Prescription Acne Treatment

Most dermatologists will employ prescription acne treatment-topical medications applied to the skin and/or oral antibiotics-to help you control your acne.

Dr. Daniel Groisser, founder and medical director of The Dermatology Group of Northern New Jersey, has treated acne patients for many years. Here is how he deals with different degrees of acne.

Mild Acne

Topical antibiotics (clindamycin, erythromycin) help decrease bacteria and inflammation.

Topical benzoyl peroxide also helps to decrease bacterial load.

1. Topical retinoids-Retin-A (tretinoin), Differin (adapalene gel) and Tazorac (tazarotene)-help to increase skin turnover to prevent blockage of follicles.

Topical sulfur decreases bacteria and increases skin turnover.
Azelaic acid helps the epidermis shed.

"One of these prescription acne treatments-or a combination-may be used, depending on type of lesions (open and closed comedones) and skin type (sensitive versus nonsensitive; oily versus normal versus dry)," he says. "Improvement can be seen anywhere from 4 to 8 weeks."

Dr. Groisser cautions his patients that their condition may get worse before it gets better. He schedules a follow-up appointment in four to six weeks to evaluate progress. If acne has not improved, he may prescribe an oral antibiotic.

Prescription Acne Treatment for Moderate Acne

Oral antibiotics (tetracycline, doxycycline, minocycline, erythromycin) may be added to the topical regimen to decrease bacteria and combat the increased inflammation of moderate acne.

Oral contraceptives may be used in females to regulate hormone levels, as androgens stimulate sebaceous glands to produce more sebum.

"These oral medications may be used alone, but are more frequently used in combination with topical medications," Dr. Groisser says.

If the patient's condition doesn't change-or if it actually worsens-within 6 to 12 weeks, Dr. Groisser will consider prescribing Accutane. (See next section on severe acne.)

Prescription Acne Treatments for Severe Acne

Accutane (isotretinoin) is used for severe cystic acne or acne that is resistant to topical medications and oral antibiotics.

"This prescription acne treatment is highly effective, but it must be used with caution and requires experience in prescribing," Dr. Groisser says. Accutane has been linked to birth defects, so female patients must have two negative pregnancy tests before beginning the medication. They are also advised to be on two forms of birth control if they are sexually active during the course of prescription acne treatment.

"In all patients, careful monitoring of the blood-liver function tests, triglycerides, cholesterol-is necessary during therapy," Dr. Groisser says. "The treatment course usually lasts about 5 to 6 months, and 95% of patients can expect no recurrence of acne. Patients can expect clearing of acne in as early as two weeks."

Retinoids Revealed

Some patients secrete so much oil that it will reappear within 15 minutes of cleansing their face. Such cases prompt many physicians to prescribe retinoids like Retin-A (tretinoin), Differin (adapalene gel) or Tazorac (tazarotene), which are derived from vitamin A. These topical prescription acne treatments help minimize oil secretion. They work by:

• Reducing the production of sebum in the sebaceous glands and shrinking gland size.
• Decreasing inflammation and possibly eradicating bacteria.
• Penetrating the plug that congests the pore, allowing it to open.

Retinoids have become increasingly popular over the last decade. There are various strengths and formulations, which a dermatologist will prescribe based on acne severity.

You will usually be directed to wash your face and wait 20 to 30 minutes before applying the medication. Avoid the skin around the eyes and mouth, which can become irritated. Retinoids should be applied sparingly, as a little goes a long way.

Use of other products, such as benzoyl peroxide, while utilizing retinoids should be undertaken only with a dermatologist's blessing, as irritation may occur. As Dr. Groisser indicated earlier in this chapter, acne may appear worse before it improves during the first month of treatment. This occurs because deep lesions are rising to the surface.

Never discontinue therapy without talking to your doctor, and be patient. Wait 6 weeks before determining that the course of treatment isn't working-and then be sure to visit your dermatologist for a consultation. Complete improvement may take up to six months.

Problems occur when patients fail to follow directions. The most common side effects of retinoids are redness, swelling and scaling. Talk to your doctor, as your dosage and frequency of application can be adjusted.

Accutane

Dr. Groisser outlined the risks associated with Accutane earlier in this chapter, but a more thorough discussion is warranted.

Accutane has been routinely used for severe cases of cystic acne since its introduction in 1982. For some patients, it is the only drug that controls major breakouts.

Its use has become controversial, however, because it is associated with birth defects, as well as psychological side effects-particularly depression and suicide. (Several high-profile lawsuits have made it into international newspapers.) As Dr. Groisser emphasized, female patients must take proper birth-control measures when they are on the drug, as well as early pregnancy tests if there's any chance they have conceived. You must tell your doctor if you are pregnant, nursing or have recently had a baby.

Regulatory agencies in many countries are currently assessing whether the drug should continue to be prescribed. Dermatologists, however, believe they can successfully monitor their patients and that denying the drug to those who need it most-patients whose self-esteem is severely compromised by feelings of insecurity, inferiority and major depression-puts them at greater risk for mental-health problems.

The debate will continue, as Accutane is the "last stop" for many cystic acne sufferers, who have found it to be the only medication that controls their severe, potentially disfiguring breakouts. Even so, some patients still require another type of drug or a recess from using it. Close to 20% of patients may have to go off the drug for six months and then try another treatment regimen.

Make sure the dermatologist you see is experienced in prescribing Accutane so that you have the best chance of achieving results. Many dermatologists believe that only dermatologists-not family physicians or other primary-care providers-should prescribe Accutane, as they are best trained to deal with the drug's nuances and potential side effects. Dermatologists are often frustrated when patients come to them already on Accutane, when another treatment course would have performed better, with fewer potential side effects.

Accutane dosage must also be appropriate, and dermatologists often find that patients are not taking the right dose or that there is an interaction between Accutane and some other drug the patient is taking. This will prevent the Accutane-and quite possibly the other drug-from working properly.

According to Dr. Audrey Kunin, a board-certified dermatologist and founder of the DERMAdoctor line of skin care products, there are two new drugs currently under investigation for treatment of severe acne. The first is Isotrex, which is essentially Accutane mixed with a protective sunscreen base. It is currently available in Canada and Europe, and no one can predict how long it will take to receive approval by the FDA in the United States. Instead of taking it orally, the drug is mixed with the sunscreen liquid and applied directly to the skin. The second drug is Atrisone, which is a topical form of dapsone, a drug that is taken orally to treat infections and skin conditions that cause blisters. The drug works as both an antibiotic and anti-inflammatory, and it is a possible alternative to Accutane. According to Dr. Kunin, initial reports from clinical trials seem to indicate that Atrisone may be an effective drug down the road.

Dr. Kunin really understands acne because she learned in medical school that skin problems affect everyone, from infants to the elderly. During medical school, she had always dreamed of starting a cosmetics company that would allow her to marry the fields of dermatology and beauty. That's why she launched DERMAdoctor in 1998. Some of her products are quite unique, and there's literally something for everyone. She strongly encourages anyone who has been taking the same medication or following the same treatment regimen for a year, while continuing to experience breakouts, to talk to the dermatologist about a change. Generally, she allows six to eight weeks for any prescription acne treatment therapy to work. This doesn't mean acne will be 100% cured, but there should be some sign of improvement.