Acne Q and A

• Introduction
• What are the common acne myths?
• What causes acne?
• How do you assess acne?
• Hoe long and how often should I use products?
• What are the different types of acne?
• Acne - when should it start and when should it stop?
• What are the other common Acne treatments?
• Questions specific to Aknicare®

Introduction

For some people, acne represents nothing more than the key to the door into adulthood - almost a rite of passage as the body changes. As the most common disease in the world, it is often taken for granted that spots, blackheads and greasy skin will stake their temporary claim on the faces of almost everyone in the world.

However, for approximately 15% of people, these spots will persist, or be widespread and scarring. With surprisingly poor, inadequate information available to teenagers about acne management, many do not even realise the pharmacy assistant and pharmacist are able to provide help.

How much do you really know about acne and its causes? Do you know that there is no proven link with diet and acne? Did you realise that not everyone grows out of having acne, with 5% of women and 1% of men in their 40's still suffering from a 'teenage' problem?

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What are the Common Acne Myths?

The starting point of correct acne management should start from clearing up the myths:

1. Acne is caused by food. Scientific studies have not found a link between diet and acne. Prisoners in the United States were enrolled on a trial to determine whether chocolate had a direct effect upon the sebaceous glands. At the end of the trial, it was concluded that acne was not affected by chocolate consumption. However, it is always sensible to advise a healthy, balanced diet, whilst reassuring that food will not affect acne.

2. Acne is contagious. Doctors have studied the effect of extracting pus from one spot and injecting it directly into unaffected skin. This experiment concluded that it did not spread spots.

3. Acne is caused by dirt. Spots are caused by activity beneath the skin and therefore surface dirt will play only a small role in the formation of acne. People think that the black in a blackhead is caused by dirt, but it is the skin's natural melanin, which turns black once it comes into contact with the air. Some people will even claim that over-washing can cause acne, but this may be hard to prove.

4. Acne is caused by too many hormones. Hormones have a large role to play in the formation of acne, but it is easy to misunderstand this as the body producing too many hormones. In one acne clinic held at a top Leeds centre for acne research, all patients attending that day's clinic were asked to provide a blood sample, which was later analysed for hormone levels. There was no significant increase in male hormones in these patients, which suggested that it is therefore sensitivity to male hormones present in normal levels in the skin that is to blame.

5. Everyone grows out of acne. Acne usually has a four to eight year timeline from start to finish. If you get it when you are 12 you should se the end of it between 16 and 20. The average age range for acne is 14 to 22. However Acne can persist into adulthood and 8% of acne sufferers are over 40 It is rare to have acne for a lifetime, but some people will not grow out of their acne. Research from Leeds University suggests that acne lasts on average for eight years.

6. Acne and spots are not same. Many people will try to distinguish between acne and spots. In fact, acne is just the medical name doctors give for spots. However, someone with the occasional, mild spot would not be described as having clinical acne. Approximately 15% of all people who have 'spots' will require further help from a doctor to treat their skin.

7. Stress causes acne. The ordinary stress in day to day living is not an important factor in acne. Only situations of extreme stress, such as divorce, exams or death of a close family member may induce acne or make existing acne worse; however this is not common and will usually respond well to usual acne treatments.

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What causes acne?

There has been extensive research into this disease and dermatologists blame four main factors in the skin.

• Firstly, the body seems to become extremely sensitive to the male hormones (the androgens) in the body.
• Men and women have male hormones, but because men have higher levels, this is why they are often more affected.
• These male hormones do not have to be in high doses to get the oil producing glands (sebaceous glands) over worked, which in turn makes them pump out more oil.
• In those affected by acne, the dead skin cells that sit near the top surface of the skin start to slow down their rate of shedding and clog up the pores where the oil normally escapes from.
• The combination of these two will result in the skin forming a tiny blockage, the starting point for all types of acne.
• This blockage is a wonderful environment for the acne bacteria that normally lives on the skin, to start to multiply, which in turn leads to a chain reaction leading to infection and inflammation. This is what is commonly known as the spot. But, if the blockage doesn't become infected, then it will remain as a solid plug - or the blackhead, as we know it.

