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Doctors' Answers to "Frequently Asked Questions" - Acne

These comments are made for the purpose of discussion and should NOT be used as recommendations for or against therapies or other treatments. An individual patient is always advised to consult their own physician.

Acne Treatment [posted 1/12/99]
Question: I am using the new product Differin (adalapene gel) from Galderma. I use it one time at night. On the label it said to wash your face before applying. Instead of washing my face with regular soap I use the Benzac Wash 10% (benzoil peroxide) by Galderma before applying. Do you think that is a good idea? Should I use regular soap? Also, my face seems to be staying the same with the new gel. I use to use Cleocin T gel 1% and the acne showed results. I tried using the same thing, but the acne stayed the same. Why? And what acne product would you say gets rid of acne the fastest. I know that some don't show results until 1-2 months, but do you know of any medication that shows results very quickly after applying? It can be prescription. I heard of Benzamycin. Do you think that will show fast results?

Answer: Best results are achieved with Accutane in most patients. I would not mix the Benzac with the Differin unless you test small areas.

Acne Treatment with Birth Control [posted 1/6/99]
Question: I am 27 years old and since my late teens have been experiencing moderate acne. I have taken every antibiotic ever used to treat acne, as well as Retin A, Benzol Peroxide gel and cream, salycilic acid, etc. Nothing made a significant change, and I deeply regret taking so many oral antibiotics for so many years (is this bad?). I never took Accutane because I have dry skin and wear contact lenses. My acne seemed related to stress and hormones, so I was excited when Ortho-Tricyclin was approved as an acne treatment. However, when I took it nothing changed. Last year I was in France and a dermatologist there prescribed a birth control pill and a hormonal supplement. This pill is widely prescribed in France (called "Diane 35") and in England (called "Dianette"), and contains: ethinyl estradiol 0.035 mg, acetate of cyproterone (French word) 2 mg. The hormone (called "Androcur") contains an additional 12.5 mg of the "cyproterone." I have been taking it for over 6 months, and it has cleared up my skin better than anything has up to this point (although I think the added has given me slight weight gain). What exactly is this stuff? Why would it work better than the Ortho-Tricyclin? Why isn't it available in the US when it is such a popular acne medication in Europe?

Answer: Birth control pills have been used for 40 years for acne, although only recently approved by the FDA. I would ask your gyn to match the one closest to this formulation. Also, if you haven't tried spironolactone, it's worth a try.

Acne Treatments  [posted 12/09/98]
Question: I am 44, premenopausal, and have had acne since I was about 22. My periods are the same as they've always been, about 25 days apart. I've used Retin-A since 1985 and have alternated topical cleocin and erthromycin, but mostly cleocin. Over the past year my acne has greatly worsened and now it is worse in the middle of my menstrual cycle rather than during the menses as before. Not using the medicine is much worse than using it, but it seems to have lost a good deal of its effectiveness. I used to use benzyl peroxide 5% until I developed a rash sensitivity to it and my derm told me to quit using it. I recently started using Clearasil  sulfur and resourcinol cream. It cleared up my acne on my chest, back and shoulders (which I'd never really treated before), but it's too rough on my face more than a couple times a week. Why has my acne suddenly increased at this advanced age and what can I ask my doctor about that might work? I am unwilling to take internal antibiotics because of the risks and they usually make me feel sick. I rarely get cysts, but the little infected red bumps are there most of the time now. Thanks.

Answer: Acne is due to testerone levels. Testerone in women is a product of conversion from either estrogen or progesterone and is done in the fat cells. Losing weight will help. Possibly birth control pills which change your sexual steroid levels. I suspect you have either gained weight or your estrogen levels are changing as you approach menopause. Sometimes spironolactone is helpful in women with acne, worth a try.

Salicylic Acid Use [posted 11/19/98]
Question: My dermatologist told me that salicylic acid affects the liver even if applied topically. Is it true? If so, what are the other side effects of using salicylic acid for the control of acne? Thank you.

Answer: Possible but, uncommon in usual topical doses unless you have pre-existing liver or renal problems. Local irritation is usually the only problem.

