Cystic acne and its scarring seem to be disappearing from New Zealand faces. Here’s why.

A bright green star adorned the freckled face of the teenager manning the supermarket check-out. Groups of schoolgirls sauntered past, clutching Stanley cups, cheeks dotted with neon stickers. At first, I wondered if they were a fashion accessory, but no, they had a purpose. They’re pimple patches, a way to shrink a zit while making it look cute.

My first thought was “I wish we’d had those when I was a teenager”.

Back then, I’d relied on a thick layer of Dream Matte Mousse to disguise my bumpy skin. If cute star-shaped pimple patches had existed, I’d have needed an entire constellation to cover my face.

Then another thought occurred to me. It had been a long time since I’d seen someone with the type of severe acne I had as a teenager years ago.

Where did all the acne go?

Twenty years ago, having cystic acne as a teen was, to put it lightly, soul destroying. I had huge, puss-filled cysts sprouting belligerently along my chin like the Southern Alps, as well as “bacne” and “chestne”.

Back then in the early 2000s acne was everywhere, as ubiquitous as low rise jeans, yet for all the camaraderie of this shared affliction, it was still something we desperately tried to cover. My school had a strict no makeup rule, though tactful teachers would turn a blind eye to the layers of concealer and foundation smeared on with a trowel.

I dreaded swimming pools, sleepovers, down lighting, any situation that brought more attention to my inflamed dermis. I spoke to my GP, who sympathised, but before I could be referred to a dermatologist, I needed to jump through many hoops.

I tried Proactiv – whatever was in it was powerful enough to leave face shaped bleach marks on every towel in our bathroom, but my acne remained stubbornly intact. 

I tried tea tree oil and multiple brands of birth control to no avail. I tried low-dose antibiotic Doxycycline – the same type used to treat chlamydia and prevent malaria, and that didn’t banish my acne either. The upside? I also remained remarkably free of both chlamydia and malaria.

Finally, I was referred to a dermatologist waiting list where my acne and I languished for many months waiting for the appointment. When I finally got one, I was prescribed isotretinoin under the brand name Accutane.

Accutane cleared my skin up within weeks. 

Acne remains one of the most common skin conditions in Aotearoa, affecting 85% of people at some point in their lives. Of people affected, 15% develop severe acne. But we may not see that full 15% any more, thanks to an obscure healthcare policy change that occurred in 2009, allowing GPs to prescribe isotretinoin.

Prior to that, the drug was a lot harder to obtain, requiring a referral and regular visits to a dermatologist, which was either costly, a drawn-out process, or both.

There was a clear reason for the long wait times. New Zealand has only around 80 dermatologists, leaving us with roughly one third the specialist dermatologist density of Australia. 

Specialist dermatologist and New Zealand Dermatological Society spokesperson Dr AJ Seine says allowing GPs to prescribe isotretinoin has transformed acne care, enabling them to manage the vast majority of routine cases.

Since the 2009 policy change, annual prescriptions of isotretinoin have increased by 87%, from 26,897 in 2008 to 50,613 in 2023. 

One such patient was Sophie Dunn, who developed acne in her mid-20s. “It was never severe, but it was really persistent for a number of years.” With her wedding approaching, she decided enough was enough. “I thought, ‘God, I’m sick of this persistent acne. I’m just over it’,” she remembers. “I went to my GP and they were like, ‘Yep, absolutely, let’s get you on isotretinoin’. I thought my skin would have to be much worse to warrant it.”

The accessibility of the treatment was a major factor for Dunn. “Seeing a dermatologist is expensive, it’s not something most people would even consider. But getting an isotretinoin prescription from a GP was straightforward and cheap. After a month, my skin had cleared up.”

Rachel Read has been suffering from acne and was recently prescribed
isotretinoin by her GP. “It massively affected my confidence,” she recalls. “There were many, many moments when I thought: Are people looking at it? Are they staring at it? Have I covered it up properly? Why is this happening to me?”

In the end, it was social media, where “people’s skin looks completely different”, that Read learned about treatment options for her acne. “I would’ve spent hundreds, if not thousands, of dollars over the years going to different skin clinics and having laser treatments,” she says. “I felt like I had exhausted all options. It was actually TikTok that educated me about isotretinoin.”

Treatments for acne have become far more accessible, but is acne itself disappearing? Seine doesn’t think so. “The prevalence remains quite high. In actual fact, adult acne seems to be on the rise,” he says. “It might look like you’re seeing fewer people walking around with bad acne or horrific scarring… I think it is because we’re intervening at an earlier stage.”

Historically, he says, isotretinoin was treated very differently. It was considered a “break only in severe cystic emergency” drug of last resort. Instead, teenagers were often simply told to wait acne out. Part of the hesitancy was concern about the drug’s potential side effects, particularly regarding mood disturbance and mental health.

“It’s not without risks, but it is an incredibly safe drug,” says Seine. “The mood disturbance risk that people worry about with isotretinoin – yes, it is a real risk, but actually it’s incredibly rare for it to happen, especially at low doses. And you’re dealing with an at-risk population in teenagers who are prone to mood disturbance if they have the drug or don’t.” He references a large-scale scientific study which compared teenagers with acne on doxycycline and other oral antibiotics against those on isotretinoin and found acne patients on isotretinoin experienced less depressive symptoms and psychological distress.

Since 2009, attitudes towards isotretinoin have changed dramatically, and Seine says “getting onto it sooner rather than later to prevent scarring is really important”.

So are we treating acne earlier than ever before?

“Yes, thank goodness!” says Dr Aaron Secrest, consultant dermatologist and clinical director of dermatology at Christchurch Hospital. Secrest remembers trying different oral antibiotics and birth control for female patients before even considering isotretinoin early in his career. “Now there are pushes for it to be considered a first-line treatment for acne.”

He says parents and patietns are realising that acne is highly treatable (“you don’t have to live with it”)  but at the same time, social media is amplifying problems with young people’s confidence.

“Now we have filters – immediate air brushing. People are seeing everyone’s most beautiful selves posted all the time,” he says. “I explain to patients that I hate how judgmental our society is on physical appearance, but I cannot change that entrenched systemic problem. I can, however, help the patient in front of me feel better about their skin and their appearance.”

Compared with Australia and the UK, New Zealand has made it far easier and cheaper for people to access isotretinoin, the most effective treatment for acne. The result may be that acne has all but disappeared from public view. What was once a commonplace affliction across faces in classrooms, nightclubs and workplaces has become increasingly rare to see.

Acne has always been a burden worn on your face, and eliminating that burden can only be a good thing. But perhaps in medicating away visible acne, we’ve also shifted our idea of what “normal” skin looks like. Clear skin has become the baseline expectation. Paradoxically, that may leave anyone with even mild acne feeling more conspicuous than ever.

Luckily, we have a neon star for that.