Acne Scar Treatment Singapore

acne scars treatment

Acne Scar Treatment Singapore

The acne scar treatment approach must take into consideration your acne scar type and skin type. From our years of experience, a multimodal treatment approach that places emphasis on your unique acne scar morphology, skin phototype and treatment safety will give you the best acne scar treatment results.

How Common Are Acne Scars?

Acne scars are often associated with acne vulgaris. Although most adolescent will experience acne of varying severity in their lifetimes, a significant proportion of individuals will have moderate to severe acne scarring which they find distressing. In cross-sectional survey of individuals age 15-24 years, about 30% of individuals considered it a major problem and burden.

What Are The Acne Scar Types?

The most common acne scar types are Atrophic acne scars. In most individuals, there is often a mixture of ice pick, boxcar and rolling acne scars. We call this Mixed atrophic acne scars or Polymorphic atrophic acne scars.

Ice pick scars are most common, they are less than 2mm in diameter, and taper as it extends to the deep dermal layer of your skin. Ice pick scars are the deepest and poses the most treatment challenge.

Boxcar scars are wider than ice pick scars, having a sharper vertical border. Variant of boxcar acne scars may either be shallow or deep in depth.

Rolling scars have wider surface combined with sloping borders. Rolling scars can be superficial or deeply tethered to the deep dermal layer of the skin.

Two Important Factors that Acne Scar Treatment Hinge Upon

From clinical experience in our local context, the 2 most important criteria for planning any acne scar treatment would be your skin phototype and acne scar type.

Individuals with darker skin types should go for treatments that have lesser risk of post-inflammatory hyperpigmentation (PIH). PIH occurs when the skin is inflammed or irritated, leaving dark marks on the skin. Fractional ablative laser treatment such as the Carbon dioxide (CO2) and Er:YAG lasers are associated with prolonged downtime and a higher incidence of post-inflammatory hyperpigmentation. This is due to the laser disrupting the epidermal-dermal junction as it penetrates the skin.  Over the last few years, advances in fractional resurfacing technology have managed to substantially reduce the risk of PIH by bypassing the epidermal layer. Fractional microneedling radio-frequency treatments such as the Genius and INFINI are able to precisely deliver energy into the dermis while minimising injury to the epidermal layer of the skin. This greatly reduces the chance of PIH.

A proper examination of your skin is integral to determining the acne scar type. Although most individuals will have a mixed atrophic acne scar phenotype, the variations and the dominant scar type will influence the type of acne scar treatments you will need. No single treatment modality will address all your acne scars, a combined approach gives the best results.

tca cross acne scars in Singapore
Mixed Atrophic Acne Scar Grade 4
Mixed Atrophic Acne Scar Grade 3-4
acne scars treatment
Mixed Atrophic Acne Scar Grade 3-4

Acne Scar Treatment Options

There is a variety of acne scars treatment being offered in Singapore. These are categorised broadly into the following:

  • Topical treatments e.g. chemical peels, TCA CROSS
  • Lasers and energy-based devices e.g. Fractional CO2 laser, Genius, INFINI
  • Injectables e.g. Fillers, Rejuran S
  • Surgical e.g. Subcision, punch excision

For ice pick scars, procedures such as TCA CROSS or punch excision are good options. TCA CROSS involves the focal application of concentrated acid to promote collagen remodelling via coagulation necrosis and wound healing. Punch excision involves the use of an instrument to surgically remove the ice pick scar which is then stitched together, but this will result in another scar.

Superficial rolling and boxcar scars respond better to energy based and laser resurfacing treatments. Studies have shown increased collagen synthesis, elastin fibers and dermal remodelling with laser and energy based devices for acne scars. Fractional microneedling radio-frequency treatment is safer in individuals with darker skin phototypes.

Deeper rolling acne scars are mostly released via subcision. Subcision is a surgical technique to release the tethered scars that are pulling your acne scars downwards.

Multimodal Approach for Mixed Acne Scar Types

From our experience, many individuals in Singapore have mixed atrophic acne scar type and darker skin phototypes. A multimodal approach to acne scar treatment that maximises treatment efficacy while minimising side effects is recommended.

The principles would be to treat the deeper scars such as ice pick and deeply tethered scars. Once these deeper scars have surfaced, fractional microneedle resurfacing is carried out to treat rolling and boxcar scars.

As this combined approach is highly customisable, the specific treatment parameters can be adjusted according to your acne scar type, downtime and treatment goals in mind.

It depends on the type of acne scar treatment. TCA CROSS is a tolerable procedure, a stinging sensation is felt for only a few minutes. For subcision and fractional microneedle treatments, the procedure is performed under local and topical anaesthesia respectively. This optimizes your comfort during the procedure.

From Dr Ng’s experience, these treatments are conceptualized for all skin types, especially individuals with darker skin phototypes.

This would depend on individual acne scarring pattern and healing response. In general, for deep ice pick scars, you may need at least 3-6 treatments. Subcision is carried out for selected deep rolling scars, and often 2-3 treatments should suffice. The majority of individuals will see good improvement in their acne scar appearance after 4 sessions of fractional microneedle radio-frequency treatments.

