Causes and Treatments of Acne

Acne makes up more than 10% of Greenville Dermatology’s patient population so it is a very common affliction of not only teens, but adults as well. I know from personal experience, having acne myself as a teen and missing my senior prom because of it, that it can significantly affect your self-image. Compared to when I was a teen, there are so many more options for treating acne these days. Acne can start as early as 8 years old, although most people get it later in their teens.
CAUSE: Contrary to what some believe, acne is not caused by eating chocolate cake, pizza, coke or junk foods. These beliefs arise I think since most teens eat these types of foods and also have acne. Only one food product, milk, has actually been shown to make acne worse and it is believed that it is because we inject cows with hormones to produce more milk and these hormones get passed into our children when they drink the milk. Getting organic milk, which is supposed to be hormone-free, may help. So, the rapid change in hormones during puberty causes the oil glands to enlarge more quickly than the skin can handle it. The skin cells start to stick together and clog up the pores creating a situation where the acne bacteria start to grow more effectively causing acne. Hormone-rich milk just makes this worse. Acne is also not caused by a dirty face—you cannot “clean” acne away by scrubbing several times a day. In fact, this may actually make acne worse by upsetting the natural bacterial flora on the face enabling the “bad” acne bacteria to grow while the good bacteria are scrubbed away.
TREATMENT: At first, over the counter medications such as benzoyl peroxide or salicylic acid cleansers and gels, or combination packages such as “Proactiv”, etc., can be very effective and for a lucky few, is all that is ever required. Once red bumps (called ‘papules’) and white heads (called ‘pustules’) begin to form, prescription medication is often required and signals the time when an appointment with your dermatologist should be made. Most dermatologists, including myself, will treat acne with a combination of prescription medications. Unfortunately, we do not have any simple, single medication treatments for acne that are relatively side effect free once acne reaches this stage. I usually will treat the papules and pustules with an oral antibiotic. There are many to choose from and currently, there are at least two once-a-day medications, Solodyn and Doryx, that make taking an antibiotic as easy as possible. Oral antibiotics like these usually take at least a month of use before any improvement can be seen. Even at one month, there will still be some residual papules and pustules remaining that will improve with continued use of the medication. I like to see my patients back at this time to ensure that the medication is working. If not, then a switch to another antibiotic is sometimes needed. Unfortunately, we cannot perform a lab test such as a culture or blood test to see what antibiotic a patient will respond to. This makes treating acne somewhat a “trial and error” activity. In addition to the oral antibiotic, I also prescribe a benzoyl peroxide cleanser. This helps to keep the acne bacteria from becoming resistant to the antibiotic we are using, and treats the surface acne. Some dermatologists prefer to prescribe benzoyl peroxide as a gel or cream. I see nothing wrong with this and it is a matter of personal preference. Benzoyl peroxide can bleach the color out of clothing and when using it as a gel or cream, this seems to happen more easily which is why I prefer to prescribe it as a cleanser. Finally, I prescribe a topical “retinoid” product such as Retin-A, Differin, or Tazorac. The American Academy of Dermatology (AAD) suggests using a retinoid on all acne patients as it helps the skin to “turn over” more rapidly, preventing the skin cells from sticking together and clogging up the pores. Therefore, these retinoids prevent acne. Unfortunately, retinoids also are irritating and drying to the skin and take the longest (about 3 months) to see results. Most teens (and adults) tend to quit using these medications long before that because of the lack of quick results and the irritation they sometimes cause.
So, in my clinic, a patient with acne will be treated with an oral antibiotic, a benzoyl peroxide cleanser, and a retinoid which they are instructed to start all at once. The oral antibiotic should start working in a couple weeks to a month, with continued improvement as time goes on. Ideally, if the patient has been using the retinoid and cleanser regularly, they should be able to taper off the antibiotic after two to three months. However, acne changes, getting worse sometimes and better other times, and most of us get lazy with our medication regimens and often times patients are on antibiotics constantly or off and on for many months to years. So, it is VERY important that the patient use the medication as prescribed. Way too often, a patient of mine will come back for their follow up and say that they only took the pills since that was the only thing that seemed to be working. Unfortunately, without the benzoyl peroxide or retinoid, they will always have to take the pill to keep their acne under control.
ACCUTANE: Accutane, or “isotretinoin” is a powerful and special acne medication that has been available to patients for almost 30 years. It acts like high doses of vitamin A in our bodies and so is not an antibiotic as some people believe. In the past, before Accutane, dermatologists would sometimes give acne patients vitamin A injections for their acne. This worked well, but caused some liver problems as well as very dry flaky skin as high doses of vitamin A can be toxic. Accutane is a way to get the effects of high doses of vitamin A, clearing up acne, but minimizing the side effects. Even so, Accutane has a lot of side effects, the most prominent being that it can cause birth defects if a female who taking it gets pregnant. These effects last only a month after completing Accutane, but require that females on Accutane practice strict birth control measures. In addition, it has been known to cause depression in some individuals. We prescribe Accutane for patients who do not respond to multiple antibiotics as described above, or patients who have more severe, deeper acne that is causing scarring. I personally have treated close to if not over 1000 patients with Accutane and have not had any serious problems occur and in fact my own son has successfully been treated with it. Despite its side effects and risks, Accutane works extremely well and is taken usually for only 20 weeks. I cannot recall a case of acne that Accutane did not clear. However, I have seen some patients require a second and rarely, a third course of Accutane, or patients who have had to be on Accutane for 24 or 28 weeks.
I hope that one can appreciate that acne can be a difficult skin affliction to treat and takes both the dermatologist and patient working together in an honest trusting relationship to achieve success. We do our best here at Greenville Dermatology to accomplish this. Please come and see us for your acne. Call 864-242-5872 to make an appointment.