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Summary

HORMONES + INCREASED SEBUM + DEAD SKIN CELLS + BACTERIA = ACNE

How do you assess acne?

There are literally hundreds of ways that acne can be treated and many reasons for apparent failure of a product. To confidently recommend appropriate treatment, will depend upon answers to the following:

What does their acne look like to you?

Acne is a visual disease and most commonly occurs on the face, although the back, neck, chest and shoulders may also be affected. You need to look for:

• Blackheads/Whiteheads - Non inflamed acne
• Yellow and/or red spots - Inflamed acne
• Or combination of both
• Scarring
• Excessively greasy skin

These will give you the clues to both how long they may have had acne (scarring and red marks left from recent spots), and what type of acne they have, as well as how severe it is. Depending upon answers to the above, you can recommend treatments as per the 'acne treatments' section and use the treatment flow chart that is part of module 2 to help.

How does their acne affect them?

Some people will apparently be unbothered by a case of bad, inflamed acne and might appear to be genuinely unconcerned about treating it. Others can appear to be distraught over a few spots and might take up a lot of your time and ask many questions. What will often help put that person's acne into perspective is to ask them how it affects them, not how you might think it affects them - the two could be different! The psychological impact of acne is covered later in Module 2, but understanding how acne affects them.

How long have they had acne?

Some people will rush to their doctor, insisting upon strong treatments or referral to a dermatologist at the first signs of acne, whilst others may sit out their acne and literally wait to 'grow out of it'. Acne lasts an average of eight years and therefore should be treated as soon as it first appears.

What treatments have already been tried?

Some people claim to have tried 'everything on the market'. This is almost impossible, for it depends upon which market they are referring to. Usually they will be talking about self-medication; treatments bought off the shelf designed to help with 'problem skin types'. It is likely that these products have been used and, if, after a couple of weeks, there is no improvement, they will consider the product 'useless' and it will be resigned to the back of the cupboard.

You will need to get an accurate idea of what they have already used to be able to assess what treatments should be used next.

• Self Medication: Products that can freely purchased off the shelf. These may claim to help 'problem skin', 'oily skin types', 'spot prone skin'. There will usually be a couple of ingredients that have an antibacterial, soothing or drying effect on the skin.
• Pharmacy or over the counter products: These will usually contain ingredients proven to help control acne such as benzoyl peroxide or salicylic acid. These products commonly cause localised irritation to the skin, which may often be the reason for stopping treatment suddenly.
• Prescription treatments: With a combination of over 100 prescription acne products available it is rare that all treatment options would have been exhausted. Once you understand how different treatments work, it will enable you to give helpful advice to your patients. Acne treatments are covered later in this module.

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How long and how often should I use products?

It is very common for patients to walk away with their prescription, products, and treatments only to give up on them too soon. TV adverts have persuaded too many influential teenagers that product X can clear spots in days!! Therefore a lack of compliance can contribute towards failure to treat acne effectively. Encouraging compliance can literally make the difference between scarred skin and emotional scars and someone who treats their skin and gets on with their lives. Therefore compliance can be encouraged in the following ways:

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What are the different types of acne?

The most common type of acne is called 'acne vulgaris' and is evident by the familiar spots, blackheads, whiteheads and greasy skin that affects up to 90% of the population at some time in their lives.

Acne is not necessarily a progressive disease - it may never be more than what a doctor would classify as mild, but a patient may end up suffering from this type of mild acne for 20 years or more. There have also been accounts of patients who have suddenly developed severe scarring acne within a matter of weeks.

Usually, treatments will depend upon the severity of the acne.

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Acne - when should it start and when should it stop?

For some people, acne may last no longer than a few months, whilst others may be plagued for, in some cases, many decades. It is impossible to predict exactly how long acne will last. However, it may be an indicator that the acne could be persistent if either one or both of the two below has occurred:

Acne may also persist well in the later years. SkinMed customers range in age from 10 to 80. This is unusual, but gives an idea how acne should not just be considered to be the bane of teenage life.

