Acne Clear and Acne Care

What is photodynamic acne therapy? How does it work to help my acne?

2009-02-07T15:04:00.000-08:00

Photodynamic therapy, is a relatively new acne treatment that uses a combination of a drug called 5-amino levulinic acid (ALA) and blue light or mixed blue and red light for the treatment of moderate to severe acne. This is in contrast to those older ultraviolet light acne treatments that are kwown to provide only transient improvement, added to that the prolonged use of especially of ultraviolet A, may worsen those with comedonal acne (i.e. mostly blackheads and whiteheads). Also, the increased risk of skin cancer and photoaging makes the older ultraviolet light acne treatments even a less desirable acne therapy.

What the dermatologist does is to apply the 5-amino levulinic acid to the affected areas for about 15 to 30 minutes, this followed by using either a pulsed light device or pulsed dye laser to activate the areas where the 5-amino levulinic acid was applied. The results have shown that it is great for those with severe forms of acne condition. It is learnt that photodynamic therapy are also being used to treat certain types of skin cancer.

Am I a good candidate for laser acne therapy if I have darker skin type?

2009-02-07T14:56:00.000-08:00

As we may or may not know that acne is quite a common concern in people with darker skin. In fact, lasers have been avoided for acne treatment for those with darker skin because of the risk of potentially disfiguring complications such as acne scarring, keloids, and skin discoloration.

However, the advances in technology today have made laser treatments for acne safer for those with darker skin types. For instance, there are some acne treatments, i.e. using both lasers and intense pulsed light devices that are being tested and have shown encouraging results for acne on the face and on the chest and back for those with darker skin. It is important to note that as with other skin types, maintenance acne treatments such as by using retinoids, topical acne antibiotics, and benzoyl peroxide, are usually needed to minimize the recurrence of acne.

It was reported that lasers and intense pulsed light devices that are being used to treat acne for this purpose, i.e. in people with darker skin included:

ClearLight (blue: 405 to 420-nm);
Aura laser (532-nm KTP laser, green light); and
Aurora (an intense pulsed light/radiofrequency kind of combination device)

Can I do laser treatments while I am on oral or topical acne treatments?

2009-02-07T14:51:00.000-08:00

We may not aware that laser and intense pulsed light treatment are often best to combine with other, i.e. mostly topical acne treatments for maximum acne treatment results. (Topical means a product that is used on our skin, such as a lotion, cream or gel)

When the laser procedures are completed, we should continue with the usual maintenance acne therapy, i.e. topical acne treatment to prevent the recurrence of the acne. However, we should stop to use retinoids (i.e. products that are generally in the vitamin A family) for 4 to 5 days before a laser or intense pulsed light treatment and then restart again 3 to 4 days after the treatment.

For other acne medications such as topical antibiotics or benzoyl peroxide (i.e. an antiseptic that is commonly used topically to treat acne, and is widely used as it does not induce bacterial resistance), and depending on our skin sensitivity, we may stop for 1 to 2 days around the procedure. From the acne clear and acne care perspective, it is advisable to review all of our acne medications with our doctor prior to any laser or intense pulsed light procedure in order to determine our level of sensitivity.

How many acne treatments do I need from those procedures done in the doctor’s office? How long does it take to see the results?

2009-02-07T14:46:00.000-08:00

Studies have shown that the number of acne treatment sessions required to achieve satisfactory results will depend on the system used and the severity of our acne at the start of the treatment. We also need to follow-up with the maintenance acne treatments in order to minimize future acne flare-ups.

The results from the laser or intense pulsed light treatments can occur from 1 day to 1 month after starting the treatment.

What laser and light treatments are available to treat my acne?

2009-02-06T18:19:00.000-08:00

Laser stands for "light amplification by stimulated emission of radiation." Laser energy can be provided by various sources, i.e. from a gas to a liquid to a solid.

These energy sources allow for specific wavelengths of light to be intensified and directed through a column to our sebaceous gland (i.e. oil-producing grand located in the deeper layers of our skin, and are attached to the hair follicles. The oil produced can travel up the follicle to end up on the surface of our skin) or melanin high up or deeper in or within our skin. Also, it can target water in the skin or various components of blood vessels within our skin. In short, it works to heat and damage the skin in a very specific ways without damaging the surrounding skin tissue, hence in the process of healing our skin will look clear and healthy, i.e. without acne or broken blood vessels or brown spots or even wrinkles. Studies have shown that the longer the wavelength, the deeper the light will penetrate. Additionally, there are specific elements in our skin that prefer certain wavelengths of light.

On the other hand, intense pulsed light devices are similar to lasers with the exception that they use a wider range of wavelengths as opposed to only one single beam of light. From the acne clear and acne care point of views, this is very useful as it helps us to target our source within a range of light.

What was noted is that, CO2 lasers were used to heat water within our skin in the past, however, this method is not perfect as it would cause destruction of the upper layers of our skin and sometimes may go even deeper. Usually, a 2 to 3 months’ healing time is quite common, after which there could still be redness for months, and then areas of our skin could appear darker or lighter than the adjacent skin. This treatment is not recommended for the treatment of active acne, or for those within 6 months of taking oral isotretinoin, nevertheless, it is still being used to treat certain types of acne scarring.

