It is a cliche “of the teenage years” a worried-looking young person standing in front of a mirror, and looking with dismay at a fresh pimple or blackhead. (Acne vulgaris is most common in people between the ages of 12 and 25, but you may have a similar problem in your thirties or forties.) As anyone who has had acne knows, it is not just a skin disorder. That is true especially during adolescence; young adults are in a vulnerable state of development, and acne can scar you not just physically, but emotionally as well. So, it’s wise to treat the condition early and vigorously.
Myths About Acne
People sometimes think acne is caused by dirt or by eating the wrong kinds of foods, but neither idea is correct. In fact, with too-vigorous cleansing you may just create more skin lesions and increase scar formation. While the skin should be kept clean, it’s better to wash with mild cleansers that are pH-balanced for facial skin, such as Cetaphil. Acne is caused by bacteria, and the body’s natural systems are fighting them. When you pick at or squeeze a pimple or blackhead, you are interfering with that process, and you are likely to increase scarring. Diet rarely causes acne. Once a pimple appears, nothing will change its course, and so you should try to prevent it beforehand. When you use any acne medication, spread it over the entire affected area to forestall more eruptions. Also, be patient just as it took a while for the lesions to appear, it will take time for them to stop developing.
Many factors interact to produce acne. It usually develops after puberty, when the adrenal glands produce more androgens (male hormones) in both sexes. These hormones cause sebaceous (oil) glands in the skin to enlarge and produce greater amounts of oil, or sebum. Oil normally flows from a sebaceous gland through a duct to the skin surface. The higher amount of oil stimulates production of sticky cells in the duct. If the cells clump together and clog the duct’s opening onto the skin, a comedone (blackhead or whitehead) is produced.
A kind of bacteria, Proprianibacterium acnes, can thrive in the clogged oil duct, leading to the inflammation and tenderness of acne lesions. In addition, the bacteria produce substances that attract white blood cells. As these cells attack the bacteria, pus is formed. When the oil gland and duct can hold no more of the debris, they may burst and release the substances under the skin. As a result, pustules (small pus-filled bumps), papules (red bumps), nodules (bigger bumps), or cysts (painful nodules) may be formed. Because most sebaceous glands are associated with hair follicles, acne lesions are usually follicular as well; and they are usually found on the face, neck, chest, upper arms and back.
As acne is caused both by bacteria and by abnormal processes in the skin, it may be treated with antibacterial medicines or with medicines that affect the skin itself (topical therapy).
You can place antibacterials directly on your skin to treat mild or moderate inflammatory acne. Some common medicines used for killing or inhibiting acne bacteria are benzoyl peroxide (available over the counter), erythromycin, clindamycin, and sulfur products that contain sulfacetamide. You should use benzoyl peroxide at first as a 2.5% gel, and later as a stronger concentration.
Most true antibiotics (antibacterial medicines produced by fungi) are available only through a doctor’s prescription. Clindamycin doesn’t kill acne bacteria, but slows their growth and reduces inflammation. Erythromycin also inhibits bacterial growth, and may be used combined with zinc. Some bacteria have become resistant to this drug and to related antibiotics, and so if erythromycin doesn’t help your acne, probably clindamycin won’t improve it either.
All of these medicines may have side effects or may be more effective if combined with other drugs. If you use them, follow the pharmacist’s instructions; and if problems arise, call your doctor for advice.
Other Acne Medicines
While antibiotics act against bacteria, you can use other medicines to control the excess oil production, inflammation, and other skin processes leading to acne. These medicines include chemicals such as salicylic acid, glycolic acid, tretinoin, sulfur, resorcinol, and vitamin E. Many of them are found in over-the-counter medicines.
Tretinoin (Retin-A) is a comedolytic agent. That means it reverses the abnormal cell production in the oil duct, unclogging the passage and allowing the oil to flow out normally. For mild acne, this is what you should use first. If you have dark skin with darker spots left by acne lesions, you can also use Retin-A to slowly lighten the spots. As this drug can be irritating and increases sensitivity to sunlight, it’s important to begin with a weak form and increase the strength gradually, and to use a sunscreen regularly. Usually it takes three or four months to show maximum improvement.
Recently, other comedolytic medicines have appeared on the market. You can get prescriptions for Adapaline (Differin), Tazorotene (Tazorac), and Azelex (20% azelaic acid). Azelex also prevents pigment production in the top layers of the skin, making it a good choice for long-term therapy.
Antibacterial and other drugs can be used together or sequentially to increase your control of acne lesions. Retinoids (Retin-A, Differin, and Tazorac) will unclog oil glands and make the duct less hospitable to acne-producing bacteria; combining them with antibacterials will decrease both bacterial growth and inflammation.
Azelex itself is both antikeratinizing; that is, it prevents the skin thickening that may result from acne and antibacterial. Also, it can be combined with other antibacterials or retinoids.
If your skin is sensitive, it may be irritated by these combinations, and so you should begin by using one of them in the morning and the other in the evening. If your skin tolerates them, you can then try using both at the same time, and increasing the dosage to twice a day.
While time and changes in hormonal levels will eventually take care of acne, you don’t need to just wait patiently. By using a variety of specific anti-acne treatments and combining them with a generally healthful lifestyle, including enough sleep, good nutrition, and exercise, you can keep acne under control.