Adult Pimple Outbreaks [posted 11/6/98]
Question: I am a 30yr old adult and have never had an acne problem, but do get these recurring pimples on my buttocks and face especially during the summer but not restricted to summer only. I presently live in a very humid climate and feel this might have something to do with this condition. I work outdoors, sweat profusely and get extremely dirty, but how could this effect my buttocks also? I lived in the desert for the last six years, and upon coming back to where I live now they have come back. While I lived in the desert, they almost disappeared. Could this be the reason they have returned, and what would you suggest I can do to get rid of them? Please help, this is embarrassing.

Answer: Acne vulgaris arises from heavy oil production by skin glands and subsequent infection by anerobic bacteria. Factors which increase oil production or bacteria will give rise to more acne. Humidity and lack of sunlight are thought to be two of the factors. Focus on using an anti-bacterial soap, use oxy 5 on the affected areas and if this is not sufficient see an MD for prescription treatment.

Suggestions for Acne Treatment [posted 10/28/98]
Question: I am 19 years old and have suffered from moderate acne for about 2 years. I have seen various dermatologists and have been on numerous treatments, but to my disappointment have seen little if no results. I have been on the following oral antibiotics: tetracycline, achromycin, and minocycline. As for topical prescription treatments I have been prescribed: benzoyl peroxide, erythromycin, azelex, retin-a, retin-a micro,vanoxide hc, differin, cleocin, klaron, and avita. I am currently taking minocycline and applying erythromycin twice a day, but have seen very little results. What do you feel is the most effective treatment for moderate acne (oral and topical)? Thank you!

Answer: Accutane would be the next best if you have tried all of the above.

Acne & Norgestimate in Ortho Tri-Cyclen Birth Control Pills [posted 10/23/98]
Question: If Norgestimate is the ingredient of Ortho Tri-Cyclen which improves acne because of its anti-androgenic properties then why is Ortho Cyclen not also sited to be of benefit to acne, having the sustained higher values of norgestimate in its components?

Answer:Can't say, maybe not specifically tested and approved by the FDA.

Acne Treatment [posted 10/13/98]
Question: I am a 22 year-old male student with acne and I have been using Benzac AC 10 for many years. My acne clears up for a little while if I use the Benzac two or three times a day. Does this mean there is a better treatment out there or something else I could be doing to help cure it? If so, what do you recommend? (seeing a dermatologist is difficult because I don't have a doctor in the area)

Answer: Benzoyl peroxide is about the only one available over the counter. If it works keep with it. Local and systemic antibiotics-usually tetracycline, erythromycin or clindamycin ;topical retinoic acid, and systemic isotretinoin are the usual regimen in about that order depending on the severity and scarring potential of your acne. Except for benzoyl peroxide all need prescriptions. This does not need to be done by a dermatologist. Most family docs and internists can care for this.

Acne Treatment [posted 10/2/98]
Question: I have terminal acne and oily skin , I have been on a maintenance Accutane dose of 40mg a week for approx. 5 years without any problems, and my skin does great. Recently I had a blephoplasty and became concerned about Keloid scarring-my surgeon had no recommendations--but I stopped taking it about a month before the surgery. I am a week post-op my eyes look great, but my skin looks awful, small tiny bumps all over and extreme oil. When can I resume my accutane? How can I tell if it will be Keloid? I have fair skin and have never had keloid that I know of.

Answer: If you were to develop keloid, you would usually have one by 18 or 20 years of age, or have someone in the family with keloid. I'd restart it.

Acne Treatment [posted 10/1/98]
Question: I noticed in several of your responses regarding accutane that you mentioned it didn't "cure" acne. My dermatologist is suggesting that I take it and has told me that after a five to six month treatment, I will no longer have acne. Is this then not the case. I am a bit worried because even though my skin is oily, it is also dry which surprised her and I don't want to have even drier skin and experience the side effects of accutane only to have the acne reoccur. Also can side effects to the liver be permanent?

Answer: The acne will usually come back until you age enough to change your hormone levels and reduce the acne. It may not need to be treated with accutane;but, something potentially less toxic. It will not be "cured" with accutane since it does not eliminate the cause-generally high testosterone levels and excess oil production due to same. The liver problems can be permanent if left untreated and with very high levels. However, we stop the medication before there is a risk of permanent damage. Most patients will need cycles of this drug for several years. Some can get by with only a few cycles.