The advances in technology have made newer acne devices more effective and specific to target the source of our acne, and within a broader context without damaging the surrounding skin, i.e. the sebaceous gland, the P. acnes bacterium (i.e. short for Propionibacterium acnes, a bacterium that grows and flourishes under certain condition and is the main culprit for inflammatory acne), or the blood vessels that supply the swelling and redness. Additionally, those acne treatments can be done over time without limiting the activities of the person being treated. In short, the newer acne devices are more accessible and more useful in the treatment of many skin conditions, and caused less painful experience than the earlier devices.

It was learnt that the FDA has approved several lasers and light systems for the treatment of acne. Basically, they are designed to treat inflammatory acne associated with the active growth of P. acnes, and are not effective if we have only blackheads (i.e. also called open comedo, is a type of acne that does not contain active bacteria. Is the result of the follicle that have turned black after exposure to oxygen) or whiteheads (i.e. white bumps in our skin that are closed to the the surface. Is a type of acne lesion, also called closed comedo).

Listed below are the laser and other related procedures for reference:

Laser

OmniLux - blue light
OmniLux Revive - red light
Smoothbeam - is a diode laser that used to treat both acne and depressed scars caused by acne. This laser emits energy at 1450-nm. Statistics showed 6 months remission of acne lesions after treatment.
Aura (KTP - green light)
CoolTouch - is a 1320-nm laser system that is used for back acne and acne scars. CoolTouch works by targeting the sebaceous glands without damaging our skin's surface.
Nlite-V - a 585-nm pulsed dye laser that is used for moderate inflammatory acne on the face. Nlite-V emits a wavelength of yellow light that heats our small blood vessels, as well as encouraging the healing and stimulating the collagen (i.e. protein that is responsible for the elasticity of the skin and plays an important role in the development of scars) production.
CO2 - will heat up larger areas of our skin and can have a significant amount of healing or down time associated with them. It is used to treat certain types of acne scars that are not very deep, and also commonly used to treat signs of sun damage and wrinkles.
Erbium - as in CO2.

Intense pulsed light

ClearLight - is the first device to get clearance from the FDA for the treatment of acne. It is used to treat moderate to severe inflammatory acne (i.e. a class of acne where the main lesions are papules and pustules but not comedones). ClearLight works by targeting the bacterium P. acnes by using high intensity light to excite specific elements of P. acnes and to destroy them without harming the surrounding tissue.

Light-emitting diodes

OmniLux Blue - a new type of system that uses light-emitting diodes in the visible spectrum at 415-nm and is used to treat mild to moderate inflammatory acne, and that treatment are generally well tolerated.

Radiofrequency (is produced by an electrical current instead of a light source and can penetrate more deeply through our skin. It is safer because it is not scattered by tissue or absorbed by melanin.)

Aurora

Experimental

Pulsed dye therapy

What we could say about the trend ahead is that advances in technology will sure help in better understanding our acne clear and acne care needs, and to expand their uses in very specific ways for us to better manage to have an acne free complexion.

What is electrocautery?

2009-02-06T18:13:00.000-08:00

Electrocautery is the use of an electric current that is converted into heat and passed through a fine tip in the treatment of acne.

It works by directly applying the heat to the acne lesion that exfoliates the skin and kills the bacteria. It also sometimes used to open our whiteheads (i.e. a type of acne lesion, are white bumps in our skin that are closed to the skin surface. Also called closed comedo) for the contents to be extracted in order to clear the lesion (i.e. a mark in the skin). Nevertheless, there exists a risk of scarring from this treatment that explained why it is not being considered as a main treatment for acne and is not often used.

Is cryotherapy right for me? Is it good to treat acne?

2009-02-05T15:33:00.000-08:00

Basically, cryotherapy involves the use of liquid nitrogen or carbon dioxide slush to treat our acne. These procedures are useful, but the drawback is that they require special storage containers and are becoming less popular and uncommon as newer acne treatments procedures are being available. Despite this, people do love the way their skin looks after the treatments, though there is a risk of scarring.

Cryotherapy works by exfoliating the localized areas of our skin where the pimples are concentrated. It is noted that liquid nitrogen is very cold, i.e. 195° F, which means that it needs to be stored in a special container as it can evaporate at room temperature. In general, both the liquid nitrogen and CO2 slush are applied by the doctor to specific pimples. The after treatment result is that the site can easily turn red and become a little swollen, which lasts anywhere from half an hour to a day. What followed is that we will find our pimple dries up and exfoliates off with washing over the next few days or so. Sometimes a very light layer of the cryogen can be applied to our entire face for a general peel. What was noted is that our skin will usually turns red, follows by peeling over the next week. However, the peeling process is not an obvious peeling of our skin, but the skin does look smoother and feel softer to the touch.

What is microdermabrasion? Do they really work for my acne?

2009-02-05T15:29:00.000-08:00

Microdermabrasion works by using fine crystals blasted at the skin and then vacuumed back away from the skin. These two components help to temporarily clean out the pores, and make our skin feel smoother. Through this, the upper layers of our skin are exfoliated off, this helps to provide other acne treatments to penetrate more evenly.

