How to treat acne bomi kim by Bomi Kim

@ BOMI KIM

HOW TO TREAT ACNE

All rights reserved. No part of this book may be reproduced in any manner whatsoever without the written permission of the author except in the case of brief quotations embodied in critical articles and reviews. Published in the United States by SVA, New York, and in South Korea by Bomi,Inc., Seoul. Originally published in hardcover in the United States by SVA, New York, in 2014.

Book Design: Bomi Kim

ISBN: 978-0-307-27882-1

www.bomikim.com

Printed in United states of America

CON TE N TS

1. WHAT IS ACNE? 6

2. CAUSES 12

• Genetic

• Acquired

3. MYTHS ABOUT ACNE 22

4. MEDITATION 28

• Oral medicine

• Dermatology Treatment • Ethical diifferent meditation

5. HABITS TO MAKE BETTER SKIN 54

• How to wash your face

• How to pop a pimple properly

• Recommanded products

6. AFTER MEDITATION 64

• Inner beauty

• How to get rid of acne scar

HOW TO TREAT ACNE

1. WHAT IS ACNE? Acne is a common skin disease that causes pimples. Pimples form when hair follicles under your skin clog up. Most pimples form on the face, neck, back, chest, and shoulders. Anyone can get acne, but it is common in teenagers and young adults. It is not serious, but it can cause scars. No one knows exactly what causes acne. Hormone changes, such as those during the teenage years and pregnancy, probably play a role. There are many myths about what causes acne. Chocolate and greasy foods are often blamed, but there is little evidence that foods have much effect on acne in most people. Another common myth is that dirty skin causes acne; however, blackheads and pimples are not caused by dirt. Stress doesnâ&#x20AC;&#x2122;t cause acne, but stress can make it worse. 1

HOW TO TREAT ACNE

ACNE VULGARIS (or simply ACNE) is a common human skin disease, characterized by areas of seborrhea (scaly red skin), comedones (blackheads and whiteheads), papules (pinheads), nodules (large papules), pimples, and possibly scarring. Aside from scarring, its main effects are psychological, such as reduced self-esteem and in very extreme cases, depression or suicide. One study has estimated the incidence of suicidal ideation in patients with acne as 7.1%.

TESTOSTERONE is a steroid hormone from the androgen group and is found in mammals, reptiles, birds, and other vertebrates. In mammals, testosterone is secreted primarily by the testicles of males and

In adolescence, acne is usually caused by an increase in androgens such as testosterone, which occurs during puberty, regardless of sex. Acne more often affects skin with a greater number of oil glands; these areas include the face, the upper part of the chest, and the back. Severe acne is inflammatory, but acne can also manifest in noninflammatory forms. The skin changes are caused by changes in pilosebaceous units, skin structures consisting of a hair follicle and its associated sebaceous gland, changes that require androgen stimulation.

the ovaries of females, although small amounts are also secreted by the adrenal glands. It is the principal male sex hormone and an anabolic steroid.

Many different treatments exist. Eating fewer simple carbohydrates like sugar may help. Medications for acne include: benzoyl peroxide, antibiotics (either topical or by pill), retinoids, antiseborrheic medications, anti-androgen medications, hormonal treatments, salicylic acid, alpha hydroxy acid, azelaic acid, nicotinamide, and keratolytic soaps. Early and aggressive treatment is advocated by some to lessen the overall long-term impact to individuals. Acne occurs most commonly during adolescence, affecting an estimated 80â&#x20AC;&#x201C;90% of teenagers in the Western world.Lower rates are reported in some rural societies. In 2010 it was estimated to be the 8th most common disease globally affecting 650 million people. For most people, acne diminishes over time and tends to disappear â&#x20AC;&#x201C; or at the very least decreases â&#x20AC;&#x201C; by age 25. There is, however, no way to predict how long it will take to disappear entirely, and some individuals will carry this condition well into their thirties, forties, and beyond.

Signs and Symptoms

Typical features of acne include: seborrhea (increased oil-sebum secretion), comedones, papules, pustules, nodules (large papules),

and possibly scarring. The appearance of acne varies with skin color. It may result in psychological and social problems. Some of the large nodules were previously called “cysts” and the term nodulocystic has been used to describe severe cases of inflammatory acne. The “cysts”, or boils that accompany cystic acne, can appear on the buttocks, groin, and armpit area, and anywhere else where sweat collects in hair follicles and perspiration ducts. Cystic acne affects deeper skin tissue than does common acne.

