ACNE VULGARIS
James E. Fulton Jr., M.D., Ph.D.
November 3, 1998

ABSTRACT
This article discusses acne pathogenesis and treatments, emphasizing its genetic background. An effort is made to bury the acne myths and discuss the actual aggravating factors. The old treatments are reviewed, but the emphasis is on newer treatments, such as benzoyl peroxide scrub cleansers, the alpha hydroxy normalizing tonics and the vitamin A conditioning lotions. The use of isotretinoin in severe cases is reviewed. There is an emphasis on how the regime is actually done on a daily basis. The improvement of acne scars is outlined. Hopefully, this information will help improve acne health care around the world.

BACKGROUND
Acne is a chronic disease of teenagers and young adults. There are many aggravating factors, but it is basically a genetic problem brought out by hormones. Neonatal acne can begin at birth from the stimulus of mother’s hormones. The problem is more prevalent in the male infants because of the testosterone produced by the male testes in uterus. The acne that develops right after birth begins on the nose, migrates across the cheeks and onto the jaw line, but usually disappears by six months of age. As there is a rapid reduction in stimulating maternal hormones and, consequently, the level of testosterone in the infant. This problem will return again in males during the teenage years. Although, the female children may have a similar problem, it usually is less severe but tends to be more chronic. Just as with the neonates, teenage acne begins on the center of the face at ten years of age, then migrates out onto the cheeks at fifteen years of age and across to the jaw line at eighteen years of age. The wave moves as the sebaceous glands mature across the face.

The level of oil production and the bacteria content of the pores are only background factors. Most important is the predisposition for the dead cells of the follicular lining to sludge up and impact. These impactions become larger and larger, developing into visible closed comedones. These may become inflammatory and develop into papules, pustules and scars. Older treatments, such as dietary restrictions, sunlight and systemic antibiotics have only been of limited benefit. The modern therapies usually consist of an aggressive topical skin care regime, consisting of vitamin A and glycolic acid conditioning lotions. If the complexion does not respond to this daily treatment, mechanical extractions and isotretinoin may be added to the regime. As the patient completes their 20-week therapeutic course of isotretinoin, their problem may go into remission. However, many patients develop facial scarring. We use the laser-assisted chemabrasion to smooth out this complexion. However, it is more helpful to begin the skin care program early and avoid both the physical and mental scarring.

ITS CAUSES
Acne is genetic. It is inherited as an autosomal dominant gene. If both parents are afflicted, three out of four of the children may have the complexion problem. We believe the gene came from a Mediterranean pool and was spread around the world by the early Spanish conquistadors. When the Spanish came into the Philippines and intermarried, acne became an epidemic problem of the islands. When the Spanish went to Mexico, they lost the war. Wherever they had penetrated; for example, Mexico City, there is a cystic acne problem. Further into the country where there are more Indians, there is less acne. This Mediterranean gene is particularly troublesome, as it may lead to the type IV cystic acne problems.

Although acne was originally believed to be related to the level of oil or sebum production in the skin or the level of bacteria in the pores of the skin, these turned out only to be aggravating factors. A certain level of oil production is necessary to support the colonization of the pore by the bacteria, called Propionibacterium acnes. These bacteria release a lipase and live off the triglyceride in surface oil called sebum, producing free fatty acids as a byproduct and using the glycerol from the triglyceride as carbon source. The free fatty acids may aggravate the lining of the pore and, in genetically predisposed individuals, the cells that line the pore begin to sludge up, stick and develop into microcomedones. These lesions finally become visible as open and closed comedones. Or, if there is an inflammatory response, these lesions develop into inflamed papules or pustules. The dermatologists have separated this phenomenon into Grade I (blackheads or open comedones); Grade II (whiteheads or closed comedones); Grade III (inflammatory papules or pustules); or Grade IV (large nodules or cysts) (Figs. 1-4). Not only is acne inherited, but the type of acne or the location on the face, back or chest, also is genetically predisposed. For example, if mother only had acne of the back, usually, the son will have the same pattern.

