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Power to the Patient
By Isadore Rosenfeld
Warner Books Copyright © 2002 Isadore Rosenfeld, M.D.
All right reserved.
Chapter One ACNE
When Zits Are the Pits
There are at least ten different forms of acne, two of which are extremely important: acne vulgaris (meaning "common," not "vulgar") and acne rosacea (adult acne). The former is the subject of this chapter.
Acne vulgaris is a skin disorder that plagues most teenagers and young adults. It starts in puberty and can persist into young adult life. Some 80 percent of us develop the pimples and bumps of acne vulgaris some time or another while we're growing up. In most cases, the pimples (often referred to as zits) and their variants-blackheads, whiteheads, pustules, and cysts-as a rule clear up by the mid- to late twenties, but they can last longer. They are not usually severe, but can have a serious impact on physical or emotional health when they recur and persist in large numbers on the face, the shoulders, the neck, and the upper back.
Acne vulgaris runs in families; if any of your close family members have it, chances are you do, or will, too. More young men are affected than women, but the ratio changes when acne continues into adult life.
Despite great progress in its treatment, the most important advance in dealing with acne has been the debunking of the many myths that have for so long surrounded it. The following beliefs were inviolable until fairly recently and are unfortunately still held by many:
Myth: Acne is due to poor personal hygiene-dirt and skin oil that haven't been washed away often enough.
Fact: There is no evidence that acne is caused by dirt or an excess of skin surface oils. In fact, you can worsen matters by scrubbing the skin too vigorously. Gentle washing with normal soap is all you need; don't waste your money on expensive "cleansers." Also, keep your fingers away from your pimples. Squeeze your sweet-heart, not your zits. Use oil-free "non-comedogenic" cosmetics.
Myth: The wrong diet causes acne-too many French fries, too much chocolate, pizza, and junk food.
Fact: No connection has ever been established between diet and acne. Vitamins don't help either. Strangely enough, many patients insist that their skin breaks out after they eat a particular food, usually chocolate. In such cases my advice is to avoid that food even though there is no scientific study linking diet to acne. But whenever a patient does make such an association, I sneakily take the opportunity to promote a balanced diet with lots of grains, fruits, vegetables, and fish. It won't necessarily help the acne, but it will reduce the risk of heart disease and cancer!
Myth: Acne is the result of unhealthful sexual habits, including masturbation and "tainted" sex partners.
Fact: "Loose" living, as it used to be called, can give you AIDS and sexually transmitted disease, but not acne. Nor will masturbation!
Myth: Stress causes acne.
Fact: Actually, the opposite is true. Acne causes stress; stress per se does not result in acne, although lack of sleep and chronic tension do increase androgen production in some people and may lead to a breakout. More important, picking, squeezing, and rubbing your pimples when you're nervous aggravates them. So if you're under stress, keep your hands in your pockets.
Myth: Acne should be left untreated and allowed to run its course because it's a normal cosmetic problem.
Fact: This is a good tack for insurers to avoid paying for doctors' visits. The physical and emotional fallout from acne can be devastating. Prompt and continuing treatment can prevent outbreaks and reduce the likelihood of developing permanent scars.
Myth: Acne vulgaris always clears up after adolescence.
Fact: One adult in nine, aged twenty-five to forty-five, continues to have acne.
How Acne Develops
Why does acne begin at puberty? Why does it affect younger men more commonly than women? Why does it usually clear up as we get older? The answers lie in our hormones. In adult life each gender has some of the other's hormone. (Thankfully, men have lots of androgens-testosterone-and only nominal amounts of estrogen, and vice versa for females. That's why I shave and my wife doesn't.) But when the body first produces its sex hormones at puberty it makes large amounts of both in boys and girls, in order to ensure adequate bone growth and sexual maturation. The high concentration of male hormones in both causes acne in both genders. Here's why:
Hair follicles in the skin are surrounded by sebaceous glands that make oil that is delivered to the skin surface. The extra amounts of male hormone at puberty increase the production of this oil, and the glut eventually clogs the ducts and their openings on the skin surface. This results in pimples, either blackheads or whiteheads (doctors call them come-dones). Since boys produce more male hormones than do girls, they have more pimples-and more acne.
