Acne: Treatment Options

Acne treatment varies depending on the severity and skin type.

Mild acne is defined as involving less than 1/4 of the face with some pustules, papules, and black and whiteheads. Generally, these patients can obtain a decent response using mild over the counter products such as Benzoyl peroxide 5-10% to control outbreaks. Usually, by the time I see patients, they have already tried it, failed it, and are on Pro-Active! Pro-active works on mild acne but does not seem to work for more severe cases and or causes too much dryness.

For mild acne, I personally like to use the Neostrata Antibacterial cleanser for acne. It is a physician grade product sold in doctor's offices and now in some CVS drug stores. It is an alpha hydroxy product so it causes the skin to exfoliate faster, reducing acne outbreaks with time. I also prefer salicylic gel or solution to benzoyl peroxide. Salicylic products help "thin" the skin by removing any dead skin cells and sebum around the hair follicles, thus making it harder for pustules and comedones to form. I use this because I had a lot of facial hair that worsened my acne. After my laser hair removal, I use it for the occasional outbreak. I also use it on men around their beard line and women for their bikini line if they suffer from acne or ingrown hairs there. Please note that salicylic is contra-indicated in pregnancy!

Most of my acneic patients don't want to use moisturizers because they feel it will worsen their acne. Moisturizers are important to keep the skin's immune barrier working, which will prevent further skin damage. From over the counter, mild products again like neutrogena, Cetaphil, and Purpose are good. In my center, the two products I use for my mild acneic patients are alpha and poly hydroxy moisturizers. Both of them cause the skin to exfoliate while hydrating. The difference is that the alpha hydroxy is a smaller molecule and penetrates the skin faster, thus causing more irritation in the beginning. This irritation subsides after a few weeks. I use the polyhydroxy products on my more sensitive patients whereas for my oily skin patients, I use the alpha hydroxy products. For super sensitive skin, Avene makes Diacneal cleanser and moisturizer for acne which are great.

Treatments for mild acne can include chemical peels and microdermabrasions. Use chemical peels (glycolic peels that help exfoliate the skin faster) for active acne and microderm, a mechanical exfoliation for acne scars and maintenance of great, glowy skin. Both are relatively mild treatments and there is no down time with it! It is great for maintenance as well as for acne!

For moderate acne, which involves at least 1/2 to up to 3/4's of the face, treatment needs to start early to prevent scarring. For my Caucasian patients, they will complain of pink, red, and brown marks on their face, while my people of color (Asians, Latinos, African Americans) will complain of dark brown to black marks on their face. For many of my patients, these marks can last for 1-2 years if not longer and that is what frustrates them (and me!)

The most important thing is to control the acne using both skin care products and skin treatments to stop the acne and improve on the scarring. I start patients on good skin care products as discussed in the mild acne treatment, add a few additional items, and start on treatments. Using good skin care products is a must because you do not want to start an expensive treatment and not be able to maintain the results using clinically ineffective products from the drug store!

For moderate acne, a good cleanser, salicyclic acid acne treatment, moisturizer that is an alpha hydroxy acid, and SPF are a must. I also add hydroquinone and Retinols. I like to use hydroquinone, a skin lightening cream to reduce the formation of dark marks as well as the existing ones. In this country we use Hydroquinone 2-4% to stop the melanocytes, the cells that cause pigment from being overactive. No, you do not become lighter and look like Michael Jackson, but your skin will lighten to your natural color which is like the inside color of your forearm (take a look, that's your normal skin color).

In many countries, they do not use Hydroquinone because of a reported increase in cancers. We have not seen it in this country and thus, the FDA allows only physicians to use these products. Kojic Acid is another lightener which I will often use together to enhance the action or separately for patients who do not want to use hydroquinone. Use the Hydroquinone once or twice a day on the full face. For the stubborn spots, reapply it on the spots after 5 minutes for more effect.

Retinols are great to help the skin exfoliate faster. When the skin exfoliates faster, you help prevent acne from forming and help lighten scars. The best one's are prescriptions such as Retin-A, Tazorac, Retin-A micro, Renova, etc. Retin-A (the generic is Tretanoin) causes a lot of dryness and peeling because it forces the skin to exfoliate faster. If this gets to be too much, you can use it every other day or try adding a "blender" to it to make it less irritating. A blender product I use is from a wonderful skincare line called OBAGI. You blend the two products together and it allows for a smoother, gentler delivery of RetinA with less side effects. I also like to use the Avene Retrinal, a break down product of Retin-A so it is less irritating and gets you great results (cheaper too!)

