Chapter 2
Diagnosis and Treatment

Acne is easy to diagnose. It is the only skin disease in which comedones are present. Other skin diseases, such as rosacea and skin rashes caused by allergies or insect bites, may have red lesions that resemble papules, but there is an absence of comedones. Therefore, the presence of comedones, whether alone or in combination with other skin lesions, indicates the presence of acne.

Treatment to Fit the Type and Severity of Acne

Once acne is diagnosed, the doctor evaluates the type and severity of a patient's lesions in order to determine what treatment is best. Acne treatment is individualized. It depends on the type of acne a person has as well as how severely acne lesions are inflamed. For example, treatment for whiteheads and blackheads focuses on removing dead skin cells that clog the follicles, while treatment for pustules is aimed at destroying infection and reducing inflammation. In an effort to achieve these different goals, different medications are needed.

The Acne Scale

To ensure that each patient receives the most effective treatment for his or her individual problems, doctors employ a special scale known as the acne grading scale. The acne grading scale rates the severity of acne on a scale from zero to eight, with zero indicating very mild acne and eight indicating very severe acne. For example, if a patient has a few comedones, he or she is given a zero rating. The rating increases with the number, size, and severity of a person's lesions. Therefore, a patient with half of his or her face covered with papules, comedones, and a few pustules receives a four rating, which denotes moderate acne. A rating of eight indicates very severe acne, with the patient having acne lesions of all types, including numerous cysts, covering almost all of his or her face. Once a person's acne has been rated, doctors match the rating to specific treatment plans recommended by the American Academy of Dermatology, an organization that studies skin diseases. At the same time, the doctor makes adjustments in the recommended treatment for individual differences. For example, these differences may include such factors as how dry or oily the patient's skin may be, the patient's gender, whether the patient is allergic to any medications, and whether the patient is pregnant or planning to become pregnant soon.

A Common Goal

Because there are many differences in the severity and types of acne lesions, there are a wide variety of acne treatment options. These include over-the-counter medication people can purchase without a doctor's prescription as well as more powerful, doctor-prescribed medications. Acne medication may be taken orally or applied directly onto the skin in the form of a topical treatment. Often, oral and topical treatments are combined. Once acne outbreaks are eliminated, a special type of surgery known as skin dermabrasion can lessen acne scars.

No matter what form of treatment is used, all acne treatments share a common goal: to control the sequence of events that cause acne outbreaks in order to prevent new outbreaks from occurring. Experts agree that since there are so many different acne treatment options available, most cases of acne outbreaks can be controlled. Edmonton, Canada, dermatologist Don Groot explains: "We've got acne by the tail now. If we catch it early, you can do wonders with acne. It's not a difficult disease to treat anymore."¹⁹

Topical Treatments

Some of the most popular and effective treatment options available for acne are topical treatments. Most commonly used to treat cases of mild to moderate acne, topical treatments come in cream, lotion, or gel form and on specially prepared pads. Those used to treat the mildest cases of acne can be purchased without a doctor's prescription.

Salicylic Acid

Salicylic acid is a popular topical treatment that can be purchased without a doctor's prescription. Salicylic acid does not treat infection or inflammation. Therefore, it is mainly used to treat comedones. When salicylic acid is rubbed onto the skin, it penetrates the pores and gets inside clogged hair follicles. Salicylic acid causes the dead skin cells inside the follicles to dissolve. This allows oil trapped in the follicles to reach the skin. Many patients report that treatment with salicylic acid helps eliminate acne outbreaks. A patient explains: "I have blackheads on my back. I wipe my back with salicylic acid wipes every night. It didn't help immediately, but after about a month, I noticed a difference. I think it's helping."²⁰

Benzoyl Peroxide

Benzoyl peroxide is another topical treatment that can be purchased without a doctor's prescription. In fact, it is the main ingredient in most over-the-counter acne preparations. Used to treat mild inflammatory acne, benzoyl peroxide is available in different strengths. It is often used with products that contain salicylic acid by patients who have both comedones and mildly inflamed pustules.