It is necessary to keep the skin clean after the procedure with regular cleansing. An antibiotic ointment may be prescribed for certain procedures. Sun exposure and protection is pivotal to reduce post-inflammatory hyperpigmentation.

Most individuals will notice an improvement from 6 months onwards. Collagen stimulation, the restructuring of the dermal architecture and remodelling takes place over months. An expectation of improvement within days or few weeks would be unlikely and unrealistic.

 
An initial consultation is necessary to assess your acne scars, medical history and discuss the treatment options.
Consultations are strictly by appointment only. Please call +65 6769 6007 or Whatspp +65 9855 3022.

Request a CallBack

Get in touch with us with any questions, pricing, or bookings.

Or give us a call at +65 6769 6007 | WhatsApp us +65 9855 3022

References:

  1. Szepietowski, J., Wolkenstein, P., Veraldi, S., Tennstedt, D., Machovcová, A. and Delarue, A. (2018), Acne across Europe: an online survey on perceptions and management of acne. J Eur Acad Dermatol Venereol, 32: 463-466.
  2. PETERSON, J.D., PALM, M.D., KIRIPOLSKY, M.G., GUIHA, I.C. and GOLDMAN, M.P. (2011), Evaluation of the Effect of Fractional Laser with Radiofrequency and Fractionated Radiofrequency on the Improvement of Acne Scars. Dermatologic Surgery, 37: 1260-1267. https://doi.org/10.1111/j.1524-4725.2011.02110.x
  3. Cucu, CButacu, A-INiculae, B-DTiplica, G-SBenefits of fractional radiofrequency treatment in patients with atrophic acne scars – Literature reviewJ Cosmet Dermatol202120381– 385https://doi.org/10.1111/jocd.13900
  4. Rullan, Peter P et al. “A Combination Approach to Treating Acne Scars in All Skin Types: Carbolic Chemical Reconstruction of Skin Scars, Blunt Bi-level Cannula Subcision, and Microneedling-A Case Series.” The Journal of clinical and aesthetic dermatology vol. 13,5 (2020): 19-23.
  5. Al Qarqaz, FAl-Yousef, ASkin microneedling for acne scars associated with pigmentation in patients with dark skinJ Cosmet Dermatol201817390– 395https://doi.org/10.1111/jocd.12520

     

Benzoyl Peroxide for Acne

benzoyl peroxide acne treatment

What Is Benzoyl Peroxide?

Benzoyl peroxide for acne treatment is well established. Benzoyl peroxide (BPO) is an anti-septic and a strong oxidising agent. BPO is capable of killing bacteria (we call this the bactericidal effect) by disrupting critical components of the bacterial cell wall. BPO is commonly found off the shelves in various formations and concentrations. BPO can be found in gels, creams and facial washes. Common concentrations in the market include BPO 2.5%, 5% and 10%.

Why Is Benzoyl Peroxide Important?

There are 4 main factors contributing to acne. These include an overactive sebaceous gland, abnormal keratinization within the hair follicle, inflammation and colonization of bacteria. Cutibacterium acnes (C.acnes) plays a vital role in the formation of Acne Vulgaris

Incorporating benzoyl peroxide for acne treatment therefore helps to reduce C.acnes colonisation and diminish antibiotic-resistant C.acnes strains. Treating solely with a topical or an oral antibiotic would substantially increase antibiotic resistance and make it harder to treat your acne. Nowadays, many topical creams comprise of a fixed combination of medicines to treat your acne. Common examples include Clindoxyl gel (Clindamycin + BPO) and Epiduo gel (Adapalene + BPO).

If your are suffering from moderate Acne Vulgaris where inflammation is predominant, your doctor may prescribe an oral antibiotic. However, it is good practice to integrate BPO into your treatment regime to reduce antibiotic resistance and enhance your treatment success.

Are There Side Effects with Benzoyl Peroxide?

Despite benzoyl peroxide treatments being an familiar go to product for acne, many individuals often complain of the dryness, redness, itchiness and peeling of the skin. While some doctors may recommend short contact therapy to reduce side effects, studies have been scarce as to the duration and concentration to leave BPO on the skin before you should wash it off.

cutibacterium acnes

Minimal Contact Time for Benzoyl Peroxide to Kill off C.acnes

Fortunately, a recent experimental in vitro study shed some light on the contact time of BPO with respect to its concentration. C.acnes was isolated from over 90 participants in this study. Different concentations of BPO was added and the minimal inhibitory concentration (MIC) was determined. MIC is defined as the lowest concentration at which the drug inhibited bacterial growth.

