Introduction

My mother always wanted me to be a dermatologist.

Good hours and good pay, was what she'd say. But I was convinced that I would be anything but. Who wanted to treat acne and warts all day long? Yet, despite my best intentions, I fell in love with dermatology.

A medical school rotation in dermatology at the Santa Clara Valley Medical Center in San Jose opened my eyes to the fact that dermatology had a lot going for it. I could care for children and adults and perform as little or as much surgery as I liked. Plus, I discovered that skin conditions weren't even remotely limited to those in my own childhood (warts) and adolescence (acne) -- they affected everyone.

Upon my arrival back at the Medical College of Ohio that summer, I found myself under the tutelage of Drs. Walter and Dorinda Shelley, naively unaware that these two experts were considered pioneers in dermatology. Their offbeat and unique insights into dermatological therapy widened my understanding of how medicine is often as much an art as a science. Working with them solidified my interest and fanned my enthusiasm.

But while I have to begrudgingly accept the fact that my mother was right about my eventual career choice, even she never predicted the nontraditional use of my degree -- a use that has allowed me to help millions of people seeking skin care solutions. Here's what happened...

Back in 1998, in the midst of the dot-com boom, I didn't even know how to turn on a computer. However, my husband, Jeff, whose passions included both business and the Internet, saw an unmet need -- and www.DERMAdoctor.com was born. It was a great opportunity to provide skin care items online, as well as thoughtful advice and expertise. But our business start-up wasn't like that classic IBM commercial where the orders start rolling in. Rather, it was the e-mail that was overwhelming. Perhaps this occurred because it was next to impossible to obtain an HMO referral to see a specialist...or maybe it was the average sixteen-week wait to see a dermatologist...or it could be that so much of rural America was underserved by specialists. Whatever the reason, I got literally thousands of questions. And responded to every one. After answering similar questions over and over again, I started writing articles in order to provide complete descriptions of the conditions I was being asked about. As a result, the skin care information on DERMAdoctor.com grew and grew.

By the end of 1999, a recurrent theme had surfaced. Conditions previously not addressed by the cosmetics and skin care industries, like keratosis pilaris (a.k.a. chicken skin bumps), were continually being queried. Critiques of products in widely recognized categories were also accumulating.

Friends from medical school remember that I had wild dreams about starting a cosmetics company, marrying dermatology with beauty. It was time to dust off my dream and launch my targeted line of skin care solutions: DERMAdoctor Specialist Skin Care. It took four years and countless hours of self-education (and frustration!) before our first product hit the market.

Traditionally, skin care has been quite sterile, clinical, and predominantly masculine. Since I was essentially a mirror image of my own target audience, I knew that clinical skin care could use a feminine approach, even a touch of fun and whimsy. After all, most skin conditions are chronic. I was searching for something I could enjoy using day after day, something I'd enjoy looking at in my medicine cabinet (I prefer my skin therapy to be not only luxe but pretty), and something that was highly effective. I figured everyone else would be seeking the same thing.

Now more than five million people a year in America and around the world turn to DERMAdoctor.com and DERMAdoctor Specialist Skin Care for answers. However, I felt there was another unmet need in the marketplace -- the need for a truly practical and comprehensive do-it-yourself skin care book.

It is not my intention to encourage people to diagnose themselves and replace the dermatologist. Rather, I wish to empower them to take the best possible care of their skin. DERMAdoctor.com has consistently positioned itself to be the definitive source of skin care information, educating consumers on up-to-date prescription medications, procedures, and workups. Sometimes seeing a physician needn't be your first response to a problem. Chicken skin bumps? There is no reason not to begin treatment at home. Poison ivy on Saturday night? Good luck getting into the dermatologist come Monday morning, not to mention dealing with the agonizing itching in the meantime.

Personalized skin care begins at home and can help prevent problems down the road. The DERMAdoctor Skinstruction Manual is one of your best tools and resources for at-home skin care.

Textbooks are boring. Magazines may not offer enough information for you to make an informed medical decision. The DERMAdoctor Skinstruction Manual provides information that's interesting, sometimes funny, occasionally poignant, and always up to date, with the best that medicine has to offer. It's about what really works or doesn't work. It's what you need to know about a treatment, a condition, an issue. It's about self-empowerment. And it's me and you, talking one on one about how I really treat skin issues; it's how I sit down, girlfriend to girlfriend, and discuss what really matters.

