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Official Lines on How Acne Should be Treated
In a revised December 1995 FDA Consumer article on acne, the US Food and Drug Administration's official lines on treating acne are, and I quote:
"Mild acne can often be cleared up simply by washing your face
There are also drugs that can be prescribed for more severe cases.
In very rare instances, where these measures don't work or haven't
With the exception of perhaps plastic surgery, I think many experienced acne sufferers have tried most of the above treatments. I know I did, and some more. All the years of treatment didn't make my acne any better. Still, I believe it must have helped some people. If you have not exhausted all the Western treatment options, I suggest you give them a try first. After all, they are scientific and methodical. In my case, I only began to look for alternative treatments after I couldn't get satisfactory results from Western doctors.
With my experience as a patient, together with additional research, I have prepared a more detailed account on traditional Western procedures and treatment options on acne. A better understanding on the subject should help you when you look for the right doctor the next time.
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Most Western doctors agree that acne is not caused by dirt. Still, they believe strongly that it is imperative to keep the face clean. Most doctors would agree that pricy soaps or cleansing agents are not necessary.
In general, washing the face twice daily with warm water and a mild antibacterial soap would serve the purpose. Washing too often may actually make your acne worse. The washing can help cut down on the build up of the bacteria P. acnes on the skin, and reduce the amount of environmental contaminant on the skin that can act like sebum and hinder the pores in expelling dead skin cells.
Fingers are a no-no for picking pimples, but they are the best for washing our face. If a face cloth must be used, use it gently. Do not use it to scrub the face. Scrubbing irritates acne already present, increasing inflammation. It can also break the pimples open on or under the skin, creating a cyst.
A wide variety of anti-acne soaps, pastes, and cleansers contain mildly abrasive substances such as polyethylene granules or aluminum oxide. These abrasives are very popular because people believe they can use them to scrub out clogged pores. However, studies conducted on the effectiveness of these ingredients are at best inconclusive.
When choosing cleansers, take care to read the ingredients. All soaps contain a certain amount of "tallow" types of ingredients to hold the bar together. But if one of the top four or five ingredients is an "oil", it's better off to pass on it. Oily cleansers, if not rinsed away completely, can act as a sebum substitute and clog our pores.
After cleansing, rinse face completely, and gently pat dry with a clean towel.
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The nonprescriptive acne medications listed below are for external use only. In general, use one medication at a time to reduce the chance of skin irritation. It is also easier to detect in case of unwanted skin reaction. You may want to experiment with these topical products first and see if they could improve your mild acne. Should you need to see a doctor, my experience is that the doctor would likely prescribe a combination of internal drugs and topical medications.
Most external treatments are designed to dry the face to some extent and to cause some degree of mild peeling which loosens plugs in oil glands. This peeling tends to smooth the face and resolve the old and new lesions. External medications can be irritating and may need a period of adjustment. Some minor irritation often occurs at the start of therapy. As peeling is underway, your face may not look the best for a while.
Sulfur 3 to 10 percent: Sulfur has been used for treating acne and other diseases for thousands of years in Chinese and other Oriental cultures. Though there have not been extensive scientific studies conducted on this ingredient, dermatologists generally accept it as a safe and effective acne treatment at concentrations of 3 to 10 percent.
Sulfur is used as an active ingredient in soap, cream and lotion. It is believed to act by causing the outer layer of dead and dying skin to peel away. It also may kill bacteria like P. acnes. Care should be taken to avoid getting sulfur products into one's eyes. If excessive skin irritation develops, discontinue use and consult a doctor.
Sulfur 3 to 8 percent + Resorcinol 2 percent; or
The combinations are used to make acne cream, lotion or stick. Apply them to affected skin areas only. Do not use on broken skin or apply to large areas of the body.
Salicylic Acid 0.5 to 2 percent: A skin-peeling agent that has been used to treat acne and other skin disorders for more than a century. The salicylic acid is found to be particularly effective against angry, inflamed pimples, whiteheads and blackheads. Since a milder dose of 0.5 percent is almost as effective as a stronger dose of 2 percent, it might be wise to start treatment with a lower (0.5 or 1 percent) dose of salicylic acid.
Salicylic Acid comes in the form of gel, lotion, cream, soap and medicated pads. When using salicylic acid products, be careful not to get them into eyes. If excessive skin irritation develops, discontinue use and consult a doctor.
