The 5 steps to grading acne conditions

a) Acne and it’s causes

Acne is an inflammatory condition of the pilosebaceous unit and is most common amongst young adolescents when more androgens, (the male sex hormones which influence the sebaceous secretions) ore being produced. The sebaceous glands become more active and the skin appears very shiny. This condition of excess grease is called seborrhoea.

Bacteria that are present in the hair follicle breaks down the sebum. The sebum then releases fatty acids that irritate the wall of the follicle. The epidermal lining thickens, narrowing the upper portion of the hair follicle so that the sebum builds up further down.

When the follicle becomes completely blocked with the dead, hardened skin cells and bacterial infection takes hold resulting in the form of a pustule. If the follicle is blocked with hardened sebum, open and closed comedones form. This type of acne is known as acne vulgaris.

Papules also form in the hair follicle making the follicle swell and sore. Sometimes the contents of the follicle escape into the surrounding tissue causing dermal inflammation and painful cysts. When these heal they can leave pitting and permanent scarring on the skin.

Indeed post-acne scarring is a condition for treatment in its own right. Regenerative treatments such as chemical peels, micro-needling and microdermabrasion can remedy acne scarring.

Acne cannot be cured but it can be controlled. Depending on the severity of the condition, medication may be prescribed by the GP prior to any clinical treatment – very often it will be antibiotics, medicated skin creams or steroid lotions.

Acne usually affects men between the ages of 14 – 19 and women from 14 – 17. It gradually improves and has usually disappeared completely by the age of 25 once the hormones have completely settled. However up to 12% of women in their 40s do still develop a mature acne.

It is a misconception that acne sufferers should use the strongest most astringent products on their skin. Very often this can have a drying effect on the skin and can cause the sufferer to produce more sebum.

Products with strong detergents or de-greasing action irritate the skin which can cause the follicles to become more blocked, increasing papules, pustules and comedones. The initial approach to the acne skin should be to reduce inflammation, sepsis and pore blockage.

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b) The acne grading system

Acne conditions are gauged by the level of severity to provide a benchmark for their treatment. The most widely recognised grading system runs from Grade 1 to Grade 5, with 5 being the most severe.

The gradation is judged simply according to the type and number of lesions present plus other accompanying symptoms including the lesion location. The lesions counted and assessed are –

  • Pustules
  • Papules
  • Seborrhoea
  • Closed comedones
  • Open comedones
  • Inflammation / No inflammation
  • Scarring
  • Macules
  • Nodules
  • Cysts
  • Location

Acne grades 1-3 are treatable through aesthetic therapists and a wide range of remedial skin treatments.

Acne grade 4-5 refer to acne that is highly inflamed and may require medication to remedy. Treatment in this type of acne should only be performed by a GP / dermatologist. Low-grade acne is the remnant, the aesthetics.

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Acne grade 1

Known as comedonal acne, the grade one condition shows predominantly open and closed comedones on the chin, forehead, nose. There are no inflammatory lesions but the T-zone may show seborrhoea. The cheeks, neck, back and shoulders are generally clear.

Treatment approaches to this form of acne are generally deep cleansing, exfoliative clinical treatment and antiseptic salicylic acid peels.

Acne grade 2

Acne grade 2 will show open and closed comedones, papules and some pustules. The T-zone area will be worst affected by the majority of the skin generally clear but with a sensitised appearance.

Acne grade 2 excess oil can be caused by excessive scrubbing that oil production will compensate for leading to an imbalanced pH.

Acne grade 3

Grade 3 acne will have papule and pustules widely dispersed throughout the T-zone and spreading onto the cheeks and possibly chest and back. There will be open comedones and a heavy thicken texture to the skin and general sluggishness. This form of acne is most common in teenagers and those in their early twenties. A low level of surface linoleum acid levels can be linked to comedones formation.

The treatment approach to this type of acne is the reduction of inflammation. A good starting point is LED Blue light and IPL. Retinol may be used to remove excess sebum as well as resurfacing treatments such as chemical peels and lasers. Microdermabrasion should be avoided while the condition is pustular.

Acne grade 4

Open and closed comedones, papule and pustules over the entire face and sometimes spreading to neck, chest, back and the shoulders. Some papules will be of the deeper nodular type and very painful and some cystic conditions may arise. GP / Dermatologists are required to reduce inflammation and sepsis before aesthetic treatment can commence.

Adult female acne – Grade 4

This condition is principally influenced by hormonal imbalances. It appears differently to adolescent acne in that lesions will principally be around the lower face and be of the inflamed type ie papules, pustules and painful nodules.

Macules will be a common feature of this condition. These are flattened, crusted lesions symptomatic of a high androgen climate. Other areas of the skin may exhibit dryness or sensitivity.

50% of women will suffer from acne at some point in the lives. This condition can be brought on by stress lack sleep and a high sugar diet.

Acne grade 5

Grade 5 acne is a highly inflamed, chronic condition. Nodules, cysts and occasionally abscesses will present along with widespread papules and pustules. The entire face, neck, back and shoulders will be typically affected and pitted scarring will be a feature of this condition.

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c) Different levels of acne scarring

A common culprit of acne scarring is picking. Let’s consider the types of scars that can form.

  • Hypertrophic (raised)
  • Atrophic (indented)
  • Hyperpigmented (excess pigment)
  • hypopigmented (loss of pigment)

Atrophic / Hypertrophic scarring

Types of acne scars -

Atrophic scarring shows damage deep within the skin that has failed to repair itself fully causing an indented scar.

Acne is the most commonly occurring atrophic scarring and will present in three ways:-

  • Box scarring
  • Ice pick scarring
  • Rolling scarring

Acne Cometica is a mild form of acne caused by cosmetics.

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d) What are the treatment approaches for acne scarring?

Topical treatments for acne -

Resurfacing & regenerative treatments are the most suitable practices to treat acne scarring. Chemical peels, micro-needling and microdermabrasion are fantastic choices. Fraxel laser is an option. This laser resurfaces the skin to get rid of hyperpigmentation and smooth acne scars.

Besides aesthetic treatments, product choices used at home will impact the healing of acne. A key product of significant relevant is retinoid.

Retinoids are vitamin A derivatives that range from potent prescription products such as Tretinoin and synthetic Tretinoin derivatives such as Tazarotene to cosmeceutical products such as retinol.

Retinoids promote healthy skin turnover and proper skin function through reducing cohesion, enhancing desquamation, inhibits pigment buildup, antioxidant functions, stimulates collagen and reduce keratinisation within hair follicles which can cause clogged pores.

Due to stimulating effects, retinoid is to be used with caution in sensitive skin. In addition, prescription retinoid would contraindicate aesthetic treatment for a specific time. This most potent strength can thin the skin.

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e) Starter skincare kit for acne scarring

Paula’s Choice – Clear Extra Strength Trial Kit

Clear Extra Strength Trial Kit
  • The travel kit works to unclog pores, prevent breakouts and fight blackheads and redness.
  • Skin Type: Combination skin, Oily skin
  • Concern: Breakouts, Blackheads, Enlarged pores
  • Ingredients: Avobenzone, Salicylic Acid/BHA, Sodium Laureth Sulfate

The Clear Extra Strength Sample Set helps in the battle against stubborn breakouts and blackheads. These mini’s let you try the products for 2 weeks so that you can discover what’s right for you. This set includes a facial cleanser, a BHA exfoliant, a day moisturiser with SPF and a nighttime moisturiser.

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