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ASK THE DOCTOR: Zapping zits; Treating troublesome blemishes
By DR. JIM MITTERANDO
This is the second of a two-part series on acne.
Part I -- Chocolate, dirt among myths about acne

No single acne medication is right for everyone. Treatment involves trial and error to find the right combination. It takes six to eight weeks to see results from acne treatments. Common mistakes are not giving a treatment enough time to work and spot-treating pimples to ‘‘dry them out.’’ Medications don’t affect current pimples, but prevent future breakouts. That’s why the creams need to be applied all over the face. Excessive washing and scrubbing can irritate skin and worsen acne. Over-the-counter products that advertise to pull dirt or oil out of the glands do not work. Facial scrubs, astringents and masks can irritate skin and don’t treat acne. Acne is not an infection. Dysfunctional, plugged oil glands lead to increased bacteria that produce enzymes that irritate oil glands. Antibiotic creams and pills are used to decrease the bacteria on the skin and thereby reduce acne by reducing irritation.

Topical treatments

  • Benzoyl peroxide: This is an antibiotic cream or gel and one of the most effective and common treatments. There is no difference between the over-the-counter and prescription versions except the prescription is cheaper and comes in larger tubes. Benzoyl peroxide comes in three strengths: 2.5 percent, 5 percent and 10 percent. People commonly think the higher strengths are better, but the lowest strength is just as effective and less irritating and drying.

    Benzoyl peroxide can stain your clothing or bed sheets, so put it on in the morning after you get dressed. If you need to use it twice a day, put it on again after your evening meal.

    I am not a big fan of other antibiotic creams such as erythromycin and clindamycin because resistance commonly develops within six months of use. Bacterial resistance is not a problem with benzoyl peroxide.

    Retinoids: Added when other antibacterial creams are not sufficient to control acne. Retinoid creams, such as tretinoin (RetinA) reduce plugging of the oil glands. Other retinoid creams include adapalene (Differin) and tazarotene (Tazorac). These creams may be irritating and may initially worsen acne during the first two to three weeks of use. For this reason, benzoyl peroxide is used first before starting a retinoid cream to prevent an outbreak. Redness and peeling of the skin is worse during the first three weeks and then improves.


    These creams should be used at night because they cause increased sensitivity to the sun. Also make sure to use sunscreens and decrease sun exposure to avoid problems. Because benzoyl peroxide inactivates retinoid creams, the two creams should not be applied simultaneously. Benzoyl peroxide may be applied in the morning and a retinoid cream at night. Sometimes the combination of these two creams can be too drying to the skin. In that case, you can alternate creams using benzoyl peroxide one day and the retinoid cream the next.

    Azelaic acid: (Azelex) kills bacteria and reduces clogged pores. It appears to be as effective as benzoyl peroxide or tretinoin. There is not as much experience with this medication and it is often added if someone cannot tolerate other creams or when the acne does not respond to other treatments.

    Salicylic acid cream: (Loreal Pure Zone, Clearasil Total Contol, Johnson & Johnson Clean and Clear) is available with or without a prescription. It is not as effective as tretinoin, but it is not as irritating. Good for those who can’t tolerate certain creams. It must be used continuously since its effects stop when you stop using it.

  • Tea tree oil: Some people use tea tree oil for acne. It is mildly effective but not as good as benzoyl peroxide.
Oral treatments
Tetracycline or erythromycin: More severe cases of acne may require oral antibiotics. Ideally, treatment is for several months but some people require prolonged use for several years. Unfortunately, bacterial resistance can develop with prolonged use - especially with erythromycin. These antibiotics can upset the stomach and increase the risk of vaginal yeast infections in women. Doxycycline, minocycline: These antibiotics are tried when the above don’t help. Doxycycline is more likely to cause extra sensitivity to the sun. Some dermatologists prefer minocycline, though studies have show it is no more effective than tetracycline. Minocycline’s drawbacks include high cost and rare life-threatening reactions including hepatitis. Most antibiotics for acne should be avoided during pregnancy and breastfeeding. Oral contraceptives: Birth control pills are not considered a first-line treatment for acne in women but can be added when treatment with acne creams is inadequate. Accutane: People with severe, scarring, cystic acne and for people whose acne does not respond to other treatments can try accutane. Accutane can be a very effective and miraculous cure. It also can have serious side effects: depression, hepatitis and pancreatitis. It can cause severe birth defects if a woman gets pregnant while taking this medication.

Women are required to use two forms of birth control - oral contraceptives and condoms - and have monthly pregnancy tests while taking this medication. Periodic blood tests are required for both men and women to check their liver and triglycerides (fats). Accutane often causes very dry skin and lips as well as a red face during the first several months of treatment. It also can make people severely sensitive to the sun.

Dr. Jim Mitterando is a family doctor at Cohasset Family Practice and a staff member at South Shore Hospital in Weymouth.Readers should send questions to: Ask the Doctor, The Patriot Ledger, P.O. Box 699159, Quincy, MA 02269-9159, or by E-mail to his attention at features@ledger.com

.Questions of general interest will be answered in this column. The information in this column is not intended to diagnose individual conditions, and individual replies are not possible. Readers should see their own doctors about specific problems.

Copyright 2003 The Patriot Ledger
Transmitted Tuesday, May 20, 2003