How TO HANDLE ACNE
For a substantial number of us, acne can be a torment. It afflicted us as teens, it plagues our
own kids now, and it can linger even after menopause. Acne is a complicated topic because it
exists in many forms and has many treatments. This chapter will help clear up some of the
confusion and provide you with the information you need to ask your dermatologist the right
questions.
WHAT YOU NEED TO KNOW
* What causes acne? • Acne and age
* The different grades of acne
WHAT ARE THE POSSIBLE TREATMENTS?
* Topical medications • Microdermabrasion
* Oral medications • Facials
WHAT You NEED TO KNOW
What Causes Acne?
"No one else in my family seems to have acne, so why do I?"
Acne (or a history of it) does tend to run in families, but this is not always the case. While
doctors understand the process of acne pretty well, we just don't understand all of its causes or
why it occurs in particular family members and not others. In any case, hormones are almost
always to blame.
Both males and females experience surging hormones around ages 10 to 14 that stimulate the
oil glands on the face, chest, and back to secrete more oil. These oil glands connect to hair
follicles—which are like tiny canals for hair—and the oil empties onto the skin through the
follicle. The overabundant oil (called sebum) gets mixed with dead skin cells from the hair
follicle and forms a plug. As bacteria begin to grow in the mixture of oil and cells, chemicals
are released that cause inflammation, breaking down the follicle. The oil, dead cells, and
bacteria then spill into the surrounding skin, causing more inflammation, swelling, and pus.
How bad the acne is depends on how big the plug (called a comedone) is, how deep it is in
the skin, and how much inflammation it causes. If the plug is close to the surface and there isn't
much inflammation, you might just have a blackhead or whitehead. If it forms deeper down in
the follicle, then you might have a red bump or a pustule. If it forms very deep down and there's
a lot of inflammation in the area, then a cyst forms. It's this type of cystic acne that usually
causes scarring.
The Different Grades of Acne
"There are five children in my family, and we all have acne. Our dermatologist has prescribed
different treatments for all of us. Can you explain why?"
Yes. You all probably have different types of acne (which dermatologists have categorized in
a numerical system from I to IV), and each type requires its own individual treatment.
Some of the material that follows may seem technical, but since this topic is so complicated,
the best way for you to educate yourself is to roll up your sleeves and learn as much as you can.
Blackheads and whiteheads (grade I). Almost everyone has some of this in their teenage
years, which is also called comedonal acne,. These blackheads and whiteheads are usually
found in the T-zone area but can occur anywhere, and, depending how severe the acne is, there
may be anywhere from a few to several hundred lesions. Grade-I acne can usually be treated
with acne washes and topical treatments such as gels, lotions, or creams.
Red bumps (grade II). This type has comedones (blackheads and whiteheads) and red bumps
(papules) and is usually more inflamed than the previous two types. Grade-II acne can be found
all over the face, and is generally treated with acne washes, gels, lotions or creams, and
sometimes with oral antibiotics.
Pustules (grade III). This type of acne surfaces when the red bumps from grade II contain pus.
Sometimes these pustules can be very inflamed and lead to scarring. If you have just a few
comedones and pustules, your doctor might prescribe acne washes and a gel, lotion, or cream.
However, if the acne is more severe, she might recommend oral antibiotics, oral contraceptives,
or in cases with scarring, Accutane.
Cystic acne (grade IV). This type of acne contains characteristics of the previous three grades,
plus cysts that are tender, deep, and hard. If these cysts are causing permanent scarring,
Accutane will probably be prescribed, as it's the most effective medication for this type of acne.
If the cysts aren't so severe or there isn't any scarring, a combination of all of the abovementioned treatments might be used (with the exception of Accutane).
Acne and Age
"I'm in my 40s now, but I've had acne since I was a teenager. It seems as if it's different now,
but I still have it. Am I ever going to grow out of having acne?"
For many people, acne lasts throughout their entire reproductive lives. It tends to begin when
hormones start to activate in early puberty, and it can last until menopause. However, with
postmenopausal hormone replacement, some women have acne into their 50s, 60s, or even 70s
depending on the type of hormone replacement used. Acne definitely changes over the decades,
though: Teenage acne is quite different from postmenopausal acne and should be treated as
such. Below is a summary.
