Most people’s acne included a mix of different kinds of spots, such as:
• blackheads - small blocked pores that often look black or brown in colour
• whiteheads - small blocked pores that look white or yellow in colour
• papules - inflamed (red) lumps, slightly raised from the skin and small (less than 5mm in size)
• pustules - like papules, but with a tip of pus
• nodules and cysts - deeply inflamed spots (more than 5mm in size)
Sometimes the young people we talked to knew they had a particular kind of acne, based on the main spot type they got. Devan’s GP worked this out by examining his skin to see and touch the spots.
Ollie explains about different acne spots.
Ollie explains about different acne spots.
Age at interview: 16
Sex: Male
Age at diagnosis: 13
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So, I think you can get, like I was saying before, sort of yellow infected ones which are not particularly nice, and I think that comes from the sort of the sebum, or the whatever it is, the pus is, I don’t know conglomerates and scales over, and that’s quite horrible, and those obviously look the worst. And then you can also get…I do-, obviously I don’t know the medical terms, but I know you get red ones, which are the most uncomfortable I find, and they're really painful, and they're sort of more like l-, sort of less of like a pustule, and more of like just a lump. Seems like obviously quite a small… like a spot, and those are a lot harder cos you can't really like break the skin of them or anything like that, and they're really painful during shaving and stuff like that.
Hester often had painful and long-lasting spots.
Hester often had painful and long-lasting spots.
Age at interview: 21
Sex: Female
Age at diagnosis: 15
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For most of my history of acne it was just kind of suffering from cystic acne, so just like big lumps under the skin. Which is quite difficult because they can take weeks and weeks to fade, and they’ll leave you like a lump of scar tissue underneath. And yeah, so and you tend to get like a couple of big ones of those. And when I got them on my jaw, they sort of all joined up, so it was like just really like a big solid like lump of, of kind of infected tissue. And I, so I wasn't really sure what to do about that. And then I just left it, but. Yeah. So I'd get like those big lumps. And then because of that there'd be like-, and obviously my skin was quite bumpy even when it was fading. And then just having like quite a lot of fade marks. So I guess especially if I scratched them, I think- I don't know if my skin just lost its ability to recover as well, maybe over just the long period that I had acne. So it tended to be that at the beginning they would fade within a couple of days. And then towards the end like I'd be left with kind of fade marks for weeks, for, you know, maybe even months.
Dr McPherson talks about the types of spots often involved in acne.
Dr McPherson talks about the types of spots often involved in acne.
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So acne has lots of different types of spots. Some people will have mostly one type, some people will have all different types. All spots come- are focused around something called the pilosebaceous unit and that’s where the hair grows out of a follicle, with a little sebum producing gland which is called the sebaceous unit. The earliest type of spots are mostly comedones and people will know these as whiteheads and blackheads, and those are called open comedones [blackheads] and closed comedones [whiteheads]. That’s really just a build-up of sebum and other stuff within the hair follicle. The more inflammatory type of spots are pustules and that’s when you get a different type of cell, called a white cell. And those are the ones which look like squeezable spots, so they look quite pus-y and they look quite different from comedones – most people will be able to tell the difference between a whitehead and a pustule. Then you can get more problematic or larger spots, you can get cysts, abscesses. And then you can get – from spots, you can get marks and scarring. And you know some of those scars can be more lumpy, hypertrophic or keloid.
Having visible acne was a concern, especially on parts of the body like the face. Some people had times when their acne suddenly became more severe, which they described as a ‘breakout’ or ‘flare-up’.
Acne spots are often red because the skin is inflamed. They can look “swollen”, “raw” and “angry”. People would ask Rachael questions because her acne “looks really painful”, even when it didn’t hurt. Tom felt his skin was “covered in red things”. Becky and Ollie avoided wearing white or brightly coloured clothing because they worried it would make the redness of their acne stand out more. Doing sports and getting sunburnt were mentioned as examples when the skin could become redder, but others found exercise and sunlight helped their skins. A few people said their acne sometimes looked like a bruise or a rash when the spots clustered together.
Sarah developed both acne and an unknown rash at the same time.
Sarah developed both acne and an unknown rash at the same time.