For procedures to treat moderate acne, you have several options of peels to lasers. The treatments vary due to the depth of penetration in the skin. The deeper it penetrates the skin, the more expensive the treatment becomes because it leads to better results faster.

For patients on a more strict budget, a series of peels at higher strength is a good beginning. It will not take care of deep scarring. Progressive Peels are can penetrate about 5-12 microns deep in the skin and will work for more superficial acne, but not for that deep cystic acne. I use Neostrata Chemical Peels because they are made from natural sugar cane juice that is acidic allowing it to penetrate the skin and cause it to exfoliate faster. The reason this is important is that as we age or if we have problem skin, the exfoliation process that occurs naturally in our skin every six weeks, slows down. So less and less skin exfoliates, leading to more problem skin, a thicker layer of dead skin on top making products useless after a few weeks (just because it can not penetrate through).

When we do peels, we can remove that superficial dead skin, and penetrate a little deeper to where the acne is. And, no, you will not look like Samantha from Sex in the City (she had a peel and was lobster red for a day). Our peels are superficial progressive peels that are physician grade but gentle. Peels done at the salon/spa and at home are very mild even though they may say 50% glycolic. They can not use a true acid because they are not medical professionals and thus, their peels are buffered. Be a smart shopper and get a real peel with a physician!

A better option for moderate acne is using ALA and an intense pulse light treatment because it penetrates deeper (about 20-25microns deep). ALA is amino levulinic acid which has been shown to dry up the sebaceous glands to stop acne from forming (this is how accutane works without the same side effects). It needs a series of treatments and generally provides good results. People may need a touch up after the series of treatments are done to maintain their results. The ALA is applied to the skin for one hour and then an intense pulse light laser is used to "activate" the ALA. You may be sunburned looking for a few days. Repeat treatments occur every four weeks. I am not to impressed with just using the blue light acne laser treatment. I have not seen great results with it. Most of my patients state that they would not do it again, and thus, I do not offer it as a sole treatment, but only in conjunction with the ALA. Darker complexions can do the ALA and the blue light without concern. If you are going to do the ALA and the skin rejuvenation, I recommend that you use hydroquinone 4% for about 4 weeks in advance to minimize any risk of hyperpigmentation. Darker skin is more likely to get injured by the laser light due to the extra melanin. Using hydroquinone one month in advance will reduce this risk. Many places don't even bother, but since I am of Indian descent and have been burned in the past by "other laser places" I highly recommend it. Why take a chance...this is your face!

Another option and my favorite is the Pixel resurfacing laser. This is a true laser treatment (not an intense pulse light) that can penetrate deep into the skin (about 30-150 microns! That is the deepest you can go without needing sedation!). How it works is that it causes new collagen and elastin to be made and dessicating any current acne. You do need several treatments every 4-6 weeks apart to get optimal results. There is down time of looking sunburned with dry peeling skin for a few days. For patients with more moderate to severe acne, it may cause "new acne" because the treatment will bring up whatever is going on under the skin up to surface. This does not mean it is not working but rather its its penetrating deep into the skin, making differences. Acne can start about 2-6 weeks under the skin before it shows up on the skin surface. A normal skin cycle is about 6-8 weeks long. When we do any skin treatments, we expedite the exfoliation process, causing the skin to turnover faster, thus, if you had some new acne forming underneath, it will come up to the surface. Don't worry, the next treatment will take care of it. And once again, for my patients with darker complexions, I believe that using hydroquinone 4% 2-4 weeks in advance will provide optimal results.

For more severe acne, you need treatments ASAP. These patients have scars for their acne already and what we want to do, is prevent new scarring and help with the old scarring. I only recommend the laser treatments because we need deep penetration. I usually do a combination treatment with some ALA and intense pulse light followed by the Pixel. Because you will be getting treatments, we keep you on our mild Avene or Neostrata cleansers to help your skin heal and prevent new outbreaks. These patients need about 6 treatments of the Pixel or some combination with the the ALA and Pixel. The reason you need so many, is that the skin is very damaged and needs more treatment. After the treatments are finished, you must stay on good products to maintain what you just did! I use our Neostrata line or for another wonderful product line called OBAGI. This is the cadillac of skin care lines! This is what the plastic surgeons use after a face lift and many derms after all treatments are done. It can be used on all skin types and all ages except for women planning on having kids in the next six months because it does use both Retin-A and hydroquinone which are both contra-indicated in pregnancy.

