James J. Romano, MD
Acne is a chronic inflammatory disease of the sweat glands and hair follicles. It affects patients of all ages. It results from multiple factors, but the abnormal degree of keratinization or epidermal cell stickiness is one of the most important factors. This leads to a high degree of clogging of the pores, which, in turn, leads to the sequence of redness, inflammation, infection, pustule, rupture and scarring. This should be viewed as a sequence, and acne may be present at any stage. It may end at any stage or progress from inflammation all the way to unsightly scars. Open or closed comedones (whiteheads and blackheads), papules, pustules, hyperpigmentation, spots, and nodular or cystic lesions can all be present. Hormones and some drugs can stimulate the condition or make it worse.
The goals of treatment are to reduce the degree of stickiness and clumping of the exfoliated, oily epidermal skin cells and to decrease inflammation and bacteria. This is an ongoing process. All treatments work mostly by preventing new acne. The existing blemishes heal on their own. The improvement process takes time, and you must be patient. There are often initial “flare-up” periods when you start a program or new product, and your acne will often get worse before it gets better. This process can be frustrating. You may need to change and modify products or usage several times before the “right combination” is obtained. This is why you need a professional to evaluate, initiate, and regularly follow up your program. This way the least amount of time is wasted and you don’t lose time “experimenting” on this or that product.
Our office offers an intensive and comprehensive approach to acne treatment, which is outlined below. Dr Romano’s approach is a combination of internal and dietary recommendations and topical skincare interventions. Following strict adherence to the regimen you can expect 90 to 100 percent clearing of your condition by the end of two months.
1. Initial Consultation and Evaluation
A thorough evaluation is necessary. Every patient has unique skin anatomy and conditions that will require a customized and highly individualized treatment program. You need to establish a relationship with your skincare specialist, as you will need to work together closely. We perform a comprehensive history and skin exam. This involves an in-depth history of your acne and examination of your skin. We assess the nature and distribution and type of acne, breakouts, pigmentation, spots, scars, irregularities and other related factors
Treatment consists of recommending supplements, office treatments, and your home program, which eventually leads to clearing your acne and then instituting a maintenance program. Once your acne is controlled, surgery for treating scars or irregularity, if present, may be considered. The following are our basic recommendations that will be customized for each patient:
a. Lifestyle and Diet:
- Low-fat diet, low carbohydrates, high fiber
- Avoid unfavorable carbohydrates (read The Zone Diet)
b. Aggravating Factors
These are factors known to aggravate acne, and you may want to see if any of these affect you:
- Vitamins B-6 and B-12 may worsen acne.
- Inorganic iron should be avoided; this inactivates vitamin E.
- Female hormones antagonize vitamin E.
- Iodine supplements may cause or worsen acne.
- Carbonated soft drinks.
- Milk contains hormones that can aggravate acne (this includes all dairy products).
- Certain medications such as anticonvulsants, lithium, oral contraceptives.
- Topical or internal steroids.
- Sunlight can mask your acne, but the effects are temporary and ultimately more harmful, causing hyperpigmentation of healing lesions, which then become very difficult to treat.
- Cosmetics can aggravate acne. Look for “non-comedogenic” or “non-acnegenic” and be careful to completely remove all makeup each night. Do not reuse makeup sponges.
- Clean makeup brushes used for foundation and concealer daily with antibacterial soap. Brushes used for powder, blush, or bronzer should be washed with a gentle shampoo once a week.
- Hair care and styling products can clog pores. Hair should be pulled away from face at all times, especially during sleep. Change your pillowcase at least once a week.
- Wipe phones off regularly with rubbing alcohol.
There are numerous supplements that have been shown to have a positive effective on the acne process. Some of these remedies were introduced as far back as the 1940s. These have all been evaluated and tested in scientific studies and reported in the literature.
- Folic Acid 5-10 mg/day.
- Vitamin A 300,000-500,000 units/day (be aware of over-dosages. Men need more than women).
- Vitamin E 400-800 mg/day. (Deficiencies affect absorption of vitamin A).
- Pyridoxine 50 mg twice daily, especially for premenstrual and menstrual acne.
- Zinc 90-135 mg/day.
- Selenium 200 micrograms daily.
- Omega-6 essential fatty acids. This is obtained through flaxseed oil capsules.
- High-chromium yeast (Chromax) 400 micrograms daily.
d. Topical Products
There are numerous products known to have a beneficial effect on acne. These may be part of your in-office treatments, home program, or both. They may involve prescription medications, our own custom formulations, or current well-known acne treatment products. These are all applied directly to the skin and to the breakouts.
- Retin-A is very beneficial and comes in different strengths, formulations, and doses.
