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Questions and Answers About Acne
side effects should be reported to the doctor.

OTC topical medicines are somewhat effective in treating acne when used
regularly. Patients must keep in mind that it can take 8 weeks or more
before they notice their skin looks and feels better.

Treatment for Moderate to Severe Inflammatory Acne

Patients with moderate to severe inflammatory acne may be treated with
prescription topical or oral medicines, alone or in combination.

Prescription Topical Medicines

Several types of prescription topical medicines are used to treat acne,
including antibiotics, benzoyl peroxide, tretinoin, adapalene, and azelaic
acid. Antibiotics and azelaic acid help stop or slow the growth of bacteria
and reduce inflammation. Tretinoin, a type of drug called a retinoid that
contains an altered form of vitamin A, is an effective topical medicine for
stopping the development of new comedones. It works by unplugging
existing comedones, thereby allowing other topical medicines, such as
antibiotics, to enter the follicles. The doctor may also prescribe newer
retinoids or retinoid-like drugs, such as tazarotene or adapalene, that help
decrease comedo formation.

Like OTC topical medicines, prescription topical medicines come as
creams, lotions, solutions, or gels. The doctor will consider the patient's
skin type when prescribing a product. Creams and lotions provide moisture
and tend to be good for people with sensitive skin. Gels and solutions are
generally alcohol based and tend to dry the skin. Therefore, patients with
very oily skin or those who live in hot, humid climates may prefer them. The
doctor will tell the patient how to apply the medicine and how often to use it.

Some people develop side effects from using prescription topical medicines.
Initially, the skin may look worse before improving. Common side effects
include stinging, buming, redness, peeling, scaling, or discoloration of the
skin. With some medicines, like retinoids, these side effects usually
decrease or go away after the medicine is used for a period of time.
Patients should report prolonged or severe side effects to their doctor.
Between 4 and 8 weeks will most likely pass before patients see their skin
improve.

Prescription Oral Medicines

For patients with moderate to severe acne, the doctor often prescribes oral
antibiotics (taken by mouth). Oral antibiotics are thought to help control
acne by curbing the growth of bacteria and reducing inflammation.
Prescription oral and topical medicines may be combined. For example,
benzoyl! peroxide may be combined with clindamycin, erythromycin, or
sulfur. Other common antibiotics used to treat acne are tetracycline,
minocycline, and doxycycline. Some people have side effects when taking
these antibiotics, such as an increased tendency to sunburn, upset
stomach, dizziness or lightheadedness, and changes in skin color.
Tetracycline is not given to pregnant women, nor is it given to children
under 8 years of age because it might discolor developing teeth.
Tetracycline and minocycline may also decrease the effectiveness of birth
control pills. Therefore, a backup or another form of birth control may be
needed. Prolonged treatment with oral antibiotics may be necessary to
achieve the desired results.

Treatment for Severe Nodular or Cystic Acne

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Questions and Answers About Acne

moisturizers, should be oil free. Patients may find it difficult to apply
foundation evenly during the first few weeks of treatment because the skin
may be red or scaly, particularly with the use of topical tretinoin or benzoyl
peroxide. Oily hair products may eventually spread over the forehead,
causing closed comedones. Products that are labeled as noncomedogenic
(do not promote the formation of closed pores) should be used; in some
people, however, even these products may cause acne.

What Research Is Being Done on Acne?

Medical researchers are working on new drugs to treat acne, particularly
topical antibiotics to replace some of those in current use. As with many
other types of bacterial infections, doctors are finding that, over time, the
bacteria that are associated with acne are becoming resistant to treatment
with certain antibiotics. Research is also being conducted by industry on
the potential side effects of isotretinoin and the long-term use of medicines
used for treating acne.

Scientists are working on other means of treating acne. For example,
researchers are studying the biology of sebaceous cells and testing a laser
in laboratory animals to treat acne by disrupting sebaceous glands.
Scientists are also studying the treatment of androgenic disorders, including
acne, in men by inhibiting an enzyme that changes testosterone to a more
potent androgen.