Benzoyl peroxide is an oxidizing agent, meaning it releases oxygen. The bacteria that cause acne can only exist in an oxygen-free environment, such as a clogged hair follicle. When benzoyl peroxide penetrates hair follicles and releases oxygen, acne-causing bacteria are killed. This not only relieves existing infection but also stops new pustules from forming. A young woman describes her experience with benzoyl peroxide: "After two and a half weeks I was clearer than I had been since before puberty.… Using this benzoyl peroxide… has really changed the way I feel about myself and my ability to take on the world."²¹

Other Antibacterial Ointments and Vitamin A

In addition to benzoyl peroxide, there are a number of other antibacterial ointments used to treat mild inflammatory acne. These ointments contain chemicals such as sulfur that kill bacteria. In addition, there are a number of stronger antibiotic creams, gels, and lotions that contain powerful bacteria-killing drugs such as tetracycline and erythromycin, which are used to treat moderately inflamed acne. Although these products do control infection, they have no effect on clogged hair follicles. Therefore, these products are often combined with salicylic acid or a more powerful prescription-strength ointment such as Retin A, a popular retinoid.

Retinoids are derived from vitamin A, which has a potent effect on the skin. Scientists have found that when vitamin A is applied to the skin, it slows the growth of skin cells. This is important in preventing acne because when new skin cells form, old skin cells are shed. Slowing the growth of skin cells keeps dead skin cells from building up inside the hair follicles. This stops new comedones from forming. In addition, for reasons that scientists cannot explain, vitamin A slows down oil production and stimulates the production of collagen. This gives the skin a smoother appearance. Therefore, vitamin A is often used to help smooth out acne scars. According to the American Academy of Dermatology: "Vitamin A products can make a big difference in the appearance of the skin. They speed [collagen] cell turnover and slow down oil production."²²

Oral Medication

In addition to topical treatments, many people with moderate to severe inflammatory acne take oral medication, either alone or in combination with topical ointments. There are three main types of oral medications used to treat acne. They are antibiotics, hormones, and isotretinoin.

Antibiotics

Bacteria-fighting oral antibiotics such as tetracycline, erythromycin, clindamycin, and doxycycline are often prescribed for people whose acne does not respond to topical antibiotic treatment. Oral antibiotics are absorbed through the digestive system, into the bloodstream, and then into the skin and hair follicles. Here they kill acne-causing bacteria and reduce inflammation. This helps stop new acne lesions from forming and gives the skin a healthier appearance by lessening redness. However, most oral antibiotics are absorbed into the bloodstream quickly. Consequently, they are eliminated from the body rapidly. Therefore, in order to maintain a constant level of bacteria-fighting medication in the bloodstream, oral antibiotics must be taken frequently for an extended period of time. Indeed, some people with acne take antibiotics two or three times each day for six months to a year. Moreover, once treatment with oral antibiotics is stopped, unchecked bacteria often cause new acne outbreaks. In an effort to prevent this from occurring, when the skin begins to clear, treatment with oral antibiotics is gradually tapered off, rather than stopped abruptly, and replaced with topical antibiotic treatment. This helps restrain the growth of acne-causing bacteria.

Despite these drawbacks, treatment with oral antibiotics can be quite successful. A patient describes how treatment with tetracycline helped him. "I used benzoyl peroxide and medicated pads, but they didn't help. My acne was too bad. It took tetracycline to get it under control. It helped a lot, not 100 percent, but a lot. Even with the tetracycline, I still had some little pimples, but not those big old welts. Once the tetracycline kicked in I wasn't embarrassed about my appearance anymore."²³

Hormones

For many teenage girls as well as women with adult-onset acne, treatment with female sex hormones such as estrogen offers another treatment option. Usually taken in the form of low-dose birth control pills, hormonal therapy increases the level of female hormones in a woman's bloodstream. This reduces or blocks the production of androgen. Once androgen production is decreased, sebum production is decreased as well. The result is decreased acne outbreaks. A woman describes her experience with hormone therapy: "I was surprised when my doctor prescribed birth control pills to clear up my skin. It sounded strange. But I was at the end of my rope as far as my skin was concerned. I tried just about everything else, so I decided to give birth control pills a shot. I am so happy with the results. My skin hasn't looked this good in years."²⁴

Isotretinoin

For patients with severe cystic acne or for patients with moderate inflammatory acne that has proven to be resistant to oral antibiotics, isotretinoin is the most effective acne treatment available. In fact, it is the only medication that effectively controls severe cystic acne. Commonly sold under the brand name Accutane, isotretinoin is a vitamin A derivative that is administered in pill form.