Pathophysiology Acne develops as a result of blockages in the follicles. Hyperkeratinization and formation of a plug of keratin and sebum (a microcomedo) is the earliest change. Enlargement of sebaceous glands and an increase in sebum production occur with increased androgen (DHEA-S) production at adrenarche. The microcomedo may enlarge to form an open comedo (blackhead) or closed comedo. Comedones are the direct result of sebaceous glands’ becoming clogged with sebum, a naturally occurring oil, and dead skin cells. In these conditions, the naturally occurring largely commensal bacterium Propionibacterium acnes can cause inflammation, leading to inflammatory lesions (papules, infected pustules, or nodules) in the dermis around the microcomedo or comedone, which results in redness and may result in scarring or hyperpigmentation.

HYPERKERATINIZATION (hyperkeratinisation in British English) is a disorder of the cells lining the inside of a hair follicle. It is the normal function of these cells to detach or slough off (desquamate) from the skin lining at normal intervals. The dead cells are then forced out of the follicle (primarily by the growing hair). However, in hyperkeratinization, this process is interrupted and a number of these dead skin cells do not leave the follicle because

Diagnosis

of an excess of keratin, a natural protein found in the skin.

There are multiple scales for grading the severity of acne vulgaris, three of these being: + Differential diagnosis.

• Leeds acne grading technique: Counts and categorises lesions into inflammatory and noninflammatory (ranges from 0–10.0).

Other similar conditions include: rosacea, folliculitis, keratosis pilaris, perioral dermatitis, and angiofibromas among

• Cook’s acne grading scale: Uses photographs to grade severity from 0 to 8 (0 being the least severe and 8 being the most severe). • Pillsbury scale: Simply classifies the severity of the acne from 1 (least severe) to 4 (most severe).

others

HOW TO TREAT ACNE

History • Ancient Egypt, Ancient Greece and Ancient Rome: Sulfur was used to treat acne. SULFUR is one of the oldest known acne treatments. Yes, sulfur. The same stuff match sticks are made

• 1920s: Benzoyl peroxide was used as a medication to treat acne.

of. Historically known as brimstone, sulfur was used in ancient times to treat skin problems like dermatitis and dandruff, to rosacea and warts.

Sulfur is a natural element, and has

• 1970s: Tretinoin (original Trade Name Retin A) was found to be an effective treatment for acne. This preceded the development of oral isotretinoin (sold as Accutane and Roaccutane) in 1980. Also, antibiotics such as minocycline are used as treatments for acne.

an odor that is quite… distinctive. The scent of rotten eggs comes to mind. Luckily, most of today’s products don’t smell that bad.

How it Works:

When applied topically, sulfur causes the skin to dry and peel. Despite how this sounds, it is actually a good thing for your skin if you have acne. Sulfur helps reduce skin oiliness, and prevents pore blockages from forming.

Sulfur is found in a wide array of skin care products, including soaps and cleansers, lotions, masks, and spot-treatments.

• 1980s: Accutane is introduced in the United States, and later found to be a teratogen, highly likely to cause birth defects if taken during pregnancy. In the United States, more than 2,000 women became pregnant while taking the drug between 1982 and 2003, with most pregnancies ending in abortion or miscarriage. About 160 babies with birth defects were born.

HOW TO TREAT ACNE

2. CAUSES The exact cause of acne is unknown, but doctors believe it results from several related factors. One important factor is an increase in hormones called androgens (male sex hormones). These increase in both boys and girls during puberty and cause the sebaceous glands to enlarge and make more sebum. Hormonal changes related to pregnancy or starting or stopping birth control pills can also cause acne. Another factor is heredity or genetics. Researchers believe that the tendency to develop acne can be inherited from parents. For example, studies have shown that many schoolage boys with acne have a family history of the disorder. Certain drugs, including androgens and lithium, are known to cause acne. Greasy cosmetics may alter the cells of the follicles and make them stick together, producing a plug. 7

HOW TO TREAT ACNE

Hormonal Hormonal activity, such as menstrual cycles and puberty, may contribute to the formation of acne. During puberty, an increase in sex hormones called androgens cause the follicular glands to grow larger and make more sebum; A similar increase in androgens occurs during pregnancy, also leading to increased sebum production. Use of anabolic steroids may have a similar effect. Several hormones have been linked to acne: the androgens testosterone, dihydrotestosterone (DHT) and dehydroepiandrosterone sulfate (DHEAS), as well as insulin-like growth factor 1 (IGF-I). Development of acne vulgaris in later years is uncommon, although the incidence of rosacea, which may have a similar presentation, is increased in older age groups. True acne vulgaris in adult women may be a feature of an underlying condition such as pregnancy, or disorders such as polycystic ovary syndrome, hirsutism, or Cushing’s syndrome. Menopause-associated acne (known as acne climacterica) occurs as production of the natural antiacne ovarian hormones estradiol and progesterone fail, permitting the acnegenic hormone testosterone to exert its effects unopposed.

