When acne outlives teen
Blemishes still a very grown-up problem for some
BY REBECCA RAKOCZY Cox News Service
Agelines and acne? This wasn't supposed to happen, or so Kim Noble thought.

PHOTO BY MARSHALL GORBY / COX NEWS SERVICE Why some people travel through life with unblemished skin - and others with acne scars- depends on many factors, including genes. It's likely that if your parents suffered from acne, you will, too.

Acne, normally the bane of teenagers, was flaring up on Noble's 50-year-old face, causing the Atlanta businesswoman no small degree of frustration.

"I started when I was a teenager with acne problems, and as I got older, it got worse," she said. "I was told it was due to stress and due to hormones," said Noble, who has been seeing a dermatologist for years, but still has flare-ups.

"I've tried everything that was out there, from (rubbing) alcohol to injections to Accutane to Proactiv," she said.

She's not alone, said Dr. Jodi Ganz, an Atlanta dermatologist who estimates that half of her patients are adults suffering from mild to severe acne breakouts.

"There are a ton of people with adult acne. For women, flare-ups usually occur the week before their periods; that's what we call 'hormonely linked acne.' And there is a lot of what we call 'graduate school acne' for both men and women- flare-ups that occur between the ages of 25 and 30 in populations that have not had a breakout since age 16," she said.

And while teen angst over pimples is legendary, adults are floored when pimples erupt.

"We see people who are extremely upset about this; they thought this was a normal part of teenager-hood, and they would outgrow it," she said.

Acne begins occurring usually the year before puberty's onset, said Dr. Leslie Lawley, an assistant professor of pediatric dermatology at Emory University in Atlanta. And that age keeps getting younger.

"We've seen girls having their periods at age 9, so they are getting acne earlier," she said.

Acne, she said, is caused by an increase of hormones, which causes facial glands to create more oil that clogs up the ducts, allowing certain bacteria to grow.

"That can lead to blackheads and whiteheads, and more inflammatory bumps," Lawley said.

Women - like Noble - seem to deal with acne flare-ups longer: A recent University of Alabama-Birmingham School of Medicine study published online by the American Academy of Dermatology shows middle-age women - those over 50 - are twice as likely as men to suffer from some form of acne.

Why some people travel through life with unblemished skin - and others with acne scars - is also due to genes; it's likely that if your parents suffered from acne, you will, too.

But there also is speculation that our lifestyle and culture may contribute to the incidence of acne.

"The rate of acne is so much less in non- Western-ized cultures," Ganz said. She cites a 2002 study by the Department of Health and Exercise Science at Colorado State University that looked at 1,200 individuals ages 15-25 in Papua New Guinea and Paraguay, and found extremely few cases of acne.

"There has to be something on a bigger level here - how our lifestyle and overall eating habits affect our skin," she said.

Treatment

Drugstores offer a mind-boggling array of products and treatments that range from "The Power Pimple Peel" to the formidable sounding "Teminator 10," next to long-time standards such as Clearasil and Stridex. A stroll down most crowded malls will find a marketing Proactiv, the skin regimen touted by celebrities such as Jessica Simpson, Vanessa Williams and Sean "Diddy" Combs as an acne cure-all.

"The over-the-counter stuff isn't necessarily bad for mild acne," Ganz said. "Look for topical creams, products with salycic acid or benzoyl peroxide; that's what's in Proactiv, by the way," she said.

But you might want to see a dermatologist if the over- the-counter products don't work after two months, both Ganz and Lawley advise.

"If they're using these things regularly, and the [skin] is not responding after two months, it should be worth it to go to a dermatologist and start prescription treatments," Lawley said.

Be patient, both doctors say. Typically, even with prescription medications, it can take six to 10 weeks before these drugs show any signs of working.

The following is a brief list of the types of medications usually prescribed by dermatologists for moderate to severe acne. Check with your doctor or health-care provider; usually he or she can prescribe a generic form of a drug, which is less expensive than brand names.

