What is acne? What are the different types of acne?

Acne (acne vulgaris, common acne) is not just a problem for teenagers; it can affect people from ages 10 through 40. It is not unusual for women, in particular, to develop acne in their mid- to late-20s, even if they have not had breakouts in years (or ever). On the positive side, those few individuals who have acne into their 40s may well grow out of it. Acne can appear on the skin as any of the following:

• congested pores ("comedones"),



• whiteheads,



• blackheads,



• pimples ("zits"),



• pustules, or



• cysts (deep pimples, boils). The pus in pustules and cysts is sterile and does not actually contain infectious bacteria.

These blemishes occur wherever there are many oil (sebaceous) glands, mainly on the face, chest, and back.

You can do a lot to treat your acne using products available at a drugstore or cosmetic counter that do not require a prescription. However, for tougher cases of acne, you should consult a physician for treatment options.

What causes acne?

No one factor causes acne. Acne happens when oil (sebaceous) glands come to life around puberty, stimulated by male hormones from the adrenal glands of both boys and girls. Sebum (oil) is a natural substance which lubricates and protects the skin, and under certain circumstances, cells that are close to the surface block the openings of sebaceous glands and cause a buildup of oil underneath. This oil stimulates bacteria (which live on everyone's skin and generally cause no problems) to multiply and cause surrounding tissues to become inflamed.

Inflammation near the skin's surface produces a pustule; deeper inflammation results in a papule (pimple); deeper still and it's a cyst. If the oil breaks though to the surface, the result is a "whitehead." If the oil accumulates melanin pigment or becomes oxidized, the oil changes from white to black, and the result is a "blackhead." Blackheads are therefore not dirt, and do not reflect poor hygiene.

Here are some factors that don't usually cause acne, at least by themselves:

• Heredity: With the exception of very severe acne, most people do not have the problem exactly as their parents did. Almost everyone has some acne at some point in their life.



• Food: Parents often tell teens to avoid pizza, chocolate, greasy and fried foods, and junk food. While these foods may not be good for overall health, they don't cause acne or make it worse. Although some recent studies have implicated milk and dairy products in aggravating acne, these findings are far from established.



• Dirt: As mentioned above, "blackheads" are oxidized oil, not dirt. Sweat does not cause acne, therefore, it is not necessary to shower instantly after exercise for fear that sweat will clog pores. On the other hand, excessive washing can dry and irritate the skin.



• Stress: Some people get so upset by their pimples that they pick at them and make them last longer. Stress, however, does not play much of a direct role in causing acne.



• Hormones: Some women break out cyclically, but most women (and men) don't. Some oral contraceptive pills may help relieve acne, but unless a woman has abnormal menstrual periods and excessive hair growth, it's unlikely that hormones play much of a role in causing acne. Pregnancy has a variable effect on acne; some women report that they clear up completely, and others get worse, while many others see no overall change.



• Cosmetics: Most cosmetic and skin-care products are not pore-clogging ("comedogenic"). Of the many available brands, those which are listed as "water-based" or "oil-free" are generally a better choice.

In occasional patients, the following may be contributing factors:

• Pressure: In some patients, pressure from helmets, chinstraps, collars, suspenders, and the like can aggravate acne.



• Drugs: Some medications may cause or worsen acne, such as those containing iodides, bromides, or oral or injected steroids (either the medically prescribed prednisone or the steroids that bodybuilders or athletes take). Other drugs that can cause or aggravate acne are anticonvulsant medications and lithium, which is used to treat bipolar disorder. Most cases of acne, however, are not drug-related.



• Occupations: In some jobs, exposure to industrial products like cutting oils may produce acne.

What other skin conditions can mimic acne?

• Rosacea: This condition is characterized by pimples in the middle third of the face, along with redness, flushing, and superficial blood vessels. It generally affects people in their 30s and 40s and older. There is sometimes no "bright line" separating acne from rosacea; however, there are no blackheads or whiteheads in rosacea.