- Topical antibiotics such as Cleocin-T, Brevoxyl, Duac and others are helpful, and are prescribed by your physician as needed.
- Cortisone injections may be applied directly into the acne pustule in extreme and difficult breakouts.
- Glycolic acid, salicylic acid, and azeleic acid promote exfoliation, preventing pores from becoming clogged.
- Benzoyl peroxide kills acne bacteria. The bacteria will often become immune to this topical agent; alternating with salicylic acid is recommended. Using 5% or higher will give the best results.
e. Oral Medications
These need to be determined and prescribed by Dr. Romano or your dermatologist.
- Accutane. This should be determined and prescribed by your dermatologist
- Antibiotics. Tetracycline, minocycline. These seem to be very helpful in small daily doses, and once an improvement is obtained and maintained, you can then begin to wean yourself off.
- Birth-control pills. Ortho Tri-Cyclen has been approved by the FDA to treat acne. Yasmin is another birth-control pill used to treat acne. It has not been approved by the FDA for this use and would be considered off-label. This pill contains spironolactone.
- Spironolactone. This is a diuretic; it does not affect hormones. It is often prescribed for women with hormonal abnormalities that contribute to recalcitrated acne. It may cut sebum (oil) production 50 to 75 percent. Prescribed for women only.
f. In-Office Skin Treatments
These are treatments that are provided by our office. This is usually the most important and critical part of the program, and the part that will demonstrate the most benefit to you.
Glycolic acid / salicylic acid / chemical peel treatments are extremely beneficial in reducing the oiliness and cell clumping that leads to blocked pores, infection, and the whole cascade of the acne process.
Bleaching treatments and creams help to minimize the pigmentation and spots that are often the after-effect of a healing acne lesion and are very noticeable and unsightly.
Monthly or bimonthly facial treatments using enzymes and/or glycolic acid peels of at least 40% exfoliate unhealthy cells and clean the pores to prevent cell clumping.
Deep pore cleansing including manual extractions of pustules, whiteheads, and blackheads cleans out acne-prone pores to prevent breakouts before they start.
Masks containing calming and anti-inflammatory ingredients including kaolin clay, tea tree oil, lavender oil, charcoal, and aloe vera decrease redness and infection.
Ultrasound treatments with a skin-clarifying ampoule assist in deeper penetration of antibacterial and anti-inflammatory properties.
Medical-grade cosmetic and cover-up makeup. This is excellent for both men and women and adds that last little benefit that makes a huge difference.
g. Home-Care Program
This is an extremely important part of acne care and treatment. Your attention to the home program and aggressiveness with this can make or break your successful outcome. This must be performed day and night. Proper adherence is mandatory to ensure success of treatment. This will include a highly customized program by your medical esthetician. Basic products containing active ingredients for your home care intervention may include:
- Deep pore / clarifying cleanser
- Evening treatment
- Spot treatment
- Weekly masks to exfoliate and deep clean
Once acne is under control, other things can be done to improve the skin smoothness and color, as well as prevent further breakouts.
- Microdermabrasion smoothes the skin and decreases pigmentation and scarring.
- Skin lightening and bleaching program.
4. Surgical Interventions
There are numerous procedures and interventions that can be performed once your acne is under control and quiescent. These are aimed at further smoothing the skin and removing irregularities, scars, and wrinkles. They include:
- Filler substances such as collagen, Dermalogen, silicone and others have been injected underneath the skin to raise and smooth depressed scars.
- Chemical peels. These range from light, affecting the epidermis only, to deep. They remove a certain depth of your skin cell layers, and in so doing, smooth the skin. They range in chemicals from Jessner’s, TCA (trichloroacetic acid) to phenol. The strengths are variable, and so too are the healing and down times, which may range from several days (the weekend peel) to seven to ten days.
- Dermabrasion (now occasionally referred to as “macro”-dermabrasion. This is a much deeper and more mechanical removal of the upper skin layers to even out the skin and remove scars and irregularities.
- Laser resurfacing. There are several different types and light energy sources for laser treatments. The most common is the CO2, or carbon dioxide laser. Erbium and other lasers have been used as well. These are known to be aggressive and provide a deep scar-removal effect, but many think the dermabrasion works as well and heals faster.
- “Subcision” is a term used to describe the under-cutting of a depressed scar. In theory this releases the depressed scar to rise up, but in practice, you usually have to add something to fill in the subcised area to effect the raising.
- Punch and suture is a technique is used to actually cut out depressed and unsightly scars and then stitch them shut. The scars are less deep, and usually dermabrasion or laser is performed at the same time to decrease scarring.