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.