Although the level of oil or sebum production is important, it is not an absolute causative factor. There are many people with oily skin without acne and some with rather dry complexions with severe acne. However, the oil does provide the nutrients for the bacteria. As these bacteria populate the pore, they produce irritating fatty acids. However, there are other components of sebum, such as the wax esters, which are also irritating to the pore. This process of cellular reactions has been called retention hyperkeratosis (1). The epithelium that lines these pores produces cells at a rapid rate and the cells stick. Acne develops.

These bacteria maintain the "acid mantle" of skin. Their lipase operates down to pH 5.2. This explains why the pH of skin on the face is 5.2. This pH barrier protects the skin from other contaminants, such streptococci and staphylococci. In healthy skin, these bacteria cannot enter into the flora of the pore. However, the use of systemic antibiotics, such as tetracycline or topical hexachlorophene soap, such as Phisohex Ò soap or the combination of the two can destroy this normal relationship and lead to peculiar gram-negative bacterial infections or the gram-positive folliculitis from the Streptococci and Staphylococci (2).

As we mentioned, acne begins on the nose. As these are the pores that are the most susceptible to testosterone, they mature first. The acne process destroys the susceptible pores, and, as other pores mature on the cheek and jaw line, these pores that are genetically defective become impacted and are then destroyed. So, acne comes across the face like a fire and, then, burns out (Fig. 5). Once the fire has reached approximately one inch below the jaw line, it stops because the pores on the neck are not susceptible to testosterone. However, acne can jump onto the back and chest and be a problem for those areas down to the belt line and, occasionally, across the buttocks.

In summary, acne is genetic and runs in certain families. The treatment is best done topically to prevent the cells from sludging up and becoming impacted. Treatments which attack the secondary problems of acne, such as the oil production with birth control pills or the bacteria with systemic antibiotics only lead to temporary marginal improvement. Isotretinoin treatments can produce more long-term remissions.

THE MYTHS

Dirty Skin
One of the most common myths is that acne is related to dirty skin. The comedones, as they come to the surface and dilate the pore, develop into open lesions that become black. They darken for two reasons: 1) the oxidation of the oil and 2) the build-up of the melanin from the melanocytes that live in the orifice of the pore. These are deep-rooted impactions that cannot be simply washed away.

The acne is coming up from below and is not related to dirty skin. Even if you wash your face 20 times a day, you cannot remove these impacted lesions easily. The only cleanser that is useful is a benzoyl peroxide scrub cleanser. The benzoyl peroxide diffuses down the pore, kills the bacteria and additionally irritates the cells of the pore so they will no longer stick. This treatment program can be combined with alphahydroxy acid conditioning lotions and vitamin A gels to loosen up the impacted pores. In summary, the problem is not due to dirty skin.

Dietary Factors
Another favorite myth is the dietary factors. Doctors at the University of Pennsylvania fed 50 teenagers a pound of chocolate a day (3). Two got better, two got worse and the rest stayed the same. Ever since then, the dietary factors have not been discussed as a major event. Basically, acne is genetic and doesn’t make a lot of difference what you eat. The one exception is dietary iodides (4). Excessive iodides are excreted out through the oil gland and may flare up the acne impactions. Experimentally, when acne sufferers ingest a saturated solution of potassium iodine (15 drops twice a day) they will secrete iodide into the sebum in about ten days and their existing acne impactions may flare in about two weeks.

This excessive iodide becomes important in three scenarios: 1) Dietary supplements, such as mineral and vitamin pills that contain elemental iodide. Excessive doses can be excreted out through the oil glands and flare up acne. 2) Some diet programs emphasize seaweed and some religious cults sprinkle dried seaweed on all of their food. Certain seaweeds concentrate iodide and this heavy load of iodide can be excreted out through the oil glands and irritate the follicles. 3) Some drinking water is high in iodide and can aggravate the problem. This is especially true in island cultures where the water is desalinated and, then, some seawater is added back to the water to make it a little tastier. This combination may have a high iodide level that can lead to acne flare-ups. However, the usual dietary intake from fish or continental water is not enough to aggravate the complexion in most individuals.

