Acne: The Struggle Is Real


As a practicing physician assistant in dermatology, I see scores of patients with acne looking for skincare regimens and quick fixes that will give them the long term results they dream of. Acne is one of the most common skin conditions: 80% of Americans deal with it at some point in their lives, and as many as 20% will suffer from its more severe forms.

If you carry the physical and emotional scars of acne, I can assure you that you’re not alone. According to the American Academy of Dermatology (AAD), up to 50 million Americans suffer from acne. In fact, I myself struggled with it during my teens and twenties, and fought the good fight using topical treatments and oral antibiotics. I even considered spending several thousands of dollars on cosmetic procedures. After consulting multiple dermatologists to no avail, I finally found an effective treatment, and my skin has remained blemish-free ever since.

But we’ll get back to my story a little later – let’s start by understanding what causes acne breakouts.

What causes acne?

First, look at your parents, or even your grandparents. Genetics is one of acne’s main causes, so don’t forget to say thank you for this precious gift.

In addition to your DNA working against you, there is also a fight with follicle plugging, excessive oil (sebum) production, inflammation, and a little, pesky bacteria call Propionibacterium acnes. Essentially, the cycle goes like this:

  1. Your skin produces excess oil.
  2. The oil combines with skin cells to clog pores.
  3. The bacteria on your skin multiply exponentially.
  4. The lesion forms just in time for your prom or holiday work party.

There are several factors that can worsen the appearance of acne lesions such as hormones, menstruation, stress (yes, the third eye in the middle of your forehead may have been brought on by that exam or important presentation), and medications (anti-epilepsy and antidepressants drugs, namely).

Also, the belief that acne is worsened by certain foods with a high glycemic load – basically all the delicious carbs we love – has not been completely disproven, although it has been knocked down a few pegs on the scale of exacerbating factors. I always tell my patients that if eating a bag of lightly salted potato chips causes acne flare-ups, then they should just stay away from them.

acne pimples

How is acne treated?

While acne treatments have been studied and prescribed since Ancient Rome, the rudimentary sulfur and mineral bath treatments of those years having given way to the AAD’S more rigorous guidelines of care for the management of acne vulgaris, there still is no perfect, universal formula. Each protocol is individualized according to several factors that I like to keep in mind whenever I’m building a regimen for a patient:

  • Skin type (color, oil production, sensitivity)
  • Likelihood for compliance (some regimens can be simplified for the patient who hates a long grooming routine or is unreliable with medications)
  • Severity of acne (mild, moderate, severe, cystic)
  • Body areas involved (face, chest and/or back)
  • Cost of medications and financial situation

Based on the AAD’s February 2016 guidelines, mild acne is generally treated with benzoyl peroxide (BP), topical retinoid (must be older than 9 years old), or a combination of BP and topical antibiotics and retinoids.

My initial discussions with patients allow me to learn more about their acne journey, and review all their over-the-counter failures, late night infomercial blunders, and home remedies (I’ve heard some off the wall concoctions). I also try to gauge their ability to comply with a regimen and begin to build a more advanced one based on these mishaps.

Overall, patients get excited when you tell them how much better their skin will look if they work with you and are open with their level of compliance. I can’t overstate the importance of compliance. Skincare isn’t an “overnight” thing, and keeping up with a regimen that will reduce oil production, decrease inflammation, and help unclog pores is paramount to success.

In terms of follow-up and timing, this is what I typically tell patients: “I want to see you back in about 6 weeks. Our skin turns over every 28 days like a menstrual cycle, not all at once like a snake shedding, but slowly over time. Now add two weeks to that. That’s when we’ll be in the meat and potatoes of your progress. We’ll then be able to determine what’s working, what’s not, and what needs to be adjusted. In order for this relationship to work you’ll need to be honest and tell me if you stuck with the plan or if you gave up.”

My success story

Consistency is a concept I didn’t fully understand as a teenager and even in my early 20’s – likely because no one actually took the time to explain that overnight success wasn’t going to happen, but also because I was motivated for about 48 hours after my office visit, and got bored/forgot about using my topical medications after that.

It wasn’t until a few years after that I was given the privilege of being a part of my sister’s wedding as maid of honor, and could not bear to have a single pimple on that day. Ripe in my training as a PA student, I was determined to get clear skin and sought help from the preceptors, professors, and physicians I was learning under.

My research led me to oral isotretinoin, previously and more commonly known to the public as Accutane. I knew about the risks, the regular blood testing required during follow-up, and – more importantly – about the drug’s high success rate. After five months of dry lips and of the most matte skin I’ve ever had, along with a few other adverse effects, I completed the therapy with skin that to this day remains clear and blemish-free.

Everyone’s results are different, and you must be completely committed and trusting of your physician/care provider if you choose this path. Patients I offer this treatment to are specially chosen based their medical history and my trust in them. We have a lengthy discussion about the drug’s serious and common side effects, and they are required to communicate any issues to me the moment they occur.

Acne isn’t a one-trick pony. It’s a complex, intricate condition, and a delicate topic that should always be approached with sensitivity and thoughtfulness. Remember that if you suffer from acne you are not alone, and that it’s likely that you’re not going to see magical results from one medication (topical or oral). However, you will be rewarded if you continue to be open with your providers about your success and failures.

P.S. Don’t forget your sunscreen.

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