In general, a series of five to seven microdermabrasion treatments are done in order to get optimal acne treatment results. This shall follow by maintenance treatments every 6 to 8 weeks. It is noted that no comprehensive studies exist showing the benefits of microdermabrasion, nevertheless, people who undergoes for microdermabrasion do suggest that it does help to improve their acne condition.

What is dermabrasion? Is it ideal for acne scars?

2009-02-05T15:16:00.000-08:00

It is a process whereby the upper and middle layers of our skin are removed in order to improve our acne scarring condition. However, dermabrasion is ideal for people with the following skin types who have superficial acne scars:

Unexposed Skin Color

Tanning History

Ivory white, pale white

White

Beige or lightly tanned

- Burns easily, never tans

- Burns easily, tans minimally

- Burns moderately, tans evenly

- Burns minimally, tans easily

We have to take into account the healing time involved, and that local anesthetic is a must because dermabrasion is indeed a very painful experience.

If we have very deep, pitted acne scars then dermabrasion is not an ideal solution as the scars would end up deep and wide and would most likely be more obvious than before. In this case, the best acne skin care treatment for this type of acne scars is either we try to fill them with some temporary fillers, such as collagen (i.e. the main protein in connective tissue that is responsible for the elasticity of our skin and plays an important role in the development of scars) or Restylane, or with one of the more permanent fillers available on the market like Artecoll. Alternatively is to use a method called punch grafting, a technique that use a cookie-cutter type of blade to punch out the scar, and then followed by adding skin taken from another site to fill in the hole, and thereafter with dermabrasion to smooth the edges.

Are chemical peels safe?

2009-02-05T15:13:00.000-08:00

From the acne clear and acne care perspective, it is safe if done properly and can be done along with a topical or oral acne regimen to achieve better acne treatment results.

In fact, chemical peels have become an increasingly popular option for us to treat acne and to minimize scarring from acne. There are several different solutions available for chemical peels, and each has its advantages and disadvantages.

Common peeling agents shall include α-hydroxy acids (or glycolic acid), salicylic acid, and trichloroacetic acid. Among them, salicylic acid which is fat soluble does have anti-inflammatory effects and may penetrate into those sebum-heavy follicles more easily than the water-soluble α-hydroxy acids. On top of that, there is usually more active peeling after a salicylic acid treatment than with glycolic acid. Hence, many consider salicylic acid as a very useful peeling agent in the treatment of acne.

As for trichloroacetic acid which can be used in strengths from 5% to approximately 20%, is generally a more active peeling agent for achieving a superficial peel. Because the strength of the peel does varies depending on how it is applied, and with the possibility of some risk of scarring associated with deeper penetration of trichloroacetic acid, as such this treatment should be done by a qualified dermatologist.

Light chemical peels is generally useful to help correct our surface scarring and hyperpigmentation (i.e. darkening of skin resulting from higher amounts of melanin in a particular spot). Although the light chemical peels do not penetrate beyond the upper layers of our skin, its light or superficial chemical peel may cause our skin to stay red for a few hours before returning to normal. It is considered unusual to have blisters or areas of bleeding after a superficial chemical peel and we should have no obvious peeling of the skin after the treatment.

What is hormonal therapy? Do I need to have my hormones evaluated?

2009-02-04T15:58:00.000-08:00

Hormonal therapy is an excellent option for women with acne (i.e. moderate to severe acne or in women with late-onset acne. To know more about different types of acne, please refer to this page), more so if oral contraception is also desired. In fact, hormonal therapy implies oral contraceptives, either alone or in conjunction with other hormone treatments for undesirable increased of hair growth on our face or other parts of our body, excessive hair loss from the scalp, irregular menstrual periods, and other conditions as well.

Generally, hormonal therapy is useful for women with endocrine abnormalities and for women who are nonresponsive to or unable to tolerate those conventional acne therapies, i.e. oral antibiotics, topical antibiotics, and retinoids along with benzoyl peroxide. Nevertheless, hormonal therapy is proven effective when used in conjunction with other antiacne therapies/conventional acne therapies (i.e. oral or topical acne antibiotics, topical retinoids, azelaic acid, salicylic acid, and benzoyl peroxide). For those with concerns about the reduced effectiveness of contraception when oral contraceptive pills are used in conjunction with oral acne antibiotics, recent evidence suggests that their effectiveness in contraception should not be reduced.

Studies show that hormonal therapies work best in adult women and sexually active teens with persistent, painful, deep, inflammatory papules and nodules, and often comedones on the forehead and chin, though the skin may or may not be oily in this case.

How hormonal therapy works to treat acne is to block the effects of androgens (i.e. a class of hormones that cause the sebaceous gland to enlarge and produce more serum, which is an important factor in the causation of acne) on our sebaceous gland (i.e. oil-producing glands located in the deeper layers of our skin, and are attached to the hair follicle and the oil can travel up to the surface of our skin. We may want to read here for the details of human skin structure) and the skin cells that are lining our pores. It accomplishes this with the use of estrogens (i.e. female sex hormone) or a class of drugs known as antiandrogens (i.e. androgen receptor blockers such as cyproterone acetate, chlomadinone acetate, desogestrel, drospirenone, flutamide and spironolactone) or by agents designed to reduce our body's production of androgens by the ovary or adrenal gland, example of this included oral contraceptives, low-dose glucocorticoids, cyproterone acetate, estrogens, or gonadotropin-releasing hormone agonists.