Teenage acne. Most people starting their sexual development have at least mild acne at some
point during their adolescence. Oil secretion definitely increases, and blackheads and
whiteheads often develop. As the teen years progress (especially if there's a family history of
severe acne), it can become quite severe, with large cysts and subsequent scarring.
Acne during these years tends to be unpredictable, because the hormone levels of teenagers
fluctuate so much. Young women in particular have irregular cycles and menstrual periods that
aren't established yet, so their estrogen and progesterone levels may be changing quite a bit
from month to month. This is why your 16-year-old daughter's mild acne can turn severe in a
matter of months.
In addition, most teenage acne is concentrated through what's called the T-zone (the forehead,
nose, and chin), although it may go on to involve the cheeks; and young skin tends to be much
oilier than older skin. But this is very individual: Some people have extremely oily skin that
persists even into their 30s and 40s and tends to be acne prone even then; others have oily skin
only in their teens, and by their 30s have drier, clearer skin.
Acne in the 20s and 30s. In most cases, skin at this stage is already beginning to be less oily and
breakout prone than in the teens. Sometimes, though, acne may start in the 20s or 30s—even if
the person had clear skin in their teenage years. Again, hormones are usually the culprits.
Remember, if you've recently gone off oral contraceptives, this probably accounts for your
more severe breakouts.
If your acne is mild, give nonprescription medications a try for two or three months, then see
your dermatologist. However, if your acne is moderate to severe, make an appointment right
away, but use the nonprescription medications until you can be seen by your dermatologist.
Acne breakouts in the 40s (perimenopausal acne). For most men, acne is gone by the time
they reach their 40s—but this isn't necessarily the case for women. For some women, their 40s
mean complete freedom from acne; for others, acne may actually worsen during the five to ten
years prior to menopause (also known as perimenopause).
Menopause occurs in most women in their early 50s. But during perimenopause, our
hormonal systems are already beginning to change, even though we're still having regular
periods. Women in their 40s tend to notice that their periods are gradually getting lighter and
may even notice late periods, which may indicate that ovulation didn't occur that month (called
an anovulatory cycle).
Acne in the 40s is generally different from adolescent acne in that there aren't as many
blackheads, whiteheads, papules, or pustules. Instead, it's more microcystic—that is, small,
hard, tender cysts often occur around the chin, jawline, and sometimes down on to the neck.
Severe acne with very large cysts (or nodulocystic acne) is rare in eithersex in the 40s, but the
small cysts of microcystic acne are still capable of scarring if they get inflamed enough.
Postmenopausal acne. It used to be that women were entirely free of acne after menopause,
but hormone replacement therapy (HRT) has changed all that.
HRT uses different types of estrogens, progesterones, and sometimes even testosterone to
keep a postmenopausal woman's hormone levels appropriately balanced. The low-dose estrogen
itself usually isn't a problem for the skin—more often it's the progesterone- or testosteronerelated side of HRT that causes acne.
But HRT is complicated and individualized for each woman, and you're probably aware of
the debate over whether HRT should be used at all. If you're undergoing this therapy, you may
want to ask your dermatologist or gynecologist if switching to a different type of progesterone
compound or a lower estrogen dose might be helpful to your skin. Many different types of
progesterone exist, and you may find one that works for you without causing you to break out.
There's also a new IUD available that delivers progesterone right to the uterus where it's
needed, without much systemic absorption. Usually acne isn't a problem if one of these are
used, but you should know that insurance companies generally won't cover them for acne and
that they can cost between $500 and $700.
POSSIBLE TREATMENTS
"There are so many different types of treatment for acne now. Which one should I be using?"
Most acne can now be controlled, but there are so many options for treatment that you need a
customized treatment plan. This is why having a good doctor is important.
If your acne is mild, it's perfectly fine to try over-the-counter remedies, most of which have
benzoyl peroxide or alpha- or beta-hydroxy acids in them. If your acne is moderate or severe,
make an appointment with your doctor. A good primary-care physician will be comfortable
treating mild to moderate acne, but a dermatologist should treat severe acne.