Results from this study shows:

  • Lower concentrations of BPO (<2.5%) required more time to kill off C.acnes
  • BPO concentrations of 5% or higher have swift bactericidal effects, and may be more suitable to use used as a rinse-off formulation.
  • BPO is effective against both antibiotic-resistant and antibiotic-suspectible to C.acnes strains

Median contact time for Bactericidal effects of BPO depended on their concentration:

  • BPO 1.25 % (60 minutes)
  • BPO 2.5% (15 minutes)
  • BPO 5% ( 30 seconds)
  • BPO 10% (30 seconds)

Recommendations:

  • If you have sensitive skin, it is best to start with the lowest concentration of BPO you can find.
  • Use with a light weight moisturiser to buffer against BPO side effects.
  • Start with a reduced frequency of BPO application and gradually increase once your skin gets used to it.
  • 30 seconds contact time may be enough if you are using BPO concentration of 5%.

Summary

Benzoyl peroxide for acne plays an integral role whether as part of treating an acute flare of acne vulgaris or part of your maintenance treatment regimen. Although benzoyl peroxide is effective, it has common side effects, therefore choosing the right concentration and contact time will be important for patients who may have sensitive skin or sensitive to benzoyl peroxide for acne treatment.

References:

1. Boonchaya, P., Rojhirunsakool, S., Kamanamool, N., Khunkhet, S., Yooyongsatit, S., Udompataikul, M., & Taweechotipatr, M. (2022). Minimum Contact Time of 1.25%, 2.5%, 5%, and 10% Benzoyl Peroxide for a Bactericidal Effect Against Cutibacterium acnes. Clinical, cosmetic and investigational dermatology, 15, 403–409. https://doi.org/10.2147/CCID.S359055

2. Sagransky M, Yentzer BA, Feldman SR. Benzoyl peroxide: a review of its current use in the treatment of acne vulgarisExpert Opin Pharmacother. 2009;10(15):2555–2562. 

3.Thiboutot DM, Dréno B, Abanmi A, et al. Practical management of acne for clinicians: an international consensus from the Global Alliance to Improve Outcomes in AcneJ Am Acad Dermatol. 2018;78(2):S1–S23.

Finasteride and Minoxidil treatment singapore

Norwood Hamilton Scale for Male Pattern Hair Loss

What is Androgenetic Alopecia?

Androgenetic alopecia affects both men and women. The pattern and distribution of hair loss is quite distinct. In about 60-70% of female pattern hair loss, the vertex or mid-frontal area is affected. For men, almost 98% will have bitemporal recession and over 75% will have mid-frontal and vertext hair loss in their eighties.

The hair follicles are shown in several histology studies to have miniaturized. Many individuals may noticed increased hair shedding and hair thinning of slow onset for many years. This may occur in some cases during the adolescent period in males. Th prevalence of hair loss increases with age for females, with about 40% of women affected after menopause.

Dihydrotestosterone (DHT) is the major metabolite of testosterone that is implicated in male pattern hair loss. Finasteride, an inhibitor of Type 2 5 alpha enzyme, decreases DHT levels on the scalp and serum. Clinical studies have shown that finasteride decreases hair loss, increases hair growth and this improved apperance is sustained with maintenance treatment.

Sinclair Scale for Female Androgenetic Alopecia

Finasteride or Minoxidil Treatment? Which is Better?

So, is oral finasteride better than minoxidil solution? A study of participants with male pattern hair loss were randomly allocated into two groups for 12 months. The first group took oral finasteride 1mg daily, while the second group applied Minoxidil 5% twice a day. This method of study is known as a randomised controlled trial. Such a study reduces biases and is considered a gold standard in the scientific community. 

At the end of treatment, the hair density of both groups were evaluated using the modified Norwood-Hamilton scale. In the finasteride 1mg/day group, 80% of the participants were shown to have modest to significant hair growth. As with the Minoxidil 5% group, 52% of the participants showed improvement at the end of 12 months.

Is Finasteride Safe?

Yes, oral finasteride has been extensively studied and found to be a safe treatment for male androgenetic alopecia. The most common side effects (<5%) are difficulty getting an erection, decreased sex drive and reduced semen volume. These sexual side effects have been shown to reduce over time. Most of the sexual side effects (4.4%) occured during the first year and reduced drastically (0.6%) at the 5th year of oral finasteride 1mg. Therefore, this does indicate that there is no increased risk of sexual side effects with long term treatment with oral finasteride.

Other reported side effects include breast pain, breast enlargement, testicular pain, depression and allergic reactions.

It is important to note that finasteride reduces Prostate Specific Antigen (PSA) levels. The PSA test is used to screen for prostate cancer. You must let your doctor know that you are on oral finasteride if you are undergoing such a test.

combined finasteride and minoxidil treatment singapore

Is Combination Finasteride and Minoxidil Treatment Better?

Topical Minoxidil treatment has shown to reduce hair loss, and even promote hair growth. The exact mechanism of action is unknown. Topical Minoxidil may work by increasing the potassium channels, increasing growth factors in the dermis and blood flow to the hair follicles. Most individuals tolerate topical minoxidil well. Side effects such as scalp itchiness, irritation and dandruff may occur in some cases.

For very motivated individuals, one study has shown an increase in hair weight with combination finasteride and minoxidil treatment. It is possible that through different pathways, these 2 drugs may synergise hair regrowth potential.

What About Topical Finasteride and Minoxidil Treament?