Sexual Flustrations
The community may feel that acne is aggravated by sexual flustrations. This is related to couples marrying around age 22. The acne often soon disappears. However, it is not related to the marriage, it is just that acne tends to burn out around age 23. However, the marriage scenario can also aggravate acne or, in the case of the female, the use of birth control pills can aggravate acne during the first several months of use. This may be an aggravating problem during the early months of marriage.

In conclusion, these myths may have a grain of truth. Like hair on the forehead may contain hair conditioners aggravating acne, or dietary factors such as iodide or the flare up of acne from birth control pills. However, it is important to bury these myths and realize that acne is basically genetic, runs in certain families and the treatment usually can be done with a topical skin care program.

ACNE AGGRAVATING FACTORS

Stress
One of the key aggravating factors is stress. There are two types of stress involved. For example, the acute stress of school examinations causing existing impactions to break down, becoming inflammatory and developing red nodules and pustules. These are existing comedones that flare up. With an aggressive skin care program and removal of all the impactions, these flare-ups will disappear.

The other type is chronic stress. This is more difficult to manage. An impending divorce or loss of a family member may lead to chronic stress. This increases the hormone levels, causes more oil to be produced, more cells to impact and aggravates the complexion problems in genetically predisposed individuals (fig 6). These stress problems are usually red inflammatory nodules of the chin and respond to ice compresses, topical skin care programs and removal of the stress. Sometimes, low doses of a steroid such as prednisone, 5 mgs. or dexamethosone, 4 mgs. taken orally for several weeks may help reduce this stress-hormone cycle.

Hormones - Birth Control Pills
Usually, during a pregnancy, the acne is aggravated in the first trimester, improved in the last trimester, and then, flares again 90 days after birth. The same happens with birth control pills. During the first two or three months the acne may get worse. After six months, however, the complexion may be improved. However, it is a double-edged sword because five years later, or whenever the birth control pills are discontinued, the acne may flare up again, similar to the flare ups seen ninety days after a pregnancy. Because of this, we do not rely on birth control pills as our main therapeutic regime, as a topical skin care program is effective, especially when combined with isotretinoin. Some birth control pills are more aggravating than others are. The progestin dominant pills, such as Ovral and Lo Ovral, may flare up acne. The more estrogen dominant pills, such as Ortho-novum 777, Demulen and Ortho-TriCyclen usually improve acne until they are discontinued. Then, ninety days later, there maybe a flare-up that can last for years.

Cosmetics
The patient's favorite cosmetic can be destroying their skin. Cosmetics may contain irritating oils. The big offenders are isopropyl myristate, acetylated lanolin and certain D&C red dyes. The isopropyl myristate is put into cosmetics and skin care products as an emulsifier. It is a cousin of the fatty acids found in your own skin. The myristic acid is a C-14 fatty acid (fourteen carbon segments long), and when it is hooked to isopropyl (three carbon lengths long) it becomes isopropyl myristate. It is more soluble than the fatty acid itself and can go down the pore to cause a problem. Lanolins, by themselves, are too non-polar to be much of a problem. However, the cosmetic chemists like to make them more water-soluble by adding acetate, making acetylated lanolin. These more water-soluble lanolins can penetrate the pore and cause an aggravation. Certain D&C red dyes are coal tar derivatives and when solubilized in cream rouges, can penetrate into the pore and can cause comedonal type II acne in the cheek area where the rouge is applied. It is best to use a water-based make-up or pressed powder that doesn’t contain these aggravating factors (fig 6).