In my opinion, one of the main goals of acne treatment is to prevent permanent scarring. If
you're starting to scar, your dermatologist may quickly move to oral antibiotics, oral
contraceptives, or Accutane. For less severe types of acne, cleansers, gels, lotions, and creams
may be very effective, either used alone or in combination with oral medications.
Remember that discoloration is different from permanent scarring. Permanent scarring is a
depressed, raised, or white area that doesn't go away. Discoloration is red or brown, the skin is
soft and flat, there's no indentation or change in texture, and while it may last for months, it's
almost always temporary.
Acne Treatment Tips
1. Be patient. It takes eight to ten weeks to see if a new acne medication is working.
2. Apply creams, gels, or lotions in a thin layer over the entire area, not just on the lesions.
3. Don't pick! Picking can cause scars.
4. Stop the medicine and call your doctor if your skin is red or irritated for more than a couple
of days.
5. Schedule a follow-up appointment in eight to ten weeks with your dermatologist.
Topical Medications
Washes. Most acne washes are formulated for oily skin and areappropriate for patients in their
teens and 20s. Nonprescription washes usually contain benzoyl peroxide (either 5 or 10
percent) or glycolic or salicylic acids, but if your skin is dry or sensitive, these ingredients will
probably just irritate you and should be avoided. Prescription washes, on the other hand, are
usually a bit stronger, but they can be formulated to be less drying.
Acne medications can be irritating by themselves, so it may be best to use a gentle,
nonirritating wash such as Cetaphil Gentle Skin Cleanser.
Gels, lotions, and creams.
While nonprescription products are fine if you have very mild acne, you may need prescription
items to make any real headway. Most over-the-counter gels, lotions, and creams (topical
agents) contain low-strength benzoyl peroxide, a little alpha-hydroxy acid, salicylic acid, or
retinol (which is not the same thing as Retin-A).
Fortunately, there are a lot of different prescription gels, lotions, and creams for your
dermatologist to choose from now. Almost everyone can find something that will work for
them, but you may need to try several until your doctor finds the right ones for your skin. Don't
get discouraged if the results aren't instant: It takes eight to ten weeks to tell if an acne medicine
is working.
Gels tend to be used for oily skin, whereas lotions and creams are usually prescribed for
patients with dry or sensitive skin. Some of the choices include vitamin-A derivatives such as
tretinoin (see below); Differin cream or gel, which is related to vitamin A but may be slightly
less irritating; and Tazorac, which can be irritating.
Tretinoin. Sold under the brand names of Renova, Retin-A, Avita, or Retin-A Micro, this
class of vitamin-A relatives works well for most types of acne. A secondary benefit is that
tretinoin has been clearly shown to help reduce wrinkling over time. Renova is even formulated
in a moisturizing base to facilitate use in older, drier skin. The concentration of tretinoin
probably doesn't matter very much, as excellent effects over time are seen with lower
concentrations—higher concentrations definitely cause more irritation but don't necessarily
work better.
Unfortunately, tretinoin causes irritation in many people, but before you give up on it, make
sure you're using it correctly. To do so, you need to do the following:
1. Wash your face with a very gentle cleanser and dry it thoroughly.
2. Wait 10 to 30 minutes before applying the cream to reduce the chance of skin irritation.
3. Spread one pea-sized amount gently over the entire face—don't just dot it on lesions.
4. Apply tretinoin at night because sunlight makes it inactive.
5. Be sure to use a sunscreen with an SPF of 15 or greater in the morning since the vitamin-A
derivative may make you slightly more sensitive to the sun.
6. Avoid waxing, scrubs, or depilatories that may irritate the skin, and if you're having a facial
or microdermabrasion, be sure to let your aesthetician know ahead of time that you're using
tretinoin.
Azelex. This is a relatively new but excellent treatment for mild to moderate acne. It's usually
used twice a day and is significantly less irritating than vitamin-A derivatives. Some doctors
recommend it in combination with other topical agents, so that Retin-A, for example, would be
used at night and Azelex in the morning.