The idea of combining topical finasteride and minoxidil treatment together is attractive. It is convenient to use and reassuring for men who are worried about the side effects of oral finasteride.

One study compared the efficacy of topical Finasteride and Minoxidil (combination) vs. Minoxidil (monotherapy). At the end of 24 weeks, the combined treatment group showed a greater improvement (65% vs 25%) compared to using topical minoxidil alone! In this study, the participants tolerated the combined topical finasteride and minoxidil treatment well. There was no reported sexual side effects such as loss of libido and erectile dysfunction.

Dutasteride Treatment For Hair Loss?

The main contributing factor to male pattern hair loss is Dihydrotestosterone (DHT). Circulating testosterone is converted into DHT by the enzyme 5 alpha-reductase (there are 2 types). Finasteride works by inhibiting Type 1 5 alpha-reductase enzyme, while Dutasteride works by inhibiting both Type 1 and Type 2 5 alpha-reductase enzymes.  Compared to finasteride, Dusteride is 3 times and 100 times more potent at blocking Type 2 and Type 1 5 alpha-reductase enzymes respectively.

Dustasteride is an established treatment for benign prostatic hyperplasia (BPH). In some studies, it has shown to improve male pattern hair loss by its similar mechanism of action to finasteride. When compared to finasteride, studies have shown Dutasteride 0.5mg/day to be more effective at improving hair growth with no increase in side effects. Dutasteride is considered an off-label use for androgenetic alopecia. A discussion with your doctor is necessary before starting any off-label medical treatments.

How Much Does Oral Finasteride Cost?

One box of PROPECIA® (Finasteride 1mg, MSD) costs from $85-95 for a box of 28 tablets in Singapore. However, there are HSA approved versions of Finasteride 1mg available. One box (28 tablets) Finasteride 1mg daily  is only at $64.9 at APAX Medical & Aesthetic Clinics. 

More Information:

Request a CallBack

Get in touch with us with any questions, pricing, or bookings.

Or give us a call at +65 6769 6007 | WhatsApp us +65 9855 3022

References:

  1. Kaufman KD, Olsen EA, Whiting D et al. Finasteride in the treatment of men with androgenetic alopecia. J Am Acad Dermatol 1998; 39: 578±89.
  2. E. Arca, G. Acikgoz, H. B. Tastan et al., “An open, randomized, comparative study of oral finasteride and 5% topical minoxidil in male androgenetic alopecia,” Dermatology, vol. 209, no. 2, pp. 117–125, 2004.
  3. H. C. Eun, O. S. Kwon, J. H. Yeon et al., “Efficacy, safety, and tolerability of dutasteride 0.5 mg once daily in male patients with male pattern hair loss: a randomized, double-blind, placebo-controlled, phase III study,” Journal of the American Academy of Dermatology, vol. 63, no. 2, pp. 252–258, 2010.
  4. Kaufman KD, Finasteride Male Pattern Hair Loss Study Group Long-term (5-year) multinational experience with finasteride 1 Mg in the treatment of men with androgenetic alopecia. Eur J Dermatol. 2002;12(1):38–49.
  5. Diani AR, Mulholland MJ, Shull KL, Kubicek MF, Johnson GA, Schostarez HJ, et al. Hair growth effects of oral administration of finasteride, a steroid 5a-reductase inhibitor, alone and in combination with topical minoxidil in the balding stumptail macaque. J Clin Endocrinol Metab 1992;74:345-50.
  6. Saifuddin Sheikh, Ateeq Ahmad, Shoukath Ali M, et al. A new topical formulation of minoxidil and finasteride improves hair growth in men with androgenetic alopecia. Clin Exp Dermatol Res 2015;6:1.
  7. Zhou, Z., Song, S., Gao, Z., Wu, J., Ma, J., & Cui, Y. (2019). The efficacy and safety of dutasteride compared with finasteride in treating men with androgenetic alopecia: a systematic review and meta-analysis. Clinical interventions in aging14, 399-406. doi:10.2147/CIA.S192435

Post Inflammatory Hyperpigmentation PIH

Post Inflammatory Hyperpigmentation or PIH

Post inflammatory hyperpigmentation or PIH is a common dermatological condition. PIH is considered an acquired melanosis (a condition of excessive melanin in the skin) as a response of the skin to any form of inflammatory, irritation or injury.  It is this initial event that causes excess pigment to be built up within the skin. Although PIH can happen to all skin types, it is especially common and causes more distress in individuals with a darker skin type (Fitzpatrick Skin Type III to VI).

post inflammatory hyperpigmentation treatment singapore

What Causes Post Inflammatory Hyperpigmentation

Post inflammatory hyperpigmentation can occur to any individuals of any age. 

Inflammatory conditions such as acne vulgaris, atopic dermatitis and lichen planus commonly result in PIH. In addition, insect bite reactions, trauma, phototoxic reactions and allergic conditions may provoke PIH. Likewise, drugs such as tetracyclines, antimalarials and certain chemotherapy drugs (bleomycin, doxorubicin and 5-fluorouracil) are associated with PIH.

