Acne

Acne (also called acne vulgaris, pimples, or zits) is an inflammatory skin condition that causes “bumps” characterized as either whiteheads, blackheads, papules, pustules or cystic nodules. Despite its stubborn nature, there are many effective topical and oral therapies that can help treat acne. Even if you’ve failed treatments in the past, sometimes it comes down to finding the right combination of products for your skin. Fortunately, Skin and Scripts Teledermatology can provide personalized skin care regimens from a board certified dermatologist to help you best manage your acne.

Acne affects 40 to 50 million people in the United States and is commonly seen in the preteen years but can persist well into adult life. It can also begin in the mid 20’s and 30’s (especially hormonal “jawline acne”).

Unfortunately, regardless of one’s age, acne often has a negative psychological impact on patients and has been associated with anxiety, depression, social isolation, and low self-esteem.

There are three main factors that cause acne; 1) overproduction of oil, 2) clogged pores, and 3) an overgrowth of bacteria inside the clog pores that leads to inflammation. The oil glands in your skin produce a substance called sebum, which acts as a natural skin moisturizer. As your body matures, sex hormones cause oil glands to produce larger quantities of sebum. When a person doesn’t shed their skin cells as frequently as they should, the excess sebum will cumulate under the skin and clog the opening (the pore). This clogged pore is called a comedone, more commonly known as a black head (open comedone) or a whitehead (closed comedone).

Additionally, there are many bacteria that live on the surface of our skin as a part of what we called the “normal flora” ( the good bacteria that colonizes our skin to prevent bad bacteria from growing) This bacteria is harmless but can become trapped under the skin with all the excess sebum causing irritation and inflammation. The inflammation can be superficial causing pink/red papules or very deep causing cystic nodules. This is why there is a great variation in the severity of acne in different people.

Changes in hormone levels often affects acne. Many females will notice a slight flareup of acne before or during a menstrual cycle. This is due to fluctuations in hormones that activate the oil glands. Birth control pills or pregnancy also influence the degree or severity of acne. In males the hormone testosterone plays a significant role in flaring acne. While stress and tension do not cause acne, they can definitely make it worse.

There’s no evidence that chocolate, soda, or fatty foods cause acne. There has been one published study that showed a correlation between drink skim milk and acne. In the study it showed that people who drank a lot of skim or low-fat milk regularly also tend to have more acne.(1)

1. LaRosa CL, Quach KA, Koons K, Kunselman AR, Zhu J, Thiboutot DM, Zaenglein AL. Consumption of dairy in teenagers with and without acne. J Am Acad Dermatol. 2016 Aug;75(2):318-22

Unfortunately, there is no cure for acne but there are many great medical treatments. Because acne is caused by so many factors, it typically takes a multi-step regimen to really get things under control. For mild acne, topical creams are often enough the clear acne but for more severe cases oral medications are also needed. Even the most effective medications may take 4 to 6 weeks to start working.

Fortunately, there are many good over-the-counter products that can be very helpful in controlling mild acne. These include topical salicylic acid, benzoyl peroxide, and adapalene. It’s important to note that if you’ve been on an over-the-counter regimen for 3 to 4 months without any improvement then it’s time to seek medical attention from a dermatologist and start a prescription regimen.

Topical creams commonly used for the treatment of acne include salicylic acid, glycolic acid, benzoyl peroxide, azelaic acid, erythromycin, clindamycin, topical dapsone and retinoids. Topical therapies are sometimes combined for greater efficacy.

Retinoids

Retinoids: are the gold standard in acne treatment and unclog pores by promoting cell turnover. Increasing the rate at which skin cells shed prevents oil from accumulating under the skin. Retinoids come in different strengths with the most mild being adapalene, followed by tretinoin and then tazarotene. Retinoids are very effective in clearing acne however they can be very drying and irritating especially in those patients with sensitive skin. Thus, it’s important to start with a lower strength retinoid initially, using it 1-2 nights per week and gradually work your way up every night.

Salicylic acid

Salicylic acid: is a beta hydroxy acid that works as a chemical exfoliant making skin cells less sticky, so they shed more rapidly. Salicylic acid is ideal for people with oily skin as it helps decrease oil production. Caution should be taken if skin is on the dry side and when using during the cold winter months. Caution should also be taken if combining with prescription retinoids as this combination can increase the chance of skin dryness and irritation.