Genetic The predisposition for specific individuals to acne is likely explained by a genetic component, which has been supported by twin studies as well as studies that have looked at rates of acne among first degree relatives. The genetics of acne susceptibility is likely polygenic, as the disease does not follow classic Mendelian inheritance pattern. There are multiple candidates for genes which are possibly related to acne, including polymorphisms in TNF-alpha, IL-1 alpha, CYP1A1 among others.

Psychological While the connection between acne and stress has been debated, scientific research indicates that “increased acne severity” is “associated with increased stress levels.” The National Institutes of Health (USA) list stress as a factor that “can cause an acne flare.”

Infectious Propionibacterium acnes (P. acnes) is the anaerobic bacterium species that is widely concluded to cause acne, though Staphylococcus aureus has been universally discovered to play some role since normal pores appear colonized only by P. acnes. Regardless, there are specific clonal sub-strains of P. acnes associated with normal skin health and others with long-term acne problems. It is as yet inconclusive whether any of these undesirable strains evolve on-site in the adverse conditions or are all pathogenically acquired, or possibly both depending on the individual patient. These strains either have the capability of changing, perpetuating, or adapting to, the abnormal cycle of inflammation, oil production, and inadequate sloughing activities of acne pores. At least one particularly virulent strain, though, has been circulating around Europe for at least 87 years. In vitro, resistance of P. acnes to commonly used antibiotics has been increasing, as well. It is unclear if the parasitic mite Demodex, has an effect.

Diet The relationship between diet and acne is unclear as there is no good quality evidence. However, a high glycemic load diet is associated with worsening acne. There is also a positive association between the consumption of milk and a greater rate and severity of acne. Other associations such as chocolate and salt are not supported by the evidence. Chocolate does contain a varying amount of sugar that can lead to a high glycemic load and it can be made with or without milk. There may be a relationship between acne and insulin metabolism and one trial found a relationship between acne and obesity.

HOW TO TREAT ACNE

What makes causes acne during our daily life; 1. Using chemical based makeup products All makeup products are not good for all types of skin. Some products even have artificial color, lanolin, mineral oil, artificial fragrance and other chemicals that can irritate your skin and cause acne breakouts. Try to use herbal products that are made for your skin type. 2. Skipping moisturizer Irrespective of what type of skin you have, it needs an appropriate moisturizer. Without moisturizer it will be not possible to maintain the moisture level of your skin. This in turn can irritate your skin which can cause frequent breakouts of acne. Be gentle with your skin and keep it hydrated to prevent over-drying your skin. 3. Use of cell phone Whenever you are using a cell phone, you are putting physical pressure on your face. This kind of pressure not only exposes your skin to loads of bacteria, but the actual force that the bacteria apply against your face can cause acne breakouts. 4. Too much stress When you are in stress there is an increase of the hormones in the body that causes acne. So, take steps to reduce stress and try to do things that can help you relax and minimize the drama. 5. Dirty clothes Using dirty clothes and especially bed linen, sheets and pillows can be the actual reason behind your acne. Dirty clothes can be the breeding ground of bacteria. Always use clean towels and clothes for your skin. Also try to change your pillowcase and bed sheets once or twice a week. Plus, try to use detergents and fabric softeners that contain less chemical products. 6. Wrong hair products

Even usage of wrong hair products can cause acne. Remember hair often touches your face and this way

the chemicals present in the hair care products get in contact with your skin. Unless you are washing your hair every night before bed try to keep your hair tied. Also try to use herbal hair care products. 7. Using dirty makeup applicators If you lover to wear makeup, then you need to make efforts to keep the brushes, sponges, and other applicators you use to apply your makeup clean. Makeup tools are crawling with bacteria and dead skin cells, and thus they can cause acne. Remember to only use a makeup sponge once and clean your brushes once a week with a brush cleanser or shampoo. 8. Fast foods Consumption of fast foods on daily basis can actually give you acne. Fast foods contain high amount of fat, sugar and white flour that will mess with your body and can cause acne. Overall unhealthy diet affects your skin. Try to eat these foods only on occasion. 9. Wearing the wrong clothes Clothes made of fabrics like polyester and lycra can trap dead skin cells and sweat against your body. This in turn can various skin problems including acne. Choose clothes with natural fibers (think cotton and bamboo) that breathe so your skin doesnâ&#x20AC;&#x2122;t suffocate. 10. Excessive smoking

According to a research done at the San Gallicano Dermatological Institute in Rome, it was found that non-inflammatory acne (NIA) is very common among frequent smokers. It was also identified that smokers who had experienced acne in their teen years were four times more likely to have acne as an adult than non-smokers who also had acne in their teens.

11. Spraying perfume

Use of perfumes over the skin can cause skin irritation as well as acne. Make sure to avoid your face when spraying perfume. An easy way to do this is to spray perfume on your wrists, then rub them against your neck to spread the fragrance. Also steer clear of bath

HOW TO TREAT ACNE

and shower products with added fragrance. 12. Not removing makeup at night

Going to bed at night without washing and treating your face can be one of the main reasons behind acne breakouts. Every night you should be using a rinse-off cleanser, a hydrating toner or light moisturizer, and then only go for bed.