Age at interview: 22
Sex: Female
Age at diagnosis: 16
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I can’t really remember when I was diagnosed with acne. I think it was in Lower Sixth in secondary school. When I was younger than that, more kind of Year 10/11, beginning of Lower 6th, I also had this very nasty kind of red rash. We, it was variously diagnosed as eczema, dermatitis. We never got a kind of clear idea of what it was or how to treat it. It would be kind of around my eyes and around my neck and just generally looked very red and unsightly and that just disappeared by the time I got into 6th Form. What didn’t disappear was the acne and that just kind of remained throughout 6th Form and also throughout my time at university up to the present. Although it has certainly gotten better than it was while I was an undergraduate when I think it was particularly bad.
So the rash and the acne came at the same sort of time for you?
A similar time and then one disappeared and the other didn’t. If I’d had the choice honestly I’m really glad that the rash disappeared ‘cos the rash was very difficult to cover up and [pause, thump/door closing in corridor] that really upset me, the rash – the acne, a lot less.
Many found their spots were raised (sticking out from the skin). Sometimes people could see that the spots contained pus. This made the skin “uneven” or “lumpy”, because spots were “protruding” from the skin. Shu En’s spots weren’t always visible but felt “under the skin”. Different kinds of acne spots meant it was sometimes still visible with make-up on, even if the redness was covered up.
Hester talks about the fluid in some acne spots.
Hester talks about the fluid in some acne spots.
Age at interview: 21
Sex: Female
Age at diagnosis: 15
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With the big lump it just used to kind of ooze [laugh]. It’s not very pretty. But yeah, and like underneath I think kind of sort of like bloody fluid just used to leak out, and that would, that would be kind of what would come down. And then I think because it was leaking like that, it would kind of like crust over. So I'd get like a hard kind of, yeah, a hard crust, like. And that's what would get stuck to like my pillow, for example. And then obviously when I woke up like I'd sort of pull it off with it. So yeah, and just like random sporadic bleeding as well. Especially in the night I think cos I’d sort of rub my face against it. But yeah, it was very, very sore. And I remem-, it would be windy, for example, just even like my hair hitting my face or even just the wind on my skin. Whenever I'd wear a jacket I had to make sure that like it was zipped up properly, because if it wasn't, like if the zip hit me in the face, like it would be really painful and I'd be in tears.
Some people said their skins became oilier with acne, but others struggled with dry and flaking skin on some parts of their face and body. Alexandra said her skin was “greasy” when she had acne and others, like Abbie and Eli, found theirs more shiny than usual.
‘Combination skin’ means that the person has both oily and dry areas of skin. This was a problem for Nina, who “struggled” because her skin was “very oily” but cleansing products would “dry up the skin” and cause “flaking off”. As spots dried up, many noticed that their skin would peel and flake as well.
Acne severity is often measured medically in four main categories:
• mild
• moderate
• moderately severe
• severe
Some people were told by their doctors which category their acne was in, based on how many spots they had and whether they’re painful/inflamed. Rachael was upset hearing she had ‘moderately severe’ acne, but others found it useful to know. Marga found it good seeing where she was “on the scale” because it made the “logic” behind trying different treatments “more easily understandable”.
Deborah talks about how her acne has changed over time.
Deborah talks about how her acne has changed over time.
Age at interview: 25
Sex: Female
Age at diagnosis: 12
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Would you be able to say a bit more about those differences between sort of teen acne and then adult acne?
Yeah. Yeah, absolutely. I've always had oily skin, with my acne. But while I was a teenager it was incredibly oily. My skin's sort of normalised more from that now. But I've found as I've become less oily skin, I've got larger pores. Which now is my main problem with acne, because the larger pores are more prone to it, rather than it being the oily skin. So now I'm more focused on getting the right moisturisers, getting - staying hydrated, drinking lots of water, things like that. Whereas when I was a teenager it was all just oil control. Which make-ups can I use, which things can I take to sixth form to wash my face with at lunch, or you know, you can buy those little towel bits of paper that soak up all the oil and things. So I think it definitely has changed quite a bit. I mean, even before, when I first got my breakouts - I can't even remember what my skin was like then. I was 12, you know? I think my skin was just changing so often. I do have quite sensitive skin as well, I've always had that. So that's sort of been an added complexity to all of it, because you can't just throw lots of chemicals at my skin without it reacting badly. So yeah, it's definitely different now than how it was before.
One of Molly’s GP's showed her a chart for measuring acne severity.
One of Molly’s GP's showed her a chart for measuring acne severity.