Drugs
Some drugs can flare up the acne complexion. The most significant are some drugs that effect the brain. These seem to increase the oil production. The classic example is hydantoin. When taken, the collagenase in the body is inhibited and collagen builds up. The gums become hypertrophied and the face swells up and the pores become blocked. Some patients can be taken off hydantoin and not have future difficulty with epilepsy. Others need to maintain the hydantoin, perhaps at a decreased dosage, and accelerate their skin care program to clean the complexion.

Another drug that causes difficulties is lithium and adamosis. It affects the brain and causes an acne flare up. The exact mechanisms are unclear. Other drugs, such as steroids, can sensitize the pores to acne. The chronic use of prednisone for inflammatory conditions can lead to the development of the moon faces, a buffalo hump and an acne flare up. Topical steroids, such as the synthetic potent fluorinated steroids, can also aggravate the complexion. Steroids should be avoided in those that are acne prone.

Sunlight
Some complexions are better in the sunlight, some are worse. There is a condition in Europe called Majorca Acne, named after the island of Majorca. The Germans and the English go down to the islands for a couple of weeks and have intensive sun exposure. When they return to their homeland, they are broken out with inflammatory papules and nodules, usually of the chest and back area. The sunlight irritates the pore, similar to the fatty acids and causes a flare up in some individuals. A good exfoliating skin care program that causes the skin to peel will release these impactions and clear up the problem.

Excoriation
Picking is a problem in some individuals. Some people have minor acne and bad fingernails. Almost everybody picks, but some people pick pathologically. When they begin to feel "worms" or "mites" in the skin, they are beyond the realm of the usual picker. We recommend ice compresses to reduce the inflammation and no fingernails. Some patients need to break this obsessive-compulsive cycle. We recommend Prozac 2.0, 40 or 60 mgs. daily. The fingernails can also carry bacteria and cause infections, such as impetigo. We authorize "controlled" picking after we have explained to the patient how to do the acne extractions. If they live a far distance from the clinic, they, or a family member, can learn how to do their own extractions very gently after the skin care program has loosened up the impactions.

Hormones
The main aggravating factor continues to be hormones. There is no good control for the oil production, except isotretinoin, which will temporarily reduce the oil level. Interestingly enough, after isotretinoin is discontinued, the oil production may go back up, but the acne complexion may stay clear. Of course, another therapeutic approach to oil control is castration of the testes, but there are not too many volunteers for this program.

OLD TREATMENTS
Over the years, many treatments have been tried for acne. In the 1940’s, the new synthetic vitamin A was the rage. However, the usual dose of oral vitamin A to control acne was several hundred thousand units daily. This chronic use led to vitamin A toxicity, which consisted of hair loss, headaches, arthralgias and depression. The program never became very useful. When Doctors Kligman, Plewig and Fulton developed vitamin A acid, it was a topical alternative; it did not cause toxicity and became a major therapeutic breakthrough (5). More on that later. More recently the use of a modified molecule of vitamin A called isotretinoin has become popular as a systemic treatment. This compound is effective in reducing the oil production. It is used for four or five months. There are still the same side effects of vitamin A, such as hair loss, migraine headaches, dry skin, arthralgias and depression. However, isotretinoin is quite useful if the patient is having chronic severe cystic acne with the development of life long scarring.

Tetracycline
Tetracycline became a major treatment agent in the 1950’s and 1960’s. Systemic tetracycline would diffuse into the pore and inhibit the Propionibacterium acnes. However, this antibiotic only inhibited about 50% of the bacteria and reduced the fatty acids about 40%. The remaining residual bacteria and fatty acids were enough to continue on with the acne problem in most patients. In a few patients, the tetracycline was really dramatic, but in most, it was hardly better than a placebo (7).

One lipid soluble tetracycline called minocycline still remains popular today. This is the one antibiotic that occasionally does help in pustular acne. However, by the time the patients come into the office, they have often received several tetracyclines including minocycline, so we have found the topical skin care program more effective. However, if the patient comes in on minocycline and feels they are improved, we will leave them on the antibiotic for several weeks until they have acclimated to the topical skin care program.