13. Tanning

Exposure to sun dries out your skin and cause tanning. Spending too much time under the sun can make your skin produce more oil. Also, tanning causes your skin to increase cell production which will give you more acne breakouts. Not to mention an increased risk of cancer and pre mature aging signs.

14. Not Trying an Acne Treatment Long Enough

Skin reacts slowly to treatment. Even if the acne came on fast, it still requires time to heal. That usually takes between 6 and 12 weeks, says Barbara R. Reed, MD, a dermatology professor at the University of Colorado Hospital in Denver.April W. Armstrong, MD, MPH, is an assistant professor of dermatology at the University of California Davis Health System. She tells patients to give a product 1 month and then keep using it if they notice any improvement. In some cases, your skin might feel a bit irritated the first couple of weeks of treatment, says Diane S. Berson, MD. She is an assistant clinical professor of dermatology at Weill Medical College of Cornell University, Ithaca. “It’s not an infection, it’s an inflammation. It can even get worse before it gets better,” Berson says.

15. Trying Too Many Products at Once

People usually layer on products when they don’t get results in the first few days of treatment, Reed says. “What then happens is that they start trying different products, abandoning them very quickly if they do not see results in a day or two. They also add one product to another. Sometimes the products can cause irritation of the skin and add further insult to the owner,” she says.

When someone self-treats their acne, they may

accidentally distress their skin. This can make the acne lesions bigger, more likely to pigment, and heal with spots and scars, 16. Over-Scrubbing or Over-Cleansing the Skin

Scrubbing the skin will actually worsen acne, as it can compromise the skin’s protective barrier and increase irritation,

Berson says; Instead, gently wash with a nonirritating, pH-balanced cleanser to lessen inflammation. It’s also important to thoroughly rinse off the cleanser, because the residue can be irritating, she says; “Acne is not from dirt,” Reed says. “Many people tend to over-wash and over-scrub when they get acne. As one of my teachers used to say, ‘If acne were from dirt, you would have it on your feet!’” 17. Choosing the Wrong Products for Acne-Prone Skin Harsh cleansers,

Alkaline bar soaps, and alcohol-based products may worsen acne, says Berson, who has consulted for skin care product-makers Galderma Stiefel, Procter & Gamble, and Neutrogena. Reed says she advises patients to look for “noncomedogenic” or “for acneprone skin” products. Noncomedogenic products don’t contain ingredients that tend to clog pores in people with acne-prone skin. Certain ingredients found in products such as cosmetics, sunscreen, and moisturizers are more likely to clog pores. They include isopropyl palmitate, isopropyl myristate, butyl stearate, isopropyl isostearate, decyl oleate, isostearyl neopentanoate, isocetyl stearate, myristle myristate, cocoa butter, acetylated lanolin, and D & C red dyes. Products containing oil can clog pores and lead to breakouts.

18. Waiting Too Long to See a Dermatologist

It’s time to make an appointment once acne starts taking a toll on self-esteem, becomes painful, causes scarring, or if over-the-counter (OTC) medications aren’t clearing it up. Dermatologists have more tools to treat acne and can prescribe stronger concentrations of OTC medications and oral antibiotics. They also offer light and laser therapy and chemical peels. But

HOW TO TREAT ACNE

these treatments are probably not necessary to treat a patient’s acne,

Armstrong says; ‘Dermatologists can give prescription medicines that are tailored to the type of acne a person has and also their skin type,’ Reed says; ‘It’s also possible a person could have rosacea, which usually requires different treatment than acne. Rosacea is a long-term disease that causes redness and pimples.’

19. Over-Using or Under-Using a Prescribed Acne Medication

Berson says she stresses to patients to use the medication as instructed. Over-usage won’t help clear the acne. It can cause more redness and dryness. Not sticking to a regimen delays any potential improvements. Half of the battle is consistency. Many people under-use because they lose motivation after the first 2 weeks. They can’t expect results overnight, Armstrong says. Under-using the medication by spot-treating fails to prevent breakouts.

“You need to apply medication to the entire affected area that tends to break out, instead of spot treating. With spot treating, you haven’t addressed the area next to it, where another pimple could be brewing, Berson says.

20. Stopping the Use of Acne Medication Once It Clears Up

It’s best to taper medication usage by using it less and less. For example, if you’ve been using it twice a day, use it once a day for a while, then once every other day, then twice a week, and then stop. It often takes acne 4 to 6 weeks to return, just like it took it the same amount of time for it to get better, Reed says.

To keep skin blemish-free, most people need to continue usage with at least one acne product. It’s possible to cut down to a few times a week if someone is using an OTC medication.