An evaluation of hormones done by an endocrinologist is usually required for women with acne who have proven resistant to conventional acne treatments or if there is a sudden, severe onset of acne. Other cases in which an endocrine evaluation is required:

Women with acne who have irregular menstrual periods or increased hair growth in the face and abdomen (called hirsutism, which is generally caused by increased androgens, a common sign of polycystic ovary syndrome);
Women who relapse shortly after oral isotretinoin therapy

Hormonal screening tests (such as DHEAS, total testosterone, free testosterone, luteinizing hormone/follicle-stimulating hormone ratio, prolactin, 17-hydroxyprogesterone) shall involve a physical exam by the doctor and a series of blood tests to measure specific levels of hormones in the blood that are timed to correlate with a certain phase of women menstrual cycle. These tests are designed to help us pinpoint the source of our increased androgen production so that appropriate therapy can be instituted. It is no surprise to know that though women with acne are more likely to have abnormalities in hormonal evaluations than women without acne, however, most women with acne who are evaluated for hormonal abnormalities have androgen levels that are within normal limits.

What are the side effects of oral isotretinoin?

2009-02-03T15:29:00.000-08:00

We may not know that oral isotretinoin is considered by many as a very controversial drug because of some of the side effects associated with it (in fact there are congressional hearings and attempts to take it off the market). On the other hand there are also many considered oral isotretinoin treatment to be life saving as no other drug available at this time that can actually treat and often clear those severe, scarring, and disfiguring acne.

Nevertheless, through proper counseling and monitoring, oral isotretinoin can really be a miracle cure for those with severe, scarring acne condition as well as help avoiding the worst side effects that might happen.

Potential Side Effects of Oral Isotretinoin

Common side effects:

Dry skin, dry eyes, chapped lips and dry mouth – it is noted that some new formulations of oral isotretinoin are less affected by food and also have fewer side effects in terms of dryness of skin, eyes, and mouth and less of a potential effect on our lipids;
Nosebleeds;
Muscle aches, backaches, and mild headaches usually at the start of oral isotretinoin therapy;
Skin fragility especially on the hands.

Uncommon or serious side effects:

Hypertriglyceridemia (liver function abnormalities) – studies show that this can be improved with continued administration of the drug or after oral isotretinoin was stopped; however, regular blood tests are still required to ensure our liver function as normal. What is important is that we should try to avoid drinking alcohol while on this acne therapy as oral isotretinoin is easily metabolized or digested by our liver;
Severe headaches;
Mood swings/depression/suicidal ideation – though this may be due to different reasons, should this happen, oral isotretinoin should be discontinued in these cases;
Pseudotumor cerebri (i.e. increased pressure build-up on the brain);
Bone changes (including osteoporosis) - typically found in patients on higher doses of the drug or in whom high doses are used over longer periods of time than usual. Example of this included loss of bone density, bone fractures or delayed healing;
Visual changes, e.g. decreased night vision, may last even after oral isotretinoin was stopped.

Most serious but avoidable:

Birth defects – it is very important for any woman who is of child-bearing potential who plans on taking isotretinoin to have two negative pregnancy tests before starting oral isotretinoin treatment and for at least 1 month after the therapy. Adequate contraception is essential, and the importance of this cannot be overstated before and during treatment, and for 4 weeks after discontinuing oral isotretinoin treatment. It is good to know that oral isotretinoin is a potent teratogen that is known to cause birth defects in children whose mothers get pregnant while taking oral isotretinoin or within 1 month after stopping isotretinoin. To know more about “should women continue topical or oral acne treatment while they are pregnant,” we may want to read here.

What dose of isotretinoin is right for me?

2009-02-02T05:17:00.000-08:00

As a matter of fact, the dose can vary and depend on our weight and the severity of our acne condition. The doctor will first determine how much we weigh in kilograms and prescribe the dose accordingly. The dose can range from 0.1 to 2 mg/kg, with the most common dose being 0.8 mg/kg/day and divided into two, i.e. morning and night. It is noted that oral isotretinoin is best absorbed and most effective when taken with food and when taken twice a day.

Usually, our doctor will start us on a lower dose for the first month or two so that we can acclimate to the side effects (at least to some extent), and then increase the dose for the rest of the 16 to 20 weeks severe acne treatment course. However, depending on the acne treatment results achieved and in some cases, higher doses for longer than 20 weeks may be required. Also, in some very severe cases of acne, oral prednisone (i.e. a corticosteroid commonly used to treat inflammation), will be given for a duration of 2 to 6 weeks, usually before oral isotretinoin acne treatment is begun.

We may want to know that before we start oral isotretinoin, we should have a detailed discussion with our doctor regarding any concerns that we may have about oral isotretinoin acne treatment, more so if we have any personal or family history of depression. The doctor will give us a booklet that the makers of oral isotretinoin provide; this is for us to review at home and to discuss with our family. Once we have made up our mind, we and our doctor must sign and date on several pages on our next visit. At this pre-oral isotretinoin visit, we are required to have our baseline blood tests, which will be repeated monthly while we are taking the drug.

