Acne 101

If you still have acne as an adult, you have to wonder, will it go away by the time I develop wrinkles? Will it ever go away? I’m 23 and I’ve been wondering since 13, when I was first inducted into this not-so-exclusive society. I have tried countless products to clear up my skin, from over-the-counter (OTC) gels and lotions to prescription oral and topical treatments. I feel I’ve tried it all, short of rubbing a potato on my face... which some Web sites actually recommend.

It’s comforting to know I’m not alone in the matter: 85 percent of teenagers (ages 12-24) have active facial acne and 20 percent of adults do, too. Still, tired of the nicknames, “Pizza Face” and my personal favorite, “Road Map” (because you can connect the dots like a...you get the idea), I’m on the quest for permanent riddance of acne. But how?

The first step to eliminating acne is to understand how it forms. Inside the hair follicle, an oily substance called sebum mixes with the hair and keratinocytes, which are cells that line the follicle. Together they form a plug that prevents the sebum from emptying onto the skin’s surface through the pore. The mixture of oil and cells allows for bacteria to grow, which causes inflammation. Adelaide A. Hebert, MD, professor of dermatology at The University of Texas Medical School at Houston, explains what causes this sticky situation:

“We have a whole list of things that cause acne. One is hormonal influences, the things that send us through puberty. That’s why we don’t often see acne before the teenage years. Bacteria are another issue; Propionibacterium acnes are responsible for some acne. Then you have free fatty acids, bacteria breakdown, the oil and inflammation that play a role in acne.”

It’s possible that the modern diet may also play a role in the formation of acne, Hebert explains. Investigators who conducted research on an island where no fast food existed noted that its inhabitants had no acne at all. Hebert says that, of course, there may have been other factors. “I’m not going to say that fast food is 100 percent correlated with acne, but today, there are more hormones in the milk that our children drink, more antibiotics and other chemicals in products that children consume,” she says, “so, it’s a different era than perhaps 50 years ago, and it may have some influence.”

As you may have noticed, not everyone acquires acne. Is life just that unfair? Several factors influence one’s tendency for break-outs. Acne can be a genetic problem. Those with sensitive oil glands are prone to acne as well. Also, hormone levels are highly individualized. People of different ethnicities experience different types of acne.

“Depending on your coloration and ethnicity, your acne can cause a variety of problems. If patients pick their pimples, sometimes they leave a brown mark, which is more long lasting and troublesome to the patient than the original pimple was. And what we see a lot in our African-American and Asian patients is that the brown spots actually bother them more than the acne ever did.”

The pill and acne

Because hormonal influences are such a significant cause of acne, dermatologists (and gynecologists) often prescribe birth control pills for some female patients to fight acne.

Hebert agrees they are proven treatments. “If you look at the three major studies on birth control pills, there is about a 64 percent reduction in acne lesions with the birth control pill alone. But while a 64 percent reduction with no other treatment is good, it’s not enough for a dermatologist. We want to see our patients improve much better than that, so we generally combine therapies. Unfortunately for men, we don’t have any similar hormone treatment.”

Not every female is a good candidate for birth control pills. In that case, a prescription originally intended for treating hypertension also is used for treating acne and other endocrine disorders.

“For older women with acne, we will consider using a product called spirinalactone, if they’re in the age group where they’re not really good candidates for birth control pills,” Hebert says. “A target receptor in the skin is blocked, so you don’t get the response to the hormones that would drive the acne.”

Don’t!

While I have never found a cure for my acne, I know what not to do. Certain behaviors and environmental factors can cause flare-ups.

Dust
Like dust. Hebert says that a dirty environment does not help the skin. Just the irritation can be troublesome. It’s difficult to be dust-free, but the Asthma and Allergy Foundation of America (AAFA) has a few recommendations: wash your sheets weekly in hot water, try dust-proof mattress covers and pillowcases, and avoid wall-to-wall carpeting, wool blankets, and down-filled blankets and pillows in the bedroom.

Stress
Stress doesn’t cause acne, but it can add to the problem-- as if you didn’t have enough to stress about! Often, a dermatologist can help you find an acne regimen to work around the stress.

Sunlight
Sunlight may seem like a quick fix for acne, but the positive results are only temporary. After the seemingly therapeutic effects of a day sunbathing, the skin seems more agitated. Additional risks with too much sun are photodamage, photoaging and of course, skin cancers.

Cosmetics
Cosmetics can be acne irritants. Fortunately, there are foundations and cover-ups available with acne-fighting ingredients. Look for labels that read “non-comedogenic” or “non-occlusive.” Products bearing such labels don’t block pores. Also, be sure they’re oil-free. Stay away from thick makeup. Thick powders and foundations just accentuate what you’re trying to cover up.

Pimple popping
No matter how tempting, DON’T. Some find it entertaining, as witnessed by the number of YouTube videos featuring teenage pimple-poppers hard at work. And, although it seems as if those pimples are begging to be released, taunting you each time you look in the mirror, leave them alone.

“If you just leave an acne pimple alone,” Hebert advises, “in 10-14 days it goes away. But, if you pick it and it ruptures, you create inflammation and allow more bacteria to enter. So, just leave it alone or have your doctor manage it.”