The DERMAdoctor Skinstruction Manual is how I relate to people. I was never good at the "mill" that medicine has become. I would find myself spending twenty or thirty minutes or more with each patient, having an in-depth discussion about their skin condition and treatment options. That's not going to get me far in a practice in this day and age, but that in-depth approach has allowed me to develop the material you'll find here.

Also, this book reflects what is going on in my life. Whether it's my personal experience with my surgically induced menopause or my son's outbreak of chickenpox, my life and The DERMAdoctor Skinstruction Manual are closely intertwined.

When I was a child, my mother often turned to Dr. Spock's book on child care, searching for information on tonsillitis and other disorders. I like to think of The DERMAdoctor Skinstruction Manual as that kind of resource -- convenient, all-encompassing, accessible, and entertaining.

Everyone has a skin condition. It doesn't matter if it's your first case of acne or your first issue with crow's-feet. The DERMAdoctor Skinstruction Manual allows you to make educated decisions and find appropriate solutions for your skin. It shares all the skin care secrets and tips that I have long recommended to my own patients. When you have this book in your home library, the skin doctor is always in.

Copyright © 2005 by Audrey Kunin, M.D.

Chapter One: Acne

No One Needs to Suffer

It's rare to escape the acne experience. Approximately forty-five million young adults between the ages of twelve and twenty-four have acne. And that number doesn't even include the millions of acne patients in their twenties and thirties who are more likely to develop acne than their teen counterparts.

A strong genetic predisposition is the source of most acne, exacerbated by hormonal changes (most women already know this!); stress associated with school, jobs, and starting families; and, occasionally, poor skin care habits.

How Does Acne Form?

Acne is a disorder of keratinization -- the development of the cells lining the sebaceous (oil) glands.

Instead of easily exfoliating themselves onto the surface, the cells become sticky, bind together, and plug the glands. But the sebaceous glands continue to secrete sebum, automatically triggered by DHT, the active form of testosterone. The excess sebum and lack of oxygen beneath the plug create a perfect environment for Proprionibacterium acnes (P. acnes), the bacteria that live on the skin. Too many P. acnes bacteria contribute to the inflammation within the gland.

Eventually, a combination of persistent plugging, excessive oil buildup (envision an expanding water balloon), and inflammation produced by bacterial overgrowth causes the gland to rupture. On the surface, this manifests as an inflamed acne papule or cyst.

Not All Acne Is Created Equal

There are different types of acne lesions. These are:

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Dermatologists also give acne a "grade" for severity, based on an estimate of the total number of lesions. Grade 1 is the mildest, with very few lesions. Grade 4 is the most severe. (A grade also allows the dermatologist to track improvement or lack thereof.)

Treatment is based on the types of lesions and the grade.

Treating Acne

Every dermatologist has her favorite acne regimens that have proven successful for her patients.

When a patient comes to my office, I evaluate the types of lesions and the grade, then determine the therapy. The goal of all acne treatments is to:

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Many acne treatments conveniently provide more than one benefit, helping simplify the process. I allow six to eight weeks for any therapy regimen to show considerable (notice I didn't say "miraculous") improvement. If a patient does not improve enough, I will often change her medication. (Anyone who finds herself on the same medication for a year while continuing to break out shouldn't hesitate to talk to her doctor about a change!)

Prescription Systemic Therapy

Systemic therapy (pills) is best for inflammatory acne and practically mandatory for acne cysts. There are three categories of oral medication:

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Antibiotics

P. acnes bacteria thrive on excess sebum and in a low-oxygen environment. The result of bacterial growth is the production of highly inflammatory free fatty acids, which cause whiteheads, red bumps, and painful cysts. Antibiotics are used not only to kill P. acnes but also to reduce inflammation.

A stray monthly pimple doesn't warrant a long-term commitment to antibiotic therapy, but a patient plagued by blemishes -- whether numerous or resistant to topical therapy -- may qualify.

Several types of antibiotics are commonly used. They include:

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The tetracycline family (tetracycline, minocycline, doxycycline) is considered the most effective group of antibiotics for acne therapy.

Tetracycline is most commonly prescribed in doses of 500 milligrams (mg), taken twice daily.

Minocycline (Minocin) is a more aggressive member of this antibiotic family and is given in a dosage of 50 milligrams, once or twice a day. It also is much more expensive. I reserve minocycline for patients who don't respond to tetracycline and patients with primarily cystic acne.