If we are a woman, the doctor will also review pregnancy and contraceptive issues with us and make sure that we are not pregnant at the start of oral isotretinoin treatment. We have to aware that the risk of birth defects exists while the retinoid is in our body. Once the retinoid is cleared, usually 6 weeks after discontinuing oral isotretinoin acne therapy, there is no longer a risk. Also, patient information form and video are obtainable from the manufacturer to help us better understand on any contraceptive and pregnancy issues.

Why didn't oral isotretinoin work for me?

2009-02-02T05:09:00.000-08:00

It is good to know that recurrence of acne is not uncommon after an oral isotretinoin course. However, some people are able to successfully retreated with oral and topical acne antibiotics, benzoyl peroxide, and topical retinoids, though a significant number may require retreatment with isotretinoin. A study conducted showed that, only 38% of patients had no acne at the 3-year follow-up after a single course of oral isotretinoin, while the remaining patients were able to control their acne with topical acne treatment, topical treatment plus oral acne antibiotics, or a retreatment with oral isotretinoin.

The study also showed that relapse was more likely to occur in patients who were 16 years old or younger and in women than in men, and that relapse is most common in the first year after treatment too. From the acne clear and acne care point of views, maintenance acne treatment such as with a topical retinoid may reduce the relapse rate.

How many courses of oral isotretinoin can I take?

2009-01-31T15:53:00.000-08:00

To minimize the risk of adverse long-term reactions that oral isotretinoin can have on our bones and other organ systems, we should follow the maximal lifetime dose of oral isotretinoin that is considered safe and appropriate.

In general, most people on a typical course of oral isotretinoin of 0.8 mg/kg for a 16 to 20 weeks’ course could do three treatment courses over their lifetime if necessary. However, the 0.8 mg/kg is considered as an average acne treatment dose, hence dose may be increased in order to get the desired acne treatment results.

Studies show that low-dose oral isotretinoin can still be very effective in some people. This not only minimizes the side effects but also allows us to use it intermittently, over time, as needed and with proper monitoring without concern of reaching the maximal dosage.

Good news is that many of the side effects caused by taking oral isotretinoin are dose related, what that means is that we may work along and within the dose limit given to achieve the desired acne treatment results, and to avoid and minimize those harmful side effects.

Can I have laser or cosmetic treatments, waxing, or other treatments done while I am on oral isotretinoin?

2009-01-31T15:48:00.000-08:00

It is learnt that oral isotretinoin (sold under the trade name of Accutane, and its generics is known as Sotret or Amnesty) affects our skin cell turnover, which means that any surgery or laser resurfacing treatment, or even deeper chemical peels when done within 6 months of taking oral isotretinoin can lead to excessive scarring and disfigurement.

In fact, our skin is drier and more sensitive while on oral isotretinoin therapy, as such any treatment that potentially irritates the skin can be a problem. Hence, our skin may react more strongly to waxing or other hair removal methods too.

Nevertheless, with the advent of the newer lasers today, i.e. nonablative lasers, this is probably less of a risk today because they do not remove the upper layers of our skin. Still, many doctors prefer to wait for at least 6 months before doing any elective procedure, especially if it is for cosmetic purposes.

Laser or intense pulsed light hair removal is sometimes done while on oral isotretinoin, but we should be careful to have the procedure done by a qualified doctor and let the doctor know we are on oral isotretinoin.

What should I avoid while taking oral isotretinoin to treat my acne?

2009-01-30T18:01:00.000-08:00

The following may come in handy:

Women should not get pregnant while taking oral isotretinoin or for at least one month after stopping oral isotretinoin to treat their acne.
Remember not to give blood while taking isotretinoin or for 1 month after stopping it. Studies show that those who are pregnant when exposed to your blood, her baby risks exposure to birth defects.
It is advisable to use 2 forms of contraceptive, i.e. oral contraceptive and a condom while on oral isotretinoin, this is to make sure pregnancy does not occur. Do note that birth control pills that do not contain estrogen (i.e. female sex hormone) may not work while we are on Accutane. Always check with the doctor where appropriate.
Do not take isotretinoin with other antibiotics unless after talking to our doctor.
Do not have cosmetic procedures to smooth our skin (which shall include waxing or laser procedures), while on isotretinoin or for 6 months after we stop.
Never breastfeed while taking isotretinoin or for 1 month after stopping the drug for treating our acne.
Try to avoid excessive sunlight and ultraviolet lights and tanning booths, because oral isotretinoin can make our skin more sensitive to ultraviolet light.
Let our doctor know what other drugs or herbal products that we are currently taking. This is important as some of these products may decrease the efficacy of our oral contraceptive and would have to be discontinued for the duration of our acne treatment and 1 month after.
Avoid vitamin A supplements as they will increase our chances of having side effects.

For other acne clear and acne care questions and soultions, we may want to refer this page here.

When I start oral isotretinoin, will my acne get worse before it gets better?

