Adolescence is a time when young people search for identity. A youth’s peer group becomes a central focus of identity fulfilment and emotional satisfaction. Teens develop a heightened awareness of themselves relative to peers and flaws can seem magnified. These cognitive and emotional changes develop just in time for the onset of acne.
Acne is a common disorder caused by obstruction and infection of the hair follicle. Hormones in the body stimulate glands within the hair follicles to secrete oils. If the follicles become plugged, they form comedones or whiteheads/blackheads. If the follicles become infected, they form pustules or zits. Pustular acne can cause irreversible scarring.
There are many misunderstandings about acne which can interfere with appropriate treatment:
- Acne is NOT a hygiene problem. Excessive washing of the face, especially with abrasive products will worsen acne.
- Acne is NOT generally worsened by food. Although some people rarely notice a worsening of acne if they eat large amounts of certain foods, it is generally not food intake that worsens acne.
- The topical medications will NOT cure acne. The medicines commonly used for acne will almost always manage acne quite successfully but the medicines will need to be maintained to keep acne under control.
- It is NOT possible to predict when acne will subside. Most adolescents will outgrow acne at the end of puberty; however, some will not. The duration of medication use is entirely dependent on the duration of acne.
- The severity of acne is NOT stable before or during treatment. Most acne is a dynamic process, meaning there will be times of worsening and improvement. These episodes of worsening will need to be managed during the course of treatment.
- Acne will NOT get better immediately. The medications used will take at least six weeks to improve acne. The full benefit of medicines takes four to six months. Pigmentation marks from acne can take up to one year to improve.
- Makeup and moisturizing creams do NOT generally worsen acne. Makeup and face products should be labeled “non-comedogenic”. Maintaining adequate moisture in the skin has been shown to improve acne.
- Scarring from acne will NOT get better over time. Scarring is a permanent complication of acne which can and should be prevented. Whitehead and blackheads will not scar, but zits will likely scar. Recurrent picking and traumatizing of lesions will worsen scarring. The main goal of acne therapy is to prevent scarring; however, this requires constant management.
General Acne Care
- Wash your face no more than twice a day with mild soap such as unscented Dove. Do not use any harsh or abrasive cleansers.
- Treat your skin very gently. Any rubbing, pressure, or irritation on the skin can irritate the follicles and thus worsen acne.
- After washing, pat your face dry. Do not rub with a towel. Avoid resting your hands on your face.
- Avoid picking at lesions. Trauma to zits can increase the chance of scarring. If you have a large pustule that you would like to pop for cosmetic reasons, unroof the top of the zit with a small, sterile needle and squeeze very gently, using the pads of the fingers, to remove the pus. All superficial pus that can be removed will come out with one light squeeze. Recurrent pressure will make the zit bigger and redder, not smaller.
Over the Counter Medications for Acne Use
All topical creams are put on in the same manner. One pea-sized amount of cream on your finger should cover the entire face. Cream should be put on the entire face and not just areas of acne because they are for prevention of new lesions. Distribute tiny dots of medication by barely touching the medicine to the face approximately two to three inches apart. After multiple small dots are made, gently massage the medication into the skin. Gradually increase the frequency of medicine use to avoid side effect by applying every third day for one week, every other day for one week, then every day. Purchase products as individual ingredients rather than in combination – the dose and vehicle (cream, gel, etc) will be more accurate.
Benzoyl peroxide has an antibacterial effect in the skin and helps prevent zits. The gel preparation penetrates the skin better than the cream and is generally the most effective. Benzoyl peroxide can be drying and cause irritation. Five percent gel is generally sufficient for the face and ten percent for the chest or back. Apply in the evening about one hour before bed so the medication doesn’t rub off on the pillow case. Benzoyl peroxide can bleach clothing so wash hands well after application and wear bed clothes that won’t be harmed from bleach effect.
Adapalene is a retinoid medication which prevents the formation of comedones. These medicines take at least six to eight weeks to work and can make acne appear worse prior to improvement – this is a sign that the medicine is working; it should not be an indication to discontinue the medicine. Differin 0.1 % gel is an adapalene preparation now available over the counter. It will work best if used in conjunction with benzoyl peroxide but applied at a different time of the day: first thing in the morning is best.
Salicylic acid is an exfoliative which means it removes the top layer of skin and helps prevent comedones. Clearasil makes a 2% salicylic acid cream. Salicylic acid can be used in the morning instead of adapalene for mild acne. It is cheaper than adapalene but likely not as effective.
Irritation and/or dryness can be treated with Cetaphil Moisturizing cream. Don’t use lotions because they don’t work as well. It is best to use a moisturizer once or twice a day in a preventative fashion while advancing topical medications to avoid dryness. If dryness occurs, the moisturizer should be applied three to four times a day to catch the skin up to the normal level of lubrication. Once the skin adjusts to the acne medication, dryness will be less of an issue. If an unpleasant amount of dryness or burning with application of medicine occurs, the frequency of medicine use may need to decrease temporarily while moisturizers are used more frequently to increase lubrication. Medicines can be more irritating if applied on recently wet skin. If skin does become irritated, medicines should be applied at least one-half hour after washing. If you forget to wash your face one-half hour prior to going to bed, it is more important to apply the medicine than it is to wash your face. Any of the acne medicines can cause photosensitivity or an increased risk of sunburn. If you are planning to be in the sun for a long time, you should use a sunscreen with a sun protection factor (SPF) of at least 30.
There are many prescription medications that are stronger and more effective than over the counter medicine. If your acne treatment is not going well, especially with ongoing zits or pustules that may cause scarring, please see one of our Pediatricians at Canyon View Pediatrics for help.
- Start treatment for acne at the first sign of presentation in adolescence to prevent it from getting worse.
- Use medicines consistently until six months after no new whiteheads, blackheads or pustules appear. This will likely take 3 -5 years.
- Zits cause permanent scarring. Don’t let them go untreated. See one of our pediatricians if over the counter medications are not working well.
John Bennett MD, FAAP