I remember back in middle school when I started getting acne and asking my mom to take me to the dermatologist. I always felt better after seeing the dermatologist. He or she always wrote me a prescription for a medication which was supposed to clear me up. I tried oral antibiotics, topical antibiotics, retinoids, sulfur, and a few other prescriptions. Inevitably, they didn’t work, and I’d come back for another prescription, this time hoping that this one would actually clear me up. What all of these dermatologists failed to tell me is that most prescriptions only work to clear up acne to a degree.
As the researcher for Acne.org, I read hundreds of clinical trials and studies on acne each year. The latest article I just read was to test the “…efficacy and tolerability of tazarotene foam, 0.1%, in the treatment of acne…” Like most other articles on prescriptions for acne, the conclusion to this study sounds familiar: “Tazarotene foam, 0.1% significantly reduced the number and severity of acne lesions after 12 weeks and had a safe and acceptable tolerability profile.” That sounds great, doesn’t it? But when you read the article, you find that the decrease in acne lesions hovers around 50%. Sure, results are scientifically significant, but is someone with 20 zits on their face going to be happy with 10? That is still full fledged acne if you ask me. In my opinion, dermatologists should communicate clearly that most prescriptions will help improve the skin, but will not clear you up.
1 exception: Accutane (isotreinoin) completely clears acne in most people who take an adequate dosage for a long enough period of time, but comes with side effects, some of which can be long-term and some of which can be severe.
1 other exception: When used within The Acne.org Regimen, 2.5% benzoyl peroxide will also completely clear the skin, and does so without any severe or long-term side effects. It’s refreshing to be able to tell people what dermatologists were never able to confidently tell me. The Acne.org Regimen will clear you up. Completely.
- Feldman SR, Werner CP, Alio Saenz AB. “The efficacy and tolerability of tazarotene foam, 0.1%, in the treatment of acne vulgaris in 2 multi center, randomized, vehicle-controlled, double-blind studies.” Journal of Drugs in Dermatology. 2013; 12(4): 438-46.
People around the web tend to refer to The Regimen as The Acne.org Regimen. For the sake of clear communication, I’ve updated how we refer to it on Acne.org to reflect this.
A long overdue page on the particularities of male acne is now live. Check it out!
A typical full dose of Accutane (isotretinoin) is 40-50mg per day and the typical length of treatment is 15-20 weeks in order to achieve the recommended cumulative dose of 120mg/kg of bodyweight over the course of a cycle. However, as the years go on, researchers have been conducting more studies on low-dose Accutane (isotreinoin) to see if they can get the same results with less side effects. Generally speaking, the research is showing that even at a low dose of 20mg per day, people see good results, albeit not as impressive as when the full dose is used, and also with a higher incidence of relapse.
However, one recent study published in Advanced Biomedical Research is particularly interesting. In this study, they gave patients a low dose of 20mg per day but kept the patients on this low dose for quite a long time (10-22 months) in order to achieve the usual recommended cumulative dose of 120mg/kg of bodyweight. 96.4% of patients “demonstrated complete clearing of their acne, defined as no acne or occasional isolated lesions.” Relapse was low as well. “In a 5-year follow-up, relapse accrued in…7.9% of patients.” Side effects were, “…mild, and only 6 patients (out of 146) discontinued study medication because of severe adverse events.”
This is the first study where patients receive a low dose of isotretinoin, but are kept on this dose until the cumulative dose reaches the full 120mg/kg. Results from this study look impressive, and relapse rates are low. The authors admit, however, “The only pitfall is it is longer than 10 months duration of treatment period.”
Perhaps it is time to take a second look at how Accutane (isotretinoin) is administered.
- Rasi A, et al. “Efficacy of fixed daily 20mg of isotretinoin in moderate to severe scar prone acne.” Advanced Biomedical Research. 2014; 3: 103.
Traditional at-home light therapy, which must be performed daily with tabletop red and/or blue light, produces very few side effects but also tends to produce disappointing results. However, dermatologists are now using light therapy on patients in their offices in a different way with better results but with more pronounced side effects. The procedure is called photodynamic therapy (PDT). The first step is what makes PDT different from at-home light therapy. A photosensitizing agent is applied to the skin. This primes the skin to react to the light that is applied. Next, red and/or blue light is shone on the skin for 15-20 minutes. Due to the power of photosensitizing agents, the reaction with the light creates more side effects and can include severe pain during the procedure and a full week of downtime afterward. The entire procedure is repeated 3-5 times at 2-4 week intervals, and is normally reserved for moderate to severe acne.
Results tend to be far better and longer lasting than light therapy alone when the procedure is done correctly. What is “correct” is up for debate, but science is pointing us more toward red light, which penetrates the skin more deeply. Other considerations are also important. Check out the new Photodynamic Therapy (PDT) page of acne.org for the full story on this new therapy.
I read three studies recently on Sodium L-Ascorbyl-2-Phosphate (SAP), which is a topically applied vitamin C derivative. It is an antioxidant which is showing statistically significant acne clearing over time. It seems to clear the skin about as much as other topical prescriptions. This sounds impressive, but keep in mind that most topical prescriptions only clear the skin 40-50%. This is why The Regimen is so important because it completely clears the skin, which is what people really want. But I digress…
The three studies I read were in the International Journal of Cosmetic Science, Cosmetic Dermatology, and the Journal of Cosmetic Dermatology. They all used 5% SAP and show around 40-50% clearing of acne after 8-12 weeks with very few side effects. SAP has a good safety profile. Only a very small percentage of participants in the studies withdrew because of adverse effects even at a relatively high 5% titration.
