Teen acne treatment in Singapore:
a guide for parents and teenagers

What is normal teenage acne, and what is not?

Acne begins when rising androgens at puberty enlarge the sebaceous glands and increase their output, follicle cells shed abnormally and block the opening, Cutibacterium acnes multiplies in the blocked follicle, and the immune system responds with inflammation. It usually starts on the forehead, nose and chin, often before any other sign of puberty, and in most teenagers it is comedonal or mildly papulopustular, settles with time and leaves no lasting mark. That is the acne that is normal at 13 to 19. The large majority of teenagers have some of it, and in that group a sensible routine and patience are often enough.

What is not normal is acne that is inflamed, deep, spreading or leaving marks. Painful lumps under the skin that are slow to settle, spots across the cheeks and jaw and onto the chest or back, red or brown marks that outlast the spot, and any dent the fingertip can feel are the signs that acne has moved past what a routine can manage. So is acne that is changing behaviour: a teenager who is avoiding photographs, sport or friends because of their skin is carrying a burden worth taking seriously, and that is a reason to be assessed.

Grading in plain terms

Two look-alikes are checked at assessment. Uniform, itchy small bumps on the forehead, chest or back may be Malassezia folliculitis, which does not respond to acne treatment, and small white bumps that never come to a head may be milia. The full account of grading is on acne treatment Singapore.

When should teenage acne be treated early to prevent scars?

Scars are made while acne is active. Every inflamed spot is a small wound in the dermis, and whether it heals flat or leaves a dent or a mark depends on how deep the inflammation went, how long it lasted and how the individual's skin heals. A clinical study of acne scarring found that scarring was related to the severity of the acne and that a delay between the onset of acne and adequate treatment was associated with a greater degree of scarring. The practical conclusion is that the time to treat acne that is inflamed is now, not after the exams, and not once it has been left to see whether it settles.

The threshold for seeing a doctor is therefore lower than many families expect. It is not reserved for severe acne. It is reached when inflamed spots are regular rather than occasional, when marks are being left, when the acne is spreading to the trunk, or when the teenager is picking. In Singapore's Fitzpatrick III to V skin, the brown marks left by inflammation, post-inflammatory hyperpigmentation, can persist far longer than the spot that caused them, which is a second reason to shorten the inflamed period.

Signs that the window for early treatment is open

• New inflamed spots most weeks, not just around exams or periods
• Marks that are still visible long after the spot has gone
• Any dent that can be felt with a fingertip when the skin is stretched
• Painful lumps that are slow to settle, or that recur in the same place
• Acne on the chest, shoulders or back, which scars more readily than the face
• Picking or squeezing that the teenager cannot stop

The sequence of acne, marks and scars, and why each stage is treated in order, is set out on the acne-to-scar pathway. Scar treatment itself is not started while acne is active, because resurfacing skin that is still breaking out treats scars that are still being made.

“I will not resurface a teenager's scars while the acne is still making new ones. Control first; the scars can wait, and they are easier to treat once they have stopped arriving.”

Dr Sin YongOn teenage acne

What does a doctor use for teenage acne: topicals, oral treatment and light?

Medical treatment of acne is first-line, and the current guidelines from the American Academy of Dermatology and the earlier paediatric recommendations agree on the structure: a topical retinoid and benzoyl peroxide as the foundation for nearly every grade, antibiotics used only in combination with benzoyl peroxide and for a limited period, hormonal options in older girls where appropriate, and isotretinoin for severe or scarring acne. Lasers and light are directed at the inflammatory component alongside medication, not instead of it. What is chosen for a given teenager depends on grade, skin type, what has been tried, and what the family can realistically keep up.

What a doctor also does is subtract. Many teenagers arrive on a routine of five products bought online, each promising to clear skin fast, and the first step is often to remove most of them. Scrubs, harsh cleansers, toothpaste on spots and squeezing all add inflammation, and inflammation is what scars.

How does a consultation for a teenager work, and who gives consent?

Consultations for anyone under 18 are held with a parent or guardian present. The parent or guardian makes the appointment, attends, gives consent to any treatment and is part of every decision, and the enquiry is made by the adult rather than by the teenager. This is not a formality. Acne treatment is a sustained course, it depends on daily habits at home, and some medicines need monitoring; the plan has to be one the family can carry, so the family is in the room when it is made.

