Acne for dummies-book -by Herbert P.Goodheart,MD
Herbert P. Goodheart, MD, has been in the private practice of dermatology for over 25 years. He is a fellow of the American Academy of Dermatology and a member of the Greater New York Dermatological Society. For 20 years, Dr. Goodheart was an Assistant Clinical Professor of Medicine in the Division of Dermatology at the Albert Einstein College of Medicine, Bronx, New York, and is now an Assistant Clinical Professor in the Department of Dermatology at the Mount Sinai College of Medicine in New York City. Dr. Goodheart is the author of Goodheart’s Photoguide of Common Skin Disorders, Diagnosis and Management, a clinical guide to assist the primary care provider and dermatologist-in-training in the identification and treatment of common skin disorders.
Introduction
Acne — it’s not exactly a subject that you like to talk about every day. At social events, you do your best to conceal it under makeup (although if you’re a man, makeup is usually not a realistic option). For kids, acne is more than just a stage of adolescence — it’s the pits! In fact, acne can be a problem for people of any age. Even newborns and seniors can develop acne! Americans currently spend more than $4 billion a year on skin
treatments, nearly $100 million of which goes toward nonprescription acne medications alone. We lavish millions on expensive special soaps and cleansers, prescription therapies, and visits to physicians. Besides money, we also spend an enormous amount of time at beauty counters, salons, spas, and tanning parlors.
Much of this extravagance is encouraged by the messages we get from the media that market unrealistic promises. Ad campaigns promote skin care products using models and movie stars that have perfect, radiant skin. They perpetuate the idea that clear, youthful appearing skin is the only way to go; imperfections are to
be looked down on as something to be ashamed of. Many myths and misconceptions about skin care in general, and acne specifically, continue to be widely believed.
During my 25 years of practicing dermatology, I’ve observed my patients trying to cope with the embarrassment of acne and related skin disorders. That’s what motivated me to write a realistic, practical guide for the understanding and treatment of acne and related conditions. My goal is to dispel many of the myths and misconceptions and to help the reader find out more about his or her condition and manage it more successfully.
Keep in mind that attractiveness to others is much more than physical beauty. It also includes such factors as intelligence and personality. Remember — beauty and acne are only skin deep!
About This Book
Acne For Dummies is intended as a reference for people who have
teenage acne, adult acne, and other acnelike conditions such as
rosacea and razor bumps.
When I reviewed the existing books on acne that are intended for
the general public, I discovered that most of them offer limited,
and at times misleading, information. Many adopt a self-serving
manner selling products or trying to prove that their point of view
is the acne “cure.”
Although some of these books describe well-accepted therapies,
others promise results that can’t be realistically delivered, and are
based solely upon the authors’ opinions without any credible
research to back up their claims. Furthermore, these publications
often fail to address African-Americans and other minority groups;
they’re targeted to a white, mostly adult-female, audience.
This book is intended to have a wide appeal to readers of all ages:
teens and their parents, women and men of all ages, persons of
color and of various ethnic backgrounds. I also want it to serve as
a source of information for pediatricians, primary care providers,
physician assistants, nurse practitioners, school nurses, school
librarians, healthcare providers in the military, and anyone else
who cares for people with acne and related disorders.
Conventions Used in This Book
To help you find your way in this book, I use the following
conventions:
Web page addresses appear in monofont.
Italics are used both for emphasis and to point out new words
or terms that are defined.
Bold highlights the keywords in bulleted lists or action parts
of numbered steps.
Sidebars, which look like text enclosed in a shaded gray box,
consist of information that’s interesting to know but not necessarily
critical to your understanding of the chapter or section’s
topic.
Foolish Assumptions
Every author has to make some assumptions about his audience,
and I’m not any different. So, I assume that:
You or someone you know has acne or an acnelike condition.
(How’s that for a wild guess?)
You want to know more about how to treat acne on your own.
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You want a concise and easy-to-understand guide to over-thecounter
and prescription acne medications and treatment
options. You want to know what works and what doesn’t.
You want to find simple, clear explanations about caring for
your skin without all the hype.
You’re looking for information on acnelike conditions, such as
rosacea and razor bumps.
You’re a healthcare provider who’s looking for an easy-to-use
reference for yourself and your patients.
Well, if one or more of these descriptions sounds about right,
you’ve come to the right place.
How This Book Is Organized
Acne For Dummies is organized into seven major parts — the
following sections give a quick rundown on what you’ll find in each
of them. You don’t have to read this book cover to cover (although
I wouldn’t mind if you did). You can just jump in anywhere you like
because each section is self-contained.
Part I: Facing Up to Acne
In Part I of this book, I give you the essentials of acne: its definition,
its causes, its appearance, how it arises in your skin, and
whom it affects. I also provide you with some general information
about the scene of the crime — your skin — and how to determine
whether you should treat it on your own or call on a doctor.
Part II: Figuring Out Your Acne and
How to Tackle It on Your Own
Here you find that not all acne is alike; in fact, you discover all skin
isn’t alike. Acne has many faces and different features in both
sexes and in the various age groups. In Chapter 4, I talk about
teenage acne; Chapter 5 explores acne in adults; and in Chapter 6, I
discuss the factors that may or may not make your acne worse.
Finally, in Chapter 7, I provide you with a complete guide to overthe-
counter acne-fighting preparations.
Introduction 3
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4 Acne For Dummies
Part III: Turning to the Pros
to Treat Your Type of Acne
Part III is loaded with an abundant supply of information tailored
to focus on the right professional treatment for all types of acne. I
start off by helping you find a dermatologist or other medical professional
to help you get your treatment underway. Then I discuss
the many choices you have among medications, lights, lasers, and
surgery, as well as alternative methods to treat acne. Discussions
of acne in teens, adults, folks with dark complexions, the elderly,
the very young, and the expectant mother — they’re all here.
Part IV: Dealing with Scars and
Associated Conditions
In this part, I get physical and emotional. I give you tips on how to
treat acne scars based on the kinds of scars you have and the kind
of skin you have. Because acne can be so emotionally devastating,
I also delve into the emotional hurdles that you or your friends and
family have to contend with and how to help avoid, manage, and
prevent them. I help you figure out when to seek professional help
and what treatments might be right for you.
I then complete the picture with skin conditions that look like
acne — the acne impersonators such as rosacea and pseudofolliculitis
(shaving bumps). I also tell you what symptoms may suggest
an associated hormonal disorder.
Part VI: The Part of Tens
The parts of tens are a mainstay feature of For Dummies books. In
this grouping of top ten lists, I go over ten terrific Web sites where
you can find additional reliable information about acne and
rosacea. You can also find my top ten tips for keeping your skin
looking its best. And finally, I include my ten recommendations for
things to never, ever do to, for, or with your skin.
Part VII: Appendixes
The appendixes in this book are intended to be helpful for you as
you come across information that’s not familiar. I included a glossary
so that you can look up jargony words that are part of the
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Introduction 5
acne world. Here you’ll find terms your dermatologist uses, unfamiliar
terms that are on the carton of your over-the-counter acne
medicines, and even some that are on the TV commercials we all
get to see while we’re watching The OC, Desperate Housewives, or
whatever programs geared toward teens or adult women might be
on. I define each word when I use it the first time, but you may find
it easier to check the glossary if you’re skipping through the book.
I also have an appendix that lists all the medications I cover
throughout this book and includes the various brand names that
acne and rosacea drugs can go under in different countries.
Icons Used in This Book
The cute little round pictures that you see in the margins are like
road signs that tell you about the things you should pay attention
to while you’re reading or browsing this book. They also tell you
about the material you can avoid reading because it goes into too
much technical detail.
This icon points out important information. It’s the real “take
home” stuff. Even, if you miss what’s above or below, keep these
tidbits in mind.
These chunks of information are helpful hints to really help you
take better care of your skin and, sometimes, your pocketbook.
This information is useful and important.
This icon indicates that there’s lots of jargon and extra material.
It’s not critical and you can skip it if you’re not very interested. On
the other hand, if you’re a budding dermatologist or just like technical,
jargony bits, definitely don’t skip ’em. It’s your call.
This icon alerts you to things that you should avoid or be very
cautious about — stuff that can be harmful to your health or your
bank account. Definitely pay attention to this advice!
This icon tells you when you should give your healthcare professional
a call.
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Where to Go from Here
Where you start in this book completely depends on you. If you
need to figure out what kind of acne you have, definitely go to Part II.
If you’re interested in how these pesky little zits form, Chapter 3 is a
must-read. If you only want to look at treatment options, skip to Part
III. If your acne has cleared up, but you want to manage and improve
the lingering scars, check out Chapter 17. As with any For Dummies
book, you can skip around and read what’s important to you at any
given time.
6 Acne For Dummies
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Part I
Facing Up to Acne
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In this part . . .
This is the place to start for the full story on acne. I give
you an overview of the condition — its causes and
appearance — and provide a few pointers on determining
if you can treat it yourself with over-the-counter products
or if it’s time to call in a dermatologist. Then, I introduce
you to the parts and functions of your skin, along with tips
on caring for this vital organ. Finally, I walk you through
the lifecycle of a pimple, explaining how acne forms.
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Chapter 1
Dealing with Acne
In This Chapter
Putting your best face forward
Outlining treatment options
Seeking the cure
Looking at the look-alikes
Benjamin Franklin said, “In this world nothing can be said to be
certain, except death and taxes,” to which I would add a third
certainty — acne. Acne is one of those equally dreaded, nearly universal
experiences through which most of us pass during our teen
years and, more recently, is increasingly coming back to revisit
many of us as adults. In this chapter, you find out that you’re not
alone in your desire to have clear skin. Along the way, you discover
that acne is a treatable condition and many of the treatment
options are made to order for your type of acne.
Acne Explained
Acne is the most common skin disorder in the world. Blemishes,
bumps, papules, pustules, spots, whiteheads, zits, goobers, the
plague, or whatever you call it, almost everyone is liable to get it.
In the United States and Canada, acne affects 45 to 55 million individuals
at some point in their lives, the vast majority of whom are
teenagers. In fact, nearly 80 percent of all young people will face at
least an occasional breakout of acne. Acne imposes itself on young
men and young women about equally, but young men are likelier to
have more severe forms of acne.
The events that take place in the sebaceous glands and hair follicles
trigger acne. The exact cause is unknown; however, regardless
of a person’s age, acne is a condition of clogged hair follicles and
the reaction of sebaceous glands, glands that are attached to hair
follicles and produce an oily substance called sebum. Mix in some
dead skin cells that become “sticky” and block the pores, add a bit
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of bacteria, and you have the makings of a breakout. For the full
story on your skin, check out Chapter 2. And for a more detailed
description about how pimples form, see Chapter 3.
Doctors believe that these events, and acne itself, result from several
related factors, including your hormones (which are responsible
for increasing oil production) and heredity (the tendency to
develop acne is often inherited from parents and other relatives).
Less commonly, acne can occur as a reaction to certain drugs and
chemicals, and other physical factors may exacerbate the problem.
I cover all of these issues, including the myths and misinformation
concerning the causes of acne, in Chapter 6 (and I review several
hormonal disorders that can result in acne in Chapter 20), but I’ll
put one myth to bed right now that will come as good news.
Pizza, French fries, and other greasy foods don’t cause acne or
make it worse. You’re welcome. (I’m a doctor, so I’m compelled to
remind you that though these foods won’t affect your acne, they
aren’t the building blocks of a healthy diet.) But before you snidely
bring this mistaken notion to your mom’s attention, another one of
her common statements is right on the money: “Quit playing with
your face.” Picking does make zits worse!
Waking up to whiteheads,
blackheads, and zits
In most cases, acne starts between the ages of 10 and 13 and usually
lasts for 5 to 10 years. The appearance of teenage acne (acne
vulgaris is the technical term that I throw around here and there in
the book) is largely the result of your body’s increased production
of hormones. The good news is that those embarrassing blemishes
usually go away and are often gone for good by the time you reach
your early 20s.
However, the not-so-good news is that for some unlucky folks, acne
vulgaris can persist into their late 20s or 30s or even beyond. But
back to the good news: There are many steps you can take to zap
the zits and improve the appearance of your skin, as I explain in
the “Creating Your Acne-Treating Program” section, later in this
chapter. And turn to Chapter 4 for the complete rundown on the
causes, appearance, and other considerations of teenage acne.
10 Part I: Facing Up to Acne
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Taking it on the chin later in life
Although acne is typically thought of as a condition of youth, an
ever-growing number of women (less often men) get acne for the
first time as adults. Acne is no longer just a teenage affliction.
There’s definitely been a rise in the number of adult women in
their 20s and 30s with acne — even those who never had a pimple
before!
Teenage and adult-onset acne have somewhat different characteristics.
For one thing, the appearance is different: Adults have fewer
blackheads and whiteheads; for another, adult acne tends to be
more often located on the lower part of a woman’s face. Also, the
appearance of female adult-onset acne is often closely linked to a
woman’s menstrual cycle as well as increased sensitivity to hormones
such as those brought about by pregnancy, starting or stopping
birth control pills, and other hormonal abnormalities.
If you’re really unlucky, you have adult-onset acne and have also
brought along some acne vulgaris from your teenage years. I provide
the full story on acne in adult women in Chapter 5.
Chapter 1: Dealing with Acne 11
Lights, camera, acne!
Whether you’re a teenager who is noticing acne for the first time or an adult who anticipated
permanently waving goodbye to it forever, you’re in good company. The careers
of Cameron Diaz, P. Diddy, Jessica Simpson, Alicia Keyes, Mike Myers, and Vanessa
Williams have thrived despite their continuing complexion problems with acne.
And think about some of those rugged faces from the silver screen. From the looks
of it, Tommy Lee Jones, Laurence Fishburne, Bill Murray, Edward James Olmos,
James Woods, and the great British actor and movie star Richard Burton (who married
Elizabeth Taylor, considered to be one of the most beautiful women in the world)
more than likely had pretty wicked acne when they were teenagers.
Of course, heavy makeup, favorable lighting, medications, and experienced dermatologists
have also probably helped them. I won’t be able to supply your own personal
makeup artist or a lighting technician to accompany you to school or work, but
I do provide tons of recommendations on how to use acne-fighting medications and
find a good dermatologist in this book.
You may not aspire to be a movie star. But the names I mention here are just a small
number of the people who have achieved success in an area where looks count
the most. Countless other people exist in all walks of life who went beyond their
acne to become successes in their fields. And so can you.
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Creating Your Acne-Treating
Program
If you have acne in the 21st century, you’re fortunate. Why?
Because there are so many great ways to treat it and there are
many more to come. But there are no quick cures for acne; in fact,
there aren’t really any cures. The goal of treatment is to manage
your acne, help control it, prevent it from scarring, and help you
look your best. The truth is that acne tends to heal itself over time,
but the right therapy can make your skin look better.
12 Part I: Facing Up to Acne
Ye olde pimple remedies
For those of you who are squeamish or are dog lovers, skip to the next paragraph.
Seventeenth-century Britons were as concerned about pimples as we are today.
According to an old manuscript of home remedies that was recently discovered,
people with acne were advised to cut the heads off two puppies, hang them up by
their heels to bleed, collect the blood, mix the blood with white wine, and apply the
concoction to the face. Yeech! Don’t try it; it won’t work!
At the beginning of the 20th century, most of the acne treatments involved the correction
of intestinal disorders such as indigestion and constipation. Recommended
anti-acne regimens included low-fat and low-sugar diets. Sound familiar? Excessive
sweating was discouraged, and — get this — some doctors recommended that
erotic preoccupation be avoided (without doubt, a difficult prescription to follow).
Active surgical treatment at that time included opening up and draining acne lesions
(they’re the zits), vigorous scrubbing, steaming, and washing with soap and hot
water. All of this was followed by the application of foul-smelling chemicals including
sulfur. For difficult-to-manage acne in middle-aged women, arsenic — both
applied to the skin and injected into it — was sometimes used!
In the middle of the 20th century, when I was a teenager, I distinctly remember some
of my fellow high school classmates coming to school with red, scaly faces the day
after they visited their dermatologists. I’ve since learned that they were subjected
to restrictive diets, carbon dioxide slush, superficial X-ray treatments, and ultraviolet
light exposures, only to be followed by self-applied rigorous cleansings, scrubs,
and chemical peeling agents. Ugh, no wonder their faces looked like red apples! It
seems barbaric today, but that’s all they had to treat acne at that time. Believe me,
people who have acne today are much better off than when I was a teenager.
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Meeting the players
Until the last couple of decades, there was very little anyone could
do to treat acne. But we’ve now come a long way from the “dark
ages” of arsenic and puppy blood (see the sidebar “Ye olde pimple
remedies”). Now we have excellent methods to treat acne and the
future looks even brighter. There are
Over-the-counter topical (applied to the skin) products that
contain such tried-and-true medicines as benzoyl peroxide
(see Chapter 7 for a complete list of products, their pros and
cons, and how to use them effectively)
Topical antibiotics and retinoids (I discuss these in Chapter 9)
Oral antibiotics (take a look at Chapter 10)
Hormones and anti-androgens for females (see Chapter 11)
Oral retinoids, like Accutane (see Chapter 13)
Chemical peels, special lasers, and lights (see Chapter 14)
Some people also claim that various alternative and complementary
approaches have helped improve their acne (in Chapter 15, I
outline the possibilities and give you my input and advice on such
matters).
Deciding whether to treat yourself
If you’re just starting to get breakouts or you have really mild acne
with a few blemishes here and there, the over-the-counter (OTC),
do-it-yourself route that I describe in Chapter 7 may be just the
ticket for you. Look in the mirror. If you see a few blackheads and
whiteheads or a few pimples, you can probably find ways to treat
them on your own.
You can find many acne products waiting for you at your local
drugstores and cosmetic counters. You can do many things to
improve the appearance of your skin without a prescription if
you’re a teenager just starting to get acne. Shelves are also stocked
with products specifically geared toward adult women.
You can also follow some of my skin-care tips and further ideas to
help you that I bring up throughout the book, like the face-washing
advice I provide in Chapter 2, the tips for healthy skin in Chapter 22,
or the list of things you should never do to your skin in Chapter 23.
Chapter 1: Dealing with Acne 13
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Although going to a doctor generally costs more than buying a
cream at your local drugstore, you’ll likely save money in the long
run and get better results than you’ll get by running through the
gamut of OTC acne products.
Relying on the experts
For some folks, acne can be more serious. In fact, by their midteens,
more than 40 percent of adolescents have acne severe
enough to require some treatment by a physician or a dermatologist
who is an authority when it comes to acne. And adult women
who are having problems getting their acne to respond to treatment
often need to make an appointment with a doctor.
But no matter who you are, you should definitely have your acne
evaluated by a knowledgeable healthcare provider if:
Your acne didn’t respond to home remedies, diets, herbal
medications, facials, special soaps, or nonprescription OTC
treatments.
Your skin can’t tolerate the OTC preparations.
Your acne is widespread and it involves your chest and back.
Your acne is beginning to scar or has already scarred.
Your acne has become more severe.
You are a female who develops facial hair or has irregular
periods (I address this issue in Chapter 20).
You’re not a “do-it-yourselfer” and you want the pros to
handle your acne.
You have dark skin, and patches that are darker than your
normal skin appear after your acne lesions clear. (For treatment
considerations particular to folks with darker skin, turn
to Chapter 12.)
In addition, you may need help dealing with acne scars, both the
physical and emotional:
Preventing and repairing scars: Even very mild or occasional
breakouts have the potential to leave permanent scars. There
are now exciting innovations in dermatologic surgery using
lights, lasers, and chemical peels to help improve the appearance
of the skin before and after acne has left its marks.
(Check out Chapters 14 and 16 for more information.)
14 Part I: Facing Up to Acne
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Healing the inner scars: The emotional effects of acne haven’t
always been fully appreciated, but many studies have demonstrated
its damaging psychological impact. Nowadays there is
a much greater interest in preventing and healing the inner
scars of acne. In Chapter 17, I talk about the psychological and
social scars of acne.
Avoiding quickie, quacky cures
Because your acne appears on your face and everyone can see it,
you may feel desperate to make it go away. But because it’s not life
threatening, you may feel reluctant or embarrassed to go to your
healthcare provider about it. Certain people prey on that knowledge.
They want to sell you expensive over-the-counter acne
“cures” that don’t do you any good, or get you to order them after
watching testimonial-filled infomercials.
The people giving those acne “testimonials” on TV are almost
always professional actors reading a script. And even those stories
that are “real” generally mean nothing. You can always find one or
two success stories while ignoring 99.9 percent of failures.
Even if it’s on TV, on the radio, the Internet, or in magazines, that
doesn’t mean it’s necessarily true. The world of acne fighting is
filled with snake oils and false promises.
There are promises that guarantee “five day cures” for your acne,
and there are the real slow pokes that state, “try this all timetested
home treatment for acne and have clearer blemish-free skin
within 30 days of use.” You can find many similar “cures” if you
search the Internet, so check out Chapter 21 where I give you some
roadmaps to some realistic acne advice you can find on the Web.
Also, check out www.quackwatch.com, a nonprofit organization
whose purpose is to combat health-related frauds, myths, fads,
and fallacies pertaining to health-related issues. Its primary focus
is on quackery-related information.
Chapter 1: Dealing with Acne 15
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Recognizing Impostors and
Related Conditions
There are several skin conditions that appear to be acne, but that
aren’t acne at all. Rosacea and keratosis pilaris closely resemble
acne, as does another acne look-alike, pseudofolliculitis barbae —
also known as razor bumps. These conditions, among others, are
pretenders that sometimes even fool doctors into thinking they’re
actually acne. There are many ways to control these acne impostors;
in Chapters 18 and 19 I show you how to do it.
16 Part I: Facing Up to Acne
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Chapter 2
Getting Comfortable with
the Skin You’re In
In This Chapter
Peeling back the layers
Finding ways to keep your skin in shape
Do you know what the biggest organ in your body is? It’s not
your brain, and it’s not your large intestine. Give up? The subject
of this book may have given the answer away, so I’ll suspend
any further guesswork and tell you: It’s your skin. That’s right; your
skin is an organ (just like your heart, lungs, and liver). And if you
spread out the skin of the average adult it would measure 20
square feet, about the size of a twin-sized bed sheet!
In this chapter, I cover the ins and outs of your skin so that you
can see just where your acne originates. I acquaint you with the
many functions that your “largest organ” performs and tell you a
little about how to take care of it.
Exploring Your Largest Organ
You may not really think of the skin as an organ, like the heart and
lungs. To many people, skin seems more like a simple cover to prevent
their insides from falling out. An organ is a somewhat independent
part of the human body that performs a specific function.
Once you know that, you can see that the skin is an organ, because
it performs the following specific functions (in addition to others):
Protects your body from infection
Serves as a waterproof barrier between you and the outside
world
Shields you from the sun’s harmful rays
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Provides cushioning like a shock absorber that defends you
from injury
Insulates your body and keeps your temperature right around
a cozy 98.6 degrees Fahrenheit (37 degrees Celsius)
Acts as an energy reserve
Alerts you to potential harm through your sensations of touch
and pain
Repairs itself (that’s why cuts heal)
Produces vitamin D
Because your skin has so many functions, you may not be surprised
to discover that it also has a rather complicated structure
with many working parts. It contains hairs that have their own oil
glands and tiny muscles — I’ll bet that you didn’t know that hairs
have muscles! Your skin has sensory nerves — hot, cold, touch,
and pressure receptors. It also is home to blood vessels, lymph
vessels, and sweat glands. Plus, your skin has microscopic pigmentproducing
cells, cells that work on your immunity, as well as cells
that protect and replace themselves. With all that going on, you
may be surprised that your skin doesn’t have its own zip code.
Human skin is made up of three layers. First come the top two
layers — the epidermis (the outside layer of skin that you can touch
and see) and the dermis (which is located directly beneath the epidermis).
Then comes the third, bottom fatty layer that the epidermis
and dermis rest upon, which is called the subcutaneous layer.
The prefix epi means “upon” and derm means “skin,” so, together,
they form epidermis (upon the skin). And obviously, dermis means
“skin.” The prefix sub means “under” and cutaneous is another reference
to “skin,” so the word subcutaneous means “under the skin.”
(I guess they should have named it the “subdermis” if they wanted
to be totally consistent.)
In the sections that follow, I take you on a guided tour of each of
these layers. And like any good tour guide, I provide you with a
map in Figure 2-1.
Getting above it all: Hey, your
epidermis is showing!
Your epidermis is really strong. The majority of the cells that make
up the epidermis are called keratinocytes. Keratinocytes are filled
with an exceptionally tough, fibrous, protein known as keratin.
18 Part I: Facing Up to Acne
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Chapter 2: Getting Comfortable with the Skin You’re In 19
Figure 2-1: A cross section of your skin.
The Latin term for cells is “cytes.” Therefore, keratino-cytes, by definition,
are cells (cytes) comprised of keratin.
Just as your skin has more then one layer (epidermis, dermis, and
subcutaneous layer), the epidermis itself has three layers. Within
these layers, there’s constant cellular motion going on.
Outer layer: The outermost layer of the epidermis is known as
the stratum corneum, also known as the horny layer. This layer
provides your body with a durable overcoat that protects
deeper cells from damage, infection, and from drying out.
This layer of your skin is actually made up of dead skin cells.
(Your hair and nails are made of dead cells too!) So when
you look at your skin, you’re really seeing skin that is dead.
But these deceased skin cells only stick around for a little
while. Soon, they flake off — like when you wash, scratch
yourself, go shopping, sit in class, fall asleep, and even read
this book. Basically, all the time. In fact, every minute of the
day we lose about 30,000 to 40,000 dead skin cells off the surface
of our body.
Hair
Sebaceous
(oil)
gland
Nerve Follicle Sweat gland
Subcutanous
layer
Fatty tissue
Muscle
Dermis
Epidermis
Pore
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Middle layer: This layer is known as the stratum spinosum.
The cells in this layer looked kind of spiny to the scientists
who first described them.
Inner layer: Known as the basal layer, the inner layer is like a
production facility for the new skin cells (keratinocytes) that
eventually make their way up through the stratum spinosum
to the outer stratum corneum to replace the dead older cells
you lose from the surface.
The keratinocytes in the basal layer stand up like little soldiers
at attention on what’s called the basement membrane, a
barrier that separates the epidermis from the dermis; it’s the
anchor that joins the epidermis and dermis together. The keratinocytes
are kept alive by the underlying dermis — which
serves as their blood supply because the epidermis has no
blood supply of its own. But their upward journey carries
them farther away from their supply lines, and as they
approach the top, they begin to die. By the time they’ve
reached the outer layer of the epidermis, they’ve lost virtually
all of their cellular contents except for tough keratin fibers
and other solid proteins. Even as they dry up and die, they
become much more resilient and durable and become the flattened
cells that form the stratum corneum. This one-way trip
takes about two weeks to a month to accomplish. Figure 2-2
demonstrates the process.
When an injury or an acne pimple penetrates the basement
membrane, a scar may result. (I describe acne scarring in
Chapter 16.)
Scratching the surface: Now your
dermis is showing!
Your dermis, the layer of skin that lies just under your epidermis,
has an intimate relationship with your epidermis. It comes equipped
with sensory nerves, sweat glands, blood vessels, and hair follicles.
It nourishes the epidermis by providing gases such as oxygen and
carbon dioxide, which reach the epidermis by diffusing through the
basement membrane. The epidermis can’t survive without the
dermis, because it has no nerves or blood supply of its own.
Throughout the dermis are collagen and elastin fibers. Collagen is a
resilient protein that provides rigidity and strength to the dermis.
Elastin is made of a protein structure that is able to coil and recoil
like a spring. This protein is what gives the skin its elasticity.
20 Part I: Facing Up to Acne
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Figure 2-2: The maturation and upward migration of epidermal cells.
Also located in the dermis is the hair follicle (refer to Figure 2-1). A
hair follicle is a hair-containing canal; a tube-shaped sheath that
surrounds the part of the hair that is under the skin. It’s located in
the epidermis and the dermis. Blocked hair follicles are often at the
root of the acne problem. In fact, it seems like the hair follicle is
the central focus of this entire book! (To read a detailed description
of how a follicle becomes blocked and a pimple forms, skip
ahead to Chapter 3.)
Styes, boils, shaving bumps — I could go on and on — all have
their origins in the hair follicle. In Chapter 19, I go into a few of
these conditions that folks often mistake for acne.
Digging deeper: Your
subcutaneous layer
Fat cells known as lipocytes reside in the subcutaneous layer. Our
visit to the subcutaneous layer will be brief because as far as acne
is concerned, there’s not much action going on here.
Dead cells are shed
Basement membrane
Keratinocytes
Cells mature
and flatten
Blood vessels
in the dermis
Basol layer
Horny layer
Chapter 2: Getting Comfortable with the Skin You’re In 21
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But if you’re interested, your subcutaneous layer is what your
outer layers of skin rest upon. Your fatty layer is your body’s insulator,
cushion, and natural shock absorber (and it also helps to
keep the diet industry in business!). The subcutaneous layer contains
arteries, veins, lymph vessels, and nerves that are larger than
those found in your dermis. If you go any deeper, you’ll come upon
muscles and possibly some of your inner organs. That’s out of
bounds! So I’ll end the anatomical tour right here in Fat City.
22 Part I: Facing Up to Acne
The skinny on skin
Here are some skin facts you can use to impress your friends and family:
Skin is your heaviest organ. It accounts for about 15 percent of your body weight.
That means that the skin of a 400-pound sumo wrestler can weigh in at as much
as 60 pounds! The skin of an average adult woman weighs about 20 pounds.
The thickness of the average epidermis varies from 0.5 millimeters on your eyelids
to 4.0 millimeters or more on the palms of your hands and the soles of your feet.
You produce a totally new epidermis about every 30 days!
Most of the dust in your classroom or bedroom is made of tiny fragments of
human skin. In just one minute, 30,000 to 40,000 skin cells fall unseen from the
surface of your body. That means you lose around 15 million or so skin cells in
one year. (Imagine how dusty it must be in that sumo wrestler’s bedroom!)
Your dermis is several times thicker than the epidermis and is particularly thick
on the upper back. Our thick upper back may have protected us from sabertoothed
tigers when we walked on all fours. On second thought, I doubt it.
“Goosebumps” come from tiny muscles called erector pili. These muscles
attach to each of our hairs and make them stand at attention when we’re cold
or afraid. We can see this phenomenon on a frightened cat whose fur stands on
end. It’s meant to make kitty look bigger and scarier to other animals. And when
we had more body hair during the Stone Age, it probably did the same for us.
You have about 3 to 5 million hairs on your body.
Your nails grow faster in warmer weather. They grow at a rate of 0.5 to 1.2 millimeters
per day, with fingernails growing faster than toenails.
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Basic Operating Instructions:
Taking Care of Your Skin
Different people and different skin types need to do different things
for their skin. We have an old expression in dermatology that still
rings true: “If it’s dry, wet it; if it’s wet, dry it.” In recent decades,
another truism has been added: “If it’s fair, shield it; if it’s dark,
you’re probably very fortunate.” That’s because your melanin protects
you from skin cancers, wrinkling, and keeps you looking
young.
If your skin is fair, if you burn easily, or if you have a personal or
family history of skin cancer, you should protect yourself from the
sun by wearing hats and caps, using sunscreens, and avoiding
going to tanning parlors. If your skin is dark, you may have other
reasons to protect it from the sun (see Chapter 12 where I talk
about the dark spots that occur in dark skin). People with dark
complexioned or Asian skin may have other reasons to be very
sensitive and prone to irritation and possibly less tolerant of many
of the topical medications that are used to treat acne.
The ultimate operating instruction: Whether you have dry, regular,
or oily skin, a big acne breakout or smooth sailing on the pimple
front, there’s something that’ll keep your face looking its best and
most attractive to the rest of the world and is guaranteed to help
you make friends and influence people. I suggest that you simply
exercise your muscles of facial expression — and smile!
Washing your face
Rocket science? Maybe not. But as a dermatologist, I have a few
reasons for walking you through a little face-washing tutorial. First,
I often begin my instructions for applying medications in later
chapters with phrases like “Wash your skin . . .” or “To a clean, dry
face, apply . . .” so, it seemed to make sense that I fill you in on the
details. The second reason for this bit of Face Washing 101 is even
simpler — many people screw it up. But don’t worry: I’m here to
help. And, if you’re like many folks, my face-washing routine can
simplify your mornings and evenings and save you some cash.
These days, society as a whole is really into soap — the cleaner the
better! As little kids, we’re told to scrub, scrub, scrub with plenty of
soap and water. As teenagers, we use more soap — to fight acne and
oily skin. As adults, we tend to follow the same routines even though
our skin has changed. And the range of different types of soaps
available is mind boggling — super-fatted, deodorant, rejuvenating,
Chapter 2: Getting Comfortable with the Skin You’re In 23
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oatmeal, avocado, citrus, aloe vera, sandalwood, wintergreen, peppermint,
patchouli, and vitamin E to name a few.
Many types of cleansers are also available. Some exfoliate as they
clean, and the medicated ones generally contain benzoyl peroxide
or salicylic acid in various concentrations. Overcleansing with
these products can be irritating. More often than not, these items
will only dry out and irritate your skin, particularly if you’re already
applying a topical anti-acne medication (see Chapters 7 and 9).
Washing excessively — more than twice a day — with any soap
(regular soaps, acne soaps, antibacterial soaps, soaps with abrasives,
or even gentle soaps) has little positive impact on your acne.
In fact, if you have acne, your skin may be red and inflamed, and
frequent washing only makes it redder.
Washing your face with a mild soap just twice a day is the best tactic,
regardless of your skin type or acne activity. I recommend the following
soaps and cleansers, depending on your skin type. These triedand-
true recommendations may not sound as exciting as a Provencal
honey-lavender soap with grape seeds, but they flat out work:
Oily skin: Ivory soap
Dry skin: Dove soap
Extra-sensitive skin or allergic reaction to soaps: Nonsoap
cleanser such as Cetaphil, Aquanil, or Neutrogena Extra
Gentle Cleanser
At the risk of sounding like a parent — with the whole “wash
behind your ears” thing — now that you have your soap, here’s
how to use it:
1. Get the soap wet, using lukewarm water.
2. Using your fingertips or a soft washcloth, apply the soap
to your skin and rub it gently into your skin using a circular
motion. Don’t use loofah sponges, brushes, or sandpaper
please.
3. Splash your face with lukewarm water until the soap is
completely gone. Expect to rinse your face for just a few
seconds — perhaps as long as it would take to sing “Happy
Birthday.”
4. Pat — don’t rub — your skin until it’s dry. Use a soft
cotton towel.
And that’s it!
24 Part I: Facing Up to Acne
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Dealing with dry skin
If you have overly dry skin (known as xerosis in the medical world),
it’s probably more of a problem for you when the weather is cold and
the humidity is low. This occurs most often in the winter months in
northern climates. In Western societies, our modern lifestyles also
emphasize overbathing, which only serves to worsen the dryness.
On top of that, we often live and work in overheated spaces.
If your skin is dry, keep it moist by using only mild soaps or soap
substitutes as I recommend in the preceding section. You could also
consider moving to a more humid climate — think rain forest. If
you’re already using a mild soap (and assuming a move to the
Amazon is out of the question), apply moisturizers regularly, particularly
when your skin is still damp (check out the “Giving your skin a
drink!” sidebar in this chapter to find out why). Finding the right
moisturizer for your skin may involve trial and error. Look for those
that are labeled as noncomedogenic. I happen to recommend Oil of
Olay, but many other excellent products are available. Go ahead and
use a moisturizer that contains a sunscreen if you think you need
one. You can also use room humidifiers to help hydrate your skin.
If you have acne and dry skin, you probably know that acne treatments
can make your dry skin worse. Using moisturizers over your
topical acne medicine can make these symptoms more tolerable. If
you wear makeup, you can apply it over the moisturizer.
Some common recommendations for dry skin are of questionable
or no value, including the following:
Ingesting copious amounts of water
Taking lots of vitamins
These “remedies” won’t hurt you, but don’t look to them to cure
your dry skin. Instead, treat your acne and dry skin with TLC and
the gentlest of cleansing methods.
If your skin gets flaky and scaly, that doesn’t mean that you have
wrinkles. In fact, several of the topical treatments that I cover in
Chapter 9 can cause your skin to look dry and scaly as a side effect,
but some of these medications can actually prevent wrinkles.
Coping with an oil glut
If you have excessively oily skin, that’s due to your sebaceous
glands producing more sebum (the acne-related oil that I discuss
in detail in Chapter 3) than you’d like them to. This is often the
Chapter 2: Getting Comfortable with the Skin You’re In 25
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case if you also happen to have acne. But for now, here are some
tips on caring for your oily skin:
Be happy that you’ll save a few bucks on not buying
moisturizers.
Be happier because your skin will tend to stay more wrinklefree
and younger looking!
Be even happier because your skin will tend to be less sensitive!
But you probably want some more concrete tips, so here you go:
Even though your skin’s oily, don’t irritate it. Washing your
face twice a day should be enough. I realize that you may have
been told to wash 77 times a day with strong abrasive soaps,
but that will only irritate your skin and make it redder — and
if you have acne, all that scrubbing will only make it look
worse! For advice on exactly how to wash your skin, check
out “How to wash your face.”
If parts of your face feel oily during the day, the oil can be
wiped away with a mild alcohol-and-water astringent such as
Neutrogena Clear Pore Oil-Controlling Astringent, Noxzema
Triple Clean Astringent, or Clean & Clear Advanced Acne Pads.
26 Part I: Facing Up to Acne
Giving your skin a drink!
The next time you take a long bath or stay in a swimming pool for a long time, notice
how soggy and rippled the skin on your palms and soles looks after a while. That’s
because they’ve been immersed in water for a long period and your waterproof protective
layer of sebum (the oily stuff that plays a large role in acne, as I discuss in
Chapter 3) got washed away, so water can now get readily absorbed into the outer
layer of your epidermis.
The rippling or wrinkled appearance develops because your skin has increased its
surface area to accommodate all the water it absorbed during that time. It’s waterlogged!
The “wrinkling” is so obvious on your palms and soles because they have
the thickest stratum corneum. If you watch your hand for 5 minutes or so, you’ll see
that the corrugated look disappears. That’s because the water soon evaporates
from your overhydrated stratum corneum.
Now, if you apply a moisturizer before the water evaporates, you can “lock in” the
water that was absorbed while you were bathing or showering. Moisturizers don’t
add water to the skin; instead, they reduce water loss by slowing its evaporation.
Your take home message: If you have dry skin, apply a moisturizer while your skin
is still damp.
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Chapter 3
Tracing the Evolution
of a Pimple
In This Chapter
Following the formation of a pimple
Classifying your acne
Ah, the pimple. It’s the bane of many a school picture and wedding
day. Pimples help keep photo retouchers in business.
But for many people, pimples aren’t simple nuisances that pop up
at inopportune times. Instead, they’re a daily reminder that seemingly
uncontrollable forces are at work in the skin.
In this chapter, I outline the events that are required to make acne
lesions. (A lesion is dermatologist lingo for any abnormality or
mark of the skin. A pimple is a lesion. A blackhead is a lesion. Your
nose isn’t a lesion, unless you have two of them.) I take you
through many of the conditions necessary for a lesion to form and
evolve: blocked hair follicles, overworked oil glands, and bacteria.
Then I help you categorize your acne in order to understand when
and why different treatments are used on the various types.
Paying the High Price for Oil
Acne lesions originate and mature in the hair follicle, the epicenter
of our acne story. (To get a visual of what a normal, healthy follicle
doing its job looks like, take a peek at Figure 3-1.) Ultimately, in
order for acne to develop, a follicle must be blocked. A blocked follicle
isn’t the only condition necessary for acne to form (I detail
the others in the sections that follow), but it’s a big one. So, to talk
about the roots of acne, you need to go directly to the hair follicle.
Technically, the hair follicle and sebaceous gland are called the
pilosebaceous unit (PSU). For simplicity sake, I just refer to the
whole thing as the “follicle” or “hair follicle” in this book.
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Figure 3-1: A normal follicle.
The hair follicle (actually the PSU) is made up of three components:
Sebaceous gland: This gland resembles a cluster of grapes
and produces and pumps out a beneficial oily substance
called sebum (pronounced see-bum) that coats and conditions
the hair and skin. The oily sebum is composed of a rich blend
of different lipids (fatty chemicals). Sebum rises to the surface
of your epidermis to keep your skin lubricated and protected.
It also helps makes your skin waterproof. Plus, sebum helps
carry dead skin cells out of the hair follicle and to the exterior
skin so that the body can get rid of them.
In people with acne, there is an excessive production of
sebum. Along with its producer, the sebaceous gland, its
fellow cast member, the hair follicle, and its director testosterone
(an important hormone), sebum plays much more than
a bit part in the acne story.
Sebaceous duct: This tiny tube steers the sebum (and the dead
skin cells it carries) from the sebaceous gland into the hair
canal, the part of the follicle through which sebum travels onto
the hairs before it is carried out to the exterior of your skin.
Hair: I’m talking about the actual hair that sprouts out of your
pores (follicular orifices, or the holes in your skin that your
Hair shaft
Skin pore
Arrector pili muscle
Hair canal Hair follicle
Sebaceous duct
Hair bulb
Sebaceous gland
28 Part I: Facing Up to Acne
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hair grows out of). Hairs are sometimes called strands or hair
shafts. Hairs are found all over our bodies; well, almost all
over. There’s no hair on your palms, I hope. Hairs help carry
sebum to our skin.
Priming the pump with hormones
Hormones play a central role in the acne drama. Hormones are the
body’s chemical messengers. Without hormones, you wouldn’t
have acne, but you’d be in pretty bad shape, because hormones
control just about every bodily function, from regulating your
metabolism to ensuring that you can mature and have children.
In both males and females, a particular group of hormones, called
androgens, are primarily associated with the formation of acne. The
term androgen is a general term for hormones that have more masculinizing
features. Androgens are responsible for the development
of secondary sex characteristics in males (facial hair, increased
muscle mass, the ability to reproduce, and so on). The androgen
testosterone is the main male hormone. However, if you’re female,
you have androgens too, but they’re produced in smaller quantities
and are much weaker than in your male counterparts.
Estrogen and progesterone are the primary female hormones that
control menstrual cycles and regulate pregnancy. Both of these
hormones can have an affect on acne as well — albeit less than
androgens — by their periodic monthly fluctuations. (I talk more
about these hormones in Chapter 5.)
The androgenic hormones help us regulate how much sebum (the
healthy oil I describe in the preceding section) our sebaceous
glands produce. People who get acne aren’t producing any more of
these androgens than anyone else; it’s just that their sebaceous
glands are very sensitive to the hormone’s message to increase
production. The glands respond by pumping out excessive
amounts of sebum. Your face, chest, and back contain the highest
concentrations of sebaceous glands; that’s why you’re more likely
to have acne on these areas.
Adolescence is generally the worst time for acne because androgens
are increasing steadily during the teen years, and they signal your
sebaceous glands to get larger and to generate more sebum, as
shown in Figure 3-2. As adolescence ends, the amount of androgen
secretion diminishes and acne tends to disappear for most teens by
age 18 or 19. But for various reasons that I discuss in Chapter 5,
some women (and much less commonly, men) retain a heightened
sensitivity to their androgens and continue to have acne beyond
adolescence. Some women even get acne for the first time as adults.
Chapter 3: Tracing the Evolution of a Pimple 29
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Figure 3-2: The sebaceous gland overreacts to androgen stimulation.
Clogging your pores and narrowing
the hair canal
Every day, millions of skin cells die off. You continually make new
skin cells and get rid of dead ones. Your body has ingenious ways of
getting rid of these dead cells. In the case of your skin, sebum carries
the dead skin cells to the outside of the body where they flake off.
Sometimes, though, as sebum ferries dead cells from the inside of
your hair follicle along the oily sebaceous ducts and out through
the hair canal, the exit route of the follicle is blocked by the excess
oil. This blockage causes the opening of your hair canal to narrow,
and your pores, the tiny openings in your skin that serve as exits
for your hairs, get clogged (see Figure 3-3). The exit of oil is also
often impeded by a process called abnormal follicular keratinization.
That’s a fancy way of saying that instead of flaking off with the
sebum when they reach the skin’s surface as they normally do, the
dead skin cells and keratin clump together with the oil to further
clog the sebaceous ducts and hair canals.
Oily skin
Growth of
sebaceous gland
Increased oil production
Androgen
Stimulation
30 Part I: Facing Up to Acne
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Figure 3-3: The clogging of pores and the narrowing of the hair canal.
Acne is not caused by forgetting to wash the oil off, or even by
eating loads of greasy French fries and junk food. It’s not the oil in
your tummy or on your skin; it’s the oil in your skin.
Forming blackheads and whiteheads
The trapped sebum, cells, and keratin form a very sticky
mixture — a real traffic jam that blocks the exit route. This plug
acts just like a cork in a bottle, locking in all that stuff inside with
nowhere to go, so that it can’t exit onto the surface of the skin
(see Figure 3-4). The plug is called a microcomedo (pronounced
my-kro-cahm-e-doe). You can’t see a microcomedo with the naked
eye; it’s too small. Over time, the increasing amount of trapped
sebum builds up a lot of pressure and the hair follicle blows up like
a balloon and becomes a visible comedo (pronounced cahm-e-doe;
the plural of comedo is comedones).
There are the two types of comedones (which you can see in
Figure 3-4 and also in the color section of this book):
Oily skin
Pore
Oil bottleneck
Oil trapped
in hair canal
Enlarged
sebaceous
gland
Chapter 3: Tracing the Evolution of a Pimple 31
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Figure 3-4: The microcomedo forms and becomes either a blackhead (A) or a
whitehead (B).
Blackheads: If the comedo enlarges and pops out through the
surface of the skin, the tip looks dark and it’s called a blackhead.
The dark color is not due to dirt; it’s the result of a
buildup of melanin, a dark pigment in the skin that turns
black when exposed to oxygen in the air. Blackheads are also
known as open comedones.
Whiteheads: If the comedo stays below the surface of the skin,
it’s light in color and looks like a small whitish bump; it’s called
a whitehead. Whiteheads are also called closed comedones.
Comedogenesis is the medical term for the process that forms
whitehead and blackheads.
Battling bacteria
The microcomedo may develop into, and remain, a comedo. But
sometimes it becomes an inflammatory lesion. Inflammation is a
reaction of the skin to disease or injury; in the case of acne, the
inflammation is a reaction to the bacteria known as Propionibacterium
acnes. Signs of an inflammatory lesion include swelling,
redness, heat, and sometimes pain. The presence of these bacteria
does not mean that poor hygiene is a cause of your acne.
Here’s a list of common inflammatory acne lesions:
A
Open comedo blackhead
Closed comedo whitehead
The canal swells
B
Microcomedo
32 Part I: Facing Up to Acne
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Papule: A small, firm red bump, commonly referred to as a
pimple or zit. It’s made up of inflammatory blood cells and
doesn’t contain obvious pus.
Pustule: A papule that contains pus, a whitish, goopy substance
that’s really just a bunch of white blood cells. Pustules
are also known as “pus pimples.”
Nodule: A large and often tender, lumpy, inflamed, pus-filled
papule or pustule that’s lodged more deeply in the skin. The
term cyst is often used interchangeably to mean “nodule”
because of the resemblance of a nodular acne lesion to a cyst.
One other common acne lesion is sometimes formed late in the life
cycle of a lesion from the remains of an inflammatory lesion:
Macule: A macule is a flat red, purple, or brown spot that
forms where a papule or pustule used to be. A macule remains
for a while after an acne lesion has healed or is in the process
of healing. For more details on how your skin heals, check out
Chapter 16.
To see what the preceding lesions look like, take a look at the color
section of this book.
P. acnes jumps in
In order for comedones to move up the inflammation chain into a
full-blown lesion, they need the help of a certain bacteria. You
know how people add yeast to make a cake rise? Well, the bacterium
known as Propionibacterium acnes helps make the zits rise.
From now on, I just call him (or is it her?) P. acnes, for short.
P. acnes is an anaerobe. That means that it prefers to live in areas
that have very little oxygen such as in the low oxygen environment
that exists in a hair follicle.
P. acnes generally minds its own business. These usually “friendly”
and harmless bacteria are present on everybody’s skin, but in the
proper environment (like a nice roomy, oily, hair follicle), they can
cause trouble: In some kids and adults who are predisposed to
have acne, P. acnes invade the plugged hair follicles (the comedones)
and multiply.
These P. acnes never become bored or go hungry because they
continuously munch on the oily, fatty sebum that serves as a food
supply for them. They accomplish this culinary feat by producing
chemicals known as enzymes. Enzymes are proteins that cause a
chemical change in other substances without being changed themselves.
P. acnes enzymes are like our knives and forks that help us
to chop up our food into smaller pieces so that it’s digestible.
Chapter 3: Tracing the Evolution of a Pimple 33
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The P. acnes produces the enzyme lipase, which can split apart certain
fats (triglicerides) into smaller pieces (free fatty acids) so they
can digest them.
P. acnes eating breakfast, lunch, and dinner, combined with the
force of the trapped sebum, can cause ruptures or leaks in the wall
of the comedo, allowing the free fatty acids into the surrounding
dermis. (Check out Chapter 2 for information about the dermis, the
skin layer that’s below your epidermis.)
Calling all white blood cells!
When the bacteria start to use their lipases to produce free fatty
acids, this causes other chemical 911 signals to be sent to your
white blood cells. That’s because the free fatty acids are very irritating
to the skin. Your body responds to the irritation by recruiting
an army of red and white blood cells (sounds like the Russian
revolution!) to seal off the area where the free fatty acids and bacteria
are located. White blood cells are your body’s natural defense
system. They rush to the scene accompanied by red blood cells to
try to clean up the mess. Despite their good intentions, sometimes
these helpful little cells overdo it and produce inflammatory acne
lesions. The cleanup attempt results in red, swollen pimples or
pustules that may even lead to even larger lumps, papules, and
nodules. See Figure 3-5.
Scarring: Your skin’s repair kit
The responsibility of repairing any injury that takes place belongs
to cells in the dermis known as fibroblasts. These cells produce collagen.
The collagen in your dermis plays the major role in patching
up any damage to your skin. When there is an overproduction of
collagen, the excess collagen becomes piled up in fibrous masses,
resulting in a characteristic firm scar. The P. acnes bacterium can
also contribute to destruction by releasing tissue-destroying chemicals
that can damage normal collagen, and result in scarring.
34 Part I: Facing Up to Acne
It’s Latin to me
The word comedo means a “glutton” in Latin and derives from a verb meaning to
eat. I guess the microcomedo must be a little glutton? The word is comer to those
of you who know some Spanish. Do you think the ancient Romans knew about the
voracious eating habits of P. acnes, or did they just think that acne was caused by
eating too much Roman junk food? Another conjecture has it that the ancients imagined
the blackhead to be a flesh-eating maggot or “flesh worm.” Gross!
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Figure 3-5: The microcomedo becomes an inflammatory papule (A),
pustule (B), or nodule (C).
Acne scars are the visible reminders of where the body’s inflammatory
battle against an acne lesion took place. The deeper an acne
lesion is lodged in the skin, the greater the chance for scarring. For
more on scars and healing, take a gander at Chapter 16.
Classifying Acne
It’s important for us dermatologists to be able to describe acne in
various categories. It helps us to better understand what our
patients have to say and it helps us to communicate with one
another. It also helps us to follow the progress or lack of progress
in our treatments. Here are the basic categories of acne; terms that
you’ll run into later in this book, and likely in your doctor’s office:
Non-inflammatory acne: This category of acne is identified
when a person’s lesions are primarily whiteheads and blackheads.
It’s sometimes called comedonal acne, because it’s
characterized by comedones.
A
B
C
White blood cell
Bacteria
Papule
Bacteria
Pustule
Nodule
Chapter 3: Tracing the Evolution of a Pimple 35
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Inflammatory acne: In this type of acne, papules or pustules,
red or purple macules, and nodules, often termed “cysts,” are
predominant.
A single patient can have a combination of both non-inflammatory
and inflammatory acne. Typically, this combination is seen in
teenagers rather than adults. Adults more often have inflammatory
acne. The way acne is treated often depends on which type
you have:
For acne that is primarily comedonal with blackheads and
whiteheads, we use agents known as retinoids, such as
Retin-A, Differin, or Tazorac to treat them. These drugs are
comedolytic, which means they break up comedones.
If you have inflammatory acne, we tend to rely more often on
benzoyl peroxide and/or topical and oral antibiotics.
If you have a combination of both types of acne, we tend to
use benzoyl peroxide in combination with the retinoids.
You can read more about these treatments, and many others, in
Part III.
36 Part I: Facing Up to Acne
A mountain or a molehill?
Keep in mind that one person’s “mild” is another person’s “severe” and vice versa:
To illustrate this point, I must tell you about two types of patients:
A 35-year-old man appeared in my office covered with papules, pustules, nodules,
and scars on his face and chest. When I asked him for the reason for his visit, he
pointed to his finger and said, “For this wart.”
He wasn’t in the least concerned about what I considered to be his severe acne. I
couldn’t resist, so I asked him about it and he said, “All the men in my family have acne
and I, like them, have no problem living with it. I’m married, and my wife couldn’t care
less about it either,” he continued. So I treated his wart and he left with a smile.
On the other hand, I have several patients, both male and female, who call me every
few months, feeling extremely upset if they get even one small pimple on their chins.
Go figure!
Moral: A pimple is in the eyes of the beholder, or one person’s mountain is another
person’s molehill.
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Part II
Figuring Out Your
Acne and How to
Tackle It on Your Own
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In this part . . .
Not all acne is alike. Acne has many faces and features,
and the condition often varies according to
age group (teens and adults) and gender. So, I spend some
time in this part distinguishing between the signs and
symptoms of teenage acne, which affects both boys and
girls, and adult-onset acne, which largely targets females
in their 20s, 30s, and beyond. I also set the record straight
by weighing in on the various factors that some people
claim make your acne worse. Finally, I provide you with a
complete guide to over-the-counter acne-fighting preparations,
explaining how to use them, what to expect, and
what side effects to be on the lookout for.
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Chapter 4
Examining Acne in Teens
In This Chapter
Addressing teenage acne
Figuring out what causes teenage acne
Putting some old notions to rest
Battling the blues
Acne is the most common skin problem that teenagers face.
Just about nine out of ten of them have to deal with pimples
or acne at some time. That’s right, nearly 90 percent of kids have
to deal with at least an occasional breakout of pimples.
In this chapter, I give you the lowdown on teenage acne. I help you
spot teenage acne in all its glory. I help you deal with the emotional
scars of acne. And I remind you (or tell you for the first time if you
haven’t heard it before) that you don’t have to accept acne as a
rite of passage. You can do something about it.
Identifying Teenage Acne
We dermatologists generally refer to the acne that you get as a
teenager as acne vulgaris. Yeah, it sounds horrible, but vulgaris is
the Latin word for “common,” not “obnoxious” or “repugnant.” And
as you saw in the stats I just tossed around, common is a good
choice of words! (Some adults also suffer from acne vulgaris that
sticks around after the teen years turn to the 20s and beyond. But
most adults usually have a somewhat different type of acne, which
I discuss in Chapter 5.)
In teenagers, acne is one of the signals that your body is going
through a tremendous upheaval called puberty (see the
“Understanding the Causes of Teenage Acne” section, later in the
chapter, for details). Teenage acne often begins around the ages of
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10 to 13. It may start before puberty in both sexes, but teenage
girls tend to start getting acne at a younger age than boys; however,
boys tend to have the more severe cases.
Studies have shown that puberty is occurring at an earlier age
these days, and so is acne. Most teenagers grow out of it when
they reach 19 or 20; however, don’t be surprised if your acne persists
into your early 20s and even into later adulthood.
But just because acne is common and almost every teen suffers
through it doesn’t mean you can’t do anything about it. You don’t
have to just wait for it to go away. That’s what I’m here for — to
help you knock out those pimples, whiteheads, and blackheads.
With so many excellent acne treatments available today, treating
your acne will prevent (or at least greatly lessen) the scarring that
often results from untreated acne.
40 Part II: Figuring Out Your Acne and How to Tackle It on Your Own
The curious case of the mail-order miracle
Jonathan is 16. He first started getting acne when he was about 14 when he saw a
few small whiteheads and blackheads on his forehead and nose. Then his skin
became greasy. His mom told him that if he just washed his face more often, his
skin would look better and the pimples would clear up. But despite increased washing,
his acne got worse and he started developing a few red pimples in addition to
the whiteheads and blackheads. His mom started buying an acne cream from the
drugstore. Jonathan tried it for a few months and it seemed to help a little.
But when he turned 16, he became really embarrassed and extremely self-conscious
about how bad his acne made him look and he hated going to school. His mom then
ordered a product that she saw advertised by doctors and movie stars on television.
It was very expensive, but it promised to stop Jonathan’s acne in its tracks! So Mom
began ordering it by mail on a monthly basis. But just like the other over-the-counter
product that she tried, this one helped a little, but not for long.
By the time his mother brought him to me, Jonathan’s acne was completely out of
control, and the mail-order product was starting to really irritate his face. After a
few months of prescription cream medication, his face became almost completely
free of acne! I reminded Jonathan and his mom about a few key points: You can’t
wash acne away, and in many cases washing your face too frequently or scrubbing
too hard can worsen the appearance of acne (see Chapter 2). I also mentioned that
it’s hard for movie stars and “television doctors” who have never even seen your
skin to make the correct diagnosis, let alone know exactly the best way to treat your
personal skin problem.
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Not that many teens have real problems (like scars or serious emotional
problems) from acne, but if you do, there are a bunch of
things that can be done to help you with those issues as well. In
Chapters 16 and 17, I cover the physical scars and the emotional
ride that some teens with acne have to endure.
If you want to jump ahead, you can check out Part III, where I provide
advice on tackling the problem with the help of a dermatologist.
Or take a look at Chapter 7, where I have advice on how to
handle it on your own. Read on, though, if you want the full story
on teen skin and the acne that it hosts. (You can also check out the
sidebars throughout this and other chapters for stories about
some of my real patients.)
Taking a look at teen skin
Teenagers’ faces are all different. Your skin may be dark or light
complexioned. You may have dry skin, oily skin, combination skin,
sensitive skin, or be “thick-skinned” (I’m talking blowtorch-resistant,
here). I can’t generalize, but there are a couple of tendencies that
make your skin different from that of adults:
More oiliness and less sensitivity: Teen skin tends to be a
little oilier, and that’s probably a good thing because many
treatments that are effective for teenage acne can be somewhat
irritating to the more sensitive skin that commonly
affects adults. The extra oil serves as a waterproof barrier
between you and the outside world and protects your skin
from irritation. In Chapters 7, 9, and 10, I list some of the different
medications that can be used to treat acne-prone skin.
Easier to heal: Your skin tends to be more “forgiving” and to
heal more completely after experiencing acne. This is especially
important when it comes to avoiding permanent scars
and those dark spots that tend to appear in people of color
when their acne lesions heal. I go into physical scars of acne
in Chapter 16 and the dark spots and other issues related to
acne in dark complexioned skin in Chapter 12.