PIH may occur after common laser procedures and chemical peels. These include fractional ablative laser such as CO2 and Er:YAG. In addition, pigment specific lasers such as the Q-Switched and Pico-second lasers may trigger paradoxical PIH if the energy absoprtion of the laser is too strong.

pore size reduction Singapore

What Are The Different Types of PIH?

PIH may exists in 3 forms depending on the layer of the skin involved i.e. Epidermal PIH, Dermal PIH and Mixed Epidermal/Dermal PIH. When there is inflammation of the epidermis, pigment producing cells produce more melanin that is subsequently transferred to the surrounding skin cells. On the other hand when inflammation is more pronounced, the basal cell layer (which separates the epidermis from the dermis) is disturbed, leading to excess melanin being trapped in the dermal layer of the skin. This phenomenon is aptly named pigmentary incontinence.

What Does PIH Look Like?

PIH is located at the site of skin post-inflammation, infection or injury. Once you have recovered from the initial inciting event, your skin may appear light to dark brown in colour. In dermal PIH, it may even take on a grayish or bluish appearance. PIH often darkens following sun exposure. Daily sun protection with regular sun screens is of utmost importance!

Post Inflammatory Hyperpigmentation Treatments

Although PIH is common, and affects many individuals, it remains a challenging condition to treat. If you opt for conservative treatment (just watchful waiting), PIH may fade by itself although this may take anywhere from 9 months to more than a few years. Even with appropriate medical treatment, you may not see modest results until 9-12 months later. This is especially so when there is dermal PIH involvement.

A range of topical treatments for epidermal PIH are available, however, the clearance rate varies across individuals. These many include monotherapy or combination therapy of lightening agents. They are prescribed according to your existing skin condition, skin type and history of skin sensitivity. These may include:

  • Retinoids e.g. Tretinoin
  • Hydroquinone 2% or 4%
  • Arbutin
  • Niacinamide
  • Kojic Acid
  • Azelaic acid
  • Corticosteroids
  • Glycolic acid
Q-Switched Nd:YAG lasers may help to lighten PIH where there is dermal involvement. Multiple sessions may be required for the desired effect. There have also been reports on IPL and Picosecond lasers being used to treat PIH, with varying degress of success.

More Information:

  • Post Inflammatory Hyperpigmentation – DermNet
  • Post Inflammatory Hyperpigmentation – NCBI

Request a CallBack

Get in touch with us with any questions, pricing, or bookings.

Or give us a call at +65 6769 6007 | WhatsApp us +65 9855 3022

References:

  1. Kaufman BP, Aman T, Alexis AF. Postinflammatory Hyperpigmentation: Epidemiology, Clinical Presentation, Pathogenesis and Treatment. Am J Clin Dermatol. 2017 Dec 8. 
  2. Woolery-Lloyd HC, Keri J, Doig S. Retinoids and azelaic acid to treat acne and hyperpigmentation in skin of color. J Drugs Dermatol. 2013 Apr. 12(4):434-7. 
  3. Park JH, Kim JI, Kim WS. Treatment of Persistent Facial Postinflammatory Hyperpigmentation With Novel Pulse-in-Pulse Mode Intense Pulsed Light. Dermatol Surg. 2016 Feb. 42 (2):218-24.
  4. Lee YJ, Shin HJ, Noh TK, Choi KH, Chang SE. Treatment of Melasma and Post-Inflammatory Hyperpigmentation by a Picosecond 755-nm Alexandrite Laser in Asian Patients. Ann Dermatol. 2017 Dec. 29 (6):779-781.
  5. Kim S, Cho KH. Treatment of procedure-related postinflammatory hyperpigmentation using 1064-nm Q-switched Nd:YAG laser with low fluence in Asian patients: report of five cases. J Cosmet Dermatol. 2010 Dec. 9(4):302-6.

Expectations and Realities of Acne Treatment

Expectations and Realities of Acne Treatment

Introduction

Acne Vulgaris is a common dermatological condition. Although most teenagers will be affected by acne, of varying severity and duration, most cases can be treated effectively and safely. Acne can persists into adulthood for many teenagers. Facial acne scarring occurs in at least 20% of teenagers. Over the past few years, there has been an upward trend in adult onset acne cases. Again, the distribution and severity may differ from adult onset acne compared to adolescent acne.

The duration of acne vulgaris is highly variable. While acne may erupt due to stress, lack of sleep or even a change in lifestyle, this fortunately lasts a couple of days to weeks. Cases like these tend to subside quickly with simple treatments.

 

Help - My Acne Does Not Seem to Stop!

On the other hand, acne may last months or even several years! In cases where your acne is just not going away, research has shown that acne to be a chronic inflammatory disease of the pilosebaceous unit. What this means is that the constant inflammation underneath the skin can lead to scarring and causes suffering such as low self-esteem for a prolonged period. The chronic inflammation is a result of androgen dependent increase in sebum production, abnormal skin cell maturation (keratinisation), inflammation and bacteria (Propionibacterium acnes.) colonisation within the hair follicles.

