Stephanie Gardner, MD
Years ago, teenagers with acne were told to cut out the potato chips and given a tube of Clearasil. Today, we know far more about the reasons why some people develop acne and how it can most effectively be treated.
All cases of acne are not created equal, and neither are all acne treatments. Although all acne has its roots in the same process -- hormonal fluctuations that stimulate oil production -- not all acne is equally severe and not all cases of acne will respond to the same types of treatments.
Most cases of acne fit within one of three main categories, says Macrene Alexiades-Armenakas, MD, PhD, an assistant clinical professor of dermatology at Yale School of Medicine and a specialist in laser therapy for acne, who practices in New York City:
Comedonal acne. This is the kind of mild acne that involves blackheads and whiteheads. It forms because a component of skin oil called sebum, along with old skin cells, block the pores of the skin. Comedonal acne appears most often on the forehead, nose, and chin.
Inflammatory acne. This form of acne occurs when the area just under the “plug” (the blackhead or whitehead) becomes reddened and inflamed.
Cystic acne. The most severe form of acne, cystic acne develops as the result of an actual infection in the area of the outbreak. Cystic acne often runs in families. It’s often very painful and can result in disfiguring, permanent scarring.
The type of treatment that works for you will depend both on the kind of acne you have, and the additional factors that seem to trigger acne outbreaks.
Most cases of mild comedonal acne occur in teenagers and young adults, and these can usually be treated with traditional topical creams and gels. The most common of these are retinoids, like Retin-A, Differin, Renova, and Tazorac. They work by unblocking clogged pores.
Dermatologists will often combine a topical retinoid with an oral antibiotic, such as doxycycline, tetracycline, minocycline or erythromycin, which kills the bacteria that cause inflammation around the blocked pores.
"This type of treatment is focused on teenagers, who usually have a period of a year to four years when they’re breaking out because of changing hormone levels and increased oil production, and in some cases, genetics," says Amy Taub, MD, founder and medical director of Advanced Dermatology in Lincolnshire, Ill. Taub is also an assistant clinical professor of dermatology at Northwestern University’s Feinberg School of Medicine.
Each of the antibiotics has its own set of side effects -- doxycycline causes sun sensitivity, for example, and tetracycline can cause yellowing of teeth in children -- so dermatologists will work with their patients to help choose an antibiotic that works best for them.
Mild to moderate comedonal acne can often be aggravated by external triggers, like hair gels and makeup. "Some of these makeups and gels are so occlusive that when the person stops using them, the acne goes away," says Macrene Alexiades-Armenakas.
Many cases of inflammatory acne are "hormonal" in nature -- that is, they occur in teenage girls and women, and are aggravated by hormonal fluctuations like those that occur during the menstrual cycle. For these women, dermatologists often choose to prescribe either oral contraceptive pills or another medication called spironolactone.
There are now three oral contraceptives that are specifically approved by the FDA for the treatment of acne in women: Yaz, Estrostep, and Ortho Tri-Cyclen. Only pills that combine the female hormone estrogen with the synthetic version of the male hormone progesterone, progestin, can stabilize hormonal fluctuations in a way that can treat acne.
Oral contraceptives are a very effective treatment for acne in many women, but you have to give them time to work, says Bethanee Schlosser, MD, assistant professor and director of the women’s skin health program in the department of dermatology at Northwestern University’s Feinberg School of Medicine. "I ask patients to give the pills at least three months of use before judging their impact. That’s when the studies found a notable difference between placebos and oral contraceptives. Many patients went on to get further benefit at about six months out. This is not an overnight process."
Some women may prefer not to use oral contraceptives, or should not take them because they are smokers or otherwise at high risk. These women, as well as those who only get partial acne relief from contraceptives, are often prescribed a drug called spironolactone.
This medication is a diuretic -- that is, a "water pill" that causes frequent urination. It also blocks receptors for male hormones, which modulates the hormonal surges that can stimulate oil production, causing acne. Spironolactone isn’t approved by the FDA to treat acne and probably won’t be, Schlosser says, because as a generic drug there’s little motivation for a manufacturer to pay for the trials needed to go through the approval process. But most dermatologists agree that it works well as an acne treatment.
When acne does not respond to the standard one-two punch of topical retinoids and oral antibiotics, patients have two other choices: the drug isotretinoin, or Accutane, or one of several procedure-based treatments for acne that involve using laser or light treatment to reduce inflammation and kill acne-causing bacteria.
Accutane is an extremely powerful treatment for acne, often clearing up severe, scarring breakouts that had not responded to any other treatments within a matter of a few months.
But it also carries with it a host of risks and side effects, including inflammatory bowel disease, ulcerative colitis, liver damage, bony malformations, depression, and a virtual certainty of severe birth defects for the babies of women who take Accutane while pregnant.
In 2005, the FDA established an online tracking database, called iPledge, and now requires all patients to sign onto the database to continue receiving their prescriptions. The iPledge system requires women to submit two negative pregnancy tests before they can receive an initial prescription for isotretinoin. Women must also undergo a monthly pregnancy test before each refill. Men are also tracked because of Accutane’s depression risk.
"Anyone taking Accutane really needs to be counseled properly about all of these risks,” says Alexiades-Amenakas. The drug also impairs wound healing, so if a patient with severe cystic acne begins taking the drug, those cysts typically resolve with scars. "It gets rid of the underlying problem, but you’re almost guaranteed to heal with scars if you’re at that level of inflammation when you start taking Accutane."
The alternative to Accutane for people with severe, stubborn acne, is a treatment involving laser/light therapy. The two main options are:
Photodynamic therapy. "In this technique, we apply a prescription liquid to the patient’s face, chest, or back -- wherever the acne is -- and then apply a light or laser to activate the medicine," Taub says. "Not only does the medication kill bacteria -- which is less important, because bacteria will come back -- but over a few months, it also reduces the size and activity of the oil glands."
Isolaz. This treatment combines a vacuum with a broadband light. The vacuum cleanses pores and extracts excess oil, while the light helps destroy the acne-causing bacteria as well as reducing the activity of the oil gland.
"For people with the most severe acne who’ve failed other treatments, I usually count on Accutane or laser treatment," says Taub.
SOURCES:Macrene Alexiades-Armenakas, MD, PhD, assistant clinical professor of dermatology, Yale School of Medicine, New Haven, Conn.Amy Taub, MD, founder and medical director, Advanced Dermatology, Lincolnshire, Ill.; assistant clinical professor of dermatology, Northwestern University Feinberg School of Medicine, Evanston, Ill.Bethanee Schlosser, MD, assistant professor and director, women’s skin health program, department of dermatology, Northwestern University Feinberg School of Medicine, Evanston, Ill.
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