2009-01-30T17:58:00.000-08:00

In some cases, there can be a flare of the acne in the first month after starting oral isotretinoin (sold under the trade name of Accutane, and its generics is known as Sotret or Amnesty). However, to avoid this from happening, we may start a short course of prednisone (i.e. a corticosteroid commonly used to treat inflammation) to minimize the inflammation and to avoid the flare that would accompany it.

In most cases, we should start at a lower dose and incrementally increase the dose over the first one to two months for us to get used to the drug.

Is oral isotretinoin suitable for my acne condition?

2009-01-30T12:18:00.000-08:00

It is acknowledged that oral isotretinoin is the first-line treatment for severe acne and may also be used in people who have failed conventional acne treatment, such as through the combination of topical retinoids, benzoyl peroxide, topical or systemic acne antibiotics or where appropriate hormonal acne therapies too.

In general, we may go for oral isotretinoin for our acne condition if we are having:

Severe nodulocystic acne (i.e. scattered noducles mostly concentrated on our face, chest and our back) or severe acne variants
Inflammatory acne (i.e. mostly papules, pustules, cysts) with acne scarring consequences that has failed conventional acne treatment
Moderate-to-severe acne with frequent relapsing
Acne coupled with severe psychologic distress

To have a better understanding of what is nodules, papules, pustules and cysts, we may want to read “What does acne look like?”

How long is the usual course of oral isotretinoin before I see results?

2009-01-30T12:06:00.000-08:00

Studies have shown that most cases of severe acne respond to a single 4 to 6 month treatment course and that the effect of oral isotretinoin, especially for those having severe nodulocystic acne, can be dramatic. It is known that, pustules heal more quickly than papules or nodules (What is papules, nodulocystic and nodules?). Also, lesions on our face, upper arms, and legs tend to respond more quickly than lesions on our back or chest.

Usually, it takes approximately 1 to 2 months after starting oral isotretinoin acne treatment to see real improvement in our acne condition. It is good to know that treatment may start at a lower dose in order for our skin to get used to the drug before increasing to a higher dose in the months that follow.

The result of oral isotretinoin treatment is that we will see fewer or no new lesions, further the lesions that do come up should be smaller and should resolve more quickly. Studies have shown that results tend to last for at least several months to years after stopping this acne treatment.

What follows are the laboratory evaluation procedures that get involved:

Pretreatment evaluation
Review of the side effects
Review of pregnancy/contraception (women only)
Review of informed consent booklet

Blood tests at pretreatment and on weeks 4 and 8
Baseline fasting cholesterol
Triglyceride level
Standard liver function test
Pregnancy test (women only)

Monthly evaluation
Review of the side effects
Review of birth control methods
Physical exam to document improvement
Answer questions and review results

Can I continue topical or oral acne treatments while I am pregnant? How long should I wait before I get pregnant?

2009-01-29T16:16:00.000-08:00

It is learnt that acne is at its worst when women are at the height of their child-bearing potential, hence it is very important to let our doctor know all of the medications (including over-the-counter acne medications) that we are using to treat our acne if we become pregnant.

In fact, the FDA's (i.e. short for Food and Drug Administration) has divided drugs into five categories, i.e. ranging from completely safe to absolutely forbidden in pregnancy. And to qualify for a particular category, a drug must pass (or fail) certain scientific tests in either animals or humans, or both tests. We may want to refer to the FDA’s standards for each category as shown below:

Category A - Generally considered safe

Controlled studies show no risk in first trimester
No evidence of second- or third-trimester risk
Risk of fetal harm remote

Category B - Caution advised

Animal studies show no risk or adverse fetal effects. No controlled human first-trimester studies are available
No evidence of second- or third-trimester fetal risk
Fetal harm possible but not likely

Category C - Weigh risk/benefit

Animal studies show adverse fetal effect. No controlled human and animal studies are available

Category D - Weigh risk/benefit

Positive evidence of human fetal risk
Maternal benefit may outweigh fetal risk in serious or life-threatening situations

Category X – Contraindicated

Positive evidence of serious fetal abnormalities in animals, humans or both
Fetal risk clearly outweighs any maternal benefit

We may notice that except for category "A" and "X", these ratings do require a judgment call, for example, harm to the baby is never a certainty, and that some drugs such as epilepsy medications, may be so crucial to the mother's safety as to make taking them the least risky choice.

If a drug is rated "X," avoid it at all costs if we even think we're pregnant. However, if it falls into the "B" or "C" categories, we should check with our doctor before discontinuing it as the risks may be low enough while its benefits is sufficient to make its continued use the wisest course.

Generally, topical BP (i.e. benzoyl peroxide, an antiseptic commonly used topically to treat acne as it does not induce bacterial resistance) and topical erythromycin (i.e. an antibiotic commonly used to treat skin infections) can be used during pregnancy although BP is in the pregnancy category C. It is leant that Azelaic acid (i.e. a natural material produced by a yeast that is used as a topical treatment for mild to moderate acne) which is rated in pregnancy category B, is approved for use by pregnant women in some countries. However, topical retinoids (i.e. products that are generally in the vitamin A family) are not recommended for use in pregnant women.

