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Suffering in Silence : Acne can be agony for teen-agers, but the past decade has brought dramatic changes in treatment. Now the problem is getting people to seek help.

TIMES HEALTH WRITER

Acne is rarely thought of as persistent and debilitating, but for Lareina Deherrera, 33, the scourge of adolescence is just that.

“Acne caused the most deep-rooted despair. It’s like having a terminal illness. It almost destroyed me,” says the Northridge woman whose 20-year ordeal with acne is finally drawing to a close. Recently, she underwent successful laser surgery, a promising new technique for removing facial scars left by acne.

In addition, Accutane and several other effective treatments for acne and acne scars developed over the past two decades have dramatically changed how doctors view the disease today. What hasn’t changed, however, are people’s attitudes toward acne, according to a new survey.

In a poll of 1,000 teen-agers with acne, one-third said they felt embarrassed, anxious or lacked self-esteem due to their complexion, and almost all worried about their skin. Yet only 16% had seen a doctor and only 13% used prescription medicine.

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The survey, undertaken by NFO Research Inc., in Greenwich, Conn., was presented in November at an American Medical Assn. meeting.

“I think the psychological effects of acne are underestimated,” says Dr. Diane Baker, a dermatologist in Portland, Ore., who presented the survey findings. “Even kids with cases that are not severe, it is embarrassing to them, and their self-esteem suffers at a time when self-esteem is already fragile. But for years, it’s been the impression, on the part of parents and teens, that this is something that you have to put up with.”

But doctors say it doesn’t have to be that way for the millions of people with acne. Help is here.

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Acne occurs in 80% of girls and 90% of boys during adolescence. It may begin earlier in girls and last longer, but boys tend to have more severe cases. Five percent of all teens will have such severe acne that permanent scars are left.

It’s a myth that foods like chocolate and greasy French fries cause acne. Nor is the cause due to dirt or poor hygiene. Acne is triggered by hormones, which surge during puberty and cause the oil glands of the skin to enlarge, Baker says.

However, teens tend to blame themselves.

“I think there is a guilt about it. They think, ‘It’s my fault that I have this, and I have to suffer with it,’ ” she says.

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But the most severe acne, cystic acne, tends to be hereditary, so it’s particularly important to take teens with this family history to a doctor as soon as the acne begins.

It’s also wise to see a doctor for mild acne or an initial episode since it is impossible to predict how bad the acne might become, says Dr. Patrick Abergel, director of the Dermatology and Cosmetic Laser Surgery Center in Santa Monica.

“People wait too long to come in,” says Abergel. “Even when acne is in its minor form, children should be taken to a dermatologist. There is a very simple cream that will improve, if not eradicate it. And that will be the end of the story.”

Mild acne can be treated with antibiotics or the topical cream Retin-A (tretinoin), which came on the market in the 1970s. Accutane is almost always successful for cystic acne.

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“We now have a treatment for cystic acne that we didn’t used to have,” says Abergel. “We shouldn’t even see cystic acne anymore. That should be an image of the past.”

But with the launch of Retin-A and Accutane in the past two decades, it seems even more tragic that millions of teen-agers suffer with acne, experts say.

Why wouldn’t teens or their parents seek help for acne? There are several reasons, including: a lack of knowledge about such successful treatments; the cost of acne treatments, and the psychological hurdle of admitting that the acne is a serious problem.

While most adults know about Retin-A and Accutane, the survey found that 67% of teens instead use over-the-counter medications for acne.

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Over-the-counter products containing benzoyl peroxide can be effective for fairly mild cases, Baker says. But, like all acne treatments, “it takes four to six weeks to work. It has to be continued.”

For acne cases in which there are lots of pimples, she says, “you pretty much need a prescription medicine. And one of the benefits of seeing a doctor is that you learn how to use the treatments properly.”

Acne treatments often require special supervision, Baker adds. Retin-A, for example, can cause sun sensitivity and should never be prescribed without warnings to use sunscreens.

Accutane is even more risky. While hugely successful, the drug can cause severe birth defects if the patient becomes pregnant while using it. Moreover, Accutane can cause sun sensitivity, dry skin and lips, hair thinning, joint and muscle pain and elevated cholesterol levels.