• Pseudofolliculitis: This is sometimes called "razor bumps" or "razor rash." When cut close to the skin, curly neck hairs bend under the skin and produce pimples. This is a mechanical problem, not a bacterial one, and treatment involves shaving less (growing a beard, laser hair removal.) Pseudofolliculitis can, of course, occur in patients who have acne too.



• Folliculitis: Pimples can occur on other parts of the body, such as the abdomen, buttocks, or legs. These represent not acne but inflamed follicles. If these don't go away on their own, doctors can prescribe oral or external antibiotics, generally not the same ones used for acne.



• Gram-negative folliculitis: Some patients who have been treated with oral antibiotics for long periods develop pustules filled with bacteria resistant to the antibiotics which have previously been used. Bacterial culture tests can identify these germs, leading the doctor to prescribe different antibiotics or other forms of treatment.

When should you start to treat acne?

Since everyone gets acne at some time, the right time to treat it is when it bothers you. This can be when severe acne flares suddenly, mild acne that just won't go away, or even when a single pimple decides to show up the week before your prom or wedding. The decision is yours.

What can you do about acne on your own?

Think back to the three basic causes of acne and you can understand why the focus of both home treatment and prescription therapy is to (1) unclog pores, (2) kill bacteria, and (3) minimize oil. But first a word about...

Lifestyle: Moderation and regularity are good things, but not everyone can sleep eight hours, eat three good meals, and drink eight glasses of water a day. You can, however, still control your acne even if your routine is frantic and unpredictable. Probably the most useful lifestyle changes you can make are to apply hot compresses to pustules and cysts, to get facials (see below), and never to pick or squeeze pimples. Playing with or popping pimples, no matter how careful and clean you are, nearly always makes bumps stay redder and bumpier longer. People often refer to redness as "scarring," but fortunately it usually isn't in the permanent sense. It's just a mark that takes months to fade if left entirely alone.

Open the pores

Cleansing and skin care: Despite what you read in popular style and fashion magazines, there is no magic product or regimen that is right for every person and situation.

• Mild cleansers: Washing once or twice a day with a mild cleansing bar or liquid (for example, Dove, Neutrogena, Basis, Purpose, and Cetaphil are all inexpensive and popular) will keep the skin clean and minimize sensitivity and irritation.



• Exfoliating cleansers and masques: A variety of mild scrubs, exfoliants, and masques can be used. These products contain either fine granules or salicylic acid in a concentration that makes it a very mild peeling agent. These products remove the outer layer of the skin and thus open pores. Products containing glycolic or alpha hydroxy acids are also gentle skin exfoliants.



• Retinol: Not to be confused with the prescription medication Retin-A, this derivative of vitamin A can help promote skin peeling.

Kill the bacteria

• Antibacterial cleansers: The most popular ingredient in over-the-counter antibacterial cleansers is benzoyl peroxide.



• Topical (external) applications: These products come in the form of gels, creams, and lotions, which are applied to the affected area. The active ingredients that kill surface bacteria include benzoyl peroxide, sulfur, and resorcinol. Some brands promoted on the Internet and cable TV (such as ProActiv) are more costly but not really any better than ones you can buy in the drugstore.

Benzoyl peroxide causes red and scaly allergic skin in a small number of people, which goes away as soon as you stop using the product. Keep in mind that benzoyl peroxide is a bleach, so do not let products containing benzoyl peroxide leave unsightly blotching on colored clothes, shirts, towels, and carpets.

Reduce the oil

You cannot stop your oil glands from producing oil (unless you mess with your hormones or metabolism in ways you shouldn't). Even isotretinoin (Accutane, see below) only slows down oil glands for a while; they come back to life later. What you can do is to get rid of oil on the surface of the skin and reduce the embarrassing shine.

• Use a gentle astringent/toner to wipe away oil. (There are many brands available in pharmacies, as well as from manufacturers of cosmetic lines.)



