What to Do When Acne Persists | Anne Marie McNeill M.D., Ph.D

Is it my imagination, or is everyone more stricken with acne these days?
Dr. McNeill:  There does appear to be more prevalence and persistence.  Interestingly, we are finding that certain cultures, such as Japan, are experiencing more acne compared with previous generations.  In other, remote cultures, such as tribal communities in Africa, there is still no incidence of acne.
So, then, it is environmental?
Dr McNeill:  We do not know for sure.  It seems that any number of factors can increase acne, depending on the person:  stress, hormonal changes, lack of sleep, high sugar foods all seem to contribute to acne.
Chocolate.  Settle the question here and now, does it or does it not cause acne?
Dr. McNeill:  Unfortunately, it does.  A very well done study is the definitive answer to this long debated question.   Ingestion of 100% Ghiradelli chocolate increased acne lesions in acne-prone individuals.   If you are a person that is prone to acne, lay off the chocolate.
American Academy of Dermatology (AAD) 69th Annual Meeting: Abstract 305. Presented February 6, 2011.
What is appropriate treatment, and is treatment different for a teenager and adult?
Dr. McNeill:  The treatments are very similar for adults and teenagers, and are graduated, as follows:

1. A benzoyl peroxide wash and topical antibiotic and/or tretinion. If that fails,
2. Add an oral antibiotic. If that fails,
3. Consider isotretinoin (sometimes known as the brand name Accutane).

When you describe failure of an antibiotic, what time frame are you giving it to fail?  Most dermatologists would first prescribe another antibiotic.  Some people that take antibiotics to help with acne jump around to different ones as “they lose effectiveness” and are on antibiotics for years to help with acne. 
Dr. McNeill:  I disagree with this approach.  Most credible studies about antibiotics show that if they are effective for a patient, they will be effective within 3 months, and remain effective for a period of time.  If a patient believes that the antibiotic has lost effectiveness, what has most likely happened is that the acne has become more severe and treatment needs to be adjusted. The trouble is, we don’t want people on oral antibiotics for years. If the acne lasts for years, it is time to consider isotrentinoin.
So, isotrentinoin.  What is it and why is it so scary?
Dr. McNeill:  Accutane is a brand name for isotretinoin that is used to treat nodular, or cystic acne, that has not responded to other medications and has led to continued scarring in patients.  It works by shrinking the sebaceous, or oil, glands and is the only acne treatment that can be called a cure in 85% of patients.
Because it is a serious drug, there are serious side effects when not taken properly, most notably, birth defects to babies when accutane is taken by a female while pregnant.
How is accutane taken properly?
Dr. McNeill:  Isotretinoin must be taken under a qualified dermatologist’s supervision and monitoring.  ANY female of child bearing age must use two forms of birth control, submit to monthly pregnancy tests, pledge not to get pregnant while taking accutane, and participate in the iPledge program, where she will attest to her understanding not to get pregnant while on accutane.
What about suicide and depression, is it true that accutane can cause these in patients?
Dr. McNeill:  There was a teenage boy that committed suicide shortly after beginning isotretinoin.  He happened to be a senator’s son, and the senator lobbied hard (and unsuccessfully) to have the drug pulled from the market.  Since that case, doctors who prescribe the medication are required to monitor patients for signs of depression and suicidal thought, as well as ask about any history of mental illness or depression before placing patients on isotretinoin.  As a practical matter, many patients are the opposite of depressed when they are on isotretinoin, their skin looks and feels so much better that they feel much better.  It is very upsetting to look in the mirror and see a face full of cysts, scars, scabs and acne, especially in teenagers. There are lots of studies documenting overall improved self esteem after taking isotrentinoin.
So, interaction with the doctor prescribing accutane is necessary, for how long, what is a typical course of accutane?
Dr. McNeill:  ABSOLUTELY!  Plan to see your doctor once a month for the 6 to 8 months that you are on accutane, as well as taking blood tests to prove that you are not pregnant.
What happens at the end of treatment, will the acne really be cured?  Will another course of accutane be necessary, at some point?
Dr. McNeill:  It is considered cured in 85% of all patients.  There are some people that experience another bout of acne at some point in their lives, and another course of accutane is an acceptable treatment if such occurs.
What side effects can be expected?
Dr. McNeill:  Dry mouth and cracking lips, dry skin.  No waxing or other cosmetic procedures while taking accutane.  Avoid sunlight, as the skin will be more sensitive.  We always give very specific skin care recommendations for while you are on isotrentinoin.
What about the costs of accutane, is it covered by health insurance?
Dr. McNeill:  Accutane is available in generic form, is generally covered by insurance, and for people suffering with acne, often the total treatment of accutane for 6 to 8 months is more economical than years of expensive topical treatments and oral antibiotics.