TEEN HEALTH:
Acne - Takes Patience & Persistence

by Dr. Ann L. Engelland

Mark P,17, had had acne since he was 14. He knows that his Tigers' football helmet strap and sweat will only make his face look worse.

Rachel R has had acne since age 8. She also has very oily skin, has had irregular periods since age 10 and has an unusual amount of body hair. Over the past three years she has become obese. “What is going on?,” she wonders.

Gary S, 18, has become increasingly depressed and withdrawn over the past year in no small part because of his unmanageable acne. He wants to try Accutane but his parents have heard that it can cause severe depression.

Vicki G, 16, has been using over the counter and prescription medications for years. Her friend at the Boston Post Road CVS told her about birth control pills for acne. She doesn’t know where to go for help.

(September 15, 2004) These anecdotes illustrate some of the complex concerns of kids struggling with acne. For teenagers, the quality of life issues are enormous and alone are a reason to treat acne aggressively. Fortunately, there are multiple ways to approach the problem, and with patience nearly everyone can expect to have significant improvement in his or her condition.

How common is it?

Probably everyone is hit with acne at some point. By the age of 16, 83% of girls and 95% of boys have acne.

What do we know about the impact of acne on lifestyle?

Recent research suggests bad skin may have a greater impact on anxiety and depression than even severe, life-threatening medical problems. Since most kids have acne on the face, it's right out there, front and center. Parents and health care providers, who may have grown up thinking it's a rite of passage, need to look again.

What causes acne?

It is helpful to know a few basic facts about acne. There is no one cause, and therefore, no one treatment. Prevalence varies by race, hormone levels and family history.

Acne is a disorder of the pilosebaceous unit (psu) in the skin. Each “psu” is comprised of a follicle, a hair, a sebaceous gland (producing sebum or skin oil), and a sebaceous duct. There are several different factors which may aggravate the psu and cause it to become a pimple. These include:

  • Hyperkeratinization: keratin is the dry uppermost layer of skin that can become too thick to allow release of oils, thereby plugging the pores and producing a comedone - a blackhead or whitehead.

  • Inflammation: when tissue become irritated, red, sore, and swollen.

  • Androgen: though naturally occurring in both females and males, increased levels or increased sensitivity to androgen can lead to acne.

  • Overactivation of the sebaceous glands, producing excess amounts of oil.

  • Bacteria: Overgrowth of bacteria, particularly one called Propionibacterium acnes, plays a role. That's why antibiotics are often used.

  • Immune response: when the psu is filled with keratin and sebum and sometimes spills over into adjoining tissues, there is a natural immune reaction which may be quite potent and cause severe inflammation and even the development of lumps and nodules as the body attempts to fight off the offending substances.
Can it be anything else?

In medicine we say “never say never” and acne is no exception. There are other conditions that may masquerade as acne - but most clinicians know acne when they see it based on the company it keeps. However, what may be overlooked is an underlying hormone or nutritional imbalance that predisposes to acne. Treating the zits without addressing the hormones won't solve the whole problem in these cases.

Rachel, quoted above, needs to be evaluated by an expert in adolescent medicine or endocrinology for a condition that causes her to produce excess androgen. A common condition, previously known as "polycystic ovary syndrome" needs to be ruled out. These girls are at risk for chronic menstrual disorders, obesity, problems of lipid metabolism and eventually infertility. Early diagnosis and correct treatment can spare a girl years of disfiguring skin, weight management concerns and fertility issues.

Myths about acne?

Myths persist, as they do for any disorder that is chronic and ubiquitous and in many cases self-limited. There is no scientific evidence to suggest that stress, diet, hygiene, or cosmetics contribute to acne. Even so, a 2001 survey of medical students found many of these educated folks still believing that their zits were caused by stress and cosmetics.

WHAT CAN BE DONE?

It’s not surprising that clinicians believe the biggest cause of failed treatment is failure to stick with the plan. The frustration felt by Rachel, Gary and Vicki is very common. Kids need to know that many treatments take several weeks before they will show their effects. Forewarned can be forearmed.

