Acne, Part 2

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

(Page 3 of 4)

Birth control pills do all three of these things. They help prevent the formation of active androgens. They increase sex hormone binding globulin (SHBG), which binds to androgens and prevents them from going anywhere. They decrease the levels of circulating testosterone. And the progestin (the synthetic form of progesterone) in an oral contraceptive competes for binding sites on androgen receptors.

The only oral contraceptive the FDA has approved for the treatment of acne is Ortho Tri-Cyclen. This medication went through the rigorous testing and studies required by the FDA to prove that it was indeed beneficial for acne.

Spironolactone. Many women are turning to noncontraceptive antiandrogen options in the treatment of their acne, like the diuretic spironolactone (Aldactone). This drug — used to reduce water retention and control high blood pressure — has a molecular structure that mimics androgens. This allows it to bind to androgen receptors, blocking true androgen and helping to control acne. There are downsides to spironolactone use, however, including symptomatic low blood pressure, irregular menstrual cycles, spotting, and higher levels of potassium in the bloodstream. (If you take the drug, it's important to avoid binging on foods high in potassium, like bananas.)

Yasmin. For women who want the benefits of an antiandrogen but don't want to be on a diuretic, or for those who want to be on birth control pills but hate those extra few pounds of water retention that tend to go hand in hand with birth control pills, a new-generation oral contraceptive, Yasmin, may be a solution.

Yasmin contains drospirenone, a progestin that is structurally very similar to spironolactone. Because of this resemblance, Yasmin may be a beneficial "off-label" drug for addressing androgenic acne and can help you avoid those extra few pounds.

Injectable Steroids

The stray acne cyst can be rapidly resolved with a small shot of steroid solution known as triamcinolone (Kenalog). The upside: a quick fix for those "little emergency" situations like weddings and proms. The downside: this is simply not the way to treat widespread, recurrent acne. Nor is it pleasant to experience the infrequent side effect of a "sink" spot because of fat atrophy at the injection site. (Fortunately, it fills in over several months.)

Topical Therapy

A hot topic in acne therapy is how to best handle breakouts with topicals. Some consumers don't want to take pills; others, for various reasons, can't take pills. Most simply want to get clear skin fast and are willing to incorporate any agent into their routine that maximizes treatment.

Topicals are as varied in their actions as systemic therapies. They are invaluable for treating minor outbreaks and supplementing systemic therapy.

Synthetic Retinoids

These derivatives of vitamin A are indispensable in acne therapy. Similar in action to Accutane, they work to normalize the keratinization process. (For more information on Accutane, see the sidebar on page 9.) They can help eliminate blackheads, dry up excess oils, and squelch papular and pustular acne. But, unlike with Accutane, these benefits are only temporary.

Prescription retinoids are the most potent. But if for some reason they can't be used, a nonprescription retinol (like Afirm) can be beneficial. Prescription options include:

• Tazarotene (Tazorac)
• Tretinoin (Retin-A, Avita)
• Adapalene (Differin)

Retinoids are extremely potent. To avoid irritation, make sure to follow these steps:

• At the beginning, use just every other night.
• Wait thirty minutes after washing before application.
• Apply a pea-sized amount of cream or gel to your finger.
• Dab the cream or gel around the area to be treated and rub it in well.
• Avoid getting the substance in your eyes and wash your hands well afterward.
• Do not layer with any other skin treatment or moisturizer.
• Reduce frequency of use if your skin becomes irritated.

Whether over-the-counter or prescription, vitamin A topicals should not be used while pregnant or nursing. They also may increase sun sensitivity; wear sunscreen with an SPF of 30 daily.

Topical Antibiotics

A myriad of prescription topicals possess bacteria-killing abilities. These products can help treat whiteheads and small inflammatory acne lesions and are typically applied twice a day. Some options are:

• Clindamycin (Cleocin T)
• Erythromycin (Erycette, Emgel)
• Metronidazole (MetroGel, MetroLotion, MetroCream, and Noritate)
• Sodium sulfacetamide (Plexion Lotion & Cleanser)

Benzoyl Peroxide (BPO)

Benzoyl peroxide is a tried-and-true acne treatment. Its benefits derive from its bacteria-thwarting abilities.

Strengths range from 2.5 to 10 percent. Benzoyl peroxide can be found in both over-the-counter and prescription treatments — often at the same levels! Gels, creams, lotions, soaps, masks, and even shaving creams provide formulations for every need. Recent variations have married benzoyl peroxide with other ingredients.

Some prescription-only options include:

• Benzamycin (combination of BPO and erythromycin)
• Clinac BPO (combination of OC Eight Mattifying Gel and benzoyl peroxide)
• Benzaclin (combination of BPO and clindamycin)

Some over-the-counter products are:

• BenzaShave 5% medicated shaving cream
• Peter Thomas Roth BPO 2½% Medicated Shaving Cream
• PanOxyl Bar 5%
• Peter Thomas Roth BPO Gel 10% and Sulfur

Benzoyl peroxide can be a useful aid in acne therapy, but don't go overboard. It can cause dryness, redness, and irritation if overused. There are even an unfortunate few people who are allergic to it. Pay attention to what your skin is telling you and reduce your use should any irritation develop.

Azelaic Acid

Azelaic acid is a naturally occurring dicarboxylic acid found in grains like wheat, rye, and barley. Studies show that it possesses antibacterial activity against P. acnes, and it may also help normalize the keratinization process within the sebaceous glands.

Look for it in prescription acne medications like Azelex 20% Cream.

NDGA

Is there any topical medication that can reduce DHT, the hormone that revs up the sebaceous glands, causing oily skin and acne flare-ups?

Scientific research says yes.

The ingredient is NDGA — nordihydroguaiaretic acid, a natural plant-derived lipoxygenase inhibitor (which means it inhibits inflammation). Some studies suggest that the botanical NDGA possesses the ability to reduce the activity of 5 alpha-reductase, the enzyme responsible for changing testosterone into DHT.

DERMAdoctor's own 2n1 rosacea cream contains NDGA. It can help make your acne regimen more tolerable and effective by improving the appearance of redness caused by acne, inflammation, and other treatments, as well as visible blemishes. And since it isn't yet another topical antibiotic, it is complementary with other acne therapy.

Sulfur

Sulfur helps inhibit the growth of P. acnes and unclog pores. You can find it as a solo ingredient, in either over-the-counter or prescription options. In combination with sulfa, it's approved for use in prescription acne rosacea and seborrheic dermatitis (dandruff).

Some prescription-only options include:

• Sulfacet-R (sulfur and sulfa)
• Rosula (sulfur, sulfa, and urea)
• Ovace (sulfur and sulfa)
• Plexion (sulfur and sulfa)

Some over-the-counter products are:

• Rezamid Acne Lotion (sulfur and resorcinal)
• Sulforcin Acne Treatment Lotion
• Peter Thomas Roth BPO Gel 10% and Sulfur

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.