In a society where clean, smooth skin, free of blemishes, seems to be a prerequisite for social acceptance, acne can be a severe test of one's emotional stamina. It usually occurs during adolescence—precisely when increasing maturity is striving for expression, and appearance has assumed enormous importance. Young adults, particularly women, may also experience a distressing outbreak of acne where once there was none. (The abrupt onset of acne in middle age may be a symptom of an endocrine disorder that merits consultation with a physician.)

Although it is not a life-threatening disease and only occasionally results in disfiguring scars, acne often causes immeasurable mental anguish to those afflicted. Advertisers of skin preparations play on these anxieties in promoting their products. Some self-help products can indeed serve a useful function in acne care. But to understand why over-the-counter (OTC) medication is so problematical, one needs to understand the factors that lead to acne.

Understanding Acne

Acne (eruption of the face) vulgaris (common) is primarily a disorder of the so-called pilosebaceous units of certain areas of the skin. Each unit consists of a hair follicle—from which a hair shaft protrudes—and a sebaceous gland that secretes sebum (a whitish fatty substance) into the follicle and through the pores to the surface of the skin adjacent to the hair shaft. The normal follicle is lined with cells that age, die, and are easily extruded through the pores of the skin. In time, these cells are replaced by new cells and the cycle is repeated.

Acne is caused by an abnormality in this orderly process of cell extrusion and replacement. When the skin pore becomes blocked with cellular debris, sebum cannot escape through the blocked pore onto the skin surface. The primary lesions of acne that result are comedones (whiteheads): collections of dead cells, sebum, and bacteria that clog the shaft of the hair follicle. On exposure to air, comedones darken (blackheads).

Many dermatologists believe that, as the amount of sebum within the pilosebaceous unit increases, the follicle's normal bacteria release an enzyme that splits the sebum into smaller molecules called fatty acids. Acting as irritants, those fatty acids then cause disruption of the follicular wall—and additional lesions called papules and pustules appear. Papules are red, solid areas that protrude above the skin surface. Pustules are papules that extend deeper into the skin and contain pus. Most of us know these lesions as pimples.

The amount of sebum secreted varies widely in different areas of the skin. The most active sebaceous glands are located in the scalp, followed by the forehead, face, chest, and upper back. Except for the scalp, these areas are the most frequent sites of acne.

As part of the normal maturing process, the sebaceous glands at puberty increase in size and secrete more sebum under the influence of increasing amounts of sex hormones, principally the male hormone testosterone, present in both males and females. The increased sebum production, combined with obstruction of the pores by cellular debris, sets the stage for the development of acne. If the overactivity of the sebaceous glands or the plugging of the pores could be better controlled, acne might pose less of a problem.

Over-the-Counter Medications

Unless acne is severe, a visit to the doctor is not usually necessary. Only about one case in 10 deserves medical attention. Most mild or moderate cases of acne respond to effective OTC medication and to home care.

An assortment of OTC acne products crowds the marketplace. Besides the creams, cleansers, lotions, soaps, powders, and gels you might expect, you can also buy cleansing sticks, scrubs, medicated towelettes, tablets, and many other items. Except for cosmetic agents designed solely to camouflage the lesions, many of these products contain the same time-worn medicaments tried by physicians through the years in an attempt to manage this stubborn disorder.

An advisory panel that reviewed OTC acne remedies for the U.S. Food and Drug Administration (FDA) found four common ingredients to be of value. Of these, the most effective by far is benzoyl peroxide, which forms the basis of many OTC products (such as Benoxyl 10, Fostex, Loroxide, Noxzema Acne-12, Oxy-5, Oxy-10, Oxy-10 Wash, and Vanoxide). The other three ingredients, sulfur, sulfur/resorcinol combined, and salicylic acid, were found to be safe and effective only in mild cases. The rationale for each of these ingredients is their irritative effect by which they tend to unplug follicles. Avoid OTC products that do not list at least one of these active ingredients on the label.

Because people differ in the sensitivity of their skin and the severity of their acne, no single acne product is ideal for everyone. If your skin is sensitive and your acne mild, try a product with a 5 percent concentration of benzoyl peroxide. If your skin is not especially sensitive and your acne moderate, you might start with a 10 percent benzoyl peroxide formulation. If either product seems unsuitable—too weak or too harsh—switch accordingly.

Follow directions carefully. If your skin becomes overly dry and scaly—even with a mild product—stop applications for a while and also cut down on your use of soap.

Prescription Medications

Acne patients whose skin has not responded to OTC medications may decide to consult a physician. And certainly all those with severe cases of acne should seek help to prevent destruction of tissue and to minimize the possibility a permanent scarring. If you do need medical help for acne, first consult your family physician, who can then decide whether to treat your case or to refer you to a dermatologist. A doctor can prescribe medication specifically tailored to each patient's needs, with dosage and proportion of ingredients adjusted individually. Acne usually can be kept under control until the passage of time obviates the need for treatment.