Exploring teen acne
Good ol’ acne vulgaris, teenage acne. If you have it, you have an idea
what it looks like (or you can take a look at the color section of this
book for a photo). But there may be more in store. Plus, if you
skipped over Chapter 3, getting a handle on some of the terminology
here can help you out if your dermatologist starts throwing it around.
So, without further delay, here are the main features of teen acne:
Chapter 4: Examining Acne in Teens 41
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Centered on the T-zone: Typically, teenage acne tends to flare
up on the forehead, nose, and chin. Take a look at Figure 4-1 to
see a picture of this T-zone. Sometimes however, acne can
have a mind of its own and it can pop up anywhere on your
face or trunk.
Blackheads and whiteheads: We dermatologists call these
two unwelcome visitors comedones. Actually we call blackheads
open comedones and whiteheads closed comedones.
(You have to turn to Chapter 3 to find out why, though.) These
black and white bumps are largely the upshot of teen acne
and aren’t so common in adults.
Inflammatory lesions: These acne lesions are called papules,
pustules, nodules, and cysts. These are the red, pus-filled,
lumpy, inflamed, and sometimes sore, painful zits.
Figure 4-1: Teens often experience acne
flare ups in the T-zone.
Tracking acne’s footsteps
In its full glory, teenage acne generally looks like a mixture of
blackheads and whiteheads (comedonal acne) with papules and
pustules (inflammatory acne) and macules (healing lesions).
Awesome! Here’s how teenage acne can look in different kids.
Maybe you’ll find your type in one of the following descriptions:
42 Part II: Figuring Out Your Acne and How to Tackle It on Your Own
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Initially, the main lesions may be whiteheads and blackheads.
Often they start out in a nice, embarrassing, central location —
the nose and forehead. This part of the T-zone is where your
skin tends to be most oily and, therefore, likely to develop acne.
As time goes on, you may discover a zit (also called pimples
or papules; the red stuff) here and there, and an additional
blackhead or whitehead now and then. There’s a good chance
that they will come and go. At this point, we’re still in the “it’s
no big thing” stage. This type of acne is a rite of passage that
almost all of us go through. If you’re lucky, this will just pass
by itself or you can help it clear up with some inexpensive
over-the-counter stuff that you can buy at your local drugstore
(see Chapter 7 for the names of these medications).
Sometimes, however, the going can get a little rougher: The
whiteheads and blackheads want to hang around a lot longer
and sometimes a population spurt of inflammatory papules
and pustules really start making their presence felt. They can
be seen in the center of the face but may also be scattered all
over the place including your neck, chest, and back.
If you have dark skin, you may not see all of this red stuff
because your acne may look brown or even darker on your skin
(see Chapter 12 where I go into acne that’s seen in darker skin).
As individual acne lesions heal, macules (dark red or purple
spots) form and linger until the lesion heals completely. The
macules may look brown or almost black in color if you are
very dark-complexioned.
In some teens, especially those who have inherited a tendency
to develop scarring acne, acne nodules may appear.
They can get quite large, lumpy, and painful. They’re inflamed
lesions that are situated deeper than ordinary papules and
pustules and can, if they go untreated, leave deep or thickened
scars. This is called nodular acne (see Chapter 3 for a
full description).
Fortunately, even if acne reaches this point, dermatologists can
treat it very effectively in many people with oral antibiotics
and, if necessary, with an oral retinoid, known as isotretinoin,
or Accutane. (I discuss this powerful drug in Chapter 13.)
Besides these strong medicines, we have many new tricks up
our sleeves, such as lasers and special lights to treat your acne.
Chapters 14 and 16 explain these cutting-edge treatments.
Chapter 4: Examining Acne in Teens 43
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Understanding the Causes
of Teenage Acne
You may think you have teenage acne as some sort of punishment
for a crime you didn’t even know you committed. Actually though,
you’re breaking out for two main reasons. The first is that, as you
mature, your hormones are telling your oil glands to produce too
much oil, and your body isn’t handling the oil very well. Another
reason you’re breaking out? Well, you may be able to go ahead and
blame your parents or other ancestors for this one. Heredity plays
a huge role in whether you end up with acne. In this section, I go
over both topics to give you a better idea of why you’re breaking
out. (In Chapter 6, I provide you with many other theories and possible
causes of acne.)
Passing through puberty:
Hormones gone wild
By the time you hit puberty, it may seem like all you hear about is
hormones and how they’re to blame for every problem you have,
from shyness to a low paying job to acne. In the case of acne, what
people are telling you is the truth. Hormones are to blame!
Hormones are the chemical messengers that provide the signals
that regulate many of your body’s functions and that are responsible
for the changes you experience during puberty. They’re also
responsible for bringing your acne to the forefront. (I go into more
detail on hormones in Chapter 3.)
The most important hormones when it comes to acne are your
androgens. Androgens are really a group of closely related hormones.
The androgen testosterone is the main “male” hormone.
Besides bringing on puberty-related changes, it’s also central to
our acne story.
44 Part II: Figuring Out Your Acne and How to Tackle It on Your Own
It’s Greek to me
The original name for acne was derived from the Greek word akm — and Latin acme
meaning high point or peak. I’m thinking the name came from the fact that some of
the pimples looked like the size of Mount Olympus to akm — sufferers.
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Androgens are a natural part of development for both boys and
girls, but boys tend to produce more of them, especially testosterone,
which is why boys have bigger bodies and stubbly beards.
The higher level of testosterone in boys is considered to be the
reason that they tend to get more severe breakouts of acne than do
girls. As in males, androgens also are necessary for the development
of acne in females.
Estrogen and progesterone are female hormones that play the primary
role in puberty. These female hormones play less important
roles in the evolution of teenage acne than do androgens, but their
influence on acne’s ups and downs, as well as their part in its treatment,
is significant. I talk about both of them in relation to adultonset
acne in Chapter 5, and I tell how they’re used in the
treatment of acne in Chapter 10.
Chapter 4: Examining Acne in Teens 45
Dousing occasional flare-ups
When she was in eighth grade, Margot’s parents had taken her to see a dermatologist
who prescribed a cream and a gel. This approach worked very well for several years
and kept her acne under good control. However, during midterms in her sophomore
year of college, she began getting red bumps all over her face. She started to wear a
coverup makeup, which she hated to use. “It looked so artificial,” she said. “I stopped
going out on dates; I was so embarrassed about the way I looked.” Moreover, her pimples
would flare up “like clockwork” right before her periods.
When I first saw her in my office, I recommended that oral antibiotics (acne medications
that are taken by mouth) might help to clear up her skin. She said that she
was somewhat reluctant to start taking them because she was concerned about
the possible dangers, but nonetheless agreed to start taking them.
On a subsequent appointment, she was very pleased with how much progress she’d
made. Her face was looking better and her red pimples were now flat, so she could
more easily cover them with makeup. I then suggested that she gradually taper off
the oral antibiotic by lowering her dosage and suggested that hopefully she could
“wean” herself off of the oral therapy and see if the cream and gel alone would do
the job. If not, I told her that we could try the oral method again, if necessary.
The system worked very well. Except for breakouts before her period, Margot’s acne
was not much of a problem. On several occasions during her junior and senior years,
she required the oral antibiotics and they continued to have success in quelling her
bad flare-ups.
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During puberty, the levels of androgens in both boys and girls
starts to climb and begins to stimulate your oil glands to grow and
produce more sebum. If you develop acne, you probably don’t
have higher amounts of these androgens; it’s more likely that you
have a higher sensitivity to them. You can flip back to Chapter 3 to
see how this happens.
And how’s this for an entry in the “perfect timing” category: Just
when you guys begin to shave, up pop those bumps that get in the
way of your razor. Now you have the added problem of having to
shave over and around those papules and pustules. It’s like an obstacle
course! Turn to Chapter 19 where I give some shaving advice.
Thanking your family:
The heredity factor
That’s right. You may be able to thank your mom, dad, aunts,
uncles, and grandparents for the current state of your face. Check
in with your parents and their siblings to see whether they’ve had
acne too and how severe it was. If acne runs in your family (or
even hides — it may be lurking under shirts and blouses!), you’re
more likely to have it too. Feel free to drop them a thank-you note.
If both of your parents had acne, you’re even more likely to have it.
In fact, identical twins tend to share acne problems just like they
share looks. And they got their acne genes from their parents, who
inherited them from their parents, and so on, probably back to the
Stone Age.
Why is acne hereditary? Well, for the same reason anything is
inherited from your parents: for instance, the color of your skin,
eyes, and hair. Scientists are still trying to pinpoint the exact
genetic cause or causes of acne. We do know that you inherited
something from your parents that tells your body:
How much oil to produce
How big or small your oil glands are
How sensitive your oil glands are to androgens
How easily your pores get clogged
How quickly your skin cells replace themselves
How quickly your immune system reacts to the acne-producing
bacteria, P. acnes.
46 Part II: Figuring Out Your Acne and How to Tackle It on Your Own
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All these instructions are just swimming in your gene pool. And
sometimes, what finally emerges is often just a matter of luck! For
more on how these points meld together to actually form acne,
turn to Chapter 3.
If you were adopted, you inherited the acne tendency from your
biological family.
Acknowledging the Emotional
Acne can be difficult to deal with at any age. But for teens, the
appearance of acne can be especially trying. Who has time to deal
with this stuff? At a time in your life when you’re working on your
homework, social life, dating, trying out for the school play, and
getting a job (among all the other activities and events in life),
developing acne can seem like a major bump in the road. You’ve
got better things to do with your time. But there’s a lot that you
can do to control acne without letting your life get out of control.
Maybe you feel totally alone. Maybe you just want to stay in your
room, pull the covers over your head, curl up into a little ball, and
hide away forever. Maybe you feel worthless and you want to give
up. Guess what! I don’t think I’ve ever met a teenager — even those
without acne — who doesn’t feel that way at some time or other.
It’s natural! Even adults get that way sometimes.
You may feel uncomfortable talking about acne. Acne can be
embarrassing, but I’m sure there are people to talk to if you give it
a shot. If you try talking to trusted friends, your doctor, or your
parents or other family members, I think you’ll be surprised by
how helpful they are!
Close to 90 percent of teens face acne at some point in their lives,
which means that 90 percent of adults also know how it feels. For
more on dealing with the emotional side of acne, and getting out of
those emotional ruts that accompany it, see Chapter 17.
Chapter 4: Examining Acne in Teens 47
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48 Part II: Figuring Out Your Acne and How to Tackle It on Your Own
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Chapter 5
Addressing Acne
in Adults
In This Chapter
Describing adult-onset acne
Cycling through the ups and downs of acne in women
Uncovering acne in men
High school is a memory. You have a career, you’re going to
college, or you’re raising a family. You’ve settled down. Acne,
you assume, is a thing of the past. But just when you think that
you’re out of the woods, acne hits you right in the face.
Dermatologists regularly hear the lament “Acne, at my age?!”
expressed by women who suddenly develop acne after the ages of
20 or 30. “It’s not fair; it’s supposed to be only for teenagers!” is
usually the next statement out of their mouths. It may not be fair,
but it’s a fact. Many people — mostly women — get acne for the
first time as adults or develop acne after years of being relatively
pimple free. And sometimes teenage acne can continue unabated
from teen years into adulthood.
In this chapter, I prepare you for some surprising occasions
when acne can rear its ugly head — adulthood, pregnancy, and
menopause. Adult-onset acne is overwhelmingly a condition seen
in women. Therefore, I spend the bulk of this chapter discussing
adult-onset acne as it relates to women. And as always, I show
you that there is hope to help your acne symptoms clear up. But
if you’re one of the relatively few guys facing acne as an adult,
don’t worry; I help you get a handle on your condition at the end
of the chapter.
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50 Part II: Figuring Out Your Acne and How to Tackle It on Your Own
Identifying Adult-Onset Acne
Adult-onset acne is a type of acne that turns up after the age of 18 —
somewhat later than the typical teenage variety of acne. It can crop
up during a woman’s 20s, 30s, or even later in life. Adult-onset acne,
sometimes referred to as female adult acne or post-adolescent acne,
is overwhelmingly a condition of females.
The fluctuating nature of adult-onset acne tends to make the influence
of hormones more obvious than with the typical case of
teenage acne vulgaris (see Chapter 4); however, teenage girls often
begin to note those premenstrual pimply “ups” and “downs” as
they approach adulthood. As many woman are aware, the lesions
have a propensity to come and go more readily than they do with
teenage acne, and their appearance and disappearance is often
linked to their menstrual cycle (see the “Acne and your menstrual
cycle” section, later in the chapter).
Describing the symptoms
The appearance of post-adolescent acne differs from that of teenage
acne:
Blackheads and whiteheads (comedones) are less commonly
seen.
Breakouts are usually mild to moderate.
Significant scarring is unusual (but the term “significant” is a
relative and in the in eyes of the person who has acne, it can
be very significant).
Lesions more often appear on the lower cheek, the chin, and
along and below the jaw line. Although some women may
have breakouts on the chest and back, most have blemishes
exclusively on the face.
Breakouts are usually limited to inflammatory papules (pimples,
bumps, zits), pustules, and small inflammatory nodules. (Check
out the color section of this book for the typical appearance of
adult-onset acne.) The papules and pustules can be superficial or
deep. Many women describe certain papules as “deep ones,” the
ones that feel like they come from under the skin. (If you get ’em,
you know what I mean.) The deep ones are often more palpable
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Chapter 5: Addressing Acne in Adults 51
(you’re able to feel, or palpate them) than visible. They represent
papules and pustules that haven’t reached, and may never reach,
the surface of the skin.
When these deep lesions grow even larger, they’re called nodules
(or cysts). Nodules are tender, firm lumps that may hang around for
weeks or months. They may grow to an inch or more in diameter
and can leave scars after they heal. Fortunately, nodules and subsequent
scarring are infrequently seen in women who have adultonset
acne. (In Chapter 3, you can find out more about nodules. In
Chapter 16, I discuss scarring.)
The diagnosis of adult-onset acne isn’t always clear-cut. Your
healthcare provider may easily confuse adult-onset acne with
other acnelike disorders:
Rosacea: Symptoms of rosacea include facial lesions that
consist of acnelike red papules and pustules. Moreover, both
rosacea and acne can appear together. (I talk about how to
distinguish between the two in Chapter 18.)
Checking under the hood
Emily, a 33-year-old stockbroker, came to my office. She told me that she had very
mild acne as a teenager that cleared up by the time she was 19, but returned out of
nowhere. Since then, she’d noticed increasing numbers of red pimples on her chin
that tended to appear regularly a few days before her period and lasted only for a
few days. Some of the bumps seemed to come from under her skin and many of
these remained in place for a long time.
When I looked at her face, I noted that she had a few, very subtle reddish blotches
on her chin, but otherwise had an almost perfectly clear complexion. Then she said,
“Oh, you should have seen my face two weeks ago when I made this appointment!
I can’t believe it. It’s just like when I brought my car in to have the auto mechanic
check out a loud squealing noise and — of course — it didn’t squeak or even squeal
when he test drove it!”
Based upon her history, I concluded that she had typical adult-onset acne that has
its ups and downs, and I just happened to be seeing her on an up day. I also suggested
that she might need a new fan belt for her car.
I then prescribed a prescription gel for her to apply to her skin. I suggested that she
apply it daily and I explained that it might help to break her adult-onset acne cycle.
She scheduled a return appointment. As it turned out, she canceled the return visit,
and several months later, she sent me the following note: “Thanks! My face is pretty
clear now, but my car still squeals.” I guess I’ll stick with dermatology!
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Pseudofolliculitis barbae and keratosis pilaris: These conditions
involve hair follicles, and can sometimes be acne
look-alikes. (I cover these acne impostors in Chapter 19.)
Endocrinopathy: Sometimes what appears to be a simple
case of acne vulgaris or adult-onset acne can be due to an
underlying hormonal abnormality, called endocrinopathy
(pronounced en-de-krin-op-ath-ee). At times like this, acne
may be difficult to get under control, and other measures
such as blood tests to look for higher or lower than normal
hormone levels should be evaluated by your doctor. (I discuss
this relatively infrequent but serious situation in Chapter 20.)
Taking an emotional toll
Having acne can be just as trying for adults as it is for teens. Job
hunting, social events, and dating can be negatively impacted by a
few pimples. Even mild acne that might seem insignificant to an
outsider can force some people to miss out on opportunities and
relationships that otherwise they might have explored. I offer
some advice for managing the psychological burdens of acne in
Chapter 17. Whether you have rather mild or severe acne, effective
treatments are available, and your condition can improve.
Look at the sidebars in this chapter for stories about patients with
varying degrees of acne. The patients discussed may have the
same type of acne you have.
Emerging at Any Age
When acne begins in the teenage years, the increase in your
androgens — male hormones that are present in both men and
women — play a major role in its development. Chapter 3 explains
this process, but in a nutshell, these hormones stimulate the sebaceous
glands, enlarging them, and they respond by producing excessive
oil that helps to promote the lesions of acne.
Although the entire story isn’t well understood, the vast majority
of women who have adult-onset acne don’t have elevated androgen
levels; rather, they appear to have an increased response to
normal levels of androgen, and to a much lesser degree, to their
female hormone, progesterone, that also has androgenic effects.
The other major female hormone, estrogen, has an opposite
(estrogenic) effect and tends to curb acne.
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In addition to a woman’s own hormones, adult-onset acne may be
related to, and heightened by, the ingestion of external hormones
and drugs that have androgenic effects such as those contained in
certain oral contraceptive medications, food products, and performance
enhancing drugs.
In the sections that follow, I outline common points in your life at
which acne can be an issue and delve into why this may occur.
Acne and your menstrual cycle
If you’re reading this, I probably don’t have to tell you about those
little red bumps that appear on a monthly basis. You’re probably
well aware of those unwelcome visitors that appear, disappear, and
reappear like clockwork during your menstrual cycle. They usually
last for several days, but sometimes they can persist for a month
or longer. No fun!
Chapter 5: Addressing Acne in Adults 53
When the going gets tough
Johanna, a teary-eyed, anxious, 23-year-old file clerk told me that she had suffered
with acne “all” her life. After my usual comment that she must have been an unusual
acne-covered baby at birth, she then told me that she had been suffering from acne
since seventh grade (I guess that seemed like “forever” to her). As she held her
head down, she said that she was ashamed to look at people and that when she
was in high school some of the kids used to call her “pizza face.”
And, indeed, her acne was severe. She had pimples, pustules, and nodules, as well
as blackheads and whiteheads all over her face, shoulders, chest, and upper back.
She told me that she had tried “everything,” by which she meant numerous over-thecounter
preparations that only served to irritate her skin but did little to get rid of
the acne.
Her life was very limited and she stayed home most of the time because social situations
made her very anxious and self-conscious. She felt that the few friends she
had tended to avoid her. Her “best friend” advised her to wash her face more frequently.
She felt dirty and embarrassed. She especially dreaded times when she
would have to see her relatives at family holiday get-togethers. She preferred to
interact with people over the telephone or by e-mail.
I saw Johanna in my office for several years. We used both topical and oral therapy
to get her acne under reasonable control. She was left with some residual scars
that I couldn’t do too much about, but she seems to now relate more comfortably
with people. And now at age 26 she has a new job as a medical secretary that is
better paying, and yes, it keeps her in the public eye.
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Most often, pimples tend to pop up right before your period. This
is the time — usually two to seven days before your period —
when estrogen levels fall and progesterone levels rise and stimulate
the sebaceous glands to produce extra oil; with this extra oil
comes acne.
Much less commonly, you may see no apparent connection
between the appearance of pimples and your menstrual cycle. In
such instances, they will erupt with a mind of their own only right
before you have that important date, interview, cocktail party,
public speaking engagement, or wedding! Great!!
New baby, new bumps: Acne and
pregnancy
During pregnancy, acne is unpredictable. For some lucky women,
the result is a welcome surprise — clear skin, the “glow of pregnancy”
that you were told about. If this is your case, enjoy it! But
don’t get overconfident. When existing acne virtually disappears
during pregnancy, it often recurs afterward — sorry!
However, existing acne can also get worse. Pregnancy is a time of
tremendous hormonal upheaval. Your levels of estrogen and progesterone
are rising, and your skin becomes more sensitive to the
changes in the circulating hormones in your body. In fact, some
women may experience acne for the first time when they become
pregnant, even if they never had acne during their teens.
Acne is a perfectly normal occurrence during pregnancy (more
common than most women realize), whether you have previously
had acne or not. There’s no way to prevent it from developing
during pregnancy, but be patient and, with time, your skin will
probably clear up and return to its natural, pre-pregnancy state.
Lesions during pregnancy are generally inflammatory in their
appearance and typically take the form of papules, pustules, and
sometimes nodules. (Check out Chapter 3 for information on different
types of acne lesions.)
Acne tends to be worse during the first trimester (the first three
months) of pregnancy when the levels of these hormones are
increasing. Your progesterone is more androgenic (male hormonelike)
than estrogen and causes the secretions of your skin glands
to increase, which can lead to more acne. There are also times
54 Part II: Figuring Out Your Acne and How to Tackle It on Your Own
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when your sebaceous glands go into high gear during the first,
second, and third trimesters, causing even more frequent and serious
breakouts.
When breastfeeding, some of the hormones that trigger your acne
during pregnancy may still be at work, and you may wish to continues
treating those pesky pimples. But be aware, as I mention in the
sections that follow, that certain medications taken by mouth or
applied to your skin may wind up in your breast milk.
Safe acne drugs when you’re pregnant
The best course is to “say no” to any unnecessary drugs if you’re
pregnant or breastfeeding. Your baby is your first concern and you
want to minimize any potentially harmful agents that might reach
her. That said, the best way to treat acne during pregnancy is with
a topical acne-fighting preparation. (Check out Chapters 9, 10, and
11 for details on the agents I mention in this section as well as
other medications that fight acne.)
If you’re planning to get pregnant, discuss your acne treatments
with your dermatologist or healthcare provider. Some of the
medications that are safely used to treat acne when you aren’t
pregnant may be potentially harmful to a developing fetus.
Topical treatments that your doctor may prescribe during pregnancy
(and I discuss in Chapter 9) include:
Erythromycin: There are many topical prescription products
that contain this antibiotic.
Benzamycin Gel: Benzamycin Gel combines erythromycin
and benzoyl peroxide.
Azelaic acid: This is a natural chemical produced by a yeast.
It is the active ingredient in the prescription products Azelex
and Finevin.
The U.S. Food and Drug Administration (FDA) classifies Azelaic
acid as a pregnancy category B drug. This designation means that
animal reproduction studies have failed to demonstrate a risk to
the fetus; however, there are no adequate and well-controlled
studies in pregnant humans.
Because passage of the drug into maternal milk may occur, this
drug should be used during pregnancy or by nursing mothers only
if clearly needed.
Chapter 5: Addressing Acne in Adults 55
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On the whole, I recommend that you avoid all oral medicines to
treat acne when you’re pregnant. However, oral erythromycin — if
you’re not allergic to it — may be taken safely if your acne is really
bad. If you’re allergic to erythromycin or it’s not working, your dermatologist
may prescribe another oral antibiotic that can be used
in pregnancy.
Drugs that may be harmful to developing fetuses
The FDA classifies some topical and oral medications as pregnancy
category C drugs. This categorization means that it’s not known
whether the medication will be harmful to an unborn baby. But,
when it comes to benzoyl peroxide, sulfacetamide, and sulfur
drugs, they’ve been around for ages and no evidence has ever
shown them to be harmful to a fetus. With some of the other drugs
mentioned below, definitive evidence isn’t available one way or the
other, so I recommend that you avoid them unless your healthcare
provider or dermatologist says otherwise.
The following acne topicals have been used for many years and are
probably safe to apply during pregnancy and nursing:
Benzoyl peroxide: This drug has been around for generations.
It’s very effective for treating acne and can be purchased over
the counter (see Chapters 7 and 9 where I talk about topical
treatments and the numerous benzoyl peroxide products that
are available). There have never been reports of problems that
came from using benzoyl peroxide during pregnancy.
However, even though benzoyl peroxide is generally considered
to be safe to use during pregnancy, you should be aware
that the FDA classifies it in pregnancy category C. It’s also not
known whether benzoyl peroxide passes into breast milk.
Because this product has been around for so long, when it
was approved, the FDA didn’t require that it be tested to the
extent that drugs are nowadays.
If you’re pregnant or breastfeeding your baby, you shouldn’t
use benzoyl peroxide topical without first talking to your
doctor. You can then decide if the risks are low enough and
the benefits are high enough for you to use it.
If during pregnancy or breastfeeding, you’re advised to use a
benzoyl peroxide combination product, it’s probably wisest to
use one that contains erythromycin such as Benzamycin Gel,
rather than one that contains clindamycin, which I discuss
later in this section.
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Sulfacetamide/sulfur combinations: As with benzoyl peroxide
products, these pregnancy category C agents have been
used safely for many years. Combinations of sulfacetamide
and sulfur are contained in such products as Rosula, Rosac,
Rosanil, Nicosyn, and Novacet.
These medications should be used only when clearly needed
during pregnancy. Discuss the risks and benefits with your
doctor. These medications may pass into breast milk, so breastfeeding
while using these medications isn’t recommended.
The following FDA pregnancy category C topicals are “newer kids
on the block” and aren’t recommended for use during pregnancy:
Topical retinoids: These consist of tretinoin, Retin-A, Differin,
Tazorac, and Avita. Even though there is minimal absorption
of topical retinoids that can potentially reach a fetus, and
there’s no evidence that these agents can harm an unborn
child, you should stop applying them once you think that
you’re pregnant.
Clindamycin: Prescription products that contain this antibiotic
include Cleocin-T, as well as several generics. The effects
of clindamycin during pregnancy haven’t been adequately
studied. Clindamycin combined with benzoyl peroxide is also
found in the combination products Benzaclin Gel and Duac
Gel (see Chapter 9).
Because clindamycin may appear in breast milk and could
affect a nursing infant, it’s probably not advisable to use
products containing it if you are pregnant or plan to become
pregnant.
Aczone Gel: This agent contains dapsone. There is minimal
absorption of this drug in the bloodstream when it’s applied
topically; however, it’s known that dapsone is excreted in
human milk when taken orally. I talk about this new drug in
Chapter 9.
Clindamycin and benzoyl peroxide are also found in the combination
products Benzaclin Gel and Duac Gel (see Chapter 9).
Oral drugs known to cause birth defects
I recommend avoiding all oral medicines to treat acne when you’re
pregnant. However, an oral penicillin derivative, such as amoxicillin
(if you’re not allergic to it), may be taken safely if your acne is
really bad. If you’re allergic to penicillin or it’s not working, your
dermatologist may prescribe another oral antibiotic that can be
used in pregnancy.
Chapter 5: Addressing Acne in Adults 57
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Many oral drugs can harm your unborn baby. In these cases,
clear evidence exists that your child may have serious birth
defects if you use them. The following medications must be
avoided if you’re pregnant or if you’re contemplating becoming
pregnant:
Tetracycline: Tetracycline and its derivatives, minocycline
and doxycycline, may cause some inhibition of bone growth
and discoloration of teeth in a fetus. Tetracycline and its side
effects are covered in Chapter 10.
Hormones: The anti-androgens such as spironolactone that
are sometimes used to treat acne, can, by blocking testosterone,
interfere with the normal development of a male fetus
and cause feminization. (See Chapter 11.)
Oral isotretinoin (Accutane): Oral isotretinoin (eye-so-tret-ihno-
in) available as Accutane, Roaccutane, Amnesteem,
Claravis, and Sotret, is a powerful drug that’s used to treat
severe nodular acne in carefully selected patients. This drug
can cause severe fetal abnormalities. I discuss Accutane and
its generics in Chapter 13.
There are many restrictions currently in place regarding
oral isotretinoin, and with understandable cause. Oral
isotretinoin can cause serious birth defects to infants born
to women exposed to them. They should never — not under
any circumstances — be taken during pregnancy! Even if a
woman becomes pregnant within one month after stopping
the drug, problems can still occur.
There also is an increased risk of miscarriage, premature
births, and infant death associated with taking oral isotretinoin
during pregnancy.
A recently published Swedish study showed an increased occurrence
of certain heart defects in children born to mothers who had
taken oral erythromycin in early pregnancy (first trimester). But it
can’t be certain that factors other than erythromycin didn’t contribute
to the increase in malformations. In the same study, the risk
after treatment with penicillin demonstrated no increase in these
malformations.
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You’re never too old
Some women pass through menopause without outgrowing their
acne. Yes — acne during and after menopause! Just when you felt
certain that the years of pimples have faded from your skin and
your memory, they’re back! No, you’re not going through a second
adolescence, it’s those pesky hormones again! Although hormonally
influenced acne typically begins around age 20 to 25, acne can
persist in women over the age of 40 and continue into the perimenopausal
and menopausal periods.
Along with all the other changes that you go through during this
time, acne just seems to add insult to injury. Post-menopausal
acne isn’t a common occurrence, but when estrogen levels begin
to taper off and testosterone becomes the dominant hormone,
acne — usually mild — can appear.
Chapter 5: Addressing Acne in Adults 59
You’re never too young
When acne appears in newborns it is known as acne neonatorum. It’s actually very
common. This type of acne is seen mainly in male infants and is believed to occur
from the stimulation of an infant’s sebaceous glands by maternal androgens. Most
often, it requires no treatment because it usually goes away by itself.
The lesions of acne neonatorum usually appear at about 2 weeks of age. They consist
of tiny red bumps and pustules that are seen on the cheeks, forehead, chin,
neck, and sometimes the chest. They tend to appear over the course of a few weeks
and often vanish over the course of a few months as the baby’s large sebaceous
glands become smaller and less active.
Treatment, if necessary, has traditionally been with benzoyl peroxide; however, recent
studies have shown that a topical antifungal cream known as ketoconazole has been
shown to be effective. It can be purchased over the counter as Nizoral cream.
Infantile acne can show up in children between the ages of 3 to 6 months of age. It’s
different than acne neonatorum because it more closely resembles teenage acne —
the acne may appear as inflammatory as well as comedonal lesions.
In some instances, infantile acne has led to pitted scarring, and there’s some evidence
that this type of acne may be an indication of future problems with acne
during adolescence. Treatment of infantile acne usually consists of topical benzoyl
peroxide or a topical retinoid. Rarely, oral isotretinoin may be given for very severe
potentially scarring cases.
If treatment of acne neonatorum or infantile acne is required, consult your pediatrician,
and if necessary, ask to see a dermatologist. I tell you how to go about seeing
a dermatologist in Chapter 8.
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Facing Acne As an Adult Man
The good news for most adult men is that acne that first appears
after age 20 is an unusual occurrence. I suppose the bad news is
that if you’re reading this, you’re having just such an “unusual
occurrence.” In men with adult acne, lesions are more often seen
on the chest and back. When it arises on the back, it’s sometimes
playfully called “backne.” If you’re a guy, and you’re facing acne,
odds are that one of several things is occurring:
The teen version has stuck around: Though most acne
vulgaris (teenage acne) clears up by the time you approach
the 20 mark, it can stick around. Check out Chapter 4 for an
explanation of acne vulgaris.
You’re an athlete: In recent years, acne is being seen increasingly
on the chests and backs of men who participate in
vigorous athletic activities. Some observers speculate that
sweating and friction causes the acne because the primary
sites are most often under clothing.
You’ve used performance-enhancing drugs: Another, more
likely, source of chest and back acne may result from the use
of performance-enhancing preparations that contain such
ingredients such as creatine, colostrum, and, of course, anabolic
steroids such as testosterone and andro. I talk more
about steroids in Chapter 6.
You don’t really have acne: If you have any doubt about your
diagnosis, see a dermatologist because she may tell you that
you don’t have acne at all but may have rosacea, an adult
acne look-alike, or folliculitis (an inflammation of hair follicles)
due to shaving your face and maybe even from shaving your
chest and back. (See Chapters 18 and 19 to learn more about
these acne impostors.)
Significant scarring from acne is more common in men than in
women. In men, lesions that leave scars may be the dominant type
present, especially in men who had severe acne in their teens. In
Chapter 16, I explain the types of scars and tell you what can be
done about them.
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Chapter 6
Evaluating Other Causes and
Contributors: Myth and
Reality
In This Chapter
Exploring dirt and oil
Revisiting your diet: Is your face what you eat?
Looking at the connection between stress and acne
Aggravating your acne
Makeup: Does your face become what you put on it?
As long as people have had acne, they’ve tried to find something
to blame for the condition — including dirt, diet, stress,
makeup, and sex. Although dermatologists and researchers still
aren’t 100 percent sure about what causes acne, we’ve come a long
way in recent decades, and most doctors agree that hormones and
heredity are the fundamental sources that lead to the development
of acne (as I explain in Chapters 3 through 5).
In this chapter, I explore the role that stress and diet play in causing
acne or making existing acne worse. I also review some of the
medications and “tripwires” that have been implicated as causing
or worsening acne. I end with an appraisal of the relationship
between makeup and acne.
This chapter also looks at some of the historical misconceptions
that have persisted about acne. For example, you’ve probably been
warned not to eat too much chocolate. And you may have heard
“The Big Bang Theory,” that is, keep your hair away from your skin.
Not true.
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These types of myths are passed down from one family member to
another, told to you by a friend, and occasionally published in
beauty magazines. Myths die hard and often there is some underlying
truth that can be found to explain where and how some of them
got started; other times they’re just based on silly folklore.
Debunking Dirt and Grease Theories
The appearance of acne — the black color of blackheads and facial
oiliness — suggests that if only you rubbed and scrubbed your
face really hard and often, you could get your acne to go away. Not
so — in fact, before all of the effective acne treatments became
available to us, that was how acne was often treated — and unsuccessfully
I might add.
What may look like dirt inside your blackheads is actually melanin,
the pigment that provides the natural color of your skin. Despite
what you may have seen or heard in commercials, your pores
don’t get blocked from the top down; instead, most of the action of
acne formation takes place on the inside of your skin in your hair
follicle (see Chapter 3 where I tell you the whole story).
Think about it. If dirt was a major reason that some people get
acne, we’d probably see gazillions of blackheads, whiteheads, and
pimples on the faces of folks who do a lot of manual labor such as
coal miners, ditch diggers, construction workers, and gardeners.
But it so happens that office workers, teachers, and doctors —
even alas, dermatologists and their kids — get acne.
As for the oil, although there is a connection between how severe
acne is and the amount of oil a person’s skin produces, not all
people with oily skin have acne and not all people with acne have
oily skin. It so happens that some people with dry skin also have it.
Scrubbing and rubbing a face that has acne will only serve to irritate
and redden an already inflamed complexion. Instead, the face
should be washed daily (twice a day at the most!) with a gentle
cleanser. For detailed information on proper face washing technique,
see Chapter 2.
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Dismissing the Diet —
For the Most Part
We aren’t always what we eat. Despite occasional personal anecdotes
and persistent cultural myths, acne is probably not significantly
influenced by diet.
In fact, there have been studies in which people were actually paid
to eat chocolate. Yum! The conclusion: The chocolate-eating subjects’
acne didn’t get worse. Furthermore, several substances
found in chocolate have been identified as being mood-lifters that
apparently increase your brain’s endorphins (chemicals that
decrease pain and elevate your mood). So chocolate isn’t bad for
your blemishes; your stress level may diminish and so may your
pimples! However, your waistline may get wider.
Currently, there is some disagreement about the link between diet
and acne; several researchers are suggesting that there may be a
degree of truth behind some dietary factors having an influence on
acne. For example, certain dairy products and refined sugars that
are found in our Western diet are now being evaluated as possible
acne triggers. The jury is still out on this issue.
In the meantime, if you’re absolutely convinced that a certain food
type is making your acne worse — avoid it! But if your acne is
being treated properly, you probably don’t need to worry about
food affecting it.
Take a skeptical approach with any acne “cure” books that hype a
special diet, such as salmon, as one of the fundamental treatment
components.
Frying up an acne fable
To prevent pimples, you may have been told to avoid junk food
because it contains so much fat and grease that it’ll make your skin
greasy too and you’ll get whopper-sized McPimples!
According to studies to date, it’s the oil in your sebaceous glands
that causes you problems and not the oil in your French fries or in
your stomach. Sure, it makes sense to follow a healthy diet, which
involves avoiding greasy foods, but avoiding such foods doesn’t
guarantee a clear complexion.
Chapter 6: Evaluating Other Causes and Contributors 63
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Here’s the beef — and the milk
Many cattle are fed androgens to help them build muscle. And as
you may have read in Chapter 3, your body’s androgens are often
what kick-starts the overproduction of oil. Some researchers are
looking into whether we also get androgenic stimulation and acne
when we eat beef. On the other hand, the androgens may be
degraded by cooking before they get to our acne-prone, androgensensitive
hair follicles.
And there are some investigators (a small minority, mind you) who
believe that milk, particularly skim milk, and some other dairy
products may worsen — or even cause — acne. They claim that
the androgenic hormones that are injected into our cows to make
them produce more milk get into our bodies and give us pimples.
But it’s questionable whether the hormones in milk could survive
the high levels of gastric acidity (our stomach acid) and be
absorbed into our bodies.
My take on this debate is simple: I’ve seen many vegetarians who
choose not to eat any flesh foods (fish, chicken, beef), and a few
vegans (pronounced vee-guns), people that totally avoid eating any
animal products including dairy and eggs. Guess what — both
vegans and vegetarians still get acne like the rest of us! (And by the
way, when was the last time you saw a cow with pimples?)
So right now, nobody knows for sure, but for the time being, I think
you should listen to the age old parental advice and drink your
milk! (Unless you have a milk allergy.) Same with eating that steak.
The jury is out on the whole cow-androgen-acne thing.
No, it’s the sweets: A disease
of Western civilization?
A recent study regarding two societies, the Kitavan Islanders of
Papua New Guinea and the Aché hunter gatherers of Paraguay,
found absolutely no evidence of acne until these groups were
exposed to a Western diet. The investigators of this article (found
in the December 2002 volume of the Archives of Dermatology) suggested
that the refined sugar in our Western diets is a possible
cause of acne.
Bottom line: Besides diet, there are so many other factors that
might be responsible for their lack of acne, such as climate, sun
exposure, and less stress in their tropical homeland.
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And even when American diets were much lower in sweets 30
years ago, teens probably had as much acne as today.
No, it’s the iodides
It has been traditionally believed that overeating foods that are
rich in iodides, such as sushi, seaweed, and shellfish, can cause or
aggravate acne. Bottom line: As far as I know, there have been no
reports of acne epidemics reported so far in Japan or Korea.
Salmon saves the day, or does it?
There are those who advocate eating more fish, most notably,
salmon, which is loaded with the anti-inflammatory omega-3 fatty
acid. Its fans would have you believe that eating salmon can help
you prevent and treat acne.
Chapter 6: Evaluating Other Causes and Contributors 65
Decoupling the acne-sex links
A patient of mine made the following comments, “Recently, I woke up to find my
face covered with acne. I’m 18 years old and I get a zit now and then, but I can’t
ever remember having a breakout this bad (at least 20 pimples) appearing overnight!
I tried to recall anything that might have caused this, and my only guess is that I
also have been having sex lately. Is there some weird kind of hormone thing that’s
doing this to me? I thought sex was supposed to cure your pimples!”
This gentleman was misguided on a number of accounts. Not so long ago, it was
believed that the absence of sexual activity caused acne. Having “normal” sexual
relations during marriage was held to be a “natural treatment” for acne. Though
this form of therapy may sound appealing, there is no evidence that it works. This
idea probably stems from the fact people traditionally got married in their early 20s,
about the same time that acne usually burns itself out.
And although the androgenic “sex” hormones are a primary cause of acne, you
don’t necessarily develop acne because you have too much of this hormone or from
sex. Likewise, some folks still think that masturbation causes acne. This idea, originating
as early as the 17th century to dissuade young people from having premarital
sex, is just plain silly. The only connection between masturbation and acne is
that both are associated with adolescence. Moralists blamed many diseases,
including blindness, deafness, and terrible skin eruptions, on such “wicked” practices.
Don’t believe it! The guilt that surrounds masturbation in the minds of many
teenagers is probably responsible for this timeworn myth.
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Eating more salmon is likely a good idea for your general health.
However, farmed salmon may contain PCBs and dioxins, two substances
that have been linked to various health problems. And wild
salmon contains mercury. So don’t eat too much of it.
Understanding Stress and Acne
Modern-day living, anxiety in the workplace, too many or too few
hormones, nuclear threats, terrorism, inflation, crime, poverty,
obesity — it’s enough to give you terminal acne!
Most investigators agree that stress doesn’t cause acne; however,
most would agree that stress seems to worsen it. Just ask college
students at exam time, teenagers about to go to the prom, or someone
going for that first job interview.
It’s well known that at times of stress, the body releases excess
amounts of glucocorticoids (the body’s natural steroids). Some
people think that the glucocorticoids, having some androgenic
properties (see the next section where I talk about glucocorticoids
when they’re taken orally), cause sebaceous glands to
secrete more oil and thus worsen acne or even cause an acnelike
eruption.
It has been suggested that regular stress-reducing activity (like
exercise, knitting, yoga, and so forth) can help minimize the glucocorticoids,
and reduce their effect on sebaceous glands.
Some pundits also advise getting extra sleep and meditating. Just
like with diet and acne, there is no hard evidence that these measures
really do much to help reduce acne. However, they are
healthy habits that may reduce stress, so why not? See Chapter 15
where I cover some of these approaches.
Addressing some Aggravating
Agents
A host of outside agents such as drugs, physical factors such as cosmetics,
and even sun exposure have been considered to be triggers
and tripwires for acne. I review these agents in the next section. In
particular, certain drugs can be acnegenic (acne producing) or
create skin eruptions that look exactly like acne (acneiform reactions).
The same drugs can sometimes exacerbate pre-existing acne.
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Drugs that can induce acne
Acne reactions caused by medications are usually self-limiting,
which means they disappear when the drugs are stopped. If the
drug must be taken for an extended period of time, the acne or
acnelike lesions can be treated with the same medications that are
used to fight most forms of acne.
Corticosteroids
Oral corticosteroids are synthetic derivatives of the natural steroid,
cortisol, which is produced by the adrenal glands. They’re prescribed
for a large number of serious inflammatory diseases.
They’re called “systemic” steroids if taken by mouth or given by
injection as opposed to topical corticosteroids (see the next section),
which are applied directly to the skin. Prednisone, prednisolone,
and methylprednisolone are examples.
These drugs sometimes produce inflammatory acne lesions consisting
of papules or pustules that have a tendency to appear on the
chest and/or back (sometimes called steroid folliculitis). They disappear
after the medication is stopped. Comedones (blackheads and
whiteheads) are generally absent from steroid-induced acne.
The overuse of potent topical corticosteroids (used for many skin
conditions) on the face can cause a condition similar to acne. It is
known as steroid-induced rosacea. I discuss this condition and its
treatment in Chapter 18.
I realize that this sounds somewhat contradictory, since the oral
corticosteroid drugs are anti-inflammatory, and it would appear
that they would actually be used to treat acne. If fact, they are used
for acne treatment under special circumstances. Sometimes
they’re used to treat the nodules and scars of acne by injection. I
describe these situations in Chapter 16. And on special occasions,
we dermatologists prescribe corticosteroids orally for short threeto-
five-day, low-dose “bursts” as an “emergency” treatment to wipe
out acne for a special occasion (wedding, prom, and so on). They
can really wipe out acne fast, but only for short periods of time.
Anabolic-androgenic steroids
Abuse of these hormones can lead to acne and other serious
health problems. Besides legitimate medical uses of androgens
such as testosterone for hormone deficiencies, widespread use
and abuse of these compounds exist, particularly the anabolicandrogenic
steroids, as performance-enhancing drugs.
Chapter 6: Evaluating Other Causes and Contributors 67
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This type of acne is observed in males mainly on their backs,
shoulders, and chest, and less often on the face, whereas in female
athletes using these drugs, lesions tend to appear on the face as
well as on the back and shoulders. An already-existing acne problem
may get worse or nonexisting acne may be evoked.
Androstenedione
Androstenedione (andro) is a hormone produced by the adrenal
glands, ovaries, and testes. It’s a precursor hormone that’s normally
converted in the body to testosterone and estrogen in both
men and women. Andro made the news after the former baseball
player Mark McGwire admitted taking it around the time of his
record-breaking home run season. Although ads claim that androcontaining
supplements promote increased muscle mass, studies
have shown that andro poses the same kinds of health hazards as
anabolic steroids. The U.S Food and Drug Administration (FDA)
cautions about the risks for young people who take andro: acne, an
early start of puberty, and stunted growth.
DHEA (dehydroepiandrosterone)
This hormone, sometimes billed as the “fountain of youth” hormone,
is also a steroid hormone, a chemical cousin of testosterone
and estrogen. Because DHEA is converted into testosterone, it has
been noted to produce excessive facial and body hair, besides
causing acne.
Other oral medications
Other drugs that have been observed to have acnegenic properties
include:
Lithium
Iodine
Isoniazid
Diphenylhydantoin
Certain androgenic contraceptive pills (see Chapter 11)
Initiating or irritating factors?
In this section, I list some of the activities, exposures, or things
done to the skin that have historically been reported to bring on or
exacerbate acne.
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Acne cosmetica
This condition is described as a persistent, low-grade type of acne
usually involving the chin and cheeks of women who use cosmetics.
The lesions arise primarily as closed comedones as well as papules
and pustules. It is often thought to be caused by comedogenic (blackhead-
and whitehead-producing) substances in the cosmetics. In all
likelihood, however, these folks probably have adult-onset acne, and
they just happen to use the cosmetics to hide the acne lesions — and
of course, the cosmetics get the blame for causing the acne!
Because most major cosmetics are noncomedogenic — meaning
they don’t cause acne — this type of acne is unlikely to be seen
much, if at all, nowadays.
Pomade acne
A variant of cosmetic acne, known as pomade acne, can occur if
greases, like oils, Vaseline, cocoa butter, and hair oils are used to
style hair or are applied to the skin. If pomade or hair oil spreads
onto the forehead, it can block pores, causing comedones.
Pomade acne is almost exclusively seen in African-Americans and
usually appears on the forehead and temples. I discuss this type of
acne in Chapter 12. Treatment consists of avoiding pomades. If you
must continue using a pomade, try applying it to the ends of the
hair only to avoid contact with the scalp and hairline. See the color
section of this book for a visual.
Sunlight and acne (Mallorca acne)
Also called acne estivalis (“estivalis” means summer); this is a rare
form of acne that occurs in the summer or following a vacation in
the sun. This condition is so rare that I don’t think I’ve seen a case
of it.
But I have seen the damaging results that excessive exposure to
the sun can have on both healthy skin and skin with teenage and
adult-onset acne. For more on this issue, see Chapter 14, which
also discusses potentially beneficial types of light therapy for acne,
and Chapter 22.
Acne mechanica
This variation of acne is due to mechanical factors, including friction,
sweating, and pressure. It is provoked by such factors as chin
straps, bra straps, articles of clothing, orthopedic casts, backpacks,
chairs, and car or bus seats. The acne is seen at the sites
where these items rub and persistently press against the skin, such
as under a chin strap or cast. This type of acne is often simply an
Chapter 6: Evaluating Other Causes and Contributors 69
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aggravation of the existing lesions of acne or an inflammation of
hair follicles known as folliculitis.
Acne detergens
This refers to the aggravation of the existing lesions of acne by too
frequent washing with comedogenic soaps and rough cloths and
abrasive pads. It certainly can be irritating, but overwashing doesn’t
cause acne.
Dioxins and Agent Orange (chloracne)
Agent Orange, an herbicide, was used during the war in Vietnam.
Some veterans reported a variety of health problems and concerns
attributed to exposure to this agent, including chloracne.
Agent Orange contains dioxins (halogenated aromatic hydrocarbons),
a group of chemicals known to increase the likelihood of
cancer. The first disease associated with dioxins was the extreme
skin disease chloracne. It causes acnelike pustules on the body that
can and do last for several years and result in significant scarring.
It develops a few months after swallowing, inhaling, or touching
the responsible agent.
Most cases are due to occupational exposure, but it can also arise
after accidental environmental poisoning. Deliberate dioxin poisoning
is blamed for Ukrainian President Victor Yushchenko’s dramatically
changed appearance during the “Orange Revolution” in 2004.
Making Up and Breaking Out?
Makeup doesn’t cause acne. Acne cosmetica (see the related section
earlier in the chapter) is the traditional name for the type of
acne that cosmetics supposedly cause. I realize that some reactions
to cosmetics can sometimes look like inflammatory acne, but
it’s really just your skin reacting negatively to one or more of the
ingredients found in your makeup that makes already-existing acne
get redder and look worse.
And between you and me — I don’t believe that cosmetics have
much to do in the development or worsening of acne!! There, I’ve
said it.
I generally tell my patients, “If you’re happy with your cosmetics,
stay with them; if you feel that your cosmetics are causing or worsening
your acne, just stop using them for a few weeks and see if the
bumps go away!”
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However, there are plenty of folks who disagree with me, some of
whom are fellow dermatologists. In the next sections, I tell you
what others have to say. I present the information to be inclusive
and present the traditional belief that makeup and cosmetics are
very important issues when it comes to acne.
Reading the ingredients
Nowadays, most cosmetic products boast of being non-poreclogging
and “oil free.” And most of them have a label that
states that the product has been tested and verified as being
noncomedogenic. It’s on virtually every label on every cosmetic
product.
However, some skin-care products are considered to be comedogenic,
which means they cause whiteheads and blackheads. The
damaging effect of cosmetics on acne has been attributed to
the presence of excess oil in such cosmetics.
What ingredients in the leading cosmetic products are believed by
some dermatologists to cause acne? The following three are considered
to be the leading candidates:
Lanolin: This is oil from the skin of sheep. It’s similar to the
fatty acids found in human skin.
Isopropyl myristate: This substance adds “slip,” which makes
a product go on the skin smoother and causes a slick sheer
Chapter 6: Evaluating Other Causes and Contributors 71
Testing, testing: What’s up, Doc?
The ear of the rabbit is very sensitive. Besides bringing good luck (oh, that’s the foot,
isn’t it?) and warding off danger, the rabbit’s ear, for decades, has been used to test
cosmetic ingredients to see whether they cause comedones (blackheads and
whiteheads). Substances known to be acnegenic (acne-producing) in humans will
rapidly produce comedones in rabbit ears.
However, the rabbit ear differs from human skin and may not be an accurate model
of the human face, because humans and rabbits don’t necessary respond in the
same way to cosmetics application.
Because of these difficulties, more recent approaches used by cosmetic companies
often test makeup on the upper backs of male volunteers who have acne.
Again, it may be difficult to relate a man’s back to a woman’s face.
By the way, when was the last time you saw a rabbit wearing makeup?
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feel. There are a number of chemicals similar to isopropyl
myristate, including isopropyl isostearate, butyl stearate,
octyl stearate, and laureth-4.
D & C red dyes: These dyes derived from coal tars are also
believed to be comedogenic.
Although some experts believe these ingredients are acne-causing,
I don’t personally believe they cause acne. However, if your
acne seems to get worse when wearing cosmetics, look for these
ingredients on the label of your current products. Try new products
that don’t contain them to see whether your skin condition
improves.
Living in an oil-free world
Is your cosmetic really, absolutely oil free? On the assumption that
sebum is a beneficial component of the skin, chemists have tried to
imitate this substance, but the “oil free” claim isn’t exactly valid
and can be misleading because the oil substitutes that are used in
these products are synthetic and are considered to be more harmful
than the excess sebum found in the skin that can block pores.
The alleged bad guys
Generally speaking, the most acne-causing cosmetics are:
Foundation makeup
Pressed powders
Thick creams
Blushers
Moisturizers can also be a source of acne-producing substances. In
order to make these moisturizing products smooth onto the skin
easily, they’re often manufactured with ingredients such as acetylated
lanolin, searic acid, and cetyl alcohol. All of these ingredients
are considered to be comedogenic.
The alleged good guys
The recommended moisturizers are those that have a base of
petrolatum or mineral oil. Powder blushers are usually preferred
over creams, and cream/powder foundations are usually preferred
over the liquid type because loose powders help to “mop up” the
oil. If a liquid foundation is chosen, it should be silicone-based
(containing cyclomethicone or dimethicone).
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Chapter 7
Taking Care of Acne Over
the Counter
In This Chapter
Making the choice to treat acne yourself
Choosing the right nonprescription medicine
Looking at inactive ingredients
Perusing active ingredients
An enormous multi-billion-dollar industry exists with the
intention of treating your acne and competing for your
money. Just look at all the items that pack the shelves of drugstores,
supermarkets, and chain stores. They come in fancy,
eye-catching packages, as soaps, cleansers, lotions, pads, creams,
gels, ointments, wipes, foams, and masks, and offer a treasure
trove of preparations: oil-free, hypoallergenic, organic, noncomedogenic,
herbal, radiant, protein rich, dermatologist-tested,
and so on. No wonder people who treat their acne themselves are
so often and so easily overwhelmed and confused about what
product is right for them. But I’m here to clear things up. (In more
ways than one!)
In this chapter, I talk about ways that you can go it alone —
especially if your acne is mild. In the process, I list and describe
the over-the-counter, or OTC, medications (no prescription necessary)
that may help you along the way, and I help you figure out
which ones work and which ones don’t. But self-treatment isn’t the
right solution for everyone. So if you haven’t perused Chapter 1,
you may want to do so to determine whether self-treatment is a
good idea for you or whether you should just head straight to the
doctor’s office.
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74 Part II: Figuring Out Your Acne and How to Tackle It on Your Own
Taking Action Topically: A Primer
A topical product is one that is applied on the skin, such as a
cream, ointment, gel, foam, or lotion. Almost every OTC acne medication
is topical rather than oral, taken by mouth. Topical therapy
is generally safer than systemic (oral or injected) therapy.
Topical acne treatments (both the OTC and prescription varieties)
are made up of two general types of ingredients that you find on all
labels:
Active ingredient: This part of the medication does the real
grunt work. I recommend you start your search for an OTC
treatment by looking at the active ingredient because it’s the
most important component of a product. Most commonly
found are benzoyl peroxide, salicylic acid, sulfur, and resorcinol.
You can read more about these ingredients in the section
“Getting In on the Active Ingredients.”
Inactive ingredient(s): This part of the medicine is the stuff
that holds onto the medicine and preserves it, keeps the product
moving easily through the container, and makes the medicine
easier to apply. Inactive ingredients are sometimes
referred to as the inert ingredient or the vehicle because they
deliver the medicine. You can read more about these ingredients
in the section “The Lazy Bums! Inactive Ingredients.”
In choosing the right topical treatment, you need to consider both
active and inactive ingredients. Just as some active ingredients
may be more beneficial for your particular acne, certain vehicles
may be more conducive to your skin type. The rest of this chapter
Mirror, mirror on the wall . . .
Nobody looks at your skin as closely as you do. And maybe you facilitate matters by
using a magnifying mirror that helps you see every little spot and pore in your skin.
Everything looks gigantic. Your face looks like the surface of the moon and each
pore looks like the Grand Canyon!
But unless you’re being scrutinized by a curious cosmetologist, evaluated for one
of those real-life makeover shows on television, or you’re married to Sherlock
Holmes, nobody else is going to look at your skin with a magnifying lens! You’re the
victim of your own supercritical eye. Besides, other people are probably thinking
about what they saw in their mirror this morning. So do something better with your
time — go for a walk, ask for a raise, take up the violin, or go skydiving.
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Chapter 7: Taking Care of Acne Over the Counter 75
explains what the various active ingredients do and how you use
them. I also explain what type of delivery vehicle is best for your
particular skin type.
Don’t buy brand-name products when you can spend less on
generic. That way, you don’t have to pay for the fancy packaging
and marketing that the name brands put into their products!
After you start to treat your acne, don’t get into the routine of
checking your face every day and looking for improvement. The
treatments take time to start working — sometimes up to six to
eight weeks, so be patient!
The Lazy Bums! Inactive
Ingredients
Skin looks and feels better when it’s not too oily or too dry. If your
skin tends to be dry, a moisturizing base (vehicle) is best; if it’s
very oily, select a product that has a drying base. Of course, if you
have neither dry nor oily skin, choose a neutral product that’s neither
moisturizing nor drying. Most topical treatments fall into one
of a few different categories, based on their delivery vehicles.
Table 7-1 lists the most commonly used vehicles for delivering
effective topical acne treatments. Look for your skin type there.
The inactive ingredients don’t do anything to fight acne, but some
may be better for you than others based on your skin type. One
delivery agent doesn’t fit all. If you have oily skin or if you have
dry or sensitive skin, you may have to experiment with different
preparations.
Table 7-1 Matching Bases and Faces
Vehicle (Base) Best for This Skin Description
Alcohol solutions Oily Evaporate quickly. The most
drying of all these treatments
and can be very irritating. Cover
large areas easily.
Aqueous solutions Normal to dry These are water based and
alcohol-free. They’re less drying
and irritating than alcohol solutions.
Cover large areas easily.
(continued)
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Table 7-1 (continued)
Vehicle (Base) Best for This Skin Description
Creams Normal to oily Generally more popular than
ointments because they’re less
greasy. Often preferred by
patients because they absorb
into the skin quickly. Their water
content makes them more
drying than ointments.
Foams Normal to oily May be somewhat drying, but
they’re easy to spread, particularly
on hairy areas such as
chests and backs of males. Very
expensive.
Gels Normal to oily Essentially oil-free and have a
mildly drying effect. Some of the
newer gel preparations contain
emollients such as glycerin and
dimethicone, which help diminish
the drying effects.
Lotions Any May be somewhat moisturizing;
however, those that contain
propylene glycol may have
drying effects. Easy to apply.
Ointment Normal to dry Greasy. More lubricating and
tend to be less irritating than
creams and gels.
If you have combination skin that has an oily T-zone and a dry
lower face, you might have to use different vehicles for different
parts of your face.
As for cleansers, washes, and scrubs, I think they’re somewhat
overrated, because most of them hardly have enough time to do
anything. They get rinsed off before they can really penetrate and
do the job!
How much cream, ointment, or lotion should you apply? For those
of us old enough to remember the old hair cream commercial: A
little dab will do you. Think thin, not thick; a little works as well as
a lot. Don’t be inclined to have a “more is better” tendency. Only
the thin layer that is actually in contact with the skin gets
absorbed; the remainder is either rubbed off or unnecessary.
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Gobbing it on is wasteful, and besides, it takes longer to rub it in
and make it vanish!
Getting In on the Active Ingredients
If you spend a little time comparing the labels on the products you
find at the drugstore, you discover how incredibly similar they all
are — just about all of them contain one of the following active
ingredients plus other inactive ingredients:
Benzoyl peroxide
Salicylic acid
Sulfur
Resorcinol
Finding topical products that work is easier than you may suppose.
The active ingredient you choose depends on what kind of acne
you have:
If your acne consists mostly of blackheads and whiteheads,
get a product that contains benzoyl peroxide and then, if necessary,
add one that has salicylic acid in it.
