Raphaëlle, 17 years old, Acne

Classification of acne

This classification may seem academic but it is very useful in practice because each stage is easy to determine for each patient and recommendations have been drawn up for each stage (see therapeutic algorithm, French Dermatology Society website).

The classification is as follows:

• Grade 0: No lesions
• Grade 1: Very few scattered acne lesions
• Grade 2: Less than half the face is affected
• Grade 3: Over half the face is affected
• Grade 4: The whole face is affected, with very few nodules
• Grade 5: Highly inflammatory acne covering the face with nodules

Based on this classification, an algorithm can be used to determine 1st- and 2nd-line treatments for each stage. Sometimes, teenagers are encouraged by their parents to go see a doctor, but they do not want to be treated. Topical treatments are irritating, especially with the first few applications.

Good motivation will a fortiori lead to better compliance with treatment.

At this stage, the acne is obvious and its highly inflammatory component is likely to lead to scarring. It is therefore essential to prescribe a strong treatment from the outset, especially if the patient is motivated.

The first-line antibiotics for acne are cyclins, which are prescribed for their anti-inflammatory action. They require sun avoidance or very good photoprotection, so they are more likely to be introduced after the summer.

BPO and topical retinoids can be prescribed separately or combined for topical application. They are irritating, which is why it is necessary to start with a low concentration and gradually increase it, for better tolerance.  They are not incompatible with sun exposure, but the patient should rinse their face in the morning and use photoprotection.

It is essential to combine cleansers with a sebo-regulating cream, or only a moisturising cream if topical treatments have been too irritating.

For cleansing:

• In the evening, perform dual cleansing, starting with a make-up removal phase.
• In the morning and evening, use a cleansing product that reduces the skin’s pH to 5.5.
• For deeper cleansing, rinse-off cleansing gels are preferable to micellar water.
• Do not use aggressive products, which increase irritation and can accelerate hyper-seborrhoea.

You explain to Raphaëlle and her mother that puberty favours acne and that suitable contraception is sometimes suggested for teenagers suffering from acne. The mother points out that her daughter suffers from migraines and that contraception will in any case be introduced during her next cycle. There is no family history of thromboembolism. Raphaëlle doesn’t smoke.

Acne and the rebound effect

• Acne improves in summer because UV rays have an anti-inflammatory effect on the skin, drying it out.
• UV rays will cause the stratum corneum to thicken (hyperkeratinisation); pores will become tighter.
• Hyperkeratinisation ultimately leads to blockage of these pores: sebum is less able to evacuate, and Cutibacterium acnes proliferates more.
• This leads to the formation of comedones, which will flare up at the end of the summer when the skin is no longer exposed to the sun and becomes thinner again.
• This is known as the rebound effect. It is often said that the sun is a “false friend” of acne.

How could the rebound effect have been avoided?

To avoid hyperkeratinisation, it is necessary to:

• limit sun exposure
• apply sun protection products with SPF 50 + UVA protection.

The skin should be cleansed twice a day.

If acne is already present, apply BPO or topical retinoids in the evening, taking care to rinse the face thoroughly in the evening.

Exfoliate skin: apply an AHA (glycolic acid) or BHA (salicylic acid) every day.

As well as causing a rebound effect, UV rays lead to the post-inflammatory hyperpigmentation of acne scars, especially for high phototypes. 

What should you pay attention to?

• Acne increases after the summer, whereas it was well controlled during the holidays: presence of inflammatory papules and comedonal lesions
• Carefully analyse the stage of acne and offer suitable treatment
• Oral antibiotics can be initiated as first-line treatment for moderate acne. They are phototoxic, so are best used after the summer.

What advice would you give Raphaëlle?

• Wash face morning and evening with a cleanser that reduces the skin’s pH to 5.5.
• Apply a sebo-regulating moisturiser.
• Avoid picking at lesions if they are inflammatory.
• Use sun protection (SPF 50 sun protection product).
• Comply with treatment, applying creams gradually to improve tolerance.
• If applying make-up, use non-comedogenic products.
• Consult a doctor if there is no improvement after first-line treatment with cyclins + topical agents (BPO and retinoids), in order to start isotretinoin treatment (after one month of effective contraception).
• If contraception is required, an anti-androgenic progestin is preferred.