The patient should be told that acne is caused by his type of skin and by  hormonal changes occurring in adolescence. These changes include the development of seborrhoea and an increased production of the cornifted material  present within the  duct of the  sebaceous glands. It is this  author's practice to tell the patient that these alterations  are not usually due to abnormalities of the  sex  hormones but to  an overreaction  of  the sebaceous  unit  to  normal  levels  of  sex  hormones. Consequent upon these changes the sebaceous  follicles become colonized with normal resident bacteria which produce biologically active substances and these directly or indirectly cause inflammation.

 

   It is necessary to explain to the patient that there are different sorts of acne, not just of different severity, and different types of acne lesions. We  are aware that some patients may have predominantly noninflamed  lesions, others  may have more  inflamed lesions and in some patients there may be an equal mix  of both lesion types. Thus, the treatment given to the patient may be based upon the  type of acne  and its severity as well  as its location.

 

   Many  patients have read  or seen  advertisements which misguide them into believing that acne responds quickly to treatment. This is not usually so and must be emphasized to the patient at the outset. There is usually limited improvement in the first 2-4 weeks, but with the appropriate treatment most patients will  see 40  per cent improvement at the end of two months, 60 per cent improvement at  four months and 80 per cent or even greater improvement at six months.

 

   The patient must also be told of the possible sideeffects. An irritant dermatitis  is common with most topical acne preparations but the severity of this can be controlled by adjusting the  frequency of use of the topical therapy. Side-effects are uncommon with  oral  preparations, but include diarrhoea, abdominal  colic  and vaginal candidiasis. There is little need to emphasize these but just to inform the patient that very occasionally the tablets can produce  adverse reactions which  usually respond well to conventional treatment without discontinuing the acne therapy.

 

   The patient should be told confidently that 92  per cent of patients will respond in the way that has been

 

  Patients  also  have  misconceptions  about topical treatments; they often think that they should apply the therapy just to the spots. It is important to treat not only the spots but the whole of the sites where the skin is affected,  including  the back  and chest. Patients may make excuses - such as they  do not have long enough arms to reach their back, nor the time - but most have a friend or family member who will help them in treating their back.

 

  Doctors  often expect too much of patients; imagine that they will remember all the facts we have told them about acne and how to  treat the disease.  Guidelines routinely given to patients by this author's department are shown  in Appendix I. A  recent survey carried out by our pharmacy confirms the immense value of such handouts. explained. Only 8 per cent need alternative measures, and these will be tried if, after three months, there is no signficiant  clinical improvement  or even  after  two months if there is a deterioration.