If you’re just starting to get a few zits (inflammatory papules),
try benzoyl peroxide alone.
In the following sections, I tell you about benzoyl peroxide and
salicylic acid, as well other less active active ingredients that don’t
work so well.
The benefits of benzoyl peroxide
Benzoyl peroxide, a potent antibacterial agent that kills P. acnes,
the bacteria that are involved in producing acne, is the most commonly
used OTC acne medication, and for good reason — it works!
Benzoyl peroxide dries and peels the skin and removes dead cells,
helps to clear blocked follicles, the non-inflammatory comedones
(blackheads and whiteheads), and it works on the papules and
pustules. A triple threat!
Unlike antibiotics and other prescription medications, you can use
benzoyl peroxide for months, even years at a time, and there are
really no long-term side effects including tolerance (bacterial resistance)
associated with it. (For more on tolerance, see Chapter 10.)
Chapter 7: Taking Care of Acne Over the Counter 77
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You can find benzoyl peroxide in many brand-name OTC products,
such as Clearasil, Oxy, Clean and Clear, PanOxyl, and Neutrogena,
as well as less-expensive generic or store brand products. You can
also find it in creams, gels, lotions, foams, soaps, washes, masks,
and scrubs and in combination with other topical products.
Here are a couple of little tidbits to keep in mind:
Of all the benzoyl-peroxide options, creams, lotions, and pads
are more effective than washes, soaps, and scrubs.
Benzoyl peroxide is available as a prescription (see Chapter 9),
but prescription benzoyl peroxide formulations are no more
effective than OTC products, they just cost more.
Using benzoyl peroxide
Benzoyl peroxide is designed to treat existing acne and prevent
future breakouts. If you have acne vulgaris, you should use it even
when your face is clear. Women can use it regularly to prevent or
minimize hormone-related acne breakouts.
The strength of benzoyl peroxide varies in the different products,
ranging from 2.5 to 10.0 percent. Lower strength benzoyl peroxide
preparations, such as 2.5 percent, are less irritating than the
higher strength 5 percent and 10 percent concentrations and are
just as effective for most people, plus they’re cheaper! Start out
using the lowest dose possible, and then move up in strength if
you need to. You minimize the chances of irritation and hopefully
save some money.
In general, you begin using benzoyl peroxide products sparingly
and then work toward more frequent application (follow the
instructions that accompany the package — if you don’t understand
them, ask your pharmacist, nurse, or doctor to explain them
to you). Here are some general guidelines:
1. Start out doing this every other night. After you wash
your face, sparingly apply a very thin layer to areas of
your skin that have acne or are acne-prone.
Avoid your eyes, lips, and the corners of your mouth,
which are often very sensitive.
2. As you are able to tolerate it, build up to once or even
twice daily if you’re not making too much progress.
When you choose a benzoyl peroxide treatment, keep these points
in mind:
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Benzoyl peroxide can be irritating to your skin. For that
reason, you should avoid abrasive, harsh, or drying soaps and
cleansers while using it. After all, you don’t want to add to the
irritation by physically scrubbing your skin.
Benzoyl peroxide can bleach hair, sheets, towels, and clothing.
(It contains peroxide, a powerful bleach.) To avoid the
bleaching effect, an old T-shirt should be worn after applying
benzoyl peroxide to acne on the back or chest. Also, make
sure the benzoyl peroxide has completely dried before the
treated skin touches towels, clothes, or bedding (towels,
sheets, and pillowcases should be white).
You can apply makeup or other skin-care products, such as
moisturizer, over benzoyl peroxide.
Be patient, acne responds very slowly to treatment. It may
take several months before you notice significant improvement.
To prevent new lesions from forming, continue using
benzoyl peroxide even after your acne clears.
Side effects
Dryness of the treated area can be expected and is usually mild. If
your skin is visibly scaly, apply a light, non-oily moisturizer, like
Eucerin Daily Control & Care Moisturizer, Cetaphil Moisturizing
Lotion, or Olay Oil-Free Active Hydrating Beauty Fluid.
You may experience a mild burning sensation or reddening of the
skin when you first start to apply benzoyl peroxide. Irritation and
burning are common, but usually disappear in two to three weeks.
If the preparation you’re applying causes too much redness, peeling,
or dryness of your skin, reduce the number of times a day that
you use it, or use a weaker strength. If necessary, discontinue
using it altogether.
Use of benzoyl peroxide products may also cause contact dermatitis
(red, dry, inflamed, itchy skin) due to irritation or allergy. It can be
treated with a topical steroid such as a 1 percent hydrocortisone
cream, which is available without a prescription. Look for the
brand names Cortaid or Cortizone 10, or store brand equivalents.
Trying salicylic acid
By itself, in the low concentrations that are available over the
counter, salicylic acid isn’t very effective in treating acne. However,
it’s believed to help the skin absorb benzoyl peroxide and other
more effective prescription topical acne medications.
Chapter 7: Taking Care of Acne Over the Counter 79
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Salicylic acid is a beta-hydroxy acid (BHA). Beta-hydroxy acids are
commonly called “fruit acids” because they’re natural substances
derived from fruits, sugar, and plants. They’re found in many overthe-
counter products.
Salicylic acid works by exfoliating, which means it removes the top
layers of dead skin cells. Salicylic acid loosens the gluelike substances
that hold the surface skin cells to each other, allowing the
dead skin to peel off. It’s also oil soluble and can get into oil-clogged
pores. These actions help the skin renew itself faster and reduce the
chance for pore blockage and a subsequent acne breakout.
The OTC products that contain only salicylic acid are, at best,
minimally effective in treating non-inflammatory acne lesions
(like blackheads and whiteheads). Salicylic acid doesn’t have
any effect on sebum production; it just removes the sebum that
has reached the surface of the skin and makes your skin feel
smoother. That’s why salicylic acid is also found in some makeup
removal products.
Much more powerful salicylic acid preparations are sometimes
used by dermatologists and plastic surgeons as acne treatments
and for wrinkle removing and skin rejuvenation procedures. The
high concentrations are much more effective at clearing up blackheads
and whiteheads than the OTC products (see Chapter 14).
As with benzoyl peroxide, salicylic acid comes in a host of formulations
and is an ingredient in Clearasil, Oxy, Clean and Clear, PanOxyl,
and Neutrogena, as well as less expensive generic brands.
Salicylic acid is available in concentrations from 0.5 to 2.0 percent,
mainly in creams, lotions, pads, washes, cleansers, and astringents
(agents that dry oily skin). It’s available as a single agent or sometimes
in combination with sulfur. (For more on using sulfur, see the
section “Resorcinol and sulfur,” later in this chapter.)
Creams, lotions, and pads that contain salicylic acid are more
effective than the other options.
As part of their skin-care lines, the same companies that offer benzoyl
peroxide products often offer products containing salicylic
acid. Sometimes they’re packaged together as a “total acne treatment
system.” When these “systems” contain salicylic acid as well
as benzoyl peroxide as their active ingredients, they can work
quite effectively to treat your acne.
Those expensive mail-order OTC combination “systems” that you
see on TV infomercials can’t always be trusted or tailored to match
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your skin. But if you really want to use one, you can buy a much,
much cheaper “knockoff” variety at your local drugstore or Wal-
Mart. Read the labels!
Using salicylic acid products
Salicylic acid products are appropriate starter treatments for children
who are just beginning to develop mild comedonal acne.
When used alone for other types of acne or more advanced acne,
don’t expect very much from them.
As with benzoyl peroxide, you apply a thin layer of salicylic acid to
areas of skin affected by acne. If you discover that the salicylic acid
isn’t working very well, substitute or add a benzoyl peroxide product
to your regimen.
Side effects
Dryness of the treated area can be expected and is usually mild. If
these products are used with benzoyl peroxide formulations, the
dryness and irritation can be more severe, and if the skin is visibly
scaly, apply a light non-oily moisturizer such as one described in
the section “Using benzoyl peroxide.”
Other OTC medications
In this section, I briefly describe the medications that are of questionable
value in treating your acne. Some can be quite expensive.
Retinols and alpha hydroxy acids
Retinol is a derivative of Vitamin A. You may have heard or read
the term in advertising for products that claim to reduce fine
lines and wrinkles by increasing cell turnover (sometimes called
rejuvenation).
Retinols are sometimes used alone, or in combination with alpha
hydroxy acids (AHAs). Glycolic acid is the AHA most frequently
used for facial treatments, but lactic and citric acid are also used.
(Most often AHAs are derived from fruits, which is why they’re
sometimes called “fruit acids.” As you may expect, lactic acid
doesn’t come from fruit, it comes from milk.)
OTC products contain very low concentrations of AHA, which acts
as a mild exfoliant. Although retinols and AHAs were originally
marketed to fight aging skin, they’re both currently being touted
for use in treating acne; however, their effectiveness as an acne
treatment hasn’t been scientifically tested.
Chapter 7: Taking Care of Acne Over the Counter 81
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Chemical peels have become popular as anti-aging, facial rejuvenation
procedures; however, they’re sometimes used to treat acne
and acne scars. This method involves the application of strong
acid solutions such as AHAs or BHAs (beta-hydroxy acids), which
cause the skin to peel off and encourage regeneration of new skin.
The treatment that is right for you depends on your skin type, and
the activity of your acne. Such AHAs and BHAs that are applied
and dispensed by physicians are much stronger than those that
you can purchase over the counter. I discuss chemical peels in
Chapter 14. The over-the-counter products have been proven to be
effective for the treatment of acne.
Resorcinol and sulfur
The following agents have been used to treat acne for many generations
without great success, but they’re still available. Because
they’ve been around for so long, I include them primarily for their
historical interest and to tell you to save your money if you see
these guys listed on a label:
Resorcinol: This still-popular ingredient is frequently combined
with sulfur in OTC products. Redness and peeling of
your skin may occur after a few days.
Sulfur: Sulfur has been used for more than 50 years in combination
with other agents, such as alcohol, salicylic acid, and
resorcinol. It is found in many OTC acne medications. Sulfur
reacts with the skin in such a way that it makes it dry out,
look red, and peel. Due to its unpleasant, “rotten egg” odor,
sulfur isn’t frequently used alone as an acne treatment.
Multi-ingredient products
You can find numerous products that include various combinations
of benzoyl peroxide, resorcinol, aloe, glycolic acid, sulfur, and
salicylic acid. Also, herbal remedies are available that contain aloe,
lemon oil, and various other fruit-derived items. Such products are
difficult to evaluate scientifically.
You’re better off avoiding these products that contain such a
hodgepodge of ingredients; besides, you only pay more for them.
Avoid OTC products that fall under the heading “herbal,” “organic,”
or “natural.” Their effectiveness has rarely been tested in clinical
or scientific trials. The value of such treatments is generally
unknown. In Chapter 15, I explore some of these “new age” treatments.
And don’t bother experimenting with some old home remedies
such as rubbing on papaya or a paste of roasted pomegranate
skin, fresh cut cloves of garlic, and so on. Fruits and vegetables
82 Part II: Figuring Out Your Acne and How to Tackle It on Your Own
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don’t work. They taste good, but are better put to work in your
stomach than on your face. On second thought, I’m not so sure
about the taste of pomegranate skin.
A Word about Acne Soaps,
Cleansing Strips, Et Al
Some products physically (rather than chemically) agitate your
skin. In most cases, they remove dirt, sebum, and dead skin cells
from the surface, but they don’t do much, if anything, to treat your
acne. Having a clean face is great, but these rubby, scrubby products
often only serve to irritate and redden an already inflamed
complexion. Here are some of the most common physical acne
treatments:
Pore cleansing strips: These sticky patches temporarily lift
solidified sebum and dead cells out of your pores for a day or
so. They may occasionally cause mild irritation. They aren’t
very useful.
Acne soaps: Antibacterial foaming washes, scrubs, and soap
bars are available in many shapes and sizes. Some contain
benzoyl peroxide, others have salicylic acid and some have
triclosan, an antibacterial chemical cleanser that removes
excess sebaceous secretions.
None of them hang around on your skin long enough to do
much to help your acne. To make them more effective, leave
them on for at least 5 to 10 minutes before rinsing them off.
Exfoliants: These are products that physically scrub the skin
cells off. They can be very harsh on your skin if you have
inflammatory acne, and they can be especially irritating when
they contain salicylic acid. Exfoliants come in many forms:
abrasive sponges, cosmetic scrubs, facial masks, toners, pads,
and sponges. Avoid these products if you have sensitive skin.
Masks: Masks to treat acne are essentially self-indulgent ways
to spend more money and get a mild facial exfoliation. Masks
contain various ingredients such as salicylic acid, benzoyl
peroxide, vitamins, aloe, and lemon juice, to name a few.
Loofah sponges: Almost as bad as using sandpaper on your skin
if you have inflammatory acne. If you have non-inflammatory
acne and tough skin, I guess they can’t hurt.
Chapter 7: Taking Care of Acne Over the Counter 83
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These treatments are most effective when used sparingly and in conjunction
with other treatments that have antibacterial properties, like
benzoyl peroxide. But my final word on all of these products: Save
your money! Go with proven treatments like benzoyl peroxide and
salicylic acid preparations, if you’re going to treat acne on your own.
Evaluating Advertisers’ Claims
There is some excellent, time-tested, helpful information about
acne and acne-fighting products available, but sadly you need to
take a lot of the stuff you find with a grain of salt. Be especially
wary of the following as you walk through acne aisle at the drugstore,
search the Internet, visit your local bookstore, or watch
those infomercials:
People who are selling products: Many supposed experts
have a financial interest in pushing their own products; this
often outweighs their interest in really educating and helping
you. So learn to read between the lines and to skip all of the
hucksterism. Such keywords and phrases as magic, revolutionary,
our laboratories, and overnight should have you raising a
skeptical eyebrow.
Claims that are too good to be true: Any product or book
that has the word cure on the package or in its title, or
24 hours or even 5 weeks to clear skin, should make you very
suspicious. I don’t know how to cure acne and I’m a dermatologist
with many powerful drugs at my disposal. There is no
cure for acne, and in most instances, and even with the
strongest of medications, it often takes months to get it under
control and years of treatment to keep your skin clear.
Unsubstantiated claims about scientific testing: When a
product says it was dermatologist-tested, it wasn’t necessarily
approved or recommended by dermatologists. It could be that
just one dermatologist tested it; maybe the dermatologist
tested it and didn’t like it! But I guess the manufacturer can
still say that it was dermatologist tested. And when a highly
paid TV actor/doctor or your favorite movie star or pop star
endorses a product, I realize that it’s not easy to separate the
real claims from the phony. Perky ears, raised eyebrows, and
this book (not very modest of me!) can be your best guides.
I’ve written this book to provide you with the information you need
to make educated decisions about your acne. If you elect to go it
alone in your acne treatment, your pharmacist is an excellent source
of additional information to help you find your way through all the
hype. Also, check out Web sites that I recommend in Chapter 21.
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Part III
Turning to the Pros
to Treat Your Type
of Acne
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In this part . . .
Istart off by helping you find a dermatologist or other
medical professional to help you get your treatment
underway. Then I clearly explain — in plain English — the
many available treatment options that your doctor may
recommend including topical medications, oral antibiotics,
hormone therapy, Accutane, and lasers and lights.
Within each discussion I highlight the preferred paths for
teens, adults, and folks with dark skin. I also devote a chapter
to exploring alternative and complementary therapies.
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Chapter 8
Calling in the Experts
In This Chapter
Deciding what you want to happen
Going to see your healthcare provider
Finding the right skin specialist for you
Keeping your first appointment
Working together to improve your condition
Acne can be tough to treat, especially on your own. If you’re
ready to consider a visit to the doctor (see the criteria I suggest
for making this determination in Chapter 1), you’ve come to the
right place. In this chapter, I look over the landscape of professional
help that is available to manage your acne. Some general healthcare
providers learn about treating acne as a part of their medical training,
and your healthcare provider may be one of them. I fill you in on
how to determine whether that’s the case. If it’s not, no problem: I
explain how to find a dermatologist, a specialist who deals with all
skin disorders.
I also give you some pointers about how to make the most of your
experience in managing your acne with the experts. I give you the
“ins and outs” of dealing with the first appointment, the paperwork,
insurance issues, prescription refills, and all that other
annoying, but necessary, stuff. And I tell you what to expect from
your treatment and how to have a good working relationship with
your acne doctor.
Establishing Basic Goals
of Treatment
Whether you visit your primary care provider or a dermatologist,
the basic aims in treating your acne are usually the following:
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To prevent your acne from scarring or to prevent further scarring
if it has already been present.
To decrease the physical and emotional pain of having acne
lesions.
Of course, to make you look better!
Discuss your goals with your healthcare provider. Get a feel for
what to expect from your treatment, how long it will take, and what
to do if it doesn’t work out so well. In other words, try to get an
idea about a best-case/worst-case scenario. Seeing a dermatologist
or other skin-care specialist can be part of that plan.
Seeing Your Primary Healthcare
Provider
Visiting your primary care provider (PCP) is a logical first step
because, nowadays, more and more healthcare providers are learning
about the treatment of diseases of the skin, including acne.
They have more tools at their disposal to treat your acne than you
do because they’re often able to write prescriptions, if necessary,
for medications. Plus, even if they aren’t able to help you manage
your acne, many insurance policies require that your PCP provide
a referral for specialists, including dermatologists.
Working together to treat your acne
Your PCP may be a(n):
Pediatrician: A physician who specializes in children.
Family practitioner: A generalist who treats routine medical
problems for people of all ages.
Internist: A physician who specializes in treating medical conditions
of adults.
Your PCP may also be a healthcare specialist who isn’t a doctor:
Physician assistant (PA): Physician assistants work under the
supervision of a physician. They work interdependently with
the understanding that the physician is available for consultation
whenever needed. PAs can treat patients and, in most
states, prescribe medicine.
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Nurse practitioner (NP): A nurse practitioner is a nurse with a
graduate degree in advanced practice nursing. Some NPs
work without physician supervision, and others work
together with physicians as a joint healthcare team. Their
range of practice and authority depends on state laws. For
example, some states allow nurse practitioners to write prescriptions,
and other states don’t.
Some PAs and NPs are specifically trained in dermatology, and
some even specialize in areas such as acne. In fact, some PAs and
NPs may actually have more training in dermatology than pediatricians,
internists, and family practitioners. An advantage to seeing a
physician assistant or nurse practitioner is that it may also
decrease the waiting time necessary for an appointment with a
busy physician.
But the next question is whether or not your PCP is able to manage
your acne. You should always find out about the experience your
PCP has had in treating acne. The best way to find out is by simply
asking him.
If you and your primary care provider decide to tackle your acne
together, she’ll likely give you one or two topical medications to
apply to your skin. She may also give you certain oral antibiotics
that are effective in treating acne. (In Chapters 9 and 10, I give the
details about these agents that are used to treat acne.)
Be patient and give the medications a chance to work. Topical
medications can take weeks to months to show what they can do.
Keep in mind that medications should be used as directed or they
can’t work nearly as well. Make a habit of taking or applying your
acne medicines like you make a habit of brushing your teeth.
It’s not unusual for acne to last for many years, so ongoing treatment
may be necessary.
It may come to pass that despite the best efforts of your PCP, your
expectations for improvement in your acne haven’t been met.
You’ve been through the usual stuff — pills, creams, and lotions
that have been prescribed for you and you’re not getting any
better, or not better enough to suit you. In this case, seeing a dermatologist,
the expert in the management of this difficult and pesky
disorder, is an option to consider. Just about every case of acne
can be cleared up, but sometimes it takes a dermatologist’s help.
Chapter 8: Calling in the Experts 89
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Requesting a referral to see
a specialist
If your health plan requires that referrals to specialists be authorized
or approved by your PCP, who is often your best source, then
you need to ask for the referral. However, if your health plan allows
you to make appointments without a referral from your PCP, your
PCP is still an excellent source for helping you to identify a qualified
professional in your community (see “Finding the Right
Dermatologist for You,” later in this chapter).
You can enter into a specialist’s care via a referral in a number of
different ways, but in most cases, your specialized care typically
falls into two categories:
For a consultation: In some cases, your PCP may prefer to
have you obtain a dermatology consultation, which means that
the specialist will evaluate you and make recommendations
for further care, and then send you back to your PCP for continuing
treatment. For more on what to expect from a consultation,
see the sidebar “What is a consultation?”
For ongoing treatment: In this situation, your PCP requests
that your acne-related care remain in the hands of the specialist.
You would still continue to see your PCP for routine things
like illnesses and injuries, but your specialist will handle all
things related to your acne.
90 Part III: Turning to the Pros to Treat Your Type of Acne
What is a consultation?
A consultation is a meeting of two or more health professionals to discuss the diagnosis,
prognosis, and treatment of your acne. The consultation is basically a request
from your PCP to work with a dermatologist as a team to treat your acne.
The dermatologist sends a letter, an e-mail, or makes a telephone call to your PCP
and describes what recommended treatment he feels would be best to treat your
acne. Your PCP will then follow the consulting dermatologist’s recommendations,
and together they act as your acne skin-care team.
Ideally, theirs should be an “open-door” relationship that allows you to see the dermatologist
again if things aren’t working out.
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In either case, the medical records of your care to date should be
sent or brought by you to the dermatology specialist to review so
that any relevant medical information such as past medications
and therapies will be available to her.
Finding the Right Dermatologist
for You
All dermatologists aren’t created equal. Some are very talented and
up-to-the-minute on the latest knowledge for treating your acne,
while others may lag in their capabilities. Start by asking your regular
PCP for the person who might best treat your acne. You may
want to ask him whom he would send a member of his own family
to if they had acne.
A dermatologist must have a degree in medicine, either as a
Medical Doctor (MD) or a Doctor of Osteopathic Medicine (DO).
Dermatologists first go to medical school and then to a residency
program for their specialized training. They’re experts in the diagnosis
and treatment of diseases of the skin (including hair and
nails) in both pediatric and adult patients.
Depending on the doctor’s specialty and interest, a dermatologist
may also receive very specialized training in one or more of the following
procedures (some of which I cover in Chapters 14 and 16):
The use of lasers and other special light delivery systems to
help treat acne
Surgical corrective resurfacing procedures to reduce acne scars
Various cosmetic techniques such as Botox and “filler” injections
to improve the appearance of the face
In the following two sections, I tell you how to go about seeing a
dermatologist, a PA, or an NP and what to do when you get there.
From here on out, I refer to all of those professionals as dermatologists.
After you put together a list of prospective dermatologists,
call each office and ask if the doctor accepts your health insurance
plan. If the doctor isn’t covered by your plan, ask yourself if you’re
prepared to pay any extra costs.
Chapter 8: Calling in the Experts 91
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Using networking techniques
In addition to checking in with your PCP, you could also locate a
specialist on your own by asking your friends, family, or other
members of your community who have been satisfactorily treated
by a particular dermatologist. Don’t be shy. If you know someone
who had acne and now shows improvement, ask her how she did
it. She’ll likely be thrilled you noticed and happy to share the info.
If your house needed a renovation, you’d likely ask for references
about any contractor that you might consider. The same holds true
for anyone who is going to be responsible for your skin, the
“house” you live in.
Checking in with professional
associations
The American Academy of Dermatology is the largest dermatologic
association in the United States. Their Web site (www.aad.org)
can help you locate a dermatologist in your area. This site can also
provide biographical information about many academy member
dermatologists, including their education, specialized training,
office hours, and whether they accept your health insurance plan.
You can also find detailed maps showing how to get to their
offices. You can also call or write to the American Academy of
Dermatology, 930 E. Woodfield Road, Schaumburg, Illinois,
60173-4927; 847-330-0230.
You can find out whether the doctor you’re interested in is board
certified in dermatology. “Certified” means that she has completed
a training program in the specialty of dermatology and has passed
an exam, or “board,” that assesses her knowledge, skills, and experience
to provide quality patient care in that specialty. That means
that all the training and tests have been met by the doctor and
approved by the American Academy of Dermatology.
I would certainly recommend that you look for a dermatologist
who is board certified.
Many dermatologists have teaching positions at academic centers
such as major hospitals and medical or osteopathy schools. You
can check out their credentials and academic positions online or
by asking your local public or university reference librarian to
help you.
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Looking at your insurance directory
You know that list of names that came in the mail or that were
given to you when you signed up with your HMO or other health
insurance company? It contains a list of specialists who are in their
network of providers, which means the doctor has been approved
by your HMO or insurance company. An advantage to using an innetwork
specialist is that most insurers check out the providers on
that list and hold them to high standards.
Moreover, if you go to a specialist who is on this approved list of
providers, most of the medical bill will be covered by your insurer.
Who doesn’t want that?
If someone you wish to see isn’t on that recommended list, it doesn’t
always mean that the specialist isn’t up to snuff. In fact, it may be
worth your while to go out of network to find the right person for
you; however, it will likely cost you more money to do so.
Check with your insurance company to see whether they have an
online directory. Typically, the directory doesn’t include recommendations,
per se. But you can search their directory based on
specific criteria, like distance from a location (like your home or
child’s school) or office hours. Often you can click to find a map
directly to the dermatologist’s office and get the phone number to
make an appointment right away.
Perusing the phone book and
advertisements
Believe it or not, the phone book can help you with your choice.
Specifically, it can help you choose:
A dermatologist that’s close to your home or your child’s
school. That makes sense.
A male or female. You can then decide who you or your child
would be most comfortable with.
One that may speak your language or has translation
available to you if you don’t speak English. You could call to
find out.
But remember, the bigger ad isn’t always better.
Chapter 8: Calling in the Experts 93
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Unfortunately, the late 1970s and early 1980s saw the removal of
legal restrictions against advertising by those in the legal and
medical professions. I advise you to distrust a doctor who advertises
via large billboards, television, newspapers, gigantic yellow
page ads, or subways. Some of these doctors may start treating
their patients as customers, rather than as patients. I also strongly
advise you to avoid skin-care spas that advertise laundry lists of
treatments that they offer. I’ve seen an add that lists “laser treatment
for acne scars, male breast reduction, breast enlargement
for women, leg vein removal, buttock enlargement, buttock reduction,
cosmetic skin surgery, broken blood vessels, microdermabrasion,
chemical peels, laser lunchtime super peels, collagen/Botox
treatments, hair restoration, laser hair removal, body contouring,
liposuction.” And last but not least, in smaller print, “acne,
eczema, skin cancer screening, warts, mole removal, and rashes.”
And maybe they can check your car’s tire pressure and oil while
you’re there.
Going to the Dermatologist
for the First Visit
Whether the person you’re seeing is a dermatologist, a physician
assistant, or a nurse practitioner, it’s a good idea to come prepared
for your first visit.
Taking stock of your medical history
Before you walk out the door for your first appointment, review
your medical history. Be prepared to tell the dermatologist what
medications you take and what medical problems you have that,
unknown to you, might play a role in your having acne or the treatment
your doctor recommends.
Here are a few things your dermatologist may want to know:
Allergies: Do you have any allergies to medications?
Other skin conditions: Do you have a history of eczema (an
itchy, inflammatory skin problem that’s often hereditary and
makes your skin very sensitive) or contact dermatitis (an allergic
reaction or an irritant response to things that have
touched your skin)? These problems can be important
because they can make your skin more vulnerable to some of
the topical treatments that are used to treat acne.
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Medications, vitamins, and supplements: Go through the
items in your medicine cabinet. If you’ve recently swallowed it
or rubbed it on, your doctor needs to know about it.
Bring the medications you’ve been using to treat your acne
into the examining room. The actual tubes and bottles can
help your dermatologist read all the ingredients (both active
and inactive) in the medications and make more informed recommendations
about where to go from here. If you don’t have
the empty tubes or bottles with you, write down the names of
the medications and their dosages. If you’ve been using a
medication, describe how long you have used it. Note any
subjective information like: Was it irritating? Was it helpful?
Also make a list of non-acne products, such as birth control
pills, vitamins, herbs, supplements, or other medication.
Include the medications’ names and dosages.
Preparing on the day of your visit
With your medical history in hand, there are a few additional steps
you can take to make the most out of your first office visit:
Arrive 15 minutes early: On your first visit to any healthcare
provider’s office, you’re generally expected to fill out a form or
two. Your new doctor will need — at a minimum — your name,
address, medical history, drug allergies, and current medication.
You will also need to provide information about your
insurance coverage and how you expect to pay for your visits
(such as with cash or credit card). Arrive at the office earlier
than your scheduled appointment to take care of these issues.
Bring a parent: If you’re a minor, you should come in with a
parent or guardian. A minor is a person under the legal age of
consent, which is generally 18. Certain procedures or medications
will require parental consent, so be sure, especially on
that first visit, that an adult or legal guardian is present.
Bring your insurance card: You will be asked for your insurance
card or the card of the policy holder if coverage isn’t in
your name. If you don’t have a card with you, you should at
least know the name and date of birth of the cardholder.
Remove your makeup: When you see a dermatologist and
expect a careful examination of your face, you shouldn’t be
wearing makeup to conceal the reason you went there in the
first place — your face!
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I know from firsthand experience that trying to see through
makeup is like trying to look out of a window when it’s fogged
up. The time involved in removing makeup in the examining
room is better spent talking about your skin. So remove it
before entering the examining room. If you hate appearing in
public with a “naked” face, you can always reapply your
makeup before you leave the office.
Meeting the doc
Your first visit with your doctor will involve a review of your medical
history, focusing on the acne angle, an examination of your
skin, and treatment recommendations. In addition to checking out
your face, he may want to look at your chest and back because
acne often occurs there as well. If your acne only involves your
face, then there’s no need for you to undress.
Communicating your personal acne story
The following are my typical first-visit questions about acne. You
will undoubtedly be asked some or all of them. To ensure that you
don’t forget anything and that you and your doctor can make the
best use of your time together, you may want to spend a few minutes
thinking about these questions before the visit:
How long have you had acne?
Does it run in your family?
Is there anyone in the family with severe scarring acne?
What do you do to your skin each day — such as how many
times a day do you wash your face?
Are you applying or taking any medications?
Do you pick at lesions?
What seems to make it worse? Diet, exercise, medications,
stress?
What has been helpful? Sunlight, vacations, medications, winning
the lottery?
And if you’re a female, you’ll also get these old standbys:
Does it get worse before your period or at midcycle?
Does makeup make it worse?
Are your periods normal?
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Are you taking birth control pills and do they seem to help or
worsen your acne?
Have you noticed any unusual or excessive hair growth?
Understanding treatment recommendations
Based on a physical exam and your discussions with your dermatologist,
she will recommend treatment options, which will likely
include some sort of medication.
Before leaving the examining room, make sure that all your questions
have been answered. Your doctor is there to help you
through the process, and questions are always welcome. You
should know what to expect from your treatment and get a clear
sense of its goals.
For example, make sure that your doctor has answered these questions,
and if not, ask them:
What are the side effects of the medication you are prescribing?
How long will it take for the treatment to work?
How long do you think my acne will last?
But my standard reply when a patient asks, “How long will it take
for my face to clear up?” or “How long will I have acne?” is something
like “Gee, my crystal ball is in the repair shop this week!”
Launching a Good Working
Relationship
As in any ongoing relationship, especially if it may last for a long
time, it’s important to feel comfortable and have a sense of genuine
rapport with your dermatologist. Key points in building this relationship
include closely following your doctor’s instructions, being
patient, and feeling free to ask any questions that you may have.
Following instructions
You need to know some very specific information before you start
popping those pills or rubbing the acne stuff on your face and
body. And just like that manual that came with your new iPod or
computer, the medication your doctor prescribed comes with
instructions. If you’re like me, you’ll probably find them much
easier to understand than your iPod or computer instructions.
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Read those instructions! Both the instructions that come with
each medication and any handouts given to you by your doctor
or anyone on her staff contain valuable information about your
treatment regimen. If you weren’t given an instruction sheet or
other handwritten directions regarding medications, call your
doctor for any necessary clarification. (You could also read the
info in Chapters 9 and 10, where I spell out in detail how to make
the best of your medications.)
Being a “patient” patient
Some folks expect things to work overnight and don’t give the medications
a chance. Impatient patients are a very common problem! If
you think the stuff your doctor gave you isn’t working, often it’s
because you haven’t given it enough time to really kick in. For example,
benzoyl peroxide may take four to six weeks to really start working,
and some topical medications such as the retinoids can take up
to three months before they show their stuff. I go over the retinoids
and benzoyl peroxides in much more detail in Chapter 9.
You see your face in the mirror every day. Your dermatologist only
sees it when you come to the office for your appointments. The
improvement, or lack thereof, will be much more evident to him.
Sure, you’ll have some good days and bad days, but overall, it’s
important to stick with the routine and give it a real chance to
work and judge the progress on a monthly rather than a daily
basis. Rome wasn’t built in a day and your acne won’t disappear in
a week!
Telephoning the dermatologist
with questions
You, your healthcare provider, and her staff should view your acne
treatment as a team effort. Like any good team, communication
here is important, so don’t hesitate to call the doctor’s office with
questions or concerns you have outside of your normal office
visits.
Although office policies vary, the best time to call is in the morning
after 9 a.m. when most offices are open. Many offices go “on service”
during lunch hours and an answering machine (voicemail purgatory)
or operator who isn’t in the office may answer your call.
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If you need to cancel or change an appointment, the receptionist
can handle that information while you’re on the phone. Other
procedural-type queries may be fielded by members of the dermatologist’s
staff. And, if you have a fairly straightforward medical
question, the receptionist may have a nurse call you back.
But for more complicated situations and real “trouble shooting,”
ask to speak to the dermatologist or have him call you back
directly.
Simply tell the person who answers, “I would like to speak to the
doctor, and it’s very important. Please have him call me back.”
Leave the times and phone numbers where you can be reached in
the next 24 hours. (If it’s not an emergency, don’t say it is one!) The
staff will then pull your chart and leave it for the doctor to review.
Here are some of the most common scenarios that call for a quick
call to your dermatologist instead of sitting back and waiting for
your next appointment, which may be three months away:
Your medication isn’t working. If a medication is causing you
problems, not working, or for some reason you can’t or won’t
use it, call the dermatologist about it — or if you’re a kid ask
your parent to call. Don’t wait.
You forgot to ask certain questions during your appointment.
Call the dermatologist rather than waiting until your
next appointment.
You need refills or you lost a prescription or medication.
Possibly you lost the actual prescription or you left the medication
at your grandparents’ house, at a camping trip site, or
your dog ate it. Often the receptionist or nurse can take care
of refills over the telephone. (If your dog ate your prescription,
you may also need to call or visit the vet!)
More often that not, when you call to ask for a refill, you’ll find
that there is a specific policy that is carefully followed. Most
dermatologists, as well as many other healthcare providers,
are more liberal when it comes to refilling topical medications.
However, oral drugs carry greater risks and the policy
regarding refilling them will necessarily be much stricter.
Many dermatologists insist that you be seen in their office if
more than a year has elapsed since your last office appointment
before mailing you or telephoning your pharmacy for a
refill. This is especially the case when the dermatologist isn’t
very familiar with your case and perhaps has only seen you
on one or two occasions.
Chapter 8: Calling in the Experts 99
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You need a different prescription. Maybe you can’t afford
the prescription and need a generic substitute.
You lost information about the medication. Maybe you
forgot how often to take the pills or your PCP wants to give
you a medicine for another condition and you want to know if
that drug can be taken along with your acne medication.
You’re concerned about side effects. Maybe the stuff the
dermatologist gave you smelled horrible, made your dog sick,
upset your stomach, gave you a yeast infection, bleached
your nice blouse, irritated your skin, or made you itch like
crazy!
You need a referral. For instance, you’re moving to
Albuquerque and you want the name of a dermatologist in
that city.
Deciding to change dermatologists
You can switch dermatologists if you don’t have a good communication
with the dermatologist you’re seeing or if you’re not satisfied
with the progress of your treatment. You or your parent might
speak to the dermatologist about these issues and maybe give her
and the medication(s) more time or another office visit or two
before deciding to change doctors.
If you’re still dissatisfied, ask your PCP for another referral, or
repeat the measures that I talk about in the earlier section,
“Finding the Right Dermatologist for You.”
100 Part III: Turning to the Pros to Treat Your Type of Acne
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Chapter 9
Reviewing the Topical Tools
at Your Dermatologist’s
Disposal
In This Chapter
Choosing to treat your acne topically
Evaluating a cornucopia of topical treatments
Getting into generics
You may have tried some over-the-counter products, flirted
with various diets, or experimented with cosmetics, facials,
and soaps. Maybe you’ve even watched a few TV infomercials and
tried those products with unsatisfactory results. Well, it sounds
like you’re ready for a different approach. The good news is that
doctors have a treasure trove of excellent topical tools they can
use to treat any type of acne. In fact, for many people, topical
preparations are the only treatment necessary.
In this chapter, I tell you all you need to know about the topical
preparations available through a healthcare provider to treat your
acne and how to use them effectively.
Before starting out on our acne treatment journey, there are three
important points that you as an acne patient should be aware of:
Six to eight weeks of treatment may be required before you
see any significant improvement.
Lesions on the back, chest, and shoulders respond more
slowly to topical and oral treatment than do those on the face.
Every patient is an individual, and as such your doctor is in
the best position to tailor treatments to your needs. Always
follow your doctor’s recommendations.
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Taking the Topical Route
The use of topicals offers many advantages over oral therapy (taking
medications by mouth). The most obvious advantage is that your
skin gets the direct application of medications and very few serious
complications can result, whereas the oral route may lead to more
severe side effects (such as those discussed in Chapter 10). In topical
therapy, a vehicle (an inactive medium) “delivers” the active
ingredient (the drug itself) to its intended target. The vehicle may be
a cream, ointment, gel, lotion, or solution (an oil-free liquid, that’s
usually composed of water or alcohol).
The solutions, gels, and lotions that contain active ingredients can
also hitch a ride on convenient travel-friendly delivery systems,
such as the pledget or swab. These are small absorbent pads, used
to medicate the skin, that are made from cotton or wool. Just put
them in your bag, backpack, or pocket, and away you go.
In the treatment of acne, the vehicle may be as important as the
drug or drugs that it transports. A vehicle gives a product its texture
and substance and can sometimes determine its strength and influence
how effectively a drug gets absorbed. Check out Chapter 7 for
more on the general principles of topical therapy.
Different topical treatments for different forms of acne are determined
by many factors, such as:
Your skin type: dry, oily, combination, or normal
The types of lesions you have: blackheads and whiteheads,
papules and pustules, or both
How long your lesions have been present
Your past response to acne treatments and side effects that
you’ve encountered
Your tendency to develop scarring or disfiguring acne spots
How much a treatment costs you and whether you can afford it
The best product is one that works best for you. Topical treatment
frequently involves a trial-and-error approach, beginning with
those products that are known to be most effective, least expensive,
and have the fewest side effects. As you find things that don’t
work, you and your doctor team up to remove them from your regimen
and add different (and hopefully better-for-you) products.
That’s why it’s important for you to have a continuing dialog with
your dermatologist in order to come up with the right product or
combination of products for you to apply.
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Sometimes your dermatologist may choose to combine a drying
product (most acne products are), together with a moisturizing
product in order to make the drying product less irritating.
Opening Up the Tool Chest
Topical acne therapy aims to counter several of the major factors
that cause acne:
Blocked hair follicles
Growth of the acne causing bacteria, P. acnes
Inflammation
Oral therapy is required to tackle the other important acne causing
factors, such as:
Increased hormone production
Excess sebum (oil) production
I describe these factors in detail (including the fancy medical
terms involved with each of them) in Chapter 3.
Topical treatment is sufficient for most people who have acne, but
oral reinforcements are generally a must if you have more extensive,
deep, or scarring acne with nodules and cysts. Chapter 10 is where
you can find information about the oral weapons. The following sections
offer a wide range of topical treatments for your acne. Keep in
mind that one size doesn’t fit all and fitting the proper medication to
your skin sometimes takes trying different ones for a while.
Most dermatologists agree that the combination therapy — the use
of topical retinoids and topical or oral antibiotics or antibacterials
such as benzoyl peroxide — reduces both inflammatory and noninflammatory
lesions more rapidly and to a greater degree than
can be effected with any of these agents alone.
Reviewing topical retinoids
Most dermatologists consider topical retinoids to be the mainstay of
acne therapy. They’re often the first-line prescription treatment for
acne and they’re also utilized as long-term maintenance for almost
every acne patient. Retinoids are, far and above, the drugs of choice
in people who have comedonal (blackhead and whitehead) acne, but
they’re also effective at fighting inflammatory lesions, so chances
are that your dermatologist will start you off with one of these.
Chapter 9: Reviewing the Topical Tools 103
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Retinoids are medications that are derived from vitamin A. Retinoids
are comedolytic, which means that they work by making the skin
shed more easily so that follicular plugs don’t build up and form
blackheads and whiteheads. In addition to helping you shed your
skin, retinoids
Indirectly limit the formation of inflammatory lesions by preventing
comedones. After all, if comedones don’t ever form,
they can’t become big, inflamed pustules and papules.
Appear to discourage P. acnes (the bacterial invaders associated
with acne) growth.
Promote the shedding of skin, which enhances the penetration
of other topical anti-acne agents.
Help to “plump up” the skin and make enlarged pores (follicular
prominence, in dermatologist speak) less obvious.
Several brand-name topical retinoids, as well as generic preparations,
are on the market (check out Table 9-1 for information on
which brand-name retinoids contain which active ingredient, and
read the sidebar in this chapter to get a handle on what a “branded
generic” is). Many studies have been performed on the topical
retinoids and the results don’t clearly favor the use of one preparation
over another. Individuals vary in their response to these
agents and possible side effects, so you and your doctor will work
together to find the best prescription for you.
104 Part III: Turning to the Pros to Treat Your Type of Acne
Generic versus “branded generic” drugs
It’s a tricky business trying to find cheaper drugs. When a famous drug such as
Retin-A has its patent expire, it can then become a generic (unbranded) drug. As
an example, once a brand becomes generic, the original company often ceases to
promote or support it. Sometimes this can be a real benefit because the generic
version tends to be considerably cheaper. Hurray!
But, after a while, some generic companies come along and obtain approval from
the FDA to manufacture the drug and they put the original brand name on it. When
that happens, the branded generic price becomes higher than the generic price
because of the cost of marketing.
Sounds like double speak, a kind of contradiction in terms, doesn’t it? The bottom
line is try to be an educated consumer. Read labels and compare prices! To find an
updated list of generic and branded generic drugs, go to: www.wellmark.com/
drugformulary/df_main.asp.
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Table 9-1 The Topical Retinoids
Brand Name Generic Name Delivery Strengths
Retin-A* Tretinoin Cream, solution 0.025%
(Branded generic) 0.05%
0.1%
0.5%
Retin-A* Tretinoin Gel 0.01%
(Branded generic) 0.025%
Retin-A Micro Tretinoin Microsphere gel 0.1%
Avita* Tretinoin Cream, gel 0.025%
Differin Adapalene Cream, gel, 0.1%
solution, and
pledgets
Tazorac Tazarotene Cream, gel 0.05%
0.1%
*Apply only at bedtime
Because of the known teratogenic effects (anything which produces
nonheritable birth defects) of oral vitamin A, the use of topical
retinoids in pregnancy has been an issue of concern. Although no
studies have shown them to cause any birth defects, it is recommended
that these drugs should not be used during pregnancy or
breastfeeding.
Applying retinoids like a pro
Topical retinoids are applied in small, thin, pea-sized amounts to
clean, dry skin once a day in the morning or at bedtime. They
should be applied to all affected areas as well as to places that are
acne-prone. Retin-A (not Retin-A Micro) and Avita, which tend to
degrade in sunlight, should be applied only at bedtime. Talk with
your doctor about the best time to apply Retin-A Micro, Differin,
and Tazorac.
Dermatologists often start treatments with a lower strength preparation;
in time, your doctor may prescribe higher concentrations of
the active ingredient, if necessary, depending on your ability to tolerate
them.
Within six to eight weeks, you should notice improvement if you
have been using your product continuously. Maximal improvement
most often occurs by three to four months.
Chapter 9: Reviewing the Topical Tools 105
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Despite the common misconception, acne does not flare in the first
few weeks of treatment; rather, the “flare” is due to irritation from
the retinoid or from the natural progression of your acne, so try to
“ride it through” unless the irritation is really severe — at which
point you should call your dermatologist or healthcare provider.
It’s not uncommon for retinoids to be used improperly and discarded
before they have a real chance to work. Make sure you get
both verbal and written directions from your doctor to make sure
that you use your products correctly.
Dealing with side effects
All retinoids can cause some skin irritation during the first few
weeks of use. You may have some discomfort, such as stinging or
burning, and sometimes may experience mild redness and scaling of
your skin. These reactions are to be expected, and they’re an indication
that the retinoid is working. After several weeks, your skin generally
gets used to the medication and the discomfort eases.
A common belief is that retinoids dry the skin. But they’re actually
sloughing off dead skin cells.
If you have a sensitivity to the retinoid you were prescribed, you
can take a number of steps to help ease the irritation:
Build up a tolerance: Start off by using the retinoid every
other day, or even less frequently, until you get used to it.
If you have extremely sensitive skin, try applying the retinoid
for short periods of time, such as leaving it on for a few minutes
and then washing it off. You can put it on for as little as
two to five minutes. This tends to make it more tolerable and
the medicine still has positive effects as long as you stick with
it. As your skin becomes accustomed to the retinoid, you can
gradually increase the frequency of application and how long
you leave it on. Eventually you may be able to apply it every
day and leave it on all day or overnight.
Avoid irritating OTC products: Make sure that you’re not also
using an over-the-counter product that contains salicylic acid,
retinols, or other possible irritants.
Ask your doctor to prescribe a cream or a weaker concentration
of the medicine. Creams are the least irritating delivery
vehicle. The concentration of the agent affects the degree
of irritation.
Use a moisturizer: If you get dry and scaly, apply a moisturizer
generously in the morning. The moisturizer should be
applied over any medication you apply at night or in the
106 Part III: Turning to the Pros to Treat Your Type of Acne
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morning. (If you also use a sunscreen, apply it over the moisturizer.)
Effective moisturizers include Oil of Olay, Nivea Ultra
Moisturizing Creme, and Eucerin creams. Use only emollient,
non-irritating cleansers to wash your face when you’re using a
topical retinoid.
Retinoids may produce sun sensitivity. A common misconception
is that tretinoin shouldn’t be used during the summertime, during
sunny weather, or in tropical climates. Retinoids can make you
somewhat more susceptible to sunburn, however, this problem
eases after the drug has been used for a month or two. Retinoids
can be applied at any time of year in any geographic region.
If you’re using a retinoid in sunny conditions, particularly if you
have fair skin, just take simple sun-protective measures, such as
avoiding the midday sun, applying a broad-spectrum sunscreen or
sunblock (over the medication), and wearing a protective cap or
hat. Applying them at bedtime is added insurance against your
having problems with sun exposure the next day.
Enhancing retinoid treatment
Removal of comedones can also help to treat your acne and speed
up improvement. Your dermatologist may perform acne surgery
with a comedo extractor, a small instrument that mechanically
removes comedones. Comedo removal can be a useful adjunct to
topical therapy when your blackheads and whiteheads are somewhat
resistant to topical retinoids.
Acne surgery is a noninvasive surgery, meaning that the blackheads
and whiteheads are simply popped or squeezed out with the extractor.
The extractor is a special instrument that minimizes skin injury.
A round loop extractor is used to apply uniform smooth pressure to
dislodge the material. Lesions that offer resistance are loosened by
inserting a pointed instrument to carefully expose the contents.
Pretreatment with a topical retinoid for four to six weeks often
facilitates the procedure because it helps open up your pores.
Comedo extraction is performed less commonly nowadays since
the arrival of topical retinoids.
Comedo extraction is often performed successfully by aestheticians
as part of a facial. An experienced technician may remove
your blackheads and whiteheads with tissue paper or with another
instrument.
An improperly trained technician may also try to squeeze out your
red papules which can result in persistent redness and even scarring.
Chapter 9: Reviewing the Topical Tools 107
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Turning to topical antibiotics
Because retinoids may be more difficult for you to tolerate and can
take a long time to work, your dermatologist may elect to treat
your inflammatory lesions (papules and pustules) first with oral or
topical antibiotics. They work much faster than the retinoids. So if
you’re in a hurry to look better, the quicker response can be a
helpful incentive for you to continue therapy.
Clindamycin and erythromycin are the two most commonly used
topical antibiotics for the management of inflammatory acne.
Dermatologists consider them to be equally effective. They can be
used alone or in combination with benzoyl peroxide and/or oral
antibiotics (see Chapter 10 for more on oral antibiotics) to treat
acne as well as rosacea, perioral dermatitis, shaving bumps, and
other acnelike conditions. (I discuss these conditions in Chapters
18 and 19.)
Topical antibiotics directly kill P. acnes. In addition to their antibacterial
action, these drugs have an anti-inflammatory action that
helps to clear inflammatory acne lesions. Through their bacterial
killing ability, they also appear to have a mild indirect blocking effect
on the formation of blackheads and whiteheads (known by the fancy
medical name of comedogenesis). Check out more about how blackheads
and whiteheads form in Chapter 3. Topical antibiotics are
available in creams, ointments, gels, solutions, and lotions.
This variety allows your dermatologist or healthcare provider to
prescribe according to your skin type or preference. Many prescription
topical antibiotics are available, as you can see in Table 9-2.
Some erythromycin and clindamycin products have become available
as generics, while other have become branded generics. (See
the sidebar on branded generics.)
Table 9-2 Topical Antibiotics
Brand Name Generic Name Delivery Strengths
(Branded generics)* Erythromycin Solution, gel, 2%
lotion, swabs
A/T/S Erythromycin Solution, gel 2%
Theramycin Z** Erythromycin Solution 2%
Akne-Mycin Erythromycin Ointment 2%
Erycette Erythromycin Pledgets 2%
Staticin Erythromycin Solution 1.5 %
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Brand Name Generic Name Delivery Strengths
(Branded generics)* Clindamycin Solution, gel, 1%
lotion, pledgets
Cleocin T Clindamycin Solution, gel, 1%
lotion, pledgets
ClindaMax Clindamycin Gel, lotion 1%
Clindets Clindamycin Pledgets 1%
* There are numerous branded generics of these agents
**Contains zinc
Applying antibiotics for the best results
Topical antibiotics are applied once or twice daily, in a thin layer on
all of the acne-prone areas to clean, dry skin. In four to six weeks,
you should see a decrease in the size of inflammatory acne lesions.
The therapeutic response tends to be more effective when the topical
antibiotic is combined with benzoyl peroxide (see “Combining
benzoyl peroxide with topical antibiotics,” later in this chapter).
Topical antibiotics may promote the appearance of resistant
strains of P. acnes. Resistance is diminished by combining them
with or using them in conjunction with benzoyl peroxide (see the
“Combining benzoyl peroxide with topical antibiotics” section).
Dealing with side effects
Mild side effects such as redness, skin irritation, and scaling are
associated with use of these drugs, but most people tolerate topical
antibiotics well.
If you have a skin condition known as eczema, you may have
extremely sensitive skin. Irritation and burning may be associated
with applying certain topical antibiotic preparations. This may be
avoided if you’re prescribed an ointment-based erythromycin such
as Akne-Mycin or clindamycin in a lotion preparation.
Combining benzoyl peroxide
with topical antibiotics
Benzoyl peroxide is the mainstay of over-the-counter acne treatment
(and I provide a full rundown of these benzoyl peroxide products
in Chapter 7, along with all the other OTC acne medications).
In addition to using benzoyl peroxide alone to treat your mild acne,
benzoyl peroxide is also often used in conjunction with topical or
Chapter 9: Reviewing the Topical Tools 109
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systemic antibiotics. This treatment option is referred to as combination
therapy. In fact, combination therapy is used to treat most
cases of acne because it’s caused by a combinations of factors. I
explain these factors in Chapter 3.
Combination therapy can refer to using combination products,
such as those in Benzamycin, Duac, or BenzaClin, or by using them
in addition to a topical retinoid and an oral antibiotic, for example.
By using drugs that have different means and modes of activity,
your acne is attacked on many fronts.
Combining benzoyl peroxide with erythromycin or clindamycin
has the following advantages:
In contrast to topical antibiotics used alone, adding benzoyl
peroxide to the mixture prevents P. acnes from becoming
resistant to them.
The combination also appears to have a synergistic effect (the
combination works better than either agent used alone).
Table 9-3 tells you the names of these preparations.
Table 9-3 Combination Benzoyl Peroxide
with Topical Antibiotics
Brand Name Generic Name/Strengths Delivery
Benzamycin* 5% benzoyl peroxide Gel
(Branded generic) 3% erythromycin
Benzamycin Pak 5% benzoyl peroxide Gel
(Foil pouches) 3% erythromycin
BenzaClin Topical Gel** 5% benzoyl peroxide Gel
1% clindamycin
Duac Gel 5% benzoyl peroxide Gel
1% clindamycin
* Refrigeration is necessary to maintain potency
** Sometimes these agents come unmixed and the pharmacist or you must combine the
clindamycin or erythromycin powder with the benzoyl peroxide gel.
If you’re on the go — for instance traveling or camping, or you’re a
teen that splits time between two homes — the Benzamycin Pak
comes in foil pouches, which are easier to deal with.
If you’re looking to save some money on your combination acne
treatments, talk to your doctor about using a prescription for a
generic topical antibiotic such as clindamycin or erythromycin
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lotion along with an over-the-counter benzoyl peroxide. Use them
one on top of the other.
How to apply them
Before applying medicine to affected areas, wash your skin gently,
rinse with warm water, and pat dry. (If you’d like to check out some
face-washing tips, see Chapter 2.) Apply the gels in small, pea-sized
amounts once or twice a day or as directed by your doctor, in the
morning or at bedtime to all of your acne-prone areas.
When used alone, the benzoyl peroxide/antibiotic combination
takes about four to six weeks to show significant improvement.
Once-a-day applications are usually sufficient and allow for the
application of other topicals such as retinoids, if they are required,
at another time of day.
If you have blackheads and whiteheads (comedones), a comedolytic
agent such as a topical retinoid may be prescribed for you to apply
at a different time of day. To minimize irritation, try alternating the
products daily for two weeks until you adapt to using them both
daily.
Side effects
You can expect the same dry skin and skin irritation that are the
most common side effects for benzoyl peroxide, plus the slight
chance of mild irritation from the topical antibiotics. Side effects
may include dry skin, itching, peeling, redness, and possibly a contact
dermatitis from the sensitivity to the benzoyl peroxide. This
condition is described in Chapter 7.
To combat excessive dryness, apply a moisturizer generously in
the morning. (Check out the section “Reviewing topical retinoids,”
earlier in this chapter, for the names of some good moisturizers.) If
you apply medication in the morning, the moisturizer should be
applied over the medicated gels so that you don’t block them from
doing their job.
As with the topical retinoids, use only emollient, non-irritating
cleansers to wash your face when you’re using these preparations.
If you find that the combination products are too irritating (that’s
usually due to the benzoyl peroxide in them), you might try an
over-the-counter water-based benzoyl peroxide preparation such
as Neutrogena On-the-Spot Acne Treatment, or a benzoyl peroxide
soap bar such as Fostex 10% BPO Wash. There are also prescription
benzoyl peroxide washes such as Zoderm and Triaz Cleansers.
Chapter 9: Reviewing the Topical Tools 111
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All of these products may be left on the skin for 5 minutes and then
rinsed off. Afterward, a topical antibiotic preparation such as clindamycin
or erythromycin can be applied. That way, you still can
get the benzoyl peroxide effect and hopefully avoid the irritation.
Looking at other topicals
Newer agents, such as azelaic acid, and older preparations that contain
sulfur and sodium sulfacetamide are used as alternatives or addons
to retinoids, benzoyl peroxide, and benzoyl peroxide/antibiotic
preparations. They’re the second line of defense when the first team
isn’t doing so well or, more commonly, isn’t tolerated.
Azelaic acid
For those of you who want to go a more “natural route,” azelaic
acid might be right up your alley. Azelaic acid is a naturally occurring
acid found in grains like wheat, rye, and barley. Azelaic acid
has been shown to possess:
Antibacterial activity against P. acnes
A mild anti-inflammatory effect
A minor reduction on comedone (blackheads and whitehead)
formation
Azelaic acid can be found in 20 percent creams under the brand
names Azelex or Finevin. Apply it in small, pea-sized amounts once
or twice a day to a clean, dry face to all acne-prone areas.
Most people start to see improvement in their acne within four to
six weeks. It is tolerated fairly well; however, some people experience
mild side effects such as redness and scaling.
Because azelaic acid decreases pigmentation, it should be used
with some caution in patients with darker complexions. On the
other hand, this side effect can be an added benefit in people of
color in the treatment of dark spots that often occur when their
acne heals. (See Chapter 12 where I discuss acne in Asian, African,
Afro-Caribbean, and African-American skin.)
Topical sulfacetamide/sulfur combinations
The combination of sulfacetamide and sulfur can be effective in
the treatment of inflammatory skin lesions without the unpleasant
side effects (primarily a rotten egg odor) that occur with sulfur
preparations alone. They’re less effective than retinoids, benzoyl
peroxide, and benzoyl-peroxide-and-antibiotic combinations,
but as with azelaic acid, they’re sometimes useful as adjunctive
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therapy for the inflammatory component of acne as well as for
rosacea (see Chapter 18).
Sulfacetamide/sulfur combinations are available as lotions, creams,
and washes. You can find a host of products that contain sodium
sulfacetamide 10 percent and sulfur 5 percent, such as Rosula,
Rosac, Rosanil, Nicosyn, and Novacet, to name a few. Rosac also
contains a sunscreen. In general, apply these products twice a day
on clean dry skin to all acne-prone areas.
Some of these preparations have color tinting in them so that they
can serve as a cosmetic cover-up to hide the redness of acne.
Sulfacet-R is one of them. This medicine comes with a color
blender that allows you to change the tint of the lotion to match
your skin color.
In my experience, these products have a marginal utility and
appear to have less anti-inflammatory effect than the topical antibiotics
I describe in this chapter. If you use them, expect a slower,
and less effective, response than you get with other treatments.
Mild stinging and redness may occur with these products.
Going Generic
Did you know that when you have a prescription to be filled, you
may have a choice between filling it with a brand-name drug or a
generic drug? Generic drugs are pharmaceuticals that are essentially
similar to an original product that had been on the market for years.
The active ingredients in the original product are protected by a
patent for a specific period of time. When a patent expires, a
generic drug company introduces a copycat version of the original
drug. Because the original drug has been a proven commodity, the
generic versions are expected to work just as well as the originals.
Generic medications are
Generally 30 to 60 percent less expensive than the equivalent
brand-name product. Help control health insurance costs
for yourself and everybody else by asking for generic drugs
when possible. Ask your doctor to indicate on the prescription
that substitution is permitted if you want a generic prescription.
When you get to the pharmacy, ask if a generic version of your
drug is available and ask the pharmacist to substitute the
generic for the brand-name drug unless your doctor has written
on the prescription that no substitution can be made.