Acne Extractions
Acne extractions have always been popular in the dermatologist and esthetician office. This, combined with a good skin care program that releases the acne impactions and makes the extractions easy, can be therapeutic. However, if no topical treatment is being done and the acne impactions are very tight, the lesion can be forced deeper and cause a flare up of inflammatory acne. Thus, it is necessary to use a topical treatment first and extract later. Many of our patients live a long way from the office and we will teach them authorized extraction and how to remove these lesions gently (Fig. 7). Extraction continues to be an effective treatment when combined with the skin care program.

X-Ray Treatments
In the early days of acne therapeutics, x-ray became a mainstay. The early machines were not well calibrated and the acne patient often received a burn from the x-ray. Unfortunately, later in life, this led to the development of atrophy of the skin, thyroid nodules or epilepsy. Unfortunately, the treatment did not work and the acne continued on. This treatment is no longer in vogue today.

NEWER TREATMENTS
In 1969, doctors at the University of Pennsylvania developed vitamin A acid for the topical treatment of acne (5). This therapeutic agent was developed by Johnson and Johnson and became tretinoin or Retin A Ò. It was a major breakthrough in the topical treatment of acne. The use of the vitamin A caused the skin to peel and this released the acne impactions. Sometimes the acne would get worse before it got better as the pores were all evacuated. It was helpful to combine this treatment with effective acne extractions to remove the impactions once they had been loosened up.

Benzoyl Peroxide
In 1972, doctors at the University of Miami developed the gels of benzoyl peroxide (7). The benzyl molecule pulled the peroxide into the pore where it released free radical oxygen that killed the bacteria and opened up the acne impactions. This has become a mainstay of treatment, not only in the doctors' office, but also in the esthetician office and in the drug store. The combination of vitamin A in the morning and benzoyl peroxide at night became quite an active therapeutic program. This cleared the complexion in about two months. The birth of an effective topical treatment was accomplished.

Alpha Hydroxy Acids
Dr. Van Scott's research on the alpha hydroxy acids was another breakthrough (8). The alpha hydroxy acids, such as glycolic acid or lactic acid worked differently than tretinoin. These acids dissolved the attachment plaques between cells and caused the dead cells to fall off rapidly. This generated new skin cells from below that did not stick. The combination of benzoyl peroxide scrub cleanser combined with a normalizing tonic of alphahydroxy acids and the application of a vitamin A lotion is currently the treatment of choice for topical therapy for acne at our Institute.

Isotretinoin (Accutane®)
In 1979, isotretinoin became available for the systemic use in the treatment of acne (9). When ingested orally over a five-month period, the oil glands shrunk, the oil sebum level fell and the acne cleared up. Interestingly, the acne stayed clear on many individuals after the drug use was discontinued and the oil production resumed. The reason for this is unknown. Isotretinoin is still the major treatment for severe cystic acne.

HOW WE REALLY DO IT
At the Fulton Skin Institute, we take photographs of the patient and determine if they have dry or oily skin. We count all the lesions on the face to document the complexion problem. Then, we put the patients on a skin care program depending on whether they have dry or oily skin and also whether they live in a dry or wet humid climate. If they have dry skin and a dry climate, they will use the Acne Kit I, which starts with benzoyl peroxide wash cleanser. This goes down to the pore and kills the bacteria. After that, they will do their ice compresses to reduce the redness and swelling and to open up the skin to let the medicine penetrate in. Following that, they will apply their normalizing tonic using a cotton ball to strip off all the dead skin cells. This contains glycolic acid that dissolves the attachment plaques between the cells. Finally, they will apply their vitamin A conditioning lotion, which is a vitamin A proprionate formula (10). The short chain proprionate on the vitamin A is metabolized off as it penetrates through the skin. The molecule is converted to vitamin A acid (11). They will repeat the benzoyl peroxide cleanser, the ice compresses, normalizing tonic and the vitamin A conditioning in the evening.