Where Can People Find More Information on Acne?

National Institute of Arthritis and Musculoskeletal and Skin Diseases
(NIAMS)

National Institutes of Health

1 AMS Circle

Bethesda, MD 20892-3675

Phone: 301-495-4484 or 877-22-NIAMS (226-4267) (free of charge)

TTY: 301-565-2966

Fax: 301-718-6366

www.niams.nih.gov

NIAMS provides information about various forms of arthritis and rheumatic
disease and bone, muscle, joint, and skin diseases. It distributes patient
and professional education materials and refers people to other sources of
information. Additional information and updates can also be found on the
NIAMS Web site.

American Academy of Dermatology

P.O. Box 4014

Schaumburg, IL 60168-4014

Phone: 847-330-0230 or 888-462-3376 (free of charge)
Fax: 847-330-0050

www.aad.org

This national organization can provide referrals to dermatologists. It also
publishes a brochure on acne for adults and a fact sheet for young people.
These are available on the organization's Web site or can be obtained by
calling or writing to the academy.

Acknowledgments

The NIAMS gratefully acknowledges the assistance of Robert Katz, M.D.,
Rockville, MD; Larry Miller, M.D., Chevy Chase, MD; Alan Moshell, M.D.,
NIAMS, NIH; Gary Peck, M.D., Washington Hospital Center, Washington,

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days before their menstrual period starts

Friction caused by leaning on or rubbing the skin

Pressure from bike helmets, backpacks, or tight collars
Environmental irritants, such as pollution and high humidity
Squeezing or picking at blemishes

Hard scrubbing of the skin.

Myths About the Causes of Acne

There are many myths about what causes acne. Chocolate and greasy
foods are often blamed, but foods seem to have little effect on the
development and course of acne in most people. Another common myth is
that dirty skin causes acne; however, blackheads and other acne lesions
are not caused by dirt. Finally, stress does not cause acne.

Who Gets Acne?

People of all races and ages get acne. It is most common in adolescents
and young adults. Nearly 85 percent of people between the ages of 12 and
24 develop the disorder. For most people, acne tends to go away by the
time they reach their thirties; however, some people in their forties and
fifties continue to have this skin problem.

How Is Acne Treated?

Acne is often treated by dermatologists (doctors who specialize in skin
problems). These doctors treat all kinds of acne, particularly severe cases.
Doctors who are general or family practitioners, pediatricians, or internists
may treat patients with milder cases of acne.

The goals of treatment are to heal existing lesions, stop new lesions from
forming, prevent scarring, and minimize the psychological stress and
embarrassment caused by this disease. Drug treatment is aimed at
reducing several problems that play a part in causing acne: abnormal
clumping of cells in the follicles, increased oil production, bacteria, and
inflammation. Depending on the extent of the person's acne, the doctor will
recommend one of several over-the-counter (OTC) medicines or prescription
medicines that are topical (applied to the skin) or systemic (taken by
mouth). The doctor may suggest using more than one topical medicine or
combining oral and topical medicines.

Treatment for Blackheads, Whiteheads, and Mild
Inflammatory Acne

Doctors usually recommend an OTC or prescription topical medication for
people with mild signs of acne. Topical medicine is applied directly to the
acne lesions or to the entire area of affected skin.

Benzoyl peroxide, resorcinol, salicylic acid, and sulfur are the most
common topical OTC medicines used to treat acne. Each works a little
differently. Benzoyl peroxide is best at killing P. acnes and may reduce oil
production. Resorcinol, salicylic acid, and sulfur help break down
blackheads and whiteheads. Salicylic acid also helps cut down the
shedding of cells lining the follicles of the oil glands. Topical OTC
medications are available in many forms, such as gel, lotion, cream, soap,
or pad.