Chapter 9: Reviewing the Topical Tools 113
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Most often just as effective even though they cost less.
Applicants for generic drug approval must scientifically
demonstrate that their product is bioequivalent (meaning that
it performs in the same manner) to the brand-name drug.
Made of the same active ingredient or ingredients and the
same strength as the brand name. Bioequivalent medications
contain the same active ingredients and are subject to the
same Food and Drug Administration (FDA) standards for quality,
strength, safety, potency, and purity as their brand-name
counterparts. They must also produce the same effect on the
body as the brand-name counterpart.
The TV infomercial and Internet acne products marketed as “total
acne treatment systems” are now available over the counter as
generic “house brands.” They’re sitting on the shelves of many of
your local stores at a great savings.
Some generics don’t have the same effectiveness as the well-known
brand. If you aren’t doing well on a generic, you might want to ask
for the brand-name version. Even though generics still contain the
same active ingredient as the original branded drug, their vehicles
may be sub par and there may be instances when they act somewhat
differently on or in your body. Talk about it with your doctor.
For more information about generic drugs, you can go to the following
Web site: www.fda.gov/cder/ogd/index.htm.
114 Part III: Turning to the Pros to Treat Your Type of Acne
Topicals in the pipeline
Topical Atrisone is a new gel preparation that contains dapsone (avlosulfon).
Studies have indicated that topical dapsone reduces both inflammatory and noninflammatory
acne lesions. At this point, it’s unclear how it will rate against our other
acne drugs. As of this printing, patients using gels that contain dapsone have to be
screened by a blood test to see whether they are predisposed to a certain type of
anemia that can be associated with oral dapsone. Further cllinical trials are planned
in hopes of having this testing requirement lifted
Clindamycin and tretinoin in combination is now in the investigational phase as of this
printing. This treatment may prove to be an excellent combination of two very effective
drugs. But why wait? You can do it yourself now — with prescriptions from your doctor,
of course — and make your own combination clindamycin and tretinoin. A generic
retinoid and generic topical antibiotic can be combined in the same manner as I
describe in the section earlier, “Combining benzoyl peroxide with topical antibiotics.”
Just layer the topical retinoid over a generic clindamycin or erythromycin lotion.
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Chapter 10
Taking the Oral
Antibiotic Route
In This Chapter
Choosing to pursue oral therapy
Taking a tetracycline
Trying other antibiotics if necessary
Cutting back on antibiotics
Sorting out the details about your medications
If your acne isn’t responding to topical treatments, then oral
therapy is probably the next step. This chapter looks at the primary
oral agents used to treat acne: antibiotics. We sometimes
treat acne in women with hormones. I cover that therapy in
Chapter 11. And the most powerful acne drug of all, Accutane, is
discussed separately in Chapter 13. These oral agents are usually
prescribed to be used in combination with the topical drugs you
may have already been applying.
In this chapter, I give you the scoop on the advantages and disadvantages
to the major acne-fighting oral antibiotics. I help you
understand the dosing strategies and give you the tips to discuss
with your doctor for using the medication to get the best results
for you. (You can only get these drugs with a prescription from
your doctor.) And finally, I show you where to get help if you’re
having trouble with your oral medications.
Calling In the Reinforcements
Oral antibiotics are used in the management of moderate to severe
acne. As with the topical antibiotics discussed in Chapter 9, oral
antibiotics work on acne by virtue of their antibacterial and antiinflammatory
effects.
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116 Part III: Turning to the Pros to Treat Your Type of Acne
Compared with topical therapy, oral therapy has a more rapid
onset of action and works faster to improve your acne. Commonly,
though, multiple medications are combined for the most effective
treatment of acne. So in most cases, patients use more than one
medication at any given time. By using drugs that have different
means and modes of activity — for example, by taking oral antibiotics
and applying a topical treatment — you attack your acne on
several fronts. In designing your treatment regimen, your doctor
can choose combinations of different classes of drugs that work on
different targets, based on the severity of your acne and the possible
side effects of the medication.
Being prescribed oral medications is not a message that you
should stop applying topical medications! Make sure you go over
your full medication regimen with your doctor before you leave
her office. If you have questions later after you leave, call back to
clarify.
Deciding it’s time for oral antibiotics
Your doctor may decide to add oral antibiotic therapy to your topical
therapy because the topical medications are
Working too slowly
Not doing the job well enough to suit you
Not working at all
Or:
Your acne is scarring
You have moderate to severe inflammatory lesions
Your lesions are widespread, even on your chest and your back
Your prom is coming up next month
You experience big swings in your acne that are related to
your period (if you’re female, of course)
You’re becoming depressed
Addressing some common concerns
Whenever oral drugs are taken, the potential dangers — including
side effects, drug allergy, drug resistance, drug intolerance, drug
interactions, and fetal exposure in women who are or may become
pregnant — must be carefully considered.
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A risk-benefit assessment is particularly important whenever a
benign (non-life-threatening) condition such as acne is being
treated. That means that you should ask your doctor about the
advantages of taking an oral medication versus the disadvantages
(such as possible scarring) of not taking it. Ask about the possible
side effects — the risks — and what positive things you might
expect — the benefits — if you take the drug.
Antibiotics, both topical and oral, have been central to the treatment
of acne for many years. However, public health concerns
about their widespread use has increased in recent years due to a
number of issues:
Bacterial resistance: Resistance means that a medicine no
longer works, or becomes less effective, because the bacteria
change (mutate) and no longer respond to the drug that is
trying to kill or suppress them. No matter how many new
antibiotics we come up with to fight P. acnes, the bacterium
seems to find a way to outwit us and become resistant to our
latest weapons. It’s like trying to fight computer viruses that
find ways to adapt to ever-changing methods we use to
destroy them.
Despite the well-founded concerns about creating bacterial
resistance, these drugs have a long track record of safety.
They’re effective, efficient treatments for many people who
have acne as well as acnelike disorders, such as rosacea (see
Chapter 18).
Purported links between oral antibiotics and breast cancer:
A well-publicized study suggested that the long-term use of
antibiotics is associated with an increased risk of developing
breast cancer. The study indicated that the risk was dependent
on the cumulative dose and the amount of time a woman
was taking antibiotics. The study had many flaws and never
came to the conclusion that there was a direct causal link
between antibiotics and breast cancer.
Antibiotics’ influence on the efficacy of birth control pills:
Studies have shown that none of the antibiotics used commonly
to treat acne interfered with the efficacy of oral contraceptives
(see Chapter 11). But a woman can get pregnant
while on any brand of birth control pill, whether taking antibiotics
or not.
A recent study has suggested that the ingestion of oral antibiotics
as well as the use of topical antibiotics in the treatment of acne
may be associated with an increased risk of infectious respiratory
diseases such as strep throat infections.
Chapter 10: Taking the Oral Antibiotic Route 117
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The best take-home message for you is that you should try your
best to limit long-term use of antibiotics as much as possible until
further studies and more data become available.
Worry about the safety of long-term oral medications has lead to a
recent interest in the use of physical treatments such as lasers and
other special light therapies to treat acne. Chapter 14 reviews
some of these innovative procedures. For more information on
how you and your doctor can work together to reduce antibiotic
use, see the section “Surveying Strategies to Reduce Antibiotic
Use,” later in this chapter.
Tetracyclines: The First Team
The tetracyclines are the workhorses in oral acne therapy. They’re
the first-line oral antibiotic drugs of choice in the management of
moderate to severe acne.
The tetracycline preparations inhibit the growth of P. acnes by
going right to your sebaceous glands to attack the bacteria.
They’re bacteriostatic antibiotics, which means that they inhibit the
growth of bacteria rather than kill them. In addition, they have an
anti-inflammatory action that is equally important in the treatment
of patients with papules and pustules.
There are three types of tetracyclines:
“Plain” (generic) tetracycline
Minocycline
Doxycycline
Improvement of acne is usually noticeable in a matter of a few
weeks or less with all of these tetracyclines. This response varies
and depends on the severity of your acne; however, you may see
the papules and pustules begin to flatten and disappear, and new
ones should stop popping up. Tetracyclines may be tapered when
this improvement persists. The decision about when and if to taper
your dosage will be up to you and your doctor to decide. Often
they have to be continued for long stretches of time — sometimes
even for years.
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Reviewing warnings, risks, and side
effects of tetracyclines
Despite the low risk of side effects from tetracyclines, before taking
the drugs, you should know a few things.
Because patients frequently use anti-acne oral antibiotics on a
long-term basis (in some instances, for years), many people are
understandably concerned about possible consequences. Studies
have indicated that routine laboratory supervision of healthy
young people given long-term tetracycline therapy isn’t necessary.
In a nutshell, in most cases, you don’t need regular blood tests
done while taking these antibiotics.
When treatment extends for more than one to two years, however,
some dermatologists recommend periodically monitoring certain
blood tests. This is particularly important if you have a history of
liver, kidney, or an autoimmune disease. In such cases, you should
get them checked more often.
Damage to teeth and bones
One of the main side effects of tetracycline is staining the teeth of
children. There are also risks to the teeth and bones of unborn
babies and nursing children. You shouldn’t take them if you are:
A child under 10 years of age: The use of any of the tetracyclines
during a child’s tooth development (before the age of
10) may cause a permanent discoloration of the teeth.
A woman who is breastfeeding or pregnant: If a tetracycline is
taken during pregnancy or while breastfeeding, an infant’s teeth
can become discolored and there also may be a slowing down
of the infant’s bone growth. The discoloration of the baby teeth
is due to calcification (hardening) of the teeth, which starts in
the second trimester (after 12 weeks of pregnancy).
Tetracyclines may also temporarily stain the teeth of older
patients, particularly those with orthodontic braces. When taking
any one of the tetracyclines, you should practice good dental
hygiene, including flossing.
Other side effects
Here are some other side effects that may occur when taking the
tetracyclines:
Chapter 10: Taking the Oral Antibiotic Route 119
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As with many other antibiotics, you may experience mild indigestion
and abdominal upset. They can also cause more severe
gastrointestinal irritation (inflammation of your esophagus or
stomach).
Rashes are uncommon, but when they appear, they can be
severe.
They can sometimes produce phototoxic reactions (an
increased tendency to sunburn). This reaction is more likely to
occur with doxycycline (see the section later in this chapter).
If you have a history of vaginal yeast infections known as candidal
vulvovaginitis, a broad-spectrum antibiotic such as a
tetracycline or an erythromycin (see the “Second-Line Oral
Antibiotics” section, later in the chapter) can permit such an
infection to reappear. Candidal vulvovaginitis can also occur
for the first time when using these antibiotics.
And use them cautiously if you have a personal or family history of
lupus erythematosus (an autoimmune disease). And don’t take
them if you’re allergic to any of the tetracyclines.
Tetracyclines also have the following very rare risks:
Severe headaches due to increased pressure in the brain
(intracranial hypertension) are seen very rarely. However, you
can get “regular” headaches from the tetracyclines without
developing this complication.
A hivelike, hypersensitivity rash, which includes joint swelling.
Drug-induced hepatitis with jaundice (yellowish discoloration
of the whites of the eyes, skin, and mucous membranes),
nausea, and dark urine.
If you develop any of the preceding symptoms, call your doctor
immediately.
Taking generic (“plain”) tetracycline
By “plain” tetracycline we doctors mean the original, generic, or
“branded generic,” tetracyclines. I list the available forms in
Table 10-1.
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Table 10-1 “Plain” Tetracyclines
Brand Name Generic Name Delivery Common
Starting
Dosages
[Generic] Tetracycline Capsule, tablet, 250 or
syrup 500 mg,
twice a day
Achromycin Tetracycline Capsule, tablet, 250 or
(Branded generic) syrup 500 mg,
twice a day
Sumycin Tetracycline Capsule, tablet, 250 or
(Branded generic) syrup 500 mg,
twice a day
“Plain” tetracyclines are the most cost-effective of the tetracyclines
and are much less expensive than minocycline and doxycycline,
both of which I describe later in this chapter. However, “plain”
tetracycline isn’t always as effective as these two drugs when it
comes to treating your acne.
Tetracycline is given in dosages ranging from 250 milligrams twice
a day to 500 milligrams twice a day. It is usually begun at a dose of
500 milligrams twice daily, although 250 milligrams twice daily may
also be effective.
Plain tetracycline is taken with a full glass of water so it doesn’t
irritate your esophagus, which can be a really painful experience.
Take it on an empty stomach. (Your stomach is empty one hour
before or two hours after meals.) And finally, don’t take it with
dairy products such as milk or with products that contain iron,
magnesium, zinc, or calcium, because these compounds may interfere
with tetracycline’s absorption from your stomach and make it
less effective.
The dosage of the drug may be tapered as inflammation lessens
(usually after six to eight weeks), but this will vary depending
upon your individual response.
Taking minocycline
Minocycline is a very effective oral antibiotic for treating acne. It’s
also the most expensive. Minocycline is available in generic formulations
and is sold under several brand names, including those I
list in Table 10-2.
Chapter 10: Taking the Oral Antibiotic Route 121
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Table 10-2 The Minocyclines
Brand Name Generic Name Delivery Common Starting
Dosages
[Generic] Minocycline Capsule, tablet, 50, 75, or 100 mg,
liquid twice a day
Minocin Minocycline Capsules, oral 50 or 100 mg, twice a
suspension day
Dynacin Minocycline Capsules, tablets 50 or 100 mg, twice a
day
Vectrin Minocycline Capsules 50, or 100 mg, twice
a day
Minocycline is given in doses ranging from 50 milligrams twice a
day to 100 milligrams once or twice a day. Minocycline’s excellent
absorption means it may be taken with food, even dairy products,
without interfering with its efficacy, so you’re less likely to get an
upset stomach than if you were taking a “plain” tetracycline.
As with “plain” tetracycline and doxycycline, the dosage of the
drug can be tapered when the inflammation has lessened.
Additional advantages of minocycline include
Few, if any, sun-related problems.
It appears to be less likely to induce vaginal yeast infections
than plain tetracycline (see the section “Taking generic ‘plain’
tetracycline”).
But, in addition to the expense, minocycline use includes other disadvantages:
Dizziness: This side effect usually settles after a few days or
when the dosage is lowered.
Skin pigmentation: A reversible bluish darkening of the gums
and/or skin may occur with long-term use.
Nausea: Minocycline is more likely than plain tetracycline to
cause such side effects as nausea, vomiting, and, in high
doses (those that approach 200 milligrams per day), dizziness
or vertigo.
Permanent tooth discoloration: A very rare, irreversible blue
discoloration of permanent teeth has been reported.
Professional capping may be necessary to hide it.
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One very rare, more serious side effect may exist with minocycline: A
syndrome known as drug-induced lupus erythematosus occurs (most
often in young women), and usually develops late in the course of
therapy with minocycline. It has rarely proved fatal. The symptoms
consist of swollen glands, rash, fever, and joint pains. This condition
generally resolves within weeks or months of stopping minocycline.
Taking doxycycline
Doxycycline is also a tetracycline. It is available in generic formulations
as well as brand names that I include in Table 10-3. In addition,
doxycycline is available as a branded generic that goes by a
number of names (see Chapter 9 for more on branded generics and
Appendix B for a complete listing of brand-name acne drugs). It is
somewhat less expensive and probably somewhat less effective
than minocycline.
Table 10-3 The Doxycyclines
Brand Name Generic Name Delivery Common Starting
Dosages
[Generic] Doxycycline Capsule, tablet, 50, 75, or 100 mg,
liquid twice a day
Periostat Doxycycline Tablets 20 mg, twice a
hyclate day
Adoxa Doxycycline Tablets 75 or 100 mg,
twice a day
Doxycycline is given in doses ranging from 50 milligrams twice a day
to 100 milligrams once or twice a day. It may also be prescribed to
be taken as 75 milligrams once or twice a day. Doxycycline is well
absorbed and may be taken with food. Taking it with food will make
you less likely to get an upset stomach.
In addition to the slightly lower cost of doxycycline versus minocycline,
another advantage of doxycycline is that the potential serious
side effects sometimes seen with minocycline (dizziness,
vertigo, skin darkening, and the lupus-like syndrome) have not
been reported with doxycycline.
However, doxycycline’s main disadvantage is its phototoxic
potential — severe reactions to sun exposure— the highest of the
tetracyclines. You should be advised about sun protection if you’re
prescribed this medication. Realistically, however, this is an
uncommon side effect.
Chapter 10: Taking the Oral Antibiotic Route 123
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Second-Line Oral Antibiotics
In some cases, tetracyclines may not work and your doctor will
have to resort to some other oral antibiotic. Less commonly used
oral antibiotics for moderate to severe inflammatory acne include
Erythromycin: It’s useful as a second-line alternative when
tetracycline fails or isn’t tolerated. Younger children (under
age 10) can take it because it doesn’t stain their teeth like
tetracycline does. Although you should strive to avoid the use
of oral drugs if you’re pregnant, trying to become pregnant, or
breastfeeding, in exceptional circumstances, erythromycin
can be taken safely during these times. (See Chapter 5 for
information on treating acne during pregnancy.)
There are a couple of drawbacks associated with erythromycin:
Bacterial resistance is a concern, and stomach upsets
and diarrhea are not uncommon side effects of erythromycin.
An enterically coated (designed to pass through
the stomach undigested and into the intestines where
they’re absorbed) erythromycin product such as
E-Mycin is less likely to cause gastrointestinal upsets
and diarrhea.
As with the tetracyclines, erythromycin can permit vaginal
yeast infections, known as candidal vulvovaginitis, to
reappear. Candidal vulvovaginitis can also occur for the
first time when taking erythromycin.
Amoxicillin: This penicillin derivative is another safer alternative
to a tetracycline that can be used during pregnancy.
124 Part III: Turning to the Pros to Treat Your Type of Acne
Low-dose doxycycline
Doxycycline, used in a very low dosage known as a subantimicrobial dose, is now
being evaluated as a treatment for acne. Very low doses of doxycycline — as little
as 20 milligrams twice a day — have been shown to have anti-inflammatory effects
without acting upon P. acnes, the bacteria involved in producing acne. This
approach is intended to avoid inducing bacterial resistance.
Studies on low-dose doxycycline have so far been done on people who have
rosacea, a condition in which P. acnes doesn’t seem to play any role, and some positive
results have been noted on the inflammatory papules and pustules of rosacea
that are very similar to those of acne (see Chapter 18). The question is whether it will
also be effective in treating acne even if it doesn’t suppress P. acnes.
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Azithromycin (Zithromax): The use of azithromycin, an
antibiotic, as a four- or five-day pulse therapy in women who
have monthly premenstrual acne flares has recently gained
some interest. Pulse therapy (also called intermittent therapy)
means not taking a medicine every day; rather it’s taken, for
example, for several days per week or for one week per
month, discontinued, and then started again. The pattern
repeats itself as necessary.
Other pulsing routines have been suggested to reduce the
cost of this very expensive drug that is effective in the reduction
of inflammatory acne lesions. Some dermatologists suggest
that azithromycin is an alternative to tetracycline in
patients with moderate to severe acne. It has no serious side
effects; however, as with all of the antibiotics, buildup of bacterial
resistance is a concern.
Clindamycin: This antibiotic is a very effective acne fighter;
however, the resistance pattern is similar to that of erythromycin
and it has potentially serious side effects.
Furthermore, this drug has been associated with a severe type
of gastrointestinal infection.
Cephalosporins: The new-generation cephalosporin antibiotics
appear to have good activity against acne. Again, bacterial
resistance is a concern with these agents.
Trimethoprim sulfasoxazole (TMZ): This is an oral sulfonamide
that is very effective as an anti-acne agent. It is reserved
for unusually stubborn cases of severe acne that don’t
respond to any of the other antibiotics listed here. It is sometimes
used in situations in which Accutane (see Chapter 13)
isn’t appropriate.
TMZ has been associated with severe side effects and may
precipitate severe allergic reactions. These reactions are quite
rare. The development of resistance is also an issue.
Surveying Strategies to Reduce
Antibiotic Use
I recommend that you make every effort to taper off oral antibiotics
as soon as your acne is under control. An oral antibiotic may
be intended for daily use over an extended period of time, often for
four to six months and possibly much longer. Eventually, your
doctor will taper off the medication and finally discontinue using it
as your acne improves. The ideal long-term goal is to stop oral
Chapter 10: Taking the Oral Antibiotic Route 125
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antibiotics altogether and rely only on topical therapy. In this section,
I explain ways your doctor may decrease the total amount of
antibiotic that you have to take while treating your acne.
If necessary, antibiotics may be continued at the lowest effective
dose for long periods of time, especially if your acne is persistent.
However, this practice can lead to antibiotic resistance. (See the
“Addressing some common concerns” section, earlier in this chapter,
to find out about bacterial resistance.)
But remember, always discuss these options with your doctor.
Don’t just change your doses on your own. Your doctor knows
more about your skin and appropriate treatment for your acne
than I do (unless of course you’re one of my patients).
Rollercoastering is a term I use to describe a method of fine-tuning
the dosage of oral antibiotics that may help to minimize some
potential side effects, lessen the total dosage you take, and bring
the cost of the medication down.
For example, a dosage schedule can begin with two 50 milligram
minocycline capsules to be taken in the morning and one in the
evening, which equals 150 milligrams per day. Because the highest
recommended dosage is 200 milligrams in one day, this dosage
allows for a possible increase of an additional 50 milligrams per
day on your next follow-up visit to your dermatologist. However, if
your acne shows marked improvement on the follow-up visit, your
doctor may lower your dosage to say, 50 milligrams twice a day.
If you experience premenstrual flares of acne, talk to your doctor
about increasing the dosage five to seven days before your next
menstrual period and then lowering your dosage afterward.
Other ways to reduce the amount of antibiotics used to treat acne
include pulsing (which I describe in the “Second-Line Oral
Antibiotics” section, earlier in the chapter), using Accutane and
other oral isotretinoins (see Chapter 13), and cortisone injections
(see the sidebar in this chapter).
Your Guides to Your Medications
How did the doctor say that I should apply that cream? What were
the side effects of that pill? Should I take it on an empty stomach
or with food? If you’re like most people, you probably don’t
remember half of what was said to you in your dermatologist’s or
healthcare provider’s office.
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Be sure to ask for written material about acne in general and also
be sure you get written directions on how to use the medications
that are prescribed for you. When you get home, make sure you
read the material so that you understand the possible side effects,
correct dosage, and everything else you need to know. If you have
any questions, be sure to call your dermatologist or healthcare
provider rather than waiting for your next office visit.
Your pharmacist should be a great resource for you. You can
always ask for information about any of the drugs you were prescribed,
as well as any of the over-the-counter drugs that you may
be buying without a prescription. Better yet, ask your pharmacist
for a printout that describes all of the actions and possible reactions
you may experience with a prescription drug.
Chapter 10: Taking the Oral Antibiotic Route 127
Getting needled: A possible substitute
for antibiotics
A quick, relatively painless procedure, known as an intralesional cortisone (steroid)
injection, is extremely effective in reducing the pain, swelling, and redness of acne
papules or nodules (cysts). These shots are particularly effective for the larger, longlasting
lesions.
Each papule or nodule is given a single injection of a dilute cortisone solution, using
a tiny, ultrathin needle.
The injection can hurt a little; however, within just a few days, the lesions soften,
and in a week they become flat. Sometimes, the injections must be repeated in a
month (or more) if the lesions aren’t responding.
Many folks are needle-shy; however, after the first successful experience with this
method, most come back asking for more. By the way, the bigger the cysts are, the
less the needle hurts.
If too strong a concentration of cortisone is used, atrophy, or depressed scars that look
like dents in the skin, may result at the injected sites. These dents usually resolve after
several months, but they can be permanent. Similar atrophy may also have been the
“normal” healing response of the inflamed lesion if it had not been injected.
The intralesional injections also serve as antibiotic sparers. If only a few lesions are
present, say about one to five, these injections can serve as a substitute for oral
antibiotics or allow your doctor to lower their dosages.
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128 Part III: Turning to the Pros to Treat Your Type of Acne
You can also turn to the package insert (the piece of paper that’s
supplied by the drug manufacturer), which has all that small print
that describes every possible thing that has happened, or might
happen, to anybody who takes the drug. It has more information
than you’ll ever need to know about the drug you were prescribed
and it may convince you never to take it. See the “Looking at the
package insert” sidebar in this chapter for more information.
If you desire, remember to ask your dermatologist or pharmacist
whether there is a generic substitute for the prescribed medication.
Check out Chapter 9 for more information on what generic
medications are and how they can help you.
Looking at the package insert
Open up your package insert and check out the section named “adverse reactions”
that lists all of the side effects that were reported in people and animals who were
given the drug while it was being tested before going to market. These side effects
can look frightening because they include so many problems, ranging from sneezing
to life-threatening symptoms. The thing to remember is that this section lists
everything that happened to thousands of people and/or animals during the testing
phase regardless of whether it actually had any connection to the medicine.
It can be hard for you to decide which of the side effects on these lists you really
need to be concerned about. You probably shouldn’t be troubled about ones listed
as rare or infrequent, unless they’re also discussed in the “warnings” section. Even
the side effects listed as being most frequent don’t affect everyone who takes the
medicine. Keep in mind, every person is different and it is impossible to tell in
advance what you will experience.
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Chapter 11
Hormonal Treatment
for Women
In This Chapter
Deciding to use hormonal therapy
Taking oral contraceptives to treat acne
Figuring out if you have excessive androgens
Adding anti-androgens to your regimen
This chapter is for the females in the audience. Women often
break out with acne in their 20s and early 30s, sometimes for
the first time in their lives. This is thought to be hormone related
and it is believed to be the main reason that more adult women
than adult men have acne. And, of course, teenage girls, especially
as they approach adulthood, also have the hormonal acne highs
and lows that are generally less obvious than those seen in adult
women.
Your androgenic or male hormones play a major role in the development
of acne. (Yep, females have male hormones — just in
smaller amounts than men do. For more on this topic, read
Chapter 3.) As an adult, these male hormones can also encourage
the onset and persistence of acne; in a nutshell, the androgens
stimulate the sebaceous glands, enlarging them, and they produce
excessive oil that promotes inflammatory acne. (For information
on how androgens affect your skin, turn to Chapter 20.)
When the usual treatments such as topical measures and oral
antibiotics that are listed in Chapters 9 and 10 aren’t working well
enough, the use of certain oral contraceptives can help to block
the acne-causing response to your androgens. Many oral contraceptives
(birth control pills) inhibit these androgens from stimulating
your sebaceous glands to produce the oil that fuels your acne.
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Hormonal therapy with an anti-androgen may be used in tandem
with birth control pills when the pill alone isn’t controlling acne or
if you have, in addition to acne, some of the masculinizing symptoms
of excess androgens such as excessive hair growth or thinning
scalp hair.
Using Oral Contraceptives
When other measures fail to control your acne, you may want to
consider birth control pills. The pill helps to level out the uneven
surges of your estrogens and progesterone. Oral contraceptives
may be a good choice for you if:
You’re sexually active and desire birth control pills
You require oral hormonal therapy to regulate your menstrual
cycle
You’re prescribed the drug Accutane (see Chapter 13)
Many women who have minimal to mild acne and who are also
looking to use some form of contraception might discover that the
pill alone can bring their acne under control. Moderate to severe
acne can also be improved with a birth control pill that can be
combined with topical and oral therapies.
If you’re reluctant to take the pill or to use other birth control
methods for moral or religious reasons, anti-androgens or physical
treatments, such as laser or lights, are other therapeutic options
that you and your doctor may consider. (I cover anti-androgens
later in this chapter and lasers and lights in Chapter 14.)
Other means of hormonal birth control such as the birth control
patch and ring have an unpredictable effect on acne and can actually
provoke it at times. Depo-Provera, an injection containing synthetic
progesterone, can also worsen or trigger acne at times (see
the section “Suppressing the cycle — and the acne,” later in this
chapter).
There are both negative and positive side effects to taking birth
control pills for acne. Talk to your doctor to decide if it is right
for you.
Birth control pills are often prescribed to prevent pregnancy in
females who are given isotretinoin (Accutane), unless they’ve had
a hysterectomy or are otherwise physically incapable of getting
pregnant. Accutane is a powerful drug for treating severe acne that
130 Part III: Turning to the Pros to Treat Your Type of Acne
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has been associated with severe birth defects. Besides abstinence,
birth control pills are considered to be the preferred method of
contraception for women who are taking Accutane. I talk about
Accutane in Chapter 13.
Suppressing the cycle —
and the acne
Oral contraceptives have been available since the 1960s.They prevent
ovulation and make conditions difficult for a fertilized egg to
implant on the uterus wall.
The goal of oral contraceptives in treating your acne is to block the
effects of your androgens on your sebaceous glands. Oral contraceptives
contain estrogen, which regulates menstruation. Besides
suppressing ovulation, the estrogens in birth control pills can help
improve acne by:
Reducing ovarian androgen secretion
Blocking the androgens that are produced from stimulating
your sebaceous glands to produce excess oil (they act as
androgen receptor blockers in medspeak)
The estrogens have the ability to decrease the levels of your free
testosterone (androgen). They do this by increasing the amount of
sex hormone binding globulin (SHBG), a protein that “mops up”
your free testosterone, hangs onto it, and doesn’t allow it to stimulate
your acne-producing oil glands to produce excess oil.
Oral contraceptives that are most helpful in controlling acne are
those that contain a combination of an estrogen and a progestin
(synthetic progesterone).
The minipill, the progestin-only pill, is an effective oral contraceptive
with fewer side effects than the combination pill. However, its
effects on acne are unpredictable. Progestins have effects that can
be androgenic (acting like male hormones). Some of the newer
progestins have less androgenic activity and therefore are less
likely to worsen, and may improve, your acne.
If you’re over 35 years of age, have migraine headaches, or are a
cigarette smoker, birth control pills that contain estrogen are not
for you!
Chapter 11: Hormonal Treatment for Women 131
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Taking the best pills for acne
Taking oral contraceptives may improve your acne even if you
have no evidence of excess androgen production. In fact, the level
of testosterone in most women who have acne is within the normal
range, but the levels can be lowered and blocked if you’re taking
the right pill.
Most dermatologists recommend use of the low-dose oral contraceptives,
which are oral contraceptive combinations with minimal
androgenicity. These drugs increase SHBG and thus decrease
androgen concentrations in healthy women.
The oral contraceptives Ortho Tri-Cyclen, Estrostep, and Yasmin
are the best ones to take if you have acne. Yasmin, in addition to an
estrogen, has as its progestin, drospirenone, which is a very close
chemical relative to spironolactone, a very potent antiandrogenic
hormone that is described in the next section. Many dermatologists
feel that Yasmin is the most effective oral contraceptive available
for the treatment of acne.
Several of these oral contraceptives are packaged in convenient
dosing schedules and come in packets of 28 tablets. The first 21
tablets are the active pills; they contain the active ingredients, hormones.
(I explain what active ingredients are in Chapter 7.) The last
7 tablets in a 28-tablet packet are the reminder pills (that contain
inactive ingredients); they’re different in color and don’t contain
any hormone.
Read the package label and follow directions as indicated.
Other oral contraceptives that have low androgenicity include
Levlen, Levlite, Seasonale, Tri-Levlen, Triphasil, Desogen, and
Alesse.
Diane-35, is approved in Canada, and has been approved for two
decades in Europe as an oral contraceptive that is very effective in
the treatment of acne, but it isn’t available in the United States. It
contains cyproterone, an androgen receptor blocker and potent
progestin.
Be patient. It may take at least three months on the pill before you
see positive results for your acne.
132 Part III: Turning to the Pros to Treat Your Type of Acne
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Looking out for side effects
Although the original oral contraceptives had a number of side
effects, they’ve been modified to reduce their risks. Historically,
the most serious side effect of birth control pills had been that of
thromboembolism (blood clots) that begin in the veins of the legs.
However, the present lower doses of estrogens have all but eliminated
this potential complication.
Other potential side effects include:
Nausea, vomiting, abdominal cramping, or bloating: These
problems are the most common minor side effects. They usually
go away as the body adjusts to the drug.
Headaches: These tend to be mild, but if they become severe,
discuss the problem with your doctor.
Spotting and breakthrough bleeding: Irregular vaginal bleeding
or spotting may occur while you are taking the pills.
Slight weight gain: This may occur due to an increase in your
appetite.
Mood swings (depression, anxiety): The hormonal disruption
caused by the pill may result in mood swings and a lowering
of libido.
Breast tenderness: Swollen, tender breasts and/or breast
lumps that are not cancerous can occur.
Tell your doctor if you have or have ever had problems with
your breasts such as lumps, an abnormal mammogram
(breast X-ray), or fibrocystic breast disease. But most studies
suggest that pills neither reduce nor increase the risk for
breast cancer. Early detection is the key to successful breast
cancer treatment and survival. Doing breast self-exams is
easy, and the more you do it, the better you’ll get at it. Better
yet, mammography, particularly those using the latest MRI
equipment, will find small tumors before you are able to feel
them.
If you’re taking the pill, you need to be counseled about its risks
and you should have regular Pap smears and breast exams. A Pap
smear is a test that checks the cells on the cervix (the opening of
the uterus) for changes, which could lead to cancer.
Combination birth control pills (those that combine an estrogen
and a progestin) apparently lower the risk of uterine and ovarian
cancer according to recent studies.
Chapter 11: Hormonal Treatment for Women 133
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The effect of oral contraceptives is unpredictable, everybody is different,
and you may have to try several different ones before finding
the right one that works on your acne.
Trying Anti-androgens
Instead of the typical anti-acne drugs and birth control pills, you
may need specific anti-androgen treatment to control your acne.
Anti-androgen treatment is an option when conventional topical
and systemic therapies aren’t working, you can’t or don’t wish to
take a birth control pill, or when an endocrine abnormality is
found in which your body is producing too many androgens.
Most healthcare providers recommend that you continue taking
an oral contraceptive while taking most anti-androgens, because
there is a risk of feminization of a male fetus if you become pregnant
while taking either one of them. Ask your doctor for further
details.
If you’ve noticed that some of your acne medications that previously
worked have stopped being effective — the oral antibiotics,
topical medications, and even birth control pills are no longer
performing — you’ve had a relapse after taking a course of
Accutane, or your acne has suddenly become severe, your doctor
will likely evaluate you for androgen excess. Check out Chapter 20
where I discuss this condition and other endocrine disorders.
Spironolactone is the antiandrogen most frequently used to treat
acne. An oral antiandrogen such as spironolactone (Aldactone) is
used in women in whom hormonal treatment may be an effective
134 Part III: Turning to the Pros to Treat Your Type of Acne
Antibiotics and the pill
For a long time, it was assumed that there was an increase in the failure rate of birth
control pills when women also took commonly used antibiotics such as the tetracyclines
and erythromycins at the same time they were on the pill. A recent study
has concluded that these antibiotics that are regularly used to treat acne probably
don’t interfere with the efficacy of oral contraceptives. Basically, if you’re taking a
tetracycline or an erythromycin antibiotic for your acne, you should be aware of this
controversy so that you can decide if you wish to use an alternative or additional
form of birth control. Many pharmacists are still giving patients this warning, largely
because many birth control pill package inserts still contain this information.
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alternative, or as an accompaniment to oral contraceptives and
antibiotics. It is useful for women with recurrent outbreaks of deep
inflammatory nodules. Spironolactone has potent antiandrogenic
effects, and it works by decreasing sebum production.
Spironolactone is started at a low dosage of 25 to 50 milligrams per
day and may be increased. It may take three months to notice any
positive effects, but results may appear sooner. The dosage may
need to be adjusted during the first six months of treatment.
Your dermatologist or healthcare provider may order certain blood
tests while you’re taking this medication.
The most common side effect of this drug is an irregular menstrual
cycle; however, if you’re taking birth control pills, this is less likely
to happen. Breast tenderness sometimes occurs. Women with a
personal history, or strong family history, of breast cancer should
discuss the risks and benefits of taking this drug with their doctor.
But after more than 50 years of using this drug in humans, there is
no evidence — except in mice — that it causes any kind of cancer.
Spironolactone is sometimes used to treat hypertension (high blood
pressure) as a diuretic (water pill). If you’re already taking a medication
for high blood pressure such as a diuretic, you might ask your
doctor to substitute spironolactone for one of the water pills or
other blood pressure drugs you’re taking. This approach might help
treat your acne and high blood pressure at the same time.
Flutamide (Eulexin) is another anti-androgen that is sometimes
used in unmanageable female adult acne. It has the potential of
causing severe liver damage, which greatly limits its use.
A minimum of three to six months of therapy is required for you
and your healthcare provider to evaluate the efficacy of these
antiandrogen agents.
Chapter 11: Hormonal Treatment for Women 135
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Chapter 12
Managing Acne in
Dark-Complexioned Skin
In This Chapter
Understanding why melanin matters
Getting rid of dark spots
Preventing scars by treating your acne early
Improving the scars you do have
Covering up with makeup
Acne is an equal-opportunity skin disorder. It occurs in people of
all races and ethnicities. It has the same causes and follows a
similar course in people with all shades of skin. However, there are
some differences in the appearance and treatment of acne among
different groups. This chapter covers the methods to prevent and
treat these distinctive issues as well as suggesting approaches for
skin-care in darker skin populations.
Recognizing Diversity
Variations among skin tones all come down to melanin, which is
responsible for absorbing sunlight and giving your skin its distinctive
color. As I explain in Chapter 2, melanin is produced in
melanocytes (pigment-producing cells). Everyone has the same
number of melanocytes; however, in more darkly pigmented
people, these pigment-producing factories create more melanin
and are inclined to disperse it more widely in the epidermis.
There are important medical and cosmetic advantages to having
dark skin. Darker skin is more resistant to sunburns, skin cancer,
and wrinkles. As dark skin ages, the higher melanin content and
facial oil cause the skin to age less rapidly than lighter skin.
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138 Part III: Turning to the Pros to Treat Your Type of Acne
However, dark skin does have disadvantages when it comes to
dealing with acne — dark spots and scars are more likely to appear
(more about that later in the chapter).
Our world is host to great variability in skin color among people of
all races. We’re all pretty much the same underneath where it
counts, and making generalizations about acne and race or skin
color is difficult.
But, the following are some of the features that are more likely to
be seen in darker skin types:
Dark spots are often the number one concern to the person
with acne. Check out the next section that talks about how
they form and what you can do about them.
Inflammatory (red) acne lesions tend to be less visible.
Lesions appear to be less common in very dark skin because
the red color of inflammation is often well hidden by the surrounding
darker skin.
Sensitive skin known as eczema (atopic dermatitis) is more
common in Asians, African-Americans, and Hispanics.
Healing acne lesions tend to produce larger scars in Hispanics,
Asians, and particularly African-Americans, as compared to
Caucasians. (I discuss scars in Chapter 16.)
The good news is that people of color are less likely to have
severe nodular acne than are Caucasians.
Figuring Out Those Dark Spots!
People with white skin tend to complain about red marks that
remain red or purplish in color. These spots are called macules in
dermatologese. Like freckles and tattoos, they’re simply color
changes of the skin (you can’t feel macules, and if you close your
eyes, they don’t exist).
In black skin, those same red spots look much darker, even deep
brown or black in color and many shades in between, particularly
after they heal. African-Americans are often more concerned about
these dark acne-related macules than they are about the acne
itself. The dark spots are known as postinflammatory hyperpigmentation
or postinflammatory pigmentation — or PIP for short. To see
what PIP looks like, turn to the color section of this book.
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Chapter 12: Managing Acne in Dark-Complexioned Skin 139
How dark spots are formed
PIP is limited to the sites of previous inflammation. Think of the
spots as “footprints,” the aftermath or telltale signs that show
where the original injury (inflammatory “battle”) took place. The
original insult (and injury) that caused PIP can be a cut, a burn, a
rash, or the after-effect from a healing acne lesion.
Often these “footprints” disappear over a period of time, but they
always outlast the original inflammatory acne lesions themselves. In
fact, they may take many months or even years to fade completely.
There are actually two types of PIP. Both start off when inflammation
of the skin, such as acne, stimulates the melanocytes in your
epidermis and causes them to step up the manufacturing of
melanin. The production of melanin (melanogenesis) increases in
response to the tanning effect of sun, injuries to the skin such as
burns, cuts, surgeries, as well as the inflammation caused by acne.
The two different types of PIP are
Epidermal hypermelanosis: The busy melanocytes respond
by handing off their melanin pigment in tiny granules to surrounding
keratinocytes, your other epidermal cells. This
increased stimulation and transfer of melanin granules results
in epidermal hypermelanosis. Your skin gets darker, but the
pigment isn’t deep.
The good news is that this type of PIP often responds to topical
bleaching creams, which help to accelerate its disappearance.
That’s because the majority of the melanin pigment is in
the epidermis (the top layer of the skin) which allows it to be
treated.
Dermal melanosis: Dermal melanosis occurs when inflammation
disrupts the basal cell layer, causing melanin pigment to
be released and subsequently “dropped” more deeply into the
dermis where it gets trapped by macrophages (scavenger
white cells). This type of PIP is much harder to treat and may
never fade away completely.
These spots are not scars, and some, if not all, of them will fade in
time, or if necessary, they can be lightened with appropriate treatment
(see tips for treating them later in this section). Unless the pigment
is very deep, PIP will improve over time. Be an extra patient
patient! The dark spots take the longest to fade. The treatment of
PIP tends to be a difficult and prolonged process that often takes 6
to 12 months to achieve the desired results of depigmentation.
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Deterring the dark spots
Because these spots can take so long to disappear, it’s essential to
prevent them from appearing in the first place. Early treatment and
prevention of your acne can help put a stop to them. You should
be aware of those things that put you at greater risk of developing
PIP. For example, you should avoid:
Squeezing, rubbing, or picking your acne lesions
Over-the-counter toners, witch hazel, and alcohol products as
well as prescription acne products that may dry and irritate
your skin and lead to PIP
Harsh soaps and overwashing (for tips on how to properly
wash your face, see Chapter 2)
Scrubbing with loofahs and buff puffs
Cosmetics that might aggravate your skin and make your acne
look worse
140 Part III: Turning to the Pros to Treat Your Type of Acne
Preventing PIP
Keisha is a 30-year-old woman who started developing acne in her late 20s. When
I first saw her, the first words out of her mouth were, “What can you do to help get
rid of these scars?” She was referring to dark spots on her cheeks and forehead.
“They won’t go away. I hate them,” she said.
I looked closely at her skin and told her that she didn’t have scars. Those dark spots
were where her acne had healed; the spots were PIP. I examined her more thoroughly
and noted that she did have active acne lesions on her face in addition to the
“inactive” dark spots.
I explained to her that her “active” acne lesions caused those spots and that our first
priority was to treat and prevent the “hot spots” and let the dark spots take care of
themselves.
We began by treating her acne, and when she returned six weeks later, her acne
was getting under control and the dark spots were beginning to fade. After a total
of three months of treatment, her skin tone was evening out and she was quite
pleased.
I reassured her that if any of the dark spots remained after six to eight months of
the current treatment, I would give her additional medications to apply to try to
bleach them.
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I know, it’s tempting to think that squeezing spots will help them
heal more quickly. In fact, squeezing actually makes them worse.
Squeezing a spot carries a risk of scarring because the pus can
burst inward into the skin rather than outward to the surface.
In fact, any situation where the skin can be irritated, be it squeezing
blemishes, or plucking hair, can result in dark skin’s tendency
to produce more melanin and create dark spots.
Shaving the beard can also wreak havoc with acne and increase the
possibility to develop PIP. Check out Chapter 19, where I provide
some helpful tips on gentle shaving techniques.
Keeping Acne and Dark Spots
at Bay with OTC Medications
The same medications that are used to treat acne in Caucasian skin
are also used to treat people of color; however, when there is a
potential to develop PIP, you sometimes need to use the medications
differently.
If after eight weeks of self-treatment, your acne and your dark
spots persist, seek professional help from your healthcare provider
or a dermatologist. In Chapter 8, I tell you how to find the right professional
to help you treat your acne.
PIP may further darken with sun exposure, so to be truly effective,
any therapy should include applying a sunblock over any acne or
bleaching medications you use. Other measures to limit ultraviolet
exposure (for example wearing hats, protective clothing, and —
the best option — avoiding the sun altogether) should be part of
your routine.
Benzoyl peroxide and salicylic acid
Over-the-counter (or OTC) medications such as benzoyl peroxide
and salicylic acid may be an excellent approach if your acne is mild
and you’re able to tolerate these products, but they can be quite
irritating on some people’s skin. I discuss these products in greater
detail in Chapter 7.
Chapter 12: Managing Acne in Dark-Complexioned Skin 141
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Begin with a benzoyl peroxide preparation. If your skin is able to
tolerate it and you see improvement of your acne, stick with it. If
you want a further boost to your treatment, try adding an over-thecounter
salicylic acid at another time of day or just apply it over
the benzoyl peroxide.
Apply a sunscreen over any medication(s) you are using.
Benzoyl peroxide and salicylic acid can be irritating and drying
and produce whitish scales on dark skin. These scales are often
referred to as looking “ashy.” The appearance of the scales is difficult
for some people to tolerate. (Light skin or white skin gets ashy
too; it’s just that you don’t see the contrast as well.)
If benzoyl peroxide or salicylic acid is producing ashiness and
scales, apply a light non-oily moisturizer like Cetaphil Moisturizing
Cream or Olay Active Hydrating Beauty Fluid. If you have dark
spots, use a moisturizer that contains a sunscreen such as Purpose
Moisturizer SPF 15 or Cetaphil Daily Facial Moisturizer SPF 15. If
you prefer, you may use a heavier, greasier moisturizer.
If you have sensitive skin, be sure to use the lower strength (like
2.5 percent benzoyl peroxide water-based) products to start with.
Start treatment every second night, then build up to once or twice
daily, as you’re able to tolerate the product. Similarly, if you get too
ashy or irritated from salicylic acid products that have a mild peeling
activity, try using the lower 1 percent concentration or try
applying the medications on an alternate-day basis.
Over-the-counter bleaches
For the PIP spots, look for over-the-counter preparations that contain
1 to 2 percent hydroquinone, a chemical that’s traditionally
been the main treatment for PIP. Companies that make over-thecounter
hydroquinone-containing “fade” creams and gels include
Ambi, Esoterica, Porcelana, and Black Opal. These products are
applied as a thin layer on the affected areas once or twice a day.
You may experience a mild skin irritation or temporary skin darkening.
If skin irritation or darkening persists, stop using them and
seek professional help.
If no improvement is seen after three months of treatment, their
application should be discontinued.
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Some of these agents contain a built-in sunscreen, however, sun
exposure should be limited further by using an additional sunblocking
agent or protective headgear to shade treated skin or
lightened skin.
The over-the-counter products may be helpful, but if they aren’t
strong enough, you may require one of the prescription strength
medications that I describe later in this chapter.
There are over-the-counter products containing 10 percent hydroquinone
or higher that are available in many other countries, particularly
within Africa and Asia, and some of them have found their
way (illegally) into “health” stores in the United States — mostly in
ethnic neighborhoods within big cities. These high concentrations
actually bring the risk of a darkening reaction known as ochronosis.
Getting Professional Help
Acne treatments are generally as safe and effective on dark skin as
they are on light skin. And in most cases, the treatments are the
same. In Chapters 8 through 11, I outline the topical and oral
approaches that dermatologists commonly suggest and that are
also appropriate for people with darker skin. The main difference
in the professional treatment of darker skin is a deeper concern for
skin discoloration or scars from acne.
In this section, I fill you in on how treatments differ when used on
darker skin, including aggressive treatments of the acne and the
use of more potent skin lighteners for PIP. When treating dark skin,
a combination of topical creams and gels, chemical peels (see the
“Treating your acne and PIP with topical drugs” section, later in
the chapter), and sunscreens may be necessary for significant
improvement. This combination of various topical therapeutic
agents has been shown to be beneficial, especially on the face.
Daily use of a broad-spectrum sunscreen (SPF 15 or greater) is an
essential part of any therapeutic regimen. This step is very important
to prevent the pigmentation from becoming darker or allowing
the already lightened skin to repigment.
The treatment of PIP tends to be a difficult and prolonged process
and may not work at all. When it does work, it often takes 6 to 12
months to achieve cosmetically acceptable depigmentation.
Chapter 12: Managing Acne in Dark-Complexioned Skin 143
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Treating your acne and
PIP with topical drugs
A variety of topical treatments have been used to treat epidermal
PIP, with varying degrees of success. These agents include chemical
peels, retinoids, azelaic acid, and hydroquinone. Lightening of
dark areas may be achieved with one of these topical measures.
Each of these treatment options potentially improves epidermal
hypermelanosis, but none are proven effective with dermal
hypermelanosis.
Bleaching with prescription-strength hydroquinone
Hydroquinone is the cornerstone agent in the treatment of PIP. It’s a
topical bleaching agent that suppresses the melanocytes from producing
melanin. Hydroquinone-containing combination products
such as EpiQuin Micro, Glyquin XM, Lustra-AF, and Triluma are
available by prescription only. Some of these agents contain their
own sunscreens. In addition, some contain vitamin E, vitamin C,
retinol, or glycolic acid.
There are unsubstantiated claims that some of these chemicals
have “age-defying,” sun-blocking, wrinkle-preventing properties
when mixed with the hydroquinone. I really can’t give you any
opinion on those claims because with such a mixture of ingredients,
it’s hard to tell what each one does.
Hydroquinone may be prescribed along with azelaic acid (described
later in the next section) to lighten the dark areas more quickly.
Preparations that contain hydroquinone are applied twice a day to
the dark spots. Allergic reactions to them are rare.
Hydroquinone combination products are very expensive and are
almost never covered by prescription plans because hyperpigmentation
is considered a “cosmetic problem” for which treatment is
“not medically necessary.” I tell you this so you don’t suffer “sticker
shock” when you go to the pharmacy.
Some dermatologists will ask that a more concentrated prescription
(up to 8 percent hydroquinone, instead of the usual 3 to 4 percent)
be mixed (compounded) for you if you don’t respond to the
lower strength treatments.
Applying azelaic acid
Some products actually treat acne and bleach PIP, saving you
money and valuable application time. Azelaic acid, a prescription
144 Part III: Turning to the Pros to Treat Your Type of Acne
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product known as Azelex or Finerin, is an inhibitor of melanin synthesis.
It can treat your acne and lighten the dark spots at the
same time. Apply a small amount once or twice a day to all acneprone
areas including the dark spots. For more information on azelaic
acid, see Chapter 9. Acne tends to respond to azelaic acid in
six to eight weeks; however, the PIP spots may take many months
to lighten.
Because azelaic acid decreases pigmentation, it can temporarily
lighten areas that aren’t targets of your treatment. It can also be
irritating.
Relying on retinoids
Topical retinoids can also perform a double duty. In addition to the
beneficial actions of the retinoids in treating and preventing both
comedonal and inflammatory acne, they also may have a lightening
effect on PIP. Adaplene (Differin), tazarotene (Tazorac), Avita, and
tretinoin (Retin-A) are all prescription retinoids. See Chapter 9 for
a complete discussion of these medications.
Retinoids are known to hasten the rate of turnover (get rid of dead
cells, in plain English) of epidermal keratinocytes (the majority of
the cells that make up the epidermis) and they also seem to assist
in the normalization of pigmentation as well. Furthermore, by causing
the skin to peel, they enhance the penetration of the other
bleaching medications into the epidermis.
Creams are the least irritating, so you probably should start out
with a cream-based retinoid instead of a gel. If you have oily skin
or have a low risk for irritation, you may be prescribed a gel formulation
with a higher concentration of retinoid in it.
Topical retinoids can be effective; however, they can be a “doubleedged
sword” if you have very sensitive skin. These products may
result in more irritation that may ultimately cause more PIP.
Peeling the pigment away
It’s possible to actually remove some layers of skin over time to
remove layers of the pigment. The following procedures should be
approached with great caution and performed only by a professional
with a lot of experience in their use (for more details on
these procedures, check out Chapter 14). The risk of worsening
the PIP is always present with all of these procedures.
Chapter 12: Managing Acne in Dark-Complexioned Skin 145
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Chemical peels
Glycolic or salicylic acid peels can be effective treatments of PIP in
dark-complexioned individuals. These are superficial peels that
don’t penetrate below the upper layers of skin, and they can sometimes
help to even irregular skin tones and lighten PIP. Matching
the strength of a peel to an individual’s skin type and scarring history
is critical to avoiding complications.
Salicylic and glycolic acids may be applied by an experienced dermatologist
or cosmetic surgeon. They may need to perform the
peel multiple times in order to see improvement. Depending on the
strength of the acid peel, you may be asked to discontinue applying
some or all of the topical agents that are described in the previous
sections for a few days before the peel, and resume using them
several weeks after the peel, to maintain the results.
These procedures need to be approached cautiously as the risk of
peel-induced PIP is well known, as well as the risk of hypertrophic
scarring and keloid formation that tends to occur to the more darkly
complexioned individual. In Chapter 16, I tell you more about hypertrophic
scars and keloids.
Lasers
Certain lasers are now being used to treat PIP, but should only be
used by experienced medical professionals. People with dark skin
have been told in the past that laser treatments aren’t safe for
them. But experts using the lower powered treatments at very specific
wavelengths that are now available can help you avoid complications,
such as exacerbating PIP or producing scars.
Microdermabrasion
This procedure is a superficial exfoliation that may not be suitable
for skin of color, but it is sometimes used to treat PIP and smooth
skin texture. It can be effective in reducing superficial hyperpigmentation;
however, pigmentary streaking and worsening of PIP
may occur in people with dark skin types.
Managing the scars
Acne scars can form after cysts and nodules heal. Even minor outbreaks
of inflammatory acne can result in significant scarring if
you’re predisposed to form larger scars as is the case in many
African-Americans.
Acne scars are difficult to treat, and keloids, large scars that grow
way beyond the bounds of normal scars, are particularly difficult
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to deal with. Intralesional cortisone injections, though, are particularly
effective for patients of color. As with inflammatory nodules
and cysts, cortisone injections are sometimes injected directly into
the scars to help shrink them. In these instances, higher concentrations
than are used to treat active acne lesions are used. Other procedures,
such as soft tissue fillers, scar revision, and laser surgery,
may also be considered (see Chapter 16).
Caution must be used with all of these procedures because of the
risk of creating further scarring and PIP. Therefore, only an experienced
dermatologist or other cosmetic surgeon who is knowledgeable
about skin of color should perform these corrective
procedures. The method known as dermabrasion, used to remove
deep scars, can sometimes be too risky to use on people with
dark skin because it has a likelihood that it will make scarring
and PIP worse.
The newest treatment of keloids and hypertrophic scars is to
have them shaved flat or excised (cut out) by a dermatologist or
plastic surgeon. After the procedure is done, the patient applies
topical imiquimod (Aldara) cream for at least 8 weeks. There have
been optimistic reports that there are fewer recurrences with this
method.
Oral acne therapy to prevent
scars and PIP
The use of oral therapy doesn’t differ much according to the relative
lightness or darkness of one’s skin. But sometimes a more
aggressive approach with oral antibiotics such as one of the oral
tetracyclines (see Chapter 10) will get the less visible, “under-theskin”
papules and nodules under control and prevent the more
obvious postinflammatory hyperpigmentation (PIP) and the more
complicated hypertrophic scars and keloids that can result from
them. Scar treatment is covered in Chapter 16.
Looking at Pomade Acne
African-Americans and other individuals who have tight curly hair
frequently use pomades (oils and greasy ointments) to style or
improve their hair’s manageability. Some people believe that
pomade acne is caused by the pomade’s blockage of pores and that
as a result, many pomade users develop blackheads and whiteheads,
with perhaps a few papules and pustules on the forehead
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and/or temples — places where the pomade comes into contact
with their skin. To see what pomade acne looks like, take a look at
the color section of the book.
Pomades can also contribute to an inflammation or infection of
the scalp, called folliculitis, in which pustules and redness
develop around the hairs. This type of folliculitis can cause hair
loss and scarring of the scalp. I talk about hair follicle problems
in Chapter 19.
My best advice to you is to stop using pomades. If your acne persists
after stopping, be sure to see a dermatologist. However, if you
feel your life or hairstyle can’t be complete without pomade, you
still have a couple options to reduce potential problems:
If you’re using pomade to deal with a dry scalp, try applying
the pomade 1 inch behind your hairline.
If you’re using it to style or make your hair more manageable,
try applying the pomade to the ends of your hair only, to
avoid contact with your scalp and hairline.
Cosmetics for Women of
Various Ethnic Groups
Dark-complexioned women tend to be more concerned about skin
tone and having a clear, even complexion than they are about wrinkles
and fine lines.
Until recently, most skin-care companies have neglected African-
Americans and other ethnic consumers. Ethnic cosmetic brands
were available, but their products were far fewer than those in
Caucasian makeup lines.
In the past decade, things have markedly improved and there are
now many companies that offer skin-care products for women of
color. The color spectrum has broadened to include a wider variety
of darker color shades for you to match your skin tones and
conceal your acne while not irritating or worsening it. Products for
Asian women are still few in number; however, Shiseido now offers
a full line of products for the Asian woman. Your dermatologist
may be able to recommend cosmetic measures to make the PIP
spots less apparent until they resolve.
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You may have a problem in choosing the right cosmetic if you have
uneven skin tones that represent an uneven distribution of your pigmentation,
such as appears in PIP. Some areas are darker while some
appear lighter. In such cases, you should match your foundation to
the most predominant color, or find one with a shade in between the
two. Experiment and sample before you buy. Pigmented makeup
creams have also been successfully used to camouflage hyperpigmented
skin to a shade similar to that of the surrounding unaffected
skin.
Some companies can custom-blend foundation colors, but this may
be very expensive; Dermablend (www.dermablend.com) and
Covermark (www.covermark.com) are two such products.
They’re available in many shades that can be easily blended to
match any skin tone. In fact, they can be used for people of all skin
colors. Besides acne spots, they can be used to conceal skin
imperfections such as birthmarks, burns, and discolorations from
surgery. These products can be found in makeup counters in some
department stores and also can be obtained online.
Of course, PIP occurs just as often in males; however, most males
would not use camouflaging methods as readily as females to try
to hide it.
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Chapter 13
Attacking Acne with
Accutane and Other
Isotretinoins
In This Chapter
Going over the terminology
Getting to know isotretinoin
Preparing for treatment
Taking your medicine
If your acne is really severe and hasn’t responded to other types
of therapy, your dermatologist may turn to isotretinoin, commonly
known by its original brand name, Accutane. Isotretinoin is
a powerful oral medication and, so far, it’s the only treatment that
induces a long-term, drug-free remission of severe acne.
The vast majority of people who have taken isotretinoin bear witness
to the dramatic reduction in acne symptoms and a prolonged
improvement they’ve experienced even after only one course of
15 to 20 weeks of isotretinoin. Okay, then, why don’t I and all the
other dermatologists out there simply install an isotretinoin vending
machine in our waiting room?
There are three main reasons why isotretinoin treatment must be
closely monitored (I thoroughly cover all three in this chapter):
If taken during pregnancy, isotretinoin is highly likely to cause
severe birth defects.