Retinoids - also known as Retin A. One of the gold standards in fighting acne, retinoids work well getting rid of blackheads and whiteheads, Lawley said. Don't take any retinoid pill, however, if you're pregnant, or want to become pregnant because they have been linked to birth defects.

Combination of oral antibiotic and topic antibiotic creams. The oral antibiotic (pill) acts as an anti-bacterial to reduce infection, while the topical antibiotic reduces inflammation.

Doctors commonly prescribe a member of the tetracycline antibiotic family for the oral dose. Doxycycline is one of the more common names, which is usually prescribed with a high-percentage benzoyl peroxide cream.

"But we do worry about the global issue of antibiotic resistance. We try not to keep a patient on an antibiotic for too long," Ganz said.

"If someone needs an oral treatment, we start both on cream and oral antibiotic and decrease their reliance on oral and maintain the topical. In addition, researchers are looking at treating acne with more anti-inflammatory agents, as opposed to just antibiotics," she said.

Accutane. "If the patient has seen no results and have been on oral antibiotics, Accutane is an option, but you absolutely cannot take it if you're pregnant," Lawley said, noting that it has been linked to birth defects in children born to women taking the drug. Accutane also has been associated with depression and suicide, according to U.S. Food and Drug Administration reports.

Birth control pills. For women who aren't trying to get pregnant, low-dose birth control pills can be helpful in controlling hormones, which aggravate acne; and they're another option if the antibiotics aren't working, Lawley said. But she doesn't prescribe it before ruling out risk factors such as age, whether the patient is a smoker or has a history of migraines. And she typically recommends an exam by a gynecologist as well.

Corticosteroid injections. These are shots used to dissolve acne cysts that do not respond to other therapies and treat scar tissue.

Microdermabrasion or dermabrasion. Also known as "power peels," this method can reduce noticeable scarring and pock marks associated with acne.

Photodynamic therapy - also known as laser treatments. "ALA (a 20 percent solution of aminolevulenic acid) is painted on the skin, and a laser light activates the solution, killing the main bacteria. This is good for people who don't want to be on antibiotics, or have problems with antibiotic resistance," Ganz said.

Light therapy. Two of the newer treatments employ light and target the bacteria that cause the inflammation associated with acne. Treatments require multiple sessions during the course of a month and provide a temporary reduction in the appearance of acne.

The American Academy of Dermatology cautions patients to be sure to have a qualikiosk fied physician conduct potentially hazardous procedures to reduce the risks for error. These procedures can be costly and may not be covered by insurance.

Tanning beds and direct exposure to sunlight may initially improve acne, but continuous exposure may plug pores and lead to more pimples. Too much exposure may result in skin cancer. The medical community believes that the risks of sun exposure outweigh any benefits in long-term treatment for acne.

Insurance woes

Fighting "zits" can be an expensive proposition, as anyone who gets a bill for these drugs from his or her pharmacist knows.

Many of these drugs aren't covered by insurance; but neither are the over- the-counter treatments, where patients can spend hundreds of dollars trying different products.

Case in point: Retin A, the drug that is often considered the "gold standard" for treating acne by dermatologists, is often denied coverage by insurance because it's more popularly known for fighting wrinkles. Therefore, many insurance companies will deny coverage for adults.

"You're not a teenager, so they assume you're using it for cosmetic purposes," said Ganz, who added that she has written letters to insurance companies to back up the prescription for her patients.

Ask for generic

"New medications are not always covered until they have been out for a while, Lawley said. "But you don't always have to use the newest one."

If you ask, most dermatologists will prescribe a generic, rather than name-brand prescription, unless there is no appropriate substitution.

And don't assume your doctor knows what your insurance covers.

"I write what I think is the best treatment for them; but if their insurance doesn't cover it, I encourage my patients to give me a call and we'll substitute something," Ganz said.

"You really have to work on both ends."