In some patients, OTC acne medicines may cause side effects such as
skin irritation, burning, or redness. Some people find that the side effects
lessen or go away with continued use of the medicine. Severe or prolonged

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Questions and Answers About Acne

People with nodules or cysts should be treated by a dermatologist. For
patients with severe inflammatory acne that does not improve with
medicines such as those described above, a doctor may prescribe
isotretinoin (Accutane), a retinoid. Isotretinoin is an oral drug that is usually
taken once or twice a day with food for 15 to 20 weeks. It markedly reduces
the size of the oil glands so that much less oil is produced. As a result, the
growth of bacteria is decreased.

* Brand names included in this booklet are provided as examples only, and their inclusion does
not mean that these products are endorsed by the National Institutes of Health or any other
Government agency. Also, if a particular brand name is not mentioned, this does not mean or
imply that the product is unsatisfactory.

Advantages of Isotretinoin (Accutane)

Isotretinoin is a very effective medicine that can help prevent scarring. After
15 to 20 weeks of treatment with isotretinoin, acne completely or almost
completely goes away in up to 90 percent of patients. In those patients
where acne recurs after a course of isotretinoin, the doctor may institute
another course of the same treatment or prescribe other medicines.

Disadvantages of Isotretinoin (Accutane)

Isotretinoin can cause birth defects in the developing fetus of a pregnant
woman. It is important that women of childbearing age are not
pregnant and do not get pregnant while taking this medicine. Women
must use two separate effective forms of birth control at the same time for
1 month before treatment begins, during the entire course of treatment, and
for 1 full month after stopping the drug. They should ask their doctor when it
is safe to get pregnant after they have stopped taking Accutane.

Some people with acne become depressed by the changes in the
appearance of their skin. Changes in mental health may be intensified
during treatment or soon after completing a course of medicines like
Accutane. A doctor should be consulted if a person feels unusually sad or
has other symptoms of depression, such as loss of appetite or trouble
concentrating.

Other possible side effects include dry eyes, mouth, lips, nose, or skin;
itching; nosebleeds; muscle aches; sensitivity to the sun; and, sometimes,
poor night vision. More serious side effects include changes in the blood,
such as an increase in triglycerides and cholesterol, or a change in liver
function. To make sure Accutane is stopped if side effects occur, the doctor
monitors blood studies that are done before treatment is started and
periodically during treatment. Side effects usually go away after the
medicine is stopped.

Treatments for Hormonally Influenced Acne in Women

Clues that help the doctor determine whether acne in an adult woman is due
to an excess of androgen hormones are hirsutism (excessive growth of hair
in unusual places), premenstrual acne flares, irregular menstrual cycles, and
elevated blood levels of certain androgens. The doctor may prescribe one of
several drugs to treat women with this type of acne. Low-dose estrogen
birth control pills help suppress the androgen produced by the ovaries. Low-
dose corticosteroid drugs, such as prednisone or dexamethasone, may
suppress the androgen produced by the adrenal glands. Finally, the doctor
may prescribe an antiandrogen drug, such as spironolactone (Aldactone).
This medicine reduces excessive oil production. Side effects of
antiandrogen drugs may include irregular menstruation, tender breasts,
headache, and fatigue.

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6/8/2015 Questions and Answers About Acne

DC; and Maria Tumer, M.D., National Cancer Institute, NIH, in the
preparation and review of this booklet.

The mission of the National Institute of Arthritis and Musculoskeletal and
Skin Diseases (NIAMS), a part of the National Institutes of Health (NIH), is
to support research into the causes, treatment, and prevention of arthritis
and musculoskeletal and skin diseases, the training of basic and clinical
scientists to carry out this research, and the dissemination of information on
research progress in these diseases. The National Institute of Arthritis and
Musculoskeletal and Skin Diseases Information Clearinghouse is a public
service sponsored by the NIAMS that provides health information and
information sources. Additional information can be found on the NIAMS
Web site at www.niams.nih.gov.

