The most common skin condition in the United States
What Is Acne?
Acne is the most common skin condition in the United States. Most people experience acne at some point during his/her life. Although frequently seen in teenagers, acne occurs in adults as well. Sometimes, people who had no acne during high school develop acne in their 20s and 30s and approximately 10% of 40-year-old women have acne. Even newborns can develop acne.
Unfortunately, accurate information about acne treatment can be scarce. Dr. Craig Singer is an acne expert, and has treated thousands of patients with mild, moderate and severe acne. Dr. Singer, himself, suffered from acne when he was in college and also treated his oldest child who had severe teenage acne. Dr. Singer understands the emotional impact that acne can have on a person’s self-esteem, and he enjoys helping others suffering from this common condition.
This schematic diagram shows how acne develops: (1) oil and skin cells clog the pores (i.e. blackheads and whiteheads), (2) bacteria overgrow within the oil glands, and (3) the immune system attacks the bacteria causing inflammation and swelling (pustules and cysts). The most current thinking however is that inflammation occurs at the start of an acne lesion.
Use a mild cleanser that won’t clog your pores. (The label may say “won’t clog pores” or “non-comedogenic”). Harsh scrubs with grapefruit pits and beads should be avoided.
Do not use astringents, alcohol, or witch hazel.
If you have very oily skin, then a cleanser with salicylic acid (i.e. Neutrogena oil free acne wash) may be useful. But keep in mind that that salicylic can dry out your skin and produce irritation. Using a facial moisturizer afterwards is a must, even if you have oily skin.
Wash your face every morning, evening, and after exercise.
Glycolic acid is a gentle facial cleanser used for the treatment of acne. Alpha-hydroxy acids provide exfoliation and their low pH helps reduce P. acnes levels on the skin. Glycolic acid is well-suited for use by individuals with dry skin because the hydroxy acids act as humectants (i.e. draw water into the skin). In addition, the exfoliating activity of glycolic acid improves the penetration of other acne medications into the skin. Glycolic acid wash is available for purchase at Craig Singer MD Dermatology.
It is always a good idea to apply a moisturizer to the skin after you wash your face. This preserves the normal skin barrier and minimizes irritation. The more irritated your skin becomes, the worse the acne becomes. Even if you have oily skin, it is still wise to moisturize.
A number of moisturizers are available for purchase over-the-counter. (The label may say “won’t clog pores” or “non-comedogenic”). Some people prefer one over another. Some people find that certain moisturizers sting or irritate their skin. It may take some trial and error to figure out what you like best. Dr. Singer’s personal preference is for a moisturizer called Theraplex. However many other over-the-counter moisturizers are more than adequate. These include Neutrogena Hydro boost, Cetaphil moisturizer and Cerave moisturizing cream.
Dermatologists know that letting acne runs its course is not always the best advice. Here’s why:
- Without treatment, dark spots and permanent scars can appear on the skin as acne clears.
- Treating acne often boosts a person’s self-esteem.
- Many effective treatments are available.
There are multiple different types of acne lesions. The earliest lesion is known as a comodone (more commonly referred to as “blackheads and whiteheads”). These are the basic form of acne in which oil and skin cells clog the pores. Papules and pustules (i.e “zits”)represent the body’s inflammation towards the overgrowth of C. Acnes bacteria within the pores. Cysts and nodules refer to inflammation associated with ruptured pores and carry a higher risk of potential scarring. In general, it is easier to calm down the inflammatory lesions quicker than it is to unclog the pores.- It takes months to unclog the pores.
Acne is caused by two main influences:
- Family History – Those with a strong family history of acne, and in particular scarring acne, seem to get more acne.
- Hormones – Hormones rise with the onset of puberty and acne is the first sign of adolescence. Furthermore, hormones fluctuate with menstrual cycles and are heavily influenced by stress. This explains why those who under more stress (e.g. upcoming examinations) tend to flare of acne.
- Additional Causes
- Those people who take anabolic steroids get more acne.