OTC MEDITATION(OVER-THE-COUNTER-) While it’s tempting to begin assaulting your breakouts with many treatment products at once, doing so could cause irritation of the skin. Most acne treatments dry the skin to some extent, so overuse of these products could cause excessive dryness, peeling, and redness. You may wish to start with a single acne treatment product, and slowly add more if needed. This is especially true if your skin tends to be sensitive or easily irritated.

To achieve the best results possible, you must first understand your skin. Noninflamed acne, blackheads and milia (whiteheads), often responds well to salicylic acid products. Start with a wash or cleansing pad. If after several weeks of treatment you aren’t seeing noticeable improvement you may add a salicylic acid lotion, provided you aren’t experiencing excessive dryness or irritation.

For those who tend to get inflamed pimples, benzoyl peroxide is a good treatment to start with. Benzoyl peroxide creams and lotions can be found at nearly every drug store. Apply the lotion as directed for several weeks, and then add a benzoyl peroxide or salicylic acid wash if needed. Again, additional products should be added only if you are not experiencing excessive dryness or irritation.

There are also complete acne regimens or “kits” available over-the-counter that contain cleanser, toner, lotion. The products in these kits usually contain a combination of acne-fighting ingredients, and can help take the guesswork out of building a daily skin care routine. These regimen programs donâ€™t necessarily work better than products you purchase separately, but some people prefer them because of their ease of use.

If, after several weeks of treating your acne with over-the-counter products you aren’t seeing improvement, don’t hesitate to contact your doctor. He or she is a great asset in the fight against acne.

HOW TO TREAT ACNE

MYTH

FACT

3. MYTHS ABOUT ACNE Do you think you already know all there is to know about acne? You may be surprised that some of the things you’ve heard about acne — like what causes it and how to deal with it — aren’t actually true. Keep reading to find out some fast facts.

HOW TO TREAT ACNE

MYTH

FACT

STRESS CAUSES ACNE

YOUR TIME IS BETTER SPENT DETERMINING THE RIGHT COURSE OF ACNE TREATMENT RATHER THAN FEELING GUILT ABOUT STRESS

Description Stress can affect hormones and can theoretically promote acne However, an effective acne treatment regimen is more powerful than a bout of stress any day. Some psychiatric medications, notably lithium, which is often prescribed for bipolar disorder, may have acne as a side effect but stress itself is no big deal.

MYTH

FACT

THE SUN WILL HELP GET RID OF ACNE

DON’T BE AFRAID OF THE SUN BUT TRY NOT TO GET BURNT

Description 10-20 minutes per day of sun exposure for people with lighter skin and 20-30 minutes per day for people with darker skin may prove beneficial for acne symptoms, especially body acne. However, overly exposing your skin to the sun creates skin damage, which leaves the skin irritated. This irritation can result in more acne in the weeks following over exposure as the skin heals itself. If you notice a break out “out of the blue,” ask yourself if you got sunburnt about two weeks ago. That may be the cause.

MYTH DIET AND ACNE ARE RELATED

AVAILABLE SCIENTIFIC EVIDENCE DOES NOT YET SUPPORT A COMPELLING CASE

FACT

Description The bottom line is we need more research. We do know that people in some hunter/gatherer societies do not experience acne whatsoever across the entire population. This is in stark contrast to the widespread presence of acne throughout all modern society. It leaves us to ponder whether the indigenous people’s unprocessed diet contributes to their acne-free skin or whether their clear skin is a result of genetics or some other factor. Discovering a dietary way of preventing acne may be a future reality. However, we may live so differently from our ancestors that it has become close to impossible to replicate our ancestral diet. If you feel that you have cleared your acne using a particular diet or if you are planning on attempting a diet of some kind, please post your method on the Nutrition & holistic health forum. Keep in mind that almost any diet will appear to work in the short term because as your body loses weight, insulin and other hormones react and acne tends to recede. Then, as body weight levels out or increases, acne symptoms tend to return. Any legitimately effective anti-acne diet should continue working after the initial weight loss period.

MYTH ONLY TEENS GET ACNE

SO MANY ADULTS NOW EXPERIENCE ACNE THAT SOME DERMATOLOGISTS REFER TO IT AS AN “ADULT ACNE EPIDEMIC”

FACT

Description Exactly why this occurs is unknown but 50% of adult men and 25% of adult women now experience adult acne at some point.9-11. The good news is that it is treated the same way in an adult as in a teen.

HOW TO TREAT ACNE

MYTH

THERE IS NO CURE FOR ACNE

FACT

ACCUTANE (ISOTRETINOIN) IS CURATIVE FOR MOST PEOPLE

Description Accutane (isotretinoin) provides long-term remission of acne symptoms in approximately 2/3 of people who take an adequate dosage (1mg/kg).12-15 Since “cure” is defined as “a complete or permanent solution or remedy,” a strong case can be made that isotretinoin provides a cure for many people. However, since isotretinoin comes with such severe side effects, it is essential that anyone considering the drug enter into a careful decision-making process alongside a trusted physician.