This booklet is not copyrighted. Readers are encouraged to duplicate and
distribute as many copies as needed.

Additional copies of this booklet are available from

National Institute of Arthritis and Musculoskeletal

and Skin Diseases (NIAMS) Information Clearinghouse
National Institutes of Health (NIH)

1 AMS Circle

Bethesda, MD 20892-3675

NIH Publication No. 01-4998

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Questions and Answers About Acne

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Publication Date October 2001
Questions and Answers About Acne

This fact sheet contains general information about acne. It describes what
acne is and how it develops, the causes of acne, and the treatment options
for various forms of acne. Information is also provided on caring for the
skin. If you have further questions after reading this booklet, you may wish
to discuss them with your doctor.

What Is Acne?

How Does Acne Develop?

What Causes Acne?

Who Gets Acne?

How Is Acne Treated?

Treatment for Blackheads, Whiteheads, and Mild Inflammatory
Acne

Treatment for Moderate to Severe Inflammatory Acne
Treatment for Severe Nodular or Cystic Acne
Treatments for Hormonally Influenced Acne in Women
Other Treatments for Acne

How Should People With Acne Care for Their Skin?
What Research Is Being Done on Acne?

Where Can People Find More Information on Acne?

What Is Acne?

Acne is a disorder resulting from the action of hormones on the skin's oil
glands (sebaceous glands), which leads to plugged pores and outbreaks of
lesions commonly called pimples or zits. Acne lesions usually occur on the
face, neck, back, chest, and shoulders. Nearly 17 million people in the
United States have acne, making it the most common skin disease.
Although acne is not a serious health threat, severe acne can lead to
disfiguring, permanent scarring, which can be upsetting to people who are
affected by the disorder.

How Does Acne Develop?

Doctors describe acne as a disease of the pilosebaceous units (PSUs).
Found over most of the body, PSUs consist of a sebaceous gland
connected to a canal, called a follicle, that contains a fine hair (see "Normal
Pilosebaceous Unit" diagram, below). These units are most numerous on
the face, upper back, and chest. The sebaceous glands make an oily
substance called sebum that normally empties onto the skin surface
through the opening of the follicle, commonly called a pore. Cells called
keratinocytes line the follicle.

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Other Treatments for Acne

Doctors may use other types of procedures in addition to drug therapy to
treat patients with acne. For example, the doctor may remove the patient's
comedones during office visits. Sometimes the doctor will inject cortisone
directly into lesions to help reduce the size and pain of inflamed cysts and
nodules.

Early treatment is the best way to prevent acne scars. Once scarring has
occurred, the doctor may suggest a medical or surgical procedure to help
reduce the scars. A superficial laser may be used to treat irregular scars.
Another kind of laser allows energy to go deeper into the skin and tighten
the underlying tissue and plump out depressed scars. Dermabrasion (or
microdermabrasion), which is a form of "sanding down" scars, is sometimes
combined with the subsurface laser treatment. Another treatment option for
deep scars caused by cystic acne is the transfer of fat from one part of the
body to the face.

How Should People With Acne Care for Their Skin?

Clean Skin Gently

Most doctors recommend that people with acne gently wash their skin with
a mild cleanser, once in the morning and once in the evening and after
heavy exercise. Some people with acne may try to stop outbreaks and oil
production by scrubbing their skin and using strong detergent soaps and
rough scrub pads. However, scrubbing will not improve acne; in fact, it can
make the problem worse. Patients should ask their doctor or another health
professional for advice on the best type of cleanser to use. Patients should
wash their face from under the jaw to the hairline. It is important that
patients thoroughly rinse their skin after washing it. Astringents are not
recommended unless the skin is very oily, and then they should be used
only on oily spots. Doctors also recommend that patients regularly shampoo
their hair. Those with oily hair may want to shampoo it every day.

