During the first week of my third year medical school dermatology rotation I thought I’d definitely decided that I wanted to become a dermatologist. I’d been present in the room with my dermatology preceptor and patients who asked about what to do for their acne at least a hundred times, and I knew I could give the same speech as my dermatology teacher. I later changed my mind about becoming a dermatologist but I still have a great interest in dermatology. Most people who come into the medical clinic due to problems with acne have tried various over the counter treatments to help with common black heads, white heads or deep cysts from acne. It’s a common problem for adolescents (85% are effected) and teenagers but also effects many adults as well. Untreated acne can lead to embarrassment, loneliness and even permanent facial scarring.
So what is acne? Acne is a skin problem where the openings in the skin where hairs come out (pores) become blocked by skin cells and oil and this creates a plug. During adolescence the glands that produce oil in the skin enlarge and produce increased amounts of the oily substance we call sebum. These oil glands are most often found on the face (most commonly an area called the T-Zone of the face – around the eyebrows and nose), neck, chest, upper back and arms. Even normally, there are bacteria which are present on the surface of the skin and normally they don’t cause any problems in small numbers. With an increased production of oil on the surface of the skin that occurs during adolescence however, these bacteria reproduce and become present on the surface of the skin in much higher numbers than normal. The bacteria then combine with the oil and skin cells and become trapped in the pores (hair follicles) and lead to the formation of tender “pimples” that we call acne.
A special type of acne that affects newborn babies is called neonatal acne and usually goes away within a few weeks after birth. It is related to the hormones from pregnancy and causes small pimples often noticeable on a newborn babies face
There are multiple types or ways we describe acne and grade the severity.
1) Non-inflammatory acne is acne without redness or skin swelling and usually is described as just being whiteheads or blackheads.
2) Inflammatory acne has redness and swelling and is more severe. There can be papules, pustules, nodules or cysts present.
Causes of acne:
1) Sebaceous (oil) glands become more sensitive to hormones during adolescence and become enlarged and produce more oil than normal which increased the likelihood of acne.
2) Cosmetics that contain oil may clog pores in a similar way to the oil secreted by the sebaceous glands in the skin and can lead to acne.
3) Frequent or aggressive rubbing with soaps or cleansers can actually increase the production of oil from the skin. Wash your skin gently.
4) Some people believe that diet can affect acne. If you find that you develop worsening oily skin or acne after eating certain foods, avoid these foods if possible.
5) Psychological stress can increase or worsen acne.
Acne Treatment: Since there are multiple causes of acne, there is not once simple treatment that works for everyone. Skin doctors (dermatologists) usually recommend a combination of treatments to reduce acne formation in multiple ways. Some simple suggestions are outlined below but keep in mind that they may not work for everyone.
1) Wash your face with a gentle non-soap skin cleanser. Most of the dermatologists that I’ve trained with have recommended a fragrance free cleanser such as Cetaphil or Dove. They usually recommend using warm water and washing gently with your hands rather than using a washcloth, skin brush or skin scrubber. Some of the prescription skin cleansers contain an antibiotic or sulfa base that helps soak up the oil and decrease the bacterial count on the surface of the skin. In general we don’t recommend washing your face more than twice a day unless you have been sweating excessively or you need to wash off sunscreen.
2) Most dermatologists don’t recommend picking or squeezing pimples yourself because you might risk causing scars or worsening the infection. Hearing this however always makes me laugh (usually not out loud in front of the dermatologist though) because they often help patients to pick and squeeze their pimples in a fashion similar to what I think most people would probably do themselves at home. The difference however is that in the office, they have access to special instruments and tools to help reduce the risk of scarring.
3) Cautious use of skin moisturizers is recommended. Remember, your skin is producing oil in abundance and that is a natural skin moisturizer. If you use too much moisturizer you could worsen the acne by causing plugging of the pores/hair follicles. If you use a skin moisturizer to help minimize dryness or peeling in certain areas, be sure it’s hypoallergenic or “non-comedogenic” formula to decrease the chance of blocking the skin pores.
4) Sun screen: Many of the antibiotics and even topical medications prescribed by medical professionals can increase your chances of getting a sun burn. Use a sunscreen with at least an SPF of 15 and make sure the sunscreen blocks both UVA and UVB.
5) Over the counter products: There is a huge market for acne medications. Television ads, various articles on the internet and in magazines tout the latest non-prescription skin formula. Most of these “formulas” that I’ve encountered contain benzoyl peroxide, salicylic acid or a combination of these two ingredients and put their own brand names on them. I recommend reading the ingredients to determine if the formula you are about to purchase is similar to one you might have already tried. Benzyl peroxide is an agent that dries the skin and helps decrease the amount of oil. It is usually applied twice a day. You should be aware that it can irritate the skin and possibly cause skin redness or flaking. It can also bleach your pillow case or clothes so be careful not to get it on your favorite items. If you find that the over the counter product that you try is not working, contact a healthcare provider. Untreated or inadequately treated acne can lead to permanent scarring of your skin.
