Evidence continues to mount that birth control pills help with acne. Interestingly, it has become apparent that just because a birth control pill is approved for acne, however, does not mean it will produce superior results.

First, it’s important to understand how oral contraceptives (OCs) help with acne. Almost all OCs contain an estrogen component and a progestin component.† The estrogen component helps reduce the production and expression of male hormones which can lead to acne. Depending on the progestin used, the effects of the progestin component can range from relatively inert to theoretically leading to increased male hormone levels. But the estrogen component is much stronger and outweighs progestin, thereby allowing all OCs to help with acne.

An article published in the International Journal of Women’s Health in 2010 took a look at all of the different options and research to date. As it turns out, no matter what OC you take, it will likely produce a 30-60% reduction in acne lesion count. According to the article, “Studies comparing oral contraceptives did not convincingly show superiority of one oral contraceptive to another in the treatment of acne.” They went on to note, “Compilation of evidence was difficult due to variable study designs.  More research needs to be done to draw conclusions about the comparative efficacy of different [oral contraceptives].”

In other words, it appears women who are looking for acne symptom relief with their oral contraceptive are not constrained to “approved” brands.

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Important: Whether or not to embark upon hormonal acne therapy requires careful physician screening with a focus on risks and benefits.

†Note: Cyproterone Acetate (Diane, Dianette), which is a synthetic derivative of 17-hydroxyprogesterone approved for contraception in Europe and Canada but not the United States, and which can be used on its own or in combination with an estrogen component, was also considered as authors in this article drew their conclusions.

 

Isotretinoin (Accutane) is approved to treat people with severe acne. Typically, in order to achieve the best chance of long term acne remission, doctors are advised to prescribe patients relatively high doses of Accutane. Researchers have published two studies in the past two years attempting to gauge whether people with mild to moderate acne can achieve similar long term remission of acne with lower dosages of Accutane, and thus achieve similar success with lower side effects.

Study 1: Italian researchers looked at 150 people with “mild to moderate acne,” although most of them (114) were considered “moderate.” The average person only received around 3/4 of the amount of Accutane that is normally prescribed. After two years, only 13 people had relapsed, which comes to 9.35%, a very good relapse rate, even when compared with high doses of Accutane across the general population.  Note: After their Accutane course, the people in this study were then put on 1 full year of topical adapalene therapy which somewhat confuses the results of the study. 

Study 2: In this study, Korean researchers studied 60 people with “moderate” acne. These people were given either conventional treatment, low-dose treatment, or intermittent treatment (1 week out of each month). Although the amount of people studied was small, and thus we need to take these results less seriously than larger studies, outcomes were similar between people taking conventional and low-dose treatment. One year after therapy was discontinued, 2 out of 16 people in the conventional group and 3 out of 17 people in the low-dose group relapsed. Note: People on intermittent therapy did not fair nearly as well. More than half of these patients relapsed.

What I take from this: As usual, more research is needed on this topic. However, from what these researchers are seeing, as long as someone is not suffering with severe acne, they may be able to get away with less Accutane, and thus suffer lower incidence of side effects. I’ll keep you posted as more research on this topic comes to light. As always, please keep discussing your own personal experiences with Accutane on the messageboards so we can follow along with your particular dosage and results.

You guys have been asking, so here’s what I found to be the most interesting new information on scars and scar treatments:


Subcision plus suction.  Subcision is where a needle is placed sideways underneath a depressed scar and moved around, thereby disconnecting the scar from the skin below and allowing it to float up to the surface. The hope is that a hemorrhage will appear under the scar, leading to new connective tissue and a permanent raising of the scar toward the skin surface. For those of you who have tried this, you may have noticed that it seems to work, but that a large portion of these areas tend to recede again. However, a new common sense treatment is now being added to some subcision treatments. After the initial subcision of the scar an initial hemorrhage forms. Then, 3 days later, a suction machine, normally the same one used in microdermabrasion, is placed over the scar area and “vacuums” the skin up, ultimately reintroducing another hemorrhage under the treatment area.  This suctioning is repeated at least every other day for 2 weeks afterward in an attempt to produce more tissue under the scar. The Journal of the European Academy of Dermatology and Venereology concluded, “Frequent suctioning at the recurrence period of subcision increases subcision efficacy remarkably and causes significant and persistent improvement in short time, without considerable complication, in depressed scars of the face.” Pretty cool.


Need to wait until 6-12 months after Accutane (isotretinoin) to get aggressive scar treatment? This is a commonly held belief since isotretinoin has been linked to keloids and raised scarring, perhaps because of collagen accumulation. It remains a prudent stance. However, in one very small study, doctors dermabraded one square centimeter on 7 participants faces using a diamond fraise while they were on isotretinoin. After 6 months, the scar revision appeared successful and there were no signs of keloid or raised scarring. Although this is interesting, patients and doctors must continue to proceed with caution in this area until we get more evidence.