Benzamycin gel. This combination of benzoyl peroxide and erythromycin (a topical
antibiotic) is excellent for mild to moderate acne, and is less irritating than vitamin-A
derivatives but slightly more irritating than Azelex. Its one disadvantage is that it has to be
stored in the refrigerator. However, it does last for about a week out of the refrigerator, so you
can put a week's supply in your bathroom and then refill it weekly from the refrigerated
container.
Topical antibiotics. There are a number of antibiotics that come in gel, lotion, or cream form.
Some of the most common are clindamycin, erythromycin, and metronidazole (usually used for
rosacea). These are often prescribed for mild to moderate acne and may be used alone but are
more often used in conjunction with one of the above-mentioned topical medications.
Oral Medications
"My dermatologist prescribed minocycline for me, but I really don't like to take antibiotics on a
regular basis. Why can't I just use a cream?"
Moderate to severe acne typically doesn't get better just with topical medications because the
inflammation is too advanced and the plug in the hair follicle is too deep. A more systemic
medication such as an antibiotic can usually tackle the deeper inflammation and bacterial
growth in the follicle.
Oral antibiotics fight the bacteria in the lesion and some have anti-inflammatory properties as
well. Some of the most commonly prescribed include minocycline, doxycycline, tetracycline, or
erythromycin (or amoxicillin or penicillin derivatives if you're allergic to the others). Oral
antibiotics are usually taken once or twice a day—some need to be taken on an empty stomach,
so be sure to check with your doctor or pharmacist.
One strategy is to start with various washes, gels, or creams and use them for two or three
months. If at the end of two or three months there hasn't been much response, your
dermatologist might then add an oral antibiotic to take for several months or even up to several
years. Another strategy is to start acne washes, gels, or creams at the same time with an oral
antibiotic; if you're doing well by your next checkup, your dermatologist might then
discontinue or taper off the oral antibiotic.
The trend in dermatology is to prescribe oral antibiotics less frequently and for more limited
time periods because we've realized that using them for acne over long periods of time helps to
breed antibiotic resistance in our society as a whole and in individuals as well. In addition,
many women are prone to vaginal yeast infections while they're taking antibiotics. And other
treatments have lessened our reliance on antibiotics; having said that, there are still some
situations where they really are the best choice for treating acne. This is why it is important to
have your treatment individualized by a dermatologist.
Oral contraceptives. Oral con-traceptives can be very effective in treating acne, particularly for
women in their late teens, 20s, and 30s, because they stabilize hormone levels from month to
month. But it's wise to keep in mind that if you go off the Pill, your acne will almost certainly
get worse, perhaps not right away, but within several months.
The first medication to be approved by the FDA for use in both birth control and the
treatment of acne was Ortho Tri-Cyclen, but there are now several others that have been
approved (or are in the process of being approved) for this use as well. Oral contraceptives can
be used in combination with topical medications. Be aware that there have been a few reports
that taking antibiotics may decrease the effectiveness of the Pill, so it may help to take these
medications at different times of day.
Keep in mind that health risks associated with oral contraceptives go up significantly after the
age of 35, especially if you're a smoker. It's important to consult with your doctor before taking
oral contraceptives for acne, especially if you or any other family members have a history of
blood clots. Also be sure to report any breakthrough bleeding to your doctor.
Spironolactone. This medica-tion has been around for more than 30 years and was originally
used to treat kidney problems and high blood pressure, but it's quite effective for treating acne,
too. In low doses (which is what's prescribed for acne), it mainly inhibits testosterone, a "male"
hormone that's also present in women.
Doctors sometimes prescribe spironolactone for women who have polycystic ovary
syndrome. This disease can lead to elevated levels of "male" hormones in the blood, ovaries
that don't produce eggs regularly, increased facial and body hair, and acne. Spironolactone
helps reduce hair growth and control acne, and for many women, it also helps reduce PMS-type
symptoms.
You shouldn't take spironolactone if you have low blood pressure, for it may lower your
blood pressure just enough to make you dizzy. (This won't happen for women with normal or
slightly elevated .blood pressure—for them, lower blood pressure is a positive side effect.) This
medication can't be taken if you're pregnant or thinking about getting pregnant, since it may
affect the development of the male fetus's genitalia.