• Products containing glycolic acid or one of the other alpha hydroxy acids are also mildly helpful in clearing the skin by causing the superficial layer of the skin to peel (exfoliate).



• Masques containing sulfur and other ingredients draw out facial oil.



• Antibacterial pads containing benzoyl peroxide have the additional benefit of helping you wipe away oil.

What are other things you can do for acne?

• Cosmetics: Don't be afraid to hide blemishes with flesh-tinted coverups or even foundation, as long at it is water-based or oil-free (which makes them noncomedogenic). There are many quality products available.



• Facials: While not absolutely essential, steaming and "deep-cleaning" pores is useful, both alone and in addition to medical treatment, especially for people with "whiteheads" or "blackheads." Having these pores unclogged by a professional also reduces the temptation to do it yourself.



• Pore strips: Pharmacies now carry, under a variety of brand names, strips which you put on your nose, forehead, chin, etc., to "pull out" oil from your pores. These are, in effect, a do-it-yourself facial. They are inexpensive, safe, and work reasonably well if used properly.



• Toothpaste? One popular home remedy is to put toothpaste on zits. There is no medical basis for this. Ditto for vinegar.

What is a good basic skin regimen?

These are all good basic skin regimens that may help with the acne battle:

1. Cleanse twice daily with a 5% benzoyl peroxide wash. An alternative for those who are allergic to benzoyl peroxide is 2% salicylic acid.



2. Apply a gel or cream containing 5% benzoyl peroxide; an alternative is sulfur or resorcinol.



3. At night, apply a spot cream containing sulfur to the affected areas.



4. Use a light skin moisturizer and oil-free makeup.

What can the doctor do for acne?

If you haven't been able to control your acne adequately, you may want to consult a primary-care physician or dermatologist. Here are some of the things they can assist with:

• Topical (externally applied) antibiotics and antibacterials: These include erythromycin, clindamycin (Benzaclin, Duac), sulfacetamide (Klaron), and azelaic acid (Azelex).



• Retinoids: Retin-A (tretinoin) has been around for years, and preparations have become milder and gentler while still maintaining its effectiveness. Newer retinoids include adapalene (Differin) and tazarotene (Tazorac). These medications are especially helpful for unclogging pores. Side effects may include irritation and a mild increase in sensitivity to the sun. With proper sun protection, however, they can be used even during sunny periods. In December 2008 the U.S. FDA approved the combination medication known as combination preparation, known as Epiduo gel, which contains the retinoid adapalene along with the antibacterial cleanser benzoyl peroxide. This once-daily prescription treatment was approved for use in patients 12 years of age and older.



• Oral antibiotics: Most doctors start treatment with tetracycline or one of the related "cyclines," such as doxycycline and minocycline. Other oral antibiotics that are useful for treating acne are cefadroxil, amoxicillin, and the sulfa drugs.



• Problems with these drugs can include allergic reactions (especially sulfa), gastrointestinal upset, and increased sun sensitivity. Doxycycline, in particular, is generally safe but can sometime cause esophagitis (irritation of the esophagus, producing discomfort when swallowing) and an increased tendency to sunburn.



• Despite many people's concerns about using oral antibiotics for several months or longer, such use does not "weaken the immune system" and make them more susceptible to infections or unable to use other antibiotics when necessary.



• Recently published reports that long-term antibiotic use may increase the risk of breast cancer will require further study, but at present they are not substantiated. In general, doctors prescribe oral antibiotic therapy for acne only when necessary and for as short a time as possible.



• Oral contraceptives: Oral contraceptives, which are low in estrogen to promote safety, have little effect on acne one way or the other. Some contraceptive pills have been to shown to have modest effectiveness in treating acne. Those FDA-approved for treating acne are Estrostep, Ortho Tri-Cyclen, and Yaz. Most dermatologists work together with primary physicians or gynecologists when recommending these medications.



