Which kind of acne is it?
Doctors describe acne in three broad forms. Comedonal acne is blackheads and whiteheads, pores that are blocked without much redness around them. Inflammatory acne adds red, raised papules and pus-filled pustules, where a blocked pore has become inflamed. Nodulocystic acne is the severe form: deep, firm, painful lumps under the skin that can last for weeks. DermNet NZ lists the same lesion types, and notes that in severe acne there are also nodules and pseudocysts.
Most acne sits on the face, but it can involve the neck, chest and back, and back acne needs a different plan from facial acne. Some things that look like acne are something else. The Ministry of Health acne guideline lists suspected rosacea, drug-induced acne, Pityrosporum (yeast) folliculitis and other folliculitis among the reasons to send a patient on for a diagnosis, which is why a small, uniform, itchy rash that will not settle on acne care is looked at again rather than treated harder.
A 2012 review of studies in Asian patients says nodulocystic acne is less common in Asians than in white patients, and that the dark mark left after any inflamed spot is a bigger problem. That is why marks are planned for from the first visit, not left until the acne has gone.
What drives acne, and the triggers behind it
The Ministry of Health acne guideline names four factors. Oil production rises, driven by androgen hormones, either because their levels are high or because the oil gland is sensitive to normal levels. Acne bacteria multiply in the pore. The cells lining the pore shed abnormally and build the first microscopic plug. And the skin reacts with inflammation. Which factor leads differs from person to person, which is part of why one routine does not suit everyone.
Several things push these factors along. The guideline documents a family history of acne. DermNet NZ lists polycystic ovary syndrome, certain medicines (steroids, hormones, anticonvulsants and some cancer medicines among them), oil-based or pore-blocking cosmetics and high humidity as things that can provoke flares, and NICE adds self-administered anabolic steroids to the medicines to look for. The Ministry of Health guideline also lists smoking, stress and salon facial massage among factors reported to aggravate acne, and says the evidence for them is limited.
Diet is contested. The Ministry of Health guideline of 2012 encouraged a low glycaemic load, high fibre diet (grade B) and found no good evidence that oily food, chocolate or nuts cause acne. DermNet NZ lists diets high in dairy or in high glycaemic foods among possible provokers and calls the evidence that changing diet helps weak, and NICE advises that there is not enough evidence to support specific diets for treating acne. The guideline found no conclusive evidence for zinc supplements and none for vitamins A, C and E or omega-3 fatty acids.
What a doctor checks first
Before anything is recommended, the questions are which kind of acne it is and how severe, how long it has been going on, what has been tried and for how long, and how much it is affecting the person. NICE notes that the risk of scarring rises with the severity and duration of acne, so a doctor looks for early scarring and for dark marks as well as counting the spots. The adult acne work-up sets out this assessment in full.
Then the triggers. A new medicine, the products and make-up on the skin, and a hormonal pattern each get a question. The Ministry of Health guideline lists a suspected underlying endocrine cause, such as polycystic ovary syndrome, and acne that begins or persists outside the usual age range among the reasons to refer for a diagnosis. Irregular periods or excess hair growth alongside acne are the kind of finding that prompts that question.
Pregnancy, or a plan for one, matters before any medicine is chosen. NICE says topical retinoids and oral tetracyclines are contraindicated in pregnancy and when planning a pregnancy, and the algorithm in the Malaysian guideline carries the same warning for topical retinoids. Which skin treatments can wait in pregnancy covers the wider picture.
What helps, by class
Skin care comes first. NICE advises a non-alkaline synthetic detergent cleanser twice daily on acne-prone skin, oil-free and non-comedogenic moisturisers, sunscreens and make-up, and warns that persistent picking or scratching can increase the risk of scarring. DermNet NZ adds that abrasive skin treatments can aggravate both comedones and inflammatory lesions, so scrubbing harder is not the answer.
