Acne

What is acne?

Acne is not just a problem for teenagers, it can affect people from ages 10 through 40. It is not unusual for women, in particular, to develop acne in their mid-to-late 20’s, even if they have not had breakouts in years (or ever). Acne can appear as any of the following;

* congested pores,
* whiteheads,
* blackheads,
* pimples,
* pustules, or
* cysts (deep pimples).

These blemishes occur wherever there are many oil (sebaceous) glands, mainly on the face, chest, and back.

You can do a lot to treat your acne using products available at a drugstore or cosmetic counter, that do not require a prescription. However, for tougher cases of acne, you should consult a physician.

What causes acne?

No one factor causes acne. Acne happens when oil (sebaceous) glands come to life around puberty stimulated by male hormones from the adrenal glands of both boys and girls. Oil is a natural substance which lubricates and protects the skin, and under certain circumstances, cells that are close to the surface block the openings of sebaceous glands and cause a buildup of oil underneath. This oil stimulates bacteria, (which live in everyone's skin and generally cause no problems), to multiply and cause surrounding tissues to become inflamed.

If the inflammation is right near the surface, you get a pustule; if it's deeper, a papule (pimple); deeper still and it's a cyst. If the oil breaks though to the surface, the result is a "whitehead." If the oil becomes oxidized (that is, acted on by oxygen in the air), the oil changes from white to black, and the result is a "blackhead."

Some factors that don’t usually cause acne, at least by themselves are:

* Heredity: With the exception of very severe acne, most people do not have the problem exactly as their parents did. Almost everyone has some acne at some point in their life.
* Food: All over the world, parents tell teens to avoid pizza, chocolate, greasy and fried foods, and junk food. While these foods may not be good for overall health, they don't cause acne or make it worse.
* Dirt: Some individuals have more "oily" skin than others (as mentioned above, "Blackheads" are oxidized oil, not dirt). Sweat does not cause acne, therefore, it is not necessary to shower instantly after exercise for fear that sweat will clog pores. On the other hand, excessive washing can dry and irritate the skin.
* Stress: Some people get so upset by their pimples that they pick at them and make them last longer. Stress, however, does not play much of a direct role in causing acne.
* Hormones: Some women break out cyclically, but most women (and men) don't. Some oral contraceptive pills may help relieve acne, but unless a woman has abnormal menstrual periods and excessive hair growth, it’s unlikely that hormones play much of a role in causing acne.
* Cosmetics: Most cosmetic and skin care products are not pore-clogging (“comedogenic.”) Of the many available brands, those which are listed as “water-based” or “oil-free” are generally a better choice.

In occasional patients, contributing factors may be:

* Pressure: In some patients, pressure from helmets, chinstraps, collars, and the like can aggravate acne.
* Drugs: Some medications may cause or worsen acne, such as those containing iodides, bromides, or oral or injected steroids (either the medically prescribed prednisone or the steroids bodybuilders or athletes take.) Most cases of acne, however, are not drug-related.
* Occupations: In some jobs, exposure to industrial products like cutting oils may produce acne.

What other skin conditions can mimic acne?

* Rosacea: This condition is characterized by pimples in the middle third of the face, along with redness, flushing, and superficial blood vessels. It generally affects people in their 30’s and 40’s and older. There is sometimes no "line" separating acne from rosacea, however, there are no blackheads or whiteheads in rosacea. For more, please read the Rosacea article.
* Pseudofolliculitis: This is sometimes called "razor bumps" or "razor rash." When cut close to the skin, curly neck hairs bend under the skin and produce pimples. This is a mechanical problem, not a bacterial one, and treatment involves shaving less (growing a beard, laser hair removal.) Pseudofolliculitis can, of course, occur in patients who have acne too.

When should you start to treat acne?

Since everyone gets acne at some time, there is no "correct" time to treat it. The best advice is to take action when you think it is out of control. This can be when severe acne flares suddenly, mild acne that just won't go away, or even when a single pimple decides to show up the week before your prom or wedding. The decision is yours.

What can you do about acne on your own?

Think back to the three basic causes of acne, and you can understand why the focus of both home treatment and prescription therapy is to: (1) unclog pores; (2) kill bacteria; and (3) minimize oil. But first a word about . . .