No hands
You should keep your hands away from your face in general. Hebert explains that putting pressure on your face, whether  resting your head in your hand or pressing a cell phone to your face, can spur the development of acne. You don’t want to close off the follicles, especially with dirty hands.

No quick fix

One trip down the facial cleanser aisle at your local pharmacy should be enough to confuse you. How do you know if your active ingredient should be salicylic acid or benzoyl peroxide? Should you buy 2.5 percent benzoyl peroxide? Five percent? Ten? And, which form--cream, lotion, gel, foam, wipes, a bar of soap?

Yes, plenty of options exist and it’s best to talk them over with your dermatologist. He or she may recommend some of those OTC products alone or in addition to a prescription.

“Many topical medications are very effective,” Hebert says. “Combinations of benzoyl peroxide and antibiotics, combinations of retinoids and antibiotics, topical retinoids alone or topical benzoyl peroxides, either in creams, lotions, washes—they’re very effective. One of the key things to understand is some of the OTC preparations are fairly expensive and widely advertised. Acne is a disease that involves the entire follicle, not just the surface of the skin. The drugstore products only treat the skin’s surface and are very weak, 2.5 percent benzoyl peroxide.” Hebert says that if your acne is very mild, these OTC products can help. With significant acne, however, they don’t penetrate. Dermatologists use combinations of treatments “to impact these causative, underlying factors that lead to acne.”

Cooking up a cure

Household items have been touted as good topical treatments. Some swear by these items, and here’s what Hebert has to say about them:

• Fast for three days, drink only water: Wish it worked because it would be cost- effective! A good balanced diet is more important.
• Crushed aspirin and water as a scrub: The equivalent to a mild chemical peel, but there are better strategies. Not recommended.
• Honey: It’s rich with sugars, which creates an environment in which bacteria can’t survive.
• Toothpaste: Not dermatologist recommended, but it might help.
• Potato: The high carbohydrate can be a bacteria killer, but not something Hebert would prescribe.

Accutane: accuPAIN, accuGAIN

When all else fails, there is a treatment option that dermatologists often refer to as a miracle drug. The oral retinoid, under the brand name Accutane, clears the acne in about 90 percent of its users, most without recurrence. The medication works to shrink the oil glands, which come off the follicle. Accutane has myriad possible side effects and patients must be monitored closely. Monthly blood tests, and for female patients, pregnancy tests are mandatory by federal regulation for prescription refills. Accutane can cause birth defects if a female conceives while taking the medication and for one month after. Female patients must take a monthly online test to ensure they are using at least two forms of birth control.

After exhausting other options, my dermatologist recommended I try a cycle of Accutane treatment. A quick Google search for “Accutane side effects” yields over 573,000 results and they read like one of those happy-people-playing-frisbee commercials (until you key in on the long list of potential complications that ends with “possible death.”)

For Accutane, common side effects include dry or fragile skin, dry or cracked lips, dry mouth and nose, itching, joint pain and nosebleeds. Other possible side effects include decreased night vision, depression, a delay in wound healing, fatigue, nausea, thinning hair, sunburn-sensitive skin, rashes and skin infections. Needless to say, I was nervous about this intense medication. Luckily, Hebert put me at ease; she had many positive things to say about the drug.

“In four to six months of therapy, patients can be rendered relatively acne-free for the rest of their lives. Few medicines in my treatment armamentarium can be ‘life-changing’ in four months.”

Now in my fourth month of Accutane treatment, I already have experienced the most common side effect: sandpaper-dry lips—a small, but painful price to pay. (I carry lip balm and reapply constantly.)

The monthly blood tests are uncomfortable, but essential. My side effects have been minimal, luckily. Soon after I began treatment, I had an initial breakout lasting nearly three months. Everything was surfacing and my face had never looked so bad. I persevered and now all of my problem spots are clear. I wash my face twice daily with water only. I also moisturize constantly to ensure that the splotchy redness will fade with the completion of the treatment.

A web-based community called Acne.org is a great source of tips and information for Accutane users. The Web site offers a community forum as well as the option for users to create blogs. Reading up on users’ Accutane logs helped me see that everything I was going through, such as the initial breakout, was common. The support other users offer makes the Accutane experience easier. However, it is no replacement for physician support and advice.

Don’t give up

One big mistake acne patients make is to give up too soon on their newly prescribed acne treatments. Hebert says people will pick up their prescription, try it out, disagree with it and cease use. They won’t even contact the dermatologist to say they’re having a problem. If problems occur, alerting the dermatologist can enable her to prescribe a different medication-- one that agrees with your body.

Hebert observes, “Ask your dermatologist and follow the guidelines that they give you. The greatest key to success is getting to a medical professional who’s well-versed in acne, because the improvements we’re making all the time are an enormous benefit to the patients we care for.”

If there’s anything that I have learned about acne, it’s what works for one person, won’t necessarily work for another. (There's a reason that drugstore aisle is so long.). Finding what works for you is the most difficult step in eliminating acne. But once you do, it is so rewarding—whether it’s your dermatologist’s prescription, your pharmacy selection or a potato from your kitchen.

 

 

Last Updated: 3-04-2009

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