by Erum Ilyas, MD

One of the most common reasons to visit the Dermatologist is acne.  It can begin as early as the age of 6 or 7 and can appear at any point in your life.  It primarily starts as clogged pores- also known as comedones. This is a good word to learn as many products may be labeled as “non comedogenic” which essentially means “non pore clogging”.  Comedones can be open or closed; i.e., blackheads or whiteheads.  Clogged pores are the result of excess oil production, known as sebum, and from lack of exfoliation at the opening of the pore.  After the pores begin to clog, bacteria by the name of  Propionibacterium acnes (P acnes), can overgrow and lead to significant inflammation.

Types of Acne

Clogged Pores

Comedonal acne, primarily seen as whiteheads and blackheads, can often be treated in its initial stages with over the counter products.  Many of these products contain Salicylic acid of up to 2% concentration, or Benzoyl peroxide in varying concentrations up to 10%.   These products both remove extra oil and dead skin cells to prevent pore clogging from taking place, but salicylic acid is often less irritating.  Any product containing benzoyl peroxide will also kill bacteria on the surface of skin that could have otherwise caused further acne.  It is important to be careful of the concentration of Benzoyl peroxide in products that you choose, as some of the higher concentrations can be very irritating to some skin types.

If you have comedonal acne that has not responded well to traditional over the counter  products, prescription products from your Dermatologist will prove very helpful.
The most successful treatments for comedonal acne are retinoid products containing ingredients such as adapalene, tretinoin or tazarotene.  It is important to be under the care of a Dermatologist when using these products, as they can produce significant irritation in some skin types, especially in the first weeks of use.  They are often more successful in combination with topical products containing benzoyl peroxide, and/or topical antibiotics.

Occasionally, some patients may find their treatment options limited due to skin sensitivity and irritation.  In these cases, it is extremely helpful to visit your Dermatologist as there are less irritating options out there for you! Some of the more mild products may include azaleic acid or sulfa, among others.  It is important to also be aware that what may
look and seem like acne may actually be the result of rosacea or seborrhea, or some
patients may have a combination of causes that require a completely different approach to treatment.

Inflammatory Acne

The next stage of acne after comedonal is inflammatory.  This type of acne occurs when pores have become clogged and the bacteria P acnes is causing inflammation in these  reas.  The resulting breakout will be more pink, occasionally tender or painful, and may come to a head as a pustule or pus filled area. This stage of acne will be harder to treat with topical therapies alone, as the level of inflammation is deeper than many topical products are able to reach.  The most common and most effective antibiotics used are Doxycycline and Minocycline.  These are often prescribed for extended periods of times, most often in 6 to 12 week regimens, and often times longer when needed.  There are some less often
used antibiotics that are still effective.  It is always important to be under the care of a Board Certified Dermatologist when undergoing oral therapy for acne.  It is always important to recognize that this stage of acne has a risk of scarring, and it is important to follow up with your Dermatologist as instructed as they may be able to intervene and prevent scarring.

Nodulocystic Acne

Cystic acne can be very frustrating and painful, and can lead to significant scarring if not treated.  If you suspect that your acne is this severe, please see your Dermatologist as often oral antibiotics may be used initially, and for resistant or more severe cases a discussion with your doctor about using Isotretinoin, known as Accutane in the past, may be warranted.

Commonly Asked Questions

Why hasn’t anyone checked my hormones?

Hormonal testing in acne cases is not routinely recommended unless other signs of hormonal problems are present.  The majority of acne patients will most likely not have hormonal testing performed.  If you feel as though you have other signs of hormonal excess, such as irregular periods or excess hair growth, please inform your Dermatologist.

Should I try birth control pills for my breakouts?

This is a question that should always be discussed with your Dermatologist and Gynecologist.  As with any medication by mouth, the risks and benefits of taking a medication that will be used long term should be reviewed with your doctor.

What about my diet?

This is a great question that is difficult to answer.  There have been several attempts to link diet and acne, and population studies conducted to see if links between diet and acne are present.  Unfortunately, the studies available suggest links between acne and diet but do  not consistently show this to be the case.  There are undoubtedly going to be more studies and attempts to link the two, however based on reviewing the studies available, it is not routinely recommended to make any dietary changes other than maintaining a healthy well balanced diet.

Should I pop my pimples?

Another great question! Although there are not many studies that support removing blackheads and whiteheads directly, it is still routinely performed, and can be beneficial in
helping improve to the overall appearance of acne.

Should I get a chemical peel or microdermabrasion?

This is not a well-studied method of treating acne, despite being widely used.  These  therapies may be helpful in some patients, and especially for comedonal acne.  If any element of inflammatory acne is present, it is best to ask your Dermatologist prior to obtaining a chemical peel or microdermabrasion treatment.  Occasionally, some patients find that their breakouts become worse in the initial weeks after a treatment, and may require prescription strength topical or oral medications to help.

When should I see my Dermatologist?

As mentioned above, often the earliest stages of acne can be well controlled with over the counter preparations.  When choosing acne products, be sure to look primarily at the active ingredients listed, and less at the ads that support their use.  So many patients end up with boxes of slightly used products and have not realized just how much money they have spent.  When looking through these boxes they find out that almost all had exactly the same active ingredients, just different brand names and inactive ingredients.  If a product is helping but is irritating or difficult to use, choose another brand name with the same active ingredient.  This may help offset some of the irritating effects of the inactive
ingredients, which vary from product to product. If you have tried over the counter products without success, worry that you may have inflammatory or cystic acne, or suspect that you may have a hormonal disorder, please see your Dermatologist to review your treatment options.

Please check back for future posts on adult acne, acne for women over the age of 20, rosacea, and specific posts on topical and oral therapies!!

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