MYTH

MASTURBATION OR SEX CAUSES ACNE

THIS IS AN AGE-OLD MYTH

FACT

Description This antiquated notion, originating as early as the 17th century to discourage young people from having premarital sex, is not based on scientific evidence.

STRESS CAUSES ACNE

YOUR TIME IS BETTER SPENT DETERMINING THE RIGHT COURSE OF ACNE TREATMENT RATHER THAN FEELING GUILT ABOUT STRESS

MYTH

FACT

DERMATOLOGISTS KNOW EVERYTHING THERE IS TO KNOW ABOUT ACNE

MOST DERMATOLOGISTS DO NOT SPECIALIZE IN ACNE

Description Even though acne is the #1 reason people see dermatologists, this does not mean that a dermatologist is a specialist in acne unless she specifically decided to focus her practice on this area. Becoming a dermatologist requires a person to study and understand a huge list of skin diseases, and acne is simply one of many. It is important that an acne sufferer be his own advocate when it comes to acne and learn everything he can about available treatments before speaking with a dermatologist to prevent a revolving door of prescriptions which very often do not provide adequate clearing of the skin.

MYTH

FACT

HOW TO TREAT ACNE

4. MANAGEMENT Many different treatments exist for acne including benzoyl peroxide, antibiotics, retinoids, antiseborrheic medications, anti-androgen medications, hormonal treatments, salicylic acid, alpha hydroxy acid, azelaic acid, nicotinamide, and keratolytic soaps. They are believed to work in at least four different ways, including the following: normalizing shedding and sebum production into the pore to prevent blockage, killing P. acnes, anti-inflammatory effects, and hormonal manipulation.

HOW TO TREAT ACNE

ORAL MEDICINE Prescription Oral Medicines For patients with moderate-to-severe acne, doctors often prescribe oral antibiotics. Oral antibiotics are thought to help control acne by curbing the growth of bacteria and reducing inflammation. Prescription oral and topical medicines may be combined. Common antibiotics used to treat acne are tetracycline, minocycline, and doxycycline. Other oral medicines less commonly used are clindamycin, erythromycin, or sulfonamides. Some people taking these antibiotics have side effects, such as an upset stomach, dizziness or lightheadedness, changes in skin color, and increased tendency to sunburn. Because tetracyclines may affect tooth and bone formation in fetuses and young children, these drugs are not given to pregnant women or children under age 14. There is some concern, although it has not been proven, that tetracycline and minocycline may decrease the effectiveness of birth control pills. Therefore, a backup or another form of birth control may be needed. Prolonged treatment with oral antibiotics may be necessary to achieve the desired results.

Antibiotics Antibiotics are reserved for more severe cases and decrease acne due to their antimicrobial activity against P. acnes in conjunction with anti-inflammatory properties. With increasing resistance of P. acnes worldwide, they are becoming less effective. Commonly used antibiotics, either applied topically or taken orally, include erythromycin (category B), clindamycin (category B), metronidazole (category B), and tetracyclines such as doxycycline and minocycline. Topical erythromycin and clindamycin are considered safe to use as acne treatment during pregnancy (category B) due to negligible systemic absorption. Nadifloxacin (category N), and dapsone (category C) are other topical antibiotics that may be used to treat acne in pregnant women, but have received less extensive study.

Hormones In women, acne can be improved with the use of any combined oral contraceptive.The combinations that contain third or fourth generation progestins such as desogestrel, norgestimate or drospirenone may theoretically be more beneficial. Antiandrogens such as cyproterone acetate and spironolactone have also been used successfully to treat acne. Hormonal therapies should not be used to treat during pregnancy or lactation as they have been associated with certain birth defects such as hypospadias and feminization of the male fetus.

Topical retinoids Topical retinoids are medications that possess antiinflammatory properties and work by normalizing the follicle cell life cycle. This class includes tretinoin (category C), adapalene (category C), and tazarotene (category X). Like isotretinoin, they are related to vitamin A, but are administered topically and generally have much milder side effects. They can, however, cause significant irritation of the skin. The retinoids appear to influence the cell life cycle in the follicle lining. This helps prevent the hyperkeratinization of these cells that can create a blockage. Retinol, a form of vitamin A, has similar, but milder, effects and is used in many over-the-counter moisturizers and other topical products. Topical retinoids often cause an initial flare-up of acne and facial flushing.