Benzoyl Peroxide 2.5 to 10 percent: This compound has been used in a variety of medicines since the 1920s. It is the most common ingredient in over-the-counter skin products. In terms of treating acne, researchers have observed that it appears to act in two ways which are possibly related. The ingredient mildly irritates the blemished outer layer of skin and causes it to peel away. It then kills the underlying bacteria--particularly P. acnes--perhaps by overwhelming their environment with oxygen, which they cannot tolerate.
Benzoyl Peroxide comes in strengths of 2.5 percent, 5 percent and 10 percent, in the forms of lotion, gel, cream and mask. All are ruled by FDA as effective for treating acne. However, some studies have shown that the compound promoted the development of benign skin tumors and skin cancers on mice. Even though studies have not found any direct link between the ingredient and human skin cancer, I would prefer to use some other products mentioned above, just to be on the safe side.
Anyway, do not use this medication if you have very sensitive skin. Benzoyl Peroxide may cause irritation, characterized by redness, burning, itching, peeling, or possibly swelling. Keep away from eyes, lips, and mouth. The product can bleach hair and clothing as well.
Antibiotics (Clindamycin, Erythromycin and Topicycline): Topical antibiotics are fairly new and work directly on the skin by reducing the number of P. acnes and acting as anti-inflammatory agents. When they first came out, they were considered capable of reducing the need for oral antibiotics in the treatment of acne. However, sharp rise in resistance of P. acnes, together with erratic penetration into the follicles, has led some physicians to suggest that these products be avoided.
Topical clindamycin was the preferred topical agent, followed by erythromycin and, much less frequently topicycline (tetracycline hydrochloride). They are available as creams, lotions, gels, solutions and pads.
This form of antibiotics should be applied to the affected area twice a day after the skin is thoroughly washed with warm water and soap and patted dry. Acne lesions of the face, neck, shoulder, chest, and back may be treated in this manner. However, be careful to keep the antibiotics from the eyes, nose, mouth, and other mucous membranes.
To minimize irritation, fair-skinned patients may begin by applying the 0.025% cream one hour after washing nightly or every other night. Maximal skin sensitivity occurs in blonds and redheads and those with blue eyes and fair complexions as well as in persons who tan poorly.
The quantity of tretinoin applied may be gradually increased as tolerated, and ultimately twice-daily applications may be appropriate. During the initial 4 to 6 weeks of therapy, it is not uncommon to see redness and scaliness of the skin. Stay away from sunlight when using Tretinoin.
Azelaic acid: Available since 1973, azelaic acid was approved for marketing in Europe in 1989 and, following experience with nearly 2 million patients, received FDA approval in 1996. This compound functions as an antibacterial agent; it also normalizes the keratinization process and may be anti-inflammatory. Studies suggest that this well-tolerated preparation is as effective as tretinoin, benzoyl peroxide, oral tetracycline, and topical clindamycin. The manufacturer recommends that the 20% cream be applied twice daily.
Adapalene can be prescribed in initial therapy, adjunctive therapy, or as maintenance therapy. Adapalene is white, odorless, oil-free and alcohol-free.
Adapalene may show quicker improvement in reducing the number and severity of acne lesions, however, as much as 40% of patients could experience various degrees of skin irritation, including erythema, scaling, dryness and burning.
I have not tried this product or azelaic acid as they came out after I've switched to the alternative treatment approach. Since then my acne has been under control and I don't need to experiment with new medications.
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Antibiotics work for getting rid of an infection, like strep throat. When it comes to treating acne, all topical and oral drugs are doing is temporarily killing the bacteria, which eventually become resistant to the antibiotic. Resistance of P. acnes to oral antibiotics, particularly tetracycline and erythromycin, first recognized in 1978, has really put a question mark as to the effectiveness of such medicines.
Deciding if and when to prescribe a course of oral antibiotics for acne is a matter of personal preference. Studies fail to provide guidelines regarding selection of a particular drug, its dose, or the duration of therapy. However, side effects have been observed over lengthy periods of use of antibiotics. Conditions such as irritation of the gastrointestinal system (antibiotics can wipe out the friendly bacteria in the digestive system), candidal vaginitis (some women develop a yeast infection in the vaginal area when taking oral antibiotics) and sensitivity to light are long known. It is also important to know that oral antibiotics may decrease the effectiveness of birth control pills.