There are many other possible side effects that can occur
with isotretinoin use. They range in seriousness from dry lips
to persistent headaches and temporary hearing loss.
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Isotretinoin may be linked to an increased risk of depression
and suicide in people who take it.
Before going any further, I must tell you that most dermatologists
believe that for those who have severe acne, the benefits of
isotretinoin far outweigh the risks if the drug is taken as prescribed
and specific cautions are followed. In this chapter, I explain why
we’re of this opinion and I give you details about the drug and precautions
you can — and must — take, including the new program
established in the United States to regulate access to this drug. But,
as only your doctor can prescribe isotretinoin, he has the definitive
word on all aspects of your treatment, so follow instructions and
ask questions. And for before and after photos of a woman who has
taken isotretinoin, see the color section of this book.
You Say Accutane,
I Say Isotretinoin
Isotretinoin (its chemical name is 13-cis-retinoic acid) is related to
both tretinoin (retinoic acid) and retinol (vitamin A). Isotretinoin is
derived from vitamin A, which makes it a retinoid. (I discuss topical
retinoids that dermatologists prescribe in Chapter 9.) In Canada,
the United Kingdom, Australia, and Europe, isotretinoin is available
as a topical, as well as an oral, preparation to treat acne.
When isotretinoin is taken orally, it’s classified as a teratogen, which
means that it’s a substance that can cause deformities in a fetus.
The original brand names for oral isotretinoin were Accutane in
the United States and Roaccutane in rest of the world. Besides,
Accutane and Roaccutane, it’s now sold under several generic
brand names in the United States, including
Amnesteem
Claravis
Sotret
For our purposes, I simplify matters and simply call it isotretinoin.
(For a complete listing of isotretinoin brand names in your neck of
the woods, check out my guide to acne drugs around the world in
Appendix B.)
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Getting to Know the
Drug and Its Uses
Isotretinoin is so effective because it has the ability to hit specific
targets at the root of acne. (In Chapter 3, I go into all of the details
about how acne forms.) Isotretinoin treats acne by:
Stopping the excess oil production: Isotretinoin dramatically
reduces the size and output of your sebaceous glands. It
limits the amount of sebum and thus cuts off the acne bacteria’s
(technically known as P. acnes) food supply. Stemming
the flow of oil explains the many drying side effects that I
describe later in this chapter.
Stabilizing keratinization: Keratinization is the process
through which keratinocytes (epidermal cells) produce the
protein keratin. When acne occurs, the dead cells that are
located in your hair follicles are shed more frequently and in
an abnormal fashion. Isotretinoin helps you to more normally
shed away dead skin cells, so that they are less likely to clog
your pores. This process prevents comedones (whiteheads
and blackheads) from forming. I explain the formation of
comedones and keratinization in Chapter 3.
Doctors usually prescribe isotretinoin after other acne treatments
have failed to produce satisfactory results. Isotretinoin should never
be the therapy of first choice. It must be demonstrated that you’ve
been unresponsive to other standard therapies — the course of
which usually begins with topicals (see Chapters 7 and 9), and
moves onto oral antibiotics (or a combination of oral antibiotics and
topicals, as I discuss in Chapter 10), or antiandrogens in women (see
Chapter 11), all of which produce far fewer side effects than does
isotretinoin.
Because of its serious side effects (see “Knowing What to Expect
When You Take Isotretinoin” for more information), isotretinoin
should be used only for severe, resistant acne. The drug isn’t for
everyone. However, when any of the following types of acne exist,
isotretinoin may be considered (as the final therapeutic option):
Severe nodular acne that can’t be cleared up by any other
acne treatments including oral antibiotics
Inflammatory acne with scarring that has failed conventional
treatment
Moderate-to-severe acne with frequent relapsing
Acne with severe psychological distress
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I need to emphasize that those last three reasons to use isotretinoin
are considered to be “off-label,” meaning that the U.S. Food and
Drug Administration (FDA) hasn’t approved isotretinoin for these
conditions. Off-label use doesn’t imply that the drug is being used
improperly or illegally. The decision to prescribe isotretinoin for
the final three reasons has been based on many years of clinical
experience and a careful consideration of the potential risks and
benefits in the use of the drug.
Isotretinoin can cause severe birth defects if taken by a pregnant
female or a woman who becomes pregnant while taking the drug —
even for a short time. Because the drug stays in the body’s system
for a long time, it can cause birth defects for one month after a
woman has stopped taking it. Isotretinoin also carries an increased
risk of miscarriage when used during pregnancy or up to one month
prior to pregnancy. Studies done in males taking isotretinoin showed
no significant effects on their sperm and no long-term damage to a
male’s ability to have healthy children.
Some of the birth defects include:
Skull abnormalities
Heart defects
Deafness
Cleft palate
Central nervous system defects
In the treatment of females of childbearing potential, isotretinoin
should be used only for patients with severe, disfiguring, cystic
acne.
If you have unprotected sex without birth control, miss your
period, or become pregnant while you’re taking isotretinoin, call
your dermatologist immediately!
Preparing for Treatment
Isotretinoin’s toxicity during pregnancy has long been known, but
past efforts to reduce birth defects, including stricter product labeling
and a limited pregnancy testing system, failed to resolve the
problem. Therefore, in 2005, the FDA established an isotretinoin
federal registry program called iPLEDGE. The program is geared
toward reducing the number of birth defects, miscarriages, and
abortions associated with the drug. The iPLEDGE program only
applies to prescriptions for isotretinoin that are written in the
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United States. But the precautionary information is valid no matter
where you live, and many of the same procedures are followed
throughout the world.
The registry keeps tabs on all isotretinoin prescriptions in the
United States. Manufacturers, wholesalers, pharmacists, prescribers,
and patients are linked through a centralized computer
registry. The registry also connects to the laboratories that perform
the required pregnancy testing in this system (see the next section,
“Procedures all patients must follow,” for details). Physician and
patient identification codes are intended to protect the privacy of
patients.
Unfortunately, some dermatologists and other healthcare providers,
maybe yours, will stop prescribing isotretinoin rather than take on
the time-consuming workload inherent in the iPLEDGE registry.
Note: In this section, I use the term prescriber to refer to the person
who writes the isotretinoin prescription, whether it’s your dermatologist
or primary care provider.
Procedures all patients must follow
Everybody in the United States who is prescribed the drug, including
females who can’t get pregnant and males, must register with
iPLEDGE.
The registration procedure requires your prescriber — or a designated
person in your prescriber’s office — to connect with the
iPLEDGE Web site or phone system to enroll you into the system
before being permitted to prescribe isotretinoin. Reactivation must
be done on an annual basis. After you’re registered and been prescribed
isotretinoin, your prescriber must confirm to the registry
that you are receiving ongoing counseling each month while taking
the drug. A monthly review about birth-control requirements is
especially crucial for female patients of childbearing potential (see
the following section).
In addition to keeping tabs on all the prescriptions, registering
everyone is meant to discourage men from sharing their isotretinoin
with a girlfriend, sister, wife, and so on and to discourage women
from asking men they know to get isotretinoin for them.
Before starting treatment, your isotretinoin prescriber will order a
lot of blood tests. A complete blood count, liver function studies,
and triglyceride and cholesterol levels should be determined
before treatment begins. That’s because isotretinoin can cause
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changes in the blood and the liver. Your prescriber will likely continue
to order more tests as treatment continues.
Your prescriber will also explain the risks and requirements for
safely using the drug, and have you or your parent or guardian sign
a consent form that says you understand the risks associated with
isotretinoin, including possible birth defects as well as the possibility
of depression and suicide. (Pharmacists must also hand out a
detailed warning brochure.)
All patients, male or female, are only allowed a 30-day supply of
isotretinoin at each office visit. These prescriptions are only valid
for seven days after they’re prescribed.
You must be reliable and capable of understanding the prescriber’s
instructions on the use of isotretinoin and the risks involved, and
be willing to comply with these instructions.
Be sure to talk to your doctor about any of the following conditions
that you or a family member may have:
Allergies to foods or medicines
Anorexia nervosa
Asthma
Diabetes
Heart disease
Liver disease
Mental problems
Osteoporosis
Additionally, tell your doctor if you’re taking phenytoin (Dilantin),
because using it in combination with isotretinoin may weaken your
bones.
Additional steps females must take
Because isotretinoin is harmful to the fetus and therefore shouldn’t
be used during pregnancy, women of childbearing age must
commit to additional testing and compliance in order to receive
isotretinoin.
Table 13-1 contains a breakdown of the monthly responsibilities
that you, your prescriber, and your pharmacist share within the
iPLEDGE program if you’re a woman capable of having children.
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The discuss these requirements in the following sections (for more
information you can check out www.ipledgeprogram.com and
talk to your prescriber).
Table 13-1 Monthly iPLEDGE Requirements for
Females Capable of Having Children
Individual Interaction
Your doctor Confirms that you’ve received contraceptive counseling
Enters the two types of contraceptives that you’ve chosen
to use
Enters your pregnancy test results
You Answer educational questions before each prescription
Enter the two types of contraceptives that you’ve chosen
to use
Your pharmacist Checks with iPLEDGE to get authorization to fill the
prescription.
In addition to these steps, you also need to avoid becoming pregnant
for at least one month after stopping isotretinoin treatment.
And because of isotretinoin’s potentially serious side effects, nursing
mothers should unquestionably not use it.
Male patients who are taking isotretinoin should be informed
about the risk associated with use during pregnancy, emphasizing
that they shouldn’t share the drug with females.
Birth control discussion
You must discuss birth control methods with your prescriber or a
healthcare professional with expertise in contraception, such as a
gynecologist. Such counseling and patient education are prerequisites
to obtaining isotretinoin prescriptions.
Two negative pregnancy tests
Two negative pregnancy tests before you start isotretinoin are necessary.
The first test (a screening test) is done when the decision is
made to start isotretinoin. The second test (a confirmation test)
must be done during the first five days of your menstrual period
right before starting isotretinoin. You won’t get your first prescription
for isotretinoin until there is proof that you have had two negative
pregnancy tests.
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The pregnancy tests are performed only at certified laboratories
that are CLIA approved. CLIA stands for Clinical Laboratory
Improvement Amendments and was enacted by the United States
Congress to ensure the accuracy, reliability, and timeliness of
patient test results regardless of where the test was performed.
Ongoing pregnancy tests during treatment
You continue to have a pregnancy test every month during
isotretinoin therapy. Along with confirming that appropriately timed
initial pregnancy tests performed at a CLIA-approved laboratory are
negative prior to authorizing the dispensing of an isotretinoin prescription
for a female patient who is capable of becoming pregnant,
the iPLEDGE registry requires a new pregnancy test before each
refill is authorized.
Use of two separate forms of effective
birth control at the same time
You must be using two of these birth controls at least one month
before beginning therapy, during therapy, and for one month after
isotretinoin treatment has stopped. Effective forms of birth control
include:
Hormonal birth control — including birth control pills,
patches, long-term injections (like Depo-Provera), and
implants (like Norplant)
Condoms
IUDs (or Intra Uterine Devices)
Diaphragms
Tubal ligation (having your tubes tied)
A partner who’s had a vasectomy
The following are unacceptable forms of contraception:
Progesterone-only minipills that don’t contain estrogen (In
fact, if you’re taking this form of birth control, talk to your
doctor, as it may not work while you’re taking isotretinoin.)
IUD Progesterone T
Female condoms
Natural family planning (rhythm method) or breastfeeding
Fertility awareness
Withdrawal
Cervical shield
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All birth control methods (besides total abstinence) can fail.
Discuss the various options with your prescriber or your contraception
advisor.
In two specific situations, you don’t need to use these birth control
methods:
You commit to being absolutely and consistently abstinent (no
sexual intercourse) during and for one month before and one
month after your isotretinoin treatment.
You have had a hysterectomy (your uterus was surgically
removed).
If you are capable of becoming pregnant — even if you commit to
abstinence — your prescriber may insist that oral contraceptives
are one of the two methods used before starting, during, and for
one month after isotretinoin treatment is completed.
Chapter 13: Attacking Acne with Accutane and Other Isotretinoins 159
Overcoming embarrassment
When she was a 17-year-old girl, Liza was prescribed isotretinoin, which she took for
five months. Before starting the isotretinoin, she was asked by her dermatologist if
she was sexually active or if there was any chance that she might be pregnant. She
was also questioned about her knowledge about birth control methods. She was mortified
because she was asked these questions right in front of her father!
After she began taking isotretinoin, she was embarrassed about having to go for
the pregnancy test every month. I explained to her that it would have been irresponsible
had the doctor not brought up the issue of pregnancy or if the doctor did
not discuss birth control methods as well. Regrettably, these are embarrassing, but
very necessary topics we must discuss because of the potential serious consequences
that can occur if these issues aren’t addressed and understood completely.
Maybe her dermatologist could have been more tactful and spoke to her privately
or asked her to bring her mother on follow-up visits.
As things turned out, Liza was very happy with the results of treatment and her worst
side effect was really, really dry lips. “I went through four or five tubes of Chapstick,”
she said.
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Knowing What to Expect when
You Take Isotretinoin
If I haven’t scared you off yet with all the warnings earlier in this
chapter, here’s the section that tells you how to take isotretinoin,
what to look out for, and how to deal with some of its inevitable
side effects.
Taking your pills and
observing results
Isotretinoin is available as capsules in the following strengths: 10,
20, 30, and 40 milligrams. The recommended dose depends on
your body weight. Usually you take a pill with food twice a day for
a total of 15 to 20 weeks. (In Europe, patients are often given lower
dosages for longer periods of time.) Initially, your doctor may
decide to start you off on a low dose so that you can get used to
any side effects and then the dosage can be increased.
Often there is an observable improvement over the first month
that continues over the course of treatment. In the vast majority
of isotretinoin users, complexions smooth out, marks fade, and
acne improves dramatically. Some lesions may still remain after
you have stopped treatment, but many individuals notice that
their acne continues to improve even in the weeks after treatment
has stopped.
Shortly after starting isotretinoin therapy, some people may initially
get worse before they get better. Often that’s because they
stopped all of the other acne medications that they were using up
until then. A minority of isotretinoin users have a more serious
flare at the beginning of treatment. Your dermatologist can manage
this by adjusting the dosage or by adding other medications to
calm things down.
Most people don’t require a second course of treatment; when
needed, it should be resumed only after the drug has been stopped
for four months.
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What not to do when you’re
taking isotretinoin
You must avoid certain things while taking isotretinoin, including
the following:
If you’re a woman, don’t even consider having unprotected
sex while you’re taking isotretinoin.
Don’t breastfeed while taking isotretinoin and for one month
after stopping.
Don’t donate blood during treatment or for one month after
stopping treatment. If someone who is pregnant gets your
donated blood, her baby may develop severe birth defects.
Treatment with tetracycline and isotretinoin shouldn’t be
given at the same time because the combination has been
associated with brain swelling (pseudotumor cerebri).
Vitamin A should be strictly avoided while undertaking therapy
with isotretinoin because they’re closely related to one
another. The use of both vitamin A and isotretinoin at the
same time may lead to added side effects.
If you’re taking birth control pills, the herbal supplement
St. John’s Wort may make the birth control pills work less
effectively.
Sizing up side effects
Although they’re common, side effects with isotretinoin are usually
tolerable. In general, most folks work through many of the reactions
because the drug is so effective that people with severe acne want
to continue taking it despite some of the bothersome side effects.
Side effects of isotretinoin are dose-related. That means that the
higher the dosage, the greater chance of having side effects. One
way around this problem is for your dermatologist to put you on a
low dosage for a longer period of time. However, females will then
have to continue monitoring pregnancy tests and continue birth
control for a longer period of time.
Mild side effects
Isotretinoin is effective, in part, because it can shut down the oil
production in the body, but this action accounts for some of its
side effects. Because of the great decrease in oil production, even
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your mucous membranes, such as the inside of your nose, eyelids,
and mouth, lose oil and become very dry. In fact, dryness is the
most common side effect of isotretinoin. This reduction of oil can
result in some of the less serious side effects, such as:
Dry lips: Dry, chapped, and sometimes cracked lips are the
most common and persistent annoyances from isotretinoin.
These irritating problems occur in just about everybody who
takes the drug. You can deal with them by gobbing on lip
balm. I recommend Vaseline Petroleum Jelly, Chapstick, or
Bag Balm.
Dry eyes: You may find dry eyes to be a problem, particularly
if you wear contact lenses. You may need to stop wearing
them temporarily, but the frequent use of artificial tears such
as Tears Naturale or Visine True Tears may allow you to continue
using contacts. Artificial tears are used as one or two
drops placed in the affected eye(s), as needed.
Mild nosebleeds: Nosebleeds occur when the nasal lining
dries out. They’re usually short-lived and can be stopped with
direct pressure. Nosebleeds can be prevented by coating
nasal surfaces with lubricants, such as Vaseline Petroleum
Jelly or Aquaphor ointment.
Dry skin: You may notice peeling of your palms and soles, or
scaly skin on the backs of your hands and forearms. Helpful
moisturizers such as Eucerin cream, Moisturel, Cutemol, and
Am-Lactin, are all available over the counter.
However, reduction in oil isn’t the only annoying problem you face.
You may also experience:
Aches and pains: Musculoskeletal symptoms such as pain or
stiffness of large joints or of the lower back occur and are usually
very mild and disappear after a month or so. Try Tylenol
(acetaminophen) if you experience ongoing pain.
Increased sensitivity to the sun: I know you’re all wearing
sunscreen daily anyway (hint, hint), so apply it more often
and use a higher SPF than you might normally.
Thinning hair: Less common, but still annoying; some people
have reported thinning hair during treatment. Rarely has this
been a persistent or a permanent problem — the hair generally
grows back when the treatment regimen is over.
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More serious problems
More serious unwanted events have also been reported and you
should stop taking isotretinoin and call your dermatologist if you
experience any of the following side effects. Most, if not all, of
these side effects disappear after treatment is stopped, however,
some have persisted after therapy:
Changes in mood, depression, or suicidal thoughts or
attempts: For more on this topic, see the section “The risk of
depression and suicide.”
Chapter 13: Attacking Acne with Accutane and Other Isotretinoins 163
A no-brainer
Roger was a 15-year-old when he first walked into my office with his parents. Before
Roger came to my office, his family doctor called and told me that he had prescribed
oral antibiotics and many creams and gels for Roger to try, but they did very little to
improve his complexion. Roger’s head hung low and he avoided eye contact with
me. His face was studded with red papules, pustules, and acne nodules. He very
reluctantly removed his shirt after I asked him to do so.
When I saw his chest and back, I then understood why he was hesitant to take his
shirt off — his back and chest were covered with large acne cysts (nodules). Roger
wasn’t communicating much with me, but his parents told me that he refused to try
out for his school swimming team even though he was terrific in the butterfly and
backstroke. I guessed that he was ashamed to get undressed in the locker room
because of the appearance of his skin. On top of all this, his parents said that his
grades were falling off in school, he was sleeping later than usual, and that he
stayed in his bedroom most of the time when he was home. All of these behaviors
can be a consequence of his embarrassment about his appearance; however, they
can also be indicators of depression, so Roger’s parents were right to be worried
about him. In Chapter 17, I point out the signs and symptoms of depression.
I also noticed that his dad had obvious acne scars on his face and he told me that he
had pretty bad acne when he was a teen. He lifted his shirt and showed me that
he was quite scarred on his chest and back. It was a no-brainer; Roger had severe
nodular acne which, no doubt, would eventually heal and form scars just like his dad.
After lengthy discussions with Roger and his parents, I ordered certain blood tests that
proved to be normal and I prescribed a five-month course of isotretinoin for him.
To make a long story short, Roger’s acne cleared up beautifully. One year after he
finished taking the isotretinoin, he popped into my office with his girlfriend. He said
that he just wanted to say “hi” and show me how great his skin looked. There were
no scars! He did say that he would get a few pimples now and then, but he was able
to control them with an over-the-counter medication. I asked him about the swimming
team. Sorry to say, he tried out, but didn’t make it. Well, maybe next year.
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Allergic reactions such as an itchy red rash or difficulty
breathing: In some people, isotretinoin can cause serious
allergic reactions. Stop taking it and get emergency care right
away if you develop hives, a swollen face or mouth, or have
trouble breathing. Also stop taking isotretinoin and call your
prescriber if you develop a fever, rash, or red patches.
Changes in vision: You may experience decreased night
vision. You should be particularly careful when driving at
night. Rarely has this persisted following treatment.
Persistent headaches: A rare side effect of this drug is benign
intracranial hypertension, which is an increase in pressure of
the fluid surrounding your brain. If you have continual
headaches that are present in the morning on waking and
wear off through the day, you should be evaluated by your
doctor.
Hearing impairment: This problem has rarely persisted following
treatment.
Skeletal hyperostosis: This condition is typified by excessive
bone growth along the sides of the vertebrae of the spine. It is
diagnosed by X-ray studies. This problem is limited to those
who take a high dosage and long-term therapy with isotretinoin,
a dosage much higher than is used to treat acne.
The risk of depression and suicide
Depression is unfortunately a common problem in the age group
that needs isotretinoin most frequently — the adolescent group.
Acne appears most often between the ages of 12 to 24. The onset of
depression also commonly occurs at about the same time. In the
United States, the FDA has been receiving reports of depression and
suicide in patients taking isotretinoin and there is concern about a
possible link between the drug, psychiatric disorders, and suicide.
Emotional problems in the adolescent population coupled with the
stress of having severe acne, makes it difficult to determine whether
isotretinoin can trigger depression and suicide or whether successful
treatment may thwart such problems. This controversy has
made its current use an issue of concern for many dermatologists
and patients alike.
The package insert provided with isotretinoin prescriptions includes
warnings about mental problems and suicide. Depression, other
serious mental problems, suicidal thoughts, suicide attempts, and
aggressive, violent behaviors have been reported while patients
took the drug or soon after stopping it. No one knows if isotretinoin
164 Part III: Turning to the Pros to Treat Your Type of Acne
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caused these behaviors or if they would’ve happened even if the
person didn’t take the drug.
According to a recent study, isotretinoin doesn’t cause depression.
In fact, many patients in this study described themselves as
being emotionally better off after being on the medication. Many
dermatologists believe the research supports what they have seen
in their patients all along. (If you’re into medicalese, you can find
the study by Christina Chia and her fellow researchers in the
May 2005 issue of the journal Archives of Dermatology; http://
archderm.ama-assn.org.)
One Canadian study found that 4 percent of patients taking
isotretinoin became depressed and remained depressed during
treatment with isotretinoin; however, there were no control subjects
for comparisons. Studies of this sort, without controls (persons not
taking isotretinoin), can’t provide convincing scientific data about
whether a common disorder — depression — is caused by a drug.
The FDA currently regards these associations as unproven, but
needing further study.
The bottom line, as of 2005, is that it is still unclear whether
isotretinoin causes increased risk for depression and possible
suicide. Because suicide is a major cause of death in teenagers,
Chapter 13: Attacking Acne with Accutane and Other Isotretinoins 165
Keeping yourself informed
If you’re deciding whether or not to take isotretinoin, give it a lot of thought and do
a lot of research. Check out the Internet, talk to your doctor, and read the information
pamphlet that you were given by your dermatologist. The following are some
Internet resources that you may find helpful:
FDA’s Isotretinoin Information Page (www.fda.gov/cder/drug/
infopage/accutane/default.htm): The latest information from the
FDA about isotretinoin.
Acne.org (www.acne.org): A forum on which many people keep diaries on
isotretinoin use.
Drugs.com (www.drugs.com/MTM/isotretinoin.html): A good
site for isotretinoin information.
Accutane/Roaccutane Action Group (www.accutaneaction.com):
People who suffered continuing side effects from Accutane and Roaccutane.
Chat group (www.hayllar.com/accutane/archives/001736.
html): Sarah’s Accutane Journal.
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particularly in males, it has been difficult to determine a causal
relationship between isotretinoin and these events and there is a
great need for further study.
If you or your child is taking isotretinoin and is showing signs of
moodiness, depression, or psychosis, the drug should be stopped
and you should notify your dermatologist immediately so that the
situation can be evaluated. In Chapter 17, I provide a list of depression
warning signs, but also stop taking the drug and contact your
doctor should you see signs of acting on dangerous impulses or
seeing or hearing things that are not real.
166 Part III: Turning to the Pros to Treat Your Type of Acne
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Chapter 14
Searching for Weapons
of Zit Destruction
In This Chapter
Let there be light (and lasers)!
Peeling the pimples away
Because of the concerns and debates over the safety of Accutane
and long-term antibiotic use in the treatment of acne, lasers and
other newer technologies that work on the surface of the skin will
probably play an ever-larger role as future therapies for acne. In this
chapter, I describe the use of lasers and other light sources in the
treatment of acne and go on to tell you about what is known about
treating acne with chemical peels.
You Light Up My Face:
Zapping the Zits
Using lasers and light therapies offers a promising, noninvasive
alternative to treat acne. Lasers and lights show evidence of improving
not only inflammatory acne, but can also lead to improvement in
acne scars. (See Chapter 16 for more information about scarring.)
The long-term benefits of lasers and other light sources as methods
for prevention and treatment of acne itself, is presently an open
question, but the future appears bright. Until more is known, laser
and light therapies may offer an alternative for people whose acne
hasn’t responded to traditional acne therapies.
Lasers can be tuned to target specific structures. When used to
treat acne, the beams are adjusted to penetrate below the epidermis
without causing any injury to it. They travel into the dermis
where they can zero in on hair follicles, sebaceous glands, and the
P. acnes bacteria (see Chapter 3 for more on the formation of
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acne). Certain lasers can also be used to destroy “broken” blood
vessels (telangiectasias) in the dermis (see Chapter 18 for more on
the telangiectasias); some lasers, by heating dermal collagen, can
help to “tighten” the dermis and result in less visible scarring.
Lasers that are used in acne scar treatment are the resurfacing
(ablative) lasers and the non-ablative lasers, which are described
in Chapter 16.
Researchers are hopeful that such treatments will lead to a reduction
in the amount of drugs required to treat acne. At this stage of
the game, laser and light therapy seem to be most helpful when
used in combination with traditional acne medication treatments.
Most acne patients using these technologies generally must continue
to use topical and oral medications; however, several investigators
report that some patients tend to require less oral and
topical antibiotic treatments when lasers or lights are effective.
There are two basic groups of acne-treating lights. One group of
technologies inhibits the growth of the bacteria P. acnes and the
other group of light sources aims to shrink the sebaceous oil
glands that also play a pivotal role in causing acne.
Most insurance plans classify the light and laser treatments used
to treat acne as “emerging technologies” and will probably not pay
for your treatments. Many are still in the investigational stage and
may not be the first choice for treating your acne. All of these treatments
are expensive, time-consuming, and some are still in the
experimental stage.
Many people who have dark skin have been told that laser treatment
is not safe for them. However, in expert hands, very specific
wavelengths of lasers can minimize complications such as PIP (see
Chapter 12 for more information) and scars.
168 Part III: Turning to the Pros to Treat Your Type of Acne
Radio waves: Beam my acne away
Studies on radiofrequency emissions to heat up the sebaceous gland, tighten collagen,
and shrink scars with pulses of electromagnetic energy are showing some
promise. Currently, this technology is being used to tighten the skin as a noninvasive
facelift. The radio waves heat the dermis without burning the surface. The surface
is initially cooled with liquid nitrogen, after which a dosage of radio waves is
applied. Definitely stay tuned!
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Honing in on P. acnes with
photodynamic therapy
Photodynamic therapy (PDT) involves applying a drug called a
photosensitizing agent, which is then activated by exposure to a
light source. Light sources used in PDT include visible (nonlaser)
or laser light. This combined interaction of the solution and the
light is what gives rise to the term “photodynamic therapy.”
The U.S. Food and Drug Administration (FDA) has approved a nonlaser,
narrow-band, high-intensity visible blue-light therapy for
treating inflammatory acne. It works by killing the acne-causing
bacteria, P. acnes.
The P. acnes that reside in your sebaceous glands produce chemicals
known as porphyrins as a by-product of their metabolism.
Visible light — in this case blue light — seeks out the porphyrins
that are in the bacteria. This high intensity light activates these
porphyrins and thus kills the bacterial cells. Researchers hope that
the sebaceous gland is “knocked out” or at least slows down as a
result of this procedure (as a sort of “collateral damage”); however,
we don’t have hard evidence to actually document that this procedure
succeeds in accomplishing it.
A doctor, nurse, or technician applies a clear, painless solution,
aminolevulinic acid (ALA), to your skin. ALA is a potent, photosensitizing
agent that increases sensitivity to light. It’s left on your skin
for 15 to 60 minutes and allowed to accumulate in target cells —
the sebaceous glands. An intense, visible light source (usually a
blue light) activates the ALA. This takes about eight to ten minutes.
The chemical reaction that occurs produces heat and the bacteria
are destroyed.
Immediately after this treatment, if you go out in the sun — even
for a few minutes — you can develop a significant sunburn and
peeling. For about two days after the photosensitizing agent is
used, keep your face from being exposed to strong, direct light. Be
sure to use sun protection.
Other side effects tend to be mild and include temporary pigment
changes, swelling of the treated areas, and dryness.
Many treatments may be necessary to achieve satisfactory results.
Because this type of therapy appears to target only one cause,
P. acnes, the acne may not respond in the long run. That’s because
the destruction of these bacteria is only temporary; they revitalize
rapidly, so ongoing treatments are necessary.
Chapter 14: Searching for Weapons of Zit Destruction 169
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Microdermabrasion, a technique described in Chapter 16, is a
gentle way to exfoliate the surface of the skin. Recently, some
investigators have found that PDT can be performed on a “short
contact” basis. Using PDT after a light microdermabrasion allows
for better penetration of the ALA.
A new photosensitizing agent, known as lemuteporfin, that seems
to better penetrate the sebaceous glands, is now being investigated
as a potential acne photosensitizer.
Looking ahead: Stopping oil at the
source and other promising paths
For longer term results, it appears to be necessary to destroy the
sebaceous gland as well as the bacteria. Various light sources are
being tried in order to more deeply penetrate into the sebaceous
glands. Technologies currently under consideration as potential
acne treatment include
Intense pulsed light (IPL): These devices are similar to lasers,
but they use a wider range of wavelengths as opposed to only
a single beam of light. They employ a broad band of visible
and near infrared wavelengths of light that block out other
wavelengths. Pulsed light can deliver hundreds or thousands
of colors of light at a time. Pulsed light machines use “cut off”
filters to selectively deliver the desired wavelengths. These
wavelengths can be customized to reach the specific targets
170 Part III: Turning to the Pros to Treat Your Type of Acne
Banishing blemishes with warmth?
The latest on the zit parade to treat your acne is the heat-based, at-home acne treatment
device known as Zeno. This pricey device sells for over $200 and has a costly
tip that needs replacing after 90 treatments. It supposedly works by delivering heat
to individual zits and killing the P. acnes bacteria that are involved in causing acne.
The gadget looks like a silver cellphone and is sold online from the company as well
as by dermatologists, cosmetic surgeons, and other doctors without a prescription.
Zeno uses controlled, low-level doses of heat that’s delivered to individual pimples.
The makers of Zeno claim that the device can “clear up a pimple in just hours.”
Until more is know about this device, and it proves to be effective, how about a trip
to Tahiti, or maybe save your do-re-mi by heating a spoon with hot water and applying
it to individual zits?
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such as blood vessels or other skin components that are
being treated.
IPLs can penetrate various depths into the skin, and by using
longer wavelengths, they may able to affect the sebaceous
glands’ growth and activity. Long-term studies are necessary
to see how effective they will prove to be.
Pulsed dye laser (PDL): Results for acne have so far been
inconsistent. This laser is “tuned” to a specific wavelength of
light. It produces a bright light that is absorbed by blood vessels.
This laser is also being used to improve the appearance
of acne scars and is effective in removing the enlarged blood
vessels associated with rosacea. I talk about PDL and acne
scars in Chapter 16 and PDL and rosacea in Chapter 18.
Pulsed light and heat energy (LHE) therapy: This treatment
combines pulses of light and heat, which researchers believe
target both P. acnes and the sebaceous glands, two of the
main causes of acne.
Diode laser: This laser uses infrared frequencies that are
longer, invisible wavelengths. It appears to be effective on not
only acne, but on the acne scars as well.
Avoiding ultraviolet light
There was a time that acne was routinely treated with ultraviolet
(UV) lights. Acne sufferers would visit the dermatologist for their
weekly dosage of sunburns from sunlamps. The results? It looked
like they’d spent a long day at the beach — they’d be red and peeling
for days afterward. The treatment did make acne look better
for a time and may have had some benefit as a peeling agent. It
also helped to blend skin tones and hide the acne lesions. But as
we now know, repeated exposure to high intensity UV rays should
be avoided. Frequent exposure to ultraviolet light can promote
Chapter 14: Searching for Weapons of Zit Destruction 171
Looking back: X-rays
Many years ago, dermatologists treated severe acne with weekly doses of superficial
X-rays. The treatment dramatically reduced sebum production and often produced
excellent degrees of clearing of some of the most difficult cases.
However, long-term consequences of this treatment included the development of
thyroid and parotid cancers in many of the treated people. Needless to say, this type
of treatment is no longer used to treat acne.
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aging of the skin as well as certain skin cancers. The light sources
used to treat acne today don’t contain UV light. For more information
on UV light, the sun, and your skin, see Chapter 22.
As for the proponents of tanning salons, they contend that:
Exposure dries up acne and improves its appearance.
Using artificial tanning equipment, like beds and lamps, as
well as natural sunlight, can protect you against some forms
of cancer by increasing your vitamin D levels.
Dermatologists (including myself) believe that artificial tanning
equipment, such as beds and lamps, should be avoided particularly
if you are at higher risk of sun damage.
Taking It from the Top
Chemical peels have become popular as anti-aging, facial rejuvenation
procedures; however, they’re sometimes used to treat acne as
well. In this procedure, a chemical acid solution is applied to your
skin, causing the skin to peel off so that new skin can regenerate.
Some of the peels have fancy names, extravagant prices, and are
associated with overstated expectations. In fact, many of them are
just gimmicky variations on the basic peels I describe in this section.
The peels work on wrinkles by loosening the glue-like substances
that hold the dead cells on the surface of your skin together, causing
them to peel off (exfoliate). This allows the skin to renew itself
172 Part III: Turning to the Pros to Treat Your Type of Acne
Sunning in moderation
If you don’t have a personal or family history of skin cancer or if you easily tan,
maybe the sun can work for your benefit. As some of you people who have excessively
inflammatory acne have discovered, you may see a dramatic improvement
of your skin during the summer, particularly if you spend more time outdoors when
the days are longer.
This improvement is due to the blending of skin tones that a tan affords. Sunlight also
has a drying effect on the skin that may dampen or shrink the activity of your sebaceous
glands. Another probable mechanism may be the sensitivity to light of the chemical
porphyrins that are part of the acne-producing P. acnes bacteria’s makeup.
You still should consider the risks versus the benefits of sun exposure and think of it just
as you might think of a medication. If you decide it’s worth the risk, use the sun wisely.
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and thus lessen the appearance of fine lines and wrinkles and balance
out skin pigmentation.
Chemical peels also produce a similar exfoliating action in your
hair follicles where the sticky dead cells congregate and block your
pores, causing acne breakouts. (Check out Chapter 3 where I
describe how the cells adhere to one another and cause acne.)
Chemical peels are probably not effective for the treatment of
inflammatory lesions of acne. They seem to work best in the elimination
of blackheads and whiteheads (comedonal acne).
Peels for acne are generally superficial and less apt to cause complications
such as pigmentary changes to the skin. Deeper peels,
with stronger concentrations of acids, are sometimes used to treat
acne scars. (See Chapter 16 for more about the physical scars of
acne.) Superficial peels don’t penetrate below the upper layers of
skin and can sometimes also help to even irregular skin tones by
lightening the dark spots of acne (see Chapter 12). Finding the
treatment that is right for you depends on your skin type, the
activity of your acne, your degree of scarring, and of course — as
with all cosmetic procedures — your ability to afford it, because
most, if not all, health insurance plans don’t pay for them.
With chemical peels, persistent redness, permanent color change,
and scarring are possible, especially with the deeper, highconcentration
peels. Reactivation of cold sores has also been
seen. Most importantly, if you or anyone in your family has a history
of keloids or other types of significant scarring tendencies,
these procedures are probably not for you.
Not only can peels reactivate cold sores, they can cause them to
spread over your entire face. If you have any evidence of active
herpes blisters, don’t have any sort of peel (or microdermabrasion,
regular dermabrasion, or laser abrasion).
It’s important to protect your skin from the sun after any chemical
peel. Ask your doctor to recommend a sunblock with both UVA and
UVB protection, and apply it daily for at least four weeks after the
treatment.
Occasionally, a topical retinoid such as Retin-A is used to pre-treat
the skin by thinning the skin’s outer layer. This preparation allows
for deeper penetration of the chemical solution. The pre-treatment
period may take up to a month before the chemical peel is actually
performed. I cover Retin-A and the other topical retinoids in
Chapter 9.
Chapter 14: Searching for Weapons of Zit Destruction 173
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Chemical peels can be administered by a doctor, a nurse, or an aesthetician.
Most states limit aestheticians to lower concentrations
of these acids. The lower concentration peels that are much less
potent than those used in doctors offices have little, if any, effect
on acne.
Experiencing an AHA or BHA peel
The two most commonly used chemicals for peels are the alpha
hydroxy acids (AHAs) and the beta hydroxy acids (BHAs).
Procedures using these chemicals are commonly referred to as
“lunch hour” peels because they’re the mildest of the chemical peels
and show few after-effects; some folks get them on their lunch hours
and are ready to go back to work right away. Both of these acids are
also found in many over-the-counter cosmetic products, such as
moisturizers and sunscreens, but when a medical professional performs
the peels, concentrations are much higher.
Lactic acid, a trendy AHA found in many over-the-counter products
and prescription moisturizers, is hardly ever used for in-office
peels. Lactic acid is not a “fruit acid” like other AHAs, because it
comes from milk. See the sidebar “Cleopatra took it off the top,”
later in this chapter, for an at-home lactic acid treatment story.
The two most commonly used acid peels are
Glycolic acid: Glycolic acid, an AHA, peels off dead layers of
the skin and, typically, requires no downtime. These peels are
performed every two to four weeks in a series of four to eight
sessions.
Salicylic acid: Salicylic acid, a BHA, is oil soluble and can
therefore penetrate oil-plugged pores. When used as in-office
peels, these treatments can hasten the response of acne to
treatment by reducing the amount of sebum being trapped in
your hair follicles. It is repeated at two- to four-week intervals.
Typically, you combine this treatment with oral or topical
acne medications. The over-the-counter use of salicylic acid is
described in Chapter 7.
The application of AHA and Beta peels are relatively fast and
simple. No sedation or anesthesia is required, because you only
experience a slight stinging when the solution is applied. The treatment
usually takes about 10 to 15 minutes, but the concentration
of the chemical solution or the length of time of the treatment may
vary. After treatment, apply generous amounts of moisturizer.
174 Part III: Turning to the Pros to Treat Your Type of Acne
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The skin remains slightly pink for a few hours to a day, but you can
use makeup to cover it up, if you like. Minimize (or completely
avoid) sun exposure until the skin is completely healed.
Trying out a TCA peel
Trichloroacetic acid (TCA) peels are sometimes used for lightening
areas of pigmentation. TCA penetrates more deeply than AHA and
BHA and creates more active peeling, especially at higher concentrations.
This method also carries a greater risk of scarring. As a
result, lasers and light therapies have mostly replaced these
deeper peels for the treatment of acne and scars.
TCA peels are medium-depth peels and should only be done in a
doctor’s office or in an outpatient surgery center, because they
produce deeper penetration and destruction of the skin and must
be used with great caution. TCA peels often don’t require anesthesia
(because the solution itself has a numbing effect on the skin).
When the TCA is applied, you may at first feel a warm or burning
sensation, followed by stinging. Following the application, the skin
develops a “frosted” appearance within a few seconds and the
treatment is diluted with cool water.
Significant swelling may occur depending on the potency of the
TCA that was used. Swelling should diminish after the first week
and the skin will generally heal sufficiently to resume normal activities
in approximately seven to ten days.
You shouldn’t have such a medium-depth peel if you have dark
skin. Furthermore, wait at least a year or more after being treated
with isotretinoin (Accutane) before having such a peel.
Chapter 14: Searching for Weapons of Zit Destruction 175
Cleopatra took it off the top
Back in 20 B.C. (before Clearasil), Cleopatra, with the help of her handmaidens, exfoliated
at home by having her face soaked in sour milk. There’s lots of lactic acid in milk.
Instead of going to your doctor’s office, a spa, or floating down the Nile to the nearest
chemist, you can do it yourself at home with at-home peel kits. Companies such
as Chanel, L’Oréal, and Lancome now offer glycolic acid peel kits that are supposed
to diminish blemishes, wrinkles, and spots. How effective are they? Not very. But if
Marc Antony were still around, I’d like to ask him what his opinion was.
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Chapter 15
Seeking Alternative
Treatments
In This Chapter
Going back to the future with ancient acne remedies
Looking for herbs at your local stores
Trying vitamins and minerals
Minding the mind
Alternative and complementary healthcare measures are gaining
popularity. Alternative medicine refers to medicine that’s
used in place of conventional medicine. Complementary medicine is
a treatment that is used in addition to conventional medicine. In
this chapter, I explore treatments that are alternatives to the conventional
approaches that are described in the rest of this book. I
look back to the past (B.C. — Before Clearasil) and I investigate the
present from the ashrams of Asia to the beauty counters at
Bloomingdale’s.
Does Alternative Medicine Work?
Although more research is needed to investigate the effectiveness
and safety of alternative and complementary methods, some
people with acne have described an improvement in their skin
after taking certain herbs, undergoing acupuncture, and exploring
mind/body relaxation techniques such as meditation, biofeedback,
and hypnosis.
Right from the get-go I must tell you that the treatments I describe
in this chapter are not ones I subscribe to. I’m presenting them for
the sake of being as inclusive as possible and to let you know that
they’re out there. My medical views and opinions come from the
traditional Western medical perspective that’s based upon the
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scientific method and what is known as evidence-based medicine.
The evidence-based method focuses on using the best available
scientific evidence as a basis for devising treatments.
The clearing of acne by spontaneous remission may play a role in
the popularity of some of these natural treatments; in fact, they
may simply work by the placebo effect. A placebo is a substance or
procedure that contains no medication or obvious physical delivery
of energy. Instead, placebos simply reinforce a patient’s expectation
to get well. So if patients think they will get better by taking
them, they do.
Placebo effects can be powerful, of course, but the potential benefit
of relieving symptoms with placebos should be weighed against
the harm that can result from relying upon — and wasting your
money on — ineffective products and procedures.
Having said that, keep an open mind and I’ll try to keep mine
open too.
Exploring Traditional Chinese
Medicine
The term Chinese medicine refers to a number of practices, especially
acupuncture and herbal formulas. Chinese medicine has
been practiced for over 4,000 years. The long-established concept
has been that any illness is a reflection of an imbalance or blockage
of energy or chi (pronounced chee), in the body.
One of the major assumptions inherent in traditional Chinese medicine
is that disease is a loss of balance between Yin and Yang, the
opposite poles of energy. Yin and Yang are the dynamic force of the
Tao, constantly interacting with one another. Thus, in Chinese
medicine, the physician will treat the underlying imbalance, not
the symptoms of the disease itself.
Trying Chinese herbs
For thousands of years, Chinese formulas (along with Indian,
Tibetan, and Japanese approaches) have been used to treat acne.
Herbal medicines are the prevalent tools used by Chinese physicians
to reestablish the balance of Yin and Yang, returning the
body to a healthy, balanced state (homeostasis). Both herbs and
acupuncture (described in the next section) are methods intended
to restore homeostasis.
178 Part III: Turning to the Pros to Treat Your Type of Acne
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Chinese herbalists usually don’t prescribe one single herb for their
patients. Herbal preparations are usually made by blending a variety
of different herbs. The individual ingredients are weighed, combined,
and then cooked into a souplike mixture and drunk like a
tea. The mixture can be very foul tasting.
The problem with herbal medications is that it’s hard to know
exactly what’s in them because there is no regulation regarding
their contents. Herbs can be just as potent as a medicine you get
from your pharmacy. There have been reports of severe toxic
reactions, so you should be very cautious before trying anything
that is untested.
For those of you herbalists or do-it-yourselfers, I list just a few of
the ingredients that are sometimes used to treat acne. The various
herbs are combined based upon the type of acne that is present:
Flowers of honeysuckle, dandelion, chrysanthemum
Fruit of forsythia, Cape jasmine
Roots of scutellaria, platycodon, licorice, red sage, Chinese
angelica, scutellaria, scrophularia, coptis, red peony
Leaves of loquat
Bark of moutan and mulberry trees
Seeds of tangerine
Bulbs of Zhejiang fritillaria
Modern research techniques have been done on very few of these
botanicals; however, feverfew, a member of the chrysanthemum
family, has been shown to have anti-inflammatory properties in the
treatment of mild acne when it’s applied twice daily for six weeks.
Sometimes, if the smell or taste of the herbal medicine is unbearable,
you can take capsule or tablet forms of herbal medicines
instead.
This method is supposed to work very slowly. Some of those who
are very committed to herbal medicine have reported that if they
persevere, the herbs will work as a preventative as well as a treatment
of their acne. But many Western doctors — myself included —
believe that the acne would have cleared on its own and that any
successes had more to do with belief in the treatment itself than in
its efficacy.
Chapter 15: Seeking Alternative Treatments 179
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Let your healthcare provider or dermatologist know about any
herbal products you’re taking or considering taking.
Trying acupuncture for acne
Acupuncture is a traditional Chinese treatment often used to relieve
pain. But many people have seen therapeutic effects by using it to
stop smoking, lose weight, and to improve acne. Your chi, or
energy, travels through the body by way of invisible meridians.
Acupuncture works by using tiny needles to stimulate these pathways
at specific pressure points in order to restore the balance
between Yin and Yang.
Tiny sterile needles are inserted into the skin at specific points on
your body. The needle is left in place or stimulated either by
twirling it, by using a heat preparation known as moxa, or by an
electric current. An acupuncturist may also prescribe an herbal
formula for a person to take in addition to the treatment.
Although there have been no well-designed studies evaluating the
use of acupuncture for acne, there have been several reports that
auricular (acupuncture applied to the ear) and electroacupuncture
(acupuncture delivered by an electrical current) therapies may
have lessened the inflammatory component of acne. But, on the
whole, acupuncture is an unproven acne treatment.
Going Natural: Herbs and
Supplements Are All around You
You can find herbs, herbal remedies, and products infused with
herbs just about anywhere these days. Health food stores, drugstores,
your local market, even the cosmetics counter at the
department store all have products that contain herbs and botanicals.
In this section, I help guide you down the road to figuring out
what herbs might actually be helpful for your kind of acne.
If you’re interested in finding out more information about herbs, refer
to Herbal Remedies For Dummies by Christopher Hobbs (Wiley). And
check out the National Center for Complementary and Alternative
Medicine (www.nccam.nih.gov), part of the U.S. National Institutes
of Health, to find out the latest on herbal treatments.
My advice is to not ingest any herb or supplement without first discussing
the matter with a qualified healthcare practitioner. Just
because something is touted as natural doesn’t mean it’s safe.
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Actually, natural means, “occurring in nature.” By the way, cyanide
and arsenic are found in nature and so are hurricanes, earthquakes,
and tornados. So, I’d say that the label natural is virtually
meaningless.
Besides, many of the so-called “natural” products also contain
many other “unnatural” chemicals including preservatives, dyes,
stabilizers, and fragrances. In fact, if a product was truly natural,
you probably wouldn’t want to use it anyway. It might not stay
fresh; it might smell really bad, and it might not penetrate your
skin where it has to do its work.
Fighting bacteria with botanicals
There is a budding interest to study plants that contain antimicrobial
substances that may help eliminate P. acnes (the bacterial
strain associated with acne — see Chapter 3 for its story), thereby
potentially reducing inflammation associated with acne. Here are a
few of the more promising candidates:
Tea tree oil: Tea tree oil (derived from the tea tree plant
native to Australia) has long been regarded as a topical antiseptic
in Australia. A laboratory study found that certain
active components of tea tree oil effectively slow the growth
of P. acnes. The oil’s proponents claim that even severe cases
of acne have been shown to benefit from it.
Green tea cream: This herbal treatment is derived from the
medicinal portion of the green tea leaf. Its advocates believe
that the leaf is as effective as benzoyl peroxide in treating
acne (see Chapter 7 where I talk about benzoyl peroxide).
Calendula: Commonly known as pot marigold, you can buy
this popular ornamental plant for your garden at most nurseries
in the spring. Its orange flowers can be made into tinctures,
lotions, and creams. Acne suffers are encouraged to
wash their skin with tea made from the flowers. If marigolds
don’t clear your acne, try planting them in your backyard.
Reducing inflammation with herbs
The following herbs have been considered to have general antiinflammatory
properties and claims have been made that they may
be helpful in the treatment of acne:
German chamomile
Witch hazel
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Licorice root
Flaxseed and flaxseed oil
Black currant seed oil
Evening primrose oil
Echinacea
Goldenseal
Some herbalists contend that certain compounds can help specific
types of inflammatory acne:
Belladonna: For people who experience flushes of heat to the
face or who have inflamed pustular acne that improves with
cold applications
Hepar sulphur: For painful, pus-filled acne
Kali bromatum: For deep acne, especially on the forehead, in
persons who are chilled and nervous
Silicea: For pustules or pit-forming acne
Herbs can be as toxic and dangerous as prescription drugs!
Herbs at the cosmetic counter
Many cosmetic counters make statements about the botanical and
natural ingredients that are found in their products. A variety of vitamins,
minerals, and herbs can be quite appealing to those who seek
a natural treatment for their acne. Green tea has become a popular
ingredient in many cosmetic and health products: moisturizers,
cleansers, bath products, shampoos, toothpastes, and perfumes.
Finding a professional herbalist
Before ordering a concoction of herbs from the Internet or just
picking up a bottle of herbs off the shelf in a health food store, you
should get advice from a qualified herbalist. As with all alternative
treatments, you should always have a degree of skepticism. But if
you’re interested in finding out more about traditional herbs, you
might ask the people who work in the health food store or check
out some of the following Web sites:
In the United States: www.americanherbalistsguild.com
and www.naturalhealthholistic.com
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In the United Kingdom:
www.ex.ac.uk/phytonet/bhma.html
In Australia: http://nhaa.org.au/
In Canada: www.ccnm.edu/about.html
Going natural with minerals
and vitamins
For those of you who wish to try natural products, the mineral zinc
and the B vitamin nicotinamide both are believed to have antiinflammatory
effects on acne. Their true effectiveness remains to be
proven. Here’s some further info on these possibly helpful items:
Topical zinc is found in certain topical erythromycin ointments.
It is possible, but not entirely clear, that the zinc oxide
contained in the ointment may contribute to the effectiveness
of the product. One such prescription product is Theramycin Z.
Check this out in Chapter 9.
Oral zinc may be an effective treatment for inflammatory
acne. It’s available over the counter.
Zinc may cause an upset stomach and nausea and it may
decrease the absorption of various antibiotics including the
tetracyclines.
Topical vitamin B3 is found in Nicomide-T cream and gel.
They’re both available over the counter.
Oral nicomide, which is available only by prescription, contains
vitamin B3 as well as zinc oxide, cupric oxide, and folic
acid.
Checking Out the Ancient Art
of Ayurveda
Ayurveda is practiced in India and is gaining popularity in the West.
According to Ayurveda, all diseases are caused by poor internal
organ imbalances and an improper diet. Dietary measures using
quality herbs are stressed to reduce the severity of acne and also
to prevent breakouts.
Ayurveda depicts three biological humors or energies called
doshas. The three doshas are called vata, pitta, and kapha. For
good health and well-being to be maintained, the three doshas
Chapter 15: Seeking Alternative Treatments 183
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within you need to be in balance. This means that a person needs
to maintain his original doshic makeup through life as much as
possible to maintain good health. Factors such as the dietary
choices you make and the lifestyle you lead can cause one or more
of the doshas in your prakriti to increase or decrease from its original
level and create an imbalance. If this imbalance isn’t corrected,
you eventually lose your good health. That’s why restoring balance
is the central theme of the ayurvedic approach to health.
According to Ayurveda, acne is caused by the aggravation of all the
three doshas. The primary aggravated dosha, however, is pitta. Pitta
dosha symbolizes heat or fire in the body. Bad food habits such as
eating white flour and white sugar products, and greasy, fried, and
spicy food, together with stress, tension, polluted environments,
and excessive use of chemicals, also aggravate pitta dosha. This
aggravated dosha erupts on the skin as acne and pimples. Dietary
rules are available in detail at www.ayurvedwebline.com.
The following are some suggested Ayurvedic acne home remedies:
Drinking a half a cup of aloe vera juice, twice daily.
Applying a paste of nutmeg and a little water to acne lesions
and affected areas.
Using orange peel face packs. The orange peels are pounded
into a paste with a little water and applied to the affected areas.
Drinking the Sunder Vati herbal preparation that includes
ginger, Holarrhena antidysenterica, Embelia ribes, and Kampo.
Some Ayurvedic herbal products often contain high levels of heavy
metals, which are considered unsafe.
Ayurveda methods have not been scientifically tested, so the jury
is out.
Taking a Deep Breath:
Aromatherapy
Aromatherapy is a branch of herbal medicine. It uses aromatic essential
oils such as jasmine, orange, and rose, which are extracted from
plants. The oils are either inhaled or applied directly on the skin.
They’re supposed to modify the immune system as well as promoting
calmness and a sense of well-being. Aromatherapy has been
reported to be helpful in treating acne, rosacea, and wrinkles
through an ability to harmonize moods and emotions.
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Some of these plant-derived essences are incorporated into bath
products or used for inhalation. For example, ylang-ylang oil,
derived from a fragrant tropical flower, has been used for many
years in the tropics to induce feelings of tranquility and relaxation.
You can expect aromatherapy will smell good and — not much
else! But if stress seems to make your acne worse, I guess you may
see some improvement if you find the smells relaxing.
Considering Homeopathy
The word “homeopathy” comes from the Greek words homoios
(similar) and pathos (disease). The first homeopathic principle
states that anything that is capable of producing symptoms of disease
in a healthy person can cure those symptoms in a sick
person. Homeopathy uses a system that treats a disease by the
administration of minute, micro-dosages of a remedy that would in
large amounts produce symptoms similar to those of the disease.
The following are just a few of the numerous homeopathic treatment
suggestions for acne:
Antimonium tartaricum: This remedy claims to be helpful for
acne with large pustules that are tender to touch.
Calcarea carbonica: This remedy is supposed to help improve
the skin’s resistance to infection, especially in individuals with
frequent pimples and skin eruptions, who get chilly with
clammy hands and feet, are easily tired by exertion, and are
flabby or overweight.
Hepar sulphuris calcareum: This remedy may be indicated
when the skin is easily infected, slow to heal, and painful eruptions
like boils appear. The pimples are very sensitive to
touch and slow to come to a head; eventually, offensivesmelling
pus may form.
Pulsatilla: This remedy can be helpful if acne is worse from
eating rich or fatty foods, and aggravated by warmth or heat.
It is indicated especially around the time of puberty, or when
acne breaks out near menstrual periods.
Silicea (also called Silica): This is intended for a person with
deep-seated acne. Infected spots are slow to come to a head,
and also slow to resolve, so may result in scarring.
Sulphur: This remedy is meant for itching, sore, inflamed
eruptions with reddish or dirty-looking skin.
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You can find these items at your local health food store; select
the remedy that most closely matches your symptoms. Treatment
is taken by mouth in the form of tiny tablets, powder, granules, or
liquids.
There have been few studies examining the effectiveness of specific
homeopathic remedies for acne. Homeopathic remedies are
usually harmless, and its supposed “cures” are probably due to the
natural healing tendencies of our bodies. However, if serious acne
or an illness strikes you, it’s best to see a conventional physician
rather than a homeopath.
Practicing Mind/Body Medicine
Many teens and adults believe that stress can trigger and worsen
acne outbreaks. I talk about stress and its relationship to acne in
Chapter 6. The hormone cortisol, which is released in the body
during stressed or agitated states, has gained widespread attention
as the so-called “stress hormone.” Excesses of this hormone are
believed to worsen acne. If this is so, stress reduction techniques
and relaxation therapies that reduce a person’s cortisol could
prove to be powerful ways to treat acne.
Psychological therapies, meditation, relaxation therapy, hypnosis,
biofeedback, and cognitive imagery have made claims to have
some success in treating acne. Mind/body techniques help to alleviate
feelings of anxiety and depression. The measures described
in the next section rely on the concept of the interconnectedness
of the mind and body. As to whether people experience significant
improvement of skin conditions, such as acne, is debatable.
186 Part III: Turning to the Pros to Treat Your Type of Acne
Homeopathy’s background
This type of medicine was developed in the late 1700s by Samuel Hahnemann, a
German physician. Hahnemann theorized that if large doses of something caused
a healthy person to show symptoms of a disease, then taking mini doses would act
sort of like a vaccine, a harmless “clone” of the illness that might help that person
fight that same disease. He believed that these treatments were intended to “balance”
the body’s “humors” by opposite effects.
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Practicing yoga
Yoga is well known for helping a person deal with stress as well as
creating “balance” in the body. Yoga has been reported to offer
physiological benefits such as normalizing endocrine function,
increasing immunity, and decreasing anxiety.
If you’re interested in yoga, you can look in your phone book under
topics like “yoga, exercise, workout, fitness” and anything else that
seems appropriate to find a yoga class in your area. You can also
look for information at www.yogajournal.com. Or if you’d rather
try it at home first, look for a book or video in your local library. And
definitely check out Yoga For Dummies, by Georg Feuerstein and
Larry Payne (published by Wiley) and the For Dummies yoga DVDs.
Healthy practice . . . yes. Helps to clear acne . . . dubious!
Meditation: Contemplating nothing
Meditation is a way of soothing the body and the mind in a comfortable,
quiet place, allowing troubling thoughts to leave the consciousness.
The key element of meditation is “focusing” on either
something, or nothing. The object is to clear the mind of distracting
thoughts. Millions all over the world use this technique in
order to reduce their stress levels. It’s hard to evaluate results;
however, the price is right! You don’t need to buy anything to try
this out on your own.
Here are some basic instructions for meditating:
1. Find a quiet place to sit comfortably. Use a cushion if
you’d like.
2. Close your eyes.
3. Breathe naturally. Don’t try to breathe extra deeply, or
exhale strongly. Just breathe normally.
4. Gently bring your attention to your breath and begin to
think about something or nothing.
Choose one thing to think about when you’re starting.
Alternately, clear your mind of anything except your own
breathing.
5. Don’t try to control your thoughts. Let them come and go
as they will. But instead of acting on them, just notice
them. Feel sort of detached about them.