Isotretinoin is an extremely powerful drug that stops all the changes in the skin that cause acne. It kills bacteria and reduces inflammation. At the same time, it shrinks the sebaceous oil glands, reducing sebum production by up to 90 percent. It also slows up the growth of skin cells, which helps unblock hair follicles. Un-clogging the hair follicles allows pustules and cysts trapped below the surface of the skin to work their way to the surface of the skin, where they burst and heal. Consequently, many patients find that their acne actually worsens in the first month of Accutane treatment but starts improving thereafter. Anthony C. Chu explains: "In the first month on Roaccutane [the name for isotretinoin in Great Britain] acne can worsen.… In most patients acne slowly reduces in the first two months, but there is then a more rapid response and, again in most patients, the acne clears completely in four months."²⁵

Taken for a period of four to nine months, isotretinoin is effective in 98 percent of all cases. However, in some cases acne symptoms return after isotretinoin treatment ends. In these cases, patients may begin a second cycle of isotretinoin treatment. A patient describes her experience:

After a few weeks on Accutane, my breakouts stopped dead in their tracks. I experienced no breakouts whatsoever for the remainder of the time I took the prescription. People with fantastic skin would come up to me and say, "I wish I had your skin." It was pretty incredible. However… I was not one of the lucky ones. Although my skin has been more manageable since Accutane, I have experienced serious breakouts since ending my cycle. Even so, I remain very thankful that I took it. I would describe my acne now as light to moderate thanks to Accutane, and with my current regime [use of topical treatments] I stay clear.²⁶

Treating Acne Scars

Although acne medication can lessen and even eliminate acne outbreaks, many patients are left with permanent scars. For these patients, treatment with a form of surgery known as skin dermabrasion can help give the skin a smoother appearance. In this procedure, patients are given a local anesthetic to eliminate pain. Then, a high-speed instrument that resembles a wire brush is used to scrape away the top layer of skin and alter the contour of acne scars. Small scars may be completely removed, while the depth of large scars is reduced considerably. Because the top layer of skin is removed, after the procedure the patient's skin often appears red and may remain red for a month or more. However, according to Chu, once the skin heals, 70 percent of people who undergo skin dermabrasion report improvement in the appearance of their skin.

Risks and Side Effects of Acne Treatments

Despite the benefits of acne treatments, like all surgery and medication, those used for acne can cause side effects and health risks. For example, as in all surgical procedures, people who undergo skin dermabrasion can develop an infection or have an allergic reaction to the anesthetic.

Acne medicines too, present health risks. Topical ointments, for instance, can dry out and irritate the skin, causing it to become red and scaly. Retin A, in particular, makes the skin extremely sensitive to sunlight. If it is left on the skin when an individual goes out in direct sunlight, he or she is likely to experience a severe sunburn.

Oral antibiotics can also present problems for some patients by causing nausea, dizziness, stomachaches, and sensitivity to the sun. Furthermore, because oral antibiotics kill bacteria, they alter the level of normal bacteria present throughout the body. In women, lack of normal bacteria can lead to the growth of yeast in the vagina. This often causes the development of a yeast infection.

More troubling is the fact that long-term use of antibiotics can cause people to develop a resistance to these drugs. This can be devastating if a person develops a serious bacterial infection, such as bacterial pneumonia or strep throat, that requires antibiotics to be cured.

Hormones, too, can cause side effects such as mood swings, depression, and weight gain. An acne patient recalls: "I… took antibiotics so long that I have become very resistant to many of them. The doctors even tried birth control pills, the only real results from that was an extra twenty pounds!"²⁷ Hormone therapy has also recently been linked to an increased risk of breast cancer and heart disease.

Isotretinoin and Serious Health Problems

Even more disturbing are the health problems that isotretinoin can cause. Like Retin A, isotretinoin dries out the skin. However, because of its potency, its drying effect can cause the skin on the lips, fingers, toes, feet, and palms of the hands to swell, peel off, and bleed. Isotretinoin can also cause frequent nosebleeds, dry tear ducts, and muscular pain. In most cases, these problems disappear when treatment with isotretinoin ends, but in a few cases these problems persist indefinitely.