The anti-acne arsenal available to physicians also includes the injection of corticosteroids into acne cysts, cryotherapy, dermabrasion, tissue elevation, and incision and drainage of pustules. However, none of these treatments can eliminate acne.

Antibiotics, in usual therapeutic doses, have long been prescribed by physicians to treat particularly severe cases of acne. In recent years, physicians have found that smaller doses of broad-spectrum antibiotics, administered daily for months or even years, have had a beneficial effect on many patients with moderate acne. This low-dose antibiotic therapy has been shown to reduce the concentration of free fatty acids that irritate the hair follicle. Researchers believe that antibiotics achieve this effect by decreasing the number of bacteria in the follicle, thereby limiting the amount of bacterial enzymes that split the sebum into fatty acids. Barring allergic reactions, side effects from such low-dose antibiotic therapy are generally minimal, with gastrointestinal upset the most common complaint.

Antibiotics in special lotion or gel form have been developed that are at least as effective as low-dose oral antibiotics against moderate acne. Available by prescription, this topical form of treatment does not cause the side effects sometimes seen with oral antibiotics.

For severe acne, dermatologists frequently administer benzoyl peroxide in a gel form together with antibiotics—either oral or topical.

Tretinoin (vitamin A acid, trade name Retin-A) was approved by the FDA in 1972 as a topical prescription preparation. Available in gel, cream, and liquid forms, tretinoin appears to be particularly useful in clearing the follicle opening, thereby reducing the number of acne lesions. However, patience is required. Skin irritation is common at first; the acne may even appear to worsen during the first six weeks of treatment, and improvement is rarely seen before three months. CU's medical consultants advise pregnant women to avoid using tretinoin.

Some people treated with tretinoin also experience a photosensitivity reaction (an intense reaction to sunlight resulting in skin reddening and painful blistering) as well as mild loss of skin pigment. People using this medication should minimize their exposure to the sun and stay under the continued supervision of a dermatologist. Tretinoin is sometimes given together with benzoyl peroxide for an additive effect: tretinoin by night and benzoyl peroxide by day.

Besides this topical use of vitamin A acid, some people have advocated taking large oral doses of vitamin A supplements. In true vitamin A deficiency—which is extremely rare—the skin and the mucous membrane, including the lining of the hair follicle, become thickened and tough. Since acne involves similar changes in the hair follicle, some physicians have reasoned that megadoses of vitamin A may prevent or cure the condition. In most cases, however, the treatment has been unsuccessful.

In one large study, college students with acne were given 100,000 units of vitamin A a day—about 20 times the recommended daily allowance. Slightly more than half of them showed some improvement—but so did half of a control group that received only a placebo. Taking vitamin A in doses greater than 50,000 units a day for several months can cause a range of side effects, including loss of body hair, itchy skin, enlargement of the liver and spleen, and increased pressure inside the head.

Large doses of estrogen, the female sex hormone, have been prescribed for potentially disfiguring acne in women. The hormone works by reducing sebaceous gland secretions. Such therapy, however, may stunt growth and is therefore inadvisable in a still-growing female. And estrogen has become an uncommon anti-acne strategy since the introduction of Accutane.

Accutane: Savior or Scourge?

In 1982, a synthetic relative of vitamin A, isotretinoin (Accutane), was approved by the FDA for the "treatment of severe, recalcitrant, cystic acne unresponsive to conventional therapy, including systemic antibiotics." Hailed by The Medical Letter as "the most effective treatment ever offered for acne"—a statement seconded by the American Academy of Dermatology—the drug produces dramatic, nearly complete clearing of acne lesions in more than 80 percent of patients. The improvement is often permanent after four to five months of treatment.

Taken orally by prescription, Accutane produces a number of temporary side effects, and its use requires careful supervision by a physician. Nearly all patients experience chapped lips and dry, itchy skin, and many develop eye irritation. Some may also suffer from muscle or joint pains, headache, fatigue, rash, or gastrointestinal symptoms. Many of these side effects can be relieved by topical lubricants or other drugs, and all disappear when treatment is stopped. Long-term effects have not been established.

But the most serious problems with Accutane are severe and often lethal birth defects in children born to women who become pregnant while taking the drug. (Accutane does not harm a woman's gametes—the sex cells that pass on hereditary material—so later pregnancies are not affected by prior use of the drug.) Accutane's manufacturer, Hoffmann-La Roche, deserves credit for having swiftly launched an extensive educational campaign notifying physicians, pharmacists, and patients (through brochures and leaflets) about the birth-defect potential. As a result, many physicians have required that female patients take pregnancy tests before beginning Accutane therapy, and urged them to employ at least one birth-control method during treatment and for one month before and after.