If they have oily skin, we will upgrade their product to use the stronger formulations. They will use the benzoyl peroxide scrub cleanser that has granules to strip off the dead skin cells and open up the acne impactions. After the ice compresses, they will apply the normalizing tonic forte, which is a stronger formulation of the alphahydroxy acid. They will then apply a lotion containing the combination of the glycolic acid and the vitamin A proprionate. When these two compounds are combined together, they produce a product that is more potent than either one alone. Again, they will repeat the application at night.

Quite often after seven to ten days, the patients will develop an irritating dry rash, called Retinoid Dermatitis. This is the dry skin that develops as the patients become used to the product. Once they are hardened or acclimated to the product line, then they can continue on without getting too dry. We often recommend they skip a day or two around day seven, eight or nine and apply a non-acneogenic moisturizer.

After they have been on the products for four to six weeks, the acne impactions will begin coming to the surface and exfoliating spontaneously or they can be easily extracted during an acne facial. The patients will continue on the products, increasing their strength, if necessary, to maintain a slight peel. If their acne clears, fine. If they still have a cystic tendency, they will then consider isotretinoin (approximately one milligram per kilo taken daily for 20 weeks). Sometimes, it is necessary to reduce their topical skin care products while using isotretinoin because of the dryness from the systemic vitamin A. Later on, after the isotretinoin, they will continue with their skin care program to maintain their clear complexion.

Medical Facials or Acne Extractions
Every two weeks, the patients will have a medical facial to extract the acne lesions and also, use the closed circuit microdermabrader which uses aluminum oxide crystals to abrade the skin and open up the acne impactions (MegaPeel; DermaMed, Inc., Media, PA). The use of this abrator has benefited our patients to loosen up the acne impactions and make the extractions easier.

Usually by eight to ten weeks, the complexion is clear. The patients will then continue on their products as needed to keep a clear complexion (Figs. 8-11). 

ACNE SCARS
Some patients come to us too late; they already have facial scarring. Acne, by itself, dissolves the tissue by activating the skin and leukocyte collagenase. The collagenase dissolves the collagen, and as the lesion heals, there is a depression. The only effective method to remove these is diamond disc abrasion. Now, we combine this sanding with the CO2 laser resurfacing. We do a chemical peel of the neck, laser of the face and then do the dermasanding with the extra course abrader after the laser resurfacing (12). The key to our success is the use of an occlusive dressing for five days following the procedure (Silon TSR, Biomed Sciences, Bethlehem, Pennsylvania). After the five days of this silicone gel sheeting dressing, the patients are switched to a petrolatum-based ointment for another five days. Finally, after ten days, they begin to use their moisturizers with sunscreen. At day 17 or 18, they will begin using the bleaching cream regime if they are darkly complected. Usually, by two months, their skin is able to tolerate the acne control regime again (Figs. 12-13).

CONCLUSION
By understanding the pathogenesis and treatment of acne, it is possible to devise a topical skin care program using a benzoyl peroxide scrub cleanser to kill the Propionibacterium acnes, a normalizing tonic containing glycolic acid to dissolve the attachments between skin cells and vitamin A gels to generate new cells that do not adhere and sludge up the pores. Usually in two weeks, the problem is improved and by eight to ten weeks, the complexion is clear. Medical facials are combined with the skin care program to extract lesions as they migrate to the surface. An occasional severe patient will also receive systemic isotretinoin for twenty weeks. If they have facial scarring, a laser-assisted chemabrasion completes their rejuvenation. With this combination, we have improved the acne problem.

