Most of the kids in my year have got acne," said 14 year old high school student Tamara, "and nobody likes to talk about it." It may be a youthful observation, but it is also born out by the facts. Peta Newbold reports.

Around 85% of Australians will suffer from acne at some point in their lives. According to the Medical Journal of Australia (1999; 171: 62-63), "being so readily visible (affecting the face in 99% of cases), affected adolescents report more social isolation and self-consciousness than their unaffected peers and experience more embarrassment, social inhibition, unhappiness, anxiety, and dissatisfaction with their facial appearance."

If the acne persists beyond school days it can also affect employment prospects and relationships, yet according to Sydney Dermatologist Dr Stephen Schumack acne is just part of human development. "I tell my patients that people who don't get acne between the ages of 15 and 30 are not normal," he said.

What is acne?

• It is a skin disease, which can be anything from the occasional blemish through the spectrum of pimples, blackheads, whiteheads and even large cysts and painful swellings.
• It most often happens at the time when the hormones are seeking a new balance but it can occur at any age from just after birth right through to middle age.
• It is caused by a blockage to the opening of the oil glands in the skin (called sebaceous glands) which normally provide an oily substance called sebum which is needed to keep the skin supple and healthy. This tendency to blocked glands can be an inherited abnormality.
• Blackhead: The blockage is sometimes visible and it takes on a dark pigmentation.
• Whitehead: The blockage is invisible and the collection of sebum under the skin appears as a small white lump.
• Infection:
If the blockage is persistent the build up of sebum can cause the gland to rupture under the skin. This causes an inflamed red appearance and is often painful. Once this happens the white blood cells are attracted to the area of damaged tissue and are visible as 'pus'.
• Cysts: Sometimes the blockage is slightly deeper causing the development of quite large cysts below the skin which appear as either flesh coloured or red lumps. These may heal with significant destruction of the tissues leaving disfiguring scarring.

Acne fact vs. fiction.

There are many myths surrounding acne, some of them originally perpetuated by medical textbooks, but here are the facts:

• Acne is not caused by dirty skin or oily hair. It is a skin disease and too much cleaning can make acne worse!
• There is no link between diet and acne. A healthy diet is a good idea for everyone; but eating oily foods and chocolate occasionally, does not cause acne and will not make it worse.
• Acne will not improve with exposure to sunlight. Sun exposure is more often damaging, as it can lead to the development of skin cancers and premature ageing.
• It is not an infectious disease and it is not caused by an allergic reaction.
• It is not solely a hormonal disease but there is no doubt that hormones influence acne.

Treatment of acne.

Since acne is so common it's surprising that we still don't know the best treatment for it. This was the conclusion of a team at Johns Hopkins Children's Center in Baltimore in the U.S. this year, after analysing the evidence on 150 acne treatments in a report for the US government.

There is no cure for acne either, apart from old age or death," said Dr Schumack. "But we can control it and the good news is that on an individual basis the current treatments are very effective."

He advises that people should first talk to their pharmacist about over-the-counter treatments and if they don't work after months, rather than weeks, see a doctor. In cases of severe acne, they may then be referred to a dermatologist.

The earlier acne is treated the less likely it is to result in scarring. One study found that a time delay of up to three years between the first appearance of acne and adequate treatment was sufficient to cause facial scarring.

• Mild acne; Benzoyl peroxide and tretinoin cream are available from the pharmacist and mild scrubs and degreasing agents can also be effective. Applications that cause gentle peeling such as soaps or solutions containing salicylic acid can also be helpful.
• More resistant acne; In these cases antibiotics can be applied to the skin. These are only available on prescription from a medical practitioner. Sometimes antibiotics taken orally can be more effective but may need to be taken for many months before there's an improvement. The most effective and commonly used antibiotics are the tetracyclines, however they are not recommended for use in children under the age of 12 or in pregnancy. Hormonal therapy such as some oral contraceptives can also be effective for females along with non-contraceptive hormonal therapies such as spironolactone.
• Severe Acne; About 5 per cent of the Australians will develop severe cystic acne. This can be extremely painfully and disfiguring and is emotionally very distressing.

Patients with severe acne are always treated with conventional treatments first but there is now a relatively new medication on the market known as Roaccutane.

It is a form of vitamin A and comes with a long list of potential side effects, the most concerning is that it can seriously harm an unborn baby. Because of this, female patients should have a pregnancy test prior to initiating therapy and they are advised to maintain birth control during treatment. This medication can only be prescribed by a dermatologist, who usually reviews the patient frequently. Regular blood test and examinations help to pick up other serious potential side effects, like hepatitis, visual problems and deafness at an early stage. Less serious side effects can be hair loss, nose bleeds, depression, dry and itchy skin and the patient may even develop dermatitis. Moisturising creams or other medications can help to minimise these irritations but people who had previously suffered from severe acne have described this drug as a "miracle."

If products and medications are the 'do's' of acne control there are finally two important 'don'ts' according to Dr Schumack. "Avoid thick make-up and moisturisers, he said. "They can undoubtedly make the acne worse."

References: Australasian College of Dermatologists at http://www.dermcoll.asn.au/ Medical Journal of Australia at http://www.mja.com.au/public/issues/171_2_190799/goodman/goodman.html