Got Acne? Get Answers!

Below you will find some of the most common questions regarding acne.

If acne is a bacterial problem why don’t the antibiotics my doctor prescribed work?
Acne is a complex disease which is multi factorial. It starts out with a family predisposition for the cells to impact in the pore. At puberty more oil is produced, causing more irritation in the pore, causing the cells to stick and form the acne impactions. The bacteria in the pore called Corynebacterium acnes (adamosis) live off the oil, producing irritating fatty acids. These can aggravate the acne problem; however other components of the skin oil called sebum also aggravate the pore. The simple use of antibiotics just takes care of one factor - reducing the bacteria. It doesn’t solve the problem of increased oil or the other irritating components of the sebum. The chronic long term use of the antibiotics only improves the acne complexion around 40% in some individuals. It is better to use a topical skin care program which peels out the acne impactions -- the core of the problem. Occasionally, an oral vitamin A or Accutane® is added to decrease the oil output

I have heard so many things about Accutane, how does Dr. Fulton decide to prescribe Accutane instead of using his topical formulations? Is age a consideration? Are the side effects of Accutane really harmful?
Accutane is a great drug for the improvement of acne, however because of its side effects it is somewhat used as a last resort. We usually start when the patients are 10, 11 and 12 years old with a topical skin care program. The use of the Benzoyl Peroxide Scrub, the Normalizing Tonic with the alpha hydroxy acids, and the vitamin A conditioning lotions is usually adequate to control the acne in the early stages. Later on, if the acne progresses and becomes more inflammatory, we will add the oral vitamin A called Micel A®. Finally, when the patient is older around 15, 16, and 17 years old, we will add Accutane if the problem has become very inflammatory and the patient is developing cysts and subsequent scarring. It is important once Accutane is started to take a correct dose, full course. Usually this is 40, 60 or 80 mg of Accutane taken daily for 20 weeks. The advantage of starting first with the topical skin care is there is less opportunity for the Accutane to cause a flare-up of acne in the early stages of its use. Also as the patient grows older there is less chance for Accutane to slow down the growth and ultimate height of the patient. The side effects, considering the benefits, are minimal. There is dry skin, dry lips, dry mucous membranes, occasionally if a person has migraines they are slightly worse or if they have arthritis there may be a flare-up, and if the person suffers from chronic fatigue and depression it may aggravate this situation. The only real significant side effect is birth defects if the female patient becomes pregnant while using Accutane, so birth control methods are required while taking Accutane. As soon as Accutane is done, it is eliminated from the system within 30 days and the patient can become pregnant -- there are no problems with the previous exposure to Accutane.

I am using Retin-A® but I do not seem to clear up.
When I developed Retin-A in 1969, it was quite an irritating formula. The more the skin peeled, the better the acne would respond. However, during this peeling phase all the acne impactions are coming out so there may be an appearance of flare-up of the acne condition as all of the impactions are being evacuated. Once all the pores are clear, the acne is under control and not visible. Also, if a patient is considering Retin-A, they should use the Retin-A gel and not the Retin-A cream. The Retin-A cream contains isopropyl myristate, which is an aggravator of the acne conditions and sometimes patients will get worse because of the formulation of the Retin-A cream. There are also new formulations of the Retin-A on the market, such as Micro Retin-A that are better formulated creams than the previous product. The key is to keep the skin visibly peeling in order to get a rapid clear-up. If there is no peeling whatsoever, your particular formulation is not working very effectively on your skin. You should see at least a little peel once a week to know you are at the right therapeutic level. Also, you may need to work with your physician or aesthetician during this early phase to help extract out all the acne impactions that are coming to the surfacing. This will lead to a more rapid resolution of the problem.

My doctor put me on topical medication but I am not clearing up. Is it time for me to go to an antibiotic or to Accutane?
The evolution of the acne treatment program is continual. We start with a mild topical skin care program. If the skin is not peeling, we go to a more aggressive skin care program and, finally, consider using an oral vitamin A such as Micel A or oral Accutane. As antibiotics don’t usually improve the acne situation dramatically, we only use them on a limited basis. If someone is quite inflammatory with many pustules antibiotics will occasionally cause an improvement. If a patient comes into the office already on antibiotics and believes they are improving the situation we will continue them. However, for many patients the antibiotics are no better than placebo, so we don’t jump to their use very rapidly. However, if the skin care program is being done in a meaningful way and the patient is still developing cysts, we will add Accutane provided the patient is not attempting to become pregnant at the time.