Possible reasons for people presenting with acne into their 30's could be:

Whatever the reason someone may have acne, they can still successfully treat it. There's simply no reason for someone to suffer the misery of acne - whatever their age.

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What are the common Acne Treatments?

The aim of treating acne is to stop new spots forming and many people may have unrealistic expectations of their treatments and therefore fail to comply with their treatment regimes. As everyone is so individual, it is not uncommon for one treatment to work well on one person, whilst another finds the same treatment may actually worsen their acne.

It is common for doctors to 'combine' a topical product (i.e. something applied directly to the skin) with an oral treatment (i.e. tablets taken by mouth).

Topical Treatments

Some of the creams or gels listed below can be irritant and may cause redness or soreness to the areas applied. Next to each type of treatment listed, we have coded it either GSL, P, POM, HOM.

For your reference these abbreviations represent:

Benzoyl Peroxide (P or POM)

Benzoyl Peroxide has been used for many years and doctors agree it can be an extremely effective treatment either used alone, or in combination with other prescription treatments. There is an argument that using Benzoyl Peroxide when using antibiotics can help reduce the problem of antibiotic resistance. It is very common to see a reaction on the skin, ranging from mild redness to, in exceptional cases, considerable peeling and soreness. This is because the Benzoyl Peroxide causes a 'stripping' effect and when this happens, most people give up on it, thinking it isn't working. However, if you start with a low percentage (usually they come in 2.5%, 4%, 5% and 10% concentrations) then your skin may start to get used to it.

There are some types of Benzoyl Peroxide creams and gels that have been specially made to help combat the problem of excessive drying and redness. These products are mixed with a special ingredient that makes this problem less likely to happen. As a result, you may be able to start on a higher percentage of Benzoyl Peroxide.

Tip - Benzoyl Peroxide is used commercially for bleaching flour, it will also bleach hair or clothes. Therefore, use an old towel that can be kept specially for wiping hands after applying. Be aware of pillowcases and other bedclothes.

Topical Vitamin A Derivatives (POM)

Vitamin A derivatives have an effect on the cells which line the surface of the duct through which passes the grease from the grease glands and is therefore used where this duct is blocked. Its major effect is on the non-inflammatory lesion of acne (the blackheads and whiteheads). With regular use it reduces the number of blackheads and whiteheads. As the comedones usually precede inflamed spots, then this type of treatment can be very helpful.

Be aware that these types of creams should not be worn when in strong sunshine, as they can cause a sunburn reaction. Therefore it is advisable to apply at night and wash your skin in the morning. These preparations can be very irritating to the skin, so apply very sparingly (about the size of a pea for the face should be sufficient).

Adapalene (POM)

This is a fairly new type of retinoid-like gel cream. It can be very helpful on both inflamed and non-inflamed acne. Some patients report that it causes less irritation than some other topical creams.

Applied once daily.

Salicylic Acid (P or GSL)

The most commonly used topical agents include the antibiotics: tetracycline, erythromycin or clindamycin. These are usually present in an alcoholic solution. They are sometimes mixed in a more soothing lotion format.

They are absorbed into the skin and help reduce the level of bacteria in the skin and in the duct as well as reducing inflammation commonly present around the spots themselves.

They are particularly useful in mild to moderate acne. The antibiotic should be applied twice a day (or as otherwise directed) to all affected areas, regardless of whether spots are present or not. Topical antibiotics when used alone have probably less effect on the non-inflamed type of spots (blackheads and whiteheads). If you have the non-inflammatory type of acne as well as red or yellow spots, a product such as isotretinoin or tretinoin (see Topical vitamin A section above) could be used to help these.

In general, these types of antibiotics are very well tolerated by the skin and have few side effects.

Sensitive skin types may find the alcoholic solutions irritating to the skin and may cause excessive dryness.