Age at interview: 20
Sex: Female
Age at diagnosis: 11
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I mean I, since I’ve come to university I’ve gone to like a different doctors surgery, I did stick with him for quite a while. And I found him quite useful like one of his things was like he had like a chart and it had like a numbered boxes and different like shots of skin like with varying scales of acne so like eight was the worst, one was the least like, the most mild and he would kind of like point out where you think you are on this scale. So where I pointed out was kind of much more severe than his diagnosis which actually did make me feel a lot better about it because I realised that potentially some of the like how I was conceiving it was maybe a bit worse than it was at that point.
So that was a helpful exercise and it kind of, I think it was useful in terms of like maybe calming me down a bit.
Dr McPherson says there are different grading systems for acne severity used by medical professionals.
Dr McPherson says there are different grading systems for acne severity used by medical professionals.
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So there aren’t any, you know, very well recognised grading systems for acne. There’s lots of different types and some of them are more kind of global, so mild, moderate, severe, very severe. Some of them, for research purposes, might focus on things like spot counting. And some of them will also look at the different types of spots, so you’ve got comedones, pustules, cysts, scarring. These types of things. So, generally the kind of more global assessments are used when you’re using it sort of clinically and then decisions about treatment will be made on how severe the acne is, how much it’s affecting people, and also how likely it is to scar. So those are the most important things. Because really when you’re treating acne it’s not just for improving the acne as it is but also preventing scarring long-term because scarring can be permanent.
So, sort of terminology around mild through to severe-
Yeah.
- is that quite varied depending on-?
A lot of these grading systems are quite subjective so it depends on the doctor that’s doing it. And so people have different levels of severity. But there are certainly picture-, kind of picture grading systems which can be quite useful in terms of, you know, how much of the face is affected, how severely it’s affected, how tight together the spots are. And that will be-. So I think there is quite variable but I think there is quite close agreement for some of those grading systems between doctors and other health professionals.
Pain and when spots are popped or burst
Acne spots can be painful, especially deep and inflamed spots, but this is not always the case. Sarah’s acne was mostly small spots without pain. Most people said their acne was ‘uncomfortable’ at times. Fatima described hers as feeling “like an insect bite”. Kosta finds his skin sometimes “aches”. For others, their acne was excruciating nearly all the time. Hester had to take painkillers to get to sleep at night because of the pain. She couldn’t put on make-up because removing it felt “like taking a layer of my skin off”.
Some people found their acne itchy, which made them want to scratch. Eli’s skin is itchy after she takes off her make-up. Sometimes they scratched their skin without realising they were doing it.
Harriet’s acne wasn’t always painful, but it could be when she used topical creams.
Harriet’s acne wasn’t always painful, but it could be when she used topical creams.
Age at interview: 21
Sex: Female
Age at diagnosis: 12
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It wasn’t that painful usually, but then sometimes you’d get sort of the big kind of nodal acne where you’d have these big lumps under your skin and that would be painful. You’d like, they’d sort of throb during the day and if you touched them they’d be painful. So that was a kind of uncomfortable pain. But with, with the, sort of when you put certain creams on or, yeah, or oils and things and they have a bit of a burn, it’s not really, sometimes it’s a burn, sometimes it’s more of a tingle. But it’s that, it’s kind of that feeling of, like if you were cleaning the hob or something and it would just, it would kind of like sizzle away all the grime and you’d clean it. It’s sort of, that kind of burning is a sort of a feeling of cleanliness almost, yeah. I don’t know if that makes sense.
I think it does. It’s so hard to convey though, isn’t it, unless you sort of know…?
It’s when it, with the burning you feel like it’s doing something useful, cos you, you can sort of feel it almost, you can almost imagine like the acne evaporating from your skin. You’re like “Yeah”, this, and then you look in the mirror and you expect to be, you know, completely, completely clean skinned. But it does, it definitely feels like it’s working when it burns.
Kosta tends to scratch his acne when he feels nervous.
Kosta tends to scratch his acne when he feels nervous.
Age at interview: 14
Sex: Male
Age at diagnosis: 13
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Can I ask you about picking spots-
[laughs]
-and whether that’s something that you’ve done?
I do tend to pick the spots quite a lot I’d say during classes maybe anxiety can lead to scratching the spots. Or even sports, when you get sweaty it’s just inevitable not to scratch a spot sometimes.
Can I ask a bit more about anxiety and if something is a bit stressful?
It’s just another way of reacting I suppose, the spots. And my, in my case when I’m anxious or annoyed, I might tend to start scratching and then as the wound gets deeper you just carry on scratching I suppose [laughs].