Doxycycline is similar to minocycline. However, I have not personally had nearly the response rate to this medication as I have to Minocin, so I tend to favor the latter.

The tetracycline family may cause increased sensitivity to the sun. These drugs are not to be used if pregnant or nursing, nor are they appropriate for patients younger than thirteen years of age, as they can cause permanent discoloration of dental enamel.

Erythromycin is not as effective for treating acne and tends to cause significant stomach upset. (To reduce nausea, take it on a full stomach.) I save this for patients unable to take tetracycline or its family members and for preteens.

Sulfa is highly effective, but allergies to this antibiotic are very common, so it is infrequently prescribed for acne therapy.

Hormonal Therapy

All women produce androgens (male hormones), including testosterone; a balance of androgens and estrogen (female hormones) create harmony for the skin, like a biochemical yin and yang. But when androgens outweigh estrogens, it's blemishes galore.

A woman can make too much testosterone, as in polycystic ovary syndrome (PCOS). She can make too little estrogen to "mask" the testosterone. Or -- by far the most common cause of what's called androgenic acne -- the cells in her skin and hair follicles can have a genetically predetermined sensitivity to "normal" levels of androgen.

However, it's not the testosterone itself that's causing the problems -- it's DHT, a metabolite of the hormone. As explained earlier, DHT triggers an increase in sebum production. It also enlarges the sebaceous glands. Control the DHT and you control the acne. Hormonal medications can do that job.

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Birth control pills do all three of these things. They help prevent the formation of active androgens. They increase sex hormone binding globulin (SHBG), which binds to androgens and prevents them from going anywhere. They decrease the levels of circulating testosterone. And the progestin (the synthetic form of progesterone) in an oral contraceptive competes for binding sites on androgen receptors.

The only oral contraceptive the FDA has approved for the treatment of acne is Ortho Tri-Cyclen. This medication went through the rigorous testing and studies required by the FDA to prove that it was indeed beneficial for acne.

Spironolactone. Many women are turning to noncontraceptive antiandrogen options in the treatment of their acne, like the diuretic spironolactone (Aldactone). This drug -- used to reduce water retention and control high blood pressure -- has a molecular structure that mimics androgens. This allows it to bind to androgen receptors, blocking true androgen and helping to control acne. There are downsides to spironolactone use, however, including symptomatic low blood pressure, irregular menstrual cycles, spotting, and higher levels of potassium in the bloodstream. (If you take the drug, it's important to avoid binging on foods high in potassium, like bananas.)

Yasmin. For women who want the benefits of an antiandrogen but don't want to be on a diuretic, or for those who want to be on birth control pills but hate those extra few pounds of water retention that tend to go hand in hand with birth control pills, a new-generation oral contraceptive, Yasmin, may be a solution.

Yasmin contains drospirenone, a progestin that is structurally very similar to spironolactone. Because of this resemblance, Yasmin may be a beneficial "off-label" drug for addressing androgenic acne and can help you avoid those extra few pounds.

Injectable Steroids

The stray acne cyst can be rapidly resolved with a small shot of steroid solution known as triamcinolone (Kenalog). The upside: a quick fix for those "little emergency" situations like weddings and proms. The downside: this is simply not the way to treat widespread, recurrent acne. Nor is it pleasant to experience the infrequent side effect of a "sink" spot because of fat atrophy at the injection site. (Fortunately, it fills in over several months.)

Topical Therapy

A hot topic in acne therapy is how to best handle breakouts with topicals. Some consumers don't want to take pills; others, for various reasons, can't take pills. Most simply want to get clear skin fast and are willing to incorporate any agent into their routine that maximizes treatment.

Topicals are as varied in their actions as systemic therapies. They are invaluable for treating minor outbreaks and supplementing systemic therapy.

Synthetic Retinoids

These derivatives of vitamin A are indispensable in acne therapy. Similar in action to Accutane, they work to normalize the keratinization process. (For more information on Accutane, see the sidebar on page 9.) They can help eliminate blackheads, dry up excess oils, and squelch papular and pustular acne. But, unlike with Accutane, these benefits are only temporary.