Chapter 15: Seeking Alternative Treatments 187
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6. Continue meditating for 20 minutes or so. You may need
to work up to this goal.
7. When you’re done meditating, take about a minute to
slowly return to normal awareness. Open your eyes
slowly and wait a few minutes before standing, just to let
your body return to full awakening.
If you’re interested in finding out more about meditation, look for
Meditation For Dummies by Stephan Bodian (Wiley).
Relaxing . . . yes. Helps to clear your acne . . . doubtful!
Biofeedback and cognitive imagery
Biofeedback is a technique in which an individual is trained to control
certain internal bodily processes that normally occur involuntarily,
such as heart rate and muscle tension. During biofeedback
training, a technician helps a person perform a relaxation technique,
such as guided imagery, while she’s hooked up to monitors
that measure her heart rate and muscle tension. Guided imagery
involves the formation of mental pictures to promote a variety of
favorable physical and emotional effects. This combination of
biofeedback and cognitive imagery allows an individual to visualize
and understand the bodily changes that occur when she changes
from being tense to being relaxed.
There is no reliable scientific evidence that these techniques have
any real impact on acne.
Hypnosis
Hypnosis is sometimes touted as being effective in the treatment
for a variety of skin conditions including acne. As with the other
mind/body techniques described here, hypnosis may also help to
alleviate feelings of anxiety and depression that some individuals
experience with this skin condition. Some researchers speculate
that it can help an individual become more relaxed and, as a result,
may positively influence the activity of hormones and the immune
system (which may contribute to reduced inflammation).
There is no scientific evidence that hypnosis does much for acne.
188 Part III: Turning to the Pros to Treat Your Type of Acne
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Part IV
Dealing with Scars
and Associated
Conditions
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In this part . . .
Igive you tips on how to treat acne scars based on the
kinds of scars you have and the kind of skin you have.
Because acne can be so emotionally devastating, I also
delve into the emotional hurdles that you or your friends
and family have to contend with and how to help avoid,
manage, and prevent them. I then complete the picture
with skin conditions that look like acne — the acne impersonators
such as rosacea and razor bumps. I also tell you
what symptoms may suggest an associated hormonal disorder.
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Chapter 16
Focusing on the
Physical Scars
In This Chapter
Figuring out what kind of scars you have
Looking into whether you want to treat your scars
Treating acne scars
The bad news is that acne can have lingering long-term effects —
it can scar! The good news is that there are lots of ways to stop
acne from scarring, and many of them are presented in this book.
But if you already have scars, I have more good news — something
can be done about them. In this chapter, I delve even more deeply
into the dermatology tool chest in search of some heavy-duty and
“light” tools that may help you with your acne scars.
The treatments described in this chapter are considered to be
“surgical” in nature because they often involve cutting, abrading
moving, building up, and destroying tissue (skin).
Examining Acne Scars
Acne scars are caused by the body’s response — and sometimes,
overresponse — to injury caused by inflammatory acne lesions.
Most often, scarring results from severe nodular acne that occurs
deep in the skin. But, scarring also may arise from more superficial
inflamed lesions.
The term scarring technically refers to a process in which new
collagen is laid down to heal an injury. Collagen is a protein that
gives the skin its rigidity and strength and is produced by skin
cells called fibroblasts. In Chapter 3, I talk about how scars are
formed by collagen.
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192 Part IV: Dealing with Scars and Associated Conditions
Scars can take on a number of different appearances: They may be
flat; or sometimes, fibroblasts may work overtime and produce too
much collagen that results in scars that bulge out like lumps. They
can also form indentations (or pits) when there’s a loss of skin that
is replaced by collagen. Scars can be skin colored, whitish, purple,
red, or even darker than a person’s normal skin color.
There are times when “scars” aren’t really scars. After an acne lesion
has healed or even while healing, it can leave a pink, red, purple, or
a darkly pigmented mark on your skin. These marks are actually
macules, spots that indicate a temporary color change of the skin.
These areas of remaining inflammation or post-inflammatory change
aren’t scars because no permanent change has occurred.
Sometimes, especially in darker-skinned people, the spots tend to
be darker than the normal skin color and they tend to hang around
longer. This is known as postinflammatory hyperpigmentation (PIP),
an after-effect from a healing acne lesion itself. These lesions also
tend to fade in time, unless the pigment winds up deep in the
dermis (dermal melanosis). Dermal melanosis is a type of PIP that
is much harder to treat and may never fade away completely. I
cover PIP and options for stepping up the speed at which these
lesions fade in Chapter 12.
Some people endure their acne scars all their lives with little
change in them. Other people are luckier — their skin improves
and the scars undergo some degree of improvement over time, and
they sometimes transform (remodel) themselves and decrease in
size. I guess time does heal some, if not all, wounds.
I characterize the different types of scars next. Keep in mind that
some people have a combination of different types of scars so that
one treatment may not work on them all.
Pulling in: Scars caused
by loss of tissue
Some acne scars appear as holes, pits, or craters in the skin. Called
atrophic scars or crateriform scars, these depressed, cavity-like,
inward-directed scars are associated with a lack of tissue that
occurs when the inflammation from healed acne causes destruction
to the skin (similar to scars that often result from chickenpox). The
scar tissue contracts and binds the skin down.
Terms and descriptions related to this type of scarring will be helpful
when talking with your dermatologist and reviewing treatment
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Chapter 16: Focusing on the Physical Scars 193
options, because some treatments work better than others for different
scars. Here are some more descriptive names:
Ice-pick scars: These scars are the most common acne scars
that occur on the cheeks. They’re most often small, with a
somewhat jagged edge and steep sides — like wounds from an
ice pick. They can be shallow or deep. Ice-pick scars may
evolve into depressed fibrotic scars over time.
Depressed fibrotic scars: These scars are usually quite large,
with sharp edges and steep sides.
Boxcar scars: These scars are angular and usually occur on
the temple and cheeks, and can be either superficial or deep.
They are similar to chickenpox scars.
Rolling “hill and valley” scars: These scars give the skin a
wavelike appearance. They have gently sloping rolled edges
that merge with normal skin.
Growing out: Collagen running amok
Scars that bulge out and look like lumps are associated with an
exaggerated formation of scar tissue due to excessive amounts of
collagen production. These are the two most common of this type:
Hypertrophic scars: These scars bulge outward like lumps.
Keloids: A keloid is a scar whose size goes far beyond what
would be expected from what seems to be a minor injury. It’s
kind of an “over-scarring.”
You can see examples of both of these scars in the color section
of this book. Both hypertrophic scars and keloids occur more
commonly in dark-skinned individuals. They also tend to run in
families — that is, growth of scar tissue is more likely to occur in
people whose relatives have similar types of scars.
These scars persist for years, but may diminish in size over time.
They’re notoriously difficult to treat and impossible to completely
eradicate. A single, optimal treatment technique for hypertrophic
scars and keloids hasn’t been developed, and the recurrence rate
of these scars after treatment is high.
Surgical management is reserved for cases that are unresponsive to
a conservative treatment, such as injecting cortisone into the scars
themselves. The cortisone injections often help to shrink thickened,
raised scar tissue. This procedure is similar to the procedure that is
used to treat acne nodules that I explain in Chapter 10. Surgical
treatment is a last resort because any person whose skin has a
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tendency to form these types of scars from acne damage may also
form larger scars in response to any type of aggressive skin surgery.
In some cases, the best treatment for keloids in a person who is
highly likely to develop them is no treatment at all.
Certain lasers as well as intense pulsed light (IPL) devices that I
describe in Chapter 14 may prove to be effective for these stubborn
scars, but long-term studies are necessary to see how effective
they will prove to be.
Taking Initial Treatment Steps
The oral and topical treatments used to treat acne don’t do very
much to improve the appearance of acne scars. However, dermatologists
and plastic surgeons do offer a number of treatment
options if you have scars. The type of treatment you decide upon
should be the one that is best for you in terms of your type of skin,
the cost of the treatment, and what you want it to accomplish.
Deciding whether you want
to do anything about it
A decision to seek treatment for acne scars, and the specific treatments
that you may choose, depend on a number of factors that
you and your doctor can discuss and weigh:
How do you feel about your scars? You may have scars and
could care less about them or they may be psychologically
distressing to you. Do the scars emotionally affect your life?
Are you willing to live with your scars and wait for them to
fade over time?
What’s your age, overall health, and medical history? If
you’re a teenager or healthy adult, you’d probably want to
wait until your acne is no longer active. If you’re an adult or
senior who has medical problems and are taking several medications,
consult with your primary care provider before
embarking on any surgical procedure.
How bad are your scars? Are they disfiguring? The severity
of the scars can affect whether you’re willing to go through
treatment.
What kind of scars do you have? Some scars respond more
readily to treatment, and others, like keloids, indicate that
treatment could actually cause more scarring.
194 Part IV: Dealing with Scars and Associated Conditions
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What’s your doctor’s opinion? An expert opinion as to
whether scar treatment is justified in your particular case may
help you decide upon the most effective treatment for you.
What do you want to accomplish? Maybe you just want to
diminish the appearance of deep scars or maybe you’re trying
out for a part in a feature film.
How will you pay for treatment? Get a handle on your
finances and insurance coverage before you make any decisions.
You need to determine the costs that you’ll have to pay
out of pocket and whether you can afford to do so. A significant
investment of time and money is often needed.
Most of these procedures aren’t covered by health insurance
plans because they’re generally considered to be cosmetic in
nature. It may go without saying, but I’ll say it anyway:
They’re all pretty expensive. Just to give you an idea, a laser
skin resurfacing can cost from $4,000 to $5,000 or more!
Also be aware that acne scars are particularly difficult to treat and
they can’t always be effectively corrected by one single treatment
method. In fact, using more than one method may yield better
results. Before committing to treatment of acne scars, you should
have a discussion with your doctor.
Finding a physician
When you turn your attention to the treatment of acne scars, it’s
especially important that you find a doctor who is trained and
experienced in the procedures that I describe in this chapter, for a
number of reasons:
Many of the treatments have sometimes been offered by inadequately
trained practitioners, sometimes with devastating,
disfiguring results.
Some of the treatments may result in more scarring if you
have a propensity to develop hypertrophic scars or keloids.
You need a reputable, experienced physician to help you
weigh the pros and cons with this type of scarring.
With the exception of microdermabrasion and most chemical
peels, which can be performed by a physician, nurse, or licensed
aesthetician, the procedures described in this chapter are performed
by a dermatologist or plastic surgeon in her office.
Chapter 16: Focusing on the Physical Scars 195
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If your doctor or dermatologist doesn’t treat acne scars, check out
Chapter 8 where I tell you how to find a dermatologist who does.
You can also go to the Web sites of The American Academy of
Dermatology (www.aad.org) and The American Society for
Dermatologic Surgeons (www.asds-net.org). These sites can
help you locate a dermatologist who has specialized training in
cosmetic and other types of skin surgery.
To find a plastic surgeon who performs these procedures, visit the
online referral service of the American Society of Plastic Surgeons
(ASPS) at www.plasticsurgery.org. This is the largest plastic
surgery organization in the world and the foremost authority on
cosmetic and reconstructive plastic surgery. (Check out Chapter
21 for more online resources.)
Treating Your Scars
Don’t start any treatment for scarring until your acne is completely
gone and unlikely to come back. If you go to all the trouble and
expense to undergo a procedure (or multiple procedures) and then
get more acne, and thus more scarring, you have to go through it
all again. Just imagine how expensive that would be!
Skin resurfacing techniques (like dermabrasion), surgical excision,
and fillers have been used to diminish acne scarring for years with
mixed results. Currently, laser therapy has assumed a more important
role in the treatment of acne scars, and other newer surgical
methods featuring light and radio waves are an option to treat
your acne.
Most scar treatment focuses on facial scars. Generally, scars on
the chest and back don’t respond as well to the treatments mentioned
hereafter. Because these scars are so hard to treat, the best
approach is to try to prevent them in the first place. If the prevention
route fails, the intralesional cortisone (steroid) injections that
I describe in the “Growing out: Collagen running amok” section,
earlier in the chapter, may help to shrink them.
One remnant of the recent past in treating acne scars is the chemical
acid peel. Peels are sometimes used in the treatment of acne
and dark spots (see Chapter 13), and you may still hear about
them in conjunction with treating shallow acne scars. But, for the
most part, the results of chemical peels in treating scars are disappointing,
and the method has been replaced by others, notably
lasers, that I discuss.
196 Part IV: Dealing with Scars and Associated Conditions
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Laser skin resurfacing
There are many types of lasers and there are a number of new procedures
now available that complement or even surpass previous
scar revision techniques such as those that I describe later in the
chapter. Treatment with some of these devices can be used to help
improve and treat acne itself (see Chapter 14 where I discuss other
types of lasers that treat acne in more detail), and as a simultaneous
benefit, they can stimulate collagen remodeling and result in
the improvement of the appearance of acne scars.
Laser resurfacing can result in uneven skin tones in people with
darker skin.
Treatment with laser resurfacing takes place in an office setting.
Typically three sessions are performed. For a “full-face” resurfacing,
the cost can be $3,000 to $8,000 and up!
Sometimes, laser resurfacing and other surgical treatments
(described in the “Considering other surgical treatment options”
section) for acne scars are combined. The surgical treatment is
usually completed 6 to 12 weeks before the laser is called into
action. This waiting period gives your skin time to heal and
remodel itself.
The two major categories of lasers that are used in acne scar therapy
are the resurfacing (ablative) lasers and the non-ablative lasers.
Ablative lasers
The powerful ablative lasers literally remove the outer layers of
the skin by using high-energy light to burn away scar tissue, and
stimulate the dermal collagen to tighten, reducing the amount of
scar visibility.
This procedure is used for deeper scars and carries the risk of further
scarring. Because the skin is injured and unprotected tissue is
exposed, great effort must be put into post-operative wound care
and infection prevention. The skin may remain reddened for several
months or a year afterwards.
Non-ablative lasers
At first, ablative lasers were used to recontour or vaporize the skin’s
surface. Now, techniques involving non-ablative lasers have taken
over because of their ability to promote collagen growth beneath an
acne scar without creating an external injury. The non-ablative
lasers produce a controlled injury to certain target structures in the
dermis, while completely sparing the epidermis from damage.
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The laser beams can penetrate into the dermis without injuring the
epidermis. By heating dermal collagen, they help to “tighten” the
dermis and result in less visible scarring. The theory is that the thermal
injury caused by the laser triggers a wound repair response,
including fibroblast activation and new collagen formation.
Non-ablative laser resurfacing can be effective for treating shallow
boxcar scars, as well as for smoothing and tightening scars that
have been treated previously. It is not very effective for deep,
depressed, craterlike scars.
A topical anesthetic is applied by a doctor or his medical assistant
about an hour before performing these procedures to make the pain
tolerable. The surface of the skin is cooled to prevent the laser from
damaging the epidermis. A patient will feel both the cold spray as
well as some amount of stinging and heat during the session.
198 Part IV: Dealing with Scars and Associated Conditions
Shooting scars
Non-ablative lasers include:
InfraRed Lasers produce invisible light. They’re most commonly used for thermally
induced dermal remodeling and use water as their targets. They are minimally
absorbed by melanin, the epidermal skin pigment, which makes them
suitable for all skin types. These lasers use aggressive skin cooling to limit the
heating effect, creating a controlled injury to the dermal collagen, with subsequent
remodeling and tightening.
N-Lite Laser is another non-ablative laser. It is now being used to trigger collagen
formation.
Sprinkling laser beams: A kinder, gentler laser is now available. This latest laser
is called the Fraxel laser. Unlike older lasers, which shoot a single solid beam
of light, the Fraxel laser shoots out tiny clusters of beams that burn the skin in
patterns of dots. It burns away old skin cells and spurs the growth of new cells
and stimulates the production of collagen that, in time, tends to “fill the dots”
and smooth out the skin.
The theory behind this is that such “fractional” treatment allows the skin to heal
much faster than if the entire area were treated at once, using the body’s natural
healing process to create new, healthy tissue to replace skin imperfections.
There is less injury to the skin with this method and less downtime compared
with the older lasers, and there’s minimal discomfort as compared to the ablative
lasers.
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Considering other surgical
treatment options
Atrophic scars, such as ice-pick scars, boxcar scars, and small
depressed fibrotic scars, may be removed or improved by a punch
excision of each individual scar.
Excising scars: When zits are literally the pits
In this procedure, each scar is cut down to the layer of subcutaneous
fat; the resulting hole in the skin may be repaired with
sutures or with a small skin graft. Alternatively, the punch may
simply be elevated. There are three techniques:
Punch excision: Your doctor removes the pitted scar with a
cookie-cutter-like tool that punches out small portions of skin.
The surrounding healthy skin is joined together by suturing.
Punch replacement: As with the punch excision, the scar is
removed and then replaced with a skin graft of unscarred
skin, usually harvested from behind the ear. This method is
usually the most successful for treating deep scars.
Punch elevation: Here the scar is punched out, but not discarded.
It is allowed to float up to the level of surrounding
skin.
Your dermatologic or plastic surgeon may allow the scar from
punch techniques to fade on its own. Or she may perform the procedure
before a more generalized resurfacing technique such as
laser resurfacing is performed. Less commonly, dermabrasion,
microdermabrasion, and chemical peels are sometimes used in
conjunction with punch techniques.
The prices of these procedures vary and depend upon the number
of grafts or punches that are done. Punch grafting can run $50 to
$150 per graft or $1,000 to $2,500 per session.
Subscising scars
Subcision helps to restructure and remodel scar tissue by breaking
fibrous bands that are creating tension between the epidermis and
deeper structures. It also helps induce new collagen formation. This
method is useful for indented, rolling scars that result from scar
tissue holding the skin down. This is a very specialized procedure
that is performed by a qualified dermatologic or plastic surgeon.
To perform this technique, a sharp instrument such as a tiny
scalpel or needle is used to undercut and lift the scar tissue away
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from unscarred skin, elevating the skin to make it even. The subscising
procedure breaks down adhesions (old bands of scar
tissue), which helps to reorganize the formation of new collagen
and elastic tissue for a smoother skin surface. The overlying skin
isn’t cut, so sutures aren’t needed.
This breaking down of scar tissue helps to level the playing field.
After the wounds heal, an injection with a filler material under the
scar can help to replace any remaining defects and bring them to
surface level. The filler can be made of one’s own fat or a collagen
or other synthetic substance that I describe in the section
“Contouring the defects: Fill ’er up!”
The procedure can cost between $200 and $1,000 depending on the
number of lesions treated.
Contouring the defects: Fill ’er up!
Another option for improving the appearance of certain acne scars
is known as soft tissue augmentation. These procedures have a very
limited use, and at most, they can help with some of the shallow
“hill and valley” soft scars with gentle sloping edges. They don’t
work well for ice-pick, deep boxcar, or depressed fibrotic scars.
Materials, including your own fat, can be injected into the depressed
area of the scar to elevate it to the level of the normal surrounding
skin. The material is injected under the skin to stretch and fill out
superficial and deep “soft” scars. Many substances are available and
many new ones continue to be introduced. Most doctors have a variety
of fillers to choose from, including the following:
Collagen: Collagen injections are intended to replenish your
natural collagen and minimize surface unevenness by lifting
and filling depressed lines and scars. The original bovine collagens
Zyplast and Zyderm can’t be used in people with
autoimmune diseases. Skin testing to look for possible allergic
reactions is necessary before they’re injected.
The newer human-derived collagen products such as
Cosmoderm and Cosmoplast offer alternatives to those who
are allergic to the bovine derived collagen. No skin testing is
required with these agents.
Collagen injections are temporary, and last about six months
(give or take a few months), so ongoing touch-ups are
necessary.
Fat: To correct deeper defects caused by scarring from nodular
acne, fat transplantation utilizes your own fat. The fat is
taken from another site on your own body and injected
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beneath the surface of the skin to elevate depressed scars.
Because the fat is reabsorbed into the skin over a period of 6
to 18 months, the procedure usually must be repeated.
Newer fillers: There has been an increase in the number and
quality of filler substances used to help plump up acne scars.
Restylane and Hylaform are now available and there are many
more to come. Longer-lasting results are expected from these
materials.
Unless the borders of atrophic scars are soft, there is little place
for fillers in the treatment of acne scars. They’re probably best
used as a complementary procedure with other surgical treatments
described in this chapter. Depending on the type and
amount of filler used, treatment can cost between $400 and $750
and $1,000 and $1,200.
Trying out dermabrasion
Before there were lasers, superficial acne scars were smoothed out
with a procedure known as dermabrasion. Dermabrasion was used
to minimize small acne scars. As the name implies, dermabrasion
involves removing the top layers of skin.
Dermabrasion has been around for many decades. Initially, sandpaper
was used to remove damaged skin and allow new skin to grow
in its place — yes, I’m serious. But now, electrical machines are
used to abrade the skin. These gadgets have quickly rotating
wheels that have a rough wire brush (fraise), or a burr containing
diamond particles. The wheel is attached to a motorized handle.
Dermabrasion may make ice-pick scars and depressed fibrotic
scars more noticeable if the scars are wider under the skin than at
the surface. Dermabrasion is used mainly for the “softer” scars. It’s
rarely used for hypertrophic scars. Over the past decade, this procedure
has fallen out of favor with the availability of newer, easierto-
use techniques such as lasers. I no longer recommend it.
A qualified dermatologic or plastic surgeon performs dermabrasion
on a single visit as an office procedure. First she anesthetizes
your skin with a numbing spray, such a Freon. You may also be
given a sedative to make you drowsy before she sheers away your
scar tissue. A full-face dermabrasion can be as costly as a laser
resurfacing procedure. It can cost $2,500 to $4,500.
In darker-skinned people, dermabrasion may cause dramatic
changes in pigmentation and worsen hypertrophic or keloidal scars.
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Vacuuming your skin:
Microdermabrasion
This technique is a surface form of dermabrasion. I call it “dermabrasion
lite.” Rather than a high-speed brush, microdermabrasion
uses aluminum oxide crystals passing through a vacuum tube
to remove surface skin. The crystals are literally blasted onto the
skin and then vacuumed away accompanied by surface skin cells.
Microdermabrasion can be performed by anybody — your Aunt
Gertrude, a physician, a nurse, or an aesthetician.
At most, microdermabrasion is effective in reducing fine lines,
“crow’s feet,” and age spots, but this treatment isn’t effective for
diminishing acne scars. That’s because only the very surface cells
of the skin are removed and a mild exfoliation takes place.
Microdermabrasion runs from $150 to $300 per treatment.
Dermabrasion may result in pigmentary streaking in people with
dark skin types. If you have dark skin, make sure your doctor has
extensive experience (and success) at treating others with your
skin type.
Considering emerging technologies
Many technologies that were initially developed as anti-aging wrinkle
treatments are now becoming useful in treating the scars associated
with acne, including radio waves. This novel treatment,
referred to by the brand name Thermage, uses radiofrequency (RF)
emissions to deliver controlled amounts of energy (heat) into the
collagen layers of the skin. It has a cooled application tip to protect
the epidermis from heating up. It’s supposed to penetrate deeper
in the skin than other methods and cause thermal injury to sebaceous
glands. Currently, it’s being used to tighten the skin as a noninvasive
face-lift. More research is needed to see if it works on acne
and acne scars. The procedure can cost between $2,000 and
$5,000. See Chapter 14.
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Chapter 17
Coping with the
Psychological Scars
In This Chapter
Feeling the emotional effects of acne
Becoming alerted to signs of depression
Considering therapy
The psychological impact of acne can lead you to feelings of
diminished self-esteem and be a source of anxiety when it
comes to dealing with the world. If you’re a teen with acne, you
may have been told, “It’s no big deal, and anyway, you’ll grow out
of it. You’re just experiencing a normal part of life.” But to you,
having acne is a big deal; you feel insecure and lack self confidence.
Every day you have to deal with school and other kids who
seem perfect (even if they’re not). You don’t feel like you have time
to “grow out of it.”
The truth is that many folks don’t “just grow out of” acne and
others wind up growing into it. And if you’re an adult, you don’t
even get the benefit of having lots of other peers around in the
same boat. You have a whole different set of stressors (job interviews,
presentations, black tie events, and carpools) associated
with your acne. And darn it, you thought you were past this stage
anyway.
The main thing to remember, whatever age you are, is that acne is
treatable. (Take a look at Chapters 7 through 15 to find just the
right way to treat your acne.) In this chapter, I talk about ways to
deal with the invisible scars that some people carry around with
them — the ones that are carried on the inside. Although most
other people see acne only on the surface, the burden goes much
deeper.
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Facing Acne Can Be Tough — But
You Can Do It
Our society places a great emphasis on physical appearance. In a
culture where looks are overly emphasized, feeling good about
yourself is easier said than done. We’re constantly bombarded with
advertising that displays models and movie stars, all of whom are
depicted as paragons of beauty and flawless perfection. They often
serve as the spokespeople for health and beauty aids that imply
that you can look like them if you “get with it” and do what they do
or buy the products they’re promoting.
When you see media portrayals of all those people with perfect
skin, just remember that almost all of those photos are touched-up
and airbrushed. Some of the models even have acne, just like you!
Even mild cases of acne can leave a person with a negative
self-image — sometimes well beyond the degree of the actual physical
appearance. These negative feelings are particularly prevalent
when you have a concentration of lesions on your face, which is
your greeting card and introduction to the world. Unlike many
other skin conditions, acne lesions wind up on areas that often
aren’t concealed by clothing.
Acne is often a source of anxiety that can impact your self-image
and confidence. Some of the things you might be experiencing are:
Feeling uncomfortable in social settings
Having less self-confidence
Becoming more preoccupied with your appearance
Feeling like you’re trapped in a perpetual adolescence
Being sad and sometimes getting depressed (see the following
sections)
These negative effects and feelings can put pressures on your
social, work, or school life.
Here are some suggestions that you can use to cope with some of
these negative feelings:
Wash your face no more than two to three times a day (unless
you’re a coal miner!). Check out Chapter 2 for my face washing
tips.
Get a new haircut or hairstyle (bangs are great!).
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Spruce up your wardrobe.
Educate yourself. Read about acne in this or other sources.
Find the right dermatologist or healthcare provider to treat
your acne. (In Chapter 8, I tell you how to go about it.)
Here are some tips for if and when you start undergoing treatment:
Stand at least two feet away from all mirrors for the next two
months.
Measure progress monthly instead of daily; be a patient
patient!
Take a picture of your acne when it’s at its very worst. Put the
picture in your bottom drawer and don’t look at it for two
months, because that’s how long it may take to see significant
improvement.
Be sure you know the names of and exactly how to use your
acne medications. (I spell out all of this information in
Chapters 7 through 13).
If you’re still feeling emotionally overwhelmed and possibly
depressed, see the next section.
Detecting Depression in Yourself
and Your Family
It’s very normal for people with severe acne to feel down and
despondent; even mild acne can give you the blues. However, if
you or someone in your family is feeling unhappy more often and
doesn’t seem to enjoy anything anymore, you need to consider the
possibility that you or that person may be suffering from depression.
Here are some of the signs of depression:
Increased fatigue, low energy
Feelings of pessimism
Loss of enjoyment in things that previously gave pleasure
Crying spells
Sleep disturbances
Hating to get out of bed
Social isolation
Loss of appetite or the opposite
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Lots of new physical complaints
Decrease in sexual drive
Irritability, anger, or aggressiveness
Feelings of worthlessness and guilt
Withdraw from family and friends
Suicidal thoughts
If one or more of these descriptions rings a bell, talk to your doctor
about it. If you or your loved one is having suicidal thoughts, seek
immediate evaluation and treatment.
Helping Your Child Deal with Acne
Acne affects adolescents at a time when they’re developing their
personalities and evolving into adulthood. During this time, peer
acceptance is very important to them and physical appearance
and attractiveness is highly associated with peer status. Besides
the physical scars that severe acne can produce, your teen may
also be suffering emotionally.
Acne can be a real drag on a kid’s daily life. Acne on the face can
bring out cruel taunts, teasing, and name calling from other kids.
Some kids become so preoccupied with how their skin looks, that
they may not want to go to school, lose self-confidence, pull away
from their friends, show a dramatic change in their thinking and
behavior, become withdrawn, and even may begin to feel depressed.
The following list goes over some of the various teenage behaviors
and coping mechanisms that they may develop to deal with acne:
Grow their hair long to cover their face.
Become so embarrassed that they avoid eye contact.
“Cake on” heavy makeup to hide the pimples.
Lose interest in sports such as swimming or basketball
because of the need to undress in locker rooms and expose
their back and chests.
Become shy and even isolated and prefer to stay in their
bedrooms.
Start to develop any of the symptoms of depression from the
list in the “Detecting depression in teens” section.
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Offering your help
Here are a few seemingly simple, yet effective, ways to communicate
your willingness to help:
Let your children know how much you care: Give your child
adequate time to bring up the subjects of their acne and allow
them to address or respond to your questions about the
behavioral changes you’ve noticed.
Listen patiently: They may want to communicate their feelings
but have difficulty doing so. Think back to your own teen
years. You may not have always felt like it was easy to be open
about your thoughts and feelings.
Don’t be overly judgmental about your child’s appearance:
Approach the subject of acne in a gentle, caring manner and
try to give a little space when it comes to some of the relatively
harmless decisions they make about their clothing and
grooming habits.
Keep the lines of communication open: Take the time to pay
undivided attention to your kid’s concerns. It’s important to
keep the lines of communication open, even if your child
seems to want to withdraw.
Don’t lecture on the subject: Try to avoid telling your child
what to do. Instead, pay careful attention and you may discover
more about the issues causing his problems.
Detecting depression in teens
It is common for adolescents — or anybody for that matter — to
occasionally feel unhappy. However, when the unhappiness lasts for
more than two weeks, and the teen experiences other symptoms,
then he may be suffering from depression. Determining if a teenager
is depressed can be a very tricky undertaking. Dramatic physical
and mental changes seem to take place almost overnight and it
sometimes seems hard to tell the “normal” from the “abnormal.”
Depression is a more commonly recognized condition in adolescents
than it had been in the past. Parents should look for common
signs of depression in adolescents and they should be dealt with in
a serious manner and not just passed off as “growing pains” or the
normal consequence of adolescence. If you observe some of the
signs or behaviors listed in the following bulleted list, they may be
indicators of depression. They’re not always diagnostic of teen
depression; however, they may indicate other psychological,
social, family, or school problems. Among these are:
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Sadness, anxiety, or a feeling of hopelessness
A sudden drop in grades
Loss of interest in food or compulsive overeating that results
in rapid weight loss or gain
Staying awake at night and sleeping during the day
Withdrawal from friends
Unusual irritability, rebellious behavior, or cutting school
Physical complaints, such as headaches, stomachaches, low
back pain, or excessive fatigue
Use of alcohol or drugs
Promiscuous sexual activity
A preoccupation with death and dying
Don’t be afraid to talk to your child about feelings. If you sense a
change or that something is seriously troubling your child, you
may be right. You can even ask about suicidal thoughts. You won’t
increase the possibility of suicidal behavior by asking if someone
has thought about it. Asking such a question does not “put
thoughts into their heads” but rather is more likely to identify if
they may be at risk.
If you or your loved one is finding it extremely difficult or impossible
to handle the emotional aspects of acne, get help. And, if you
don’t feel that you can communicate effectively with your adolescent,
get help. Talk to your pediatrician or primary care practitioner
or ask for a referral for counseling. Strong suicidal thoughts
are an emergency and call for immediate action. Don’t go it alone.
Accutane and depression:
Is there a link?
For several years, there has been debate over whether Accutane
(isotretinoin), a drug prescribed for serious cases of acne, could be
causing depression that results in suicide in teenagers taking this
powerful medication. Turn to Chapter 13, where I take on this controversial
debate about this drug and its generic formulations.
Lots of kids with acne who have never taken Accutane are
depressed. Moreover, since Accutane was introduced in 1982, it’s
likely that depression during this time has decreased in those who
sorely needed the drug and were successfully treated with it.
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Chapter 17: Coping with the Psychological Scars 209
Recognizing acne as a feature
of emotional disorders
When self-esteem and self-image become an overwhelming preoccupation in some
people, they may show signs and symptoms of types of acne that have severe
underlying emotional and psychiatric underpinnings.
Acne excorieé. This is a self-inflicted skin condition in which the sufferer has a
compulsive, irresistible urge to manipulate their skin and to pick real, as well as
imagined, acne lesions. This results in a worsening of acne and sometimes scarring
of the face. Also known as acne excorieé des jeunes filles, this type of acne
is almost invariably seen in young females. Jeunes filles means “young girls” in
French, but this condition is also seen in adult women (and males aren’t immune).
Many of these females deny that they manipulate their skin, but it’s rather obvious
when you can see scabs that are almost always present on their faces. It’s
assumed that they have an underlying obsessive-compulsive disorder, a type
of emotional problem characterized by persistent thoughts and ideas and repetitive
behavior.
Body Dysmorphic Disorder (BDD). This psychiatric condition is characterized
by a fixation and chronic complaining about a nonexistent or minimal cosmetic
defect or minor flaw in one’s physical appearance. The “flaw” can be wrinkles,
large pores, or just a few pimples. The person with BDD exhibits an unreasonable
amount of anguish about them. BDD occurs equally in males and females.
BDD often results in significant suffering and social difficulties. Individuals with
BDD have variable degrees of awareness concerning the psychiatric nature of
the illness. Many people continue to agonize about an imagined defect although
they’re aware that their concerns are excessive, while other folks have no insight
into their unusual preoccupation with their appearance. Some people with BDD
frequently develop major depressive episodes and are at risk for suicide.
Treating acne excoriée and BDD is a major challenge. Certain medications and
cognitive-behavior therapies can complement each other and be helpful for some
people. Cognitive-behavior therapy involves discovering, challenging, and changing
the underlying negative thoughts and beliefs that the people with these conditions
repetitively dwell upon.
In addition to these treatments, family education and counseling, to help family
members understand what’s going on and how to help the sufferer, and group therapy
may be of benefit. Unfortunately, individuals with acne excoriée and BDD often
refuse psychiatric referral because of their poor insight into the underlying psychiatric
illness.
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Thinking about Therapy
Your dermatologist, internist, pediatrician, school nurse, school
counselor, or other healthcare provider may be able to steer you in
the right direction and find someone who can help you or your
child contend with some of these emotional issues while they work
on the physical ones.
The good news is that the vast majority of people suffering from
depression can be treated successfully. Speak to your doctor about
the way you feel and ask her to treat you or your child or to make a
referral to a psychologist or psychiatrist.
Ideally, you or your child’s primary care provider or psychotherapist
should maintain a close relationship with your dermatologist
so that they can discuss treatment and any changes in medications,
and so on.
There are many types of psychotherapy and psychotherapists. You
can choose from:
Psychiatrists: They are medical doctors and are able to prescribe
prescription medications, if required.
Clinical psychologists: They usually have a master’s or doctoral
degree in psychology.
Psychiatric social workers: To become qualified as a social
worker that provides psychotherapy, a person must have
earned a minimum of a master’s degree in clinical social work.
Counselors: Generally, they may have only a bachelor’s
degree in education, psychology, or theology.
Some dermatologists, albeit few and far between, are capable of
handling both the physical and emotional consequences of acne.
Several of my colleagues have been trained as dermatologists as
well as psychologists and psychiatrists. If you’re fortunate to have
access to any of these specialists, go for it!
Avoid quick fixes promised by audio and videotapes or books. You
can’t find true “quickie cures” for acne or for its emotional components.
Both sets of symptoms require time and patience.
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Chapter 18
Reining in Rosacea and Other
Acne Look-Alikes
In This Chapter
Understanding rosacea
Contemplating the causes of rosacea
Treating rosacea with topical medication
Adding oral medication to your regimen
Covering up and correcting the redness
Introducing the other acne foolers
A33-year-old woman entered my office in tears. Her face and
nose were red as a beet and she had red pimples on her chin,
cheeks, and forehead. “Not only do I look horrible, but when
people look at me, I’m sure they think I’m an alcoholic! I’ve always
had perfectly clear skin; I didn’t even have a pimple when I was a
teenager,” she said. “I can’t cover it with makeup and I hate to
leave the house!”
She said that her problem started about a year before when she
first noticed a tendency to flush and blush more readily than usual.
In time, her face became persistently red, and then she started getting
pimples and visible blood vessels on her cheeks, forehead,
chin, and nose. It was an easy diagnosis for me to make: She had all
the signs and symptoms of rosacea!
Rosacea (pronounced rose-ay-shah) is a common skin disorder
that is frequently mistaken for acne. In fact, as recently as 20 years
ago, rosacea was referred to as acne rosacea. In this chapter, I give
you details about what rosacea is, how to treat it, and how to
cover it up while you’re waiting for it to clear up. I also help you
figure out what conditions aren’t rosacea even though they may
look like it.
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Rosacea 101
It’s easy to understand why rosacea was called “acne rosacea” for
so many years, because rosacea and acne look so much alike.
They both have red papules and pustules and, of course, appear
on the face.
Rosacea occurs at a time in adults’ lives when they don’t expect to
have to deal with pimples and the flushing and blushing reactions
of the condition. For adults in the prime years of their careers, the
psychological effects of rosacea can pose problems. (In Chapter 17,
I cover the emotional tolls that affect some people who have acne.
It seems that rosacea can have a similar psychological impact on
people’s lives.)
However, just as with teenage acne, it’s important as an adult to
continually remind yourself of an important fact: Your rosacea is
treatable and your emotional well-being will improve following successful
treatment. Later in this chapter, I show you the many methods
that are available to treat your rosacea.
Describing those affected
Anyone can develop rosacea. However, people from certain ethnic
backgrounds are most likely to get it. If you have fair skin and have
ancestors hailing from Great Britain (including Ireland, Scotland,
and Wales), Germany, and Scandinavia, or certain areas of Eastern
Europe, you have the greatest tendency to have rosacea. The condition
is rare in Hispanic, African, and African-American populations
along with other dark-skinned people.
Women are affected with rosacea two to three times more often
than men. And if you’re between 30 and 50 years of age, have fair
skin, blonde hair, blue eyes, and have the proper hereditary pedigree,
you’re in the higher-risk group to develop rosacea. (For more
on the causes, see the “So, what causes rosacea?” section, later in
the chapter.)
Heredity plays the major role in whether you develop rosacea. If
you flush or blush easily and have a family member who has been
diagnosed with rosacea, you’re at greater risk for getting it.
Reporting the signs and symptoms
Rosacea may first appear as erythema (redness of the skin) on
your cheeks and forehead that later spreads to your nose and chin.
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These areas comprise the central one-third of the face. Very often,
people who have rosacea describe how they’re inclined to flush
and blush easily. This condition occurs whenever a blood vessel
dilates (widens). When the blood vessel dilates, it then contains a
greater volume of blood, which produces redness. When a person
develops persistent erythema (abnormal redness), the condition
usually doesn’t go away on its own.
As rosacea progresses, three main lesions arise against the background
of erythema — two of which are very similar and generally
indistinguishable in appearance from the acne lesions I cover in
Chapter 3. However, they look different when examined by a microscope.
The three main rosacea lesions are
Telangiectasias: Many people refer to telangiectasias (tell-anjek-
tay-shas) as broken blood vessels, but there’s nothing
broken about them. They’re actually enlarged blood vessels
that look like thin red lines on the face, especially on the
cheeks. Sometimes the tiny vessels look like the shape of a
spider (spider telangiectasias). Telangiectasias can be more
than “tiny” in some folks. I explain their treatment in the
“Managing the Redness” section, at the end of this chapter.
Papules: These tiny red pimples appear as small, firm, red
bumps. Papules are the primary inflammatory lesion in
rosacea.
Pustules: These are mature papules that contain visible
pus. Pustules are generally found in the company of papules.
Papules are also inflammatory lesions, but they’re not as
common as papules in rosacea.
The papules and pustules tend to come and go, but the telangiectasias
stay put. Rosacea lesions tend to be spread symmetrically
on the face, but on occasion, the lesions may occur on only one
side of a person’s face. Take a look at the color section in this book
to see what typical rosacea looks like.
Rosacea is typically a longer lasting condition than acne vulgaris
(teenage acne) and adult-onset acne (I talk about them in Chapter
4 and 5, respectively) because it can go on and on through one’s
adult life. Rosacea also requires somewhat different therapy than
acne. The good news is that rosacea is generally easier to treat
than are most cases of acne, and I detail the many effective treatments
that are available later in this chapter.
Chapter 18: Reining in Rosacea and Other Acne Look-Alikes 213
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Addressing additional
signs and symptoms
Lesions of rosacea are most typically seen on the central third of
the face — the forehead, the lower half of the nose, the cheeks, and
chin. However, additional rosacea-related problems involving the
eyes and nose may occur.
The eyes have it: Ocular rosacea
Like acne, for the most part, rosacea is a cosmetic problem; however,
some people who have rosacea may also have eye involvement,
known as ocular rosacea. Ocular rosacea is most frequently noted
when rosacea of the skin is also present; however, eye symptoms
may precede the skin manifestations in up to 20 percent of people.
The eyes of patients with ocular rosacea may:
Feel irritated and gritty as if there is something in their eyes
Tend to look bloodshot
Become overly sensitive to light
If you have these symptoms, you should consult your doctor or an
ophthalmologist (a medical doctor that specializes in eye disorders)
to establish the correct diagnosis and to get appropriate therapy.
Sometimes, the use of prescription eye drops will help improve
ocular rosacea, and sometimes, oral antibiotics are prescribed to
treat it.
Many people who have ocular rosacea mistakenly think they have
pollen or other airborne allergies.
The nose has it: Rhinophyma
Rhinophyma (rye-no-fie-mah) can be an unsightly manifestation of
rosacea (see the color section of this book). Rhinophyma occurs
when oil glands enlarge and a bulbous, red nose develops. This condition
usually occurs in men over 40. It consists of knobby bumps
that tend, over time, to get larger and swollen. It is quite uncommon
and is rarely seen in women. In jolly old England, this type of nose
was referred to as “drinker’s nose” or “grog blossoms.”
The usual treatments that are described in this chapter to treat
rosacea don’t work very well on rhinophyma, but it can be successfully
treated with surgery and special lasers that I tell you
about in the “Going the surgical route for rhinophyma,” section,
later in this chapter.
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Comparing the appearance to acne
Despite their similarities, rosacea is different from acne vulgaris
and adult-onset acne in many ways. Rosacea
Lacks the mature comedones (blackheads and whiteheads)
seen in acne vulgaris. Lesions are generally small, pimple-like
bumps and telangiectasias (tiny, visible blood vessels in the
surface of the skin); in contrast, acne lesions are varied and
may include comedones, as well as small or large nodules and
cysts, but no telangiectasias.
Doesn’t seem to have a hormonal connection. The microcomedo,
the primary lesion of acne vulgaris that I describe in
Chapter 3, arises in response to hormonal (androgenic) stimulation,
whereas rosacea seems to arise “out of the blue” — or
should I say “red” — and doesn’t appear to have any relationship
to androgenic hormones. Also, lesions don’t appear to
fluctuate with a woman’s menstrual cycle.
Usually makes its debut well after the acne-prone years.
Acne vulgaris is especially common during adolescence.
Occurs primarily on the central face. Adult-onset acne tends
to occur on the lower part of the face and acne vulgaris generally
has a much wider distribution such as on the chest and
back.
Is associated with facial redness and flushing. Blushing and
flushing reactions aren’t associated with acne vulgaris or
adult-onset acne.
Is generally non-scarring, unless acne vulgaris is also present.
Fortunately, the inflammatory lesions of rosacea tend to
heal without forming the types of scars that can result from
inflammatory acne lesions.
Determining whether
it’s just rosy cheeks
If you believe the ads, we have 15 million and counting rosacea
sufferers in the United States alone! You may fit the profile —
fair-skinned, Celtic ancestry, and all that. You may show varying
degrees of facial redness and blushing and flushing, but that doesn’t
mean you have rosacea. So don’t be in a rush to volunteer as a
poster child for rosacea.
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Rosacea is a condition that is regularly overdiagnosed by healthcare
providers. What’s more, many people come into my office after
having diagnosed themselves as having rosacea. Some of these selfdiagnosers
reach their conclusion after seeing ask-your-doctor television
advertisements that introduce them to the condition.
In many instances, rosacea can be hard to distinguish from weathered,
sun-damaged skin that’s seen in many fair-skinned farmers,
gardeners, sailors, or other folks that worked or spent long periods
of their lives outdoors. Such long-term sun exposure can lead to
persistent red faces and tiny broken blood vessels that sometimes
look quite a bit like rosacea.
Then, some people are blushers who don’t have rosacea at all. In
fact, if you carefully evaluate the location of redness on some of
their faces, you discover that the redness seems to occur in different
places than where it’s commonly seen in rosacea. Their symptoms
tend to appear on the sides of the cheeks, the front and side of the
neck, and the ears, as opposed to the central area of the face.
Moreover, a red face can be due to a variety of skin disorders such
as photo dermatitis (an abnormal reaction to light exposure) and
seborrheic dermatitis (a red, scaly rash that can be on the face),
and sometimes it can be associated with certain underlying diseases
such as systemic lupus erythematosus, as well as rarer disorders
(such as carcinoid syndrome and systemic mastocytosis).
The so-called hot flashes of menopause, medication reactions, and
allergy to cosmetics can also be confused with rosacea.
And sometimes, what has been called “rosacea” on your face — is
simply rosy cheeks! You’re just stuck with a healthy looking facial
glow. Traditionally, folks like you didn’t receive a medical diagnosis
but were described as having a “peaches and cream” complexion.
If rosy cheeks and telangiectasias are your only complaint, you
shouldn’t be labeled with the diagnosis of rosacea until other signs
or symptoms develop such as those I describe in this chapter.
Now, if you’ve decided by now that you don’t think you have
rosacea, please give this book to a friend or family member who
has acne or rosacea.
So, what causes rosacea?
Although the precise cause of rosacea remains a mystery,
researchers believe that heredity plays a role in the process (as I
cover in the “Describing those affected” section, earlier in the
chapter). As to the physical causes of the condition, there are
216 Part IV: Dealing with Scars and Associated Conditions
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many theories, but none of them have been proven. The various
theories about the actual causes include:
Blood vessels: Some investigators believe that there is a natural
chemical in the body that has a potent effect on blood vessels
and that causes them to swell in people who have
rosacea. The result, these scientists believe, is the flushing
and redness characteristic of rosacea.
Bacteria: A bacterium called Helicobacter pylori, which causes
intestinal peptic ulcers, was thought to be a cause of rosacea,
but that theory has apparently been put to rest. P. acnes, our
little bacterial friend that’s been associated with acne, is also
believed by some investigators to play a role in rosacea. I
introduce you to P. acnes in Chapter 3.
Mites: A mite called Demodex folliculorum, which lives in hair
follicles, is thought by some scientists to be the cause of
rosacea. The belief is that the mites clog oil glands, which
leads to the inflammation seen in rosacea. These mites reside
in almost everyone’s skin and, like P. acnes, may just be innocent
bystanders.
Examining Irritants and
Rosacea-Prone Skin
If you have rosacea, you may also have skin that is unusually vulnerable
to chemical and physical irritants. Skin-care should be kept
simple so as to avoid the triggers that can worsen the condition.
Handling your skin with care!
Avoid overzealous washing of your face. Be gentle with your skin.
You should wash your face with lukewarm water and a mild, nonirritating
soap, by using your fingertips to apply the soap gently.
Check out my complete instructions for proper face washing in
Chapter 2.
Cosmetics can irritate rosacea; so don’t use skin-care products
with harsh ingredients. Before using any skin-care products, carefully
read the labels. Go for the fragrance-free products that are
gentle and have the fewest ingredients.
Chapter 18: Reining in Rosacea and Other Acne Look-Alikes 217
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The following ingredients seem to cause the most irritation:
Alcohol
Witch hazel
Menthol
Peppermint
Eucalyptus oil
Clove oil
Salicylic acid
In choosing cosmetics, also keep the following points in mind:
Select cosmetics that are water soluble, so that they require
no strong solvents to remove them.
Avoid astringents and exfoliating agents.
218 Part IV: Dealing with Scars and Associated Conditions
Celebrity rosacea
If you have rosacea, then you have something in common with the following prestigious
group of people:
Rembrandt van Rijn: The great Dutch painter, who created a series of self-portraits
as he aged, was known for his honest rendering of his facial features. A
recent medical journal studied his self-portraits and concluded that he may
have had rosacea. A blotch under the right eye looks like spider’s legs and
resembles a telangiectasia lesion. The bulbous nose with coarse skin suggests
that he had rhinophyma.
J. P. Morgan: The financier, who had a humungous rhinophyma, offered $100,000
to anyone discovering its cause. As far as I know, no one has received payment
so far (he died in 1913).
W. C. Fields: The sharp-tongued comedian is also among those said to have
had rosacea. Just like J. P. Morgan, his trademark bulbous nose resulted from
it. Everyone thinks his nose looked that way because of his drinking, when in
fact it was due to rosacea. However, there’s little doubt that alcohol flushed his
face and worsened his rosacea.
Bill Clinton: The former United States president reportedly flushes and has a
swollen red nose and red bumps on his chin and on his right cheek. These are
all symptoms of a moderate case of rosacea.
Princess Diana: She reportedly had a mild case of rosacea that she was able
to hide under makeup.
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Look for water-based moisturizers.
Look for makeup and moisturizers with a sunscreen already
added.
Opt for powdered blushes because, unlike creams, they’re
unlikely to contain emulsifiers that can irritate rosacea.
Discard your old, spoiled cosmetic products.
As for sunscreens, try to stick with the ones that contain zinc
oxide or titanium dioxide, the barrier sunscreens, especially if
other sunscreens irritate or worsen your rosacea (see the section
“Making it worse — fact and fiction,” where I describe them).
For men who have difficulty shaving around the bumps of rosacea,
try using an electric razor rather than a blade to reduce abrasion.
Also avoid using after-shave lotions, especially those containing
alcohol. I describe shaving bumps and shaving techniques in
Chapter 19.
Making it worse — fact and fiction
In the following sections, I investigate some things that may make
rosacea worse. I start off with the stuff that most dermatologists
tend to agree about and then I discuss more questionable items.
Avoiding the triggers
If you do have rosacea, you can take steps to avoid making your
condition worse. Here are common triggers you should avoid:
Sun exposure: You should avoid excessive sun exposure, particularly
during the midday. Steer clear of UV tanning lamps
and beds.
Sun protection is extremely important for anyone with rosacea.
Sunscreens and sun blockers should be used regularly and liberally
to protect the face. Use sunscreens with an SPF factor of
15 or higher. If chemical sunscreens cause stinging, irritation,
or worsening of your rosacea, switch to physical barrier sun
blocks, which contain titanium dioxide or zinc oxide.
Medications: The use of topical corticosteroids (anti-inflammatory
medications used for many skin conditions) can cause a condition
similar to rosacea known as steroid-induced rosacea. I discuss
this condition in “Being aware of topical steroid-induced
‘rosacea’” later in this chapter.
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Excess alcohol ingestion: First of all, let’s get one thing
straight: Rosacea is not caused by drinking excessive amounts
of alcohol! That’s a serious misconception that’s been around
for ages and should be put to rest! Traditionally, most doctors
believed that many, if not most, cases of rosacea were caused
by excessive alcohol intake. It’s an unfortunate belief that still
persists among the general public.
Hold on, not so fast! That doesn’t mean that you should go
dashing to your liquor cabinet for that single malt or to your
fridge to reach for that six-pack! Though drinking habits have
nothing to do with causing rosacea, it is accepted that the
blushing and flushing of rosacea may flare up when some
people drink alcohol — especially red wine. It’s questionable,
however, that the drinking of alcoholic beverages causes a
long-term worsening of the condition.
Questioning the doubtful candidates
There is no convincing evidence as to whether the following
factors — I call them my “doubtful candidates” — have any longterm
harmful effects on rosacea. But, they do increase the redness
of the face temporarily:
Spicy foods, smoking, and caffeine: These items have been
known to cause facial reddening in some people who have
rosacea.
Cooking over a hot stove or oven: Overheating or flushing
from high temperatures in the kitchen has been reported as a
reason for rosacea to flare up.
Emotional stress: Just cry or get angry and your face may
turn red. Just as in the case of acne, some dermatologists
think stress worsens rosacea. They believe that at times of
stress, the body releases lots more glucocorticoids (the
body’s natural steroids), which can worsen rosacea.
Physical exertion: Exercise if you’re fair and you’ll flush. Yes,
some folks who have rosacea feel that exercise makes it worse.
220 Part IV: Dealing with Scars and Associated Conditions
Booze and bumps?
Many in the medical profession thought that drinking brought on a continual dilatation
(widening) of facial blood vessels and an increase in blood flow to the skin. The
increase in blood flow was thought to lead to the thready little broken blood vessels
on the cheeks, the reddened “drinker’s nose,” and ultimately to the skin condition
known as rosacea. We now know that the booze doesn’t cause the bumps!
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Of course, a hot shower also makes your face turn red! You obviously
can’t avoid some of the things on the list — and in some
cases, doing so would be bad for your health and turn you into a
“couch potato.” However, because I’m a doctor, I must recommend
changing important lifestyle habits such as giving up smoking and
cutting back on your caffeine intake. Remember, you’ll receive
many more health benefits besides possible improvement in your
rosacea by doing so.
Treating Rosacea
Most mild cases of rosacea can be treated and controlled with topical
agents alone. (Topical refers to a product that is used on the
skin, such as a cream, ointment, lotion, foam, gel, or a cleanser.)
However, if topical treatment isn’t doing the job, an oral antibiotic
is generally prescribed (systemic therapy). Compared with topical
therapy, systemic therapy has a more rapid onset of action.
If possible, your doctor will try to control your rosacea on a longterm
basis with topical therapy alone. Oral antibiotics (check out
the next section) are reserved for initial control of rosacea and for
breakthrough flare-ups.
Chapter 18: Reining in Rosacea and Other Acne Look-Alikes 221
The extensive trigger list:
Mission impossible
It seems that anything and everything has been reported to cause rosacea flareups!
The following list obtained from questionnaires sent to rosacea sufferers will
prove the point. It reads like everything that’s good, nutritious, or fun to do in the
entire world:
Foods: Liver, citrus fruits, tomatoes, chocolate, soy sauce, vinegar, and some
cheeses. Also foods high in niacin (a B vitamin) or histamine.
Climate: Extremely hot or cold temperatures and the wind. These conditions
increase blood flow and cause the small blood vessels in the face to widen.
Other tripwires: Menopause, stress, hot water, fragrant skin-care products, and
certain perfumes have also been implicated in the survey. Also included are
certain medical conditions such as high blood pressure, fever, and colds.
So why don’t you become a hermit and move into a dark cave? Just kidding! If you
notice that something does affect your rosacea on a consistent basis, discuss it
with your doctor, otherwise, I recommend that you continue to go outside, eat, and
live your life.
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In my practice, I start patients off with both an oral antibiotic such
as a tetracycline (see the section on tetracycline later in this chapter)
as well as a topical medication such as a metronidazole (see
the section on metronidazole later in this chapter). That’s because
it may take a topical agent six to eight weeks for an acceptable
therapeutic response, whereas oral antibiotics start working in a
week or two. As my patient improves, the dosage of the oral antibiotic
is gradually reduced and then stopped.
The goal of combination topical/oral treatment is to produce clearing
of rosacea and to maintain it, if possible, with topical therapy
alone.
The topical and oral drugs that I describe in the following sections
have an anti-inflammatory action that helps to clear up the papules
and pustules of mild to moderate rosacea. However, these drugs
aren’t effective in clearing up the flushing, blushing, and persistent
redness (telangiectasias) of rosacea. I talk about treatment of these
signs and symptoms of rosacea in the section “Managing the
Redness,” later in this chapter. All of the medications that I mention
in that section require a prescription.
Taking a look at the topicals
Some of the topical medications that are used to treat acne can be
used very effectively on rosacea; however, some precautions must
be taken because many people who have rosacea also have very
sensitive skin. Consequently, standard acne medications such as
topical retinoids and benzoyl peroxide can be drying and irritating.
Retinoids may sometimes even sensitize the skin to the sun and
worsen rosacea. Despite my reservations, if your skin tolerates
these products without any irritation, there’s no reason not to use
them, particularly if they work. I talk about all of these agents in
Chapter 9.
Just as we use topical agents in combination with each other (or in
combination with oral agents) in the treatment of acne, this
approach has become popular for managing rosacea too. On the
subject of combining topical treatments, Noritate cream applied at
night and a sodium sulfacetamide/sulfur product such as Ovace,
Klaron, or Avar applied in the morning appear to work better than
when each of these agents is used alone.
In this section, though, I discuss topical medications that are used
to treat rosacea. You may recognize a few familiar friends such as
azelaic acid and sodium sulfacetamide and sulfur that I discuss in
Chapter 9 that are sometimes used to treat acne. Doctors and
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researchers aren’t sure exactly how the following medications
work in the treatment of rosacea, but it does appear that it’s
mostly due to an anti-inflammatory effect.
Each of these products is considered to be as effective as the
others in the treatment of rosacea.
Metronidazole
Metronidazole is the most frequently prescribed first-line topical
therapy for rosacea. Irritation and burning are uncommon from
these topical medications, especially when the creams are used.
They’re generally prescribed as one of the following:
MetroCream, MetroGel, and MetroLotion: Commonly
referred to as the Metros, all of these products contain 0.75
percent metronidazole. The Metros are applied twice a day to
clean dry skin on the rosacea-prone areas.
The latest Metro is the higher strength 1 percent MetroGel
that’s applied once daily. Besides having a higher concentration
of metronidazole, it’s a water-based formulation that contains
niacinamide, which is thought to have anti-inflammatory
effects.
Noritate cream: This product is similar to MetroCream, but
with 1 percent metronidazole, it’s 25 percent stronger than
the Metros. Noritate (“no irritate,” get it?) is used only once a
day, a routine that helps patients use it regularly.
Azelaic acid
This gel is used to improve the inflammatory pimples of mild to
moderate rosacea. Finacea and Skinoren (in Europe) are the brand
names available. Finacea is available in a 15 percent azelaic acid
gel. They’re applied twice a day to clean dry skin. Some patients
report temporary burning or stinging with this treatment.
If you have a dark complexion, your doctor should monitor you for
signs of skin lightening.
Sodium sulfacetamide and sulfur
Medications containing sodium sulfacetamide and sulfur are also
effective for rosacea. Brand names include Klaron, Plexion, Rosula,
Rosac, Rosanil, Novacet, and Ovace, to name a few.
Sodium sulfacetamide and sulfur products are available as lotions,
creams, and washes. Some of these products contain a humectant
(a substance that promotes retention of moisture) and can be used
in rosacea patients who have dry, sensitive skin.
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These products are generally applied twice a day to clean dry skin.
Itching, stinging, and irritation may occur with these preparations.
Treating rosacea by mouth
The same systemic oral antibiotics used to treat acne that I discuss
in Chapter 10 also calm the papules and pustules of your rosacea.
