ENDOCRINE PERSPECTIVE
by Geoffrey P. Redmond, M.D.
Dear Dr. Redmond: So many of our clients have problems with acne, and they're always asking what they can do themselves to improve their condition. Your February '96 column in IHR explains that the acne problem is related to the same hormones that cause increased hair growth, and I am wondering what advice you would recommend we give these people. How useful are the home treatments and non-prescription drugs in treating acne, especially for mild cases?
ACNE IS A VERY COMMON condition. While it does not normally appear before puberty, after that it is very common. Though it is "supposed to" go away after the teens, it often persists, occasionally into the 50s and 60s.
Acne is an androgenic disorder, like hirsutism, which means that it is set off by the effects of the family of hormones called androgens. These include testosterone, DHEA-S and others. While these are sometimes thought of as male hormones, adult women do have active levels in their blood - but the levels are only a fifth to a tenth of those found in men.
The first event leading to acne is stimulation of the sebaceous glands by androgens, accompanied by a thickening of the surface protein of the skin. Next, the pores plug up and trap the oil inside, leading to whiteheads and blackheads. Bacteria grow inside the trapped oil, causing the production of irritating chemicals. Finally the body's immune system comes into play.
While the immune system fights the bacteria, it also causes the redness, swelling and later scarring, which account for the unsightly aspects of acne. There is some evidence that those with worse acne have a stronger immune response. While this is good in some ways, it also results in more intense skin inflammation producing larger acne lesions.
In my previous column on acne, I wrote about hormonal treatments which block the stimulating effect of the androgens on the oil glands. Because this form of treatment stops acne before it begins, it often gives the best result. However, many people with mild acne do not need this form of treatment ‹ which requires a visit to a medical specialist, blood tests, and oral medication. What about simple, home treatments for acne that donąt require a prescription?
The best over-the-counter (OTC) acne medicine is benzoyl peroxide. It is sold under several brand names, of which the best known is Oxy 5 and Oxy 10. These have 5% and 10% benzoyl peroxide respectively. The medication works as an antibacterial, and may dry the oiliness of the skin also.
Benzoyl peroxide should be applied daily, but it often causes irritation or redness of the skin, so it is sometimes better to apply it and wash it off after 30 to 45 minutes.
There are many other OTC acne remedies, many of which are not very effective. Some contain ingredients that may make things worse or can irritate some peoplesą skin. I suggest using only those which contain benzoyl peroxide without a lot of additional ingredients.
Proper skin care is important with acne. A soap-free skin cleanser, or a soap that is only slightly drying, is best: very drying soaps, or soaps with high moisturizer content may cause problems.
Astringents contain alcohol which dries the skin. While these are widely marketed by cosmetic companies, they are usually better avoided. Although use of an astringent may make the skin feel less oily immediately after use, it will not stop the increased oil production involved in acne and may irritate the skin.
Some women with acne notice that it gets better after sun exposure. This is not a good way to control acne for two reasons. Firstly, long term sun exposure greatly increases the risk of skin cancer (including melanoma). Secondly, while the skin dries up initially after sun exposure there may be a rebound later, when oiliness actually increases. Sunbathing may therefore exacerbate acne in the long run. When your clients who have acne go out in the sun, they should use a non-comedogenic (non-acne causing) sun screen lotion that has a Sun Protection Factor (SPF) of at least 15.
Another important aspect of skin care for people with acne is the use of moisturizers. There are hundreds of brand-name moisturizers on the market to meet the demands of people with dry skin, particularly those who live in a northern climate. While women with acne usually have oily skin, many of the treatments for acne produce dryness. Some women have oiliness in some facial areas and dryness in others. Many will benefit from the use of a moisturizer, but should be urged to use one that will not cause acne itself. If a moisturizer leaves the fingers feeling oily for more than a few minutes after application it is probably not suitable for skin with acne. Two good ones are Vaseline Intensive Care Extra Strength (not made from Vaseline which should not be put on the skin), and Mi Fine Skin. The latter was developed by a Cleveland dermatologist and is the best in my experience. It can be ordered by telephone (1-800-SKIN-066).
As IHR readers know, diet is not an important factor in acne. Chocolate and high fat foods do not cause acne, and eating less of these foods ‹ while it may be good for health overall ‹ will not solve an acne problem.
For mild acne, regular use of a skin cleanser at least twice a day, and a daily application of a benzoyl peroxide preparation, will produce considerable improvement. If this doesnąt work, a visit to a dermatologist or other physician experienced with acne is the next step.
The most common medical treatments are topicals such as tretinoin (Retin-A, erythromycin, clindamycin), and oral antibiotics such as tetracycline, minocycline, and erythromycin. Of the oral antibiotics I prefer erythromycin, as it does not cause the photosensitivity or yeast infections sometimes induced by the former two.
Once a break out occurs it takes time for it to heal. Acne treatments must be used all the time, not just when lesions appear. Even if a treatment is going to help, it may be a few weeks before improvement occurs.
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