Does it ever affect your concentration or if you’re doing some work and it affects that at all?
I have to admit if I do start scratching my face it does become quite constant and I can’t stop scratching. That might just be me or it just can be a natural reaction for everyone I suppose.
Lots of people said they knew that they shouldn’t scratch or pick at their acne. Kosta has heard it causes scarring. Many people found it was difficult not to pick or squeeze spots, and most had done this at some point. Sometimes they hoped that squeezing a spot would make it ‘die down’ and give relief, which some found it could, but it can also cause it to become more sore and visible (inflamed, bleed, scab over). Bleeding and oozing spots could then stain clothes, bedding and towels.
Ollie’s acne is sometimes itchy but he tries not to pick it.
Ollie’s acne is sometimes itchy but he tries not to pick it.
Age at interview: 16
Sex: Male
Age at diagnosis: 13
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Well personally I don’t really pick my spots that much. The reason why my back got so bad with all the scarring and stuff with that is that it just used to get quite itchy so I just used to scratch and not really care. But I don’t feel much of a temptation for picking spots just because it's quite painful and it's not very nice, and I found that they come back worse and you can end with huge ones if you, if you have a cluster of spots and then you pick them all away, and it leads to scarring of course and you get more yellow – the pustule ones – from picking, cos I think the dirt or whatever infects it. So, actually I think the problems of picking your spots definitely outweighs the enjoyment you get from picking them.
Rebecca picked and squeezed her spots, which she says later linked to a psychological condition called dermatillomania.
Rebecca picked and squeezed her spots, which she says later linked to a psychological condition called dermatillomania.
Age at interview: 18
Sex: Female
Age at diagnosis: 12
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But then like when I was about 14, 15, like I started like picking at my skin as well and became obsessed about like getting rid of everything that I saw was an imperfection. And when my acne had like started to calm down a bit, I was still picking at my skin, even though there was nothing really there. And it developed into dermatillomania, which is what I suffer with now and continue to suffer with, even though the acne isn’t always there any more.
Could you say a bit about what dermatillomania is?
Dermatillomania is like an obsessive condition where you pick at your skin basically. And like I know for me it’s just anything I feel shouldn’t be on my skin, like I just start picking at my skin. And then it just turns into scabs and then I’ll pick my scabs because they’re also imperfections and things that I see on my skin. So-
Could you tell me a bit about that time when you first started picking and when you then got the diagnosis of dermatillomania?
Well, a lot of people that I know didn’t really know what dermatillomania was. And for me I started doing a lot of research because I thought ‘this can’t be normal, like what I’m doing’. And in the end I did go to my local Children and Adolescent Mental Health Services to basically say, “Look, I’m suffering with this.” And to start with, they actually didn’t know what it was. And they decided that they wanted to try and transfer me to see a dermatologist because it weren’t anything that they could deal with. But then I had to basically educate them on what it was because I’d done my research. And then they kind of realised that obviously it’s not just a skin condition, it is something to do with your mind as well.
Knocks to the skin could make spots burst accidentally. Popped or burst spots can be painful and people often felt embarrassed about it. Deborah will “wince” when she accidentally catches a spot. Some found that topical treatments stung when applied, but this was sometimes seen as a good sign that they were ‘working’.
Alexandra wore a bandage under her bra to help with pain and reduce spots popping on her back.
Alexandra wore a bandage under her bra to help with pain and reduce spots popping on her back.
Age at interview: 22
Sex: Female
Age at diagnosis: 13
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I do know that from my, my peers and my friends none of them had acne on their back, so I did feel a bit like, “OK, am I the only one here?” Now some of them sometimes had a little bit of, like a spot or something. But that was one [laughs].
And I didn’t have that, I had lots of them and very severe ones as well, and painful ones, and I my mom used to help me as well, so she would sometimes with the bigger ones, if they were under my bra strap and they would hurt she would get a bandage on it. So my mom used to help me as well, so she would sometimes with the bigger ones, if they were under my bra strap and they would hurt she would get a bandage on it. So I sometimes had four bandages on my back during a day. And that did help a little bit, you know, it released some of the pain.
And then if it would erupt, yeah, it’s not like I could really clearly feel them popping or something, that would sound very weird, but you do sometimes when I went to the loos in in my secondary school building I would check sometimes if something had happened, yeah. Because it would, you know, you don’t want to get it, to be on your shirt or something and people could see that. So I used to never wear anything white for instance.