Whether oral antibiotics exert their effects through antibacterial activity or a yet undetermined mechanism of action is unknown. Antibiotics may alter the amount of lipase available in the follicle and reduce the free fatty acid concentration without necessarily altering the population of P. acnes organisms. Oral antibiotics also may have an anti-inflammatory effect.
For over 30 years Tetracycline has been a common and safe antibiotic prescribed by doctors to treat acne. Tetracycline does not cure, but only suppresses acne-type skin disorders. Doctors nowadays may not prescribe as much, but I came from the old school, and I've taken my share of the medicine. My experience with it was that after some initial success, its effectiveness would gradually wear off. Still, I was put on this medicine by various doctors for many years.
Tetracycline or its derivatives (doxycycline, minocycline, methacycline, demeclocycline, oxytetracycline) are oral antibiotics. Patients differ in the amount of tetracycline they need. A full daily dose of tetracycline is generally prescribed for the first few weeks or months to see how well it controls the skin problem. After the acne seems to be under control, the doctor would generally advise a gradual reduction of the dosage. There's a lag period of one to three weeks between the change in dosage and its effect on skin. If the acne problem became worse again, in my experience, some doctors would put me back to the previous higher dosage; some would prescribe other medications.
Use of the medicine is not recommended during the last half of pregnancy and during breast-feeding. Tetracyclines may cause the unborn infant's teeth or the nursing baby's teeth to become discolored and may slow down the growth of their teeth and bones. As well, tetracyclines should not be given to children up to 8 years of age because of similar side effects. I always suspect that my teeth are a bit too yellowish because I took too much tetracycline. You see, I don't smoke and I don't drink. Why should my teeth be yellowish if not for the tetracyclines that I had taken for so many years?
Erythromycin is an antibiotic used to treat a wide variety of bacterial infections, such as respiratory tract infections, middle ear infections, skin infections, among others. When used as a treatment against acne infections, erythromycin has a similar effect as tetracyclines. Although the mechanism by which this product acts in reducing inflammatory lesions of acne vulgaris is unknown, it is presumably due to its antibiotic actions. It can be used systemically and topically.
May cause stomach upset, diarrhea, loss of appetite, nausea, vomiting and stomach cramps during the first few days of use as your body adjusts to the medication.
Least photosensitizing of the tetracyclines.
Similar to tetracycline, minocycline makes you more sensitive to sunlight. So you may need to use a sunscreen when taking this antibiotic. It may cause dizziness or light-headedness to some people. Long-term use can cause skin pigmentation.
Corticosteroids are man-made forms of cortisol, a hormone made by the adrenal glands. Cortisol plays an important role in the function of almost every part of the body. Corticosteroid medications have 2 main actions in the body. They reduce inflammation and decrease the activity of the immune system.
Corticosteroids are not anabolic steroids (abused by some athletes to increase muscle mass).
All corticosteroids have potential side effects. Two things increase the risk of side effects with corticosteroids: high doses and long-term treatment. Some side effects may cause multiple symptoms, not all of which may occur.
Some common side effects include severe allergic reactions such as difficulty in breathing, fainting, tightness in the throat, swelling of the face or eyes; serious infections in the form of high fever or painful urination; bleeding in the digestive system; high blood pressure; slow wound healing; difficulty in sleeping, among others.
I had not been prescribed with Corticosteroids by my doctors before. With that list of side effects, I would prefer to pass it.
Elevated levels of male hormones (androgens) are known to cause acne in some women. These high levels of androgens prompt the sebaceous glands to increase the secretion of sebum. The androgens can also cause follicles to harden in affected areas of the face. Estrogen (female hormone)-dominant oral contraceptives work to reduce excess androgen and have shown significant improvement to women with acne. Occasionally, birth control pills are used specifically for the treatment of acne.
A synthetic form of vitamin A called 13-cis retinoic acid, or isotretinoin, sold by prescription as accutane, is a prescription medication used in cases of severe, cystic acne. This medication, which received FDA approval in 1982, is the most potent agent available for treating acne. However, its significant side effects in causing fetal malformations continues to cast a shadow over its use in women of childbearing age. Women must not take accutane if they are or may become pregnant during treatment.
Because of accutane's significant side effects, its use should be restricted to persons with severe, cystic acne. However, some doctors recommend its use in patients with moderate acne who have had an inadequate response to antibiotics, who have progressive disease with scarring, or who have significant emotional distress due to acne.
