That's why I asked Dr. Stein Gold some of the more pressing acne questions: all the things you want to talk to your dermatologist while you're visiting his office, but either don't have the time to fit in or simply forget to inquire about. So to see Dr. Stein Gold's top acne advice, just keep reading.
BellaSugar: What causes acne?
Dr. Linda Stein Gold: There are several factors that go into play when we're talking about acne. All acne lesions occur on a hair follicle, and the first sign of an acne lesion is a little clog on the hair follicle. That blockage can turn into either a whitehead or a blackhead, or if there's bacteria and an a lot of inflammation, it can turn into an inflamed bump: a pimple.
BellaSugar: What other factors come into play in the formation of acne?
LSG: There are different components that go into acne: there's the inflammation, there's that clog of abnormal keratinization, which is the blockage of the hair follicle; there are hormones and increased sebum on the skin, and there's the P. acnes bacteria. So there are four different things, and we usually try to target different aspects in the pathophysiology of the acne. We try to target different ways to get the best results in our acne care.
BellaSugar: When do you think it's it time to seek professional help, and when is it OK to treat pimples at home?
LSG: If you have just a few spots on your face, there are some over-the-counter treatments that you can try. Benzoyl peroxide [gel or wash] is very good. Start with that, and give that a try for several weeks or a month or so to see if that's all you need. The only issue with benzoyl peroxide is that it can bleach things, and it can be irritating, but that's a good start. If you have a little more severe acne or if you're not doing better after a few weeks with the over-the-counter products, then it's a good idea to head to a dermatologist.
BellaSugar: I'm sure this is on a case-by-case basis, but what are your top ways to treat acne at your office?
LSG: Each patient is really assessed individually as to whether they have more localized acne on the face, or if it's widespread, involving the face, the shoulders, the chest, and the back. How inflamed is it? Are they just superficial bumps, or do they have super-inflamed bumps? I look to see whether or not they have evidence of scarring already. So depending on how severe their acne is, that determines how aggressive I am in my treatment approach. I tend to like to get it under control fairly quickly. The other thing that's really important is that I try to make sure I give patients a treatment that works for their lifestyle. [For busy people,] I try to give them things that they can use once a day instead of twice a day. I like to use combination products, because you get two medicines in one.
BellaSugar: In general, what do you think is a good basic skin care routine for someone who has some acne problems?
LSG: Generally washing with either a gentle cleanser or a cleanser that has a benzoyl peroxide is a good idea, depending on how sensitive your skin is. I always like to put my patients on a topical retinoid, because that works in a lot of different ways. Some of them, like adapalene, or Differin, have been shown to actually work on not only the blackheads and the whiteheads, but also to help decrease the inflammation. And it's also really important to use a retinoid to maintain the healthy skin and maintain a clear complexion. People forget that acne, at its beginning, is underneath the skin, so you don't even see it. So if you tend to just spot treat your acne, like you see on TV — you know, kind of like the "zap the zit" — you're always going to be chasing after it. It's important to treat the whole acne problem area in order to keep your complexion clear.
BellaSugar: What about moisturizers and toners?
LSG: I don't usually have patients use a toner if they're on a good acne regimen. I think that just adds excess dryness to the skin, and a lot of medicines do tend to dry the skin a little bit. I do recommend a moisturizer. I really recommend sunscreen, at least SPF 30. And when you look at the sunscreens and the moisturizers, just make sure it says "noncomedogenic" on it, which means it won't cause acne.
BellaSugar: At one time, all three of us on the BellaSugar team were on antibiotics and some sort of a tretinoin treatment, but we were getting dry skin. If you do experience dryness as a result of acne treatment, is there some way to sort of gently slough it off without causing irritation?
LSG: That's a good point. People want to tend to scrub the skin a lot with acne, and it's been shown that it can actually make the acne worse. If you start off with a good moisturizer with your acne regimen, you can keep it in good check. And you mentioned the oral antibiotic, and that's something we use very commonly. There was an interesting study done recently, looking at using oral doxycycline and Epiduo [adapalene and benzoyl peroxide]. This study asked the question, first of all, "Do you need to add a good topical if you're using an oral antibiotic? Does it make any difference?" And the answer was yes. By adding the Epiduo on top of the doxycycline, there was a significant improvement in acne after three months. Ideally, we try to get patients off the oral antibiotic after about three or four months if possible. The goal is to get you under control quickly, often with an oral antibiotic and a potent topical, and then stop the antibiotic and just maintain with the topical.
BellaSugar: When does acne start to go away? When will the breakouts stop!?
LSG: It's really an individual issue. There's definitely a population of patients, and especially adult women, but we can see it in adult men, who continue to have it into their 40s. But it gets less and less with time. And with women, they see that they start to flare up around their menstrual cycles.
BellaSugar: Is the actual location of acne on the face an indication of anything? If it's on the chin or forehead, for instance, does that mean anything in particular?
LSG: I can tell you in adult women that we do commonly see it on the jawline; it tends to be more cystic or under the skin. We might use more hormonal therapy for an adult woman who has that kind of acne.
BellaSugar: And so then do you treat acne differently depending on where it is on the skin?
LSG: Not necessarily. If you have the cystic, under-the-skin acne, often we'll go with more of a systemic treatment — something more like birth control pills or something called spironolactone, or even oral antibiotics.
BellaSugar: What about blackheads? It's so tempting to want to get them out.
LSG: Yes, [but] you have to be careful with any type of self treatment of your acne because you can definitely cause scarring. That's where the topical retinoids come in. They help to loosen those up, and they're the best treatment we have for the blackheads. It's not something that happens overnight. You really have to use these on a long-term basis over the process of months. If you're consistent with it, you'll see an improvement.