Why do we scar in the first place? Scars are the result of wound healing, which is one of the most complex biological processes, and includes the following 3 phases.  Some new info below:

(1) Inflammation: Upon closer investigation through biopsy specimens, researchers found that the initial inflammatory reaction was stronger and had a longer duration in patients who scarred.

(2) Granulation tissue formation:  Next, damaged tissues are repaired, new capillaries are formed, and new collagen begins forming. Researchers are noting, “The balance of collagen types shifts in mature scars to be similar to that of ounwounded skin, with approximately 80% of type I collagen.”  This one is a bit above my head. If anyone knows why this might be interesting, please comment.

(3) Matrix remodeling: As the healing process moves on, extracellular matrix metalloproteinases (MMPs) take on the job of deciding how much tissue will be built.  Too much MMPs and you may see a raised scar.  Too little and you may see a depressed scar.  However, why some people have too much or too little MMPs remains a mystery.


I’ve read all the other scar related research that has been published as well. Basically it’s mostly the same stuff we have known before. The bulk of the evidence continues to show (1) significant improvement with ablative lasers (CO2 and Erbium;YAG) with pretty severe down time afterward, (2) somewhat less improvement with fractional lasers and needling but with less down time, and (3) the never-ending search for the perfect filler. If anything remarkable comes out in the near future I will let you know.

…we still have no clue.

After scouring the research from the last several years regarding sebum (skin oil), acne bacteria, gene transcription, and a bunch of other super techie stuff, the answer to what causes acne is…um…we still have absolutely no idea. Most diseases are tricky things, and acne is no exception. Scientists are really only still scratching the surface when it comes to nailing down what actually happens that starts the acne ball rolling.

Let’s take acne bacteria for instance. Over the past few years, scientists have located more strains of P. Acnes, the bacteria present in human skin. We don’t know which strains might be harmful and which might actually be helpful. Furthermore, we don’t know which of the secretions of which of the bacteria strains cause problems and why. Additionally, we don’t know if it’s the secretions that cause a problem or if certain strains of bacteria interact with cells in some other way, such as interacting with cell RNA, toll-like receptors, or inflammation. And, um…if these bacteria do interact with skin cells in some way, we don’t know whether it’s dermal cells, oil cells, or immune/inflammatory cells.

The story is equally muddled when you look at the immune response of the skin, the inflammatory cascade, cell signaling, et cetera, et cetera.

Regardless, it’s not all bad news. Some directions of inquiry are starting to look more interesting than others. For instance, scientists are starting to frame acne as an inflammatory disease and are focusing in on how to mediate the body’s inflammatory response in the skin.

With time, we may be able to better specify what causes acne, which could theoretically lead to a cure. Rest assured that I’ll keep on top of the latest research. In the meantime, The Regimen should work well to keep acne under complete control, and in more severe cases, Accutane is an option as well.

The more I learn about antibiotic therapy for acne, the more wary and less enthused I become. Due to overuse and misuse over the past twenty years, antibiotic resistance has become widespread throughout the skin of the world population. This is evidenced by the increasing ineffectiveness of both oral and topical antibiotics in clinical studies. Antibiotics never worked very well for acne, and now they work even less well.

According to a “Global Alliance to Improve Outcomes in Acne” published in the Journal of the American Academy of Dermatology, antibiotics should be avoided as the sole treatment of acne. Researchers agree strongly that if antibiotic therapy is used, it should be combined with other therapies. When you look at the superior effectiveness of these other therapies the question arises as to why someone would want to include antibiotics at all. For example, when one takes into consideration the fact that benzoyl peroxide kills 99.9% of acne bacteria on its own and does not create resistant colonies of bacteria, one has to wonder why so many prescriptions for antibiotic acne therapy–over 11 million per year–are still written. According to an article published in the journal Expert Opinion on Pharmacotherapy, “…evidence demonstrates that [topical antibiotics] are no more effective against inflamed lesions than [benzoyl peroxide], and are less effective against non-inflamed lesions…To date, [benzoyl peroxide], as both mono- and combination therapy, is the most evidence-based approach.” Other acne treatments exist, and while they may not be as effective as benzoyl peroxide, they easily outpace antibiotics.

The misuse of antibiotics can also cause antibiotic resistance in other skin bacteria, especially the bacteria known to lead to impetigo and folliculitis. If all of this weren’t enough, when we look at how gene mutations work in bacteria, we see that genes which allow for resistance to antibiotics are easily transferred from acne bacteria to other bacteria in the skin, thus further promoting unwanted antibiotic resistance in other skin bacteria.

If your doctor has you on antibiotic therapy for acne and nothing else, it may be time to have a talk with her/him. The authors of the expert opinion review also note that topical antibiotics should be used for no longer than 3 months and oral antibiotics for no longer than 6 months. So, if you have been on antibiotic therapy for a long time, it may also be time for an appointment with your dermatologist. Since poor compliance with antibiotic regimens are one of the main causes of antibiotic resistance, just make sure you do not stop antibiotic therapy on your own without consulting with your physician first.