On the other hand, pregnant women who have severe acne or acne that leaves significant scars, oral tetracyclines, including doxycycline and minocycline, should be avoided at all costs because they are harmful to the developing fetus. Also oral trimethoprim is not recommended. Generally, erythromycin is considered the safest choice, followed by topical azelaic acid. It is advisable to review with our obstetrician before any medication for acne is used, who may tell us to hold off on certain acne treatments until after the first trimester of our pregnancy.

Points for reference:

It is advisable not to use retinoids during pregnancy though it is okay to stop using the retinoid once we think we may be pregnant.
Acne medications such as oral isotretinoin (e.g. Accutane, Sotret and others) must not under any circumstances be taken during pregnancy. Women who are taking oral isotretinoin must discontinue the drug at least 4 weeks before even trying to get pregnant. Therefore, it is very important for women who plan to take isotretinoin to have adequate contraception to ensure that they will not get pregnant either during the acne treatment or for 4 weeks after.

Due to the serious side effects of it, the makers of oral isotretinoin has instituted programs called System to Monitor Accutane-related Teratogenicity (S.M.A.R.T.) or variations of it to help ensure that women do not get pregnant while taking this medication or for at least 1 month after. What follows are some of the birth defects that are associated with oral isotretinoin:

Brain abnormalities/deformities
Cleft palate
Deafness
Ear abnormalities/deformities
Heart abnormalities/deformities
Hormonal abnormalities
Skull abnormalities/deformities

Which topical acne treatment formulations should I choose? Are creams better than gels, ointments, lotions or foam formulations?

2009-01-28T13:25:00.001-08:00

It is learnt that when our skin is very oily, gels are much better tolerated but when our skin is very dry, those that come in creams or ointments formulations are usually more appropriate. We may want to know that lotions and oils are usually better used in the summer months or when there is more humidity in the air.

In general, the more moisturizing a product, the greasier it is; on the other hand, the more drying a product is, the more irritating it can be, that is to say that, both of these can make the products less acceptable to some people. Also, from the acne clear and acne care points of views, combinations of more drying and more moisturizing products can be used concomitantly for achieving excellent results for most acne treatments. The reason behind it is most topical anti-acne medications/topical acne treatments are at least somewhat drying, studies have shown that combining them with moisturizers will make them less irritating, and to help increase our acne regimen compliance and thus maximizing our acne treatment end results.

While some acne treatment products are more effective when presented in certain formulations, i.e. BP (i.e. short for benzoyl peroxide, an antiseptic commonly used topically to treatment acne, and does not induce bacterial resistance) is known to be more active when used in the gel formulation compared to other formulations. Nevertheless, should we get more irritating in a gel formulation, what we could do is to use a lower concentration in a gel formulation, alternatively is to choose a higher concentration in a cream, or to try those cleansers in their various strengths.

Fortunately, lots of choices are out there already, in fact, more new and improved acne treatment options are becoming available on a regular basis to make the acne products appealing and suitable to various skin types as to our specific needs.

Should I use moisturizer while I am on topical acne treatment?

2009-01-26T15:04:00.000-08:00

In general, if our skin is very oily, moisturizers are not required and need not be used. Nevertheless, the best time to use a moisturizer is when our skin feels dry or if we know that we are prone to having easily irritated skin; or put it another way, if we experienced overwhelming dryness that make us unhappy and less compliant with our topical acne treatment/acne regimen, then moisturizers may serve its purpose from otherwise very effective acne therapy. However and from the acne clear and acne care perspective, if excessive dryness persists, a change in our acne medications/treatments may be indicated.

Many not aware that it is also very helpful to use moisturizers with the retinoid (i.e. products that are generally in the vitamin A family and act at specific sites called retinoid acid receptors) category of acne medications, we could either mixed with the retinoid or applied right over it when first starting our acne treatment. This has proven effective to minimize the irritation and peeling that may otherwise occur.

It is leant that there are many moisturizers available in the market and the vast majority of which are over the counter. We should look for a moisturizer that is suitable for our face and one that has an SPF of 15 or higher if we are using it in the morning. The rationale behind is that it helps to moisturize our skin and protect us from the damaging rays of the sun, the effects of which may be magnified by the acne regimen that we are on.

As a rule, we should use a moisturizer that is more rich and creamy at night as there is greater water loss from our skin at night and a lighter cream or lotion with SPF in the morning. What we could do is to apply moisturizer over our morning acne regimen, and any makeup can be applied over the moisturizer as desired. We should first wash or exfoliate (i.e. the process of removing the upper layers of dead skin), then by using a toner (if we are so inclined) before using the topical acne treatment/medication and finally by a moisturizer with or without sunscreen depending on the time of day.

Do remember to look for moisturizers with "nonacnegenic" or "noncomedogenic" written on the label or packaging.

Definition of:

Acnegenic – products that induce inflammatory lesions such as papules, pustules to form, as a result of a type of follicular irritant contact skin reaction that usually happens within 2 to 3 days of using the product.

Comedognic – products that induce open or closed comedones to form after 2 to 3 weeks of use. Do note that the term noncomedogenic is not specifically defined in the federal guidelines.

Are topical or oral steroids good for severe inflammatory acne?