REFERENCES
1. Plewig G, Fulton JE Jr., and Kligman AM. Cellular dynamics of comedo formation in acne vulgaris. Arch Dermatol Forsch 1971 242: 12-29.
2. Fulton, JE Jr., McGinley K, Leyden J, and Marples R. Gram-negative folliculitis in acne vulgaris. Arch Dermatol 98:349-353, 1968
3. Fulton, JE Jr., Plewig G, and Kligman AM. Effect of chocolate on acne vulgaris.JAMA 210:2071-2074, 1969
4. Fulton, JE Jr., MD, Ph.D. and Black E. Dr. Fulton’s Step-by-Step Program for Clearing Acne, Harper & Rowe, New York. 1983 P. 75-82.
5. Kligman AM, Fulton, JE Jr., Plewig G Topical Vitamin A Acid in Acne Vulgaris. Arch Dermatol 99:469-476, 1969.
6. Plewig G, Fulton JE Jr., and Kligman AM. Pomade Acne. Arch Dermatol 101:580-584, 1970.
7. Fulton, JE Jr., and Shenk A. Benzoyl peroxide topical therapy. Acne Update for the Practitioner (S.B. Franks, Ed.). York Medical Books, 1979 pp. 141-147.
8. Van Scott EJ, Yu RJ, Hyperkeratinization and Alphahydroxy Acids. J Am Acad Dermatol 1984, 5:867-879.
9. Peck GL, Olsen TG, Yoder FW, et al. Prolonged remissions of cystic and conglobate acne with 13-cis retinoic acid. New Engl J Med 1979; 300:329-333.
10, 11. Fulton U.S. Patent #5,043,356
12. Fulton, JE Jr., and Silverton K, Resurfacing the Acne-Scarred Face Dermatol Surg 1999;25:353-359

FIGURES (not shown here)
Figure 1. Acne Grade I. The development of open comedones in an older teenager is a good prognosis. It means that their pores are handling the problem rather well and have a chance to mature, dilate and develop into open comedones. However, if this is in a younger teenager and the older brother has cystic acne, it maybe a sign of bad things coming in the future.

Figure 2. Acne Grade II. The most difficult type of acne to treat is this myriad of closed comedones that develop in Acne Grade II type. There are often three hundred of these impacted pores on the face. They need a very irritating skin care program of using glycolic acid and vitamin A skin conditioners and a thorough medical facial with expert extractions to get out these closed comedones.

Figure 3. Acne Grade III. These are the inflammatory papules and pustules. The patients often have sensitive pores that have poor resistance to the acne problem. The pores break down rapidly before they develop into mature open and closed comedones. Small microcomedones breakdown rapidly and cause an intense inflammatory response. This may lead to scarring

Figure 4. Acne Grade IV. When the lesions become larger, this is called nodular or cystic acne. The patient may have a background of Grade I, Grade II or Grade III, but then develop these cysts. These patients develop more inflammatory reactions that can lead to severe scarring. The key is to put them on a good skin care program, improve their acne and then switch them, if needed, to isotretinoin.

Figure 5. Acne comes across the face like a wave. It starts on the nose, matures to the cheeks and then finally ends up at the angle of the jaw. This case is halfway through her progression and needs to treat the acne to one inch below the jaw line. This will stop the new pores from becoming impacted and lead to a remission of the problem.

Figure 6. Acne Aggravating Factors. Acne is basically genetic and runs in certain families. However, there are many aggravating factors. Stress is perhaps the most common, but birth control pills, cosmetics, certain dietary factors, such as iodide or certain drugs, such as Dilantin may aggravate the problem.

Figure 7. Authorized Picking. The patient needs to learn how to extract so the impactions are removed without injuring the tissue.

Figure 8, 9. Before and after the daily use of the skin care regime. This patient was diligent and used the benzoyl peroxide scrub cleanser, ice compresses, the glycolic normalizing tonic followed with the vitamin A conditioning lotion. Within two weeks, the complexion was improved and it was clear in eight weeks. The patient then continued on the program to maintain remission.

Figure 10, 11. This patient had Grade III acne. He applied the acne control regime diligently and cleared up his complexion. Note, there were a few scars before the treatment that became more visible after the clearing. Make sure you mention this to the patient on their initial visit so they will not be surprised with the scarring that is already developed with the acne process.

Figure 12, 13. Before and after dermabrasion. After the acne clears, the scars are improved with a combination of laser and sanding. This procedure is called, laser assisted chemabrasion.

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