• Spironolocatone: This drug blocks androgen (hormone) receptors. It can cause breast tenderness, menstrual irregularities, and increased potassium levels in the bloodstream. It can help some women with resistant acne, however, and is generally well-tolerated in the young women who need it.



• Cortisone injections: To make large pimples and cysts flatten out fast, doctors inject them with a form of cortisone.



• Isotretinoin: (Accutane was the original brand name; there are now several generic versions in common use, including Sotret, Claravis, and Amnesteem.) Isotretinoin is an excellent treatment for severe, resistant acne and has been used on millions of patients since it was introduced in Europe in 1971 and in the U.S. in 1982. It should be used for people with severe acne, chiefly of the cystic variety, which has been unresponsive to conventional therapies like those listed above. Those with milder forms of acne often relapse shortly after finishing a course of isotretinoin, making this drug less useful in such cases. This means that isotretinoin is not a good choice for people whose acne is not that bad but who are frustrated and want "something that will knock acne out once and for all."

• Used properly, isotretinoin is safe and produces few side effects beyond dry lips and occasional muscle aches. This drug is prescribed for five to six months. Fasting blood tests are monitored monthly to check liver function and the level of triglycerides, relatives of cholesterol which often rise a bit during treatment, but rarely to the point where treatment has to be modified or stopped.



• Even though isotretinoin does not remain the body after therapy is stopped, improvement is often long-lasting. It is safe to take two or three courses of the drug if unresponsive acne makes a comeback. It is, however, best to wait at least several months and to try other methods before using isotretinoin again.



• Isotretinoin has a high risk of inducing birth defects if taken by pregnant women. Women of childbearing age who take isotretinoin need two negative pregnancy tests (blood or urine) before starting the drug, monthly tests while they take it, and another after they are done. Those who are sexually active must use two forms of contraception, one of which is usually the oral contraceptive pill. Isotretinoin leaves the body completely when treatment is done; women must be sure to avoid pregnancy for one month after therapy is stopped. There is, however, no risk to childbearing after that time.



• Another concern, much discussed in the popular press, is the risk of depression and suicide in patients taking isotretinoin. Government oversight has resulted in a highly publicized and very burdensome national registration system for those taking the drug. This has reinforced concerns in many patients and their families have that isotretinoin is dangerous. In fact, large-scale studies so far have shown no increased risk for depression and suicide in those taking isotretinoin compared with the general population. Although it is important for those taking this drug to report mood changes (or any other symptoms) to their doctors, even patients who are being treated for depression are not barred from taking isotretinoin, whose striking success often improves the mood and outlook of patients who have suffered and been scarred by acne for years.



• Laser treatments: Recent years have brought reports of success in treating acne using lasers and similar devices, alone or in conjunction with photosensitizing dyes. It appears that these treatments are safe and can be effective, but it is not clear that their success is lasting. At this point, laser treatment of acne is best thought of as an adjunct to conventional therapy, rather than as a substitute.



• Chemical peels: Whether the superficial peels (like glycolic acid) performed by estheticians or deeper ones performed in the doctor's office, chemical peels are of modest, supportive benefit only, and in general, they do not substitute for regular therapy.



• Treatment of scars: For those patients whose acne has gone away but left them with permanent scarring, several options are available. These include surgical procedures to elevate deep, depressed scars and laser resurfacing to smooth out shallow scars. Newer forms of laser resurfacing ("fractional resurfacing") are less invasive and heal faster than older methods, although results are less complete and they may need to be repeated three or more times. These treatments can help, but they are never completely successful at eliminating scars.

How would you sum up current-day treatment of acne?

Treating acne requires patience and perseverance. Any of the treatments listed above may take two or three months to start working (even isotretinoin). Unless there are side effects such as dryness or allergy, it is important to give each regimen or drug enough time to work before giving up on it and moving on to other methods. Using modern methods, doctors can help clear up just about everyone.

Just hang in there. And don't pick. Please.

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