Here, I provide you with the rosacea-specific information and tips
associated with these drugs. For complete information, including
how to take the medication and potential side effects, please see
Chapter 10. Of course, your doctor always has the last word on
these prescription drugs.
Whenever any systemic drugs are taken, the potential dangers —
including side effects, drug allergy, drug intolerance, drug interactions,
and fetal exposure in women who are, or may become
pregnant — must be carefully considered.
Tetracycline and tetracycline derivatives, such as minocycline and
doxycycline, are the first-line oral drugs of choice in the management
of moderate to severe rosacea. The tetracyclines are antibiotics.
They have antibacterial properties and many uses besides
treating rosacea, but as far as rosacea is concerned, this antibiotic
has a powerful anti-inflammatory action that helps to clear up the
papules and pustules.
With the tetracyclines, improvement of rosacea is usually noticeable
in a matter of a week or two. The papules and pustules begin to flatten
and disappear and new ones stop popping up. Tetracyclines are
then tapered when this improvement becomes persistent (usually
after three to four weeks). Minocycline is probably the most effective
oral medication to treat rosacea. It’s also the most expensive.
None of the tetracyclines should be used if you’re pregnant or
breastfeeding.
Other oral medications that may be prescribed include:
Other antibiotics: A variety of other oral antibiotics (such as
erythromycin, azithromycin, clarithromycin, and amoxicillin)
have been used to treat rosacea successfully. Typically they’re
prescribed as second-line alternatives when a tetracycline
fails or isn’t tolerated.
Oral metronidazole: This drug’s brand name is Flagyl, and it
may be used when antibiotics aren’t working.
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Trimethoprim sulfasoxazole (TMZ): Trimethoprim sulfasoxazole
is reserved for unusually stubborn cases of severe rosacea
that don’t respond to any of the other antibiotics listed.
Rarely, TMZ has been associated with severe side effects and
may precipitate severe allergic reactions.
Although isotretinoin, better known as Accutane, is extremely effective
in the treatment of severe acne, it hasn’t been very useful in
rosacea. It may clear rosacea, but the improvement is often temporary
and the rosacea tends to rebound. In other words, the risks —
which are plentiful — are probably not worth the benefits in the
treatment of rosacea! Isotretinoin (Accutane) has many potential
side effects and I review the ups and downs of this powerful drug in
Chapter 13. While isotretinoin (Accutane) hasn’t been proven to be
very helpful for severe inflammatory rosacea, there have been
instances where the drug has demonstrated a reduction of some of
the volume of rhinophyma lesions. I talk about the treatment of
rhinophyma later in the chapter.
Because rosacea doesn’t seem to have a relationship to hormonal
fluctuations, the use of hormonal therapy that I mention in Chapter
11 for the treatment of acne has no place in the treatment of
rosacea.
Check out Chapter 15 where I delve into old and new alternative
and complementary methods to treat acne and rosacea. Herbs
reported to help clear rosacea include neem, cat’s claw, tea tree,
ginger, and lavender. There’s no scientific evidence to back up
these claims, however.
Managing the Redness
While you’re waiting for the medicine to work to relieve you of those
bumpy papules and pustules, why not try to conceal the redness?
The next section gives you a few helpful pointers, and later in this
chapter, I suggest some more permanent ways to get rid of the red.
Covering up with camouflage
Because treatment isn’t enough to handle the redness, you may
want to consider strategic camouflage techniques.
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Green-tinted foundations can hide the red. Green neutralizes red.
It’s that simple. That explains why your normal shade of beige or
other neutral skin tone foundation doesn’t quite conceal the redness
that peeks out from underneath. Cosmetic foundations that
have a green tint are included in the products made by companies
such as Este Lauder, Clinique, and Prescriptives.
Other nonprescription products that may be used to cover up the
redness are Dermablend and Covermark. They can be matched to
your normal skin color. These products can be found in makeup
counters in some department stores and also can be obtained
online at www.dermablend.com and www.covermark.com.
The prescription cover-up products, Avar (tinted green) and
Sulfacet-R, both are tinted and thus offer ways to hide the red.
Sulfacet-R is also available in a tint-free preparation and is particularly
useful for oily skin. These products can serve as a cosmetic
cover-up to hide the “broken” blood vessels and redness of
rosacea. Sulfacet-R comes with a color blender so that you can
match your skin tones. Both of these are types of sodium sulfacetamide,
which I discuss in the section of the same name earlier in
the chapter.
Buzzing the telangiectasias away
Your dermatologist can treat your telangiectasias by electrocautery—
destroying them with a tiny electric needle using extremely low voltage
electricity. The needle zaps along the length of the blood vessel
and destroys it. Simple electrocautery tends to be sufficient for most
small telangiectasias; it is relatively painless, and is the most cost
effective approach to get rid of telangiectasias.
For the larger variety of telangiectasia, lasers such as I describe in
the next section may be the treatment of choice.
Your insurance will probably not cover these procedures, because
they’re considered to be cosmetic in nature.
Getting the red out: Light-based
therapies
Topical and oral therapies don’t treat the telangiectasias or the
larger, persistent erythematous (red) areas of rosacea. Special
lasers known as vascular lasers and intense pulsed light (IPL) therapy
are now being used by dermatologists and plastic surgeons to
“erase” this red background away.
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Light-based therapies use various wavelengths of light to penetrate
the skin and target the blood vessels on the face and cause the vessels
to heat up and collapse.
These light treatments haven’t proven to be effective for flushing
and blushing reactions, nor do they seem to be superior to oral
antibiotics in treating the inflammatory component of rosacea. All
of this is still in an early, investigational phase. The treatments are
very expensive and generally not covered by health insurance
plans. I shed more light on lasers and IPL in Chapter 14.
Going the surgical route
for rhinophyma
Recontouring procedures with a scalpel or a carbon dioxide laser
have been used successfully to “sculpt” the excess nose tissue of
rhinophyma back down to a more normal shape and appearance.
This may also be accomplished by electrocautery, a process of
destroying tissue by using a small electric probe to cauterize (burn
or destroy) unwanted tissue, or by dermabrasion. Results can last
for many years and sometimes may be permanent. I explain dermabrasion,
carbon dioxide lasers, and other surgical measures in
Chapter 16.
Dermatologic or plastic surgeons perform these procedures.
Health insurance plans are generally very reluctant about covering
such treatments, which they consider to be “cosmetic” in nature.
Identifying Rosacea Look-Alikes
The conditions that I mention in the following sections are really
impossible to differentiate from rosacea except in three respects:
they’re usually easy to treat, they generally disappear on their own
(self-limiting), and they tend to show up in different areas of the
face than does rosacea.
Recognizing perioral dermatitis
Also known as periorificial dermatitis, this condition is a rosacea-like
skin eruption seen almost exclusively in women. Like rosacea,
nobody knows its cause. Fluoridated toothpastes and bacteria have
occasionally been implicated, but without any consistent evidence.
Chapter 18: Reining in Rosacea and Other Acne Look-Alikes 227
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Perioral dermatitis occurs in a characteristic circular pattern
around the mouth, chin, and lower cheek in women between the
ages of 15 and 40 years. Less commonly, it can occur in young children.
The lesions look just like those of rosacea or acne and consist
of papules and pustules, except there are no telangiectasias.
The papules and pustules tend to be very small, and sometimes
whitish scales can be associated with it. Take a look at the color
section of this book to see what this condition looks like.
The biggest difference between rosacea, acne, and perioral dermatitis
is that the latter often clears up permanently after treatment.
Perioral dermatitis is usually found clustered around the mouth,
but it may appear around the eyes and nose.
Treatment is similar to that of rosacea. The use of topical MetroGel
or Noritate cream or topical antibiotics such as Cleocin T or Emgel
can help to clear up this condition, especially for mild cases. An
oral antibiotic such as one of the tetracyclines or erythromycin is
used if topical treatment fails.
Being aware of topical steroid-induced
“rosacea”
Also called steroid rosacea, this type of “rosacea” isn’t really
rosacea, and I can tell you the cause of this condition — the inappropriate
use of topical steroids (cortisone) on the face. The
steroid creams are often prescribed for other skin conditions such
as eczema or psoriasis and then overused by the unsuspecting
person who continues to apply them. The condition typically worsens
when the topical steroids are discontinued (an occurrence
known as rebound rosacea).
Here’s what happens: There is a rapid flare of papules and pustules
when the topical steroid is stopped, so the unsuspecting person
reapplies the offending medication and the condition improves.
When the treatment is stopped again, the lesions appear again and
reestablish the vicious cycle. Some of my dermatology colleagues
refer to this as steroid-use dermatitis (others replace the term “use”
with “abuse” or “misuse”).
It looks just like ordinary rosacea, but a history of long-term, indiscriminate
misuse of potent topical steroids on the face helps to
confirm the diagnosis. This condition is treated by stopping the
topical steroids and by taking a tetracycline derivative for a few
weeks or more to get over the hump of the rebound.
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Chapter 19
Fighting the Feisty Follicle
In This Chapter
Getting to the root of the problem
Treating shaving bumps
Considering hair removal
Exploring other hair bumps
It seems like this entire book takes place in, or has to do with,
your hair follicles. When a hair follicle becomes inflamed, it may
become a papule or a pustule and look just like acne! Yes, there are
more “acne pretenders” besides the ones I talk about in Chapter 18.
In this chapter, I further explore your hair follicle, a place that can
also serve as a location for other pretenders — razor bumps and
keratosis pilaris.
Reining in Razor Bumps
If you’re a guy with curly hair (and much less often a woman), the
area under your chin, upper neck, or cheeks can be subject to an
uncomfortable cluster of papules and sometimes pustules, which
can make shaving very difficult. This condition is known as pseudofolliculitis
barbae (PFB); more commonly called razor bumps. That’s
right, “pseudo” as in phony. Although no one would argue that your
inflamed follicles are fake, your condition isn’t actually folliculitis.
The term folliculitis simply refers to any inflammation or infection
of hair follicles.
Besides being a cosmetic liability, these bumps can really become
itchy, painful, and tender. In addition to the papules and pustules,
if the condition goes unchecked, the following lesions may ultimately
result:
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Persistent flesh-colored bumps: These lesions are actually
hypertrophic scars that sometimes go on and result in keloids. I
discuss hypertrophic scars and keloids in Chapter 16.
PIP: Postinflammatory pigmentation, or dark spots, may also
become a prominent feature on people with PFB. See Chapter 12
for more information on dealing with PIP.
PFB is a condition that can appear in folks from all ethnic backgrounds.
It’s extremely common in men of African descent as well
as some men of Hispanic origin and non-Hispanic Caucasians with
curly hair. And yes, it can also be a plague to some women in these
groups.
Examining the causes
People with curly hair have curved hair follicles. Most African-
American people have curved hair follicles. The majority of
Caucasians and virtually all Asians have straight hair follicles that
produce straight hairs, which explains why we see more African-
American men with PFB. PFB lesions are seen on the beard area —
particularly on the neck and below the jawbone. Take a look at the
color section of this book for an up-close view of the condition.
Reentry of a hair missile: Ingrown hairs
Because the hair shafts of people with curly hair are curved, the
hairs that emerge from their follicles tend to be tightly coiled. It’s
true of beard hair as well as other body hair. After shaving, a single
curly hair becomes a sharply pointed tip that if aimed toward the
body, can grow right back into the skin. Figures 19-1A and 19-1B
illustrate the process.
The penetration of sharp hairs causes a misguided reaction by
your body’s immune system that sees your penetrating hairs as
“foreign invaders.” Your immune system overreacts by attacking
the hair with white blood cells and thus produces inflammatory
papules and pustules that resemble acne.
Parallel hair penetration: Shaving below the surface
When they’re shaved too closely, hairs can also grow parallel to
the skin and penetrate the side of the follicle. Check out Figures
19-1C and 19-1D. This penetration also causes a reaction of your
immune system, producing papules and pustules.
Reemerging hairs: Adding insult to injury
Furthermore, newly erupting hairs from below may pierce and
aggravate areas that are already inflamed. Thus, growing hair or
230 Part IV: Dealing with Scars and Associated Conditions
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hairs that have been plucked may traumatize an existing papule or
pustule.
Try your best not to pluck hairs growing in areas in which you
have PFB, because new hairs will again grow from below and penetrate
a site that is already inflamed. For tips on how to remove hair
without causing further problems, see the section “Dealing with
Those Hairs,” later in this chapter.
Figure 19-1: When shaved, the curly hair emerging from a curved follicle becomes
a sharp tip that curves downward as it grows (A), and reenters the skin (B).
When hair is cut too closely (C), it may grow parallel to the skin and penetrate
the side of the follicle (D).
Shaving correctly with PFB
If you have PFB, you need to establish proper shaving techniques.
Allowing you hairs to grow long enough so they won’t grow back
into the skin can be helpful, or you might decide to stop shaving
permanently! Growing a beard is probably the best way to prevent
PFB, though most people don’t choose this option.
If you want to try the stop-shaving approach but you’re in the military,
law enforcement, or work in a company that requires you to
be clean-shaven, ask your healthcare provider to give you a letter
that explains your PFB condition and why you should be excused
from shaving.
A
C
B
D
Chapter 19: Fighting the Feisty Follicle 231
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If you intend to keep on shaving, the following sections give you
some tips on preventing PFB. The key with all of these techniques
is to reduce how close the shave is so that you reduce the chance
of ingrown hairs. Hairs cut too short are at risk of curling into the
skin while growing and causing more razor bumps.
Whatever method you choose when shaving, be sure to use the
sharpest implement.
Razor shaving
Just like washing your face, shaving is a little more complicated
than some people think, especially if you’re prone to skin problems
such as PFB.
You can avoid a close shave by using a guarded razor. Two that I
recommend are the PFB Bump Fighter or an Aveeno PFB Bump
Fighter Razor. Both of these products should be available at your
local drugstore. These razors are covered with a plastic coating
that prevents the razor from contacting the skin directly and produces
less trauma to the skin.
Here are my tips for shaving in the most pain-free and healthy way:
Soften your hairs before shaving. Try shaving after you take a
warm shower. Steaming helps to soften your beard. Washing
your face before shaving removes oil and causes hairs to
become more erect, making them easier to cut. Lather the
beard area with a non-irritating, lubricating shaving gel such
as Aveeno Therapeutic Shave Gel, Edge, or a benzoyl peroxide-
containing prescription shaving foam such as BenzaShave.
Use shaving gels to hydrate your hairs and to provide lubrication
between the razor blades and your skin.
Shave with downward strokes. Go with the grain. Shaving in
the same direction that the hair lies (typically down) will result
in less pull on the hairs and less tendency to cut them too
short. Shaving with the grain will also minimize skin irritation.
Minimize repeat shaving strokes. Not only is it a waste of time
and energy to go over and over the same area, but repeated
shaving may result in hairs being cut too short.
Don’t stretch the skin during shaving because this leads to a
closer shave and increases the chances of producing ingrown
hairs.
Don’t shave on a daily basis if you don’t have to.
Don’t use aftershave or cologne on the shaved areas. Instead,
after shaving is finished, rinse thoroughly with warm water
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and apply a mild moisturizing aftershave lotion such as
Cetaphil Lotion.
Rinse your razor of all cut hairs at regular intervals. It helps to
reduce the drag across the skin. Change your blades at least
once a week and more often if skin irritation persists.
Be sure not to use those double, triple, and quadruple razors,
which wind up shaving you two, three, and four times! These
modern razors are so good at what they do, they shave below
the skin surface and only make things worse.
Electric shaving
Using an electric razor with gentle pressure is another method that
reduces the closeness of the shave. Just as with a wet razor, an
electric razor should be cleaned regularly so that the mechanism
doesn’t become clogged with hairs.
When using an electric shaver, you want the hairs to be dry and
stiff before you begin, so they’re easier to cut. So you should not
start by washing your face or thoroughly wetting the beard with
water as you do with a wet shave with a blade.
Instead, you may want to apply a pre-shave lotion designed for electric
shavers (such as Lectric Shave). Such products, often alcoholbased,
dry up the oils and moisture on your skin and make the
whiskers stand straight up.
Try using electric hair clippers that leave the cut hairs long. Aim to
have a “five o’clock shadow” immediately after shaving.
Treating razor bumps on your own
The good news about PFB is that it can be treated. You can start by
treating it yourself, using the physical method I recommend in the
next section. You can also use topical medications that contain
benzoyl peroxide (see “Buying benzoyl peroxide,” later in this section).
If you don’t get satisfactory results, contact your dermatologist
for help. He can evaluate your condition and help you take the
next steps.
Physically stopping PFB
A curled hair can be flipped up before it has a chance to plunge
into the skin by using a fine needle or toothpick to gently lift it
before reentry.
Chapter 19: Fighting the Feisty Follicle 233
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1. Inspect your beard to look for potential plunging hairs or
for hairs that have already taken the plunge. Prime candidates
include those that are pointing back toward your skin
or those that are lying flat.
2. Use a fine needle or toothpick to lift the hair between the
follicle and the tip.
3. Gently redirect the sharp pointed end of the hair away
from your skin.
Probing too aggressively with a needle or toothpick can lead to further
inflammation.
Buying benzoyl peroxide
Benzoyl peroxide is the most commonly used over-the-counter
acne medication, and is also the most effective medication for
treating PFB. It comes in varying strengths ranging from 2.5 to 10
percent. There’s no proof that anything higher than 2.5 percent
works any better than the higher concentration, and the lower concentrations
are cheaper and may be less irritating to your skin.
Clear By Design, Clearasil, Fostex, Neutrogena, and Noxzema are
just a few of the benzoyl peroxide brand names available.
A cream or water-based product may be gentler if your skin is very
sensitive; however, alcohol-based products may be more potent if
you’re able to tolerate them. Experiment with the different products
until you find the right one for you.
Here are some application tips:
Apply the benzoyl peroxide sparingly in a very thin layer to
the entire PFB-prone areas once or twice a day. You may have
to continue applying it for as long as you have the problem, or
you can try stopping it for periods of time when the PFB
comes under control.
Avoid abrasive, harsh, or drying soaps and cleansers while
using benzoyl peroxide.
Be patient, your PFB often responds very slowly to treatment. It
may take six to eight weeks before you notice any improvement.
Dryness of the treated area can be expected and is usually mild.
You may experience a mild burning sensation or reddening of the
skin when you first start to apply benzoyl peroxide. These symptoms
usually disappear in two to three weeks. For more information
on using benzoyl peroxide, take a look at Chapter 7.
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Other OTC products
In addition to benzoyl peroxide, topical fruit acids, such as glycolic
acid and salicylic acid, products that contain lactic acid, and mixtures
of all three are also advertised as PFB treatments. They’re
not as effective as benzoyl peroxide, and I only mention glycolic
acid here. I provide more details about these acids in Chapter 7.
Glycolic acid: Besides benzoyl peroxide, glycolic acid, which
is an alpha hydroxy acid (AHA), is the most common ingredient
found in over-the-counter PFB products. It’s found in many
cosmetics and moisturizers. Examples of glycolic acid preparations
are Alpha-Hydrox and Neo-Strata. Cleansers containing
glycolic acid and other AHAs can be used prior to shaving
with a razor and moisturizers that have an AHA in them are
recommended after shaving.
Hydrocortisone cream: You can purchase over-the-counter 1
percent hydrocortisone cream, which is topical cortisone for
itching or irritation. Apply a small amount once or twice a day
for itching or stinging, only if necessary.
Getting professional help
If going it alone isn’t working out, you may need to see your dermatologist
or healthcare provider about getting a prescription medication
for your PFB. (If you don’t already have a doctor you trust
to help you with this problem, turn to Chapter 8 where I tell you
how to go about finding the right doctor for you.)
Combining benzoyl peroxide with topical antibiotics
If over-the-counter isn’t working for you, prescription benzoyl peroxide
combined with a topical antibiotic such as Benzamycin,
Duac, or BenzaClin gel may work very well for you.
To save a little money, you could also talk to your doctor about
using a prescription for a generic topical antibiotic such as clindamycin
or erythromycin lotion along with an over-the-counter
benzoyl peroxide. Use them one on top of the other.
As with applying benzoyl peroxide alone, it may take six to eight
weeks for the product to work and the same potential side effects
of dryness and irritation may also apply. Benzoyl peroxide also is
available as prescription shaving foam known as BenzaShave.
If you have supersensitive skin, prescription Akne-Mycin (erythromycin,
2 percent) ointment may be right for you. It also may take
six to eight weeks for it to work. It’s less harsh on your skin.
Chapter 19: Fighting the Feisty Follicle 235
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Chapter 9 gives you more information about these drugs, but here
are some general tips for using these medications for PFB:
Apply medication sparingly in a very thin layer to your PFBprone
areas once or twice a day.
If you must shave, apply the medication after you shave. Wait
at least 30 minutes to cause the least irritation.
Apply a moisturizer over the medicine to help prevent dry
skin and other irritation.
Using topical retinoids
As with the treatment of acne, the topical retinoids appear to help
reduce the inflammatory lesions of PFB. Topical retinoids can perform
a double duty for you. In addition to the beneficial actions of
the retinoids in treating some of the inflammatory lesions of PFB,
they also lighten PIP (if you have it) as well.
Adaplene (Differin), tazarotene (Tazorac), Avita, and tretinoin (Retin-
A) are all prescription retinoids. Check out Chapter 9 for more information
about prescription-strength topical acne medication.
Apply topical retinoids in small, thin, pea-sized amounts to the
PFB-prone areas. Creams are the least irritating, so you probably
should start out with a cream-based retinoid instead of a gel. All
retinoids can cause some skin irritation during the first few weeks.
You may have some discomfort, such as stinging or burning and,
sometimes, mild scaling of your skin. If you have a sensitivity to
the retinoid you were prescribed, then use it every other day, or
even less frequently, until you get used to it.
Maximal improvement most often occurs within three to four
months.
Trying other topical measures
Your dermatologist has a few other topical tools at his disposal.
Consider these additions to your topical therapy if you’re itching
or have dark spots and your doctor feels you need them:
A prescription-strength topical cortisone cream may be helpful
if you have a great deal of itching or irritation.
Glyquin, a combination of glycolic acid and hydroquinone (a
bleaching chemical) is a moisturizing cream especially helpful
for those with PFB and PIP. Apply it once or twice a day.
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Opting for oral antibiotics
When your beard becomes populated with papules and pustules,
gets to be super itchy, or your scars seem to be growing, it’s time for
more aggressive therapy. At times like this, your dermatologist may
elect to treat your PFB with oral as well as topical preparations.
Oral antibiotic drugs have an anti-inflammatory action that helps
to clear inflammatory lesions (papules and pustules). I discuss the
oral antibiotics such as the tetracyclines in detail in Chapter 10.
Injecting the bumps with cortisone
When scars become unsightly or the papules become itchy or
painful, a very common method to deal with them is by injecting
the lesions with cortisone. The shots are given in addition to oral
and topical antibiotics. Intralesional cortisone injections (a relatively
painless procedure) can be extremely effective in reducing
the inflammation and sometimes the size of inflammatory papules
and hypertrophic scars. They also help decrease itching. Check
out Chapter 10 to see my explanation for this procedure.
This usually requires repeated treatments because PFB is a chronic
problem.
Dealing with Those Hairs
Whether you’re a man or a woman, if you discover some dark hairs
on your chin, cheeks, or neck, you may find them to be annoying
or cosmetically objectionable. If you have PFB, this section offers
some ideas to lessen your follicular problems.
Your excess hairs may be due to hirsutism, an excess of hair in a
masculine pattern seen in women. Hirsutism can be seen in certain
cases of hard-to-treat acne. You may also have excessive hair
growth on other areas besides your face such as on your chest,
nipples, and pubic area (see Chapter 20 where I tell you more
about hirsutism). This section provides lots of solutions for this
condition as well.
Many methods are available for temporary or permanent hair
removal. The following sections go over some different methods.
Removing hairs temporarily
Technically referred to as epilation, plucking, tweezing, and waxing
are common choices for temporary hair removal. These methods
Chapter 19: Fighting the Feisty Follicle 237
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remove the intact hair with its root. Performed by aestheticians or
by yourself, these procedures are commonly used and are safe;
however, they can sometimes result in irritation and folliculitis. As
you may know, your hair will still grow back with these approaches.
But contrary to myth, shaving, plucking, and tweezing don’t promote
heavier hair growth.
Chemical depilatories are another option. Depilatories remove hair
from the surface of the skin. They separate the hair from its follicle
by destroying the bonds that hold the hairs together. Nair and Neet
are commercially available products. For PFB, chemical depilatories
such as Magic Shave and Royal Crown Powders are effective in
removing and softening hairs. Chemical depilation may be best
suited for treatment of large hairy areas in people who are unable
to afford more expensive treatments such as electrolysis and laser
epilation. The main disadvantages of chemical depilatories are irritation
of the skin and the unpleasant odor of the products.
These products dissolve the hairs but can be too strong and cause
chemical burns on facial skin.
238 Part IV: Dealing with Scars and Associated Conditions
Sugaring, threading, and camouflaging
your hairs
Here are some other ideas for removing and hiding unwanted hairs:
Sugaring: This is an ancient method of hair removal, still in use today.
“Sugaring” is similar to waxing. Long used in parts of the Middle East, the use
of natural sugars is becoming popular in place of waxes. They appear to epilate
as effectively as, but less traumatically than, waxing.
The sugar mixture is prepared by heating sugar, lemon juice, and water to form
a syrup. A sticky paste is applied to the skin, and a strip of cloth or paper is
pressed into the preparation. The strip is then quickly pulled away, taking hairs
with it. Many states require a cosmetologist or aesthetician’s license to do hair
removal like sugaring.
Threading: This is a method used in some Middle Eastern countries; cotton
threads are used to pull out hairs by their roots. Called khite in Arabic, the application
involves the use of a long twisted loop of thread rotated rapidly across
the skin. By maneuvering the twisted string, hairs are trapped within the tight
entwined coils and are pulled or broken off.
Bleaching: This is an inexpensive, safe alternative to dark hair removal. It works
well when hair growth isn’t excessive. Bleaches lighten the color of the hair so
that it is less noticeable. Several types of commercial hair bleaching products
are available. All contain hydrogen peroxide as their active ingredient.
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Until you see how your skin reacts to a chemical depilatory, leave
these products on your skin for less time than is recommended on
the package instructions.
Removing hairs permanently
Techniques of permanent epilation include electrolysis, thermolysis,
and laser epilation.
Electrolysis and thermolysis
Hair destruction by electrolysis or thermolysis is performed with a
fine, flexible electrical wire (probe) that produces an electrical current
after being introduced down the hair shaft. The electricity is
delivered to the follicle through the wire, which causes localized
damage to the areas that generate hairs.
Thermolysis (diathermy) employs a high-frequency alternating
current and is much faster than the traditional electrolysis
method, which uses a direct galvanic current. Thermolysis works
by causing water molecules in the skin around the probe to
vibrate, which creates heat. If enough heat is produced, it can
damage the cells that cause hair growth.
Electrolysis and thermolysis are slow processes and require multiple
treatments for permanent results.
Both electrolysis and thermolysis are excellent procedures to
accomplish permanent hair removal, however, treatments can be
rather uncomfortable and can worsen PFB, create folliculitis, and
result in postinflammatory pigmentary (PIP) changes in the skin.
These methods are difficult to use on inflammatory lesions.
Make sure to find a competent electrologist. Ask around. One of
the best ways to find a good one is to ask friends and family for
recommendations. These practitioners can be found in beauty
salons, doctor’s offices, personal offices, or they may work out of
their own homes.
Many states require that electrologists be licensed or certified
within the state in order to practice electrolysis. For states that do
not regulate electrolysis, look for electrologists who have a certification
from an accredited electrology school.
Laser epilation
Lasers can treat larger areas and do it faster than electrolysis and
thermolysis. They have skin-cooling mechanisms that minimize
Chapter 19: Fighting the Feisty Follicle 239
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skin damage during the procedure. Skin and hair color often determine
if a laser should be used. Lasers are most effective on dark
hairs on fair-skinned people.
As with electrolysis and thermolysis, multiple treatments are often
necessary for long-term hair destruction. Results are inconclusive
regarding whether lasers are more effective in permanent hair
removal than the more traditional methods such as electrolysis.
They’re certainly more costly.
In dark-skinned people, the Nd:YAG laser seems to be safe and
effective. (In Chapter 14, I talk more about lasers.) This laser is currently
the most effective laser for hair removal in dark-skinned
individuals who have PFB.
Slowing down the hairs
Vaniqa (eflornithine hydrochloride cream) is a prescription topical
cream that works by inhibiting an enzyme required for hair growth.
It is indicated for the reduction of unwanted facial hair in women
and must be used continuously to be effective. You may notice
results after four to eight weeks, but your hair growth will return if
you stop using the cream.
Oral treatment with anti-androgens should be considered when hirsutism
is associated with an underlying disorder. Androgen inhibition
with spironolactone or flutamide is sometimes used when
medical reasons are identified as the cause of the hirsutism. All of
these drugs must be given continuously because when they’re
stopped, androgens revert to their former level (see Chapter 20).
Recognizing and Feeling Keratosis
Pilaris: “Hair Bumps”
Keratosis pilaris (KP) is a very common skin disorder that tends to
run in families. Although the condition isn’t serious, it can be frustrating
because it’s difficult to treat. It begins most often in childhood
and often continues into adulthood. KP results from the
buildup of keratin (coarse proteins in your skin that form your hair
and nails) that plugs the openings of hair follicles in the skin. (I talk
more about keratin in Chapter 3.)
KP is particularly common in teenagers on the upper arms and it
tends to be most obvious when it occurs on the cheeks. Lesions
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may remain for years but they may gradually diminish or even disappear
before age 30. KP can be unsightly, but it is completely
harmless. Take a look at the color section of this book for a visual.
Distinguishing KP from acne
KP occurs as small, rough patches — usually on the arms and
sometimes on the cheeks. It can also appear on the thighs and buttocks.
It causes no pain or itching. It has a sandpaper-like feel to it
and looks like gooseflesh. The diagnosis of KP can often be made
by simply rubbing the area with your hands. Often, there may be
some red papules mixed in with the rough bumps.
I bring the subject of KP up because healthcare providers so often
mistake it for acne. The whitish papules tend to look like closed
comedones (whiteheads) and the red papules tend to resemble the
inflammatory lesions of acne, whereas in reality KP is a disorder of
hyperkeratosis (too much keratin). Check out the color section in
this book to see KP up close and personal.
Treating the hair bumps
No cure or very effective treatment is available for KP. However,
the good news is that in most people the bumps usually diminish
in number with increasing age. Treatment is directed at softening
the keratin deposits in the skin and may include medicated creams
and lotions that contain either urea, such as Carmol 20, or lactic
acid, such as AmLactin Moisturizing Lotion. You can also use
petroleum jelly, cold cream, or 2 percent salicylic acid (which
removes the top layer of skin) to flatten the pimples. Salicylic acid
products and their uses are covered in Chapter 7.
Topical retinoids such as tretinoin, Retin-A Micro, and Differin
cream have all been used to treat KP. The results have not been
impressive, however.
Chapter 19: Fighting the Feisty Follicle 241
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Chapter 20
Reviewing Endocrine
Disorders Associated
with Acne
In This Chapter
Encountering androgen excess
Looking at other hormonal causes of acne
Because hormones influence acne, there are instances when
acne’s presence, coupled with other signs or symptoms, may
indicate that something else in your body may be going awry. This
is particularly the case if you’ve found it difficult to get your acne
under control. When you’ve tried many different approaches and
your acne remains, your dermatologist or healthcare provider may
suspect that you have a hormonal imbalance (endocrine disorder).
In this chapter, I explore some of the more likely endocrine disorders
that can produce excessive androgens, as well as those that
can manifest with elevated cortisol levels. Both of these hormones
can be responsible for producing or aggravating pre-existing acne.
It should be noted that the use of anabolic-androgenic steroids, as
performance-enhancing drugs, are known to produce hormonal
imbalances and acne in men as well as women. I talk about those
hormones in Chapter 6.
When you go for your first visit to have your acne evaluated, you
will likely be asked for a complete history about your acne and for
other general and specific health information. (For a more complete
picture of visiting the dermatologist for the first time, check
out Chapter 8.) Many of the questions your doctor asks you are
intended to determine if your acne is in any way related to a hormone
imbalance or abnormality.
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Connecting Androgen
Excess and Acne
The most common endocrine-related issue when it comes to acne
is androgen excess. As I review in Chapter 4, it is thought that
males tend to have the more severe cases of acne because they
produce much higher levels of androgens than do females; however,
far and away, most of the acne-related hormonal problems are
seen in women.
Women are the primary sufferers from endocrine imbalances. As in
males, androgens also are necessary for the development of acne
in females.
If you’re female, certain instances call for particular attention to
endocrine function and suggest that you’re experiencing elevated
levels of androgens. The following are possible signs that you
should be tested with this in mind:
An evident worsening of your acne or an unresponsiveness
to treatment.
Excessive hair growth on your face and other parts of your
body. Your doctor will ask you if you have excessive hair
growth on such areas as your face (particularly the upper lip,
chin, cheeks, and temple areas; see the color section of this
book); also, you may be asked about hair growth on your
chest, nipples, pubic area, upper back, lower back, buttocks,
inner thighs, and genitals. If this type of hair growth is present,
it is referred to as hirsutism, an excess of hair in a masculine
pattern.
Thinning of your hair well before menopause. Androgenic
hair loss is characterized by decreased hair on the top and the
temple areas of the scalp similar to a man’s hair loss.
Marked changes in your menstrual cycle. In your first few
years of menarche (the beginning of your menstrual periods
that usually occur during puberty), it’s normal to have irregular
menstrual cycles; however, if these irregularities persist,
or you go from regular to irregular — or if you never have a
period — that may indicate that you have an endocrine
abnormality.
Infertility. An inability to conceive after one year of unprotected
intercourse.
244 Part IV: Dealing with Scars and Associated Conditions
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Obesity: Markedly being overweight or the inability to rid
yourself of excess weight can be a sign of an endocrine abnormality
or be simply due to excessive calorie intake.
Testing for endocrine imbalances
If you develop any one of these signs or symptoms, you should
receive a complete endocrine and gynecologic evaluation. This
evaluation requires specific blood tests and examinations that are
usually done by your gynecologist or by an endocrinologist.
If you’re an adult male who has acne, an endocrine evaluation is
rarely performed. You may be asked about medications and hormonal
supplements as well as general questions about your health
and your sex life. In very rare occasions, your doctor may suspect
an underlying disorder such as adrenal hyperplasia (see the section
later in this chapter), and may order an endocrine evaluation.
Make sure that you tell your doctor if you take any anabolic
steroids because they can produce persistent acne in men.
If your dermatologist, gynecologist, or primary healthcare provider
suspects androgen excess, he would probably order the following
screening blood tests:
Free testosterone levels: Elevations of free testosterone will
often determine whether further testing is necessary. Free
testosterone is the testosterone that’s not bound to your sex
hormone binding globulin (SHBG). When it’s elevated, it can
stimulate your acne-producing hair follicles and sebaceous
glands. It is also “free” to cause other masculinizing signs and
symptoms. For more on free testosterone and SHBG, see
Chapter 11.
Dehydroepiandrosterone sulfate (DHEAS): This chemical is
used as a marker to see whether the adrenal glands are the
source of excess androgen output.
These tests may determine if you have androgen excess and may
provide clues to the origin of your excessive androgen production.
If an abnormality is indicated by any of these blood tests as well as
other sophisticated tests that may be out of the normal range,
your doctor may recommend an evaluation by an endocrinologist.
This doctor is a specialist in the study of the glands and hormones
of the body and their related disorders (known as endocrinology).
Alternatively, you may be referred to a gynecologist knowledgeable
in endocrinology.
Chapter 20: Reviewing Endocrine Disorders Associated with Acne 245
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Considering the most common cause
of androgen excess: PCOS
In females, polycystic ovary syndrome (PCOS) is the most common
cause of androgen excess. The name comes from small cysts found
in women’s ovaries.
This disorder is characterized by menstrual irregularities, hirsutism,
acne, ovarian cysts, varying degrees of insulin resistance,
and often, obesity. Women with PCOS have a much higher risk of
miscarriage. Many women are unaware that they have this disorder.
PCOS has also been called ovarian androgen excess because
the ovaries produce androgens in increased amounts. Because
acne is influenced by androgens, it’s not surprising that acne is a
major symptom of PCOS.
Making the diagnosis
After reviewing your medical history and your family history, your
physician will determine which tests are necessary. He may ask if
you have been unable to become pregnant, or if there is type 2 diabetes
in your family, which might make him more suspicious that
you are more likely to have PCOS. Elevated androgen levels, DHEAS,
or free testosterone, as I discuss earlier, help make the diagnosis of
PCOS. The diagnosis is also aided by a physical exam and pelvic
ultrasound (a noninvasive way to tell if you have ovarian cysts).
Most physicians will consider diagnosis of PCOS only after making
sure you don’t have other conditions such as Cushing’s disease
(overactive adrenal gland) or congenital adrenal hyperplasia —
both of which are described later in this chapter.
One of the major features of PCOS is insulin resistance. This occurs
when your body cells don’t respond to even high levels of your own
insulin. This causes glucose (sugar) to build up in the blood and can
result in type 2 diabetes. (Type 2 diabetes used to be known as adult
onset diabetes.) It’s believed that the higher levels of blood insulin
produce an increase in ovarian androgen production, particularly
testosterone, and a decrease in concentrations of SHBG, the protein
in charge of “mopping up” free testosterone (see Chapter 11).
Treating PCOS
Although this condition isn’t curable, there are several approaches
to correct the hormonal imbalance and symptoms of PCOS.
PCOS can be treated with medications used for the treatment of
type 2 diabetes such as insulin-lowering therapy. Anti-androgen
246 Part IV: Dealing with Scars and Associated Conditions
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medications such as birth control pills, spironolactone, and flutamide
have been shown to reverse the endocrine abnormalities
seen with PCOS; these medications also help in decreasing hair
loss, diminishing facial and body hair growth, normalizing the menstrual
cycle, producing weight loss, and, of course, reducing acne
lesions. These hormones are reviewed in Chapter 11.
Touching On Other
Endocrine Disorders
Acne is a symptom of several hormonal disorders. They include
congenital adrenal hyperplasia, Cushing’s disease, and Cushing’s
syndrome. In all of these disorders, the body produces excess corticosteroids.
These corticosteroids can have androgen-like activity.
A detailed discussion of the features and treatment of these entities
is beyond the scope of this book; however, I briefly describe
them in the next few sections.
Congenital adrenal hyperplasia
Congenital adrenal hyperplasia (CAH) is caused by a missing
enzyme (a protein that causes a chemical change in other substances
without being changed itself) that your body needs to
Chapter 20: Reviewing Endocrine Disorders Associated with Acne 247
Recognizing and treating PCOS
Angela, a 17-year-old girl, came to my office and told me about the difficulty that
previous doctors had in managing her acne. Her mother said that Angela had still
not gotten her first period and it was quite obvious that she was markedly overweight.
(She weighed 180 pounds and was only 5 feet tall.)
Angela’s acne was severe and she had excessive hair growth on her face. It was
apparent to me that she might have the endocrine abnormality known as polycystic
ovary syndrome (PCOS) or another similar endocrine problem. I referred her to
an endocrinologist, who, after obtaining a series of blood tests, diagnosed Angela
as having PCOS. Her blood tests revealed that she had elevated androgens and evidence
of insulin resistance. The endocrinologist started Angela on a medication
that improved her sensitivity to insulin and she was also given anti-androgen hormones
pills to take.
She lost 20 pounds; her periods began after six months of treatment, and her acne
improved. The therapy also reduced some of her hirsutism. With the proper treatment,
Angela has been able to live a normal life and now has two healthy children.
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function properly. The missing enzyme results in an overproduction
of male hormones (androgens).
The most common type of CAH results from low production of an
enzyme of the adrenal gland called 21-hydroxylase. Mild forms of
the disease (called nonclassical CAH) result in symptoms such as
severe acne, excess facial and/or body hair (hirsutism), early
development of pubic hair, receding scalp hairline, menstrual disturbances
in females, and infertility in both males and females.
Cushing’s disease and
Cushing’s syndrome
Acne, or more accurately, “acnelike” lesions, can be seen in
Cushing’s disease and Cushing’s syndrome.
Cushing’s disease is the name given to a condition caused by a pituitary
tumor that secretes excessive amounts of adrenocorticotropic
hormone (known as ACTH). This hormone stimulates the adrenal
glands to produce excessive amounts of the hormone cortisol.
Other tumors or conditions also may lead to excess secretion of
cortisol such as tumors of the adrenal glands. This closely related
disease is called Cushing’s syndrome. Most often, Cushing’s syndrome
is caused by taking steroid hormones for long periods of
time, particularly in high doses.
The symptoms include upper body obesity, a rounded (“moon”)
face, increased fat around the neck, and thinning arms and legs.
Other symptoms include fatigue, weak muscles, high blood pressure,
and high blood sugar.
Women usually have excess hair growth on their faces, necks,
chests, abdomens, and thighs. Their menstrual periods may
become irregular or stop. Men have decreased fertility with diminished
or absent desire for sex.
The “acne” appears to be more akin to a folliculitis and consists of
papules and pustules. Lesions usually arise on the chest and back
and, in time, disappear when the oral cortisone is stopped, or
when the levels of cortisone become normal after Cushing’s disease
and Cushing’s syndrome are properly treated.
Blood and urine cortisol tests, together with the determination of
adrenocorticotropic hormone (ACTH), are the three most important
tests in the investigation of these conditions caused by an
overproduction of cortisol.
248 Part IV: Dealing with Scars and Associated Conditions
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Part V
The Part of Tens
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In this part . . .
Ah, the Part of Tens. It’s like the icing on the cake. In
this part, I provide you with ten great Web sites to
learn more about acne and rosacea, I provide ten of my
best tips for keeping your skin looking and feeling healthy,
and I tell you about ten things that you should never do to
your face. Enjoy.
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Chapter 21
Ten Terrific Acne and
Rosacea Web Sites
In This Chapter
Searching the Internet
Taking in the sites
You can find a wide range of resources related to acne on the
Internet. Many of them make fraudulent claims about their
ability to “cure” your acne and are simply after your money.
Instead of wandering aimlessly though the Web, I’ve done some
clicking on my own for you and checked all of the sites that are
mentioned in this chapter. They’re chock-full of information and
advice about acne and rosacea.
AcneNet
www.skincarephysicians.com/acnenet/index.html
This site is brought to you by the fine folks at the American
Academy of Dermatology (www.aad.org), the largest of all dermatologic
associations. It has a membership of more than 14,000
physicians worldwide. AcneNet is billed as “A comprehensive online
acne information resource,” and it lives up to its name. You
can read more about tips, myths, and treatments, and you can
locate a dermatologist in your area. Plus, if you back up the URL a
bit to www.skincarephysicians.com, you can find all sorts of
additional skin-care information and resources from the experts.
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American Society for Dermatologic
Surgeons
www.asds-net.org
The ASDS represents specialists in dermatologic surgery. This
organization is comprised of experts in the diagnosis and surgical
and cosmetic treatment of diseases of the skin, hair, and nails. This
site can tell you about various procedures, technologies, and the
latest techniques that are available to dermatologic surgeons. It
also provides many helpful links for members and the general
public to search for more information on dermatology, dermatologic
surgery, and related topics on the Internet.
DermNet NZ
http://dermnetnz.org/acne
The New Zealand Dermatological Society sponsors this site used
by both medical practitioners and consumers. Besides acne and
rosacea, this site also has information about many other skin diseases
and their treatment.
eMedicine.com
www.eMedicine.com
This site has a wealth of the most current information about diseases
and disorders. It’s available to physicians, other healthcare
professionals, as well as the public. Nearly 10,000 physician
authors (I’m one of them) and editors contribute to it.
The consumer health site, www.eMedicineHealth.com, contains
articles written by physicians for the consumer. To access the acne
information, simply scroll down to the “Topics” section and click
on the “A” link, which brings you to the “Acne” link (along with
links to all the other “A” conditions). There are also numerous
links that tell you about the latest in health news.
252 Part V: The Part of Tens
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MedLine Plus: Acne
www.nlm.nih.gov/medlineplus/acne.html
MedlinePlus is a service of the U.S. National Library of Medicine
and the National Institutes for Health. On this site, you can find
links to the latest acne news on acne treatments, various acnerelated
directories, and a skin-type calculator, among others. They
also have an interactive acne tutorial. And if you’ve never checked
out MedLine Plus (www.nlm.nih.gov/medlineplus), take a spin
around the site — it has tons of information on whatever ails ya.
Omni: Acne Vulgaris
http://omni.ac.uk/browse/mesh/D000152.html
Omni is a U.K.-based Web catalog of Internet information on health
and medicine. This site has a great deal of information and educational
material about acne. Besides acne, it also has patient education
handouts that cover other health-related problems.
RosaceaNet
www.skincarephysicians.com/rosaceanet
Also brought to you by the American Academy of Dermatology
(see “AcneNet,” earlier in the chapter), this site focuses on the
signs, symptoms, and the latest treatments for rosacea.
Stop Spots
www.stopspots.org
This site for teens and young adults from U.K.-based Acne Support
Group presents a number of top-ten lists, including their top ten
acne tips, top ten beauty tips, and top ten problems folks with
acne face. And you thought it was only the fabulous folks at For
Dummies and a certain late-night talk show host that brought you
great top ten lists!
Chapter 21: Ten Terrific Acne and Rosacea Web Sites 253
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Acne Support Group
www.m2w3.com/acne
Written in a user-friendly style, this U.K.-based site provides information
and support for those who have acne or rosacea. It describes
many of the facts and fictions about these skin conditions and it
offers sensible advice about how to deal with them. It also has
links to many other valuable sites.
Dermatology in the Cinema
www.skinema.com
This site is awesome! It’s maintained by a dermatologist/film buff.
It features images of skin conditions that have been depicted in the
movies by using the Hollywood magic of makeup. It also has
images of some of Hollywood’s biggest stars that are shown with
their real skin conditions — warts, acne, and all!
254 Part V: The Part of Tens
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Chapter 22
Ten Tips for Healthy Skin
In This Chapter
Saving your own skin
Protecting your protector from sun damage and skin cancer
Reducing its shine
Keeping your skin from drying out
Handling your skin with TLC
That’s right. You don’t see the word acne in the title of this chapter.
And although the subject comes up here, it’s not my primary
focus. As a dermatologist, healthy skin is my thing. So, I wanted to
provide you with some tips and tricks to keep your skin healthy
throughout your life. Just think — you’re going to get your acne
under control one day, but you’ll have the skin you’re in for the rest
of your life. So, treat it right. In this chapter, I show you how.
Steering Clear of Excessive
Sun Exposure
The sun is an immense nuclear reactor. As well as producing heat
and light, it also sends out other types of radiation that can sometimes
damage your skin. The Earth’s atmosphere filters out much
of the more dangerous solar radiation, but some of it gets through —
mainly in the ultraviolet (UV) band. The UV radiation in sunlight can
cause painful sunburns and certain types of skin cancer, and can
also age your skin.
If you have a personal or family history of skin cancer or you have
very fair skin that never tans but always burns, do whatever possible
to minimize sun exposure. If you have skin of color or are naturally
very dark complexioned, you can probably ignore the following
advice unless you develop allergic reactions from the sun, take medications
that may make you extra sensitive to the sun, or have a
medical condition that sunlight worsens.
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The best way to prevent skin damage from the sun besides moving
to the Antarctic — oops, never mind, I forgot about the hole in the
ozone layer there — is to avoid excessive exposure to UV and the
sun. You can accomplish this by following these tips:
Shun the sun between 10 a.m. and 4 p.m, especially during
late spring and summer when the sun is most intense.
Wear protective headgear such as a hat with a wide brim to
protect your face, head, and the back of your neck. You can
also wear a baseball cap, long-sleeved shirts, and long pants.
Be aware of reflected light from sand, water, or snow.
Avoid tanning parlors.
Slather on the sunscreen with an SPF of 15 or greater — at least
30 minutes before sun exposure, even on cloudy, hazy days.
Reapply sunscreens liberally and frequently at least every two
to three hours, and after swimming or sweating.
Choose a broad spectrum sunscreen that blocks both UVB
(the burning rays) and UVA (the more penetrating rays that
promote wrinkling and aging).
If you’re a person of color and have the dark spots of PIP, they’re
often further darkened by sun exposure. A broad-spectrum sunscreen
will offer you the best protection. (I cover PIP in Chapter 12.)
Opting for Sunless Tanning
Sunless tanners, sometimes referred to as self-tanners or tanning
extenders, are promoted as a way to get a tan without the sun. You
can try:
Self-tanners: These artificial tanning preparations contain
dihydroxyacetone (DHA). DHA interacts with dead surface
cells in the outermost (horny) layer of your epidermis and
produces a color change. As the dead skin cells naturally
slough off, the color gradually fades back to your normal skin
color, typically within five to seven days after a single application.
DHA-containing products are available as lotions,
creams, sprays, and gels and aren’t considered to be harmful.
Airbrush tanning using DHA is now offered in salons.
Bronzers: The term “bronzer” refers to a variety of products
used to achieve a temporary tanned appearance. These products
contain a transparent color additive that also stains the
outermost layer of your skin. You can choose a bronzing gel
or cream that enhances your own skin color. The chemicals in
256 Part V: The Part of Tens
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bronzers may react differently on various areas of your body,
producing a tan of many shades. It can be washed off with
soap and water at the end of each day. Bronzers are also considered
to be harmless.
Although self-tanners and bronzers give the skin a golden brown
color, these products don’t offer protection from the damaging effects
of UV radiation unless they also contain sunscreen ingredients.
Clinique, Estee Lauder, Clarins, and Bain de Soleil all offer sunless
tanning products. Neutrogena has foams that are easy to apply to
areas with body hair.
Other means of producing a tan without the sun, including tanning
pills (which contain color additives) and tanning “accelerators”
(which contain other chemicals), should be avoided. According to
the FDA, there is a lack of scientific data showing that they work; in
fact, at least one study has found them ineffective.
Dimming the Shine of Oily Skin
If you have oily skin — you’re lucky! Oily skin has great advantages.
Your skin will probably be less likely to wrinkle, age, and sag. On
the other hand, it may feel greasy and develop shiny patches even a
short time after you wash it. The highest concentration of sebaceous
glands is in the T-zone, and the excess sebum from this area
plus the sweat glands on the skin can make your skin look even
greasier and shinier. (Take a look at Chapter 4 to see the T-zone.)
But you can temporarily squelch the shine with many products now
available such as blotting papers, oil-absorbing powders, and foundations.
Even the application of medicated prescription products
such as retinoids and benzoyl peroxide are temporary cosmetic
maneuvers that remove the surface oil. The deeper oils (sebum) are
bound to keep flowing despite what you do to the surface.
You can try tackling T-zone oiliness with Clinac O.C. (Oil Control)
Gel, which can be purchased without a prescription. It mops up
excess sebum without drying the skin. In addition, if you’re looking
for a matte finish, you can try a “mattifier,” a shine-stopping product
that helps absorb oil on your face and, ideally, prevents oil
from breaking through. The following are a few suggestions:
Neutrogena Pore Refining Mattifier Shine Control Gel
Lancome Pure Focus T-Zone Mattifier
Loreal Hydra Mattify
Chapter 22: Ten Tips for Healthy Skin 257
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Humidifying Dry Skin
If your skin is excessively dry, it may be due to a diminished production
of sebum, reduced sweat activity, and environmental factors.
Xerosis, or dry skin, can affect anyone, but it tends to be more
severe in certain folks, especially those with a hereditary predisposition.
Modern lifestyles are also a contributing factor. In Western
societies, we tend to over-bathe; use of harsh soaps and hot water
also contribute. Xerosis is a common occurrence in winter climates,
particularly in conditions of cold air, low relative humidity,
and indoor heating.
Use moisturizers to help with dry skin. Moisturizers don’t add
water to the skin, but they help to retain or “lock in” water that was
absorbed during your shower or bath. Therefore, apply a moisturizer
while your skin is still damp. The choice of product is based on
personal preference, ease of application, cost, and effectiveness.
You can find numerous over-the-counter preparations in ointment
bases, cream bases, and lotions. Eucerin, Nivea, Aquaphor, Oil of
Olay, Moisturel, and Curel are just a few of the popular name
brands. Am-Lactin (ammonium lactate 12 percent) lotion or cream
is applied after bathing. It is very effective and is used for more
severe cases of xerosis and may be purchased over the counter. If
your skin is really scaly and dry, you can also get special, heavyduty
moisturizers that are available by prescription only.
Soothing Sensitive Skin
Acne medications, many of which are irritating in the first place,
can wreak havoc with sensitive skin. Applying bland moisturizers
such as Oil of Olay and Cetaphil Lotion over acne medications and
using soap-free, gentle cleansers designed for sensitive skin is particularly
important for people who have an underlying skin condition
such as eczema (atopic dermatitis).
Women who have sensitive skin or eczema should discard cosmetics
that have been on the shelf for a long period. That’s because
they can become contaminated if some of their preservatives
break down or oxidize over time.
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Promoting a Youthful Glow
If you’re looking for ways to promote that “youthful glow” of your
skin, there are many new skin-care developments designed to do
just that:
Renova: Available only by prescription, this is an anti-aging
cream that contains the active ingredient retinoic acid.
Retinoic acid has been sold for years under the brand name
Retin-A and used for the treatment of acne, which I cover in
Chapter 9. The drug is approved by the FDA for the treatment
of sun-damaged skin. Precautions for use of Renova are the
same as those for tretinoin and the other retinoids.
Fruit acids: Products that contain natural fruit acids (alpha
hydroxy acids or AHAs) such as glycolic acid are now very
popular. They claim to “rejuvenate” the skin by encouraging
the shedding of old, sun-damaged surface skin cells, which
promotes a fresher, healthier look with a more even color and
texture. There are many products with varying concentrations
of various fruit acids in differing bases. Those available from
medical practitioners are stronger than those at pharmacies
and beauty therapists. AHAs can be alternated with other topical
anti-aging preparations including retinoid creams. Check
out Chapter 14 where I talk more about AHAs.
Caring for the Bumps
Use the gentlest skincare products available if you have acne,
rosacea, or razor bumps. Tender loving care is the byword. Treat
your skin as gently as possible. Often, people suffer from their own
overtreatment. Strong soaps, harsh exfoliants, loofahs, and rough
washcloths are much too irritating.
Soap cleansers such as Basis soap, Eucerin Bar, Purpose Soap, and
Neutrogena Cleansing Bar are all mild enough for daily washing.
Non-soap cleansers include Liquid Neutrogena Cleansing Formula,
Aquinil Lotion, and Cetaphil Lotion.
Minimizing Stress
Easier said than done, I realize. Although stress doesn’t cause acne,
many believe that it can trigger flare-ups. That’s because when the
body encounters stress, it steps up production of cortisol, which
causes the sebaceous glands to produce more oil.
Chapter 22: Ten Tips for Healthy Skin 259
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The best course of action is to keep tabs on your own personal
response, and to try to make time every day for the things that
make you feel relaxed and happy. Exercise, meditate, get a good
night’s sleep, and eat a healthy diet. You’ve got nothing to lose.
Visiting a Dermatologist
If you may permit me to brag, we dermatologists have the important
skills that come with focused, repetitive, visual scrutiny and
education regarding your skin. The ability to make diagnoses and
to identify benign versus malignant lesions is our specialty. And, of
course, we’re the experts when it comes to treating acne.
So if you can’t manage your acne on your own or you’re not getting
very far with prescription medications given to you by your healthcare
provider, make an appointment to see one of us.
After you have a dermatologist, if you wake up one morning with a
big zit and you have an important day coming up, call her office.
Tell the person at the appointment desk about your problem. If it’s
during the week when your doctor has office hours, she’ll be more
likely than not to ask you to come in for an intralesional cortisone
injection. It can flatten the bump within 24 to 48 hours. I describe
this procedure in Chapter 10.
If that big day is today, do your best to hide the zit with makeup.
Creative use of cosmetics can help conceal the redness of pimples,
and green-tinted makeup can offer extra coverage.
Giving Yourself a Break
New products are constantly introduced to “correct” our “flaws,”
and draw us into an attempt to reach an impossible standard of
beauty. Movies, advertisements, and TV present unrealistic images
of youth and beauty in our image-obsessed culture. Infomercials,
Internet ads, magazines, and yes, doctors, may promote — and
sometimes exploit — the latest “miracle” cosmetic, diet, or plastic
surgical techniques and promise you the “fountain of youth.”
There is profound truth to the old proverbs — “beauty is only skin
deep” and “it’s what’s inside that counts.”
Relax and look at the glass as half full, rather than the idea that it is
half empty. And remember — zits and pores get bigger the closer
you look at them!
260 Part V: The Part of Tens
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Chapter 23
Ten Things You Should
Never Do to Your Skin
In This Chapter
Popping pimples is forbidden . . . most of the time
Smoking is prohibited all of the time!
Irritating your skin unnecessarily
Resisting fly-by-night cures and the urge for instant gratification
Your skin is your protector that meets and greets your external
world. As your body’s largest organ, the skin serves as a
waterproof covering that helps keep out foreign invaders and protects
against temperature changes and sunlight. Your skin is tough
and it can take a lot of punishment, but some things can make it
look bad and weaken it. In this chapter, I review some actions that
are harmful to your skin.
Picking, Popping, or Squeezing
Popping zits doesn’t make things better; in fact, it often makes
things worse. I realize that it’s tempting to think that squeezing them
will help them heal more quickly — especially the swollen, red
goobers filled with stuff! But scrunching these guys only pushes the
inflamed gunk deeper and wider into the skin and that’s what most
often results in scars. So, lay off the lumps! Having said all that, I
realize that it’s hard to resist a squeeze or two here and there, but
only do so when dealing with blackheads and whiteheads.
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If you’re a do-it-yourselfer or plan to become a dermatologist or a
cosmetologist, you can buy your own comedo extractor at a medical
supply company. Better yet, see a dermatologist or go for a facial to
have your blackheads and whiteheads extracted professionally.
Pre-tanning at a Salon
Pre-tanning at a tanning salon to get ready for the intense sun at
the beach isn’t the great idea that it’s been cut out to be. In fact,
whether you acquire a tan quickly or slowly, you still damage your
skin. Just like the sun, artificial tanning equipment beds and sun
lamps emit UV rays that can cause burns, premature aging, and
skin cancers, especially if you’re a higher risk, fair-skinned person
who produces less melanin.
Smoking
You’ve heard about the risks of smoking (like lung cancer, heart
disease, and emphysema). But have you ever noticed that the skin
of elderly smokers tends to have a yellowish coloration? Next to
sun exposure, smoking is the highest factor in wrinkling. In other
words, smoking makes you look older!
The nicotine in cigarette smoke also causes small blood vessels
and capillaries of the skin to contract. This diminishing circulation
deprives the skin of much essential oxygen it needs to create and
maintain healthy skin cells.
There’s no controversy about this one — don’t smoke!