As to what exactly triggers acne is currently unclear. Although is may run in families, this is not always the case It is not uncommon to see individuals with acne, finding it puzzling as to why no other siblings are affected.

Can Acne Be Cured?

There is no ideal treatment for acne. In many other chronic medical conditions ( e.g. Atopic eczema, Asthma, Diabetes) where there is no cure, treatments are aimed at bringing comfort, reducing suffering and helping individuals find a suitable regimen to optimise their treatment. After all, the old adage of “Cure sometimes, relieve often, and to comfort always” rings true when doctors treat conditions where a cure is not attainable.

The development of effective acne treatments over the last few decades have undoubtedly benefited a significant number of people. It has helped regain confidence, reduce suffering and minimize permanent scarring. Although there is no permanent antidote for acne, most individuals are able to find a suitable treatment regime to minimise acne. Topical treatments in the form of benzoyl peroxide, retinoids, and antibiotics when used in combination can greatly improve acne control in mild to moderate cases. An oral antibiotic may be prescribed for inflammatory acne vulgaris, often with a topical agent to minimise bacterial resistance. Oral Isotretinoin (e.g. Accutane, Acnotin, Oratane) is often reserved for moderately-severe, cystic acne or acne that is not responding to oral antibiotics. The use of oral isotretinoin although highly effective, is limited by its side effects and teratogenic potential.

Does Everyone Respond Equally To Treatment?

We understand that individuals suffering from acne may feel distressed, and are often anxious to find a solution to quickly address their concerns. Individuals often wonder whether a particular treatment is really working for them or not, and may regrettably abandon treatment when they do not see the results they are expecting within a set amount of time.

Everybody is different. Humans are biological entities with different genetic make up. The response to treatment will invariably differ across individuals. As we differ genetically, our treatment response and even adverse effects will vary from one individual to another. This is known as Pharmacogenetics. Knowing that no two individuals are alike, as doctors, we try our best to come up with a treatment plan that is appropriate for your condition, skin type and medical background. We may not get it right all of the time, but you can rest assured that we will try our best to come up with a most suitable treatment plan for you. For example, in cases where acne is resistant to standard therapies or is rapidly progressing, we may need to step up treatment to control the condition.

6 Things to Know About Your Acne Treatment:

  1. Be patient. Acne treatment takes time, and responds slowly to treatment. A significant improvement may only be noticeable from 8 weeks onwards. Many clinical studies are based on a 12 week treatment duration. Its quite unrealistic to expect results in a few weeks!
  2. Flares may occur. This is especially so when many treatments are retinoid based (whether topical or oral). Retinoids are highly effective at reducing comedones, inflammation, but also increasing skin cell turnover. This initial acne flare is common and will settle quickly in most cases.
  3. Slow and Steady. We normally advise a gradual step wise approach to treatment. Many acne based creams or gels can cause skin dryness, redness and/or irritation. It is important that you begin treatment slowly, allowing the skin to adapt. This can take up to 4-6 weeks.
  4. Fight Resistance. Antibiotic resistance is a major issue worldwide. In cases where an oral antibiotic may be prescribed for inflammatory acne vulgaris, we may prescribe some topicals. A topical retinoid and/or benzoyl peroxide based treatment in combination reduces bacterial resistance!
  5. Moisturize. Many acne treatments (especially oral isotretinoin) can cause skin dryness. Regular application of a lip balm, lotion, or even artificial tear eye drops helps greatly. Skin that is too dry increases the risks of skin infections. Moisturise regularly!
  6. Perseverance. Ok, your acne is more or less under control. However, there are still few annoying outbreaks. As acne may last for many years, we advise treating newly emerging acne (whiteheads/blackheads/small papule or pustules) early.

References:

  1. Thiboutot D, Gollnick H, Bettoli V, Dréno B, Kang S, Leyden JJ, et al. New insights into the management of acne: an update from the Global Alliance to Improve Outcomes in Acne group. J Am Acad Dermatol. 2009 May. 60(5 Suppl):S1-50.
  2. Collier CN, Harper JC, Cafardi JA, Cantrell WC, Wang W, Foster KW, et al. The prevalence of acne in adults 20 years and older. J Am Acad Dermatol. 2008 Jan. 58(1):56-9. 
  3. Gollnick H, Cunliffe W, Berson D, Dreno B, Finlay A, Leyden JJ, et al. Management of acne: a report from a Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2003 Jul. 49(1 Suppl):S1-37.
  4. Lee JW, Yoo KH, Park KY, Han TY, Li K, Seo SJ, et al. Effectiveness of Conventional, Low-dose and Intermittent Oral Isotretinoin in the Treatment of Acne: A Randomized, Controlled Comparative study. Br J Dermatol. 2010 Nov 29.

Acne Mechanica

acne treatment singaproe

Acne Mechanica

Acne Mechanica refers to an acneifom eruption when mechanical forces are exerted over the skin. This can be in the form of pressure, occlusion, squeezing, rubbing, friction or stretching. Acne mechanica is more common in individuals with pre-existing tendencies to developing acne, and may even worsen mild acne to become inflammatory acne or even cystic acne

How Do I Know I Have Acne Mechanica?