Oral retinoids Isotretinoin is very effective for severe acne as well as moderate acne refractory to other treatments. Improvement is typically seen after one to two months of use. After a single course, about 80% of people report an improvement with more than 50% reporting complete remission. About 20% of people require a second course. A number of adverse effects may occur including: dry skin, nose bleeds, muscle pains, increased liver enzymes, and increased lipid levels in the blood. If used during pregnancy there is a high risk of abnormalities in the baby and thus women of child bearing age are required to use effective birth control. There is no clear evidence that use of oral retinoids increases the risk of psychiatric side effects such as depression and suicidality.

HOW TO TREAT ACNE

DERMATOLOGY TREATMENT Salicylic acid Salicylic acid (category C) helps to lessen acne due to its bacteriostatic and keratolytic properties. Additionally, salicylic acid can open obstructed skin pores and promotes shedding of epithelial skin cells. Hyperpigmentation of the skin has been observed in individuals with darker skin types who use salicylic acid.

Benzoyl peroxide cream Benzoyl peroxide is a first-line treatment for mild and moderate acne due to its effectiveness and mild sideeffects (mainly irritant dermatitis). It works against P. acnes, helps prevent formation of comedones, and has anti-inflammatory properties. Benzoyl peroxide normally causes dryness of the skin, slight redness, and occasional peeling when side effects occur. This topical does increase sensitivity to the sun as indicated on the package, so sunscreen use is often advised during the treatment to prevent sunburn. Benzoyl peroxide has been found to be nearly as effective as antibiotics with all concentrations being equally effective. Unlike antibiotics, benzoyl peroxide does not appear to generate bacterial resistance. Benzoyl peroxide is often combined with antibiotics.

Combination therapy Combination therapy using medications of different classes together, each with a different mechanism of action, has been demonstrated to be a more efficacious approach to acne treatment than monotherapy. Frequently used combinations include the following: antibiotic + benzoyl peroxide, antibiotic + topical retinoid, or topical retinoid + benzoyl peroxide.

Procedures

Comedo extraction may help those with comedones that do not improve with standard treatment, at least temporarily. A procedure with high patient satisfaction[quantify] for immediate relief is the injection of corticosteroids into the inflamed acne comedone.

There is no evidence that microdermabrasion is effective. As of 2012, evidence for light therapy and lasers is insufficient to recommend them for routine use. Light therapy is an expensive treatment modality and while it appears to provide short term benefit, there is a lack of long term outcome data or data in those with severe acne. Laser surgery can be used to reduce the scars left behind by acne. For people with cystic acne, boils can be drained through surgical lancing.

Alternative medicine Numerous natural products have been investigated for treating people with acne.Azelaic acid has been shown effective for mild-to-moderate acne when applied topically at a 20% concentration. Application twice daily for six months is necessary, and treatment is as effective as topical benzoyl peroxide 5%, isotretinoin 0.05%, and erythromycin 2%. Azelaic acid may cause skin irritation but is otherwise very safe. A topical application of tea tree oil has been suggested.

Prognosis Acne usually improves around the age of 20 but may persist into adulthood. Permanent scarring may occur.

Epidemiology Globally acne affects approximately 650Â million people, or about 9.4% of the population, as of 2010. It affects almost 90% of people in Western societies during their teenage years and may persist into adulthood. Postadolescent acne (acne after age 25) has an incidence of 54% in women and 40% in men. Acne vulgaris has a lifetime prevalence of 85%. About 20% have moderate or severe cases. Rates appear to be lower in rural societies and it may not occur in the non-Westernized people of Papua New Guinea and Paraguay. It is slightly more common in females than males (9.8% versus 9.0%). In those over 40Â years old, 1% of males and 5% of females still have problems. It affects people of all ethnic groups, and it is not clear if race affects rates of disease. Acne

HOW TO TREAT ACNE

affects 40 to 50 million people in the United States (16%) and approximately 3 to 5 million in Australia (23%). In the United States, acne tends to be more severe in Caucasians than people of African descent.

Ongoing Research A vaccine against inflammatory acne has been tested successfully in mice, but has not yet been proven to be effective in humans. In 2007 the first genome sequencing of a P. acnes bacteriophage (PA6) occurred which â&#x20AC;&#x153;should greatly enhance the development of a potential bacteriophage therapy to treat acne and, therefore, overcome the significant problems associated with long-term antibiotic therapy and bacterial resistance.â&#x20AC;?

HOW TO TREAT ACNE

ETHNIC • Skin tone makes a difference in choosing effective acne products. Darker skin is much more easily damaged by inflammation and irritation. • Women of Asian, African, Hispanic, and European descent sometimes need completely different products to take care of the same skin condition. • Folk wisdom about acne care can be very, very right or very, very wrong. Usually the skin care practices of one group do not translate very well to another. Ethnic differences are important in successful skin care, especially for acne. This article will give you five examples of the most important ethnic and genetic skin care considerations .