Acne Treatment [posted 9/29/98]
Question: I have a friend who has a slight acne problem, has been on accutane before and would like to try it again. Her dermatologist gave her Differn (sp?) as what he called a "topical alternative to Accutane". I am currently taking Accutane and I would like to know the different ways in which these drugs operate (other than topical vs. systemic).

Answer: They have much the same effect. In general, we start with topical drugs for local disease that is not scarring in nature. Generalized acne vulgaris or acne with deep scarring usually necessitates the systemic drug regimen.

Adult Acne Treatment [posted 8/13/98]
Question: I've recently been given a prescription for ortho novum tri-cyclen for adult acne. I forgot to ask my doctor about how long it would take to start working. Do you know the average length of time?

Answer: Usually 3-4 months.

Adult Acne [posted 8/7/98]
Question: How does one get rid of adult acne? I am 29 and am tired of suffering with it.

Answer: Topical antibiotics, systemic antibiotics, local application of benzoyl peroxide (available over the counter), Accutane in severe cases. All except benzoyl peroxide are prescription.

Acne [posted 8/6/98]
Question: My grandpa has what looks to be a white head pimple on his hand, but when he opens it up there is a chalky white substance inside. That reduces it for a while and then it comes back. My mother just experienced the same thing on her forehead. What is it and what can they do about it?

Answer: Sounds like acne. It wouldn't be a sebaceous cyst on the hand, but this is still a possibility. With dermatology you usually need to actually see the problem. It's hard to diagnose without visual clues.

Severe Acne [posted 7/30/98]
Question: I have had severe acne since I was 13 years old. I went through the whole treatment of different medications that are offered on the market these days, and even Accutane didn't work. I hated Accutane because it caused me worse acne than I had in the first place, as well as lots of unnecessary scarring. I am now on herbal creams that were working well for some time, but I am breaking out into large cysts that I don't know how to treat anymore. What should I do?

Answer: Did you try birth control pills? They are often overlooked and can be very effective adjunct therapy for women. Topical antibiotics will help the scarring some. Systemic antibiotics would also be recommended.

Acne Medication [posted 7/27/98]
Question: Are the infomercials advertising acne medication really working or are they a waste of time and money?

Answer: The ones that advocate benzoyl peroxide are ok. Use the 5 % first. The rest are fairly worthless. The only good medications other than benzoyl peroxide (available over the counter at any drug store) are prescription.

Cryosurgical [posted 7/24/98]
Question: I have cystic acne and have an HMO. Would cryosurgical treatment be considered cosmetic?

Answer: Usually, but, you'll need to check with their benefits office.

Cystic Acne
Question: I have just finished my 20 week course of accutane (40 mg twice a day). Accutane helped me clear up my acne, but I still have deep red scars. I was told they would fade away but its been almost 6 weeks since I have stopped accutane they haven't cleared up as yet. I also have problems shaving because after I shave I get small red pimples on my neck. They go away in a few days and then again return.

Answer: It sounds like you have some permanent problems from cystic acne. Accutane is one of the preferred treatments for this problem and I'd stay on it. Local steroid injections may be of help (by your dermatologist or plastic surgeon). If this fails, ruby laser treatment to remove all the skin to the dermis is next (this is expensive but, works usually). I'd change to an electric razor and see if these "bumps" go away. Many of my patients with acne have difficulty with blade razors. I've never been sure if it is the shaving cream or the blade itself, but they tend to improve with electric razors.

Birth Control Pill and Acne
Question: I have been advised that a product called Ortho Tri-cyclen, a birth control pill used in the cure of acne would perhaps be beneficial for my daughter. Do you have any thoughts, and/or information on the medication.