Tip - Topical tetracycline is yellow when applied to the skin and can cause staining on clothes. It also fluoresces under ultra violet light; so don't apply before going to a disco, unless you want to resemble a glow-worm!

Combined Topical Antibiotics (POM)

As mentioned in the previous section, topical antibiotics can be very helpful in helping the redness and inflammation in acne. When the antibiotic is combined with another proven ingredient, it can help increase its benefits. Therefore, manufacturers have now developed some new treatments (available only on prescription) that can be of more benefit.

They may also reduce the resistance to the organism p.acnes. This is particularly true of erythomycin and zinc and erythromycin and benzoyl peroxide.

Erythromycin and Zinc (POM)

This topical lotion is available in two sizes. One for acne confined to a small area of the body, such as the face and neck, and the larger size to help more widespread acne. Zinc has been used for many years to help treat skin problems and in trials they have found the combined use of both zinc and erythromycin helps to reduce acne.

Tip - Ask the doctor for the larger size if your acne is also on your back, as it will go further. Once opened, each bottle can be used for 6 weeks, so there is little point in asking for the bigger size if you have it only on your face and neck as any unused lotion will have to be discarded after this time.

Erythromycin & Benzoyl Peroxide (POM)

We have already explained both the benefits of erythromycin and Benzoyl Peroxide. When combined into one product, not only does it save you double costs (i.e. both are available on prescription) but it can also be much quicker to apply.

Tip - This needs to be kept in the fridge. Be aware of any children with prying fingers who may mistake it for a pot of cream! Expires in five weeks.

Clindamycin & Zinc (POM)

This is a once-a-day lotion combined with zinc.

Erythromycin & Tretinoin (POM)

This is another variation of a topical antibiotic (erythromycin), combined this time with tretinoin (see Vitamin A acid section). So, as well as helping reduce the blackheads and whiteheads, it can help with any inflammation at the same time. Some types include ingredients to help reduce skin intolerance.

Azelaic Acid (POM)

Azelaic acid has an antibacterial effect and also removes the dead skin cells from the top layer of skin that helps in unblocking the hair duct. It can therefore work on both inflammatory and non-inflammatory spots. It may also have a beneficial effect on the brown pigmentation, occasionally seen after a spot has cleared. This type of pigmentation, known as post inflammation hyper-pigmentation, is more common on dark skins.

Oral treatments (taken by mouth)

Some doctors prefer to prescribe tablets for treating acne and it is fair to say that many patients prefer to take medication by mouth. As mentioned above, it is common to be offered a combination of both tablets and creams.

The most common type of tablet to take will contain an antibiotic. These are designed to reduce the bacteria that are present in the ducts of the grease glands. Some also have a direct effect in reducing the inflammation. They also reduce (to some extent) the non-inflamed type of acne.

Oral Antibiotics (POM)

There are many types of antibiotics that are particularly useful for treating acne. As a general rule, these should be given for a period of time, usually no less than 6 months. The most common types of antibiotics used are: tetracyclines, erythromycin, minocycline, doxycycline, or lymecycline.

Antibiotics reduce the effectiveness of the contraceptive pill for the 1st month, so patients should discuss this with their doctor if they are currently taking the pill. Usually, physical methods of contraception need to be used for the first month of use. There are also some antibiotics that must not be taken with food or milk, or an hour before a meal.

It is not unusual to experience some mild degree of stomach upsets when taking antibiotics, especially the tetracyclines. This is caused by the destruction of the normal 'good' bacteria which, flourishes in the bowel. This can sometimes be reduced by taking pro-biotic supplements, such as lacto bacillus or acidophilus (available from health food shops).

The usual recommended dosage of oxytetracycline is 1 gram a day. This will usually mean taking up to four tablets a day. Sometimes, it will be given in two 500mg doses. If minocycline is being used, the normal dose is 100mg twice a day, and vibramycin is 100 mg daily. This initial high dose of antibiotics should be continued for at least two months or until a good response has been seen and then the dosage can be tailed down over a six month period.