Location! The characteristic pattern of pre-adolescent acne is mainly confined to the forehead. During adolescent period, acne lesions are commonly found in the T-Zone area (forehead/cheeks/Chin), and may involve back and chest skin in more severe cases. Adult onset acne which is mainly hormonally driven commonly affects the skin around the jawline, upper neck and chin. We call this the U-shape pattern in adult acne cases.

The distribution of acne lesions in acne mechanica can have the most unusual distributions. A violin player may experience predominant acne only on one side of the neck, whereas a young helmet-wearing soldier may find that he has stubborn acne around his chin strap area. Another common example would be a student that unconsciously lays his hands over his chin and cheeks, and does so repeatedly during the course of study, and perhaps more so before an exam!

Athletes that engage in sports where they need to don shoulder pads may find acne sitting there. A bus driver who spends hours with his back against the chair, may develop moderately-severe back and buttock acne. Another common area for acne mechanica to take place would be underneath orthopaedic casts after an injury. This can affect the upper or lower limbs or even truncal areas.

best acne treatment in Singapore

How Do I Treat Acne Mechanica?

It may seem obvious. Stop the offending mechanical forces that may be perpetuating the acne. However, in cases where acneiform lesions persists despite efforts to reduce the mechanical stress on the skin, it would be advisable to see a doctor for further assessment and management. This is because individuals who develop acne mechanica are more acne prone, and delays in treatment may lead to the worsening of the acne and cause permanent acne scars.

Nowadays, acne vulgaris is a treatable skin condition. Acne treatments take into account the severity of the acne, the predominant acne lesion type, duration and the distribution of  your acne. While milder forms of acne may respond to topical treatments, moderate to severe forms of acne may be better treated with oral medications such as an antibiotic or even oral isotretinoin. 

References:

  1. Brun P, Baran R: A special type of mechanical acne: fiddler’s neck dermatitis. Ann Dermatol Venereol 1984;111:241-245.
  2. Otto H, Mils Jr, Albert kligman. Acne Mechanica. Arch Dermatol. 1975;111(4):481-483

Acne Fulminans

Acne Fulminans

Acne Fulminans is a rare and particularly severe form of acne vulgaris. With only about 100 cases reported worldwide, acne fulminans appears almost exclusively in young men. The sudden onset of ulcerating acne lesions coupled with fever and multiple joint pain and swellings are hallmarks of this disfiguring condition.

Who Is At Risk of Acne Fulminans?

  1. Men aged 13-22 years of age with a history of acne
  2. Nodular acne
  3. Severe inflammatory acne on the chest, shoulders and back.
  4. High starting dose of oral isotretinoin 

Treatment of Acne Fulminans

An overdrive of the immune systems appears to be responsible for the abrupt onset and severity of the symptoms these individuals experience. Oral steroids that aid in immunosuppression are required in the treatment of acne fulminans. The additional anti-inflammatory effects of oral steroids help reduce fever, acne and joint pain and swelling. 

Oral antibiotics may be started concomitantly to treat any secondary infection. The use of oral isotretinoin is slowly introduced after 4 weeks of oral steroids to clear the severe acne skin lesions.

Other treatment options include Dapsone, Methotrexate, Ciclosporin and biological therapy using Infliximab.

Complications of Acne Fulminans

  • Severe Scarring
  • Keloid Scars
  • Bone destruction (clavicle, sternum, long bones)

Further Information:

  1. Acne Fulminans – Dermnet New Zealand
  2. Acne Fulminans – Emedicine

Pomade Acne treatment

What is Pomade Acne?

Pomade is a greasy, waxy or water-based hair styling substance for men. In the past, pomades were derived from bear fat or lard. Nowadays, common ingredients include lanolin, beeswax, petroleum jelly, hydrocarbons, water and glycerin. Pomades are popular because they are long lasting and give hair a slicker and shinier appearance. Generally, pomades can be classified as oil-based and water-based. 

Pomade acne (aka Acne Venenata) is common, especially with oil-based products containing wax, lanolin and petroleum jelly. These substances are considered comedogenic (pore-clogging) and may precipitate or perpetuate acne. Various vegetable, mineral or animal oils can be highly comedogenic. Click here to find out more about a list of comedogenic ingredients, and their comedogenicity ratings.

Comedomal Pomade Acne
Inflammatory Pomade Acne

How Does Pomade Acne Look Like?

It may take months and up to a year before you develop pomade acne because it has a slow progression before being clinically apparent. Although pomade acne is more common in individuals of Afro-caribbean ethnicity with curly hair, it can happen to just about anyone. As you would expect, pomade acne is often found around the hairline, upper forehead, temples, ears, cheeks and scalp. In the vast majority of cases, you will see and feel skin coloured bumps on the skin due to follicular occlusion. These are mainly closed comedomes or whiteheads. Closed comedomes have a higher chance of progressing to inflammatory acne compared to open comedomes (or black heads).

acne treatment clinic in Singapore

How Do I Treat Pomade Acne?