Accutane works in suppressing sebum production by as much as 90%. It also acts as an anti-inflammatory agent and an immunomodulator.
Almost universal side effects of accutane are dry and itchy skin. There are numerous other potential complications and warnings. Of paramount concern, as stated above, is use of the drug in women of childbearing potential. Fetal malformations regularly occur even when pregnant women are exposed briefly to accutane.
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This is a common procedure performed in a dermatologist office. It refers to several surgical approaches for removing acne lesions. These include opening up pimples by using a needle or small pointed blade and forcing out the bad stuff with a comedo extractor.
Removal of non-inflamed acne lesions is almost a standard procedure performed to every patient by dermatologists at early part of the visits. Blackheads (open comedones) and whiteheads (closed comedones) are non-inflamed lesions. These can be removed mechanically with a comedo extractor and a fine needle or a pointed blade to open comedones. Such maneuvers are temporary, and new comedones may form to replace the ones removed.Incising or cutting open inflamed lesions for drainage used to be popular; however, with the introduction of cortisone injections, this method is used less often. Incising a lesion may leave a small scar; injecting a cortisone does not. However, the rare, large, deep acne lesions may not respond to cortisones and may have to be incised.
Some doctors consider using this procedure dangerous. The infected material may be forced back into the bloodstream instead of outside the skin surface, and being carried to other parts of the body. They particularly warn against squeezing pimples that erupt in the triangular area between the top of the nose and the corners of the mouth, because some of the underlying blood vessels drain directly into the brain.
Cortisone injection of a diluted corticosteroid into larger inflammatory acne nodule and cyst lesions usually produces quick improvement within a day or two. The lesions would be flattened. Flat lesions are more readily camouflaged with makeup or a tinted acne lotion. Cortisone injection therapy is helpful as an additional treatment when acne is not adequately suppressed with antibiotics.
Dermabrasion is a surgical procedure performed to remove skin damaged by acne scarring. A machine with a rotating wheel is applied to the face. After the treatment, a scab normally forms on the treated area for several days. When this comes off, the skin is healed but very pink. It looks awful right after the treatment and continues so for several more months. Makeup may be required to hide the pink skin. After that, when the skin has faded, it may have a slightly different color, usually lighter. Discoloration and swelling are common occurances for two to three months while the wound is healing.
Sometimes, infection or excessive bleeding from the wound may occur. Scarring within the healed skin, though rare, does happen to some patients.
Despite all these painful sacrifices, dermabrasion does not actually remove scars. The procedure results only in a leveling or smoothing of the surface skin which makes scars less noticeable. If you are not desperate, don't try this.
As I've said in the homepage, my experience with this treatment was of total horror. I still can remember that sunny afternoon in the office of the Seattle doctor. He told me that he was going to try freezing on me. I would feel some coolness on my face, he said, and that was all. And that was exactly what I felt while he was doing my face. After the treatment, I took a look at myself in the mirror. Nothing particular. My acne lesions were neither better nor worse.
The nightmare didn't come until the following morning. I woke up, went to the washroom, was shocked to see a stranger with a destroyed face looking at me from the mirror. It took about thirty seconds before I realized that the stranger was myself. Oh god! What happened!
It took a total of six months before my face was back to normal. The destroyed, dead, burnt parts of the facial skin had to be peeled off slowly, patch by patch, layer by layer, until they were gradually replaced by the new skin. It was a painfully slow process, all the while I was embarrassed to death. I don't understand why this treatment could ever be accepted by the medical industry. It didn't do an iota of good to the acne condition. It's a totally stupid process. Don't ever let your doctor talk you into doing this.
Perhaps because ultraviolet light in the form of moderate exposure to summer sunlight is helpful to some acne patients, some doctors in the past began using artificial ultraviolet light such as sun lamps to treat acne. I did my only sun lamp thing at the Seattle doctor's office. No other doctor I have seen recommended using this method. As I am doing the research for this site, all literature I've read on this subject said the same thing--avoid ultraviolet light and sun lamp.
Excessive exposure to ultraviolet light from any source may lead to premature wrinkling and skin cancer. It could also result in sunburns. Ironically, it could actually cause acne. Ultraviolet light kills skin cells. As the dead skin cells clog pores, acne develops.
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