- Those with a hormone imbalance (e.g. PCOS) develop more acne.
- Certain birth control methods such as progestin only (e.g. Depo-Provera or Mirena IUD) can make acne worse.
- Acne can be triggered by mechanical occlusion such as hats, headbands, chin straps, occlusive clothing, as well as heavy makeup.
- Certain medications such as lithium can also trigger acne.
When you pick acne lesions, you are creating an injury to your skin.- This leads to persistence of the acne lesion for weeks. Also, you will likely end up with temporary redness or a dark spot on your skin lasting even longer. And finally, a permanent mark (i.e. scar) may develop from picking.
Our recommendation: When you develop a large acne cyst, it is best to perform a hot compress with a wet washcloth for five minutes and spot treat with a topical acne medication. Also, Dr. Singer can inject the acne cyst with cortisone which usually shrinks the lesion within 48 hours. We welcome patients on a walk-in basis for acne injections.
Those people who have a darker skin complexion (i.e. skin of color) tend to develop dark spots in previous areas of acne. This is known as post inflammatory hyperpigmentation. When someone with a darker skin complexion sustained an injury to the skin, a bug bites or a pimple, the pigment cells in the skin are stimulated to release excessive amount of pigmentation. This leads to an uneven complexion and can be more bothersome than the acne itself.
The first step in addressing the discoloration is to aggressively treat the acne to prevent new pimples from forming. If the acne is not adequately controlled, then any treatment of dark spots will be ineffective.
Use of sunscreen is mandatory, bleaching creams (such as Triple therapy), and chemical peels are effective. Additional treatments include kojic acid, Tranexamic acid (e.g. Lytera), etc.
Dark Spots from Acne often require a “Triple Therapy” bleaching cream
Acne Procedure Video Gallery
Beta Lift Chemical Peel
Treatment of Acne
What is Benzoyl Peroxide?
Benzoyl peroxide is considered first-line treatment for acne. Benzoyl peroxide kills the bacteria on the skin that cause acne, thus reducing pimples, pustules and cysts. It also helps unclog pores.
It is found in washes, gels, creams, and combination products such as Benzaclin™, Onexton™, and EpiDuo.™ Benzoyl peroxide is also found in over the counter preparations such as Neutrogena Rapid Clear™ or Panoxyl. ™
Lower strengths (i.e. 2.5%) produce less skin irritation than higher strengths. Also, benzoyl peroxide bleaches dark fibers of clothing and towels. If benzoyl peroxide is applied at night, we often recommend that the person sleep with a white pillowcase. If applied in the morning, be careful not to accidentally apply it to the neck as you may bleach your shirts.
If benzoyl peroxide is used in a wash form, it is important to get a five minute contact time with the skin before washing off. Otherwise it may not be effective.
Approximately 1% of people are allergic to benzoyl peroxide.
What are retinoids?
Retinoids, the cornerstone of acne treatment, are derived from Vitamin A. This class of medication is available in creams, gels and foams.
Retinoids slowly unclog the pores, getting rid of blackheads and whiteheads. They also provide an anti-inflammatory effect hoping to reduce pimples and cysts. Unfortunately, retinoids do not work overnight. – It takes at least three months to see their full benefit.
When a person applies a retinoid to the face, it causes a slow peeling of the skin.
However, if someone were to apply too much retinoid cream, too quickly, it can cause a fast peeling of the skin with significant redness, irritation, and burning. Therefore, proper understanding of how to apply these medications is essential.
Here are some general guidelines to help:
Use a gentle skin cleanser.- see above accordion
Apply retinoids to a dry face. This means that you should wait at least 15 minutes after washing your face to let your skin thoroughly dry. If you apply retinoid immediately after you wash your face, your skin is still damp and the retinoid may penetrate your skin more deeply, leading to irritation.
Only use a pea-sized or chocolate chip sized amount of retinoid for the entire face.
Always use a moisturizer after you apply a retinoid
For the first month of treatment, only use the retinoid three nights a week. If you can tolerate it after month, you can slowly increase the frequency.