What happens at the first visit

1. History with both of you: when the acne started, what has been tried, periods and any hormonal pattern in girls, family history of acne and scarring, medicines, sport, diet questions and how the acne is affecting daily life
2. Examination of the face, and of the chest and back where relevant, with grading and a check for look-alikes
3. A look at the current routine, product by product, and the removal of what is doing harm
4. A plan explained to the teenager directly, in plain terms, with the parent listening, because the teenager is the one who will apply the cream every night
5. Written instructions, what side effects to expect at the start and when to get in touch
6. A review date, because acne treatment is adjusted on response rather than set once

Dr Sin Yong talks to the teenager as the patient and to the parent as the decision-maker, and the two are not in conflict. Where a teenager wants to be examined privately, that is arranged with the parent's agreement and the parent rejoins for the plan. Where the history suggests something beyond acne, such as an endocrine cause or significant distress, referral to the appropriate specialist is discussed with the parent. The general process is described under how consultations work.

What makes teenage acne worse, and what should the family avoid?

Most of what worsens teenage acne is done with good intentions. The list below is the one Dr Sin Yong goes through at the first visit, because stopping these is often the fastest change a family can make.

• Squeezing and picking, which drive inflammation deeper and turn a spot that would have healed flat into a mark or a dent
• Scrubbing and washing many times a day, which strips the barrier and changes nothing in the gland; twice a day with a gentle cleanser is enough
• Layering several acids, a retinoid and spot treatments bought online at once, which irritates the skin and makes it harder to tell what is working
• Borrowing a steroid cream from the family cupboard, which calms redness briefly and then rebounds, and can trigger perioral dermatitis
• Stopping a prescribed treatment early because it has not worked yet, when most acne treatments are judged over a sustained period
• Stopping a prescribed treatment because the skin has cleared, when maintenance is what keeps it clear
• Products bought from overseas or online that promise fast clearing, some of which have been found by the Health Sciences Authority to contain undeclared steroids or other prohibited ingredients
• Heavy, occlusive make-up and hair products on the forehead and temples, and helmets, caps and masks worn for hours without cleaning

What helps at home

• A gentle cleanser twice a day, the prescribed treatment applied as directed, a light non-comedogenic moisturiser and a fluid sunscreen every morning
• A clean pillowcase, phone screen and sports kit, and a shower after sport
• Patience, with a review booked so adjustments are made rather than given up on
• Treating the teenager's distress as real; acne affects confidence at an age when confidence is being built, and that is a reason to treat, not to wait

Diet questions come up at nearly every visit. The evidence linking high-glycaemic diets and, less consistently, skimmed milk to acne is modest and is discussed honestly; no diet replaces treatment, and no teenager is put on a restrictive diet for their skin.

What decides the plan, and what does aftercare look like for a teenager?

The plan is decided by grade, by what is dominant in the follicle, by skin type, by what has been tried and for how long, by whether marks or early scars are already present, by sport and lifestyle, and by what the family can sustain. For girls, a hormonal pattern changes the options. For anyone with nodulocystic disease, the conversation about specialist treatment happens early rather than late. For anyone in whom the look is not acne at all, the plan changes entirely.

What decides the plan

• Grade: comedonal, papulopustular or nodulocystic
• Skin type, which sets pigment risk and how any laser is run
• Whether marks or dents are already present, which raises urgency
• Hormonal pattern in girls
• Current routine and what has been tried properly
• Whether a laser directed at inflammation has a role alongside medication

Aftercare in broad terms

Aftercare is mostly daily life done consistently: the prescribed treatment applied as directed, sunscreen every morning because several acne treatments increase sun sensitivity and because sun deepens marks, no picking, a simple routine and a review before anything is changed. After any laser the routine is simplified for a short period and actives are paused until the skin has settled. Marks are treated once the acne is controlled, and the post-inflammatory hyperpigmentation page explains why brown marks in Asian skin need patience and sun protection rather than exfoliation. Where scars remain after the acne is quiet, the acne scar treatment page describes how they are classified and treated, in order. The aftercare hub has the treatment-specific guidance.