Answer: Acne is by far the most common skin disease in the United States. It effects upwards of 85% of people between the ages of 12 and 25 and not infrequently persists into the 30's and 40's. It is accepted that in part, one of the contributing factors in producing acne is sebum, or sebaceous gland fluid. This is in part effected by hormones in both male and female patients, and therefore the hormonal state of females during their menstrual cycle will often give rise to a waxing and waning pattern of acne. There are a great many therapies for typical acne (so called "acne vulgaris"). Many of these therapies overlap with those used for other, less common forms of acne. All acne patients should use a gentle anti-bacterial soap, washing with nothing harsher than the fingertips. Avoidance of oil-containing cosmetics is also helpful, and use of moisturizing lotion for patients with mixed oily-dry skin should be confined to just the dry patches. Picking or manipulating acne pimples should be avoided, as this can lead to scarring. Commonly used antibiotic preparations be they oral or applied to the skin, in addition to salicylic acid containing compounds, often produce good results. Retinoic acid can also be used, although this should not be used unless other therapies fail, as retinoic acid can cause a rather severe redness/peeling reaction on the areas to which it is applied. Skin applications of benzoyl peroxide are also commonly used and are helpful. Overall, it is typical for many patients to require combination therapy to obtain results, and usually, these improvements are seen in 6-8 weeks after starting therapy. Hormonal therapy (including birth control pills) has been used in the past for the specific purpose of treating acne, but other, less systemic-effecting treatments are now available and usually yield good results. See your health care provider. They can provide appropriate therapy and determine if referral to a specialist is in order.

Acne Scars
Question: I am 51 years old and still battle with acne occasionally, especially cysts. Panoxyl 10 has been a great help to me, but occasionally a tough cyst doesn't respond to it and leaves a discolored area. What can be done to remove discoloration's left by some cysts. Some are on my nose and really bother me psychologically.

Answer: These will usually need a plastic surgeon or dermatologist. They can inject steroids into the area. Dermabrasion or topical laser treatment can also be used to remove this discoloration depending on the depth and severity of the color problem.

Question: I am one of the few that accutane has not cured. I have undergone 4 treatments of accutane and each time the same result has occurred. During treatment, I do not breakout, but after treatment, I breakout after about 3-4 months as usual. My dosage was two 40 mg pills every day for the duration of the treatment. The only real side effect I received was chapped lips. I am a male about 5'9" and weight 145 lbs. My first treatment was in December 1989 and the last one ended about October 1996. I am 26 years old now and see no signs of acne ever going away as I still have oily skin and continue to breakout. What I'd like to know is if there are any other solutions or anything else out there that could help me. Accutane has been the only thing that has affected my acne but I do not see any signs that it will ever go away completely.

Answer: Unfortunately, you will have acne as long as your testosterone levels are high. For men this is usually into the 40s or 50s. I assume you have tried topical medications while on accutane holiday? Accutane only is effective while you are taking it. It does not "cure" acne - it merely addresses the effects while you are taking it.

Question: I have acne mainly on my forehead and I've been using Erythromycin Topical Solution (2%) for a few days now. This solution makes my forehead really itchy. It also seems that the acne is not decreasing, but instead increasing! Should I stop using this, or does it take a few weeks for it to start working?

Answer: Treatment of Acne Vulgaris aims at killing the bacteria in the skin responsible for the infection of the oil glands. This is accomplished in several ways from topical benzyl peroxide to local antibiotic ointment to systemic antibiotics to topical Retin-A. Treatment will take several weeks to be effective and should usually be continued for several months to years. Itching will occur as the skin is affected and is fairly normal. Redness of the skin and sun sensitivity occasionally occur with topical treatment.

Question: I understand that the best strategy against acne is a proactive cleaning process. What types of soaps do you recommend? What products help reduce blemishes?

Answer: Any soap that is drying (this is, removes oils) works fine. This means that “deodorant” soaps usually work the best. Also, topical use of benzoyl peroxide (available over the counter) is extremely effective as a first line in acne vulgaris.

Question: I have been taking doxycycline for 2 months, 100 mg a day and have noticed no improvement. I have had more cysts breakout on my neck. I have also been using a 5% benzoyl wash and cleocin. I have been taking the previous two for four months. Is this normal that I have not seen results yet? What else would be suggested for me to do or take?

