What is the best way to treat acne? acne vulgaris is a scourge of teenagers everywhere, vulgaris sounds bad but in fact it’s an old word that means common which acne certainly is, acne is fascinating in the pantheon of diseases, many of us trivialize it as simply part of teenage life that fades and really doesn’t have any health consequences but what if framed in a different way acne is a disease that makes people feel bad, often very bad about themselves just when it’s most critical that they feel good about themselves, it’s a disease that can scar for life but that could have been prevented, a disease that research shows us as damaging to quality of life as chronic distressing conditions such as asthma, epilepsy or diabetes and the timing is so unfortunate just as we start to be more aware of our parents, the oil geysers that are located in their upper chest, back, neck and face, all highly visible areas begin pumping out skin grease, adults can get acne, about ten percent still have it at twenty five but almost all teenagers do get acne with one in five having a more severe case, it tends to come on earlier in women but the dudes get it a little bit worse, unlike most acne resources on the internet, I’m not going to offer you a hundred percent cure, there really is no cure for acne, most of the therapies I’m going to discuss have about a 40 to 70 percent success rate, getting to a higher success rate really depends on you finding your own special recipe that often requires you to combine different agents, what we call step up therapy. The first piece of advice is to talk to your doctor about it, say this, “my doctor has seen more embarrassing things than whatever I show him or her” so bring acne up and go back if your treatment isn’t working, now I bet I can guess the current approach some of you are taking who are suffering from acne, perhaps you wash your skin vigorously to keep blackheads to a minimum, maybe you put pimple cream on whenever you have an outbreak and you might even avoid certain foods that you think worsen your acne, well actually, the blackheads is really just melanin and oxidized lipids not dirt, so cleaning vigorously or picking can actually inflame pimples, washing once daily with the mild soap or soap less cleanser is fine.

Putting pimple cream on your existing acne doesn’t actually make much of a difference, key learning is that when you’re treating acne, you are actually not doing much for the current pimple, you’re preventing the next round so if you are applying a cream it needs to go on where you get pimples, for most people this is what we call the t-zone, it takes six to eight weeks and sometimes longer to see if acne treatment is working. Now diet and acne is interesting, most research shows no connection but the trial quality is generally poor, for example, studies trying to provoke acne with large amounts of chocolate didn’t show a fact but the trials were too short and too small to be definitive, a small trial using a low glycemic diet showed some improvement but I’d say there’s not enough evidence at this time to recommend one way of eating over another, the answer is likely just eating healthily and if a patient finds a big difference with the food, I say eat less of that food.

To understand the best treatments for acne, we need to start with a biology lesson then a mere test, then step up therapy, I think if you comprehend the biology of acne, it makes treatment a lot easier to understand, when you hit puberty, many things happen but two things in particular to your skin, first we get more plugging, this is because the hormonal changes of puberty cause more oil production, what we call sebum and the surface of the skin becomes a bit more crusty, what we call keratinization, the second thing that happens is we get more inflammation, this is mostly because of a bacteria that colonizes our skin called P acnes, the P acnes mixes with the sebum and oil and causes an inflammatory reaction which gives redness and swelling, now acne confuses us, i think because there are so many treatments, one review indicated a hundred and forty different treatments and 250 combos, so we can’t cover them all but we can ask what the clinical research says is the most effective of all these treatments and I think it follows our biology lesson, it’s developing a strategy to reduce plugging and also minimize inflammation, the gist of acne treatment is to start with one therapy, if it works great or if it only works partially or not at all, then you need to step up to the next level by changing or adding a therapy. Okay let’s take a bit of a detour and do topicals 101, topicals are medicines that you apply to your skin like a cream or a gel, or a lotion jelous had to be stronger and more drying than creams, so if you have oily skin, an L might be a good idea if you have less oily skin, then a cream would be better, now we all react differently to different topicals so it’s a good idea to experiment with the topical in one area before you apply it everywhere, let’s start with a lower strength and then ramp it up if you need more effectiveness. Now let’s say you look in the mirror and now by the way is a good time to take a picture of yourself, pretreatment to use later for comparison, let’s say you see mostly red and inflamed pimples, then you need to do something about the inflammation which means you need to try to reduce the bacteria P acnes benzoyl peroxide or BPA’s first line here and it’s available over-the-counter at any pharmacy.

It’s good to go graduate with BP as there doesn’t seem to be much difference with the different strengths, tell people to start with low strings like 2.5% and start putting on for two hours for four nights and for four hours for four nights and then the whole night and then wash it off in the morning, if you tolerate that well but you want more effect, then you can try switching to a stronger version, remember you have to give it a few months to see if it works all right, back to the mirror looking at your face, if you see plugging on your skin which would be small bumps, blackheads or whiteheads, then you need to focus on unplugging the classic’ unplugging agent, in acne care is called a retinoid. Retinoids work by making your skin less crusty and you need a prescription to get this treatment, sometimes it can make your skin a bit red and dry so again experiment dryness can be helped with a moisturizer, so if you look in the mirror and see both red spots and black or white heads on your skin then you need to both unplug and reduce inflammation by using a combination of both retinoid and BP but I suggest you start with one to see how your skin reacts, there’s some debate about which one should be first but usually most people start with BP as it’s over-the-counter. If these first-line agents haven’t worked, it’s time to look at the next options for step up therapy, if you’re a woman, you can consider using a birth control pills, it reduces the hormones that cause plugging in the first place, this is an especially effective approach if you tend to have flare-ups of acne around your period, you can also consider a topical antibiotic to reduce P acnes and inflammation, these can be prescribed pre-mixed with B P or a retinoid, if you already know you tolerate these, next we often step up to antibiotics, take it by mouth, now we do worry a bit about overusing antibiotics so it’s good to take a break every few months to see if you still need it. If your step up therapy has not worked after all these treatments, your doctor has other options that you can discuss, finally if you have exhausted all your options there is a very strong retinoid taken by mouth called isotretinoin, it is the supreme unpluger and it’s incredibly effective for severe acne. It’s a bit of a mixed message here though isotretinoin has some potential side effects and a powerful drying effect so you really need to pack your lip balm and moisturizer and so on and including the fact that absolutely cannot be taken by a woman that is pregnant, so you need to be monitored closely when you’re on this medication, having said that, I have seen isotretinoin change the lives of more severe acne sufferers, and if you think scarring is likely then this might be a reason to consider eye sight right now, in some sense, acne treatment is simple reduced plugging and inflammation but it’s also complicated as there are many many agents that do these two things. Treating acne is a bit like basketball, you have to experiment with various players and combinations, the score can fluctuate initially and it takes a little while to figure out who will win but you can win if you stick with it.

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