Lymecycline is similar to minocycline, in that it need only be taken once a day and is not affected by food or milk.

Tetracycline antibiotics are not suitable for children under 12 or in pregnant women as they can cause staining of the teeth and bone development problems.

Erythromycin is an effective treatment for inflammatory acne, but possibly less so now because of p.acnes resistance.

Trimethoprim is less commonly prescribed, but can be very successful. It is usually prescribed at doses of between 400 - 600 mg a day.

Clindamycin is a very strong antibiotic, but it can be very useful for treating acne.

Antibiotic Tablets Used In Acne

Contraceptive Pills (POM)

Combination contraceptive pills contain both oestrogen and progesterone. The female hormone oestrogen tends to have an anti-testosterone effect. Progesterone is metabolised into testosterone-like products by the body. The 'mini-pill' is progesterone only and may make your acne worse.

The contraceptive pill should not be used as a first line treatment for acne, but in those patients who require adequate forms of contraception, the combination contraceptive pill, Dianette® can be used. The benefit or otherwise of other pills is uncertain.

For some women, there may be a noticeable increase in acne spots around the time of the menstrual cycle. This is due to the body's high concentration of androgens. If your acne has been persistent and hard to treat, we suggest you read through our leaflet on Polycystic Ovarian Syndrome (PCOS) for further information.

Dianette® (POM)

Dianette® is a contraceptive pill that contains a medium dose of oestrogen, but also a drug called cyproterone acetate that combats the effects of androgens in the body.

Dianette® is often prescribed for women who have not responded to high doses of oral antibiotics. It should be given for a minimum of 6 months, but can be continued for up to 24 months or as directed by your doctor.

It is not uncommon to see a flare-up of acne in the early stages of taking this treatment. However, it may take a little longer to work than the recommendation of giving a product two months trial, so it might be worth sticking at it, to give it a chance to really work. Many people report it can take up to nine months to see the full effect.

This can be combined with topical therapy. You will need to be seen regularly by the family planning team at your G.P. surgery or family planning clinic for regular checks.

Tip - If you are seeking contraception at the same time, you should state this to your doctor, who will be able to prescribe it free on the NHS under the category of contraception.

Zinc Sulphate (GSL)

Zinc sulphate capsules at a dose of 220mg three times a day is a rather old fashioned treatment for acne, but can actually be quite helpful. The Zinc may be used in combination with antibiotics to improve the effect. It has been shown to promote healing of wounds, such as leg ulcers, but the exact method by which it works in acne is unknown.

Zinc may cause stomach upsets and possibly nausea or diarrhoea. New effervescent preparations seem to help reduce these symptoms.

Isotretinoin (HOM)

This is a synthetic form of Vitamin A and has been seen as a revolution in acne treatment, even in the worst cases that are more commonly seen by specialists. It is not a first or second line treatment but is used when other treatments have failed, or when the acne is aggressive and causes scarring. The most aggressive type of acne is the nodular-cystic, which can quickly cause deep permanent scarring. If a person has this type of acne, they should be referred immediately to see a dermatologist who may recommend this type of treatment.

Isotretinoin (commonly called by the brand name of Roaccutane) will usually have a dramatic effect on clearing the acne and is usually taken over a period of 4 months. The course needs to be completed in order to receive the correct amount of the drug. There are many and varied side effects, which can mostly be counter-acted, however, many people will have heard some accounts of more serious side-effects, such as depression, leading to suicide.

It is important to address these concerns and give a balanced view. There are some patients that may already be prone to depression (after all, up to 75% of patients state they felt depressed as a direct result of having acne) it is usually those patients who develop a quick mood change upon starting treatment that may pose the greatest risk of feeling suicidal. If patients are warned in advance of this possibility, they should be directed to seek support from either family, friends or by contacting a support service such as the Samaritans and contact their dermatologist at the earliest opportunity.