2009-01-25T17:05:00.000-08:00

It is leant that oral steroids are a preferred choice in very severe inflammatory acne because a short course will immediately reduce the number of inflammatory lesions. In fact, it is an approach that will help kick start and get quick control of our severe inflammatory acne condition. As with topical steroids, oral steroids can have a significant positive psychologic effect for acne sufferers that go beyond the reduction in severe cystic lesions and to reduce the pain and/or itching associated with them.

When oral steroids are used, they are usually given along with oral acne antibiotics or isotretinoin. As with any medications, the doctor will review with us the potential side effects that may go beyond the skin, it is noted that when the topical or oral steroids are used in high enough doses over long periods of time, what ensue is the possibility of the risk of developing cataracts (i.e. an opacity in the eye that obstructs vision) and suppression of our body's own production of cortisols (i.e. a stress hormone that helps us through whatever is at hand) under periods of stress, which is something very serious. It is reported that side effects associated with strong topical corticosteroids (i.e. a group of anti-inflammatory drugs that often used to inhibit allergic reactions or to treat severe inflammation) included thinning of the skin, stretch marks, new blood vessel formation in the skin (commonly called broken blood vessels), papulopustular flares of acne, and skin addiction to the steroid (i.e. a rebound flare of the acne when withdrawn from use).

In this respect, an injection of the steroid called cortisone in various concentrations directly into inflammatory lesions is used for large inflammatory lesions. This treatment is best done early on in the inflammatory process to both minimize the acne inflammation and help clear the lesion more quickly. Also, other acne treatments can be continued without interruption. However, there is a slight risk of localized thinning of the skin, which may or may not resolve within a few months. Studies have also shown that the injections are especially useful for those occasional flare of inflammatory acnes or the few lesions that often come with monthly menstrual periods in an otherwise successful acne management routine.

From the acne clear and acne care perspective, if we find that we need to go in weekly for injections, then it is time to reconsider our overall acne regimen.

Is benzoyl peroxide safe for treating acne vulgaris?

2009-01-24T18:50:00.000-08:00

Studies have shown that BP (short for benzoyl peroxide) is considered to be safe and effective against superficial inflammatory lesions as it has the ability to rapidly suppress the P. acnes (i.e. short for Propionibacterium acnes, a bacterium that grows and flourishes under certain condition and is the main culprit for inflammatory acne) present in our skin.

Also, benzoyl peroxide has the advantage of not being associated with antimicrobial resistance which makes it often used in combination with other oral or topical acne antibiotics to increase its efficacy and to minimize resistance. In fact, studies have shown that benzoyl peroxide if used in combination with other topical acne treatments such as topical erythromycin or clindamycin will be even more effective and better tolerated than either BP or the topical acne antibiotic alone.

The only drawback of using benzoyl peroxide for some people is due to its concentration-dependent stinging, dryness, irritation of the skin, contact dermatitis, and bleaching fabric or hair where it comes in contact with, what ensue is seen as redness, scaling and itching, or burning. Nevertheless, the irritant and contact reactions in our skin usually occur within the first few days (some may to weeks) of acne treatment and shall improve with continued use. However, benzoyl peroxide is known to bleach hair, clothes, and bed linens which we should take this risk factor into consideration when seeking for our acne solutions.

We may want to know that:

Benzoyl peroxide is available in a variety of formulations and concentrations, usually ranging from 1% to 10%. The gel formulations are preferable than creams and lotions due to its stableness and consistency in releasing the active ingredient.

If our skin tends more toward dryness (especially on our face), we should start with a lower concentrations of benzoyl peroxide products. As with all topical acne medications, it is suggested that benzoyl peroxide products should be applied to the entire affected area and not just those visible lesions (i.e. a mark in the skin). From the acne clear and acne care point of views, we should use it in the morning and evening.

Benzoyl peroxide cleansers are also useful for application to large areas on our body, such as our chest and back and can be used conveniently in the shower too.

On thing we may not aware is that benzoyl peroxide works exceptionally well when used in combination with a topical retinoid. For better acne control and acne treatment purposes, we should use the retinoid in the evening and benzoyl peroxide or a topical acne antibiotic or a combination of benzoyl peroxide/topical acne antibiotic in the morning as it helps to minimize the risk of inactivation of the retinoid. Try to put clothing on first, especially if they are to pass over our face as this helps to minimize the possible bleaching of the fabric that may ensue through contact. It is good to know that newer and more sophisticated formulations are being developed for these products to be used simultaneously without increased irritant reaction or inactivation of any of the active ingredients.

What follows is a list of benzoyl peroxide formulations for reference:

BenzaClin - 1% clindamycin/5% BP gel (water base)
Benzamycin - 3% erythromycin/5% BP gel (alcohol base)
Benzac AC - 2.5%, 5%, 10% gel(emollient, water base)
Benzagel - 5%, 10% (alcohol base)
Benzashave - 5%, 10% shaving cream
Brevoxyl - 4.8% creamy wash; 4.8% gel
Desquam-E - 2.5%, 5%, 10% gel (emollient, water base)
Triaz wash, pads, gel - 3%, 6%, 9%
Zoderm - 4.5%, 8.5% in urea base