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
unusual amount of body hair. Over the past three years
she has become obese. “What is going on?,” she
Gary S, 18, has become increasingly depressed and withdrawn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
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
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
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
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.
- Hyperkeratinization: keratin is the dry uppermost
layer of skin that can become too thick to allow release
plugging the pores and producing a comedone - a blackhead
- Inflammation: when tissue become irritated,
red, sore, and swollen.
- Androgen: though naturally occurring
in both females and males, increased levels or increased
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
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
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
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
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.
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,
Clean medicated soap.
- Resorcinol: helps exfoliate by removing
plugging oils and keratinocytes. It is available in Clearisil
- Retinoids: this family of medications
including tretinoin (RetinA), adapalene (Differin) and
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
and hormonal therapy.
- Oral antibiotics: For severe inflammatory acne and
acne that is spread to hard-to-reach places (like the
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.
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
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:
A good rapport with a clinician
Flexibility in the treatment regimen
Persistence and followup
Support and education from the clinician
Belief that it will get better
Dr. Engelland has a practice in Mamaroneck devoted
to Adolescent Primary Care. She can be reached at
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