If you are still unable to tolerate the retinoid, then try applying a moisturizer BEFORE you apply the retinoid.
Note that retinoids are contraindicated during pregnancy.
What are topical antibiotics?
Topical antibiotics are applied to the skin as opposed to a pill taken by mouth. They work by killing acne causing bacteria inside the oil glands of the pores.
Because skin bacteria can develop resistance against any antibiotic, benzoyl peroxide is often combined with the antibiotic to minimize this.
Most topical antibiotics have little systemic absorption and therefore we worry less about creating internal resistance to antibiotics. Frequently used topical antibiotics include clindamycin ( solution, lotion, gel or pads), sulfacetamide (sometimes combined with sulfur) and present in formulation such as Ovace™ and Avar™, Plexion™ etc. Recently, erythromycin was re-introduced in combination with benzoyl peroxide.
In 2020, a novel topical antibiotic preparation called Amzeeq™ was introduced. This is a topical form of minocycline which has several advantages over oral minocycline. First, it is able to achieve higher concentrations in the skin than the oral preparation. Secondly, it penetrates oil glands (where bacteria reside), breaking up oil – something that no other topical antibiotic has ever been proven to do. Third, it is extremely moisturizing and nonirritating to the skin. Other major advantages includes lack of systemic reactions as well as lack of blue gray pigmentation in the skin.
What are Oral antibiotics?
Oral antibiotics are medications taken by mouth that kill acne causing bacteria inside the oil glands of the pores. They also work by reducing inflammation in the skin thereby lessening pustules, pimples and cysts. The current thinking is to take an oral antibiotic for 3 to 4 months until inflammatory acne is improved. During that time, an optimized topical acne regimen is created and then the oral antibiotic is discontinued. Because skin bacteria can develop resistance against any antibiotic, topical benzoyl peroxide is often prescribed to minimize this.
Doxycycline is the most commonly prescribed oral antibiotic. It is well-tolerated though it may cause some abdominal pain which is minimized by coadministration with meals. Doxycycline often makes a person prone to sunburn, so sunscreen is essential.
Minocycline is also frequently used to control inflammatory acne and is easy on the stomach. However, it has more potential serious side effects including serum sickness like reaction and lupus like reaction.- Fortunately the side effects are rare.
Tetracycline– under the branded form of Seysara™ is the newest antibiotic to be released. It has the advantage of a once daily formulation, and is usually well tolerated. It is quite effective in reducing inflammatory acne and has minimal side effects.
Cefadroxil is a penicillin derived antibiotic which may be used in lieu of the above antibiotics and is reasonably well tolerated. Potential bacterial resistance however is a concern.
Taking a probiotic during the administration of antibiotics may be useful to replenish normal gut bacteria.
Topical Dapsone helps reduce inflammatory acne lesions. It is available in the branded form of Aczone.™
Dapsone is particularly useful to treat flares of acne around the chin especially related to hormonal acne.
It is well-tolerated, does not bleach clothing, and is relatively nonirritating.
Topical sulfur- an “old school” treatment for acne and it acts as an anti-inflammatory. Can be found as a 4% wash over the counter.
As mentioned above, family history and hormones are the major determinants of whether or not someone develops acne.
Hormonal therapy is a highly effective treatment for acne in women, especially in those women who notice flaring of acne the week before her menstrual cycle. Oral contraceptive pills lead to stabilization and reduction in testosterone levels with subsequent reduction in acne flares. Several birth control pills are FDA approved for the treatment of acne and include Ortho Tri-Cyclen™, Estrostep™, and Yasmin.™ Generic versions of these birth control pills are widely available. Side effects include increased risk of blood clots (approximately 7 in 10,000 women), triggering of migraine headaches, abnormal menstrual cycles, weight gain and depression. Fortunately these side effects are uncommon. Dr. Singer routinely prescribes birth control pills for the treatment of acne.
