Dr. Cole is board certified in dermatology. He obtained his BA degree in bacteriology, his MA degree in microbiology, and his MD at the University of California, Los Angeles. He trained in dermatology at the University of Oregon, where he completed his residency.
Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.
Cosmetics: Don't be afraid to hide blemishes with flesh-tinted cover-ups or even foundation, as long as it is water-based (which makes it noncomedogenic). There are many quality products available.
Facials: While not absolutely essential, steaming and "deep-cleaning" pores is useful, both alone and in addition to medical treatment, especially for people with "whiteheads" or "blackheads." Having these pores unclogged by a professional also reduces the temptation to do it yourself.
Pore strips: Pharmacies now carry, under a variety of brand names, strips which you put on your nose, forehead, chin, etc., to "pull out" oil from your pores. These are, in effect, a do-it-yourself facial. They are inexpensive, safe, and work reasonably well if used properly.
Toothpaste: One popular home remedy is to put toothpaste on zits. There is no medical basis for this. Ditto for vinegar.
If you haven't been able to control your acne adequately, you may want to consult a primary-care physician or dermatologist. The goal of treatment should be the prevention of scarring (not a flawless complexion) so that after the condition spontaneously resolves there is no lasting sign of the affliction. Here are some of the options available:
Retinoids: Retin-A (tretinoin) has been around for years, and preparations have become milder and gentler while still maintaining its effectiveness. Newer retinoids include adapalene (Differin) and tazarotene (Tazorac). These medications are especially helpful for unclogging pores. Side effects may include irritation and a mild increase in sensitivity to the sun. With proper sun protection, however, they can be used even during sunny periods. In December 2008, the U.S. FDA approved the combination medication known as Epiduo gel, which contains the retinoid adapalene along with the antibacterial cleanser benzoyl peroxide; it is applied once a day.
Oral antibiotics: Doctors may start treatment with tetracycline (Sumycin) or one of the related "cyclines," such as doxycycline (Vibramycin, Oracea, Adoxa, Atridox, and others) and minocycline (Dynacin, Minocin). Other oral antibiotics that are useful for treating acne are cefadroxil (Duricef), amoxicillin (Amoxil, DisperMox, Trimox), and the sulfa drugs.
Problems with these drugs can include allergic reactions (especially sulfa), gastrointestinal upset, and increased sun sensitivity. Doxycycline, in particular, is generally safe but can sometime cause esophagitis (irritation of the esophagus, producing discomfort when swallowing) and an increased tendency to sunburn.
Despite the concern that the long-term use of tetracycline antibiotics for acne might "weaken the immune system" or induce bacterial resistance, these concerns seem to be unwarranted.
Oral contraceptives: Oral contraceptives, which are low in estrogen to promote safety, have little effect on acne one way or the other. Some contraceptive pills have been shown to have modest effectiveness in treating acne. Those FDA approved for treating acne are Estrostep, Ortho Tri-Cyclen, and Yaz. Most dermatologists work together with primary physicians or gynecologists when recommending these medications.
Spironolactone (Aldactone): This drug blocks androgen (hormone) receptors. It can cause breast tenderness, menstrual irregularities, and increased potassium levels in the bloodstream. It can help some women with resistant acne, however, and is generally well-tolerated in the young women who need it.
Cortisone injections: To make large pimples and cysts flatten out fast, doctors inject them with a form of cortisone.
Isotretinoin: Accutane was the original brand name; there are now several generic versions in common use, including Sotret, Claravis, and Amnesteem. Isotretinoin is an excellent treatment for severe, scarring persistent acne and has been used on millions of patients since it was introduced in Europe in 1971 and in the U.S. in 1982. It should be used for people with severe acne, chiefly of the cystic variety, which has been unresponsive to conventional therapies like those listed above. The drug has many potential serious side effects and requires a number of unique controls before it is prescribed. This means that isotretinoin is not a good choice for people whose acne is not that bad but who are frustrated and want "something that will knock acne out once and for all." In order to use the drug, the prescribing physician, the patient, and the supplying pharmacy must be enrolled in the online "iPLEDGE PROGRAM." Used properly, isotretinoin is safe and produces few side effects beyond dry lips and occasional muscle aches. This drug is prescribed for five to six months. Fasting blood tests are monitored monthly to check liver function and the level of triglycerides, substances related to cholesterol, which often rise a bit during treatment, but rarely to the point at which treatment has to be modified or stopped.
Even though isotretinoin does not remain in the body after therapy is stopped, improvement is often long-lasting. It is safe to take two or three courses of the drug if unresponsive acne makes a comeback. It is, however, best to wait at least several months and to try other methods before using isotretinoin again.
Isotretinoin has a high risk of inducing birth defects if taken by pregnant women. Women of childbearing age who take isotretinoin need two negative pregnancy tests (blood or urine) before starting the drug, monthly tests while they take it, and another after they are done. Those who are sexually active must use two forms of contraception, one of which is usually the oral contraceptive pill. Isotretinoin leaves the body completely when treatment is done; women must be sure to avoid pregnancy for one month after therapy is stopped. There is, however, no risk to childbearing after that time.
Other concerns include inflammatory bowel disease and the risk of depression and suicide in patients taking isotretinoin. Recent evidence seems to indicate that these problems are exceedingly rare. Government oversight has resulted in a highly publicized and very burdensome national registration system for those taking the drug. This has reinforced concerns in many patients and their families have that isotretinoin is dangerous. In fact, large-scale studies so far have shown no convincing evidence of increased risk for those taking isotretinoin compared with the general population. It is important for those taking this drug to report changes in mood or bowel habits (or any other symptoms) to their doctors. Even patients who are being treated for depression are not barred from taking isotretinoin, whose striking success often improves the mood and outlook of patients with severe disease.
Light treatments: Recent years have brought reports of success in treating acne using special lights and similar devices, alone or in conjunction with photosensitizing dyes. It appears that these treatments are safe and can be effective, but it is not clear that their success is lasting. At this point, laser treatment of acne is best thought of as an adjunct to conventional therapy, rather than as a substitute.
Chemical peels: Whether the superficial peels (like glycolic acid) performed by estheticians or deeper ones performed in the doctor's office, chemical peels are of modest, supportive benefit only, and in general, they do not substitute for regular therapy.
Treatment of acne scars: For those patients whose acne has gone away but left them with permanent scarring, several options are available. These include surgical procedures to elevate deep, depressed acne scars and laser resurfacing to smooth out shallow acne scars. Newer forms of laser resurfacing ("fractional resurfacing") are less invasive and heal faster than older methods, although results are less complete and the procedures may need to be repeated three or more times. These treatments can help, but they are never completely successful at eliminating acne scars.