Dr. Sharon Orrange
Primary Care Physician
Dr Orrange received her BA in Biology at the University of California San Diego and a Masters Degree in Health Sciences at the Johns Hopkins University School of Public Health She received her MD from the USC Keck School of…
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LOCATION: Santa Monica, CA, USA
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  • Assistant Professor of Clinical Medicine, Division of Geriatric, Hospital and General Internal Medicine, Keck School of Medicine, University of Southern California
YEARS IN PRACTICE: 11
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Eliminating Acne as a Rite of Passage
11
Posted in Acne by Dr. Sharon Orrange on Mar 08, 2009

Acne is the most common complaint I hear from my teenage patients. Most of us have been through breakouts and still deal with them occasionally. The psychological effects of acne cannot be overemphasized and several studies on patients with acne have found a significant improvement in self esteem with treatment. I think it's helpful to deal with it openly and aggressively. A stepwise plan for acne is what I design for my patients as there is comfort in knowing there is always another option.


Why does it happen? It doesn't have anything to do with being dirty, which is what my patients believe. FOUR FACTORS contribute to acne and blackheads: Retention hyperkeratosis (fancy term but think of it as a plug that forms in the pores), increased sebum production (oily substance produced by sebaceous glands), propionibacterium (a bacteria) within the follicle, and inflammation.   


 


What makes it worse? Stress, mechanical trauma (so that could be touching or picking at it), humidity and heavy sweating, oily or greasy cosmetics, and diet. The issue of diet is controversial and most studies show there is no role. One large study, however, did show that drinking milk in high school contributed to acne and the reason that may be the case is the naturally occurring hormonal contents of milk.


 


What kind of acne do you have?  Acne affects those areas of the body that have the greatest number of sebaceous glands, including the face, neck, chest, upper back, and upper arms. The typical lesions of acne are blackheads (comedones), whiteheads, and inflammatory lesions (red, sore raised acne). Scarring and hyperpigmentation can occur.


 


What can you do to treat it?


This will depend on what kind of acne you have and here is a structured way to approach treatment. Be persistent and aggressive with your doctor to move to the next stage if you arent seeing results after a few months.


 


IF YOU HAVE


Mainly blackheads with an occasional small inflamed papule or pustule and no scarring present:


1) Start with a topical retinoid. This would be something like tazarotene gel, adapalene gel (Differin) or tretinoin gel.


2) IF NO RESPONSE: Add benzoyl peroxide, azelaic acid, or salicylic acid which are NOT topical retinoids but may also work for blackheads. Consider also a topical antibiotic at this point like topical clindamycin or erythromycin. There are combinations of these for example clindamycin/benzoyl peroxide which is nice...one cream or gel with two medications.


 


IF YOU HAVE


Blackheads and more numerous papules and pustules (mainly on your face) with mild scarring


1) Start with a topical retinoid plus benzoyl peroxide, topical antibiotic, or azelaic acid.


2) IF NO RESPONSE: start with an oral antibiotic (minocycline, doxycycline or tetracycline).


 


IF YOU HAVE


Numerous blackheads, papules and pustules, spreading to the back, chest and shoulders, with moderate scarring


1) Start with an oral antibiotic PLUS topical retinoid, benzoyl peroxide, or azelaic acid.


2) An alternative is to start with a topical retinoid plus benzoyl peroxide plus a topical antibiotic.


3) IF NO RESPONSE after 3 months: Add an oral contraceptive or antiandrogen (in women) like Spironolactone. The oral contraceptives that work best have low androgen activity like ortho tri-cyclen and Yasmin.


4) IF NO RESPONSE to # 3 you can add an oral isotretinoin (accutane)


 


IF YOU HAVE


Numerous large cysts on the face, neck and back and upper trunk and severe scarring.


1) ORAL antibiotics plus topical retinoid and benzoyl peroxide. Also in women consider adding oral contraceptive or anti-androgen therapy (Spironolactone)


2) IF no response add an oral isotretinoin (accutane).


 


OTHER EXPERIMENTAL MORE EXPENSIVE TREATMENTS:


1) Blue light therapy: ClearLight is approved by the US FDA for treatment of moderate inflammatory acne. In some small studies patients with mild to moderate acne treated for up to five weeks had a 64 percent reduction in acne lesions. ClearLight is expensive with eight treatments costing you about $800 to $1600


2) Laser therapy - We aren't sure if this is effective but the use of laser (pulsed dye laser or PDL) for acne is an option. There are conflicting studies with one showing results and the other no difference so it is hard for me to recommend for the cost.


3) Heat - The FDA has approved a device, ThermaClear, that treats acne with a pulse of heat. More studies are needed but this does look promising.


Acne is frustrating, but there are options. Hang in there, and let us know your experience.


Dr O.