Glycolic acid

Glycolic acid: is an alpha hydroxy acid that works as a chemical exfoliant helping skin cells shed more rapidly. Glycolic acid tends to be less irritating than salicylic acid, so it is more ideal for dry sensitive skin. Caution should be taken when combining with prescription retinoids. One should let their skin get acclimated to their retinoid for 4-6 weeks before adding in a glycolic acid product to their regimen.

Benzoyl Peroxide

Benzoyl Peroxide: is a potent topical antibacterial agent they can be used as either a wash or cream. When combined with other antibiotics it helps decrease antibiotic resistance. Benzoyl peroxide side comes in different strengths (2.5%, 4%, 5% and 10%) so if you have sensitive skin, it’s best to start with a lower strength.

Azelaic acid

Azelaic acid: is a naturally occurring acid found in grains such as barley, wheat, and rye with antibacterial and anti-inflammatory properties. It is used to treat both acne and rosacea but also helps lighten dark spots that are left behind from prior acne lesions. It is often used in conjunction with a hydroxy acid or a retinoid.

Erythromycin and Clindamycin

Erythromycin and Clindamycin: are topical prescription antibiotics and are used to help control inflammatory acne. In general they very well tolerated and work best when combined with a benzoyl peroxide and/or a topical retinoid.

Topical dapsone

Topical dapsone: is a topical prescription antibiotic that is effective in treating inflammatory and hormonal acne. It is typically very well tolerated and can be used alone or in combination with topical retinoids.

Oral agents used to treat acne include oral antibiotics, spironolactone, and isotretinoin. Oral antibiotics are used for their anti-inflammatory as well as antibacterial properties. Commonly prescribed oral antibiotics include tetracyclines (doxycycline, minocycline, and seracycline), amoxicillin, and clindamycin. With all oral medication it’s important to make sure your doctor is aware of other medication you are taking to avoid any potential interactions. Oral medication should be avoided if you are pregnant, nursing or trying to conceive.

Tetracycline antibiotics (doxycycline, minocycline, and seracycline)

Tetracycline antibiotics (doxycycline, minocycline, and seracycline): these antibiotics have strong anti-inflammatory properties and are often used at low doses to primarily to control the inflammatory component of acne. These antibiotics are generally very safe however can cause G.I. upset it’s not taken with food and occasionally can make people more sensitive to the sun that’s wearing sunscreen is important. to be aware of other medication you’re taking to make sure there’s no interactions. These are prescription medications that can only be provided while under the care of a physician.

Amoxicillin and Clindamycin

Amoxicillin and Clindamycin: these antibiotics are not first line agents and are typically used when patients cannot tolerate tetracyclines because of its side effects or an allergy. Like other antibiotics, these have potential side effects such as allergy, headache or G.I. upset. These are prescription medications that can only be provided while under the care of a physician.

Spironolactone

Spironolactone: is a diuretic that is traditionally used to treat hypertension but also is a great oral agent for treating hormonal acne in females. We use spironolactone to treat acne because it has the ability to block the androgen hormones from activating the oil glands. Fortunately, the typical doses used to treat acne have minimal diuretic effects and in young healthy individuals. This is a prescription medication that can only be provided while under the care of a physician.

Isotretinoin

Isotretinoin: is a vitamin A derivative and works by completely “shutting off” the oil glands. It is an oral version of tretinoin and really gets to the root cause of acne. Some say that this is the only true cure for acne as it has a 96% clearance rate after 6 to 8 months of therapy. This does not come without risk however, as this medication does carry side effects such as birth defects if taken when a female gets pregnant. More common side effects include dry skin and elevated cholesterol and elevated liver enzymes. Because of this, there is a national registry called the Ipledge program that ensures lab work is collected monthly and patients are safely prescribed isotretinoin. This is a prescription medication that can only be provided while under the care of a physician in person and is not prescribed via telemedicine.

Pregnancy causes a surge of hormonal changes that can trigger and/or flare acne. Unfortunately, pregnant women are limited in options for safe topical acne treatments and are prohibited from all oral medications. Anything we apply to our skin gets absorbed into our system in some amount, and that small amount may not be significant to cause harm to a fully developed person however it does have a potential for causing harm to a developing fetus. It is wise to be very conservative in what you applied to your skin while pregnant. Safe topical treatments for acne include benzoyl peroxide, clindamycin, erythromycin, azelaic acid, and glycolic acid.  Always take the advice of your dermatologist before starting/continuing any acne regimen while pregnant.