If you're lucky, the process stops right there, leaving you with only a few pimples. No big deal. Complications set in when "normal" bacteria on the skin surface penetrate and inflame the obstructed, bulging ducts. In order to deal with these bacteria, the immune system mobilizes its warrior white blood cells and sends them in droves to prevent the ducts from becoming infected. An excess of these white blood cells and other debris forms pus, which when added to the sebaceous ducts already choked with oil, make the pimples bigger and bigger. When the engorged ducts can enlarge no more, they burst under the skin, forming bumps of various kinds and sizes. These bumps may be papules (slightly raised and red), pustules (filled with pus), or cysts (larger, inflamed, and painful). When a cyst opens onto the skin, it scars and disfigures it. That's why so many untreated acne patients have unsightly defects.
Acne can have a serious emotional and social impact on adolescents when it mars and scars the skin: withdrawal, depression, loneliness, frustration, and in some cases suicide have all been reported among such youngsters.
Too many doctors and patients view acne as a normal and inevitable phenomenon-a rite of passage, so to speak. Youngsters are told they must live with it, despite its social consequences. The worst thing parents can do is to make light of their youngster's acne. Insist on the proper medical care to treat it. If the lesions are extensive, see a dermatologist, for, as you will see below, there are measures that can control acne, modify its course, and even cure it! These consist basically of proper skin care, antibiotics to control the bacteria that infect the ducts, hormones in some cases to prevent over-production of sebum (the fatty substance made by the glands), and dermatological procedures to deal with whatever scarring has occurred. The sooner such therapy is begun, the less emotional trauma there will be in the short run, and the fewer permanent disfiguring scars.
Don't rush to the doctor just because you've found a pimple or two. Try some home remedies first. Sun helps, but too much is bad for the skin over the long term. Avoid putting anything greasy on your skin, especially cosmetics, cleansers, and moisturizers. Use water-based makeup and oil-free moisturizers; keep away from heat and humidity whenever possible; use non-oily sunscreens; and never pick or squeeze the pimples.
The first treatment step, one you can start yourself, is benzoyl peroxide (for example, Clearasil). You can get it at the pharmacy without a prescription. It comes in gel, cream, or lotion. I suggest starting with the weakest strength of the lotion, especially if you have sensitive skin. You can then switch to the 2.5 percent gel and increase the strength all the way to 10 percent if necessary. Benzoyl peroxide dries the pimples and prevents infection by reducing the number of bacteria on the skin; it often unplugs the black or white comedones. It's a peeling agent as well. Don't wear expensive clothes when you're using it because it can bleach them. Sometimes benzoyl peroxide is all you need for your acne, but it can also be combined with several of the other therapies described below.
There are other popular over-the-counter preparations you can safely try if the benzoyl doesn't help. I have found the most effective to be products containing salicylic acid (2 percent), glycolic acid, resorcinol, and sulfur (whose anti-inflammatory properties keep the pimples from swelling). They come in a variety of brands, whose names you can check at your cosmetic counter. I have also found benzoyl peroxide combined with erythromycin (marketed as Benzamycin) to be especially effective.
If none of these treatments work, consult your skin doctor, who might recommend topical lotions of antibiotics such as clindamycin, erythromycin, or products that contain sulfacetamide for mild acne. Apply them once or twice a day to the affected skin.
If these antibiotics are not successful, the next step is tretinoin (Retin-A). This preparation, which requires a prescription, is especially good against blackheads and white-heads because it unclogs the ducts and allows the oil to flow freely to the skin surface. It also lightens dark spots caused by old acne lesions. I prefer the gel or cream; the liquid can be irritating. Start with a tiny amount of the weakest strength (that's 0.01 percent for the gel and 0.025 percent for the cream) every couple of days and work your way up gradually as needed. Too much causes peeling, dryness, and irritation. Keep away from strong sunlight when using it and wear sunscreen in sunny weather. Tretinoin will irritate your skin at first, but you will see some improvement in two to three weeks, although maximum effect may take three or four months. Differin and Tazorac are related products.