Acne is a frustrating skin condition that requires a multi-faceted approach. While doing these skin treatments, I usually ask my clients to look at their diet and regular activities. I see alot of recurrent acne where people hold their phone to their face. Invest in Blue Tooth technology or an ear piece! Clean your phone often! Also, after working out, wash your skin. This is when it is prone to everything. And stop touching your face! That is a bad habit many of my acneic clients have that needs to slowly changed.

Most studies state that diet is not related to your acne. I feel that there are plenty of things that can make it worse. For people who are very sensitive to hormones, meat and dairy are loaded with hormones given to the animals to grow quickly. Try organic dairy products or just move to soy products and try free range meats (this is meat from animals that were not fed artificial feed that is loaded with bad fats and hormones). I firmly believe less soda is better for the body because it keeps sugar levels lower and the body in general does better when the sugar levels are lower. So avoid the junk food (hence the name-JUNK)

For women on birth control, there are birth control pills that are better for your acne such as Yasmin and Ortho Tri Cyclen lo. Use those instead of the others.

Also, if you have alot of facial hair, really think about laser hair removal. It will help your acne out tremendously! The best thing to do for acne, is come in and have someone take a look at your skin and get you on a skin care program that works for you!

Acne: What Causes it?

More than 85% of Americans suffered from acne sometime in their life. It can occur anywhere on the body but typically affects the face, neck, chest, shoulders, and back. Acne affects all ages with the teenage years being the most common. However, the disease is not restricted to any age group. Acne is very frustrating for my patients. They are just surprised that it just never goes away! Acne left untreated can cause scarring which for most of us last, for a very long time.

Acne is caused by inflammation in the sebaceous glands. The different terms that doctors use, describe the different types of inflammation.

1. Comedones (aka blackheads and whiteheads) is a sebaceous follicle plugged with sebum (a thick gelatinous oily substance produced by your skin), dead cells from inside the sebaceous follicle, tiny hairs, and or bacteria. When comedones are open, they appear black and hence are known as "blackheads". This is not dirt but oxidized material inside of the skin. Closed comedones are commonly called a whiteheads; They are skin colored or look like an inflamed white "bump" in the skin. Neither blackheads nor whiteheads should be squeezed or picked open, unless extracted by a skin care specialist under sterile conditions. Facials are NOT sterile conditions. I discourage my estheticians from extractions because it usually causes more scarring. If it comes up easily with a treatment, then I let them do it. I have many patients who come in and want an agressive exfoliation of their followed by deep extractions. I do not recommend this at all because the tissue is injured by squeezing or picking and can become infected with more bacteria, worsening the situation.

2. A Macule is the temporary red spot left by a healed acne lesion. It is flat, usually red or red-pink, with a well defined border. A macule may persist for days to weeks before disappearing. When a number of macules are present, it looks like the person has very red, irritated skin. This is seen with acne and even my rosacea patients.

3. A Papule is a small, solid bump, slightly elevated above the surface of the skin. A group of very small papules and microcomedones may be almost invisible but have a "sandpaper" feel to the touch. A papule is caused by local skin inflammation.

4. A Pustule aka pus bumps, zits-are small, easily broken bumps containing pus. A pustule that forms over a sebaceous follicle usually has hair in the center. Acne pustules that heal without progressing to cystic form usually leave minimum scars as long as patients don't pick at them. The problem is most of my patients love to break these ugly pus bumps worsening the condition and more likely to cause scarring. I know I have done it and I take care of skin everyday, so I know all of you have done it as well!

5. A Nodule-is a solid, large bump that lies deep within the skin. Patients state it is like a big zit that never comes to a head, its deep inside and really painful. Because they are deep, they are more likely to scar. Nodules need aggressive treatment due to their propensity to scar.

6. A Cyst is a sac-like lesion containing liquid or semi-liquid material consisting of white blood cells, dead cells, and bacteria. It is larger than a pustule, and tends to be more severely inflamed, extending deeper into the skin. It usually is quite painful, and there is great liklihood for scarring. Cysts and nodules often occur together in a severe form of acne called nodulocystic.

