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Guest Amy Lee

If comedogenic ingredients clog our pores...

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Guest Amy Lee

If comedogenic ingredients clog our pores, then why don't our hands, palms, and fingers breakout since they're the first body parts to come into contact with?

I know this is silly, but just curious.

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Because there are no pilosebaceous units on fingertips/palms.

What it means is that the skin on the inside of a human hand (also soles of feet) is different and does not contain the kinds of pores that can get blocked and inflamed.

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Guest Amy Lee
what about buttcheeks ? i mean somebody could try putting some comedogenics on it. sounds stupid, but i mean .. seriously ....

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We DO have technology that remodels skin from the inside out so that hyperkeratinization normalizes to a noncomedogenic level of intrafollicular skin cell shedding, combined with reduced sebum secretion so that pores do not become blocked with excess sebum: it's called Accutane. It takes the acnegenic pilosebaceous units of the facial pores and literally restructures them so that they are as acnegenic as those pores of the skin elsewhere on your body which currently exhibit no acne.

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Clearly it doesn't do that, and if it does, it doesn't last. Accutane is not "technology" in my books. I'm talking full-proof solutions, Accutane and every other medication on the market is not full proof.

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That is EXACTLY what Accutane does, and why for 80% of patients who take Accutane at least 90% of their acne is cleared for at least a year with 60% of their acne permanently CURED (i.e. subsequent breakouts if they occur are never even half as bad as before Accutane). It only doesn't last when the acne's underyling primary factor in the form of excess male sex hormone levels persists, but as this usually self-resolves gradually with time (acne in the vast majority of cases self-resolves in post-adolescence), the Accutane effectively prevents one exhibiting acne while the internal acnegenic hormonal imbalance subsides. If acne persists after 2 or more courses of Accutane, bearing in mind that it is unusual enough for acne to persist after 1, an endocrinologist should be consulted to ascertain to what extent the likeliest culprit of androgenic imbalance plays a role and can be addressed.

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Hey Antony,

You've obviously done a lot of research on isotretinoin etc. I'm trying to understand what happens in the skin (on the cellular level) during the initial break-out many people seem to get. My kid had a bad reaction to topical retinoids (went from mild/moderate to cystic) while on Retin-A/Differin . The same thing seems to have happened to a lot of people here.

The retinoids are supposed to speed up the turnover of epithelial cells and decrease their cohesiveness. I can see that decreased cohesiveness is a good thing because sticky cells/sebum clogged with shed cells/ is supposed to be part of why blackheads/whiteheads/ comedones form. However, I thought acne was like psoriasis where the cells turn over/get shed too much anyway? So, I'm wondering if the initial breakout caused by isotretinoin/ local retinoids is caused by this speeded up epithelial cell production. In your research, have you come across a good explanation for the initial break-out?

You ask doctors and they say it's because the drugs push all the microcomedones to the surface. Right. That is as scientific an explanation as the patients have: all the gunk under the skin needs to be pushed out.

The acne flare-up on the retinoids can be heartbreaking, not to mention permanently scarring, so I'm trying to understand to process to find a way to minimize it. Basically, the retinoids are the best drug there is to normalize the epithelial cell production/keratinization process. They'd just be a much better drug if the initial acne flare-up could be avoided. It doesn't make sense to me to turn a mild/moderate acne into a cystic one, even for a few months, in order to clear it.

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The acne flare-up on the retinoids can be heartbreaking, not to mention permanently scarring, so I'm trying to understand to process to find a way to minimize it.  Basically, the retinoids are the best drug there is to normalize the epithelial cell production/keratinization process. They'd just be a much better drug if the initial acne flare-up could be avoided.  It doesn't make sense to me to turn a mild/moderate acne into a cystic one, even for a few months, in order to clear it.

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I've been on Accutane as of today for exactly 1 month (40mg/day; weight 70kg). My acne was mild to begin with (through considerable effort on my part, having been prone to moderate breakouts and cystic body acne before implementing my own program linked below). My initial breakout involved two cysts on opposite shoulders, 2-3 whiteheads on chest, 2-3 whiteheads on cheek and chin. It was by far no worse than any breakout I've had previously-- I've had much, much worse before. I am not yet clear but am definitely clearing. The initial breakout does appear to be directly proportional to the severity of acne. Roche claims the initial breakout occurs in 1 in 4 on Accutane but it seems that in practice it occurs in virtually everyone; they also state that it takes place within the first 7-14 days. I certainly have my own theories but am otherwise not intimately acquainted with the official dermatological explanation for the initial breakout besides the one you have already given, albeit dressed up by dermatologists in such terms as "desquamation," "hyperkeratinization," "sebum differentiation" and "sebacous gland recptors desensitized to excess androgenic stimulation" in order to sound more vaguely dermatological than simply "pushing all your gunk up to the surface!" The effective drying out of the oil glands and their crisis response effort to overcompensate with a last-dtich effort to overproduce oil, as well as simply the drying out of pores consequently constricting and expelling already solidified or trapped sebaceous blockages, these are all possibilities.

