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No. 2

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by Dr. Rodger Sayre
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Zitology 101: The Care and Treatment of Acne

“Hey Dad, look!” I spun my chair to face my son, standing in the doorway. The enthusiasm was palpable. He stood, mouth gaping, eyes bulging, and right forearm resting on his head, exposing his armpit. With his left index finger he pointed to … something. “Hair!” he announced proudly.


I walked over to get a closer look. There, centrally located in the right axilla was a solitary blond strand. “Welcome to puberty, son. There’s plenty more where that one came from,” I remarked matter-of-factly. Grinning, I buffed the top of his head, and as I backed up, yet another tell-tale sign of the impending hormonal metamorphosis caught my eye: a bright red pimple, slightly off center on the tip of his shiny nose.

“Let’s take a look at that zit!” I said, as I reached for my reading glasses.

Thus began another counseling session on personal hygiene in adolescence, particularly as it pertains to complexion. Although this is a common topic in my office, most of my practical experience comes from home. For the past five years, we have had five teens in our house. As one advances to adulthood, another takes his place. I’ve been through this a few times.

Acne is a condition primarily of teens and young adults, but it can be an issue even for those much older. Pimples, or comedones (pronounced ko’- me- dones), come in a variety of forms. Open comedones are otherwise known as blackheads. Closed comedones are commonly referred to as whiteheads. Acne is graded as mild, moderate, and severe, and is further classified as comedonal, papulopustular, and nodulocyctic. (These latter two categories are considered “inflammatory acne.”)

Acne is caused by a combination of factors. As a youngster enters puberty, sebum, an oily substance produced at the base of the hair follicle, increases in quantity. Unfortunately, the pore will sometimes get blocked by keratin, a part of the skin cells, also being produced in excess at this time. This causes the sebum to accumulate sub-surface (sometimes noticeable as a blackhead). When this material becomes infected with a bacteria, an inflammatory immune response is triggered, causing a whitehead. This inflammation goes to another level when the material leaks into the surrounding soft tissues, causing a larger nodule or cyst.

Like most medical conditions, understanding what causes acne helps us to prevent and treat it. For example, knowing that excess sebum and blocked pores are a root cause of the condition, it is certainly reasonable to expect oil-based makeup to make acne worse. Young ladies, avoid the temptation! And understanding the role bacteria plays in acne should give us good reason to keep our germ-laden fingers off our faces! My mother always said, “Rodger, keep your fingers off your face!” She was a wise woman.

But while your mother no doubt gave you some good advice regarding your skin care, some old wives’ tales need to be dispelled. For example, contrary to popular belief, chocolate and greasy foods have never been shown to cause acne. And as far as treatment goes, alcohol scrubs or vigorous cleansing with a rough washcloth and soap is actually counterproductive, resulting in a reactive overproduction of sebum. Likewise, sun exposure is not beneficial in the prevention or treatment of acne and can even be harmful. Finally, telling a teen that it is okay to unroof and gently squeeze a pimple is kind of like telling a recovering alcoholic it is good for him to have one glass of wine a day. It’s hard to stop! Squeezing whiteheads and blackheads too vigorously extrudes the contents of the comedones into the surrounding soft tissues, markedly increasing the risk of cysts, nodules, and even scars.

Some things have been shown to work well in the treatment of acne. I will split our treatment options into topical and systemic therapies for the sake of organization, although it is sometimes judicious to employ a combination of the two, or to jump immediately to third or fourth line therapies, depending on the severity of the acne.

First on the topical list is simple soap and water. Cleansing twice daily with a mild non-oil-based soap, using fingers and not a washcloth is effective in reducing the numbers of comedones. After cleansing, apply a non-comedogenic moisturizing cream with an applicator (e.g. a cotton ball). If after a month of such treatment, no obvious improvement is appreciated, it may be time to progress to one of the “over-the-counter” topical preparations containing benzoyl peroxide.

In the absence of improvement, schedule a visit with your physician. He or she may suggest a prescription of tretinoin (a vitamin A derivative) or a topical antibiotic. I often have a patient cleanse twice daily, using benzoyl peroxide in the morning, and either tretinoin or a topical antibiotic in the evening (depending on whether blackheads or whiteheads are the predominant lesion).

There are other less popular topical preparations (adapalene, tazarotene, and axelaic acid, to name a few), that are also by prescription and may be considered reasonable treatment options.

Systemic therapy must begin with a good diet! Foods rich in vitamin A and E (found in many fruits and vegetables) along with plenty of water comprise the obvious first step in maintaining a good complexion. Long-term use of an oral antibiotic such as tetracycline, doxycycline, or minocycline is generally well tolerated and sometimes dramatically effective.

The last option for oral treatment is a medication called isotretinoin (brand name Accutane). Although this medication can be of significant help, it is used with great caution in women of childbearing age, due to its potential for causing birth defects. I have never prescribed this medication. If I fail to achieve adequate control of acne using the options listed above, I raise the proverbial white flag and refer to a dermatologist.

Clearly, the treatment options for acne are many. The single biggest reason for treatment failure is in not giving the treatment long enough to work! Many require a minimum of a month to be effective. If response is inadequate after a month on a treatment plan, it may be time to consider alternative options. And so I offer another word of wisdom from my mother: “If at first you don’t succeed, try, try, and try again!”

About the author

Rodger Sayre, MD, FAAFP, has been an HSLDA board member since 1997. He and his wife, Mary, have graduated 6 of their 11 children and continue to teach the rest at home in Pennsylvania. Dr. Sayre is certified as a Diplomat of the American Board of Family Medicine and is a Geisinger Medical Group associate with a busy practice in Tunkhannock.