Topical treatment is where most acne care starts. The Ministry of Health guideline calls it the mainstay for mild acne and lists benzoyl peroxide, a topical retinoid, azelaic acid, salicylic acid and topical antibiotics as indicated for mild to moderate acne (grade A). The first-line options for mild to moderate acne in NICE guidance are fixed combinations of two topical agents, offered as a 12-week course. A topical antibiotic is not used alone, and DermNet NZ says it is used together with benzoyl peroxide or azelaic acid to lower the chance of antibiotic resistance. These products often cause dryness in the first weeks, and NICE suggests starting on alternate days or with short contact time to cope with it. Positive effects can take 6 to 8 weeks to become noticeable, and DermNet NZ says it may take several weeks or even months to see convincing improvement. Which retinoid creams a Malaysian pharmacy may supply is set out in what Malaysian law lets you buy.
Oral medicines are prescription-only and are for moderate to severe acne: an oral antibiotic for a limited period, always alongside a topical treatment and never alone, and for some women a hormonal option such as the combined oral contraceptive pill or an anti-androgen. An oral retinoid is the strongest option. The Malaysian guideline lists it for severe or nodulocystic acne and as a third-line option in moderate acne, says it is teratogenic and needs strict contraceptive practice, and says it should only be prescribed by dermatologists. The isotretinoin article sets out what is checked before, during and after.
Procedures sit beside medicines, not in place of them. The Ministry of Health guideline says peels, light-based treatment, lasers and comedone extraction are not the mainstay of acne treatment, and that a glycolic or salicylic acid peel may be used as an adjunct (grade B). For acne-prone skin, Dr Ong uses salicylic acid peels at The Retreat Clinic, chosen after the skin has been assessed rather than offered as a standard facial. The salicylic acid peel article sets out what the trials show, and chemical peels in general explains the depths and agents.
When we would say no
We do not treat scarring over acne that is still active. New breakouts keep writing new scars behind the treatment, and the money is better spent controlling the acne first.
Acne severe enough that a prescription oral retinoid is being weighed belongs with a dermatologist or another suitably qualified prescriber, and this clinic does not prescribe it. A peel does not stand in for treating the cause either: it works at the surface and in the pore, it does not switch off a hormonal driver, and it does not reach deep scars.
A peel also waits when it should. Pregnancy, an active infection such as a cold sore and a recent oral retinoid course are all reasons to hold off or to ask first, as the salicylic acid peel article explains.
When acne needs a dermatologist, or a doctor now
NICE sets out when to send acne on for specialist care. The reasons include diagnostic uncertainty, nodulocystic acne, mild to moderate acne that has not responded to two completed courses of treatment, acne that is leading to scarring or persistent dark marks, acne of any severity that is causing persistent psychological distress, and a medical disorder or medicine that is likely to be contributing. The Malaysian guideline says severe or nodulocystic acne that may need an oral retinoid should be seen within one to four weeks. DermNet NZ puts the everyday version plainly: see a doctor if pimples fail to clear within six weeks or the acne is severe.
Some signs need a doctor quickly. DermNet NZ says acne with fever, joint pain, bone pain, or ulcerated or extensive skin lesions needs a blood count and urgent referral, and NICE calls for same-day assessment of acne fulminans, a serious form with systemic symptoms. If acne is affecting your mood badly, say so. NICE treats persistent distress as a reason to refer at any severity, and thoughts of harming yourself need urgent medical help.
Marks and scars need their own plan
Acne leaves two kinds of aftermath. A dark or red mark follows an inflamed spot and can linger, particularly in richly pigmented skin, which acne dark marks in Malaysian skin explains, and the pigmentation page sets out how they are told apart from melasma and sun spots. A scar is damage to the collagen under the skin, and the acne scar and pore page maps what is possible.
This clinic treats the texture, pores and scarring that acne leaves behind once the acne itself is controlled. The order matters: the acne is brought under control first, the marks and scars come second, and sun protection runs through both.
Our view
Acne is often sold as a product problem. It is a long-running condition with a kind, a cause and a timetable measured in weeks, and the useful first visit is the one that names which kind it is and which door it needs.