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To Dermpro,

Since you are a derm pro and know so much about how the retinoids work /and or statistics, could you kindly point me to the studies that you are basing your opinion on? What makes you expect that most, if not all, people will react exactly the same way to ANY drug?

Also, what kind of retinoids (oral, topical?) are you talking about when you say it takes several months for the drug to kick in? Could you point me to the source of the information?

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For Dermpro:

1)This is a translation from a French dermatology journal:

SUMMARY

Background

Isotretinoin treatment for acne can lead to inflammatory flare-ups or an aggravation, occasionally leading to acne fulminans. The purpose of this work was to examine our cases and to propose a classification system for management.

Patients and methods

Over a 3-year period, we selected patients referred to our dermatology unit for paradoxical aggravation of acne under isotretinoin treatment. We recorded clinical data, drug prescriptions and the course of the flare-up.

Results

Over 3 years (1995-1998) we observed 32 cases of acne flare-up in patients taking isotretinoin, 6 women and 26 men.

Discussion

Four types of aggravation could be identified depending on their date of onset, the skin signs, and the presence or not of general signs. Systemic corticosteroids are generally required, together with a lower daily dose of isotretinoin and local care (excision of open and closed comedons). Factors predictive of aggravation are young age, male sex and sebaceous retention.

Conclusion

Acne fuminans is exceptional in patients taking isotretinoin compared with the number of patients treated. Clinicians should nevertheless be aware of the risk in order to make the diagnosis and provide appropriate care.

2) From Clark SM Cunliffe WJ. Acne flare with isotretinoinâ€â€incidence and treatment. Br J Dermatol 133(suppl 45):26 (1995).

Inflammatory acne flare is experienced by approximately 6% of patients in the first month of therapy, and is clinically significant in about half. Discontinuation of isotretinoin and initiation of therapy with prednisone at 0.5-1.0mg/kg/day for 2-3 months is the treatment of choice.

3) From MARC:

The 2 dermatologists from the United Kingdom (...) were firmly of the view that isotretinoin should be available only on a specialist prescription because of safety issues associated with isotretinoin. Both consider isotretinoin to be the supreme medication for acne ("most effective drug for the treatment of all but the mildest acne"). mentioned that skill is involved in selecting the optimum dose, and incorrect use can lead to a flare up of acne and significant scarring. He has had patients affected with these problems referred to him from dermatologists with experience in the use of isotretinoin.

4) And from the horse's mouth vis-a-vis Retin-A:

"When I developed Retin-A in 1969, it was quite an irritating formula. The more the skin peeled, the better the acne would respond. However, during this peeling phase all the acne impactions are coming out so there may be an appearance of flare-up of the acne condition as all of the impactions are being evacuated. Once all the pores are clear, the acne is under control and not visible. Also, if a patient is considering Retin-A, they should use the Retin-A gel and not the Retin-A cream. The Retin-A cream contains isopropyl myristate, which is an aggravator of the acne conditions and sometimes patients will get worse because of the formulation of the Retin-A cream. There are also new formulations of the Retin-A on the market, such as Micro Retin-A that are better formulated creams than the previous product. The key is to keep the skin visibly peeling in order to get a rapid clear-up. If there is no peeling whatsoever, your particular formulation is not working very effectively on your skin. You should see at least a little peel once a week to know you are at the right therapeutic level. Also, you may need to work with your physician or esthetician during this early phase to help extract out all the acne impactions that are coming to the surfacing. This will lead to a more rapid resolution of the problem.

P.S. I'd be really really grateful for any pointers/links/references that might help me overcome my "basic lack of understanding about the action of retinoids in general, and of statistics as well..." I don't think I claimed to understand how the retinoids work. In fact, I thought I said the exact opposite in my original post to Antony. And I don't think I quoted any statistics. Any pro help you can provide would be greatly appreciated.