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Displaying comments 11-1 of 11
11
Acne blue light therapy is indeed a good solution. This therapy hits the root of acne and eliminates the acne-causing bacteria. Apart from being natural and non-invasive, this therapy is also drug free. And it also claims to be safe for people of all ages. So its worth trying!!

You can find some interesting information at http://www.acneinreview.com/.
By JessicaAlabama  Jul 21, 2009
10
I still get a occasional breakout even now at 30. Its never severe and I find that a little rubbing alcohol will usually help dry it up in short time (though it can dry your skin out pretty bad if you use it for too long).
By RideTheWind01  May 06, 2009
9
I am 46 years old and I suffer from acne and rosacea. It is a horrible thing to suffer at my age and it makes me feel really ugly. i have had lots of different treatments from my doctor and i find that the more I worry the worse it gets. But, it is so difficult not to worry. It stops me going out as I dare not face people in case they say anything hurtful. My doctor has given me yet another topical treatment and if that does not work she is going to send me to an acne clinic at my local hospital. Here's hoping!!!!!!!!!!!!
By fedupoflife  Mar 14, 2009
8
To Lin3296 (poster #6)
You may actually be suffering from Rosacea instead of simple acne. The treatment is slightly different. See your doctor to clarify. Best of luck!
By pianogirl  Mar 13, 2009
7
Thank you for this interesting and informative post, which I rewad with interest.
We live in Scotland and our 15 year old grandson has persistent acne problems. Over the past year has had several treatments with oral antibiotics plus topical retinoid and benzoyl peroxide. Most recently his doctor has prescribed a chemical peel and we are hoping that this will make a difference. He is a wonderful lad but like many teenagers is going through problems with self esteem particularly because he has bilateral collabomas and as a result is registered partially sighted.
Next year he is going to Zambia and Botswana to undertake voluntary work in the community, I hope the Acne problem has gone by them, but do you think the heat will be a help or a hindrance in this respect.
By AilP  Mar 13, 2009
6
I have just turned 54, and I still suffer with breakouts on my nose. I use benzoyl peroxide wash only on my nose & chin at night but still suffer from dryness on my nose & cheeks. What a viscious cycle! I was on antibiotics for years. Has anyone had any luck with over the counters such as Proactive?
By LIN3296  Mar 13, 2009
5
Excellent and informative posting. As a pediatrician, I treat hundreds of teens with acne, and there it is important to remember that each person's skin has unique factors and no one treatment regimen fits all, but I do experience the greatest degree of success with topical retinoids in the am and benzoyl peroxide in the pm. With good compliance, these two can eliminate the need for oral agents, except in extreme cystic forms. The problem often is impatience, because there won't be big changes for the first couple weeks, and in the meanwhile there is often a period of redness and peeling. To combat these I like the cleansers with the microbeads, and gentle non-comedogenic moisterizers, especially if they have a little salicylic acid in them.

No offense, but people who find improvement with diet changes, witch hazel, or milk of magnesia do not have the kind of debilitating acne I'm seeing!
By pianogirl  Mar 11, 2009
4
I've never had bad acne, until I developed a alight allergy to milk (in my 20's, after a severe accident). If I avoid milk and cheese and clarify my butter, I am fine. Yogurt and Sour cream are not problematic; it's the milk proteins I react to. When I eat something with dairy proteins in it, I'll usually get a couple large painful pimples. I've found that rubbing witch hazel on them WORKS BEAUTIFULLY! It shrinks them up and stops the pain almost immediately!
By drdim  Mar 09, 2009
3
As a licensed dietitian nutritionist, I can attest that diet has everything to do with acne. Getting to the root of the problem, whether from improper dietary choices or reactions to foods, once detected and modified, marked improvements occur. I have found a very safe, effective topical therapy that I recommend to my clients: milk of magnesia. Right before you shower, put it on as you would a facial wash. leave it on your face until you are about to finish showering, and wash off. You can do once in the AM and PM.
By nutrocon  Mar 09, 2009
2
When I started washing my face with only dove sensitive skin soaps twice a day (then use their facial moisturizing creams) and use differin and clindamcil I saw my acne improve. I get less zits now and when I do I usually get them in my hairline. When I first started getting acne I would say that it was still in the moderate ranges. Now it only bothers me every once in a while.
By Shamrock593  Mar 08, 2009
1
I have had one form or another of acne my entire life, I'm 33 now. I did everything under the sun, retin-A, antibiotics, oxy, you name it. At age 20 I did Accutane. I have mixed feelings still about this - it is very dangerous if you get pregnant while on it, and it may have long term side effects. I developed IBS after being on it, and don't know if it's related (studies now say there is a link.) In my opinion, some of us have a predisposition for acne, and no matter how you treat it, you'll probably have it with you most of your life, in some form or another. I've just learned to live with it, and I truly don't care anymore. I guess as you get older, you get bigger fish to fry, and if acne is my only health issue, I'm doing pretty well!!!
By momah  Mar 08, 2009
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