Prescription treatments: Prescriptions for acne can be divided into topical (applied directly to the skin) and non-topical treatments.
- Prescription skin cleansers are topical washes that often contain an antibiotic or drying agent. They are made to be hypoallergenic and usually do not have a fragrant odor to them. Examples of a topic skin cleaner include a sulfacetamide/sulfur topical wash. Multiple companies produce their own brands such as Klaron, Plexion, Rosanil or Rosula. These are usually expensive and insurance companies often do not cover them.
- Benzoyl peroxide mixed with topical antibiotics: Various pharmaceutical companies make combined products that include benzoyl peroxide with various topical antibiotics such as clindamycin, erythromycin or metronidazole. Examples are Acanya, BenzaClin, Benzamycin, or Duac. These topical can be solutions, gels or creams.
- Topical antibiotic only: Many topical antibiotics are produced to help reduce the bacterial count on the skin. Most of them contain Erythromycin, Clindamycin, Sulfacetamide, Metronidazole or Dapsone. Examples are Aczone, Clenia, Cleocin T, Clindagel, Klaron, Metrocream, and Sulfacet-R.
- Retinoids: These medications often produce skin drying and can cause irritation. Examples are Retin-A, Differin and Tazorac. Differin tends be less potent and Tazorac is the strongest of the three. The first time I tried using Retin-A, I woke up with red, irritated, scaly skin that looked worse than the acne. I recommend starting with a small amount and trying on a small patch of skin first to see how your skin reacts to it.
B) Oral antibiotics: The reasons for using an oral antibiotic to treat acne are actually two-fold. The first reason is that some oral antibiotics have been found to have anti-inflammatory properties in the skin and decrease the inflammatory response leading to the pimples. The other reason is more straight-forward – to reduce the bacterial count on the skin and thereby decrease the acne. The most commonly prescribed oral antibiotics for acne at this time are Minocycline or Doxycycline but they should not be used during pregnancy or in young children.
C) Oral Isotretinoin (previously called Accutane): It’s also called Amnesteem, Claravis and Sotret. This medication is most often limited to be prescribed only by dermatologists are physicians who have had special training about this medication. This is one of the most successful medications that we have for the treatment of severe acne and is usually taken as a pill once or twice a day for 20 weeks. The reason it is not the first line of treatment for acne and mostly prescribed by dermatologists is because there are some possible serious side effects that can occur when using this medication. Isotretinoin can cause miscarriage or life-threatening malformations to babies so it cannot be taken by women who are pregnant or at risk of becoming pregnant. Most dermatologists require women of child bearing age to use birth control before they will prescribe this medication. There are strict rules for using the medication regulated by the iPLEDGE program:
1) Women have to have two documented negative pregnancy tests before starting the medication and continue to take monthly pregnancy tests throughout their treatment.
2) Any women who might become sexually active (or is already sexually active) with a male partner must use two forms of birth control for at least one month before starting therapy and continue until one month after stopping the medication.
3) Women of child bearing age who could become pregnant must get their prescription filled at the pharmacy within 7 days of receiving it from their doctor. Each month a new prescription must be written by their doctor.
4) Women who cannot become pregnant or men must participate in iPLEGE but do not have to do the pregnancy testing or use birth control.
Side effects of oral Isotretinoin: I’ve seen many patients who are treated with this medication and I’ve noticed that it works very well for their acne in most cases. Some of the common side effects that I’ve observed are:
1) Cracking or sore lips and dry or peeling skin. Patients may get nosebleeds very easily and have a tough time wearing contact lenses because their eyes dry out. They may have itchy skin (because of the dryness). Skin sensitivity to the sun is increased and risk of sunburn is severe.
2) There can be an increased level of triglycerides (fat) in the blood, it can cause liver damage and cause changes in blood counts when taking this medication so monitoring the blood cholesterol and triglyceride level as well as liver function and blood count is important.
3) There has been some talk about an increased risk for depression or suicidal behavior when taking this medication but there is not enough evidence to conclude that this is a risk.
Hormone treatment options: Women with acne are sometimes prescribed a birth control pill to help control acne. Some hormones and IUDs and injectable hormones however can actually worsen acne, so make sure to talk to your doctor about which birth control might be better for acne if you are considering this form of treatment.
A blood pressure medication called spironolactone has also been used to help with acne because it can effect hormone levels in women (and thereby decrease acne) but it can also cause an increase in the blood potassium and birth defects so it is usually cautiously.
Where to get more information:
1) American Academy of Dermatology: http://www.aad.org/skin-conditions/dermatology-a-to-z/acne
2) National Library of Medicine: www.nlm.nih.gov/medlineplus/acne.html
I hope that you have found this information useful. Wishing you the best of health,
Scott Rennie, DO
1) Haider A, Shaw JC. Treatment of acne vulgaris. JAMA 2004; 292:726
2) Ozolins M, Eady EA, Avery AJ, et al. Comparison of five antimicrobial regimens for treatment of mild to moderate inflammatory facial acne vulgaris in the community: randomized controlled trial. Lancet 2004; 364:2188