Lifestyle: Moderation and regularity are good things, but not everyone can sleep eight hours, eat three good meals, and drink eight glasses of water a day. You can, however, still control your acne even if your routine is frantic and unpredictable. Probably the most useful lifestyle change you can make is to apply hot compresses to pustules and cysts, to get facials (see below), and never to pick or squeeze pimples. Playing with pimples, no matter how careful and clean you are, nearly always makes bumps stay redder and bumpier longer. People often refer to redness as “scarring,” but fortunately it usually isn’t, in the permanent sense. It's just a mark that takes months to fade if left entirely alone.

Open the pores

Cleansing and skin care: Despite what you read in popular style and fashion magazines, there is no magic product or regimen that is right for every person and situation.

* Mild cleansers: Washing once or twice a day with a mild cleansing bar or liquid (for example, Dove, Neutrogena, Basis, Purpose, and Cetaphil are all inexpensive and popular) will keep the skin clean and minimize sensitivity and irritation.
* Exfoliating cleansers and masques: A variety of mild scrubs, exfoliants, and masques can be used. These products contain either fine granules or salicylic acid in a concentration that makes it a very mild peeling agent. These products remove the outer layer of the skin, and thus open pores.
* Retinol: Not to be confused with the prescription medication, Retin-A, this derivative of Vitamin A can help promote skin peeling.

Kill the bacteria

* Antibacterial cleansers: The most popular ingredient in over-the-counter antibacterial cleansers is benzoyl peroxide.
* Topical (external) applications: These products come in the form of gels, creams, and lotions, which are applied to the affected area. The active ingredients that kill surface bacteria include benzoyl peroxide, sulfur, and resorcinol. Some brands promoted on the Internet and cable TV are more costly, but not really any better than ones you can buy in the drugstore.

Benzoyl peroxide causes red and scaly allergic skin in a small number of people, which goes away as soon as you stop using the product. Keep in mind that benzoyl peroxide is a bleach, so do not let products containing benzoyl peroxide get on your good colored clothes, shirts, or towels.

Reduce the oil

You cannot stop your oil glands from producing oil (unless you mess with your hormones or metabolism in ways you shouldn't.). Even isotretinoin (Accutane -- see below) only slows down oil glands for a while, they come back to life later. What you can do is to get rid of oil on the surface of the skin, and reduce the embarrassing shine.

* Use a gentle astringent/toner to wipe away oil. (There are many brands available in pharmacies, as well as from manufacturers of cosmetic lines.)
* Products containing glycolic acid or one of the other alpha-hydroxy acids are also mildly helpful in clearing the skin by causing the superficial layer of the skin to peel (exfoliate).
* Masques containing sulfur and other ingredients draw out facial oil.
* Antibacterial pads containing benzoyl peroxide have the additional benefit of helping you wipe away oil.

What are other things you can do for acne?

* Cosmetics: Don't be afraid to hide blemishes with flesh-tinted cover-ups or even foundation, as long at it is water-based or oil-free. There are many quality products available.
* Facials: While not absolutely essential, steaming and "deep-cleaning" pores is useful, both alone and in addition to medical treatment, especially for people with "whiteheads" or "blackheads." Having these pores unclogged by a professional also reduces the temptation to do it yourself.
* Pore Strips: Pharmacies now carry, under a variety of brand names, strips which you put on your nose, forehead, chin, etc. to "pull out" oil from your pores. These are, in effect, a do-it-yourself facial. They are inexpensive and safe, and work reasonably well if used properly.

What is a good basic skin regimen?

These are all good basic skin regimens that may help with the acne battle:

1. Cleanse twice daily with a 5% benzoyl peroxide wash. An alternative for those who are allergic to benzoyl peroxide is 2% salicylic acid.
2. Apply a gel or cream containing 5% benzoyl peroxide, an alternative is sulfur or resorcinol.
3. At night, apply a spot cream containing sulfur to the affected areas.
4. Use a light skin moisturizer and oil-free makeup.

What can the doctor do for acne?

If you haven't been able to control your acne adequately, you may want to consult a primary care physician or dermatologist. Here are some of the things they can assist with:

* Topical (externally applied) antibiotics and antibacterials: These include erythromycin, clindamycin (Benzaclin), sulfacetamide (Klaron), and azelaic acid (Azelex).

* Retinoids: Retin-A (tretinoin) has been around for years, and has become milder and gentler while still maintaining its effectiveness. Newer retinoids include adapalene (Differin) and tazarotene (Tazorac). These medications are especially helpful for unclogging pores. Side effects may include irritation and mild increase in sensitivity to the sun. Wit proper sun protection, however, they can be used even during sunny periods. For more, please read the Sunburn and Sun-Sensitizing Drugs article.