An article in the January 18, 2003, edition of the Australian, an Australian newspaper, describes one young man's experience:

Ryan Burrows stood in the shower wearing pink dishwashing gloves to prevent his hands from bleeding, and all he could think was that his life had become "a living hell." For Burrows… the swollen hands, "which would bleed and ooze pus" if he shook anyone's hand or if they became wet were just one of the horrorific side effects he attributed to the acne treatment Roaccutane [the common name for isotretinoin in Australia].… The dermatologist told Burrows any side effects would disappear as soon as he stopped taking the drug. Two-and-a-half years later, specialists cannot explain the shooting pains in his legs and feet. His lips still bleed unless he uses lip balm constantly.²⁸

In addition, isotretinoin can permanently damage the liver, which filters drugs out of the body. Isotretinoin can also cause the texture of a person's hair to change temporarily and lead to temporary hair loss. A patient who was being treated with Accutane describes her experience: "Accutane produced the worst break-out I had ever experienced, along with scalp dryness. With hair down to the middle of my back, I was sure the talk of possible hair loss would happen to me. I quit."²⁹

Isotretinoin and Psychiatric Problems

Isotretinoin has also been linked to psychiatric problems such as depression, violent behavior, and suicide attempts. Scientists do not know why a drug that targets the skin affects the brain. They theorize that isotretinoin may lower serotonin levels in the brain. Low levels of this brain chemical have been linked to depression, violence, and suicide. However, this link is controversial. It is unclear whether isotretinoin actually causes these problems or if the emotional impact of acne itself, combined with normal mood swings common to adolescents, is the cause. According to the Food and Drug Administration (FDA), a government agency that sets standards and regulations for the safe use of drugs, between 1982 and 2000, 147 people being treated with Accutane either committed suicide or were hospitalized for suicide attempts. The administration also reported one hundred violent acts committed by people taking Accutane in 2002. One such act involved an Accutane patient who flew a small airplane into a skyscraper in Tampa, Florida, in January 2002, damaging the building and killing himself.

The number of attempted and actual suicides among Accutane users, according to Hoffman-La Roche, the drug company that manufactures the drug, is comparatively lower than that for all U.S. citizens ages fifteen to twenty-four, the age group most likely to be treated with Accutane. But for individuals who experience psychiatric problems while taking isotretinoin and their families, the danger that the drug presents seems clearer. For instance, Accutane has been implicated in the 2002 suicide of a fourteen-year-old in Palo Alto, California, who jumped in front of a commuter train while being treated with the drug. It is also a possible factor in the 2000 suicide of Michigan congressman Bart Stupak's son. According to the congressman, "The side effects of Accutane are not worth it."³⁰ In fact, the congressman would like to see to the drug banned until further studies into its psychiatric effects are completed.

Although the drug has not been banned, due to these and other cases it is illegal for doctors to administer the drug until patients read a detailed medical guide, which describes the possible health risks that isotretinoin presents. The patient must then sign a consent form stating he or she is aware of the risks.

Isotretinoin and Birth Defects

Another health risk that female patients are warned about in the medical guide is the risk of damage to unborn babies. Because everything that enters an expectant mother's bloodstream also enters the fetus's bloodstream, when expectant mothers take isotretinoin, the drug's powerful effect can harm the developing fetus. According to the FDA, 35 percent of babies born to mothers treated with the drug during their pregnancies are born with birth defects. These defects include physical deformities, undeveloped organs, blindness, and mental retardation. Isotretinoin can also cause the death of the fetus before birth, premature births, or the death of the newborn baby.

For this reason, the FDA prohibits the dispensation of isotretinoin to pregnant women. In addition, female patients must take two pregnancy tests before the drug can be prescribed, and women are warned not to become pregnant while taking the drug. Therefore, birth control is mandatory for sexually active women taking isotretinoin, as are monthly pregnancy tests. In addition, women are warned not to become pregnant for at least one month after stopping use of isotretinoin, since it takes at least one month for the drug to clear a person's system. A fifteen-year-old who took Accutane recalls her experience: "My doctor asked me if there's any chance I was pregnant—right in front of my mother. It was embarrassing to go for the pregnancy test every month."³¹

Despite the controversy surrounding isotretinoin and the side effects and possible health risks of other acne treatments, it is clear that acne treatments can lessen acne symptoms and help people have smoother, clearer skin. "Sure there were health risks," a former acne patient explains. "But I still can remember the teasing, embarrassment, and humiliation the pimples caused. That was a hundred times more dangerous and painful than anything any medicine could possibly do to me. Getting treatment changed my life."³²