Doctors are planning a world survey of patients on isotretinoin, which they hope will give them a better idea of the link between this drug and suicide. At the moment, there is no real evidence to suggest these have a definite, proven link, but any patients who may be worried should discuss their concerns with their dermatologist.

However, it is widely accepted that the usual and most expected side effects reported by patients are; dryness of the nose, eyes and lips. Sometimes the skin may become cracked and very dry, which could be helped by using a moisturiser.

It may also cause the skin to become sensitive to the sun, so a sun block should be worn at all times. There are also very serious risks to an unborn baby, so women of childbearing age are often prescribed the contraceptive pill at the same time (if they are not already on suitable contraception). Alternatively, seeking alternative means of contraception is necessary one month prior, during and one month after finishing the course.

It is not uncommon to find that anywhere between 10 days and 6 weeks into a course of isotretinoin that patients experience a flare-up of acne. For a lot of people, this can be very distressing, but usually passes within approximately two weeks. If a patient is encouraged to expect this, then it is less likely to result in surprise or panic. If any flare-up persists beyond this period of time, or if the acne worsens, rather than improves overall at any time, then the dermatologist should be consulted.

There are some patients who may relapse after completing a course of isotretinoin, with figures currently reported from dermatologists varying between 21% to 61% (Wessels et al 1999).

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Who can I ask for Help?

Most people are capable of selecting products aimed at helping their own skin type, but may easily give up on products that don't show instant results, or cause irritation of the skin. If they are given a quality service by a clinician, pharmacist of skin care specialist, they will appreciate the importance of the following:

Who Can Help?

Organisations that can offer help include:

Samaritans - for those feeling despair, loneliness or suicidal.

Child-line - For any childhood related problems, including acne.

Changing Faces - 0207 7064232

Counselling may help in some cases, and this is usually available through GP's. However, the waiting lists may be long and usually the course of counselling is restricted to six weeks. This may not be suitable for someone feeling very depressed. They may have to seek private counselling which is available through the British Association of Counsellors.

In most cases, if the depression is directly related to acne, once the acne has been successfully controlled, the patient will automatically feel better about themselves.

Aknicare® Q and A

Can the Aknicare® Medical Devices be used for primary acne treatment?

Yes. The key ingredients change the skin to influence the 4 stages in the etiopathogenesis of acne : seborrhea, hyperkeratinisation, bacterial colonisation and inflammation. It acts during the comedonic phase when inflammatory lesions appear.

Can the Aknicare® Medical Devices be used with other acne treatments?

Yes, with both antibiotics and derivatives of retinoic acid. No incompatibilities have been reported. For example, they can aid in reducing the exposure times to trans retinoic acid for oral use, countering, for example, the skin tightness that may be induced by the latter.

What are some of the advantages of a combined therapy with Aknicare® and antibiotics for topical or systemic use?

With Aknicare®, even if it is capable of controlling bacterial colonisation, no signs of bacterial resistance appear. Furthermore, if the antibiotic therapy acts on one of the stages of the etiopathogenesis of acne, with the Aknicare® medical devices it is also possible to affect hyperkeratinisation, inflammation and seborrhea.

What is the real innovation of the acne therapy with the Aknicare® products?

The role performed by free fatty acids in the development of the inflammatory process is evident and has been documented extensively; free fatty acids are generated from the hydrolysis of triglicerides (the most significant lipid component of sebum) caused by the action of the bacterial lipase released by skin bacteria. Up to now the possible options were to diminish sebaceous secretions through the use of antiandrogens (the production of sebum is stimulated by the action of the testosterone, the male sex hormone, and mainly by the reduced from caused by 5-alpha-reducase, known as dihydrotestosterone) or with the use of antibiotics that can reduce bacteria levels and the consequent presence of bacterial lipase.

What are the limits to these therapies?

Antiandrogenic therapy can be used exclusively by women and there are serious doubts as to the use of this treatment on adolescents. Antibiotic therapy is becoming increasingly controversial due to the increasing bacterial resistance of various antibiotics.

