An estimated 40 million to 50 million Americans are affected by some form of acne, and not just teenagers. Although up to 80% of people aged 11 to 30 say they've been affected, it turns out that many of us, particularly women, have acne in our late 30s and even into our 50s, says Jenny J. Kim, MD, PhD, associate professor of dermatology at the University of California, Los Angeles, David Geffen School of Medicine.
"Sometimes it is hard for patients dealing with acne to understand why, even with ongoing treatment, they cannot get rid of their symptoms forever," Kim says. "I explain that it's similar to having any chronic disease, like diabetes -- there is no cure yet, but we can control the symptoms," she says.
Why is acne so hard to treat?
Because there are so many different factors involved: plugging of pores and oil production for starters. Inflammation is really critical; studies are showing that even on the skin of acne patients where one doesn’t see acne, there are inflammatory factors on a molecular level. Bacteria called P. acnes, or Propionibacterium acnes, are also responsible, as well hormones, particularly androgens (the male hormones present in men and women). They overstimulate the oil glands and hair follicles in the skin, causing hormonal acne flares.
What's new in acne treatment?
In the last 10 or 20 years, there's been very slow movement. People are really concerned about being on antibiotics for a long time, as that can increase the resistance of bacteria. So one change has been [the use of] low-dose oral antibiotics that have anti-inflammatory effects but not antimicrobial effects. Also, we have some slow-releasing antibiotics so you’re not getting a high dose of antibiotics all at once.
Recently, a new drug that works a little bit differently was developed. It’s a topical dapsone (a gel applied to the skin). It's mainly an anti-inflammatory agent.
We're seeing more combination therapy. Since there are five different things going on, we use two or three treatments. It’s really hard for patients to take three different things in the morning and three different things in the evening, so drug companies are developing [medicines] where you have two actives, such as an antibiotic and retinoid (vitamin A derivative that can unplug follicles and pores) in one drug.
The latest studies say diet may play a role in acne, particularly a high gylcemic (high-carb) diet and perhaps skim milk. We need better research in this area, but in the future we might see diet used for regulating and treating acne patients.
We’re also combining devices with medical treatment. So we can use a topical medication that will penetrate into the [gland] where the acne is occurring and that makes that oil gland light up, and then you come in with either laser or light-based technologies. These include the pulsed-dye laser, red and blue light, and photodynamic therapy, which target the sebaceous (or oil) glands and can reduce acne flares.
But I don't think they should the first line of therapy. The problem is that there are limited large, prospective, well-controlled studies that demonstrate their effectiveness, so that will be an area we need to explore in the future.
What about scarring?
We can’t really predict which acne will lead to scarring. It’s not always the severe acne.
Acne scars can be very aggressive and difficult to treat. For mild scarring, retinoids, chemical peels, microdermabrasion (which uses tiny rough grains to buff away the surface layer of skin), and lasers can give mild improvement.
Another therapy that is approved by the FDA for acne scarring is fractional laser resurfacing. It thermally damages the tiny columns of scarred skin, while the surrounding healthy skin is left intact.
The fractional photothermolysis is nice in that it’s safe in all skin types. But it's not like magic; you can’t get rid of that scar immediately. You need multiple treatments. And they are usually not covered by insurance, so can be very expensive.
For more severe scarring, such as deep "ice-pick" scars, several surgical procedures -- including punch grafting or punch excision -- can help to remove, raise, fill, or separate the scar tissue from the underlying skin. They’re usually used in combination with other therapies, including lasers and fillers.
What about skin care?
Use a mild cleanser and sun protection that is non-irritating to the skin.
Don't traumatize your skin with scrubs, astringents, or alcohol-based products. Wait five or 10 minutes before putting on medication after washing. If you’re going to buy cosmetics, use products that don't clog the pores -- they'll be labeled "oil-free" or "nonacnegenic" or "noncomedogenic."
I find that products containing salicylic acid are useful. Separating treatments, such as using salicylic acid or benzoyl peroxide in the morning and a retinol-based product at night, might be helpful if you have sensitive skin.
Newer hydroxy acids (aka glycolic acids) appear to be better tolerated and the nice thing is that they have been shown to inhibit enzymes called metalloproteinases in our skin. This breaks apart collagen so that could help prevent acne scars.
Cosmeceuticals that contain natural products and have anti-inflammatory properties, such as licorice, oatmeal, soy, and feverfew, could be useful. But natural doesn’t always mean good. A lot of natural things cause allergic reactions. So it’s very important to consult your dermatologist and discuss what you’re using.
Kim has consulted for several companies that make skin care products, including Allergan, Medicis, and Stiefel.