For something so very common, Acne can be so very misunderstood. It’s a condition that happens to many of us and our loved ones, but we’re often misinformed about its cause, its treatment, and its risks. We recently interviewed dermatologist Dr. Payman Kosari of Dermatology, Laser & Vein Specialists of the Carolinas (DLVSC) to get the latest, straightest scoop on Acne and how to handle it. We’ll break it down into the most common myths and misunderstandings about acne as an easy way to address the issues. First though, let’s define what acne is and what it is not.
What is Acne
As a broad category, acne is a skin condition that occurs when your hair follicles become plugged with oil and dead skin cells. This causes whiteheads, blackheads or pimples. These can be occasional or chronic, and can be one or two at a time or many. An occasional pimple or breakout around your period that goes away is not considered chronic acne. These can usually be treated topically, and are not a cause for concern.
Chronic and cystic acne are different, and should be examined by a dermatologist. You can recognize it by many, persistent pimples, with large, solid or pus-filled, painful lumps under the skin. This is the kind of acne that needs treatment. Chronic acne is not only painful, it is socially uncomfortable, and can cause severe scarring. For our purposes in this article, we’re focusing on this chronic acne.
Acne Myth #1: It’s Something You’re Doing Wrong
The first and foremost thing to know is that acne is primarily something to which you are genetically prone. It’s not something you’re doing wrong, that you can just eliminate or change and the acne will clear up. Chronic, cystic acne is, in the simplest terms, an inflammatory response. And the propensity for this inflammatory response and the resulting scars is mostly genetic. The reason some of us get it and some of us don’t, and how bad it is when we do get it, is again, mostly genetic.
Dr. Kosari explains “All people usually start off making acne the same way, the initial inflammatory process in all skin is the same, it’s just that over time in scar prone skin you see inflammation that persists versus non-scar prone skin that resolves the inflammation a lot quicker.”
While there may be adjustments that you can make to your diet, your lifestyle, your cleansing regimen, etc., you are either prone to getting the inflammation that leads to acne or you are not. Did your parents or your siblings have acne? Aunts, uncles, cousins acne-prone? It runs in your family. You and your children have a greater chance of having acne then too.
Acne Myth #2: Acne is Caused by Dirty Skin
Dirty skin certainly doesn’t help, but acne is caused by inflammation around plugged hair follicles. Cystic acne is caused by an internal plugging of the hair follicle, which in turn results in inflammation, redness, and the cysts. Some people’s skin is more prone to this plugging effect than others, and this seems to be the biggest determinate of whether a person will get acne or not. This is why you can have a child who virtually never washes his face yet has almost no breakouts, and another child who is meticulous about cleansing and skincare who struggles with chronic acne.
Acne Myth #3: It’s Only For Teenagers
It is most common in the teenage years, for sure, because that’s when most people experience the greatest changes and surges in hormones, particularly testosterone. This causes enlargement of the sebaceous glands and increased sebum production, which leads to plugging of the hair follicles which creates the inflammation involved in acne.
Hormonal changes can lead to acne later in life ~ some women experience acne during early pregnancy, people taking steroids or testosterone supplements can get acne, and mid-life hormonal swings in women can bring it on.
It’s important to re-state though, that there’s a difference in the occasional pimple or breakout which goes away after a week or two, and the acne that sticks around for weeks. The latter chronic condition is what you need to worry about.
Dr. Kosari says that acne and its treatment doesn’t really differ between adolescents and adults. “More important is to determine what kind of acne the patient has. Is it inflamed acne or non-inflamed acne? That is the simplest way to look at it.”
Acne Myth #4: It’s Your Diet
There’s some support for dietary restrictions to help curb the inflammation of acne. While there is not a definitive, scientific correlation thus far, there have been studies that show that eliminating certain inflammatory foods like dairy and chocolate may help. Some people say they benefit from reducing simple carbs. And having a healthy diet of anti-inflammatory foods may help. But again, don’t let chronic acne persist for months while you work your way through an elimination diet. Most doctors consider diet to be a small part of any acne solution.
Dr. Kosari says “If you feel like there’s an association with a particular food and your acne, then it’s likely that you have a sensitivity to that food, and you can avoid it. The data doesn’t negate it but it doesn’t completely support it either.
Acne Myth #5: Just Give It Time. You’ll Grow Out of It.
For parents whose child has a seemingly endless supply of pimples, Dr. Kosari has one piece of advice. See a Dermatologist Now. Chronic acne does not just “go away”, at least not usually without the potential for leaving deep, difficult scars both on the skin and the psyche. Adolescents with untreated chronic acne report much higher rates of depression, social anxiety, self-harm and suicidal ideation. Dr. Kosari says your window for “at home” and drug-store solutions should be no more than two months. If it hasn’t significantly cleared up, make an appointment with a dermatologist.
“The biggest advice I have is that if you have a close family member who has acne scarring, as a parent you should be aggressive in treating your child’s acne. You want to try to remove the inflammation as soon as possible in skin prone to scarring. You should not take lightly the acne that comes on in puberty or early adulthood,” says Dr. Kosari.
Acne Myth #6: “Accutane” is a Last Resort
“Accutane” or the drug isotretinoin, is a powerfully effective treatment for chronic and severe acne, and Dr. Kosari regards it as one of his best weapons to rid patients of this difficult condition.
Usually, Dr. Kosari prescribes a round of antibiotics and topical retinoid over a two month period to see if that clears the acne. The antibiotics can help reduce the inflammation and the retinoids clear dead skin cells quickly. If this doesn’t work in 2 months, or if Dr. Kosari assesses the patient to be at risk of significant scarring, the next step is an isotretinoin, which works by decreasing facial oil (sebum) production.
Accutane is the original brand name for isotretinoin, part of a group of drugs called retinoids, synthetic vitamin A derivatives. The brand Accutane is actually not even sold in the US anymore; isotretinoin is available under several different brand names these days.
Patients usually take a course of isotretinoin for six to nine months, which results in an almost complete eradication of acne for most people, and which lasts for years if not a lifetime for many. It is a highly effective treatment, with no known comparison.
The main side effects of isotretinoin are fairly minor and easy to manage, mostly around the drying effect of the drug:
- Chapped, cracked lips and dry skin
- Dry eyes (contact wearers may not tolerate their lenses well while taking isotretinoin)
- Nosebleeds from a dry nasal lining
- Joint and muscle aches
- Sensitivity to the sun (be sure to wear sunscreen and limit your sun exposure while taking isotretinoin)
- Sensitivity of skin (don’t wax, or have laser treatments or dermabrasion while taking isotretinoin)
For most patients, the results of a course of isotretinoin are truly amazing, and they are so pleased that these effects are inconvenient but worth it.
For Dr. Kosari, “I have a very low threshold for using Accutane. Acne itself, frequently associated with depression and anxiety in the developing adolescent, is significantly more dangerous to the patient than Accutane will ever be. Moreover, the risk of scarring is not to be taken lightly and all measures should be taken to prevent it.”
“You’re choosing between something that could be very temporary for the teenage years (less than one year for a course of treatment) versus physical scarring that will be present for a lifetime.”