I am 20 years old, why do I have more acne on my back and chest than on my face?
As the patient grows older the acne migrates across the face like a wave and moves on to the back and chest. Sometimes with severe acne the problem will go down the shoulder and onto the buttock. Acne of the back and chest is more difficult to treat because the pores are deeper. The skin care program needs to be aggressive and to cause some peeling. Often we will use the combination of vitamin A skin conditioner in the morning and a 5 or 10% benzoyl peroxide gel at night. Sometimes we use a combination treatment if peeling is not apparent - at night we put on the vitamin A preparation, ten minutes later we put the benzoyl peroxide gel on top, let the conditioners dry and, then, wear an old white t-shirt to bed. The use of this combination will make the skin peel and as the impactions come to the surface they can be extracted and removed. If the skin is kept peeling it will usually stop the acne problem from progressing.

I am a long distance runner, football player, etc. … and exercise seems to aggravate my acne.
Acne is made worse with stress and severe competitive sports such as football can be a stress to flare up the problem. Also, with football there is a chin strap and shoulder pads which cause mechanical acne of the pores. Unfortunately, acne often flares in the fall which is also football time. These factors can lead to a major fall flare-up. The patient may need to discontinue sports or go to a milder sport such as swimming. Remember that the acne on the back and chest is more difficult to treat and needs often combination treatment with vitamin A and benzoyl peroxide 10% gel. Some peeling and some very good extraction done by a trained aesthetician, physician or parent is helpful.

I think that exercise is controlling my acne but nothing else seems to help.
Sometimes mild daily aerobic exercise burns off stress and will help any medical condition that is aggravated by stress, such as acne. Physicians have also now found exercise it useful for diabetes, heart disease and any other chronic condition that is benefited by stress reduction. However, in addition to stress reduction the patient often needs a topical skin care program, progressing into an internal skin care program such as the oral vitamin A to improve the situation.

I am 16 and taking Zoloft® for depression. Can I take Accutane and Zoloft?
Accutane does not interact with many other drugs, except things that damage your liver such as alcohol. Accutane can be taken with almost every drug. However, Accutane or any type of vitamin A therapy can cause a feeling of depression and fatigue. If one is suffering from chronic depression it may not be good to take Accutane until the depression is improved or controlled, so during the Accutane treatment an index of depression can be observed. If a person becomes too depressed they should consider stopping Accutane until they can get their life improved. There have been some suicides linked to Accutane so those people who are contemplating suicide are not good candidates for Accutane.

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My acne clears up when I am on Accutane but comes back as soon as I am off my prescription. What can I do?
Normally, after a course of 20 weeks on Accutane at the right dose, the acne is improved and quite commonly cured. However, there are patients that have remissions but usually their remission is not as bad as their initial acne problem before Accutane. The second or third course of Accutane can be taken to lead to further improvement of the acne. However, it is important to combine the use of Accutane with a good topical skin care program -- such as Acne Kit I or Acne Kit II -- to lead to further improvement of the acne. If one begins with the topical treatment first, then adds Accutane, there are less chance of flare-ups while taking Accutane. If the topical skin care program is re-instituted when Accutane is discontinued, there is less chance of a flare-up after Accutane is completed. So, in short, we recommend some topical treatment to go along with Accutane to level out the effects and lead to a more long-term improvement.

I am 49 and have bad acne. I did not have acne as a teenager, now I can’t get rid of it.
Acne normally starts at 12, gets worse at 16, and is outgrown around 23. That is the typical male pattern course. Women often start acne earlier, are often not as bad during the teenage years but continues to flare on beyond the 20s. My mother was still breaking out at 62. So acne can smolder on into the 20s, 30s and 40s and the treatment is still the same -- the acne impactions need to be evacuated with a good topical skin care program such as Acne Kit I or Acne Kit II. In the older woman the acne is often inflammatory papules and cysts, so the ice compresses are really important. They should use the Benzoyl Peroxide Scrub, the ice compresses, and their topical Normalizing Tonic and vitamin A conditioning lotions to maintain a little peel at least once a week.

