Below, Diane Berson, MD, an assistant professor of dermatology at Weill Medical College of Cornell University in New York City, discusses what causes acne and how to treat it.
What is acne?
Acne can appear a lot of different ways. Usually it consists of blackheads and whiteheads, which we commonly refer to respectively as open comedones and closed comedones. It can also consist of papules, which are pink pimples, and pustules, which are white, pus-filled pimples, and sometimes more painful and larger nodules and sebaceous cysts. Carbuncles are infected cysts.
Are the characteristics of acne different in adulthood?
Usually it's the non-inflammatory, or blackhead and whitehead lesions, that start to come out during adolescence, when kids start getting oily in their T zones: their forehead, nose and chin. As people get a little older and the acne becomes more severe, they develop more inflammatory lesions that involve redness and swelling.
Adults, especially adult females, tend to have more acne breakouts on the lower half of the face, such as the cheeks, the jaw line, the chin and the neck. No one knows exactly why those are the areas that tend to break out more, but with adult women it's assumed that those areas might be more sensitive to hormones.
Where else on the body can acne appear?
Adolescents start out with acne in the T zone, and then get more inflammed acne that can migrate down to the chest and back and sometimes the buttocks. It might mean that there are excess hormones being produced in these areas, but we don't exactly know why acne follows this pattern.
What are risk factors for acne?
It's assumed that genetics and hormones play a role in starting acne. Other factors that might contribute to flares of acne include stress and certain skincare products that clog the pores.
What causes acne?
We usually talk about the four most common factors that contribute to the development of acne. The first is increased shedding of cells that clog the hair follicle and the second is increased sebum, or oil, production; that oil accumulates in the clogged follicle. Usually increased sebum production occurs with the hormonal surge of puberty. The third factor is the growth of bacteria, which is most commonly referred to as P. acnes. The fourth factor is the development of inflammation, which is the body's response to having the pimple or the bacteria there.
When does acne lead to scarring?
The more inflamed acne is, the more likely it is to heal with scarring. Also, the longer the lesion has been there, the more likely it is to lead to scarring. Sometimes, the darker the skin tone, the more likely it is to lead to scarring.
What does good preventive care involve for teenagers and adults?
It really depends on whether they have the acne lesions yet or not. If they don't, it's just washing the face twice a day, and if they're a little oily, maybe using a cleanser or a toner that contains salicylic acid to help unclog the pores. But once they do develop the first sign of acne, we recommend that they see a dermatologist who can start them on a topical regimen to not only clear what acne is there, but to prevent further acne breakouts.
Are there over-the-counter products that you recommend?
For mild acne, I think the best ones that we usually recommend are those which contain benzoyl peroxide or salicylic acid.
What are some common myths about acne treatment?
The two big myths are that food causes acne and that dirt causes acne. Unfortunately, a lot of teenagers think dirt does cause acne, so they tend to over-scrub their face and probably make their complexion worse.
Another myth is that sunlight will help treat your acne. It can dry out the pimples a little bit, and it can temporarily camouflage the acne by making you develop a sunburn and therefore get red, but it really doesn't help treat acne, and we all know that lying in the sun isn't good for you.
And picking or squeezing can traumatize the acne lesions and that will increase the chances of developing an infection and scarring.
How is acne treated?
Usually, dermatologists will prescribe a topical retinoid. And along with this, they'll usually prescribe an antimicrobial agent such as either topical benzoyl peroxide or a topical antibiotic.
Systemic treatments are usually oral antibiotics, which are added when there's more inflammation, and for those with more severe acne, oral isotretinoin is used. For women, we often also add hormonal therapy such as the birth control pill or antiandrogens, which block the effect of certain hormones that tend to stimulate acne.
What is the current thinking on the use of the acne drug Accutane?
Dermatologists still think it's an incredibly valuable drug for those who have acne that hasn't responded to other therapies or who have acne that's very severe.
There are certain side effects and the main issue is that a woman who's of childbearing age must completely avoid pregnancy while she's taking it, because if a woman were to become pregnant while taking it, she could give birth to a baby with birth defects.
Accutane and depression have been associated, mostly in adolescents, but there's not a clear-cut relationship. There are adolescents who become depressed about their acne and depression is common in adolescents, so it's not clear if the depression is due to the Accutane. And when they go off the drug, does their depression lift because it was caused by Accutane or because their acne is better? But depression is something dermatologists are aware of and when I counsel an adolescent, I make them aware that there might be some depression or moodiness, and that they must contact me if they experience this.
How is scarring treated?
The traditional ways are with chemical peels or dermabrasion. Because peels or dermabrasion peel or abrade off a whole layer of skin, there's a lot more downtime associated with it. One of the newer ways you can try to treat scarring is with certain lasers such as the Smoothbeam and the CoolTouch. With some of these laser treatments, you can resume your normal lifestyle right afterwards.
Does acne ever reflect an underlying medical condition?
Well, certainly it can. Young girls or even adult women who present with sudden acne and also have excess facial hair growth or thinning of their scalp hair and maybe irregular menstrual cycles might have an underlying hormonal abnormality, such as an adrenal problem or an ovarian problem. You can also develop acne after taking certain medications such as lithium, antidepressants and steroids.
Is there sort of a typical length of treatment that people need?
It can take four to six months for acne to improve. It's important that especially adolescents understand that, because it's not something that's going to get better overnight. It requires a commitment to the regimen and knowing that if it doesn't get better right away, it still can and that you should stick with the regimen.
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