Overwrought at what seemed to me to be a typical smattering of pimples, my teenage daughter had been begging for months to see a dermatologist. But I'd insisted on exhausting all other approaches before going to the expense. After all, I reasoned, how hard could it be to clear up a little acne?
So I proceeded to spend a small fortune on over-the-counter products that did little to improve her complexion and even sprang for a facial that left her skin looking even more angry and inflamed. She, meanwhile, tried steaming her face over piping hot pots of water in attempts to control the breakouts and even applied odd home remedies such as toothpaste to her beleaguered skin.
When she recently refused to leave the house because of new pimples on her chin, I knew I'd lost the battle. I relented and called a dermatologist.
Then I called another. And another.
Even with experts' help, getting the upper hand on acne turned out to be far trickier than I'd imagined.
The first doctor I spoke with believed that sugars, starches and fats were at the root of most pimples and proposed -- for a $300 consultation fee -- that we revamp my daughter's diet.
This was perhaps the oddest advice I got. From a scientific perspective, it was totally unfounded; from a practical perspective, nearly impossible. It takes nearly all my energy and determination to get my daughter out of bed in the morning and off of Facebook at night. Persuade her to give up bread and sweets? That seemed unlikely.
The next physician I talked with tried to sell me on laser and light therapies over more conventional and less expensive medications. Again, there's little solid evidence that such therapies -- which can cost hundreds of dollars per session -- even work.
While I'm no acne expert, I was beginning to recognize I'd spent a lot of money unwisely. I'm not the only one who's made that mistake. The Consumer Healthcare Products Assn. reports that Americans spend well more than $330 million a year on nonprescription acne remedies. The bills for aestheticians, dermatologists and prescription acne products likely run far higher.
That's not to say that all acne treatments are bad. But being able to distinguish between those proven effective and the ones of dubious merit can save time, money and a teenager's self-esteem.
Over the counter
On the face of it, acne is a rather straightforward problem. It develops when dead skin cells and sebum (an oily substance produced by oil glands) build up and clog the pores of the skin. Mild acne is characterized largely by open, discolored plugs known as blackheads and by closed bumps or pimples known as whiteheads. More severe acne is defined by the presence of larger, inflamed lesions called pustules; these develop when blocked pores become infected with bacteria from the skin's surface.
Both oral and topical medications used to treat acne target the underlying causes of pimples. Antibiotics, for example, kill the bacteria that can cause whiteheads and blackheads to become infected; retinoids such as isotretinoin (Accutane; see accompanying box) open clogged pores.
While most dermatologists agree that nonprescription, topical products are the best first line of defense against acne, many lotions and liquids found on the drugstore shelves simply don't work.
"Over-the-counter products aren't inherently bad, but they do vary in quality," says Dr. Karl Beutner, associate clinical professor of dermatology at UC San Francisco and co-author of the American Academy of Dermatology's acne treatment guidelines.
Benzoyl peroxide is perhaps the best of the bunch. It works to open clogged pores and kill P. acnes, the bacteria linked to acne. Some studies show that, when used properly, creams containing the compound work as well as many prescription medications.
However, benzoyl peroxide has its limitations. Over-the-counter formulas are appropriate only for mild acne; prescription versions that include a topical antibiotic are required for more severe outbreaks. Benzoyl peroxide also tends to be very drying. Even when it works well, many teens give up on the medication because the creams leave their skin red and scaly.
Other over-the-counter products tend to pale in comparison to benzoyl peroxide. Although salicylic acid has been used for years in a broad range of acne products, very few studies suggest that it can prevent or reduce blemishes. There's even less evidence to support the use of sulfur, resorcinol and "natural" remedies found in a variety of acne creams, gels, ointments and scrubs.
A doctor is needed
Then there's the matter of facials. Extracting whiteheads and blackheads produces immediate improvement in the way the skin appears, but facials fail to break the cycle that causes acne. "They're not going to do anything to prevent the recurrence of new pimples," Beutner says.
Sometimes facials actually aggravate acne. In my daughter's case, trying to extract relatively small and inapparent lesions caused them to become angry, red and inflamed.
Chemical peels with glycolic or salicylic acid are another noneffective no-go, according to the American Academy of Dermatology. And they're expensive.
Many dermatologists also recommend a variety of high-tech treatments -- laser and light therapies -- to treat acne. Despite their higher cost, use of these treatments is still in the investigational stage. The evidence to support their effectiveness is based on only a handful of studies on a small number of people.
Perhaps the most important lesson I learned trying to combat acne is that sometimes my daughter is right -- she needed a dermatologist after all. Her acne progressed beyond what over-the-counter products (even the good ones) could manage; a combination of prescription medications will be required to clear up her skin.
When it comes to anything beyond mild acne, doctors hold the cards. The most effective medications all require a prescription.
But just as some acne treatments are better than others, the same is true for the doctors who dispense them.
Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. The M.D. appears once a month.