Azelaic acid cream is a new, effective, and well-tolerated topical preparation recently approved for the long-term treatment of mild to moderately severe acne. Apply it to the affected area once or twice a day. It works very much like Retin-A and also prevents thickening, pigmentation, and discoloration of the top skin. Try it if the topical antibiotics don't work.
When the acne does not respond as well as you'd like to any of these topical applications, you may need to take oral antibiotics in low doses on an ongoing basis, sometimes for as long as a year or more. Your doctor will recommend any of the following, all of which slow the growth of the offending bacteria: tetracycline (taken with a full glass of water on an empty stomach), erythromycin (harder on the stomach; although it's safe, it makes the skin more sensitive to sun, so cover up in bright sunlight or use sunscreen), minocycline (my preference), and doxycycline (also very popular). Unlike tetracycline, the latter three can be taken with food. However, take them hours apart from iron or antacids, both of which can interfere with their absorption. Pregnant women should not take tetracycline because it can discolor the teeth of their newborns.
For maximum effect, the various topical therapies can be taken together with oral antibiotics.
There is something new and effective for adult women with acne. It's called Diane-35, a low-dose oral contraceptive that combines estrogen and cyproterone; the latter neutralizes the androgens that are responsible for the increased production of sebum. This preparation takes six to twelve months to work, and the acne is apt to return when the drug is discontinued.
When all else fails and acne is severe, you may need isotretinoin (Accutane) orally, but never if you're pregnant or of childbearing age unless you use appropriate contraception-without fail!-because it can cause birth defects. Accutane works by preventing the sebaceous glands from producing oil and can permanently shrink them. Even the most severe and resistant cases usually respond within weeks to Accutane. As many as 40 percent of patients can be cured by 1/2 mg per kilo of body weight taken for five to six months. Always take this drug under the close supervision of a dermatologist. And while you're doing so, check your cholesterol and triglyceride levels; they can be increased by Accutane. Be careful with your diet during the treatment period. Never take vitamin A supplements with Accutane. Also, because it makes the skin fragile, never use it to remove hair and don't get a facial peel.
If you have been scarred by acne, several cosmetic and/or dermatological treatments are available. These include dermabrasion, in which the superficial layers of the skin are planed down, the new Cooltouch laser, and chemical facial peeling. Pitting scars, however, do not usually respond to these measures. If you require such treatment, insist on a second opinion from a dermatologist as to which approach is best for you.
WHAT TO INSIST ON IF YOU HAVE ACNE
Although acne is extremely common, it can be dramatically alleviated and often cured. Insist on a consultation with a dermatologist to avoid the devastating emotional impact that extensive acne can have on vulnerable adolescents. Rupture of untreated cysts can cause permanent scarring that can be improved by a variety of dermatological and cosmetic procedures. Insist on guidance from a specialist.
A variety of topical solutions-ranging from over-the-counter preparations to prescription tretinoins and antibiotics that unplug the blocked ducts and reduce the bacteria on the skin surface-are effective. When topical measures fail, insist on low-dose antibiotics, either alone or in conjunction with these other measures, to reduce the severity of acne. In some women, hormonal therapy can control the disorder. If other treatments aren't working, insist on Accutane. It can dramatically improve acne and cure it in almost half the cases by preventing the production of the oils that obstruct the ducts. However, do not use Accutane if you are of childbearing age unless you scrupulously practice birth control because it can cause severe fetal abnormalities.
Excerpted from Power to the Patient by Isadore Rosenfeld Copyright © 2002 by Isadore Rosenfeld, M.D.. Excerpted by permission.
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