Treatments are either topical (creams, lotions, gels) or systemic (taken by mouth). Then there are a few non-medication based treatments.

Topical Treatments: Most treatments for acne are effective because they treat one of the three major causes of acne, namely hyperkeratinization, inflammation, and bacterial infection. Let’s look at the major categories:

  • Benzoyl peroxide: the first-line product, has antibacterial and anti-sebum (oil) effects. Common brands are OxyPads, Clear by Design, Neutrogena. Any prescription with “Benz” in the name probably contains Benzoyl peroxide. The popular Proactiv system available from infomercials and on the Internet has Benzoyl peroxide (in a mere 2.5% concentration) as its basis.

  • Salicylic acid: works by helping to shed the keratinocytes which plug pores. Brands include Clearisil, Stri-dex, Oxy Clean medicated soap.

  • Resorcinol: helps exfoliate by removing plugging oils and keratinocytes. It is available in Clearisil Adult Care.

  • Retinoids: this family of medications including tretinoin (RetinA), adapalene (Differin) and tazarotene (Tazorac), works by preventing the obstruction of the psu and by reducing the inflammation in the skin.

Most of these products can cause drying—sometimes a desirable side effect for people with very oily skin. But occasionally that effect is excessive. Sunscreen should always be used with them. Some of the products are sold as creams instead of gels or lotions and are less drying.

Topical antibiotics: these are often used in conjunction with the benzoyl peroxides or the retinoids. The most commonly prescribed ones are clindamycin (Benzaclin) and erythromycin.


Systemic Treatments (pills): The three main systemic treatments are the oral antibiotics, Isotretinoin (Accutane), and hormonal therapy.

  • Oral antibiotics: For severe inflammatory acne and acne that is spread to hard-to-reach places (like the back), oral antibiotics in combination with topical treatments can be much more effective. The most common ones are erythromycin, tetracycline, doxycycline , and minocycline. Each of these has potential side effects (sun sensitivity, stomach upset, yeast infection in girls) and must be taken for 8 to 12 weeks for best results.

  • Accutane: Too bad Isotretinoin (well known brand name-Accutane) is the most controversial treatment for acne, because it is surely the only thing we have that approaches a cure. Accutane is a relative of Vitamin A and treats acne by affecting all the causes—inflammation, bacterial overgrowth, excess sebume and hyperkeratinization. It is associated with two major problems—possible depression and severe birth defects. All women on Accutane must use two methods of birth control and are monitored monthly for pregnancy—even if they are not sexually active. The link between depression and Accutane is controversial and needs to be considered carefully and individually.

  • Hormones: Hormone pills, otherwise known as oral contraceptive or birth control pills, work to treat acne by influencing the androgen hormones which are involved in sebum (oil) production. Currently only two brands of pills are FDA approved for treatment of acne and they are heavily marketed in teen magazines and media. For many teens with hormonal imbalance, need for contraception, or severe menstrual cramps the added benefit of improved skin is a welcome side effect.

Other treatments: Although somewhat controversial in this country and especially so among dermatologists, “comedo extraction” or professional black-head picking is thought by many to be a major factor in improving skin. Other treatments that are becoming more popular include chemical peels, injection of severe nodules with steroids (done by dermatologists) and light therapy.

In mild to moderate cases of acne, most clinicians will start with one or maybe two methods of treatment and see what the response is over several weeks before adding to or changing the regimen. There is no small amount of art applied to the science of treating this annoying, persistent and important problem. But it is helpful to remember the following keys to successful management of acne:

  • Patience
  • A good rapport with a clinician
  • Flexibility in the treatment regimen
  • Persistence and followup
  • Support and education from the clinician
  • Patience
  • Belief that it will get better
  • Patience

Dr. Engelland has a practice in Mamaroneck devoted to Adolescent Primary Care. She can be reached at 698-5544.

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