Why might it work? Squalene is the most abundant fatty substance in the skin. Some scientists hypothesize that acne may be partly due to squalene oxidation. SAP is an antioxidant. Next, it may help reduce inflammation, which can not only help calm acne, but may also help prevent scarring to some degree and also help clear hyperpigmentation a bit faster.
I am always trying new ingredients in Acne.org products, and this is on my list to also try. I’ll let you know if and when it makes it into one of our products.
- Ikeno H, Ohmori K. “Open Study Comparing Sodium L-Ascorbyl-2-Phosphate 5% Lotion Versus Adapalene 0.1% Gel for Acne Vulgaris.” Cosmetic Dermatology. 2007; 20(6): 368-372.
- Ruamrak C, Lourith N, Natakankitkul S. “Comparison of clinical efficacies of sodium ascorbyl phosphate, retinol and their combination in acne treatment.” International Journal of Cosmetic Science. 2009; 31: 41-46.
- Woolery-Lloyd H, Baumann L, Ikeno H. “Sodium L-ascorbyl-2-phosphate 5% lotion for the treatment of acne vulgaris: a randomized, double-blind, controlled trial.” Journal of Cosmetic Dermatology. 2010; 9: 22-27.
I recently found out about a group of students at the University of Pittsburgh who wanted to work on acne bacteria in an attempt to get it to the point where we can experiment with genetic engineering on these bacteria that have a hand in acne.
When I first pledged money they were only about half way there. As of yesterday I found out they are fully funded! Fantastic guys. Rock it out!
You can view more about this research here.
The question, “Is acne an autoimmune disease?” has always lingered in the back of my mind. An article in Swiss Medical Weekly recently looked into how an over-active immune response could be the culprit in chronic skin inflammation. Since we know that acne is largely an inflammatory disease, could this play a part? The authors state, “The skin is our largest organ, which is exposed to and protects the body from microbes, pathogens and several irritants. However, the skin can…be a site of excessive immune responses resulting in chronic inflammation, autoimmunity or autoinflammation.”
Our skin, like other organs of our body, is pretty amazing. It provides defense against a multitude of pathogens. However, in the case of acne, might it be overreacting to perceived pathogens and creating an unjustified inflammatory response in the form of excess oil and/or hyper-proliferation of skin cells? The key may be in researching inflammasomes that detect pathogens and the cytokines that these inflammasomes activate, specifically interleukin 1 (IL-1).
I have not come across much research on acne and autoimmunity, but if any of you come across some good hard science on this topic, please send it my way.
Also, have any of you gone on immune suppressing medications (i.e. Humira) and seen your acne symptoms change? I’d be curious to hear from you.
I noticed there is also a thread on the forum discussing this as well. Feel free to add your comments there as well.
- Contassot E, Beer HD, French LE. “Interleukin-1, inflammasomes, autoinflammation and the skin.” Swiss Medical Weekly. 2012; 142:w13590.
When it comes to acne, cold beats hot.
Hot: The power of heat at this time is limited in acne care. Lasers and radio frequency devices use targeted heat to kill bacteria in the skin, which can improve acne, but only to a moderate degree and for a high cost. For these reasons, I don’t advocate for these methods, especially lasers. I am intrigued by radio frequency devices and will keep my eye on them as more research comes out, but so far I don’t see much good science when it comes to radio frequency and acne. Spot treatment devices which claim to use heat to stop a pimple from forming tend to disappoint in both their efficacy and cost as well.
Cold: Cold on the other hand, has a long standing history of helping to treat acne. According to a review article published in Cutaneous and Ocular Toxicology, “Cold is…a useful treatment modality. In dermatological care, cold is often used for angioedema (under the skin swelling)…” We can see the power of ice in spot treatment. If you feel a zit forming, put a piece of ice in a Ziploc bag and hold it very gently on the spot for 5 minutes. This simple treatment can work wonders, especially when combined with proper topical treatment and anti-inflammatory agents. While less convenient, ice can also be used all over the face. If you’d like to try it, simply fill up a styrofoam cup with water and freeze it. Then peel back the styrofoam and VERY GENTLY move the ice over your entire face. This can get messy but can be fun from time to time. Just be certain to remain ultra gentle to reduce any unwanted irritation.
Cold can help, but there is no substitute for properly treating your skin. First, get on The Regimen and get cleared up. Then, feel free to use ice on occasion when you need it for spot treatment or when you just feel like adding in something for a change of pace.
- Bayata S, Turel EA. “Thermotherapy in dermatology.” Cutaneous and Ocular Toxicology. 2012; 31(3): 235-40.
Researchers at UCSF Medical School recently published a review article in the Journal of Dermatological Treatment which took a look at all available evidence on the dosing of benzoyl peroxide. They took a look at 8 studies in all. The authors concluded:
“There appears to be insufficient data…to document use of a higher concentration than 5% or even 2.5%.”
Regarding side effects, the authors note:
“There does appear a difference in the number of side effects according to the dose titration. The 2.5% formulations had a significant lower rate and lower severity of burning, erythema (redness) and peeling…”
They go on to further conclude:
“To increase compliance and thus the efficacy of the therapy, a lower titration of 2.5% should be preferred.”
Those of us who use benzoyl peroxide regularly have noticed this first hand. 2.5% works just as well or better than higher percentages because it does the same job as higher percentages without all the unnecessary irritation that can perpetuate acne cycle.
For best results, stick with 2.5%, and use it within The Regimen.
- Brandstetter AJ, Maibach HI. “Topical dose justification: benzoyl peroxide concentrations.” Journal of Dermatologic Treatment. 2013; 24(4): 275-7.