The message did not reach far enough. Between 1982 and 1986, the number of babies born with defects caused by the drug was anywhere from 62 to 1300—depending on whether you accept the manufacturer's estimates (based on actual reported cases) or the FDA's (based on extrapolation from that data).

In the spring of 1988, an expert advisory committee to the FDA recommended that distribution of Accutane be severely restricted to make it more difficult for young women to obtain. Soon thereafter the FDA instituted requirements that women sign a consent form before being given a prescription for Accutane, and that Hoffmann-La Roche print a warning picture of a deformed baby on Accutane packaging to help drive the message home.

In midsummer of the same year, the American Academy of Dermatology mailed new guidelines to its members. The academy said there were now 69 reported cases of Accutane-associated birth defects since 1982. The guidelines recommended that women taking Accutane test negative for pregnancy within two weeks of starting the drug, and that they use effective methods of contraception, with monthly blood pregnancy tests, throughout the therapy and for a month thereafter. Women intending to become pregnant should stop taking Accutane at least three months before conception.

Treating Acne Yourself

In self-treatment of acne, dermatologists recommend that the face be washed two or three times daily with soap and warm water, and rinsed thoroughly. There is no actual proof that face washing helps. But gentle scrubbing with a soapy washcloth does remove some oils, dead skin, and surface bacteria. It also produces minor irritation, which may be of some help in mild acne.

In any case, success does not depend on the type of soap used. Such heavily advertised cleansing products as Noxzema Medicated Skin Cream and Cuticura Medicated Soap are no more useful than a bar of plain soap. "Acne soaps" with sulfur are not particularly helpful because the medication is likely to wash away with rinsing.

While antibacterial soaps are indeed effective in reducing the number of skin surface bacteria, they are irrelevant for acne therapy. Although bacteria are the source of the enzymes that break down sebum into troublesome free fatty acids, these bacteria live beneath the skin's surface, deep in the follicles. They cannot be reached by the antibacterial ingredients in OTC cleansing products.

Of limited value for some people are abrasive soaps, such as Brasivol, which contain irritating granules. These products physically induce inflammation, and can be quite harsh to sensitive skin.

Many women, influenced by cosmetic advertising, have developed the habit of using face creams in place of soap and water for cleansing the face. This is not wise for people with acne, because greases and creams encourage plugging of the pores. So-called skin foods, skin tonics, lubricating creams, and vanishing creams should be avoided, too.

Even though the desire to cover up blemishes may be overwhelming, it's best not-to use any cosmetics. For those who can't resist, water-based products, applied lightly, are the least likely to cause problems. If the hair is naturally oily, it should be kept off the face. Hair dressings with a greasy or lanolin base should be avoided, even though acne lesions do not occur on the scalp. Long-term use of such products can cause "pomade acne," a clustering of blackheads on the forehead and temples.

One of the prime temptations with acne is to squeeze and pick at blackheads and plump pimples. Don't. Handling acne blemishes can lead to secondary infections, rupture of follicle walls, and eventually scars. (The extent of scarring in acne, however, is not directly related to the severity of the case. The scarring potential of the skin is the key factor.) Although there are dermatologists who approve of the home use of a blackhead extractor, we advise against it because of the possibility of skin damage.

Since products containing iodides or bromides sometimes exacerbate existing acne or produce eruptions that look like acne, patients are warned against them during acne treatment. Certain drugs, such as cough medicines, sedatives, cold preparations, and multivitamin/mineral combinations, may contain iodides. Some experts advise that since iodides also occur in iodized salt, saltwater fish, shellfish, spinach, cabbage, lettuce, and artichokes, these foods should be avoided during acne treatment.

Most authorities agree that any other type of dietary manipulation usually makes no difference in the severity of acne. With some people, however, it may seem that specific foods do aggravate the disease. The foods commonly suspected are sugar, nuts, chocolate, and fried foods. If any food seems to worsen the acne, try dropping that food from your diet and observe the effect (or lack of one). After a few weeks, reintroduce the food and again note the result. If the experiment convinces you that the food is culpable, try to avoid it. More likely you will find that changes in your diet make no difference and you can eat pretty much what you like.

If careful trial of OTC medications does not help, consult a physician. But know that control of acne may not come with the first round of professional treatment, either. It may help if you keep in mind that acne, which responds slowly to a physician's care, is likely to be even more stubborn with hit-or-miss self-medication. Take heart and have patience; in most cases, improvement can be achieved.

Luis Treacy

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