the surface of the skin); and cysts (large pus-filled lumps that look similar to boils). According to the NHS, almost everyone who has acne suffers with it on their face, while more than half experience bacne (back acne) and around 15% of people develop it on their chest.

What are the different types of acne?

It’s important to note that there are many different types of acne, not just the teenage acne (trigged during puberty) and hormonal acne (triggered by the menstrual cycle or pregnancy) that we hear so much about, as Millward explains.

“Acne mechanica is a type of acne that occurs due to friction and pressure on the skin, while acne conglobota is a severe form that usually appears on the back, which involves inflamed nodules that are connected under the skin,” he says.

Excoriated acne is more unique in the sense that it the condition is characterised by an uncontrollable urge to squeeze every spot on the skin. “This is usually a low-level grade of acne but because clients are picking the skin, they’re causing damage, which could turn into post-inflammatory pigmentation because of the constant wound,” says Jarman.

Meanwhile, maskne has taken centre stage in the past year due to coronavirus. “Mask-induced acne is very similar to acne mechanica because it’s the friction of the face covering on the skin around the mouth causing the spots,” says Jarman. “Plus, the trapped heat, as well as the client wearing a heavy moisturiser and/or foundation, generates a breeding ground for bacteria.”

What should I cover in the consultation?

All the experts say an in-depth consultation is key to starting the treatment process. “Before I even lay my hands on a client, I spend an hour in consultation piecing together the inflammation connection – finding out what is it within that person’s medical history, lifestyle, diet and skincare products that could be contributing to the issue,” says Millward.

You need to dig deep into the client’s background, covering genetics (as family members may suffer with the condition), hormone fluctuations (to see if it is related to periods, pregnancy or menopause), and even the medication they’re on – it could be the result of contraception that has been stopped recently, for example.

“There are certain health conditions you need to consider too, such as polycystic ovary syndrome (PCOS), cushing syndrome and gut problems – linked to internal bowel disease,” adds Jarman.

Another contributor could be their sugar intake, as Millward explains. “Sugar is a huge factor. Our insulin levels are being constantly triggered throughout the day and that insulin has the same response on the skin as those androgen hormones do, triggering an increase in oil production and cell turnover.”

He adds: “There’s a strong relationship between the gut and skin axis. What we’re consuming on a daily basis affects our gut health, which impacts our gut microbiome, and that has an effect on the skin.”

It’s also worth assessing what your clients may be deficient in because this could help boost their skin health. Millward says clients need to get enough omega 3 and 6 to aid the quality of sebum coming through the skin and the ceramide production within the lipid barrier. It all plays a role.

Which lifestyle factors can trigger acne symptoms?

With your clients trying to deal with one of the most stressful situations of their lives – the coronavirus pandemic – it’s no surprise that their anxiety levels could be having a big impact on their acne. “Stress is a huge factor,” says Millward.

“When stressed, our adrenal glands pump out a group of steroid hormones called catecholamines, which are shown to exacerbate acne and make symptoms worse. In addition, our immune system is suppressed, meaning our healing capacity is impaired.”

Although exercise is good for skin health, it can exacerbate acne symptoms if clients don’t follow a few golden rules. “They need to cleanse their skin before working out to allow that sweat to flush because when they’re getting hot they are activating the  oil glands,” explains Kerr. “You want that sweat and oil to flow freely so it doesn’t get blocked in the skin. This is also why people shouldn’t wear make-up when working out. Then, post-workout, tell your client to wait for their skin to cool down before showering.”

Which ingredients and treatments should I use?

A key goal in treatment is to prevent the blockages, calm down the oil production and normalise cell turnover. “Although we can’t change clients’ genetics or hormones, we can help them gain ‘control’ with repetitive exposure to a selection of active ingredients,” says Kerr.

She recommends using salicylic acid – an exfoliant that “dissolves dead skin cells and the bonds that hold those cells together and, because It is a lipid-soluble acid, it can exfoliate within the pore, not just on top of it. It also has known anti-inflammatory and antibacterial effects.”

Although we can't change clients' genetics or hormones, we can help them gain ‘control’ with repetitive exposure to certain active ingredients

Kerr also recommends using benzoyl peroxide to dry out spots and suppress the oil production, but states that use of it will cause inflammation at first. “That acute inflammation is just the client’s skin panicking to that speed-up of cell turnover and this can be scary for people, which is why it’s important to educate,” she explains. All the experts say glycolic acid is a good exfoliant to use as it can fade post-inflammatory hyperpigmentation, while sulphur can aid with regular oil flow and azelaic acid is good for decongesting sensitive and inflamed acne skins because it has a very gentle action.

“Mandelic acid is particularly good for treating Fitzpatrick skin types IV, V and VI because it can inhibit tyrosinase pigment within the skin, while topical retinoids can purge the skin and aid cellular stimulation, helping to repair the DNA inside the skin cell,” adds Jarman.

Millward states that acne grades one and two will respond well to treatments such as chemical peels, whereas for grade three “it may be that we put the client on something energy-based, like LED light or laser therapy, to bring that infl ammation down”. He adds, “You can exacerbate the condition if you’re not careful.”

All agree that adding extractions into facials is also extremely important because “if you get rid of all the blockages in the skin, there will be nowhere for that acne bacteria to invade,” says Kerr, and all say that moderate to severe cases (grades four and five) need to be referred to a dermatologist or doctor. 

However, you could work alongside the medic, as Kerr explains: “You should always refer the client and take time to educate them on how that medic will look at treating their skin, then explain why it would be beneficial for you to work alongside them to make sure their whole skin is glowing as well as healthy.

“The dermatologist will want to suppress that skin disease – they don’t necessarily care about glowing skin, while you will target skin health and function – so the two can work well together.

Kerr suggests building a relationship with a dermatologist in your area and learning how they prescribe and treat the skin so that you can really give your clients the best course of action.” PB