Many Therapies Hit the Spot for Relief of Acne
To a teenager, few things are more embarrassing than acne. Whether it’s an isolated pimple or a severe outbreak, most adolescents--and some adults--would do just about anything to clear it up.
Americans spend more than $100 million a year on over-the-counter acne treatments, and hundreds of millions more on visits to doctors and prescription medications for this skin disorder. The cost of treating acne is high, in part, because the problem is so common.
About 85% of people between the ages of 15 and 24 are affected by it, and by their mid-teens, more than 40% of adolescents have acne severe enough to require some treatment by a physician. The problem is not confined to adolescence; many people suffer from acne well into their fourth and even fifth decade of life.
Even so, it’s a lot of money spent trying to unclog hair follicles that have become blocked by a greasy, waxy substance called sebum. Sebum is produced by a small gland (the pilosebaceous gland) at the base of the hair follicles. Normally the sebum empties onto the skin’s surface. Acne develops when the follicle becomes plugged (usually by a mixture of sebum and skin cells that line the follicle) and the sebum becomes trapped inside.
As sebum builds up, the follicle enlarges, and “whiteheads” and “blackheads” develop. (Whiteheads are simply plugged follicles that remain closed beneath the skin’s surface; blackheads are plugged follicles that have opened up to the skin’s surface.) The problem is aggravated when bacteria that normally live on the skin get into the sebum-plugged follicle and begin to multiply there, causing inflammation, swelling and redness (a condition known as inflammatory acne). In some cases the buildup of sebum and bacterial overgrowth actually cause the follicle to rupture, resulting in the development of larger acne lesions like cysts and nodules (referred to as nodular or cystic acne).
While these acne lesions pose no serious threat to general health, they can have devastating emotional consequences. Acne--especially severe inflammatory or cystic acne--can undermine self-esteem, destroy self-confidence and distort self-image. It can also be the source of tremendous frustration and even lead to depression.
For some people, acne leaves physical scars as well as emotional ones. When inflammation is severe or persists for long periods of time, it can lead to permanent damage ranging from small, rounded “pockmarks” to long, linear scars. In people with darker complexions, acne can also cause the skin to become darker, or “hyperpigmented.” Although the initial acne lesions may last only days to weeks, the skin can remain discolored for months or even years.
Both the emotional and physical scarring of acne are usually preventable because almost all acne lesions can be successfully controlled with prompt and appropriate treatment.
Keeping the skin clean is an important first step. The American Academy of Dermatology recommends gently washing the skin twice a day with water and a mild cleanser to help eliminate excess oils on the skin’s surface. Scrubbing the skin and using strong detergent cleansers are not advised. (In fact, they are actually thought to aggravate the problem.)
Contrary to popular belief, however, washing alone is not enough. Medications are usually necessary to combat acne successfully. Some acne medications work by keeping hair follicles from plugging up; some reduce the amount of sebum that is produced; others control the overgrowth of bacteria.
Over-the-counter medications are often the best place to start, particularly for treating whiteheads, blackheads and mild inflammatory acne. Many gels, creams and lotions are available to choose from. To work, they must be applied frequently, sometimes as often as three times a day. Products containing benzoyl peroxide, salicylic acid, sulfur and resorcinol work by preventing follicles from plugging and are among the most popular on the market. (Benzoyl peroxide-containing products offer the added advantage of inhibiting bacterial overgrowth.)
When used properly, over-the-counter products can be very effective, though not for everyone. When these simpler measures fail, the use of prescription medications may be helpful. Antibiotics can help stop or slow the growth of bacteria, and drugs called retinoids can unplug blocked follicles or reduce the amount of sebum produced. In some cases the medications are applied directly to the skin; in others, they are taken as pills.
Isotretinoin (brand name Accutane) is an oral retinoid medication that is generally reserved for the most severe cases of nodular or cystic acne. Accutane produces dramatic results: 9 out of 10 people treated with it experience complete or near complete resolution of their acne after 15 to 20 weeks of treatment. Unfortunately, its side effects can be equally dramatic. When taken by women who are pregnant, isotretinoin can cause severe birth defects in the developing fetus.
To prevent retinoid-related birth defects, the Food and Drug Administration recently issued new prescribing rules: Women who are, or who might become, sexually active with a male partner are required to use two forms of birth control for at least a month prior to starting Accutane. Before receiving a prescription for Accutane, all women must have two negative pregnancy tests. After starting on the drug, they must return to their doctor for a repeat test during every month they continue to take it.
Most skin specialists support the use of simple nonprescription therapies first. If those don’t work, a physician with experience in treating acne should be consulted promptly. Especially with the cystic form of acne, the earlier an appropriate therapy is started, the less the likelihood of scarring afterward.
If your child has acne, it’s important to talk frankly together about the problem; sympathetic concern alone can be very comforting. Be sure the child is aware that effective treatments are available, and let the child know that you’ll help find competent care. Although some children may be embarrassed to talk about this subject--even with their parents--the embarrassment pales in comparison with their fear of humiliation in front of their peers because of acne.
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Dr. Jonathan Fielding is the director of public health and the health officer for the Los Angeles County Department of Health Services. Dr. Valerie Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. Their column appears the second and fourth Mondays of the month. Send questions by e-mail to our health@dhs.co.la.ca.us. They cannot respond to every query.