Hey Everybody. Just a heads up to keep you all in the loop…we have been working on an upgrade to the messageboards for a few months now. It’s a huge job but we’re almost done. The new messageboard is now online and should be accessible for you, but keep in mind that it doesn’t have the look or feel that it ultimately will.  We will be working on sprucing everything up this week.  The new boards will have better navigation, search, members area…pretty much everything.  Plus it should be more integrated with social media and help everybody on here get to know each other better with upgraded tools.

Thanks for your patience, and please give me your feedback.  I know you will :)


What it is:  On June 21, 2011 the FDA approved a process by which a dermatologist or plastic surgeon numbs behind the ear, removes small pieces of skin, and sends these pieces of skin to a lab where the fibroblast cells in the skin samples are multiplied many times over and then frozen. These cells are then thawed when needed and injected into the skin under wrinkles or scars (boxcar or rolling) to help even out the appearance of the skin.

PROS: The body views these cultured cells as “own” and so the immune system does not respond. Working with your own cells eliminates allergic reactions, lumps, or abscesses which may come with other fillers. But probably the most compelling advantage is how long results last. Other fillers like bovine or synthetic collagen may last only a few months, and even more advanced fillers which combine polymer beads with collagen may only last a year or so. The LaViv treatment promises to last for years. As with many fillers, recovery is extremely minor and is evidenced by minor redness or bruising at the injection site. You can immediately return to work.

CONS: People don’t see results right away. The process requires 3 staggered injections and results aren’t seen until up to 3 months. It also costs a pretty penny–anywhere from $2000-$4000. However, other fillers which last less than a year can cost about $1000, so when you look at the long term, using your own cells may be more cost effective.

BOTTOM LINE: As always, the proof is in the pudding, and the pudding in this case is still cooking. This is such a new product and process that we literally haven’t had enough time to begin seeing “real” before and afters from everyday people posting online. There are 2 before and after pictures at this link which are provided by the company. Keep in mind as well that fillers are very often best used alongside other treatments, such as laser resurfacing.

A while back we switched to new pumps–pictured below on the right. You guys let me know they were kinda annoying and I agreed, so I switched back to the old pumps–pictured below on the left. From now on, if you order any Acne.org product with a pump, you will get the old, good pumps.

The last few days I have spent going through all clinical studies/trials regarding acne and Omega-3 fats, iodine, antioxidants, chocolate, calorie intake, fatty/oily food, digestion, and zinc. Adding to this what I have learned regarding dairy and glycemic load, I’m sorry to say that nothing stands out for me as a smoking gun when it comes to diet and acne. We simply don’t have enough research yet, and nothing feels super compelling to me at this point. However, at least researchers are looking into how diet may affect acne, so hopefully by the next time I review the literature, the evidence available to the scientific community will start taking shape. In the meantime, based on digesting everything the research community has to offer regarding diet and acne, here is what I am personally going to do as far as diet goes:

1.  Keep taking fish oil and eating wild delicious sushi :)  I take 4 fish oil pills per day to make up for my Western-style diet, which like almost everyone living in modern society, is overly rich in Omega-6 fats from vegetable oils, grains, etc. There is enough evidence to persuade me of the overall health benefits of Omega-3s and I feel good taking fish oil regardless of whether or not it may be helping with my skin. Also, when I go out to eat, I specifically ask whether the fish or sushi on the menu is wild. Farm raised seafood is far inferior in Omega-3s and other nutrition than wild seafood.

2.  Keep taking a zinc supplement. Having dived deeper into the role of zinc, I am still convinced that it is likely an important nutrient when it comes to combating inflammation and keeping bacteria in check. I’ll keep taking my 30mg per day.

3.  Not worry about iodine, chocolate, fatty/oily food. I’ll keep eating seaweed salad and seafood (contain iodine).  There exists no evidence showing that the amounts of iodine consumed in these foods is in any way detrimental for acne. Based on the available evidence, I’ll also continue eating a little dark chocolate every day without worrying about how my skin will react. I will also keep eating the occasional naughty greasy meal without fear.

4.  Try to be generally healthy. Antioxidants are important calming agents in the body, and eating antioxidant-rich colorful fruits and vegetables is fun and tasty anyway. When it comes to glycemic load, whether or not scientists know if it will help with acne yet, I’ll try to keep my meals balanced with carbs, fat, and protein to keep my energy and mood level and avoid crashes.

A full update to the diet and acne page of acne.org is on its way with much more information on each of the above mentioned topics. In the meantime, when you look at the evidence at hand, eating healthy and in moderation will suffice as a general wrap up for what we know regarding diet and acne at this point. Not exactly a Eureka moment.