Spot treatment

At 14, Elissa came home from summer camp with a healthy glow, a repertoire of hilarious stories and a face full of pimples. “I don’t know whether it was the fact that she didn’t take as good care of her skin as she does at home, or whether she just had a flare-up, but it was bad,” says her mom, Bonnie Penfound. What’s worse, the breakout didn’t clear up over time. As the months wore on, the Toronto teen became despondent. “It’s just gross,” Elissa told Penfound.

Indeed, zits are the bane of many a teen’s existence. Just as they are starting to care about how they look, acne rears its ugly head (so to speak). It usually decreases in severity by the early 20s, when the hormone rushes of adolescence finally settle down. In the interim, however, kids struggle with feeling unattractive and may even have to put up with teasing from clearer-skinned teens. “There have been lots of studies that detail the psychological impact of acne,” says Calgary dermatologist Catherine Zip. “Kids just break down and cry in my office. Some of them don’t even want to go to school.”

They’re hardly alone. Up to 85 percent of adolescents will experience acne, says Zip, and of those, as many as 30 percent will seek medical treatment for the condition.

Acne is the result of clogged hair follicles below the skin’s surface. During puberty, rushes of the male hormone testosterone cause sebaceous glands, which are attached to the follicles, to produce excess sebum (oil). The result: Sebum floods the pores and clumps when mixed with excess skin cells, causing a blockage. In that oil-rich environment, bacteria proliferate, causing inflammation that shows up in the form of pimples. Males and females are equally likely to get acne, but boys, who produce more testosterone, seem to be more severely affected. A combination of hormones and genetics (acne tends to run in families) seems to determine why some teens are plagued with the blemishes, while others sail through adolescence with barely a bump.

How you treat blemishes depends on whether your child gets the occasional pimple, regular outbreaks or severe acne. But probably the first line of defence, contends Zip, are the kind of non-prescription topical products you get at the drugstore. Look for cleansers and creams containing salicylic acid, which helps slough off dead skin cells to open plugged follicles, or benzoyl peroxide, an antibacterial.

Teens should wash twice daily with a mild soap or cleanser and then apply the lotion, cream or gel faithfully, according to the directions. “All topical treatments are preventive,” Zip points out, “so you need to apply it everywhere you get acne. You’re too late if you use it as a spot treatment.”

If skin is no clearer six to eight weeks later, a visit to a dermatologist or acne specialist is probably in order. Doctors often start by treating persistent outbreaks with prescription topical and/or oral antibiotics, such as tetracycline and erythromycin, or a topical retinoid like tretinoin. Stomach upset is the most common side effect associated with oral antibiotics, and allergic reactions are unusual.

Zip favours a topical retinoid or a combination of benzoyl peroxide and antibiotic such as clindamycin or erythromycin. “Benzoyl peroxide with an oral antibiotic will make the antibiotic work better,” she says. Another alternative for girls: birth control pills. Other issues aside, certain oral contraceptives help clear up spots by blocking production of the hormone androgen. Girls who break out just before their period might be good candidates, but the results don’t happen overnight. The pills take approximately three to six months to work, and acne usually returns once the pills have been stopped.

Having tried many acne medications without success, Zuhal Patak* of Toronto, at 15, opted for a two-step procedure called ALA photodynamic therapy. After exfoliating the skin to allow for better treatment penetration, the medical esthetician coated her face with aminolevulinic acid (ALA), to make acne bacteria sensitive to light, and then sat her under an intense blue light to target and kill the bacteria. According to Mahmood Kara, a Toronto plastic surgeon who offers the treatment at his clinic, the therapy doesn’t work for everyone, but he sees some degree of improvement in 90 percent of the teens he treats.

The big issue for many families: The cost is high. At Kara’s clinic, for example, each 1½-hour session costs $350 and he recommends five initially, plus maintenance visits every three months. “This is not a cure,” he points out. But for teens like Zuhal, it can be well worth it. “I had three treatments over three months,” she says. “I could already see a slight difference after the first one.” Although she was told to come back if she broke out, Zuhal, now 16, says her skin has remained clear for nearly a year.

Zip agrees that such treatments show promise, “but they’re still considered experimental.” If other treatments don’t work, or if acne is of the inflammatory variety that can cause lifelong scars, she pulls out the big gun: isotretinoin, otherwise known as Accutane, an oral drug that slows down oil production and the growth of bacteria. Opinions vary in the medical community due to the drug’s range of scary, if uncommon, side effects, but Zip believes it can be the best option for some patients. “Acne,” she argues, “is not really just a cosmetic condition. It can hurt, it can scar and it affects well-being so much.”

*Name changed by request.

Accutane’s potential side effects include dryness of the lips, eyes and skin, liver inflammation, elevated fat and cholesterol in the blood and even a possible association with depression and suicide. “We don’t really know if Accutane causes mood changes and depression, but there are case reports that it does,” explains Zip. “On the other hand, the larger studies haven’t shown an increased risk of either depression or psychosis.” The drug definitely causes birth defects in fetuses, so girls take a pregnancy test before starting on it and must agree to take the Pill for the duration of the treatment. They must also get monthly blood tests to check trigly-cerides and liver enzyme levels and catch any pregnancy early on.

On the plus side, kids usually only take Accutane for four to six months, and doctors monitor them closely for side effects. The clincher, at least for some, says Zip: “Accutane is highly effective. It pretty much clears everyone up while they’re on it. Roughly, 40 percent stay clear, 60 percent get some acne back — usually not as bad — and 20 percent end up back on Accutane for another course of treatment.” Covered by most drug plans, Accutane ranges from $600 to $1,200 for a 20- to 24-week course of treatment, depending on the severity of the acne and response to treatment.

Elissa, now 16, counts herself among its fans. She finished her course of treatment in March 2005 and although she still gets the occasional breakout, a topical treatment usually clears it up. “Before, if I hadn’t seen someone for a while and then I ran into them, they’d say, ‘Whoa, you’re really breaking out,’” says Elissa. “It made me feel pretty bad.” Now, says her mom, she can concentrate on the other obsessions of adolescence, from boys to grades. “Kids have enough to worry about at that age, without having to think about acne,” she says.

True or false? Acne is caused by poor hygiene.
False: “You can’t wash off acne,” says David Eisen, a family doctor who specializes in acne treatment at The Acne Treatment Clinic in Toronto. “It’s below the surface.” Similarly, scrubbing away at your face or using abrasive or drying alcohol-based toners and cleansers can irritate skin, causing outbreaks.

True or false? Eating greasy foods brings on breakouts.
False: There’s very little evidence that diet influences acne flare-ups, according to Calgary dermatologist Catherine Zip.

True or false? Some cosmetics can trigger flare-ups.
True: Moisturizers, in particular, may cause acne to flare up by clogging pores, which swell and become blocked. Look for non-comedogenic and non-acnegenic makeup.