Spironolactone is an effective hormonal treatment for acne and is often combined with birth control pills. Spironolactone is a diuretic used for high blood pressure. However it has outstanding anti-androgen effects and can be incredibly useful to prevent premenstrual flares of acne. Side effects include increased urination, irregular menstrual cycles ( unless combined with an oral contraceptive pill), lowering of blood pressure, and elevation of potassium levels.
Chemical peels are an effective add-on therapy for the treatment of acne.
Chemical peel works by breaking up the oil in the skin, opening clogged pores (i.e. blackheads), and reducing inflammatory acne. They also enhances the penetration of prescription topical acne medications and help reduce dark discoloration from previous acne lesions.
A variety of different chemical peels are available, however we favor the use of Theraplex™ Beta-lift chemical peel. The reason is that 20%-30% salicylic acid is relatively non-inflammatory – this means that there is very little clinical peeling of the skin (though microscopic peeling is occurring). Therefore, people who undergo Beta-lift peel may return to work or school that same day!
Most people experience a mild stinging that subsides during the peel. The intensity is equated to a very mild (2 out of 10) stinging sensation. As the peel progresses, the stinging resolves because the salicylic acid acts as a topical anesthetic.
Every 3 to 4 weeks.
We recommend you stop all retinoid medications 3 days before. This includes: Differin, Adapalene, Retin-A, Tretinoin, Epiduo, Fabior, and Tazorac.
All other medications such as benzoyl peroxide, Benzaclin, Onexton, Aczone, dapsone, clindamycin, Finacea, etc. may be safely continued.
There are times when traditional therapies, hormonal therapies, and cosmetic treatments fail to control cystic acne.
Fortunately, there is a miracle cure for acne – Accutane.
Accutane™ (AKA Isotretinoin) is a vitamin A derivative and it is the only known cure for acne. It was first FDA approved in 1982 for treatment of severe nodular cystic acne. Since then, millions of people have successfully taken Accutane™ for the treatment of resistant acne. Dr. Craig Singer has personally treated more than 500 patients with Accutane™ with amazing results.
Yes it can. Original studies showed that 70% of people who complete a full course of Accutane ( cumulative dosing of 150 mg per kilogram) have permanent cure of acne. (Layton AM et al, British Journal dermatology 129 (3), 1993). Some studies have advocated even higher doses of Accutane, 220 mg per kilogram, which result in even lower rates of relapse.
Those who are younger, under 16 years of age, often require a second course of Accutane to achieve permanent remission. However, patients should understand that even if their acne does relapse, it is usually not as severe as it originally was, and it is more likely to be responsive to conventional therapy.
The following people meet criteria for initiation of accutane:
Moderate to severe inflammatory acne (without scarring) that has not responded to conventional therapy (benzoyl peroxide, topical retinoids, topical and oral antibiotics, and adjunctive treatments).
Scarring, inflammatory acne inadequately controlled with conventional therapy
Those who are unable to discontinue oral antibiotic therapy without flaring of their acne.
Psychological scarring from acne
Accutane improves acne through a variety of mechanisms including anti-inflammatory, cellular differentiation, and sebaceous gland activity.
Simply put, Accutane shrinks the oil glands where acne causing bacteria thrive. This results in reduced bacterial counts and reduction in the body’s inflammation. In addition, it helps unclog pores.
It is true that there are a number of potential side effects to Accutane. However, the vast majority of these side effects are completely reversible. Millions of people have taken Accutane over the past 30 years, enabling us to have good long-term safety data. If patients fully understand the potential side effects and how to minimize them, Accutane is a relatively safe drug to take.
The most common side effect of Accutane is extreme dryness, particularly of the lips. Most people need to apply lip moisturizers such as Aquafor, Chapstick, and other lip balms numerous times an hour. Your eyes may be dry with eyelid inflammation and we typically recommend artificial teardrops to minimize this risk– some people have difficulty wearing contact lenses, though most may continue to wear them. Sometimes, temporary decreased night vision is reported. Your skin will be dry as well and you’ll need to moisturize a couple times a day.
