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All About Acne
By Dr. Moghissi - May 2008
Acne is a very common problem. Anywhere from 70-96% of the population with have acne at some point in their lifetime, and the incidence is the same for women as for men. Many of the traditional treatments work quite well, but there are also many new treatments available for those that did not respond well to traditional treatment, or are otherwise unhappy with them. I’ll go over many of them here.
First, what causes acne? A bacteria called Propionibacterium acnes (P acnes), which normally inhabits the skin but causes inflammation in acne patients, along with excess sebum production with plugging of the pores (sebaceous glands) are the underlying abnormalities. Any successful treatment must address both issues. Since the skin provides a barrier to the outside world, any treatment that significantly damages the skin will often make things worse, so it is important to protect the skin during treatment. We do this by moisturizing dry skin, and protecting with sunscreens.
Initial treatment involves cleaning the skin to minimize plugging. Any cleanser that is not too harsh can be used, but we often prescribe cleanser with benzyl peroxide or salicylic acid to assist in this (more on those later). A recent study showed that in acne patients, cleaning the skin twice daily is better than once, but 4 times is no better than twice. The thought is that any improvement in better cleaning is negated by the fact that too frequent cleaning disrupts the barrier function of the skin. Thorough cleaning will also remove dead surface cells to allow topically applied medications to be better absorbed. Using a device such as the Clarisonic can also be helpful in making sure dirt, oil, makeup and excess sebum are thoroughly removed without damaging the skin. Clarisonic has data showing better product absorption resulting from better cleansing with the Clarisonic device.
Topical treatments are the next step. Benzyl Peroxide (the active ingredient in the Proactive system) works on killing bacteria. Salicylic Acid treats plugging. My acne kit contains both ingredients, which may be why I’m seeing success in patients who have failed the Proactive system. An even better treatment for plugging is the retinoids such as Retin A, Differin, and Tazarac. It does require a bigger commitment on the part of the patient. The topical antibiotics Clindamycin and Erythromycin are also effective for killing the bacteria, but very quickly develop resistance unless paired with benzyl peroxide. An additional treatment is Azelic Acid. It is used less often due to side effects.
Oral treatments include antibiotics, isotretinoin (accutane), steroids, and the birth control pill. Antibiotics are only a short term solution. They kill bacteria, but again, resistance is formed fairly quickly, both to the P acnes and to any other bacteria that may be in the body. Isotretinoin, which treats primarily plugging, causes terrible birth defects and is heavily regulated at this time, but as a last resort can be very effective. Steriods are used only rarely is resistant cases, usually in women. There are 3 brands of birth control pills, Yaz, Estrostep, and Ortho Tri-Cyclen that have received FDA indications for treating acne. They work fairly well, and are a safe long-term treatment, but of course are only an option in women.
Now we get to newer treatments. There has been a lot of interest in chemical peels. A study published in Dermatologic Surgery compared glycolic acid peels to salicylic acid peels. They did a series of 6 peels over 12 weeks and found significant improvement with both. They did conclude though, that the salicylic acid peel had sustained effectiveness compared to the glycolic acid and had less adverse events. Most spa peels are glycolic acid.
Microdermabrasion is almost like sandblasting the skin. A sand line abrasive is pelted at the skin and vacuumed up again. A new technology where an abrasive paddle is placed on the skin and vibrated is called VIbraderm. Microdermabrasion takes off part of the top dead layer of skin. This helps with skin surface irregularities, acne, brown spots, and allows other treatments be more effective. In addition, it is thought to stimulate the growth of collagen. Depending on the machine, there may be some mild redness to peeling and raw skin.
There are several light based technologies that help with acne. Lasers at various wavelengths have been tried for several years. The thought is that the correct wavelength will destroy the bacteria. It does appear to be effective, but it is unclear what the optimal wavelength is at this time. IPL (intense pulsed light) is also effective, and I have seen dramatic improvement in many acne patients with IPL in my practice. Again, it works primarily by killing the bacteria. It is expensive though, and can be uncomfortable, especially for squeamish teenagers. LED is painless, and is usually performed as a blue light, but sometimes also at red. There are studies showing dramatic improvement, but I haven’t been impressed with the results in my practice.
There have been controversies about what role diet plays in acne. In the past it was thought that diet has no effect, but recent studies may change that. Several studies have shown that following a low carbohydrate diet can improve acne. Another study found a diet high in salt water fish and seafood may be helpful. There is evidence (unfortunately) that a diet containing large amounts of milk may make acne slightly worse. The thought is that the hormones in cow’s milk may be playing a role in this.
Finally, many acne treatments cause redness, drying and peeling. Even though acne sufferers usually have oily skin, it is very important to use moisturizers when under treatment. I think it is so important, that I include a light moisturizer in my acne kit. Many acne treatments also cause sun sensitivity and increase the risk of sun burn. Therefore it is very important to use sun screen, but this is really true for everyone, not just acne sufferers!
Copyright 2017 Jasmine Moghissi, MD,PC.