Taking Too Much Vitamin A
You may have heard that vitamin A helps to cure acne. What you
may not know is that if you take too much of it, vitamin A can accumulate
in your liver to dangerous levels and cause serious health
problems. Get your vitamin A from veggies. Good sources include
leafy greens (like spinach and watercress) and orange veggies (like
sweet potatoes, pumpkin, and carrots).
There are safer derivatives of vitamin A to treat your acne — topical
retinoids and oral Accutane — that your healthcare provider can
prescribe.
262 Part V: The Part of Tens
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Traveling the Perilous Peel
and Dermabrasion Route
If your complexion is dark, you may run the risk of having streaking,
uneven pigmentation after chemical peel or dermabrasion procedures.
Moreover, if you scar easily or tend to form keloids, you
should probably consider these procedures as being potentially
too risky.
Get a second or third opinion from practitioners experienced in
these procedures on patients with your type of skin before embarking
on something you might regret.
Treating Rosacea with Over-the-
Counter Medications
Don’t try to go it alone when you have rosacea. You should discuss
your rosacea skin-care with a dermatologist. That’s because folks
who have rosacea tend to have red, inflamed, sensitive skin.
Consult with a dermatologist before experimenting with untried
products. And definitely check out Chapter 18 for more tips on
treating rosacea.
Applying Topical Steroids
to Your Face
Okay, if you have a mild rash or itch, you can go to your local store
and buy the over-the-counter, low-strength cortisone cream or
ointment to treat the symptoms for a few days or so. However,
don’t make it a regular habit and use the stuff every day! It can
cause acne and potentially thin your skin if you use it continuously.
You definitely should not use a potent prescription-strength topical
steroid on your face without being instructed to by your doctor or
dermatologist. Steroid-induced rosacea and skin thinning are much
more likely to occur with the high potency spreads. Go to Chapter 18
to find out more about topical steroid-induced rosacea.
Chapter 23: Ten Things You Should Never Do to Your Skin 263
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Shaving with Four-In-One
Razor Blades
If you have acne, shaving bumps, or sensitive skin, those razors
that guarantee the closest shaves aren’t for you. Ignore the ongoing
battle between razor companies to see who can stick the most
blades on a single disposable razor head. Besides costing an arm
and a leg, two, three, or four incredibly sharp blades will wind up
shaving you two, three, or four more times closer than is necessary
and really irritate your skin!
Easy does it. Let your hairs grow a little and when you do shave
use a single blade safety razor such as the Aveeno PFB Bump
Fighter Razor. I discuss razor bumps in Chapter 19.
Using Mystery Products
If it sounds too good to be true, it probably isn’t true.
You may hear about alternative medications from friends, relatives,
or the news media. Ads may suggest that alternative treatments
can produce positive results in patients who have acne or rosacea.
Exercise caution — some of these drugs may have fraudulent
claims, and others may even hurt you. Herbs can be as toxic and
dangerous as prescription drugs. Look out for and avoid:
“Secret” formulas (real scientists share what they know)
Amazing breakthroughs or miracle cures (real breakthroughs
don’t happen every day, and when they do, real scientists
don’t call them “amazing’ or “miracles”)
Guaranteed cures
The problem with herbal medications is that it’s hard to know
exactly what’s in them because there is no regulation regarding
their contents. For example, there have been reports of actual
harm caused by St. John’s wort, which has been found to make
some people more sensitive to the sun.
Let your healthcare provider or dermatologist know about any of
these products you may be taking or are considering taking.
264 Part V: The Part of Tens
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There have been reports of severe toxic reactions, so you should
be very cautious before trying anything that is untested.
Looking in the Mirror too Much
If you’re undergoing treatment for your acne, you should know that
it won’t improve overnight and by examining it continuously, you
just magnify any flaws — real or imagined.
When you apply makeup, use a “soft focus” with your eyes and
don’t take magnified close-up looks at your zits or comedones.
You’ll be amazed at how quickly your skin will improve if you
ignore it for a few days at a time while your medications have a
chance to work!
Chapter 23: Ten Things You Should Never Do to Your Skin 265
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266 Part V: The Part of Tens
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Part VI
Appendixes
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In this part . . .
Iprovide you with some easily accessible and useful
information that includes a glossary of terms you may
run into at the dermatologist’s office or the on the drugstore
shelves and an international list of brand name acne
medications.
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Appendix A
Glossary
Accutane: Powerful drug derived from vitamin A that’s used in the
treatment of severe acne. The generic name is isotretinoin. If
taken during pregnancy, it’s highly likely to cause severe birth
defects.
Acne: Skin condition characterized by plugging and inflammation
that involves the hair follicles and sebaceous glands. It can take
many forms including blackheads, whiteheads, papules, pustules,
and nodules.
Acnegenic: Topical or oral products that produce or worsen acne
lesions.
Acne vulgaris: Medical term for common acne.
Active ingredient: The chemical in a medication that does the
work for which the product is designed.
Adult-onset acne: Overwhelmingly a condition of females, this type
of acne turns up after the age of 18. It can crop up in a woman’s
20s, 30s, or even later in life. It’s sometimes referred to as female
adult acne or post-adolescent acne.
Alpha hydroxy acids (AHAs): Fruit acids found in plants; constituents
of many over-the-counter acne and cosmetic products,
such as moisturizers and sunscreens. Also used in chemical peels.
Androgens: General term for hormones that have masculinizing
features. Both males and females produce them. They cause the
sebaceous gland to enlarge and produce more sebum, an important
factor in the development of acne.
Antibiotic: Large category of drugs that has the ability to kill or
inhibit the growth of bacteria.
Astringent: Solution that removes oil from the skin. Often used
after a facial wash to remove any remaining traces of a cleanser.
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Atrophy: A wasting away; a decrease in size of a tissue or body part.
Azelaic acid: Natural chemical produced by yeast. Used as a topical
agent to treat acne and rosacea. It can also be used to lighten
the skin.
Basal layer: The lowermost layer of the epidermis. This layer provides
replacement cells that travel upward and replenish the skin
with new cells.
Benzoyl peroxide: Topical antibacterial agent used to treat acne.
Found in more over-the-counter and prescription products than
any other topical agent.
Beta hydroxy acids (BHAs): A class of acids, including salicylic
acid, that are used as exfoliants. They’re found in many over-thecounter
acne and cosmetic products, such as moisturizers and
sunscreens. They’re also used in chemical peels.
Blackhead: An open comedo. The dark acne lesion that consists
of a plug of keratin and sebum. The dark color is due to a buildup
of melanin.
Blue light therapy: Visible light treatment that works by killing the
acne-producing bacteria, P. acnes, for a short period of time.
Chemical peel: Application of chemicals to the face in order to
exfoliate the outer layer of skin cells.
Clindamycin: Topical antibiotic often used in the treatment
of acne.
Closed comedo: See whitehead.
Collagen: Resilient protein that provides rigidity and strength to
the dermis. Plays a major role in repairing damage to the skin and
the development of all scars, including acne scars.
Comedo: Plug of keratin and sebum within a hair follicle. It can
appear as a blackhead or a whitehead. The plural form is
comedones.
Comedo extraction: A procedure performed with a round loop
that’s used to apply pressure to dislodge the contents of blackheads
and whiteheads.
Comedogenic: Products that induce the formation of comedones
(blackheads and whiteheads).
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Comedogenesis: Medical term for the process that forms whiteheads
and blackheads.
Comedolytic: Signifies that the product breaks up and inhibits
comedo formation.
Comedonal acne: See non-inflammatory acne.
Contact dermatitis: Allergic reaction or irritant response to things
that have touched your skin. Poison ivy and poison oak are classic
examples.
Corticosteroid: Natural hormones produced in the adrenal glands.
When used therapeutically, they are powerful anti-inflammatory
drugs used to treat many types of inflammation.
Cyst: A fluid-filled mass that is usually benign. When someone has
acne, the term cyst is often used interchangeably to mean nodule
because of the resemblance of a nodular acne lesion to a cyst.
Depilatories: Creams, lotions, or powders that contain chemicals
that split the chemical bonds in hair, breaking them off slightly
below the surface of the skin.
Dermabrasion: Method to remove the skin’s top layers and reduce
acne scars using a rapidly rotating wheel or brush attached to a
motorized handle to perform high-speed sanding. Newer technologies,
such as lasers, have largely supplanted this procedure.
Dermatitis: Irritation or inflammation of the skin. A general term
that refers to an itchy red rash. It is sometimes called eczema.
Dermis: Layer of the skin just beneath the epidermis. Contains
blood and lymphatic vessels, hair follicles, nerves, and glands.
Also called the cutis.
Doxycycline: An oral tetracycline antibiotic used to treat acne
and rosacea.
Eczema: See dermatitis.
Elastin fibers: Found in the dermis, these protein structures are
able to coil and recoil like a spring. They give the skin its elasticity.
Electrolysis: A permanent way to remove hair. It destroys hairs
with electrical or thermal energy.
Appendix A: Glossary 271
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Emollient: Topical applications that are used to correct dryness
and scaling of the skin.
Endocrine system: System of ductless glands that regulates bodily
functions via hormones secreted into the bloodstream. Includes
the hypothalamus, pituitary gland, thyroid, adrenal glands, and
gonads (ovaries and testes).
Endocrinopathy: A disease of endocrine glands. A medical term
for a hormonal disorder.
Enzymes: Proteins that cause a chemical change in other substances
without being changed themselves.
Epidermis: Outer layer of the skin that lies upon the dermis.
Erector pilorum: See hair erector muscle.
Erythromycin: Oral and topical antibiotic that’s often used in the
treatment of acne.
Estrogen: Female hormone produced in the ovaries and adrenal
glands.
Exfoliation: Removal of the outer layers of skin. It can be achieved
with scrubs, glycolic and salicylic acids (chemical peels), as well
as by microdermabrasion.
Fibroblasts: Cells that produce collagen.
Folliculitis: Inflammation of the hair follicles. It can be due to
infections or eczema.
Hair canal: Part of the hair follicle through which sebum travels
onto the hairs before it is carried out to the exterior of your skin.
Hair erector muscle (erector pilorum): Muscle connected to each
hair follicle and the skin. When it contracts, it results in an erect
hair and a goosebump on the skin.
Hair follicle: Tube-shaped covering that surrounds the part of the
hair that is under the skin. Blockage of the follicle is produced by a
follicular plug and is an important step in the formation of acne.
Heredity: Genetic transmission of a particular quality or trait from
parent to offspring.
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Hirsutism: Excessive growth of thick dark hair in locations where
hair growth in women usually is minimal or absent. Usually occurs
in androgen-stimulated locations, such as the face, chest, and
around the nipples. May be a sign of polycystic ovary syndrome
in women.
Hormones: The body’s chemical messengers produced by the
endocrine glands. They travel through the bloodstream and have
specific effects on cells and organs in other parts of the body.
Hydroquinone: Chemical that’s used to lighten (bleach) the skin.
Hyperpigmentation: Abnormal darkening of the skin that can
follow inflammation; caused by higher amounts of melanin in a
particular spot. It can also result from hormones and sun exposure.
Hypertrophic scar: Scars that bulge outward like hard lumps. The
word hypertrophy means “enlargement” or “overgrowth.”
Inflammation: A reaction of the skin to disease or injury.
Inflammatory acne: In this type of acne, papules or pustules, red
or purple macules, and nodules, often termed “cysts,” are predominant.
There are few, if any, comedones.
Intense pulsed light treatment (IPL): Devices similar to lasers but
use a wider range of wavelengths as opposed to only a single beam
of light. They employ a broad band of visible and near infrared
wavelengths of light that block out other wavelengths. It is hoped
that they may able to affect the growth and activity of the sebaceous
gland and help to treat acne.
iPLEDGE: An isotretinoin federal registry program geared toward
reducing the number of birth defects, miscarriages, and abortions
associated with isotretinoin. The registry keeps tabs on all
isotretinoin prescriptions in the United States.
Isotretinoin: Chemical (generic) name for Accutane.
Keloid: Large scar whose size goes far beyond what would be
expected from what seems to be a minor injury.
Keratin: Tough, fibrous protein that is inside the cells of the epidermis.
It’s also a constituent of hair and nails.
Keratinization: A process through which keratinocytes produce
the protein keratin.
Appendix A: Glossary 273
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Keratinocytes: Make up the majority of the cells in the epidermis.
Keratosis pilaris: A condition of small, rough patches that tends to
be mistaken for acne. It usually appears on the arms and sometimes
on the cheeks.
Laser: Lasers produce single (concentrated) bands of light that can
penetrate into the dermis without injuring the epidermis. They’re
used to treat acne and its scars. When used to treat acne, the
beams are adjusted to penetrate below the epidermis and travel
into the dermis where they can zero in on hair follicles, sebaceous
glands, and the P. acnes bacteria.
Lesion: A mark in the skin. In dermatology, refers to a sore, growth,
blister, or any other type of tissue damage caused by injury or
disease.
Lipocytes: Fat cells.
Macule: Flat red, purple, or brown lesion that forms where a
papule or pustule used to be. Remains visible for a while after an
acne lesion has healed or is in the process of healing.
Melanin: Substance that gives the skin and hair its color and protects
us against UV radiation.
Melanocyte: Cell in the epidermis that produces melanin.
Menopause: End of menstruation. The stage in life when women no
longer have periods.
Menstruation: The periodic flow of blood from the uterus. Irregular
menses can indicate a hormonal imbalance that can worsen acne.
Metronidazole: An antibiotic and antiparasitic drug that’s used
topically to treat rosacea.
Microcomedo: First stage of comedo formation; a comedo so small
that it can be seen only with a microscope.
Microdermabrasion: Technique that uses aluminum oxide crystals
passing through a vacuum tube to exfoliate surface skin.
Minocycline: An oral tetracycline antibiotic used to treat acne
and rosacea.
Nodule: A large and lumpy, pus-filled, frequently reddish bump
that is lodged more deeply in the skin. They are inflammatory
lesions that are sometimes referred to as cysts.
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Noncomedogenic: Skin-care products that have been tested and
proven not to clog pores and produce comedones.
Noncomedonal acne: See inflammatory acne.
Non-inflammatory acne: This category of acne is identified when
a person’s lesions are primarily whiteheads and blackheads. It is
also called comedonal acne.
Ocular rosacea: Rosacea that involves the eyes.
Open comedo: See blackhead.
Oral contraceptives: Drugs used to help prevent an unwanted
pregnancy. If you’re female, your doctor may also prescribe them
to fight acne by virtue of their anti-androgenic effects.
Oral therapy: Something that’s taken by mouth such as a pill, capsule,
or liquid.
Papule: Pimples (zits) that appear as small, firm, reddish bumps
on the skin. They are inflammatory lesions.
Perimenopause: The transitional period from normal menstrual
periods to no periods at all.
Perioral dermatitis: Also known as periorificial dermatitis, this condition
is a rosacea-like skin eruption seen almost exclusively in
young women.
Pilosebaceous unit: Grouping of the hair follicle and its attached
sebaceous gland.
Polycystic ovary syndrome: PCOS is characterized by menstrual
irregularities, hirsutism, acne, ovarian cysts, varying degrees of
insulin resistance, and often, obesity.
Pomade acne: Type of acne is seen in African-Americans and other
individuals who have tight curly hair and frequently use pomade
(oils and greasy ointments) to style or improve their hair’s
manageability.
Pores: The openings of hair follicles onto the skin. Through them,
sweat and sebum flow onto the skin.
Postinflammatory hyperpigmentation: These dark spots are also
called postinflammatory pigmentation, or PIP, for short. The original
insult (and injury) that caused PIP can be a cut, a burn, a rash,
Appendix A: Glossary 275
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or the after-effect from a healing acne lesion. The dark spots are
limited to the sites of previous inflammation.
Prednisone: Synthetic corticosteroid that’s used to treat inflammatory
conditions.
Progesterone: Female hormone produced by the ovaries after
ovulation to prepare the uterus for fertilization.
Progestin: Synthetic progesterone.
Propionibacterium acnes (P. acnes): These bacteria are an integral
part of producing the inflammatory lesions of acne. They
live in the pilosebaceous glands of the skin.
Pseudofolliculitis barbae (razor bumps): Acnelike lesions that
occur mainly on the beard area in men of African heritage. This
condition is due to curly, ingrown hairs.
Pulse dye laser (PDL): This laser is “tuned” to a specific wavelength
of light. It produces a bright light that is absorbed by the superficial
blood vessels of the skin. The abnormal blood vessels are destroyed
without damaging the surrounding skin. This laser has been used
to successfully treat acne scars and rosacea telangiectasias.
Punch excision: Surgical technique that’s sometimes used to cut
out and reduce certain types of acne scars.
Pustule: A papule that contains pus. It’s also known as a pus
pimple. An inflammatory lesion.
Resorcinol: A weakly acidic organic chemical obtained from various
resins; found in some topical agents used to treat acne.
Retinoids: Chemicals related to vitamin A. A mainstay in the treatment
of both comedonal and inflammatory acne. The major
retinoids are Retin-A, tretinoin, Tazorac, and Differin.
Retention hyperkeratosis: Excessive buildup of skin cells that,
combined with sebum and trapped bacteria, creates a plug in hair
follicles that results in acne lesions.
Rhinophyma: Enlarged nose that results from enlarged sebaceous
glands and overgrowth of collagen, and is a feature of rosacea
that’s seen primarily in men.
Rosacea: Acnelike condition characterized by redness, papules,
and sometimes pustules in the center one third of the face in certain
fair-complexioned adults. It’s often mistaken for acne.
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Salicylic acid: Ingredient found in many over-the-counter acne
products. Helps to exfoliate the outer layers of the skin.
Sebaceous duct: Tiny tube that steers the sebum (and the dead
skin cells it carries) from the sebaceous gland into the hair
canal.
Sebaceous glands: Located in the dermis next to hair follicles,
these are small, sack-shaped glands that release sebum onto the
hair and moisturize the skin.
Sebum: Oily substance produced by sebaceous glands that coats
the hair and skin. Composed of a rich blend of different lipids (fatty
chemicals). Helps to keep the skin lubricated and protected. Clogs
pores, helping to cause outbreaks of acne.
Sex hormone binding globulin: A protein in the blood that “mops
up” free testosterone and prevents it from stimulating acneproducing
oil glands to produce excess oil.
Spironolactone: An anti-androgen medication sometimes used in
combination with oral contraceptives to treat acne in women.
Stratum corneum: Also known as the horny layer, it is the outermost
layer of the epidermis. It is comprised of dead skin cells that
protect deeper cells from damage, infection, and from drying out.
Stratum spinosum: This is the middle (“spiny”) layer of the epidermis.
These cells are always actively dividing.
Subcutaneous layer: Fatty layer of tissue located under the
dermis.
Sulfacetamide: Anti-infective used topically to treat acne and
rosacea. Often combined with sulfur.
Telangiectasias: Small, dilated blood vessels usually seen on the
face. Also called broken blood vessels, or “spider veins.”
Teratogenic: Drug that, if taken during pregnancy, is highly likely
to cause severe birth defects.
Testosterone: An androgen and the main male hormone.
Produced by the testes in men and by the ovaries in women.
Tetracycline: Oral antibiotic typically used to treat acne and
rosacea.
Appendix A: Glossary 277
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Topical therapy: Something that’s applied onto the skin, such as a
cream, gel, or ointment.
Vehicle: Part of a product that holds the active ingredient. It’s the
base (ointment, gel, or cream) to which a medication is added.
Whitehead: Small, pearly white acne lesion that consists of a plug
of keratin and sebum. Occurs when the comedo stays below the
surface of the skin. Also called a closed comedo.
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Appendix B
International Brand Names
for Some of the Medications
Listed in This Book
Table B-1 Topical Medications
Generic United France Germany U.K. Canada Australia
Name States
Adapalene Differin Differine Differin Differin Differin Differin
Azelaic acid Azelex, Skinoren, Skinoren, Skinoren, Finacea Skinoren
Finacea Finevin Finevin Finevin
Benzoyl Oxy-5, PanOxyl, Benzaknen, PanOxyl, Benzac, Benzac,
peroxide Oxy-10 Eclaran PanOxyl, Acnecide PanOxyl Brevoxyl
Benzoyt
Clindamycin Cleocin-T Dalacine T Basocin Dalacin T Dalacin T Clindatech
Erythromycin Emgel, Eryacne, Aknemycin, Stiemycin, Erysol, Eryacne,
Staticin, Eryfluid, Stiemycine, Erymax, Erythrocin, Ilosone,
Akne- Stimycine Erythrocin Eryacne Staticin Erythrocin
Mycin
Metronidazole Noritate, Rosiced, MetroGel Rozex MetroGel, Rozex
Metro- Rozagel Noritate
Gel,
Metro-
Cream
Tazarotene Tazorac Zorac Zorac Zorac Tazorac Zorac
Tretinoin Retin-A, Retin-A, Epi-Aberel, Retin-A Retin-A, Retin-A,
Avita Aberel, Eudyna Vitinoin, Stieva-A
Effederm Retisol-A
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Table B-2
Oral Medications
Generic United France Germany U.K. Canada Australia
Name States
Doxycycline Vibramycin, Vibramycine, Vibramycin, Vibramycin Vibramycin, Vibramycin,
Hyclate Monodox, Doxycycline Doxycycline Vibra-Tabs, Vibra-Tabs, Doryx
Vibra-Tabs, Doryx,
Adoxa Doxycin
Minocycline Minocin, Mestacine, Skid, Minocin, Minocin Minomycin
Dynacin Mynocine Lederderm Aknemin
Erythromycin E-Mycin, EES, Erythrocyne Erythrocin, Erythrocin, E-Mycin, EES, EES, Erythrocin,
Erythrocin Monomycin Erymax, Erythrocin Ilosone
Ilosone
Isotretinoin Accutane, Roaccutane Roaccutan Roaccutane Accutane Accure,
Sotret, Roaccutane
Amnesteem,
Claravis
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Index
• A •
abnormal follicular keratinization, 30
absorbent pads, 102
Accutane. See isotretinoin
acne. See also formation of acne
categories of, 35–36
described, 9–10, 269
duration of, 10, 40
Greek and Latin name for, 44
“growing out of,” 40, 203
look-alikes, 16, 52
acne cosmetica, 69
acne detergens, 70
acne estivalis, 69
acne excorieé, 209
acne mechanica, 69–70
acne neonatorum, 59
Acne Support Group (Web site), 254
acne vulgaris. See teenage acne
acnegenic, 66, 71, 269
acneiform reactions, 66
AcneNet (Web site), 251
active ingredients, 74, 77, 102, 269
acupuncture, 180
Aczone (dapsone), 57, 114
adrenal hyperplasia, 245
adrenocorticotropic hormone
(ACTH), 248
adult-onset acne
age for developing, 52–53, 59
described, 11, 50–52, 269
hormones and, 52–53
men and, 60
menopause and, 59
menstruation and, 52–54
overview, 49
pregnancy and, 54–55
women and, 50, 129, 269
advertisements
evaluating, 84
healthcare professionals and, 94
TV infomercials, 15, 80–81, 84, 114
aestheticians, 107
age
adult-onset acne and, 52–53, 59
first appearance of acne and, 10
teenage acne and, 39–40
Agent Orange (chloracne), 70
ALA (aminolevulinic acid), 169
alcohol solutions, 75
alpha hydroxy acid (AHA), 81–82,
174–175, 259, 269
alternative treatments
acupuncture, 180
aromatherapy, 184–185
Ayurveda, 183–184
biofeedback, 187–188
caution for using, 264–265
Chinese herbs, 178–180
herbs, 180–183
homeopathy, 185–186
hypnosis, 188
meditation, 187–188
overview, 177–178
vitamins and minerals, 183
yoga, 187
American Academy of Dermatology,
92, 196, 251
American Society for Dermatologic
Surgeons (ASDS), 196, 252
American Society of Plastic Surgeons
(ASPS), 196
aminolevulinic acid (ALA), 169
amoxicillin, 124
anabolic-androgenic steroids, 67–68
androgens. See also testosterone
adult-onset acne and, 52, 192
anti-androgens and, 58, 134–135,
246–247
described, 29, 269
elevated levels of, 244–247
estrogen’s effect on, 131
formation of acne and, 29, 44–45
increase during puberty, 29, 46
milk products and, 64
oral contraceptives and, 129–130
sensitivity to, 46
androstenedione, 68
animal testing, 71
anti-androgens, 58, 134–135, 246–247
antibiotics. See also oral antibiotics;
topical antibiotics
described, 269
oral contraceptives and, 134
substitutions for, 127
aqueous solutions, 75
Archives of Dermatology (Chia), 165
aromatherapy, 184–185
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ASDS (American Society for Dermatologic
Surgeons), 196, 252
ASPS (American Society of Plastic
Surgeons), 196
astringents, 26, 269
athletes, 60
atrophy, 127, 270
Ayurveda, 183–184
azelaic acid
dark skin and, 144–145, 223
described, 270
FDA classification for, 55
pigmentation and, 112
postinflammatory hyperpigmentation
(PIP) and, 145
for rosacea, 223
azithromycin (Zithromax), 125
• B •
bacteria. See also P. acnes
as cause of acne, 32–34
resistance to antibiotics and, 117, 126
rosacea and, 217
tetracycline and, 118
basal layer, 20, 270
base (vehicle), 75–76, 102, 278
basement membrane, 20
BDD (body dysmorphic disorder), 209
benzamycin gel, 55
benzoyl peroxide
benefits of, 77–78
brand-name products, 78
for dark skin, 141–142
described, 77, 270
generic name, 110
how to use, 78–79
pregnancy and, 56
pseudofolliculitis barbae (PFB) and,
235–236
side effects, 79
with topical antibiotics, 109–112,
235–236
washes with, 111, 112
water-based, 111
beta-hydroxy acid (BHA), 80, 174–175,
270
bioequivalent medication, 114
biofeedback, 187–188
birth control
isotretinoin and, 130–131, 157, 158–159
oral contraceptives, 117, 130–134, 275
birth defects, 57–58, 105, 154
blackheads (open comedones), 31–32,
42, 62, 270
bleaches
for hair, 238
over-the-counter, 142–143
for postinflammatory
hyperpigmentation (PIP), 145
blocked hair follicles, 29, 30–32
blue light therapy, 169, 270
Bodian, Stephan (Meditation For
Dummies), 188
body dysmorphic disorder (BDD), 209
bone growth, 119
brand-name medications
benzoyl peroxide in, 78, 110
expense of, 113
generic medications versus, 75
list of, 279–280
retinoids and, 104–105
topical antibiotics and, 108–109
breast cancer, 117, 133, 135
breastfeeding, 55, 56, 57, 119. See also
pregnancy
• C •
CAH (congenital adrenal hyperplasia),
247–248
calendula, 181
candidal vulvovaginitis (vaginal yeast
infections), 120, 124
causes of acne. See formation of acne
celebrities/movie stars, 11, 218, 254
cephalosporins, 125
chemical peels
as acne treatment, 82, 172–174
alpha hydroxy acid (AHA), 81–82,
174–175, 259, 269
at-home peel kits, 175
beta-hydroxy acid (BHA), 80, 174–175,
270
dark skin and, 263
described, 270
for postinflammatory
hyperpigmentation (PIP), 146
scars and, 82, 196
trichloroacetic acid (TCA) peels, 175
Chia, Christina (Archives of
Dermatology), 165
Chinese medicine, 178–180
chloracne (Agent Orange), 70
chocolate, 63
citric acid, 81
cleansers
cleansing strips, 83
over-the-counter, 76
282 Acne For Dummies
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recommended, 24, 259
retinoid treatments and, 107
Cleopatra (queen of Egypt), 175
clindamycin (oral), 125
clindamycin (topical), 57, 108, 114, 270
Clinton, Bill (former U.S. president), 218
closed comedones (whiteheads), 31–32,
42, 278
cognitive-behavior therapy, 209
collagen, 20, 34, 191, 270
color tinting, 113
combination therapy
benzoyl peroxide/topical antibiotics,
109–112
synergistic effect of, 110
for topical treatments, 103
comedo extractor, 107
comedogenesis, 32, 108, 271
comedogenic, 71–72, 270
comedolytic, 271
comedones
blackheads, 31–32, 42, 62, 270
described, 31, 34, 42, 270
extractions, 107, 270
as non-inflammatory, 35, 275
removing, 107
retinoids for, 36, 103
in rosacea, 215
whiteheads, 31–32, 42, 278
complementary medicine, 177. See also
alternative treatments
confidence, 204–205
congenital adrenal hyperplasia (CAH),
247–248
consultation, 90, 260
contact dermatitis, 79, 94, 271
corticosteroids
as acne-inducing, 67
described, 271
for “emergency” treatments, 67
inflammation treated with, 271
prednisone as, 276
rosacea and, 219
cortisol, 186, 259
cortisone
creams, 236, 263
injections, 127, 147, 237
cosmetics
comedogenic ingredients in, 71–72
for dark skin, 148–149
formation of acne and, 69, 70–71
herbs in, 182
oil-free, 72
removing before dermatologist
appointment, 95–96
rosacea and, 217–219, 225–226
sensitive skin and, 258
Web sites, 149, 226
creams
antifungal, 59
benefits of, 106
cortisone, 236, 263
described, 76
green tea in, 181
hydrocortisone, 79
hydroquinone, 142–143, 144
metronidazole, 223, 228
Renova (anti-aging cream), 259
retinoid, 236
success story, 40
Cushing’s disease, 248
Cushing’s syndrome, 248
cyst. See nodules (cysts)
• D •
D & C red dyes, 72
dapsone (Aczone), 57, 114
dark skin
azelaic acid and, 144–145, 223
chemical peels and, 263
cosmetics for, 148–149
features of, 138
lasers and light therapies and, 168
managing the scars, 146–147
oral medications for, 147
over-the-counter medications
for, 141–143
overview, 23, 137–138
pomade acne and, 69, 147–148, 275
postinflammatory hyperpigmentation
(PIP) and, 138–141
protecting from the sun, 23
sunscreen and, 143
topical medications for, 141–143,
144–146
trichloroacetic acid (TCA) peels and,
175
dark spots. See PIP (postinflammatory
hyperpigmentation)
dehydroepiandrosterone (DHEA), 68, 245
depilatories, 238–239, 271
depression, 164–166, 205–206, 208
dermabrasion
dark skin and, 147, 263
described, 271
microdermabrasion, 146
for scars, 201
Index 283
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dermal melanosis, 139
dermatitis
contact dermatitis, 79, 94, 271
described, 271
perioral dermatitis, 275
periorificial dermatitis, 227–228
photo dermatitis, 216
seborrheic dermatitis, 216
dermatologists
board certified, 92
building a relationship with, 97–100
consultation with, 90, 260
finding, 91–94, 196
first visit with, 94–97
following instructions of, 97–98
ongoing treatment from, 90–91
questions asked by, 96–97
referral for, 90–91, 100
switching, 100
telephoning, 98–99
treating acne scars and, 195, 196
when to consult with, 89
dermatologist-tested products, 84
Dermatology in the Cinema (Web site),
254
dermis layer, 18, 20–21, 270, 271
DermNet NZ (Web site), 252
DHEA (dehydroepiandrosterone), 68, 245
diet, 63–66, 219, 221
diode laser, 171
dioxins, 70
dirt and grease, 62
doctors. See healthcare professionals;
primary healthcare provider (PCP)
do-it-yourself treatments. See self
treatments
doxycycline, 123–124, 271
dry skin, 25, 26, 75, 111, 258
• E •
eczema, 94, 109. See also dermatitis
elastin, 20, 271
electrocautery, 226, 227
electrolysis, 239, 271
eMedicine (Web site), 252
“emergency” acne treatments, 67
emollients, 272
emotional disorders, 209. See also
psychological scars
endocrine disorders
congenital adrenal hyperplasia,
247–248
Cushing’s disease, 248
Cushing’s syndrome, 248
endocrine system, 272
endocrinologist, 245
endocrinopathy, 52, 272
endorphins, 63
enlarged pores, reducing, 104
enterically coated medications, 124
enzymes, 33, 272
epidermal cells, 21
epidermal hypermelanosis, 139
epidermis layer, 18–20, 272
epilation, 237–238, 239–240
erector pili, 22
erector pilorum (hair erector
muscle), 272
erythema, 212–213
erythromycin (oral), 56, 58, 124, 272
erythromycin (topical), 55, 108, 272
estrogen
acne helped with, 52
adult-onset acne and, 59
in birth control pills, 131
described, 29, 272
menstruation and, 54
puberty and, 45
Eulexin (flutamide), 135, 240
exercise, 219
exfoliation, 80, 83, 272
• F •
fair skin, 23, 212
family practitioner, 88
FDA. See Food and Drug Administration
female adult acne, 269. See also adultonset
acne
Feuerstein, Georg (Yoga For Dummies),
187
feverfew, 179
fibroblasts, 34, 272
Fields, W. C. (comedian), 218
flutamide (Eulexin), 135, 240
foams, 76
follicles. See hair follicles
folliculitis, 148, 229, 272
Food and Drug Administration (FDA)
on androstenedione, 68
on azelaic acid, 55
blue light therapy approved by, 169
drugs not recommended during
pregnancy, 56, 57
isotretinoin and, 154
Web site, 114
formation of acne
bacteria and, 32–34
clogged pores and, 30–31
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cosmetics and, 69
diet and, 63–66
dirt and, 62
grease and, 62, 63, 69
heredity and, 46–47
hormones and, 29, 44–46
irritating factors and, 68–70
medications and, 67–68
myths about, 61–62
sex and, 65
stress and, 66
• G •
gels
aczone, 57
benzamycin, 55
described, 76
metronidazole, 223, 228
shaving, 232
generic medications
brand name versus, 75, 113–114
branded generic and, 104
information resources, 114
list of, 279–280
retinoids, 104–105
tetracyclines, 120–121
topical antibiotics, 108–109
Web sites, 104
glucocorticoids, 66
glycolic acid, 81, 174
goals for acne treatments, 12, 87–88
goosebumps, 22
grease, 62, 63, 69
greasy foods, 10, 63
Greek and Latin name for acne, 44
green tea, 181, 182
• H •
Hahnemann, Samuel (founder of
homeopathy), 186
hair. See also hair follicles
bleaching, 238
hirsutism and, 237, 244, 273
plucking, 231
removing, 237–240
slowing the growth of, 240
thinning, 244
hair bumps (keratosis pilaris), 16, 52,
240–241, 274
hair canal, 28, 30, 272
hair erector muscle (erector
pilorum), 272
hair follicles. See also pseudofolliculitis
barbae (PFB)
blocked, 29, 30–32
described, 21, 27–29, 272
folliculitis and, 149, 229, 272
headaches, 120
healthcare professionals. See also
dermatologists; primary
healthcare provider (PCP)
advertisements by, 94
consultation with, 90
endocrinologists, 245
plastic surgeons, 196
when to see, 14–15
healthy skin, tips for
dermatologists and, 260
dry skin and, 258
oily skin and, 257
sensitive skin and, 258
skincare products and, 259
stress and, 259–260
sun exposure and, 255–256
sunless tanning and, 256–257
youthful glow, 259
heat-based acne treatment (Zeno), 169
hepatitis, 120
Herbal Remedies For Dummies
(Hobbs), 180
herbs
Chinese herbs, 178–180
in cosmetics, 182
finding an herbalist, 182–183
green tea, 181, 182
for reducing inflammation, 181–182
safety issues, 180–181, 264
heredity, 46–47, 212, 272
hirsutism, 237, 244, 273
history of acne treatments, 12
Hobbs, Christopher (Herbal Remedies
For Dummies), 180
home remedies, ineffectiveness of, 82–83
homeopathy, 185–186
hormonal therapy for women
anti-androgens, 134–135
oral contraceptives as, 117,
130–134, 275
overview, 129–130
hormones. See also specific hormones
adult-onset acne and, 52–53
androstenedione, 68
described, 29, 273
DHEA (dehydroepiandrosterone), 68
in food products, 53
in performance enhancing drugs, 53, 60
Index 285
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hormones (continued)
rosacea and, 225
teenage acne and, 44–46
horny layer (stratum corneum), 19
humidifiers, 25
hydrocortisone cream, 79
hydroquinone, 143–144, 273
hyperpigmentation, 273. See also PIP
(postinflammatory
hyperpigmentation)
hypertrophic scars, 146, 147, 230, 273
hypnosis, 188
• I •
inactive ingredients, 74, 75–77
infantile acne, 59
inflammatory acne. See also nodules
(cysts); papules
described, 32–33, 36, 273
herbs for, 181–182
macules, 33, 43, 138, 274
pregnancy and, 54
pustules, 33, 213, 230, 276
teenage acne and, 42
topical antibiotics for, 108
injections, cortisone, 127, 147, 237
instructions
from dermatologists, 97–98
package inserts, 128
for using oral antibiotics, 126–127
for washing your face, 24
insurance, 93
insurance card, 95
intense pulsed light treatment (IPL),
170–171, 226–227, 273
internist, 88
intralesional cortisone (steroid)
injections, 127, 147, 237
iodides, 65
iPLEDGE (isotretinoin federal registry
program)
additional steps for females, 156–159
blood tests and, 155–156
described, 273
purpose of, 154–155
registration procedure, 155
isopropyl myristate, 71–72
isotretinoin. See also iPLEDGE
(isotretinoin federal registry
program); retinoids
benefits of, 151, 153
birth control and, 130–131, 157,
158–159
birth defects risk, 58, 154
blood tests and, 155–156
brand names for, 152
depression and suicide risks,
164–166, 208
described, 152, 269, 273
dosages and results, 160
ineffectiveness for rosacea, 225
information resources, 165
monitoring treatment, 151–152
preparing for treatment, 154–155
procedures for, 155–156
reasons to stop, 163–164
reasons to use, 153–154
side effects, 161–164
what to avoid, 161
• J •
junk food, 63
• K •
keloids, 147–148, 273
keratin, 18–19, 240
keratinization, 153, 273
keratinocytes, 18–19, 20, 139, 145, 274
keratosis pilaris (hair bumps), 16, 52,
240–241, 274
ketoconazole (antifungal cream), 59
• L •
lactic acid, 81, 174
lanolin, 71
laser epilation, 239–240
lasers, 274
lasers and light therapies
blue light therapy, 169, 270
dark complexioned skin and, 168
diode laser, 171
intense pulsed light treatment (IPL),
170–171, 226–227, 273
laser skin resurfacing, 195, 197–198
photodynamic therapy (PDT), 169–170
postinflammatory hyperpigmentation
(PIP) and, 146
for prevention and treatment of acne,
167–168
pulsed dye laser (PDL), 171
pulsed light and heat energy (LHE)
therapy, 171
ultraviolet light, avoiding, 171–172
lemuteporfin, 169
lesions, 27, 274
lipase, 34
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lipids, 28
lipocytes, 21, 274
loofah sponges, 83
lotions, 76
lupus erythematosus, 120, 123
• M •
macules, 33, 43, 138–139, 274
mail-order products, 40, 80–81
makeup. See cosmetics
masks, facial, 83
McGwire, Mark (baseball player), 68
medical history, personal, 94–95
medications. See also specific medications
acne-inducing, 67–68
bioequivalent, 114
changes in, 100
giving them a chance to work, 98
hormones in, 53
instructions for using, 97–98
refills, 99
rosacea and, 219
when to call your dermatologist
about, 99
meditation, 187–188
Meditation For Dummies (Bodian), 188
MedLine Plus: (Web site), 252
melanin
in blackheads, 32, 62
defined, 274
postinflammatory hyperpigmentation
(PIP) and, 139–140
skin color and, 137
melanocyte, 274
men
adult-onset acne and, 60
male hormones, 29
rhinophyma in, 214
scarring and, 60
shaving, 219, 231–233, 264
testosterone in teenage boys, 45
menopause, 274
menstruation, 52–54, 244, 274
metronidazole, 223, 224, 228, 274
microcomedo, 31, 215, 274
microdermabrasion, 146, 202, 274
milk products, 64
mind/body medicine, 186–188
minerals, 183
minocycline, 121–123, 224, 274
mites, 217
moisturizers
acne-producing substances in, 72
applying over medications, 106–107
applying to damp skin, 26
for dry skin, 25, 26, 75, 111, 258
non-oily, 79, 142
recommended, 72, 107
Morgan, J. P. (financier), 218
movie stars/celebrities, 11, 218, 254
multi-ingredient products, 82–83
• N •
National Center for Complementary
and Alternative Medicine (Web
site), 180
National Institutes for Health, 252
network of providers, 93
New Zealand Dermatological
Society, 252
newborns with acne, 59
nicomide (oral), 183
nodules (cysts). See also inflammatory
acne
in adult-onset acne, 51
described, 33, 271, 274
in teenage acne, 43
noncomedogenic, 275
noncomedonal acne. See inflammatory
acne
non-inflammatory acne, 35–36, 275. See
also comedones
Noritate cream (metronidazole),
223, 228
nurse practitioner (NP), 89
• O •
ocular rosacea, 214, 275
off-label use, 154
oil glands, 44
oily skin, 25, 26, 62, 257
ointment, 76
Omni: (Web site), 253
open comedones (blackheads), 31–32,
42, 62, 270
ophthalmologist, 214
oral antibiotics. See also tetracyclines
amoxicillin, 57, 124
azithromycin (Zithromax), 125
cephalosporins, 125
clindamycin, 125
concerns about, 116–118
dark skin and, 147
deciding to use, 116
developing resistance to, 117, 126
erythromycin, 56, 58, 124, 272
fine-tuning the dosage, 126
Index 287
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oral antibiotics (continued)
instructions for using, 126–127
overview, 115–116
rosacea and, 224–225
success story, 45
tapering off from, 125–126
topical medications and, 116
trimethoprim sulfasoxazole (TMZ),
125, 225
oral contraceptives, 117, 130–134, 275
oral medications
birth defects caused by, 58
brand names for, 280
causing acne, 68
for dark skin, 147
pregnancy and, 56
topical medications versus, 74, 104
over-the-counter (OTC) medications.
See also benzoyl peroxide
active ingredients in, 74, 77, 102, 269
alpha hydroxy acid (AHA), 81–82,
174–175, 259, 269
bleaches, 142–143
brand name versus generic, 75
choosing, 74, 77
cleansers, washes and scrubs, 76
deciding to use, 13–14, 73
evaluating advertisers’ claims for, 84
herbal, organic or natural, 82–83
how much to use, 76–77
hydrocortisone cream, 79
inactive ingredients in, 74, 75–77
mail-order products, 80
multi-ingredient products, 82–83
resorcinol, 82, 276
retinols, 81
salicylic acid, 79–81, 141–142, 146,
174, 277
skin irritation from, 106
skin type and, 75–76
soaps and other cleansing products,
83–84
sulfur, 82
vehicle (base) for, 75–76, 102, 278
when to expect improvement, 79
• P •
P. acnes
benzoyl peroxide and, 77
blue light therapy and, 270
described, 32, 33–34, 276
herbs for reducing, 181
resistance to antibiotics and, 109,
110, 117
rosacea and, 217
scar formation and, 34
tetracycline and, 118
topical antibiotics and, 108, 109
PA (physician assistant), 88, 89
package inserts, 128
papules. See also inflammatory acne
of adult-onset acne, 50–51
corticosteroids as cause of, 67
described, 33, 275
pseudofolliculitis barbae (PFB)
and, 230
rosacea and, 213
patience, 98
Payne, Larry (Yoga For Dummies), 187
PCOS (polycystic ovary syndrome),
246–247, 275
PCP (primary healthcare provider).
See primary healthcare provider
(PCP)
PDL (pulsed dye laser), 171
PDT (photodynamic therapy), 169–170
pediatrician, 88
peels. See chemical peels
performance enhancing drugs, 53, 60
perimenopause, 275
perioral dermatitis, 275
periorificial dermatitis, 227–228
personal acne story, 96–97
PFB. See pseudofolliculitis barbae
pharmacists, 127
photo dermatitis, 216
photodynamic therapy (PDT), 169–170
physician assistant (PA), 88, 89
picking your skin, 10, 261–262
pigmentation. See also PIP
(postinflammatory
hyperpigmentation)
azelaic acid and, 112
hyperpigmentation, 273
lightening, 175
minocycline and, 122
pilosebaceous unit (PSU), 27, 275
PIP (postinflammatory
hyperpigmentation)
described, 275–276
formation of, 139
preventing, 140
placebo effect, 178
plastic surgeons, 196
pledget or swab, 102
polycystic ovary syndrome (PCOS),
246–247, 275
pomade acne, 69, 147–148, 275
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pore cleansing strips, 83
pores, 30–31, 275
post-adolescent acne, 269. See also
adult-onset acne
postules, 50, 67
prednisone, 276
pregnancy
acne during, 54–55
birth defects and, 58, 105
medication safety and, 55–57, 124
tests, 157–158
pre-tanning, 262
primary healthcare provider (PCP)
establishing treatment goals, 87–88
providing referral to see a specialist,
90–91
types of, 88–89
working with, 89
Princess Diana (British royalty), 218
professional associations, 92
professionals. See healthcare
professionals; primary healthcare
provider (PCP)
progesterone
androgenic effects of, 52
described, 29, 45, 276
pregnancy and, 54
puberty and, 45
synthetic (progestin), 131, 276
Propionibacterium acnes. See P. acnes
pseudofolliculitis barbae (PFB)
acne versus, 16, 51
benzoyl peroxide treatments for,
235–237
causes of, 230–231
described, 229, 276
hair removal and, 237–240
self treatment for, 233–235
shaving and, 231–233
slowing down hair growth and, 240
PSU (pilosebaceous unit), 27, 275
psychological scars
adult-onset acne and, 52–53
coping with, 204–205
depression, 164–166, 205–206, 208
emotional disorders, 209
helping teenagers with, 206–208
overview, 15, 203
therapy for, 210
psychotherapy, 210
puberty, 29, 44, 45, 46
pulse therapy, 125
pulsed dye laser (PDL), 171, 276
pulsed light and heat energy (LHE), 171
punch excision, 276
pustules, 33, 213, 230, 276
• Q •
quackwatch (Web site), 15
• R •
radio wave therapy, 168, 202
razor bumps. See pseudofolliculitis
barbae (PFB)
Rembrandt (Dutch painter), 218
Renova (anti-aging cream), 259
resorcinol, 82, 276
retention hyperkeratosis, 276
retinoids. See also isotretinoin
applying, 105–106
benefits of, 103–104
brand name and generic, 104–105
building up tolerance, 106
chemical peels and, 173
for comedonal acne, 36, 103
described, 104, 276
enhancing treatments and, 107
for long-term maintenance, 103
for postinflammatory
hyperpigmentation (PIP), 145
pregnancy and, 57, 105
rosacea and, 222
side effects, 106–107
when to expect improvement, 105
retinols, 81
rhinophyma, 214, 227, 276
rosacea
acne versus, 16, 215
alcoholic beverages and, 220
camouflaging the redness, 225–227
causes/triggers of, 216–217, 219–221
celebrities with, 218
cosmetics and, 217–219, 225–226
described, 51, 211, 276
doxycycline for, 124
look-alikes, 227–228
metronidazole for, 223, 224, 274
ocular rosacea, 214
rhinophyma and, 214, 227
self treatment and, 263
skin conditions versus, 215–216
steroid-induced, 67, 263
symptoms of, 212–216
treatments for, 221–225
washing your face and, 217
Web sites, 253, 254
RosaceaNet (Web site), 253
Index 289
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• S •
salicylic acid, 79–81, 141–142, 146,
174, 277
salmon, 65–66
scars. See also psychological scars
chemical peels and, 82, 196
choosing a doctor for, 195–196
collagen and, 34, 191, 270
dark skin and, 144–147
deciding to seek treatment, 194–195
dermabrasion for, 201
emerging technologies and, 202
formation of, 34, 191, 270
hypertrophic, 146, 147, 230, 273
keloids, 146–147, 273
laser skin resurfacing, 197–198
microdermabrasion for, 202, 274
overview, 14, 34–35, 191–192
rosacea and, 215
surgical treatments, 199–201
teenage acne and, 43
types of, 192–194
scrubs, 76
sebaceous duct, 28, 277
sebaceous glands
described, 9, 28, 277
enlarged, 52
oily skin and, 25
sun exposure and, 172
seborrheic dermatitis, 216
sebum
androgens and, 46
chemists’ attempts to imitate, 72
described, 9, 28, 277
excess production of, 28, 29, 30
oily skin and, 25–26
role in acne formation, 30–31
self treatments. See also over-thecounter
(OTC) medications
at-home peel kits, 175
Ayurvedic home remedies, 184
deciding to try, 13–14
home remedies, ineffectiveness of,
82–83
popping pimples and, 261–262
pseudofolliculitis barbae (PFB) and,
233–235
rosacea and, 263
Zeno (heat-based acne treatment
device), 169
sex, 65
sex hormone binding globulin (SHBG),
245, 277
shaving, 219, 231–233, 264
skin. See also skin type; washing your
face
adult versus teenage, 41
cross section of, 19
dermis layer, 18, 20–21, 270, 271
epidermis layer, 18–20, 272
facts about, 22
functions of, 17–18
health tips for, 255–260
humidifiers for hydrating, 25
over-the-counter medications and,
75–76
picking, 10, 261–262
sensitive, 258
smoking and, 262
subcutaneous layer, 18, 21–22
T-zone, 42, 257
skin cancer, 23
skin irritation, 106–107, 111–112. See
also dermatitis
skin type
choosing topical treatments and, 75–76
combination skin, 76
dry skin, 25, 26, 75, 111, 258
oily skin, 25, 26, 62, 257
postinflammatory hyperpigmentation
(PIP) and, 138–141
skin-care spas, 94
smoking, 262
soaps
acne soap, 83
benzoyl peroxide, 111
mild, 259
recommended types, 24
for washing your face, 23–24
solution, 75, 102
spas, skin-care, 94
spider veins. See telangiectasias
spironolactone, 58, 134–135, 247, 277
starter treatments, 81
steroid folliculitis, 67
steroids. See also corticosteroids
anabolic-androgenic steroids, 67–68
for contact dermatitis, 79
cortisone creams, 263
cortisone injections, 127, 147, 237
glucocorticoids, 66
rosacea and, 67, 263
steroid-induced “rosacea,” 228, 263
290 Acne For Dummies
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Stop Spots (Web site), 253
stratum corneum (horny layer), 19, 277
stratum spinosum, 20, 277
stress, 66, 186, 219, 259–260
subantimicrobial dose, 124
subcutaneous layer, 18, 21–22, 277
sugar, 64–65
sugaring, 238
suicide, 164–166, 208
sulfacetamide, 277
sulfacetamide/sulfur combinations
benefits of, 112–113
pregnancy and, 57
for rosacea, 223–224
safety of, 56
sulfur, 82
sun exposure
doxycycline and, 123
moderation for, 172
postinflammatory hyperpigmentation
(PIP) and, 141
retinoids and, 107
rosacea and, 219
skin damage and, 216, 255–256
sunburn, 120, 123
sunless tanning, 256–257
sunscreen, 107, 143, 219
support groups (Web site), 254
surgery, dermatologic
removing comedones, 107
treating scars, 199–201
Web sites, 252
synergistic effect, 110
• T •
tanning
salons, 172, 262
sunless, 256–257
TCA (trichloroacetic acid) peels, 175
tea tree oil, 181
teenage acne
age for developing, 39–40
causes of, 44–47
duration of, 40
overview, 42–43
psychological scars and, 206–208
scars from, 43
severe problems with, 41
teeth, 119, 122
telangiectasias
described, 213, 277
electrocautery for, 226
rosacea and, 216
treatments for, 226–227
teratogen, 105, 152, 277
testosterone
adult-onset acne and, 59
blood screening test, 245
described, 29, 44, 277
levels in women, 132
role in acne formation, 44–45
sebum production and, 28
tetracyclines. See also oral antibiotics
birth defects risks, 58
described, 118, 277
dosages, 121
doxycycline, 123–124, 271
generic (“plain”), 120–121
minocycline, 121–123, 224, 274
rosacea and, 224
side effects, 119–120
tapering off from, 118
when to expect improvement, 118
thermolysis, 239
threading, 238
TMZ (trimethoprim sulfasoxazole),
125, 225
tolerance, 77, 106
topical antibiotics
applying, 109
benefits of, 108
benzoyl peroxide with, 109–112,
235–236
brand name and generic, 108–109
clindamycin, 57, 108, 270
clindamycin/tretinoin
combination, 114
erythromycin, 55, 108, 272
metronidazole, 223, 224, 274
money-saving tip, 110–111
side effects of, 109
topical medications. See also over-thecounter
(OTC) medications;
retinoids; topical antibiotics
azelaic acid, 55, 112, 223
brand names, 279
choosing, 102–103
combination therapy for, 103
for dark skin, 141–143, 144–145
described, 74, 278
generic, 113–114
new developments for, 114
oral antibiotics and, 116
oral therapy versus, 74, 102
pregnancy and, 55–57
for rosacea, 222–224
sulfacetamide/sulfur combinations,
56, 57, 112–113, 223–224
Index 291
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total acne treatment systems, 80, 114
travel, medication pak, 110
treatments for acne. See also specific
treatments
“emergencies,” 67
false cures and, 15
goals for, 12, 87–88
type of acne and, 36
trichloroacetic acid (TCA) peels, 175
trimethoprim sulfasoxazole (TMZ),
125, 225
tutorial on acne, 253
TV infomercial products, 15, 80–81,
84, 114
twins, 46
T-zone, 42, 257
• U •
ultraviolet light, 171–172
U.S. National Library of Medicine, 252
• V •
vaginal yeast infections (candidal
vulvovaginitis), 120, 124
vascular lasers, 226–227
vegetarians, 64
vehicle (base), 75–76, 102, 278
vitamin A, 105, 161, 262
vitamin B3, 183
vitamins, 95, 183
• W •
washes, 76, 111, 112
washing your face
acne and, 40
dry skin and, 25
instructions for, 24
overcleansing and, 24, 62
rosacea and, 217
soap and cleansers for, 23–24
Web sites
American Academy of Dermatology,
92, 196
American Society for Dermatologic
Surgeons (ASDS), 252
Ayurveda information, 184
cosmetics, 148–149, 226
dermatologic, 252
DermNet NZ, 252
diseases and disorders, 252
Federal Drug Administration
(FDA), 114
generic and branded generic
drugs, 104
herbalists, 182–183
isotretinoin information, 165
movie stars, 254
National Center for Complementary
and Alternative Medicine, 180
quackwatch, 15
rosacea information, 253
skin diseases, 252
support group, 254
tutorial on acne, 253
Yoga Journal magazine, 187
whiteheads (closed comedones), 31–32,
42, 278
women. See also hormonal therapy for
women; pregnancy
adult-onset acne and, 50, 129, 269
androgens and, 45
breastfeeding, 55, 56, 57
endocrine imbalances and, 244
female hormones and, 29, 45
menstruation and, 52–54, 244, 274
rosacea and, 212
testosterone levels, 132
vaginal yeast infections and, 120, 124
wrinkles, 25, 172–173, 262
• X •
X-rays, 171
• Y •
yoga, 187
Yoga For Dummies (Feuerstein and
Payne), 187
Yoga Journal magazine, 187
Yushchenko, Victor (Ukrainian
President), 70
• Z •
Zeno (heat-based acne
treatment), 169
zinc, 183
Zithromax (azithromycin), 125
292 Acne For Dummies
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B
A
C
Acne vulgaris
This 16-year-old
boy has small
papules (A), a
large pustule (B),
and whiteheads
— closed comedones
(C).
See Chapter 4.
Follicular
prominence
These little black
holes look like blackheads,
but they’re
actually open pores
frequently seen on
the nose and cheeks
of people with acne.
See Chapter 9.
Acne vulgaris
This 14-year-old girl
has blackheads
(open comedones)
on her chin. Also
note the small red
papules and macules
on her chin.
See Chapter 4.
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A
Acne vulgaris
This young woman has small, flat, reddish-purple lesions — evidence of improvement
from appropriate treatment (they were originally red papules). These blemishes heal
slowly and most of them should disappear with further therapy. Some of them, however,
may heal as “ice pick” scars. See Chapter 4.
Acne vulgaris
This 17-year-old boy has severe inflammatory acne consisting of papules and pustules.
There’s also early evidence of pitted scarring (A). See Chapter 16.
Courtesy of Goodheart’s Photoguide to Common Skin Disorders, © Lippincotte Williams & Wilkins, 2003
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Adult-onset
acne
These papules
occurred like
clockwork, right
before this
woman’s period.
See Chapter 5.
Adult-onset
acne
Postinflammatory
hyperpigmentation
(PIP) is seen in
this woman. When
her acne lesions
heal, they leave
spots like the ones
you can see on
her chin.
See Chapter 12.
Adult-onset
acne
The location of
acne papules
along the jaw line
is characteristic
of adult-onset
acne in women.
See Chapter 5.
Courtesy of Goodheart’s Photoguide to Common Skin Disorders, © Lippincotte Williams & Wilkins, 2003
Courtesy of Goodheart’s Photoguide to Common Skin Disorders, © Lippincotte Williams & Wilkins, 2003
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Severe nodular acne
This is the same woman after two 20-week courses of Accutane therapy.
See Chapter 13.
Severe nodular acne
This young woman had severe nodular acne that was unresponsive to all
attempted treatments. See Chapter 13.
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Keloids
These scars also arose from inflammatory lesions. The size of these scars
goes beyond what would be expected from what was a minor acne lesion.
See Chapter 16.
Hypertrophic scars
These scars, as seen on this young woman’s shoulder, bulge out. They
developed at the sites where the original inflammatory acne lesions healed.
See Chapter 16.
Courtesy of Goodheart’s Photoguide to Common Skin Disorders, © Lippincotte Williams & Wilkins, 2003
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Rosacea
This 59-year-old
woman has
inflammatory
papules, pustules,
and broken
blood vessels
(telangiectasias)
located on the
central one-third
of her face.
See Chapter 18.
Rosacea
This 64-year-old man
has an enlarged
nose with lumpy
protuberances
characteristic of
rhinophyma. The
excess tissue was
later successfully
removed with scalpel
and laser surgery.
See Chapter 18.
Rosy cheeks
This woman has
rosy cheeks and
telangiectasias.
See Chapter 18.
Courtesy of Goodheart’s Photoguide to Common Skin Disorders, © Lippincotte Williams & Wilkins, 2003
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Pomade acne
This man has typical comedonal lesions due to hair greases and oils. Notice how
they appear along his hairline and side of his face. See Chapter 12.
Razor bumps
This man has pseudofolliculitis barbae. Note the curved ingrowing hairs, papules, and
pustules that resemble acne under the chin and on the upper neck. See Chapter 19.
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Perioral
dermatitis
This young woman
has a ring of
acne-like papules
that circle her
mouth, typical of
the appearance of
this condition.
See Chapter 18.
Polycsystic
ovary syndrome
Besides acne, this
young woman has
excess facial hair
growth, diabetes,
and menstrual
irregularities.
See Chapter 20.
Keratosis pilaris
These are acne-like
lesions seen on the
upper-outer arm. If
you were to rub
your hand down
this teenager’s
arms, they would
feel rough-textured.
See Chapter 19.