At higher doses, you may experience joint aches, muscle aches, and low back pain. For some people this interferes with physical activity; however, most can tolerate these side effects.
You will also have extreme sensitivity in the sun, and you will be extraordinarily prone to sunburn. Therefore, you will need to take extra precautions if taking Accutane in the summer. – Some people defer accutane until the fall and winter because of this side effect.
Your skin will be very sensitive and will heal poorly with surgical procedures for up to 6 months after completing Accutane. Therefore, we advise you avoid waxing, tattoos, piercing, elective surgery and laser procedures while taking Accutane and for 6 months upon completing the course.
Rarely, Accutane may cause your acne to flare in the first month or two of treatment, sometimes with severe flaring (acne fulminans).- This is usually minimized by starting out at a low dose of Accutane for the first month. In addition,pyogenic granuloma skin lesions may rarely develop in acne cysts as well as around fingernails.
Accutane can also elevate triglycerides and cholesterol, and may cause transient elevation of liver enzymes.- For this reason we do not recommend any intake of alcohol during the course of Accutane. Severe liver toxicity is extraordinarily rare and Dr. Singer has never had a patient (nor has he ever heard of anyone) who developed irreversible liver damage from Accutane.
The most serious side effect is the teratogenic effect on a developing fetus. For this reason, any female of childbearing potential must be on two forms of contraception or be strictly abstinent (for one month prior to the start of Accutane, during the entire course of Accutane, and for one month after completing Accutane). Studies show that fetal exposure to even tiny doses of Accutane results in severe malformations. Women who become pregnant while taking Accutane are strongly advised to terminate the pregnancy. It is important to remember that millions of women who have taken Accutane in their younger years have had no problems with future pregnancies.
There is controversy as to whether Accutane produces depression and suicide. In 1998, following reports to MedWatch, the makers of Accutane added an additional warning regarding possible adverse effects of “depression, psychosis and rarely, suicide. Following the new labeling however, larger studies failed to demonstrate a convincing link between Accutane and depression. Many studies suggest that severe acne is a risk factor for depression and suicide and that the majority of people who take Accutane have an improved mood (Accutane may act as an antidepressant for people who are devastated by their acne). To date, there have been no large well-designed studies that have definitively proven or disproven that Accutane causes or worsens depression. Dr. Singer has had a few patients who became moody and tearful or became angered easily after starting Accutane. These patients symptoms resolved immediately after discontinuing Accutane. If someone has a history of depression, and it is well-controlled/stable, Dr. Singer will prescribe Accutane as long as he works closely with the patient’s mental-health provider.
Accutane has also been implicated as a cause of inflammatory bowel disease, in the form of either Ulcerative colitis or Crohn’s disease. The data regarding Accutane use as a cause of inflammatory bowel disease is conflicting. Some studies have shown no association while others have shown a 2 1/2 fold increased risk. No definitive cause and effect has ever been proven. Even in reports that demonstrate a possible causal association, the overall risk of inflammatory bowel disease in patients who take accutane is very small.
Accutane may rarely cause a condition called benign intracranial hypertension in which increased amounts of fluid develop around the brain leading to headaches and nausea. Fortunately this is a very rare side effect. Dr. Singer has only seen this once during his career.
Most people require six months of Accutane, and sometimes an additional month or two is needed.
We do require baseline fasting blood work before starting Accutane. And we will require additional bloodwork every month/ every other month during the course of Accutane.– this depends on dosing and whether or not patient has had any bloodwork abnormalities.
Women of childbearing potential will also need monthly pregnancy testing. This may be performed through either urine or blood. Home pregnancy testing is now permitted during the COVID-19 outbreak.
The iPLEDGE Program is a computer-based risk management program designed to further the public health goal to eliminate fetal exposure to isotretinoin through a special restricted distribution program approved by the FDA. The program strives to ensure that:
No female patient starts isotretinoin therapy if pregnant
No female patient on isotretinoin therapy becomes pregnant