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“We are always very concerned about prescribing Accutane,” Baker says. For example, some doctors insist that teen-age girls also take oral contraceptives if they need Accutane.

“I don’t insist on (oral contraceptives) if I am assured that the girls are not sexually active. But I certainly talk to them about it, and if they agree to go on the Pill, I prefer that,” Baker says.

Doctors also recommend a low-fat diet for people on Accutane because of its effects on cholesterol.

But even a trip to the doctor can be problematic if insurance doesn’t cover acne treatment. While Accutane is almost always covered by insurance, Retin-A may not be, depending on the insurance plan. And, according to Dr. Curren Warf, a health specialist for adolescents at Childrens Hospital, Los Angeles, MediCal rarely pays for such acne medications as Retin-A.

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Homeless teens or those whose parents or caretakers cannot afford treatment can get free acne treatment at places like the High Risk Youth Program, a joint clinic sponsored by Childrens Hospital and the Los Angeles Free Clinic. Moreover, county health facilities operate some dermatology clinics, and school-based health clinics will treat acne.

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The psychological barrier also deters kids from getting help, says Baker. According to the survey, for example, 47% of teens say they feel their complexion affects the way people react when meeting them for the first time. They may be too embarrassed to even talk about it to anyone, including a doctor.

Parents who take the attitude that acne is a normal part of adolescence may be seriously underestimating its psychological impact.

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“Acne is an assault on a teen’s self-image and affects what they will do--whether they will try out for the school play, athletic teams or class office,” Baker says. “It makes them more reticent, less outgoing, less willing to take a chance. . . . It really has a negative affect on their ability to relate to people.”

In the survey, one-third said they think their complexion is the first thing people notice about them, and half said they feel it affects the way others treat them.

Deherrera can attest to how acne can alter the dreams and plans of a young person.

Her skin erupted at age 13 with cystic acne. Repeated medical treatments failed to help her until the Food and Drug Administration approved the revolutionary acne drug Accutane in 1982. Deherrera was 21, and her acne vanished in two months.

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“It hindered my success and my happiness,” she says. “I am such a perfectionist by nature. It was so frustrating and devastating that I couldn’t overcome it.”

Later, when she became a hairstylist, she felt the scars left by the acne undermined her career.

Recent improvements in the treatment of acne scars, however, are the last piece of the trilogy of advances--beginning with Retin-A and then Accutane--to conquer acne.

Acne scarring has long been difficult to repair, says Abergel. Over the past decade, doctors have tried a technique called dermabrasion, which is similar to mildly sanding the skin after it has been frozen.

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“It’s fairly barbaric,” he says. “It’s imprecise and it has potentially severe complications. Not every patient is a candidate for it.”

Doctors have also tried collagen to fill skin depressions. But collagen is not permanent and eventually has to be redone.

People with severe scars have also undergone skin grafts, Abergel says, a painful, costly procedure that produces mixed results.

The latest and most promising technique, he says, is the use of carbon dioxide laser to graft new skin over the scars without great blood loss or stitches.

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“Using the laser, we are able to seal a graft on top of the skin and make the graft smooth and invisible,” he says.

Even though even this treatment is expensive, somewhat painful and requires several days to heal, Deherrera found it worthwhile.

“My acne has been such an ongoing thing. You look in the mirror every day and you see more you want to do,” she says. “But I’m thrilled with the laser treatment. It gave me something that no other treatment could give me.”

(BEGIN TEXT OF INFOBOX / INFOGRAPHIC)

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Emotional Reactions to Acne

Teen-agers frequently have deep emotional reactions to acne, ranging from low self-esteem to depression, according to a new poll.

Question: Do you feel frustrated, embarrassed, anxious, not confident or depressed as a result of your complexion or acne?

Frustrated Total: 42% Male: 34% Female: 52%

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Embarrassed Avg Total: 35% Male: 31% Female: 38%

Anxious Avg Total: 31% Male: 31% Female: 31%

Not confident Avg Total: 36% Male: 31% Female: 41%

Depressed Avg Total: 18% Male: 16% Female: 21% Source: NFO Research Inc., Greenwich, Conn

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