THEREFORE, THE ASSOCIATION OF TRIETHYL CITRATE AND ETHYL LINOLEATE IS AN INNOVATIVE APPROACH THAT ACTS DURING THE INFLAMMATORY PHASE, THEREBY PREVENTING AN INCREASE OF FREE FATTY ACIDS AND THE CONSEQUENT PRO-INFLAMMATORY ACTION.

INDICATED FOR BOTH MEN AND WOMEN, FOR ALL AGES AND ESPECIALLY FOR YOUNG PEOPLE (EARLY ADOLENENCE).

Can one buy individual packs of the Cleanser,Remover, Lotion, Cream, SR and FP?

Yes. However - Aknicare® provides the complete management of oily skin and acne. Therefore in the early stages - a higher success rate will be achieved with the complete set, used as the regimen suggests - morning and evening.

Once controlled, the maintenance regime is Cleanser or Remover followed by the Cream, keeping the Lotion or the Skin Roller for any minor breakouts. However, it is important to stress the importance of the Cream in the hydrating process - many treatments of this condition fail because the skin dries out and this will causes sebum production to increase in response.

Are some of the active ingredients in Aknicare® in cheaper preparations?

Yes. However - the key word here is 'some'. You pay for what you get. Aknicare® offers ingredients which:

• Reduce the thickening of the dead skin layer at the surface and from within the skin to inhibit and normalise bacterial levels (Four ingredients)
• Re-establish normal secretion of sebum
• Re-establish pilo-sebaceous duct diameter
• Re-establish normal skin fatty acid levels (linoleic acid)
• Reduce inflammation - improve skin hydration
• Physically improve the quality and appearance of skin
• Accelerate wound healing

Some customers may feel that Aknicare® is expensive, What do you say about that?

Compared to other brand name items the initial outlay may be higher. However, we are not comparing like with like. This is a high quality medically proven product that is the first topical product to target the underlying cause of acne. No other product fulfills the criteria for the ideal acne treatment as defined byb Dr. Chu. It contains a high number of active ingredients, each delivered to the right part of the skin by new delivery technology (Drysyst®, Softfeel®), which address all the issues associated with acne including the very important reduction of subsequent scarring. Lastly one can achieve further cost savings by taking advantage of multiple purchase discount offers. The complete full size set can last between two to three months bringing the cost to under 0.50p per day. If the product works then this is a small price to pay. Also, you will not need to spend money on other acne preparations. In addition these products have been designed as high quality cosmetics and have the quality and feel of designer labels.

How does the customer use the three products?

As outlined in the brochures they use the all three products sequentially:

1. Cleanser/Remover
2. Lotion
3. Cream
4. Fluid Powder
5. Blemish Corrector throughout the day, as necessary

Morning and night until they have clearer skin - they can then reduce the frequency of application of the lotion to maintain their skin.

How do the core individual products fit together?

Aknicare® Cleanser to:

• Remove up to 90% of surface oil
• Reduce the thickening of the dead skin cell layer and unblocks 'pores'.
• Changes the pH to Inhibit bacterial growth
• Clear away surface debris to enable the lotion to work most effectively
• Prepares the skin creating an absorbable surface for the other products to get into the skin

Aknicare® Lotion creates skin conditions locally to:

• Normalise sebum (oil) production in the skin. Reduces production by up to 68%
• Normalise skin shedding from within the skin
• Normalise pilo-sebaceous duct diameter from within the skin
• Improve skin linoleic acid levels
• Normalise skin bacterial levels
• Reduce inflammation and redness

Aknicare® Cream creates skin conditions to:

• Maintain normal sebum production, 'pore diameter' linoleic acid levels, skin shedding rates
• Maintain a normal skin bacterial level
• Re-hydrate the skin and maintain an effective barrier function to skin water loss
• Assist wound healing

Remember the TWO MONTH RULE and that this is the start of your skin management. Remember that the full set is not expensive in the long run - especially for the list of components in the product and also ask yourself how much clearer skin is worth.