I have tried your medication but it burns. Was told I have rosacea. Is there any mild medication I can use?
Acne rosacea is a combination of acne, usually in the older adult, combined with a skin rash. This makes a red cheek with acne in the middle. The red irritated rash does not respond well to the aggressive teenage acne program. Initially the acne must be calmed down with a combination of our Vivant Metro A during the day, combined with Alocort during the night. Usually the patient can use the Benzoyl Peroxide Wash, the ice compresses and Metro A during the day, the Benzoyl Peroxide Wash, the ice compresses and the Alocort at night. This usually calms down the rash component of the acne rosacea, then later on when the acne rosacea has improved and the rash component has disappeared a more aggressive program incorporating Derm-A-gel or Exfol-A can be slowly re-established. However, when there is a rash you must progress very slowly and take several weeks more to up the ladder of skin care. Occasionally even the Metro A is too irritating and we have to resort to a program using a commercial product called Noridate®. Noridate is a soothing lotion that can be used on acne rosacea and the antibacterial in the product improves the acne component. The patient may start on the Noridate, progress to the Metro A and finally to the Derm-A-gel or Exfol-A. Just remember with a rash go slowly, slowly, slowly.

Is rosacea a different acne than the teenage acne?
It certainly is. Teenage acne of course occurs in the teenage period, mostly of papules and pustules. Later in life, in the 40s and 50s, you may get papules and pustules on the cheeks associated with dilated blood vessels and a red rash. This acne rosacea is a more sensitive acne to treat and requires a slow progression of skin care products as discussed in question 11. We usually start with Benzoyl Peroxide Wash, and apply the Metro A during the day; then Benzoyl Peroxide Wash and Alocort at night. Then we progress on to Acne Kit I, and finally Acne Kit II if necessary. But as mentioned in question 11 you need to progress slowly.

My acne was clear when I was on birth control pills but now it has flared again.
The difficulty with birth control pills is similar to a pregnancy -- the first trimester, or the first 2 months of the pregnancy, or the first 2 months on the birth control pill the acne may flare up. The last trimester, or the 5th and 6th month of the birth control pill, the acne may improve because the estrogens have become dominant. However, 90 days after the pregnancy or 90 days after the birth control pill is stopped the acne may flare up again the same as it was before the birth control pills or even worse. The difficulty with birth control pills and acne is it is a temporary solution that doesn’t stop the acne, just creates a window and a hiatus of the acne that may flare again, often when the birth control pills are discontinued. With that in mind it is good to use a topical skin care program along with the birth control pills, and to speed up the topical skin care program when you discontinue the birth control pills, then continue on for several months with the skin care program to make sure there is no flare-up of the acne.

For parents who are worried about the effects of putting their teenagers with acne on birth control pills:
I would have no difficulty using birth controls pills for acne if they were highly effective. However, in some cases the acne is aggravated with the birth control pills, sometimes cases are improved, and some cases the acne flares up when the birth control pills are discontinued. If significant acne is developing I prefer to put the patient on Accutane rather than birth control pills.

When do you use Accutane?
Accutane is a great therapeutic agent for the treatment of bad cystic, scarring acne. I like to begin the treatment with a topical skin care program, especially when the acne sufferer is 12 and 13 years of age. I will use the topical skin care .program, then later on consider the Micel A, the oral vitamin A therapy. And finally when the patient is 15, 16 or 17 seriously consider Accutane if the patient is developing cystic, scarring acne. Then the patient should be put on 1.0 mg of Accutane per kilo of body weight for the full 20 week Accutane treatment course. A lesser dosage for less length of time may give initial improvement but the recurrence rate is higher than the full therapeutic dose for 20 weeks.

When do I use birth control pills?
I do not routinely use birth control pills for the treatment of acne because as we mentioned previously it can be a temporary improvement but when the birth control pill is discontinued the patient can have a flare-up. Sometimes the flare-up is worse than the acne was before the treatment with birth control pills. If a patient is on birth control pills, I will attempt to add on a topical skin care program, especially if they are considering discontinuing the birth control pills. So when they discontinue the birth control pills, they can really push the topical skin care program to keep all the pores clear and prevent flare-ups.

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