Deborah’s careful to avoid getting an infection from popped acne spots.
Deborah’s careful to avoid getting an infection from popped acne spots.
Age at interview: 25
Sex: Female
Age at diagnosis: 12
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Things like if you do just catch one and it bleeds, you then have to go and sort it out because you don't want it to get more infected and get worse. Which can be quite irritating to have to do if you're, if you're busy, if you're at work, if you're out with friends, if you're doing things like that. And then if you've got one that's popped, or something like that, and then you have to deal with all of those sort of things. And keeping them, them clean while they're open can be really quite challenging, especially if you're then - if you're out, and you're in make-up anyway. Do you then take off the little bit of make-up around that zit? Do you take all of it off? Do you try and reapply over, and hope it doesn't get infected? It can be quite challenging to deal with those. Especially if you're, you weren't expecting it or you weren't prepared for it anyway. You can end up getting quite sort of panicked about it, sometimes.
I was going to ask you about infections, and your experiences, if you've ever had any skin infections from acne spots?
Nothing that serious, thankfully. There have been a couple that I can tell have got considerably worse for being knocked. And therefore presumably they've got infected a little, but nothing that hasn't healed by itself and by my regime. Some of my friends have had things get quite badly infected, and have needed to go to a doctor's and see things then.
Scars and lasting changes to the skin
Many people had scars from their acne. Scars come in different forms – some are:
• a different colour to the normal skin (red, dark),
• stick out from the skin (raised, thickened), or
• pitted (like dents, gouges or ‘craters’ in the skin).
Most people with acne scarring had a range of scars. Alexandra’s skin is thicker from the scar tissue and she also has some “like a crater”. Deborah has enlarged pores and describes her skin as “blotchy”. Emma had chickenpox which she thinks interacted with her acne and may have caused her more scarring. She had some keloid scarring on her chest from acne for which she’s had steroid injection treatment to make them flatter.
Some people used make-up to cover their acne scarring (see also the section on skincare practices and styling). Many found it was easier to cover the scarring than it had been with acne.
Although people sometimes felt embarrassed about their acne scarring, Emma, Nina and Hester all thought it was better than having active and painful acne.
Chris sometimes uses Blemish Balm (similar to tinted moisturiser).
Chris sometimes uses Blemish Balm (similar to tinted moisturiser).
Age at interview: 20
Sex: Male
Age at diagnosis: 17
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If you’d, if you’d gone back to me then and said, “Look, here’s, here’s make-up product, try it out”. I probably would have tried it out. It’s just I’ve never actively seeked out a make-up product like a foundation or anything to sort it out, but now my mum, sort of, recommended me like something called BB Cream.
And that, I mean it might, might be OK for someone with acne, but for me who’s kind of got like a little bit damaged skin and I can still kind be a little bit red and blotchy sometimes it just gives like a nice matte finish to the skin, but when, like I said, when I had acne I didn’t, I didn’t really use anything.
It’s just now after, it’s kind of nice but if I could go back I would have probably used stuff to cover it up.
So do you use BB Cream on like a daily basis now or?
[Sighs] I’d say, out of the seven days of the week, I probably use it maybe three days. Like if I’m going out like - if I’m going to the gym, I’m not going to use it, but if I’m going say around town or, you know, I’m going to, you know, going out on a night out or I’m going to like a meeting somewhere…
Yeah
I’d probably use it then. Because you don’t really need to use that much and a, a little tube lasts quite a while so.
Hester contrasts her past experiences of acne with having scarring.
Hester contrasts her past experiences of acne with having scarring.
Age at interview: 21
Sex: Female
Age at diagnosis: 15
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Because I was in so much pain when it was at its worst and you know, like I used to have to sleep on dark towels because it would just bleed all the time. And I had to take like tissues around with me because I'd just have to like wipe the blood away from like my, because it'd just come trickling down my neck and stuff. And it was so horrendous, that when it healed, even though the scarring was so obvious, I just remember feeling amazing. I've got so many photos of that time when it all, when it cleared up. I have still got like, you know, my face is so discoloured but because I'm not in pain any more, I felt, I felt so good. And I think I didn't really care what people thought about me then. And, yeah. And that, so that was quite an amazing experience. Because I guess physically it didn't look that much better but because it didn't hurt me any more, I was, I was really confident [laugh]. And I was just so pleased that that the worst of it had happened, that I think I had to sit down and realise that it might not get better.
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