Accutane. Accutane (the brand name for isotretinoin) should be reserved for severe acne—
that is, cystic or scarring acne. It's sometimes used to treat people who have tried several other
acne therapies for a reasonable period of time but haven't responded.
For severe acne, especially in the teens and 20s, Accutane is far and away the most effective
treatment there is. People in this category have about an 80-percent chance of not needing
further oral medication after completing a six-month course of Accutane. The other 20 percent
who take Accutane may have a recurrence of severe acne, in which case a second treatment can
be effective. Accutane is rarely used more than twice.
Accutane should be prescribed by a board-certified dermatologist and monitored monthly or
more often, and patients using it must thoroughly understand the side effects of this drug.
Prevention of pregnancy with two methods of birth control (for example, oral contraceptives
plus condoms) is a must, since the drug can cause severe birth defects if taken during
pregnancy.
Your dermatologist will require an office visit and a careful history and examination. You'll
also need two negative pregnancy tests before starting Accutane, a screen of blood-fat levels
(cholesterol and triglycerides), and a liver-function test.
"Is Accutane safe? I got scared to death after I read all the information on it."
Accutane has been used to help tens of thousands of people who suffer from severe acne. It's a
very safe drug—when used correctly and responsibly.
Just about everyone who takes it will feel somewhat dehydrated and have dry lips, so your
dermatologist will change your skin care (I often have my patients wash and moisturize with
Cetaphil products for the duration of the treatment). You'll also need to use lip balm
approximately once an hour to prevent them from cracking.
A monthly blood test will be done to check for pregnancy (see above). The test will include a
liver test (rarely a problem unless excessive alcohol is being used) and a test for blood-fat
levels, cholesterol, and triglycerides (these go up on Accutane but come back down after you've
stopped taking it). I also tell my patients to report unusually severe headaches or headaches that
last overnight—if you get one, don't take any more Accutane and give your doctor a call. Also,
let your doctor know if you start to feel blue or depressed while you're on it (another rare side
effect).
Why Accutane Is So Strictly Regulated
Accutane is a close relative of vitamin A. Too much vitamin A can cause birth defects, which
is why your doctor will ask you to not take extra amounts during pregnancy. Because of this
risk, your dermatologist will require you to use two methods of birth control and to take
monthly pregnancy tests. But it's up to you to use that birth control and make responsible
decisions regarding your sexual activity. If you've had unprotected sex while on Accutane, it's
important to call your doctor and consider stopping the medication temporarily. Fortunately,
Accutane is cleared out of your system fairly quickly—even so, I ask my patients who have
completed a course of Accutane to wait one or two months before they try to get pregnant.
Microdermabrasion
"Will microdermabrasion help my acne?"
It depends on what type you have. If you have grade-I or grade-II acne, it should respond well
after a series of treatments followed by maintenance. But other types of acne, particularly those
that are inflamed, very pustular, or cystic, will get worse.
Microdermabrasion isn't advised without first seeing a dermatologist, as you may need to
have the inflammation brought under control first. Many dermatologists now offer
microdermabrasion in their offices so that you can be assured of getting treatment geared to
your particular skin problems. In addition, experienced aestheticians may also offer this
treatment.
Facials
"Are facials helpful for acne?"
Facials performed by an experienced aesthetician may be helpful if you have mild to
moderate acne. The aesthetician will normally steam your face and gently—that's the key
word—extract some of the plugs in your pores. If you bruise afterwards, find another
aesthetician.
Facials can be done monthly and are usually compatible with treatments prescribed by your
dermatologist. Just be sure to let the aesthetician know what medications and skin-care products
you're using. If you have moderate to severe acne, find an aesthetician who works in an office
with a dermatologist before undertaking any facials or microdermabrasion—if these aren't done
correctly, they may make your acne worse.
SUMMARY OF ACNE: WHAT TO DO
For mild acne, you can try over-the-counter medications, which may be enough to help you.
For moderate acne, see your primary-care physician or dermatologist, who can customize your
treatment, based on your skin type, age, and hormone activity.
If you have severe acne, see a dermatologist, who can help you prevent scarring and clear up
your skin.