* Oral antibiotics: Most doctors start treatment with tetracycline or one of the related "cyclines," such as doxycycline and minocycline. Other oral antibiotics that are useful for treating acne are cefadroxil, amoxicillin, and the sulfa drugs.

o Problems with these drugs can include allergic reactions (especially sulfa), gastrointestinal upset, and increased sun sensitivity. Doxycycline, in particular, is generally safe but can sometime cause esophagitis (irritation of the esophagus, producing discomfort when swallowing) and an increased tendency to sunburn.
o Despite many people’s concerns about using oral antibiotics for several months or longer, such use does not “weaken the immune system” and make them more susceptible to infections, or unable to use other antibiotics when necessary.
o Recently published reports that long-term antibiotic use may increase the risk of breast cancer will require further study, but at present are not substantiated. In general, doctors prescribe oral antibiotic therapy for acne only when necessary and for as short a time as possible.

* Oral contraceptives: Oral contraceptives, which are low in estrogen to promote safety, have little effect on acne one way or the other. Some contraceptive pills have been to shown to have modest effectiveness in treating acne.

* Cortisone Injections: To make large pimples and cysts flatten out fast, doctors inject them with a form of cortisone.

* Isotretinoin: (Accutane was the original brand name; there are now several generic versions in common use.) Isotretinoin is a wonderful treatment for severe, resistant acne, used on millions of patients since it was introduced in 1982. It should be used for patients with severe acne, chiefly of the cystic variety, which has been unresponsive to conventional therapies like those listed above.
o Used properly, isotretinoin is safe and produces few side effects beyond dry lips and occasional muscle aches. This drug is prescribed for 5-6 months. Fasting blood tests are monitored monthly to check liver function and the level of triglycerides, relatives of cholesterol which often rise a bit during treatment, but rarely to the point where treatment has to be modified or stopped.
o Even though isotretinoin does not remain the body after therapy is stopped, improvement is often long-lasting. It is safe to take two or three courses of the drug if unresponsive acne makes a comeback. It is, however, best to wait at least several months and to try other methods before using isotretinoin again.
o Isotretinoin has a high risk of inducing birth defects if taken by pregnant women. Women of childbearing age who take isotretinoin need two negative pregnancy tests (blood or urine) before starting the drug, monthly tests while they take it, and another after they are done. Those who are sexually active must use two forms of contraception, one of which is usually the oral contraceptive pill. Isotretinoin leaves the body completely when treatment is done; women must be sure to avoid pregnancy for one month after therapy is stopped. There is, however, no risk to childbearing after that time.
o Another concern, much discussed in the popular press, is the risk of depression and suicide in patients taking isotretinoin. Government oversight has resulted in a highly-publicized and very burdensome national registration system for those taking the drug. This has reinforced the understandable, but unfortunate and inaccurate, sense many patients and their families have that isotretinoin is dangerous. In fact, large-scale studies have shown no increased risk for depression and suicide in those taking isotretinoin compared with the general population. Although it is important for those taking this drug to report mood changes (or any other symptoms) to their doctors, even patients who are being treated for depression are not barred from taking isotretinoin, whose striking success often improves the mood and outlook of patients who have suffered and been scarred from acne for years.

* Laser treatments: Recent years have brought reports of success in treating acne using lasers and similar devices, alone or in conjunction with photosensitizing dyes. It appears that these treatments are safe and can be effective. However, what isn’t clear at this time, is how long the effects will last. In addition, health insurers do not generally reimburse for these procedures, so they can be costly. At this point they are best thought of as adjuncts to conventional therapy, rather than as substitutes.

* Chemical peels: Whether the superficial peels (like glycolic acid) performed by Estheticians, or deeper ones performed in the doctor's office, chemical peels are of modest, supportive benefit only, and in general do not substitute for regular therapy.


How would you sum up current day treatment of acne?

Treating acne requires patience and perseverance. Any of the treatments listed above may take 2 or 3 months to start working (even isotretinoin.) Unless there are side effects such as dryness or allergy, it is important to give each regimen or drug enough time to work before giving up on it and moving on to other methods. Using modern methods, doctors can help clear up just about everyone.

Just hang in there. And don't pick. Please.



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