Prescription retinoids are the most potent. But if for some reason they can't be used, a nonprescription retinol (like Afirm) can be beneficial. Prescription options include:

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Retinoids are extremely potent. To avoid irritation, make sure to follow these steps:

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Whether over-the-counter or prescription, vitamin A topicals should not be used while pregnant or nursing. They also may increase sun sensitivity; wear sunscreen with an SPF of 30 daily.

Topical Antibiotics

A myriad of prescription topicals possess bacteria-killing abilities. These products can help treat whiteheads and small inflammatory acne lesions and are typically applied twice a day. Some options are:

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Benzoyl Peroxide (BPO)

Benzoyl peroxide is a tried-and-true acne treatment. Its benefits derive from its bacteria-thwarting abilities.

Strengths range from 2.5 to 10 percent. Benzoyl peroxide can be found in both over-the-counter s20and prescription treatments -- often at the same levels! Gels, creams, lotions, soaps, masks, and even shaving creams provide formulations for every need. Recent variations have married benzoyl peroxide with other ingredients.

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Benzoyl peroxide can be a useful aid in acne therapy, but don't go overboard. It can cause dryness, redness, and irritation if overused. There are even an unfortunate few people who are allergic to it. Pay attention to what your skin is telling you and reduce your use should any irritation develop.

Azelaic Acid

Azelaic acid is a naturally occurring dicarboxylic acid found in grains like wheat, rye, and barley. Studies show that it possesses antibacterial activity against P. acnes, and it may also help normalize the keratinization process within the sebaceous glands.

Look for it in prescription acne medications like Azelex 20% Cream.

NDGA

Is there any topical medication that can reduce DHT, the hormone that revs up the sebaceous glands, causing oily skin and acne flare-ups?

Scientific research says yes.

The ingredient is NDGA -- nordihydroguaiaretic acid, a natural plant-derived lipoxygenase inhibitor (which means it inhibits inflammation). Some studies suggest that the botanical NDGA possesses the ability to reduce the activity of 5 alpha-reductase, the enzyme responsible for changing testosterone into DHT.

DERMAdoctor's own 2n1 rosacea cream contains NDGA. It can help make your acne regimen 0more tolerable and effective by improving the appearance of redness caused by acne, inflammation, and other treatments, as well as visible blemishes. And since it isn't yet another topical antibiotic, it is complementary with other acne therapy.

Sulfur

Sulfur helps inhibit the growth of P. acnes and unclog pores. You can find it as a solo ingredient, in either over-the-counter or prescription options. In combination with sulfa, it's approved for use in prescription acne rosacea and seborrheic dermatitis (dandruff).

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Procedures

Dermatologists may include procedures in their approach to acne. Most commonly, "acne surgery" is performed. This essentially refers to the use of a comedone extractor being firmly applied around a blackhead to push it out of the skin.

Other options include chemical peels, microdermabrasion, and (an old-time procedure) the application of liquid nitrogen to an acne cyst.

In my approach to acne therapy, I have personally found procedures rather limited and turn to them only to supplement other treatments.

Shedding Light on Acne

Those who make their way to a dermatologist often credit summer sunlight as helpful in reducing acne severity, and studies support the benefits of sunlight in acne therapy. But with today's heightened concerns about skin cancer (not to mention wrinkles!), indiscriminate use of medical ultraviolet phototherapy is not the treatment du jour. Leave it to medical science to find another way to get that summertime-like improvement.

The Acne Blues. P. acnes bacteria produce natural by-products called porphyrins. Porphyrins are exquisitely vulnerable to a high-intensity, narrow band of visible blue light. When porphyrins are exposed to this light (or, to a lesser extent, natural sunlight, which contains a less intense form of blue light), a chemical reaction toxic to P. acnes takes place. Kill the P. acnes, improve the acne.

Commercially, this process is called Acne PhotoClearing and is marketed under the name ClearLight, which has been approved by the FDA for the treatment of mild to moderate inflammatory acne -- small, red papules and pustules (whiteheads). ClearLight is unlikely to resolve blackheads or cysts, minimize pore visibility, or reduce oiliness.

Remission with ClearLight usually lasts between four and eight months. Repeated series of ClearLight may be required for maintaining a clear complexion. And not all cases of acne are triggered by P. acnes, so the procedure isn't for everyone.

Smoothbeam Laser

This laser takes aim at the literal root of the problem: the sebaceous gland. In a series of treatments, the heat of the Smoothbeam alters the structure and function of the glands.

