Acne

The DERMAdoctor Skinstruction Manual
by Audrey Kunin, M.D., Bill Gottlieb

(Page 2 of 4)

No One Needs to Suffer

It's rare to escape the acne experience. Approximately forty-five million young adults between the ages of twelve and twenty-four have acne. And that number doesn't even include the millions of acne patients in their twenties and thirties who are more likely to develop acne than their teen counterparts.

A strong genetic predisposition is the source of most acne, exacerbated by hormonal changes (most women already know this!); stress associated with school, jobs, and starting families; and, occasionally, poor skin care habits.

How Does Acne Form?

Acne is a disorder of keratinization — the development of the cells lining the sebaceous (oil) glands.

Instead of easily exfoliating themselves onto the surface, the cells become sticky, bind together, and plug the glands. But the sebaceous glands continue to secrete sebum, automatically triggered by DHT, the active form of testosterone. The excess sebum and lack of oxygen beneath the plug create a perfect environment for Proprionibacterium acnes (P. acnes), the bacteria that live on the skin. Too many P. acnes bacteria contribute to the inflammation within the gland.

Eventually, a combination of persistent plugging, excessive oil buildup (envision an expanding water balloon), and inflammation produced by bacterial overgrowth causes the gland to rupture. On the surface, this manifests as an inflamed acne papule or cyst.

Not All Acne Is Created Equal

There are different types of acne lesions. These are:

• Open comedone (the blackhead)
• Inflamed papule
• Pustule (the whitehead)
• Painful nodular cysts

Dermatologists also give acne a "grade" for severity, based on an estimate of the total number of lesions. Grade 1 is the mildest, with very few lesions. Grade 4 is the most severe. (A grade also allows the dermatologist to track improvement or lack thereof.)

Treatment is based on the types of lesions and the grade.

Treating Acne

Every dermatologist has her favorite acne regimens that have proven successful for her patients.

When a patient comes to my office, I evaluate the types of lesions and the grade, then determine the therapy. The goal of all acne treatments is to:

• Kill the bacteria
• Reduce unnecessary oils
• Unplug the pores
• Reduce inflammation

Many acne treatments conveniently provide more than one benefit, helping simplify the process. I allow six to eight weeks for any therapy regimen to show considerable (notice I didn't say "miraculous") improvement. If a patient does not improve enough, I will often change her medication. (Anyone who finds herself on the same medication for a year while continuing to break out shouldn't hesitate to talk to her doctor about a change!)

Prescription Systemic Therapy

Systemic therapy (pills) is best for inflammatory acne and practically mandatory for acne cysts. There are three categories of oral medication:

• Antibiotics (help kill bacteria and reduce inflammation)
• Hormonal therapy (reduces DHT)
• Accutane (considered the closest thing to an acne "cure")

Antibiotics

P. acnes bacteria thrive on excess sebum and in a low-oxygen environment. The result of bacterial growth is the production of highly inflammatory free fatty acids, which cause whiteheads, red bumps, and painful cysts. Antibiotics are used not only to kill P. acnes but also to reduce inflammation.

A stray monthly pimple doesn't warrant a long-term commitment to antibiotic therapy, but a patient plagued by blemishes — whether numerous or resistant to topical therapy — may qualify.

Several types of antibiotics are commonly used. They include:

• Tetracycline
• Minocycline
• Doxycycline
• Erythromycin
• Bactrim (sulfa)

The tetracycline family (tetracycline, minocycline, doxycycline) is considered the most effective group of antibiotics for acne therapy.

Tetracycline is most commonly prescribed in doses of 500 milligrams (mg), taken twice daily.

Minocycline (Minocin) is a more aggressive member of this antibiotic family and is given in a dosage of 50 milligrams, once or twice a day. It also is much more expensive. I reserve minocycline for patients who don't respond to tetracycline and patients with primarily cystic acne.

Doxycycline is similar to minocycline. However, I have not personally had nearly the response rate to this medication as I have to Minocin, so I tend to favor the latter.

The tetracycline family may cause increased sensitivity to the sun. These drugs are not to be used if pregnant or nursing, nor are they appropriate for patients younger than thirteen years of age, as they can cause permanent discoloration of dental enamel.

Erythromycin is not as effective for treating acne and tends to cause significant stomach upset. (To reduce nausea, take it on a full stomach.) I save this for patients unable to take tetracycline or its family members and for preteens.

Sulfa is highly effective, but allergies to this antibiotic are very common, so it is infrequently prescribed for acne therapy.

Hormonal Therapy

All women produce androgens (male hormones), including testosterone; a balance of androgens and estrogen (female hormones) create harmony for the skin, like a biochemical yin and yang. But when androgens outweigh estrogens, it's blemishes galore.

A woman can make too much testosterone, as in polycystic ovary syndrome (PCOS). She can make too little estrogen to "mask" the testosterone. Or — by far the most common cause of what's called androgenic acne — the cells in her skin and hair follicles can have a genetically predetermined sensitivity to "normal" levels of androgen.

However, it's not the testosterone itself that's causing the problems — it's DHT, a metabolite of the hormone. As explained earlier, DHT triggers an increase in sebum production. It also enlarges the sebaceous glands. Control the DHT and you control the acne. Hormonal medications can do that job.

Birth Control Pills. In order to treat acne hormonally, the medication must:

• Prevent the formation of androgens;
• Reduce the level of androgens circulating in the bloodstream; or
• Block the androgens from reaching their cellular receptors.

Copyright © 2005 by Audrey Kunin, M.D.

About the Author

Dr. Audrey Kunin is a practicing, board-certified dermatologist, the founder, president and chief medical advisor of DERMAdoctor.com® - a dermatology education and e-commerce site, and the creator of DERMAdoctor Specialist Skin Care.

Bill Gottlieb, a writer and editor specializing in health, is the former editor in chief of Prevention Magazine Books an Rodale Books. He is the author of Alternative Cures and the coauthor of the Calcium Key. He lives in Lake County, California.