Ok, now that you know all the different types of acne. You are still wondering why it even occurs. Acne, regardless of the form you suffer from, occurs due to inflammation. What causes the inflammation? One of the most common reasons is hormonal fluctuations in the body. This is why teenagers are the most commonly afflicted due to the sudden shift in hormones. Women are usually pestered long after this because of the monthly menstrual cycle, pregnancy, or menopause. Women can get it for other reasons such as stress, friction (whether you talk on that cell all day long, keep touching your face, wear caps or clothes that cause more friction against your skin) are all culprits.

Men can be afflicted for different reasons. Yes, it can be due to hormones, but friction (from baseball caps and cell phones), sweating (especially for back acne), and body hair can be potential causes of acne. Remember pustules have hair in the center. So if you have more hair on your body or face, you may be more likely to get acne. (And yes, there are people who are "hairy" but don't have acne. I find that my acneic patients who do laser hair removal get a tremendous improvement in their acne). Clean your cell phone often and try whenever possible to be wireless or with a headpiece.

Other causes of acne are stress. How stress effects your skin is that it suppresses your immune system, thus the normal skin defenses you have are not as strong, predisposing you to acne. And usually, people when they are stressed, do not take care of themselves as well, do not eat or sleep as well, and usually start touching their face or hair in a nervous habit, which all contributes to worsening their acne.

All the literature states diet is not a cause of acne, but what I tell my patients is that, if you find that eating or drinking certain types of foods or liquids, worsens your acne, avoid it. I have seen plenty of people who have acne due to milk, nut, and wheat allergies. Studies look at large populations for changes but can not look at individual responses to allergens or other ongoing problems. I strongly believe in eating a well balanced diet, drinking 2 liters of water a day to keep the body cleansed and detoxified. Skin is an external manifestation of the internal balance. I often due elimination diets on patients to help acne and overall health. Typically, the person who is coming in for uncontrolled acne, also has many other issues in their life that are not being addressed. All of these are contributing to their acne. Most dermatologist do not have time nor the desire to address these "other complaints" and thus the studies are not set up to evaluate for these issues. So these are the causes of acne, coming up next are the treatments for acne.

The Connection between Inner Health and Outer Beauty

As a primary care physician for the past 13 years, I have seen and heard just about everything. As the family doctor, I am given the responsibility to help my patients live better and stay healthy, but what has happened with managed care, is I have less and less time to spend with each person. I have five minutes, may be 10 minutes max to see someone, which is barely enough time to address their top concern, so the things that I believe can make the most difference in your life-wellness and prevention are never addressed.

I have become so dismayed with the whole process, that I have opened up a medical spa and wellness center to deliver the the philosophy I believe in: The integration of inner health and outer beauty. Your skin is a manifestation of what is happening internally. To treat skin well, both the inner and outer aspects need to be addressed. This blog is to help you understand the various skin conditions, the treatments available, as well as how your inner health can be affecting your outer beauty. Furthermore, different skin types have different concerns that need to be addressed and treated accordingly.

One of the most important things that I have learned in medicine is to make things simple. The more simply it is stated, the better people understand it and are more likely to understand how to take care for it. This is by no means to make anyone feel disrespected, but I just think doctors are so caught up in the technical lingo that they have forgetten how to explain things to people.

So, to begin with skin health, the most common reasons people come in to our center are for acne, spots, scars, saggy skin, wrinkles, and unwanted hair. (Wouldn't it be great if we could just get rid of all of these problems?) These skin concerns can be grouped into different categories that offer various treatment options depending on the severity of the condition. Severity is defined by
1. Mild-affecting 1/4th of the face or less
2. Moderate-affecting 1/2 of the the face
3. Severe-affecting more than 1/2 of the face

The five categories are:
1. Acne-there are different types and can affect the body anywhere, which we will discuss in the future.

2. Red skin-this includes rosacea, sensitive & dry red skin, "erythematous skin"-just a fancy term for people who have no skin problem
but just alot of red undertones and easy flushing, psoriasis, broken capillaries

3. Brown discoloration-from scarring, acne, melasma, sun damage,
age related changes to include the most common causes of brown spots and patches

4. Wrinkles-whether they are fine or deep, caused by movement or
are always present;the treatment will vary.

5. Other-are all other things that cause lumps, bumps, and
concerns. After we evaluate these, these can be treated or referred on for
further treatment.

I will break down each of these categories in more detail so you can learn more about them as well as the different treatment options. Yes, people can have multiple combinations of problems together as well! There are many other problems out there but I just wanted to discuss the most common concerns that I address daily and what can be done from them.