Results are fairly impressive. Improvement can be seen as early as three weeks -- and after four treatments some patients achieve 98 percent clearance! However, those results aren't permanent. In one study, at a twenty-four-week follow-up, 100 percent clearance was seen in just one of twenty-seven patients.

Future Treatments

Two candidates in the "acne pipeline" include topical versions of oral medications already used to treat severe cases of cystic acne.

Isotrex. Essentially Accutane mixed in a protective sunscreen base, Isotrex is available in Canada and Europe. (For more information on Accutane, please see the sidebar on page 9.) I have read mixed reviews from Canadian and European dermatologists. It will be interesting to see if this medication makes its way through the FDA and onto the U.S. market and how it will truly perform.

I have seen some first-time patients who had been given "homemade" forms of this product by other doctors, which consisted of them poking holes in the Accutane capsule and applying the liquidy gel straight to the skin. All this method accomplished was to locally irritate and dry the skin without helping clear the acne lesions.

Atrisone. The topical form of the oral medication Dapsone, Atrisone is typically used in the treatment of certain forms of blistering disorders and systemic infections. It has both antibiotic and anti-inflammatory actions. It is occasionally prescribed for severe cystic acne when Accutane cannot be used or has not been effective. Atrisone sounds promising in the initial reports and is currently in clinical trials. Should the FDA approve it, Atrisone would offer an entirely new category of acne therapy.

11 Important Points to Remember About Acne Treatment

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Everyday Skin Care for Acne Patients

Acne is not caused by a lack of cleansing, but removing pore-plugging, bacteria-nourishing oils, as well as surface cellular debris, goes a long way to minimizing breakouts.

Glycolic acid (an alpha hydroxy acid, or AHA) and salicylic acid (beta hydroxy acid, or BHA) help dissolve grease and grime, lifting away cells plugging the pores. Glycolic acid tends to be more versatile and can be found in cleansers, treatments, and toners. BHA often assists glycolic acid in AHA-BHA products.

Thanks to the plastic industry, polymers have been created to surround and lift core-plugging oils away from the skin, without causing irritation or parching. They help keep the skin free of shine all day long.

Here are the types of products dermatologists advise their acne patients to use in routine skin care:

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Final Thoughts

Too many acne sufferers go untreated for far too long. No one need suffer with acne -- today there are more effective therapy options than ever. If you have acne that doesn't respond to over-the-counter treatment, please see a board-certified dermatologist.

Ask the DERMAdoctor

QUESTION

I do a pretty good job of keeping my mild acne under control, but sometimes one or two pimples just pop up -- particularly right before an important event like a presentation at work or a party! (Must be the stress.) What's the best way to camouflage a pimple?

The DERMAdoctor:

First, you need to treat it. I recommend dabbing on a product with acne-fighting benzoyl peroxide, like Peter Thomas Roth BPO Gel 10% and Sulfur. Another possibility is an AHA-BHA product, like M.D. Forté Glycare Perfection Gel.

For those who like to carry around their emergency "zit fix" in their purse, Cellex-C Skin Perfecting Pen is a great way to dab your way to an invisible blemish, especially when you start out early. The natural botanicals have a drying effect and create an environment hostile to the bacteria. If none of these is on hand, try spotting the blemish with toothpaste. Select one that is white, free of cinnamon flavoring, and not packed with tooth-whitening peroxide.

Once you've dried it out, it's time to cover it up. One of the trade secrets of makeup artists who work on movie stars is Visine. The same stuff that "gets the red out" of your eyes can help get the red out of your face. After you've done your best to dry out the pimple, soak a cotton swab in Visine. Then hold the swab to the affected area for about ten seconds. The redness will disappear.

Next, get out that concealer. Green-tinted concealers are great for camouflaging redness. One to try: T. LeClerc Liquid Concealer-Tilleul. The green works to neutralize the redness. Don't overdo it or you'll make the blemish more obvious that it was before you tried to get rid of it. Use a small amount and tap lightly. Apply a small (repeat: small) amount to the blemish; then, using your ring finger (it exerts the least amount of pressure of all your fingers), lightly tap the concealer into the blemish.

When you apply your regular makeup, be careful not to smear the concealer, and always set your makeup with loose powder. This will reduce the chance of removing the concealer. You want to make your face look as uniform as possible, so that the pimple doesn't stick out and announce its presence to the world.

Copyright © 2005 by Audrey Kunin, M.D.