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To Dermpro,

Since you are a derm pro and know so much about how the retinoids work /and or statistics, could you kindly point me to the studies that you are basing your opinion on? What makes you expect that most, if not all, people will react exactly the same way to ANY drug?

Also, what kind of retinoids (oral, topical?) are you talking about when you say it takes several months for the drug to kick in? Could you point me to the source of the information?

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Starting a retinoid does not cause one to flare, and certainly does not cause cystic acne. If this were true, then most, if not all patients who use a retinoid would experience this, and this is simply not the case.
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P.S. I'd be really really grateful for any pointers/links/references that might help me overcome my "basic lack of understanding about the action of retinoids in general, and of statistics as well..."  I don't think I claimed to understand how the retinoids work. In fact, I thought I said the exact opposite in my original post to Antony. And I don't think I quoted any statistics.  Any pro help you can provide would be greatly appreciated.

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Ummm... please note this is what I said in my post

My kid had a bad reaction to topical retinoids (went from mild/moderate to cystic) while on Retin-A/Differin. The same thing seems to have happened to a lot of people here.

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Retinoids work so differently. The syntetic one (Adapalene / Differin) is the

mildest and good for more sensitive skins. Retin-A Micro is stronger but a

lot more effective for tougher cases. Tazorac 0.1% gel is by far the very

strongest, only recommended for worse cases and very tough skin, as I

have. Retinoids themselves have no research anywhere showing that if

used topically, they will have any detrmimental affect on the user. If it

is a breakout en-route to clearing, that's different. They don't cause a

permanent change in skin or skin cancer. But exessive unprotected

sun exposure while using can cause a worse burn than you'd get if

in the sun for the same amout of time and not a user of a retinoid.

But then, to a lesser extent - so do some antibiotics, BP and SA...

Accutate/Isotretinoin, internally, if used longer term, can lead to a

breakdown of cartilage, this of course can be harmful. Depression

has been linked to it, though since the user often sees their acne

get worse - sometimes much worse - and doesn't see clearing of

acne peak until a month or two AFTER treatment ends, this too is

a possible reason for depression while on it. Most who are on it as

a last resort would be miffed if it doesn't seem to be working or it

seems to be actually making things worse, and by that time, that

user is likely in a negative state of mind thanks to the cystic acne,

since most users use it for that specific kind, though others do too.

I've been on it twice, and my current topical is mainly Tazorac 0.1%

gel. It brought out deep seated stuff even the Retin-A Micro 0.1%

I'd been on had let go. The result long term (it took over 6 months

to fully realize it's benefits, maybe closer to a year) are really good.

The two prior courses of Accutate, the very strict diet and avoiding

the sun and using the best sunblock ever (OceanPotion SPF 50) is

also a big factor (I put it on if I'll be in the direct sun for more than

just a few minutes at a time. Beach, long drives, long walks, etc...

What frustrates, maybe Antony or Dermapro will have a take on this,

is how the topical version (Isotrex) is nothing more than a milder sort

of take on Retin-A Micro Gel (much like the .025% vehicle). It did not

do me a bit of good. I'd ordered it from Candada many years back, it

is not worth bothering with. It's said to just have the keratylitic affect

of a mild retinoid. I wish they'd make a topical version that would do

to the pilosebaceous glands what the internal pill does, but via use of

a topical (thus absorption/osmosis, etc.). If they could toss in a med.

that would inhibit the kinds of DHT (# 2) that causes skin to be oily,

that would be great also (Propecia, Proscar are internal and only are

effective on DHT (# 1) which is associated with Prostate & Hair Loss.

If they tried hard enough, I'm sure it could be done, but curing our

acne is a low priority compared to hair loss and erectile disfuction.

Mark D.

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Ummm... please note this is what I said in my post

I did not claim retinoids caused it.  I'm perfectly willing to entertain the notion that there were other factors at play. Also, I never said WHEN in the course of the treatment that happened. Based on everything I know (and you don't), I am inclined to think the retinoids had a significant role in it. 

My impression is that you think my statements were directed to your particular instance.  If my impression is correct, please be assured that they were not.

If you read the entire post, it should be pretty obvious I am not claiming EVERYONE's acne is going to turn into cystic one.

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I am surprised that no one has come up with a topical that duplicates the action of Accutane, mainly because acne is in actuality quite a big priority. Whomever comes up with an effective topical and safe version of Accutane will make untold billions of dollars....
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