ASK DR. BAUGHAN                                             June 11, 1999

A POX ON PIMPLES!

Acne affect 45 million people in the United States, making it one of the most common health problems in the country.  Although most of the time it is considered a cosmetic nuisance in adolescence, it can cause pain and scarring in some cases and can have a significant impact on self-image and confidence during the turbulent teens and beyond.  For such a common problem, you might think we would know the cause.  However, though we know a lot about how acne happens and how to treat, we still do not know why it happens. The trigger for acne is obviously the hormonal surge of androgens during and after puberty.  But why this surge affects one person to produce acne and another escapes fairly unscathed is unknown.

There are four factors in how acne happens: cells, oils, bacteria (Propionibacterium acnes to be specific), and inflammation.  Treatments are aimed at modifying one or more of these factors.

Skin cells and the cells that line the tubes that lead from our oil glands to our skin are always falling off and being replaced.  One key unknown step in the development of acne is why the hormones of puberty make these cells more sticky.  Instead of washing out of the tubes with oil and sweat, they clump together and block up the tubes.  The glands continue to make oil, building up pressure behind the plug of cells.  Bacteria love to multiply in a closed off oily place.  The pressure, bacteria, irritation of oil under the skin and the bodies immune response result in inflammation - redness, soreness, and swelling.

Most over the counter acne treatments contain resorcinol, salicylic acid, sulfur, benzoyl peroxide, or alpha-hydroxy acids.  These help loosen cells and break up the plugs.  Salicylic acid may help reduce inflammation and benzoyl peroxide has an antibiotic action, also.

Antibiotics can be applied to the skin or taken by mouth.  The most common ones used are erythromycin, tetracyclines (including doxycycline and minocycline), clindamycin topically, trimethoprim/sulfamethoxazole (Septra or Bactrim), and less frequently others.  All topical antibiotics may irritate the skin.  All pills may cause digestive system upset.  The tetracyclines may sensitize a person to the sun, resulting in severe sunburn.

Retinoids are the type of topical medicines most effective in loosening the sticky cells.  The mainstay, Retin-A, has recently been joined  by two others, adapalene (Differin) and tazarotene (Tazorac). They come in different strengths and preparations (creams, gels, lotions, liquids) to try to find the amount to do the job without causing too much skin to flake off, resulting in redness, dryness and burning.

For severe acne with painful nodules under the skin or resistant to other medications, Accutane is a pill that reduces oil production and alters the stickiness of the cells.  It is expensive, but it may only be needed for 15-20 weeks, and then the person may have prolonged relief.  It must be taken with caution, though.  The person needs to have blood tests to see if it is affecting their liver or their triglycerides.  It can cause cracking of the skin on the lips.  The biggest worry, though, is severe birth defects if a woman taking it gets pregnant.

General skin care issues are important, too.  Yes, squeezing zits generally causes more trouble than benefit.  The oils get under the skin and cause more inflammation.  Washing more than twice a day is unnecessary.  Acne is not caused by dirt or uncleanness.  Scrubbing irritates more than helps.  It may be a way to express frustration, but it does the skin no good.  Fresh air and warm weather may help, but too much sun does not.  Finally, if you notice certain foods tend to aggravate, avoid them, but repeated efforts to connect foods to acne have failed to find consistent culprits.  The oils in the skin come from hormones, not chocolate and chips.