Acne

Acne is a multifactorial disease that affects patients of all ages. Typically this begins just before puberty. There is a strong hormonal influence at all ages. There is some new data that diet, especially the ingestion of milk, plays a role in the development of acne. (This is because of the high hormonal content in milk.) Females go into a negative calcium balance as soon as age 13, so as you decrease dairy intake, you should supplement with a good calcium/Vitamin D tablet. Foods with a high glycemic index (corn flakes, rice krispies, white potatoes, white bread, sugar and soft drinks) also may increase acne inflammation and should be taken in moderation or avoided completely.

Over the Counter (OTC) Therapy: Products are available through mail order, cosmetic companies, local drug stores and supermarkets. A handful of useful ingredients contained in these various products are useful for mild acne: benzoyl peroxide, salicylic acid, and alpha hydroxy-acids (AHAs).

Conservative Therapy: Topical prescriptions containing higher concentrations are available through a dermatologist’s office. These include retinoids, salicylic acid, sulfa, benzoyl peroxide, and alpha hydroxy-acids (AHAs). A good topical regimen works well for patients with mild and “small bump” acne. A long-term approach and patience is important. Therapies such as AHA peels and microdermabrasions are effective in opening up clogged pores and improving mild or moderate acne. Risks include skin irritation and local allergic reactions (rash, itch).

Moderate Therapy: Mid to larger sized pimples may need topical antibiotics or medications by mouth for adequate treatment. Antibiotics or hormonal therapy (birth control pills, antiandrogen receptor medications) are used to suppress acne activity. Side effects may include allergic reactions to medications, alterations in blood sodium or potassium, photosensitivity, and, rarely, more serious effects such as inflammation of the liver or suppression of the blood producing cells. For this reason, periodic monitoring of the blood may be recommended. Recently concerns about antibiotic resistance have been raised. For this reason, it is now recommended that oral or systemic antibiotics only be used for short courses (usually 3 to 6 months) of therapy. Use of topical benzoyl peroxide medications will greatly decrease the likelihood that resistant strains of bacteria will emerge. Consistent use of retinoids (tretinoin, Differin, Retin-A, Tazorac, Epiduo) will open up the pores so that less antibiotic therapy is needed. There is a real worry that acne bacterial resistance might spread to important organisms such as Streptococcus or Staphylococcus. Aczone (topical dapsone) is a fairly new addition to the topical acne armamentarium.

Aggressive Therapy: Only isotretinoin (formerly known as Accutane) is in this category. This therapy is expensive, has many potential side effects, and must be monitored closely. It is a MIRACLE DRUG for many individuals with moderate, severe, cystic, scarring, or long standing acne. Acne may totally clear up after one or more courses (6 – 15 months in length) of therapy. As frightening as this drug may initially sound, it is actually just Vitamin A that has been altered to make it safer for humans to ingest at therapeutic levels. Monthly visits, pregnancy tests and lab work are required by the FDA.

How long will I have to treat my acne? Treating acne does not change the tendency for acne. Therapy controls the disease while you are on it. If you choose conservative therapy, it is possible you will be on therapy for several years. If you and your health care provider determine that isotretinoin is the treatment of choice, you may be clear of your acne and off all medications after about 6 to 12 months. 60 –75% of isotretinoin patients do not need further acne therapy. It is possible to repeat isotretinoin therapy or to be on long-term, low-dose therapy (especially for adults with chronic acne).

What are the risks of isotretinoin? Isotretinoin has been in use since 1982. It attacks acne by shrinking oil glands and changing the maturation process of skin. Common side effects include skin dryness, nosebleeds, increased triglyceride or cholesterol levels and dry eyes. Muscles and joints may become sore. There may be an increased risk of inflammatory bowel disease in predisposed patients on isotretinoin. High dose Vitamin A therapy during pregnancy leads to predictable birth defects. As isotretinoin is a vitamin A derivative, if you get pregnant while on it, the baby will possibly have severe birth defects. The FDA requires that any female of childbearing potential on isotretinoin be on two forms of contraception for a month before, during, and for a month after therapy. Note is made that ovulation precedes conception; thus, it is possible to become pregnant without ever having had a menstrual cycle. Two peaks of unintended pregnancies are in teenagers and in peri-menopausal women. All females, regardless of age or birth control method are required by the FDA to have monthly pregnancy tests.

What about depression and isotretinoin? Depression is a common symptom seen in teenagers and in many adults with or without acne. Severe acne may aggravate depression. Certain individuals have experienced mood swings while on isotretinoin. Most of the time these symptoms are mild. Suicide is the second leading cause of death among those aged 15-24. A small number of patients have committed suicide while on isotretinoin therapy. A connection between isotretinoin and suicide has not been proven. Most experts do not feel that isotretinoin alone is a significant risk factor for suicide. All of the individuals who committed suicide while on isotretinoin had other factors contributing to their actions, including, previous suicide attempts, hospitalizations, poor family situations, family history of mental illness, etc. Most patients who are depressed or upset about their acne report improved mood and self-confidence after completing a course of isotretinoin.

How do I decide what therapy is right for me? Choosing the right therapy for you will depend on many factors: severity of disease, expectations, other medical conditions, your age, the cost, etc. You must decide what risks and side effects you are willing to accept for a given set of expectations. Many medications may stop the progression of scarring in most individuals, but not eradicate old scars.