  1. The first step is to identify the type of pomade you are using. If you are using an oil-based product, and you find yourself getting an acne outbreak, you got to stop the offending agent. Using a water-based pomade is less likely to clog your pores and result in acne vulgaris. Examples of water-based promades are shown here.
  2. It may seem common sense, but you need to wash your hands thoroughly after styling your hair because you wouldn’t want the remaining bits of pomade on your fingers to stick on your face. Do you realise how many times you touch your face a day? Click here to find out.
  3. When applying pomade, avoid getting the product in contact with the scalp directly by styling the hair one third above the skin, and avoiding the hairline. 
  4. Wash off the pomade daily. Regardless of whether using a water-based or oil-based substance, you need to wash it off daily. Any product left on the skin for too long will lead to clogged pores and acne.
  5. In some cases, if the above measures do not subside the acne, you need to see a doctor to get your acne treated. Acne left for too long can lead to acne scars, even mild acne can lead to scarring. Mild acne can usually be treated with effective topical creams such as benzoyl peroxide, retinoids, antibiotics or a combination of these products. Acne marks can be improved with Azelaic acid creams. In addition, Azelaic acid has comedolytic and anti-inflammatory effects. For moderate to more severe forms of acne, you may be prescribed a course of oral antibiotics, or even oral isotretinoin

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References:

  1. Plewig G, Fulton JE, Kligman AM. Pomade Acne. Arch Dermatol. 1970;101(5):580-4
  2. O Onwudiwe, VD Callender. Pomade Acne. Acneiform Eruptions in Dermatology, 2014

Rapid Acne Clearance

best acne clinic in Singapore

Rapid Acne Clearance

A presentation that you need to give in a week, or a graduation ceremony you have been planning for the last few months, then acne strikes! It is quite common, and understandable for individuals to request for treatments for acne to disappear quickly before an important event.

While standard acne treatments take at least 6-8 weeks to show an effect, and further 4-6 weeks to show its full effect, do we have options available to reduce the effects of acne over a shorter span of time?

3 Ways to Clear Acne Rapidly

1. Intralesional Steroid Injections

Intralesional steroid injections are used extensively in dermatology in conditions such as keloids, alopecia areata and acne cysts. Steroids work by their anti-inflammatory and immuno-suppressive effects. They are safe when used in appropriate amounts, and for the right indications.

Intralesional steroid injections are suitable for nodular or cystic acne. This is so, especially if the acne cysts are causing pain and discomfort. A single injection into the culprit lesion can reduce pain, swelling and inflammation. It takes an average of 3-7 days to see an effect. This is just a temporary solution for the solitary acne cysts, and is no means curative of acne. 

Intralesional steroid injections are not suitable for smaller acne lesions, whitehead and blackheads. Potential side effects include infection, delayed wound healing, sterile abscess, skin thinning and making blood vessels more prominent on the skin. Ironically, you may develop steroid acne, but this usually resolves once the steroid effects wear off.

oral steroids for rapid clearing of acne in Singapore

2. Oral Steroids

Oral (systemic) steroids are also known as glucocorticoids or cortisones. Common oral steroids include prednisolone and dexamethasone. Oral steroids are useful for managing dermatological conditions such as severe eczema flare, vasculitis and sarcoidosis.

A short course of low dose oral steroids for a few days can quickly bring acne under control. This is more suitable for multiple inflammatory acne vulgaris lesions, where intralesional steroid injections would not be feasible. A short course of oral steroids is safe, and acts as a temporary bridge to bring the acne flare under control.

Oral steroids are not suitable for individuals with peptic ulcer disease, active infections such as Tuberculosis and Herpes infection. They are not suitable if you have diabetes, glaucoma, cataract, hypertension and heart failure.

3. Skin Care

The last thing you want to do before an important event is to exfoliate or scrub your skin excessively. Over-washing strips the natural oils from the skin surface, and an increase rate of sebum production as a compensatory phenomenon will lead to more acne. 

Skin care products that contain salicylic acid (especially if more than 2%), can increase skin peeling, dryness and sensitivity. We advise using a gentle cleanser to soothe the skin. Witch hazel has an astringent as well as an anti-inflammatory effect on the skin. This helps reduce redness and oiliness associated with acne. Aloe vera based products can help soothe the skin, and reduce inflammation. However, it is know that aloe vera products can cause skin irritation in susceptible individuals, therefore a test spot is necessary before applying it all over the face. 

best acne clinic in Singapore

Top Tip

All the above methods may bring about a temporary improvement in your acne. We need to tackle acne more seriously, and overcome the effects of acne such as acne scarring and the psychological burden it brings. Acne is considered a chronic inflammatory condition of the pilo-sebaceous glands. For many individuals, they may be battling acne vulgaris for more than a decade. There are now effective acne treatments available to treat acne, reduce scarring and promote healthy skin. However, this approach takes time, and is well worth the wait, effort and perseverance. 

References

  1. Zaenglein et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016;74:945-973.e933
  2. Leena C et al. Moisturisers for Acne. J of Clin and Aesthe Dermatol. 2014 May; 7(5): 36–44.