Answer: Acne vulgaris is a common and troubling problem. In minor cases it produces social embarrassment and the perception of a flawed complexion. In more severe cases, like cystic acne, it produces permanent scarring and occasional serious systemic infections seeded from the skin infections. The infections are due to both overproduction and subsequent plugging of sebaceous glands and growth of mainly anaerobic bacteria in this oil. There seems to be a good correlation with testosterone production in both men and women, implying that this hormone is part of the trigger for excess oil production. Treatment centers on keeping the glands from becoming plugged and killing the bacteria from infecting the plugged glands. Any rubbing or contact with the face or other areas prone to having acne should be minimized, wear hair short, etc. Cosmetics and any other skin preparation should be eliminated and the skin should be washed 2-3 times a day to minimize oil. Sun exposure is helpful, whether in tanning salons or naturally(although long term increases the risk of skin cancer and ages the skin). Local agents such as benzoyl peroxide or retinoic acid are very helpful. Also, local antibiotics such as clindamycin, tetracycline or erythromycin are used. Oral antibiotics are used if these measures are not eliminating the problem. In severe cases, systemic isotretinoin is used. This drug is not to be used in women who might be pregnant and may have effects on sperm. Patients receiving isotretinoin will have extremely dry skin and calcifications of tendons have been reported. Birth control pills are occasionally helpful in women, presumably by changing the testosterone levels. Dilantin, isoniazid, steroids, and phenobarbital may also cause acne vulgaris.

Question: I have acne and I am taking accutane. I have open pores which can be seen clearly. Are there any medication or treatments that will reduce their size or close them?

Answer: There have been many new developments in the treatment of Acne Vulgaris in the last several years. These pores can often be minimized in appearance. This may be accomplished by collagen injection or by dermabrasion usually performed by a Dermatologist or Plastic Surgeon.

Question: I need to know the side-effects of monocycline that I am taking for acne.

Answer: Nausea, diarrhea, occasional increased sun sensitivity, occasional drug allergies(rash, itching etc.).

Retin A
Question:I would like to know mare about Retin A.

Answer: Retin-A(tretinoin) is the acid of Vitamin A. It is available in liquid, gel, and cream. It is topically applied once a day to treat acne vulgaris. The method of action is not currently known; but, it appears to affect the aggregation of follicular cells. Side effects include sun sensitivity, rash, allergic reaction. Using the drug more than once a day will not improve its action. It should probably not be used in pregnant women; but, studies are inconclusive currently.

Tourette's Syndrome & Acutane
Question: My 17 year old son has Tourette's Syndrome which has been "in remission" for awhile. He has serious acne, and a dermatologist has recommended Acutane. Though it's heavy-duty, he's desperate. But we'd be horrified if it starts up his tics again!

Answer: I understand your concern; but, I doubt that Accutane would have any effect. On the other hand triggers for Tourette's are debated; however, I would be surprised if it started up as a result of the Accutane.

Latest Therapy
Question: What is the latest therapy for acne in teenagers without using accutane. Is Retin A still the best or is Differin as good.?

Answer: Retin-A is still the best. Topical antibiotics are also of help and occasionally systemic antibiotics.

Adult Acne
Question: I am a 25 year old female who never really experienced much acne as a teenager. Now that I am an adult, I've experienced wave after wave of breakouts on my forehead, chin, and other areas of my face. It's been happening for about 3 years now and I think it's due to stress. Retin-A doesn't work for me, nor does Clearasil, Origins "Spot Remover," etc. I've made an appointment with my care provider, so that I can try some-thing stronger, but I plan on having children in a few years and don't want to use Accutane. What other acne remedies are available by prescription?

Answer: There are several; but, the most effective is often birth control pills. Antibiotic therapy either topically or systematically is also effective. Ensure your hair is off your face and try to lose weight( the fat changes estrogen to testerone-the cause of acne).

Question: I would like to know more about the drug called spironolactone (sp?), as far as when it is used specifically for the treatment of acne. Mostly what is it, ie. hormone, steroid, etc.? How does it work? What are the problems or side effects when taking it. I am a 43 year old female, who has had constant skin problems ever since puberty. I have tried nearly everything, including two courses of Accutane. I continually try to educate myself in hopes that some day I will come across something that will work.

Answer: Spirolactone was initially used as a potassium sparring diuretic and still is. Due to the fact that part of its structure resembles estrogen(it has the same A ring) it has a mild estrogen like effect-consequently, useful in treating acne and hirsuitism in women. In men, it tends to produce breast development and decreased hair as well since it tends to interfere with testerone.

Back & Shoulders
Question: I have a problem with pimples. Whenever I go to the chemist they say its superficial as I have none really on my face, but I’m too embarrassed to say it's severe on my back and shoulders. Is this common? and what can I do about it? Unfortunately I live in Australia and there is no such service as this.

Answer: Very common. Topical drugs such as benzoyl peroxide is usually available over the counter(that is, without a prescription). Topical antibiotics, retin-A etc would all be effective for your problem.

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