Avoid Frequent Handling of the Skin

People who squeeze, pinch, or pick their blemishes risk developing scars or
dark blotches. People should avoid rubbing and touching their skin lesions.

Shave Carefully

Men who shave and who have acne can test both electric and safety razors
to see which is more comfortable. Men who use a safety razor should use a
sharp blade and soften their beard thoroughly with soap and water before
applying shaving cream. Nicking blemishes can be avoided by shaving
lightly and only when necessary.

Avoid a Sunburn or Suntan

Many of the medicines used to treat acne can make a person more prone to
sunbum. A sunburn that reddens the skin or suntan that darkens the skin
may make blemishes less visible and make the skin feel drier. However,
these benefits are only temporary, and there are known risks of excessive
sun exposure, such as more rapid skin aging and a risk of developing skin
cancer.

Choose Cosmetics Carefully

People being treated for acne often need to change some of the cosmetics
they use. All cosmetics, such as foundation, blush, eye shadow, and

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Normal Pilosebaceous Unit

Hair

Skin surface

Sebum ——_}f
Follicle -

Sebaceous_ ——"““ J

gland

The hair, sebum, and keratinocytes that fill the narrow follicle may produce
a plug, which is an early sign of acne. The plug prevents sebum from
reaching the surface of the skin through a pore. The mixture of oil and cells
allows bacteria Propionibacterium acnes (P. acnes) that normally live on the
skin to grow in the plugged follicles. These bacteria produce chemicals and
enzymes and attract white blood cells that cause inflammation.
(Inflammation is a characteristic reaction of tissues to disease or injury and
is marked by four signs: swelling, redness, heat, and pain.) When the wall
of the plugged follicle breaks down, it spills everything into the nearby skin--
sebum, shed skin cells, and bacteria-leading to lesions or pimples.

People with acne frequently have a variety of lesions, some of which are
shown in the diagrams below. The basic acne lesion, called the comedo
(KOM-e-do), is simply an enlarged and plugged hair follicle. If the plugged
follicle, or comedo, stays beneath the skin, it is called a closed comedo and
produces a white bump called a whitehead. A comedo that reaches the
surface of the skin and opens up is called a blackhead because it looks
black on the skin's surface. This black discoloration is not due to dirt. Both
whiteheads and blackheads may stay in the skin for a long time.

Types of Lesions

Skin surface
Blockage of
follicle opening

Microcomedo

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6/8/2015 Questions and Answers About Acne

‘Skin surface
Blackhead

Enlargement
of toliicle 5
opening —}

Sebaceous
gland ——t

Folicte |

Skin surface
Whitehead
Enlargement

of follicle
opening

Sebaceous
gland

Follicle
Closed Comedo (Whitehead)

Other troublesome acne lesions can develop, including the following:

¢ Papules-inflamed lesions that usually appear as small, pink bumps
on the skin and can be tender to the touch

¢ Pustules (pimples)--papules topped by pus-filled lesions that may
be red at the base

¢ Nodules—large, painful, solid lesions that are lodged deep within the
skin

¢ Cysts—deep, painful, pus-filled lesions that can cause scarring.

What Causes Acne?

The exact cause of acne is unknown, but doctors believe it results from
several related factors. One important factor is an increase in hormones
called androgens (male sex hormones). These increase in both boys and
girls during puberty and cause the sebaceous glands to enlarge and make
more sebum. Hormonal changes related to pregnancy or starting or stopping
birth control pills can also cause acne.

Another factor is heredity or genetics. Researchers believe that the
tendency to develop acne can be inherited from parents. For example,
studies have shown that many school-age boys with acne have a family
history of the disorder. Certain drugs, including androgens and lithium, are
known to cause acne. Greasy cosmetics may alter the cells of the follicles
and make them stick together, producing a plug.

Factors That Can Make Acne Worse
Factors that can cause an acne flare include:

¢ Changing hormone levels in adolescent girls and adult women 2 to 7
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