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This piece of paper has severe acne, that has so far been entirely unresponsive to all treatments.


Chronic inflammatory skin condition characterised by spots and looking like a teenager (especially if you are).


Affects >80% of teenagers; peak 18y; male=female


Complicated but the biggest factor is thought to be androgens causing an increase in sebum secretion. The sebum flows out from follicles and coats skin (this is a reason that eczema gets better in lots of teenagers).

This blocks the pilosebaceous duct (found in the hair follicle). Sometimes the follicle roots get overlarge, and form comodones, (the sebum on top can oxidise, meaning they are commonly referred to as a "blackhead").

In some people, the sebum gets colonised with bacteria and forms pus. In some people, the inflammation surrounding this process can be a scarring event.

This teenager has acne.

Clinical Features

The main types of rash found are comedones, papules, pustules, cysts and scars.


Rarely needed to be further investigated.


Mild acne

In mild disease: just comedones - Benzoyl peroxide or Topical retinoids. Start using a weaker mixture, every other day. If there is no irritation after this, you can increase it to every day, then a stronger one. Its better to do this than risk a stronger amount and causing irritation, leading to the patient losing faith.

If you see no improvement, try adding a topical antibiotic - this can resolve the colonisation.

Moderate acne

In moderate disease, with papules and pustules - Try a regular oral antibiotic - a tricyclic. This works by reducing inflammation. You can also consider Dianette (a combined oral contraceptive) in women.

Severe acne

By this point 66% of people will have had the acne cured. At this point, a Dermatologist may use isotretinoin - which can cure 85% of the remaining acne patients, and keep them cured for 5 years.

Isoretinoin causes lots of fun side effects:

They have to avoid alcohol, which goes down well with teenagers. Females also have to have monthly supervised pregnancy tests.


Around 5% of women and 1% of men still have acne aged 40, but this will also be responsive to treatment.