Asian Skin Acne

Overview Acne is a very common issue for people of Asian descent. Unfortunately, few studies have been performed specifically on people with Asian skin. According to an article in the British Journal of Dermatology, “There are very few studies on the prevalence of acne vulgaris among Asian teenagers.” However, there is some evidence that Asian adults suffer with acne less than other ethnicities.

What is different about Asian skin

People with Asian skin tend to have a bigger issue with marks left behind after acne lesions heal.3-6 These marks, scientifically referred to as post-inflammatory hyperpigmentation, can stick around for a longer time in people with Asian skin and can be challenging to treat. See the hyperpigmentation part of this page for more on these marks and treatment options. In addition to hyperpigmentation, people with Asian skin have a somewhat higher incidence of keloid scarring from acne. Lastly, Asians may respond differently to hormone therapy, but again, research is limited in this area.7 The best bet is to get your acne under complete control first, preventing

future breakouts and future hyperpigmentation. Then, once you are clear, if you choose to do so, you can try one of the many treatments for hyperpigmentation.

How to treat acne in Asian skin Acne develops in the same way regardless of skin color, and acne is treated in the same way in people of every ethnicity. Acne can be effectively treated with topical medications such as benzoyl peroxide and oral medications like Accutane.8-10 Because of the severe birth defects that Accutane can cause, authorities in Japan have banned its use in that country.

The bottom line Prevention is key. Get yourself completely cleared up so you are actively preventing future acne lesions, hyperpigmentation, and scarring. Then, if you so desire, you may try one of the various methods of treating hyperpigmentation.

HOW TO TREAT ACNE

Black Skin

Overview Acne is the most common skin disorder in black adolescents and black adults and is often the primary reason for a visit to a doctor or dermatologist.1-3 According to the Journal of the European Academy of Dermatology and Venereology, â&#x20AC;&#x153;Acne vulgaris is an extremely common dermatological problem in Africans and people of African descent worldwide.â&#x20AC;?4 Despite this prevalence, relatively few studies have been conducted on people with black skin.

What is different about black skin

People with black skin tend to have inflammatory acne, the most common type of acne. This is actually good news because inflammatory acne is easier to treat than non-inflammatory acne. Black people also tend to have fewer nodules and cysts, the more severe types of acne lesions. Despite the fact that black people tend to have less severe lesions, there is a higher chance of keloid scarring, especially on the chest and back, making effective acne prevention paramount. Next, all non-Caucasian skin types tend to have a higher incidence of post-inflammatory hyperpigmentation, a

fancy term for marks left after acne goes away. This is such a big issue that dermatologists often remark on how their black patients consider these marks worse than the acne itself.2,5-8 See the hyperpigmentation section below to learn more about how to contend with these dark spots that acne leaves behind. People of African heritage do not tend to suffer with rosacea.

Pomade acne; a special case Sometimes the greasy emollients which make up black hair care products can come into contact with the skin and aggravate acne. If you use these products and tend to break out along your hairline or in places where your particular hair style comes into contact with your skin, this may be the culprit.

How to treat acne in black skin Luckily, inflammatory acne develops and is treated the same way regardless of skin color, and with the right regimen is easy to clear. There are several options including topical treatment as well as Accutane. According to the International Journal of Dermatology, “benzoyl peroxide is particularly effective for the inflammatory component.” Benzoyl peroxide is a mild drying and peeling agent, but people with black skin tend to have less flakiness and scaling of the skin and tolerate it well.10-11 There is a highly effective topical regimen here on acne.org which works extremely well on darker skin types.

The bottom line The foremost concern should be prevention. Preventing acne will prevent the dark spots that are often left behind and will also prevent scarring. Concentrate your efforts on clearing up your acne and getting it under complete control. Then, if you choose, you can try on one of the many methods of hastening healing of the dark spots that are left behind.

+ Note People of African descent should not take the antibiotic minocycline to treat acne symptoms. “Fatal cases of hypersensitivity” have been reported with this drug in people of African descent.

HOW TO TREAT ACNE

Latino Acne

Overview Latino people, just like every other ethnic group, suffer from acne at a high rate and are affected in the same way emotionally.1-5 However, the medical community has performed very little research on Latino people with acne. According to the Journal of the American Academy of Dermatology, â&#x20AC;&#x153;there is a need to understand the variety of dermatologic disorders that manifest in ethnic groups of non-Caucasian skin types.â&#x20AC;? 6 But all is not lost. Acne develops the same way regardless of the type of skin a person has, and is also treated in the same fashion.

What is different about Latino skin People with Latino skin experience a higher occurrence of post-inflammatory hyperpigmentation.6-10 This is a fancy way of saying dark spots which are left behind after acne lesions have healed. These dark spots can take a long time to fade and can be as troubling as the acne itself. Check out the hyperpigmentation section of this page to learn more about post-inflammatory hyperpigmentation.

How to treat acne in Latino skin Treatments for acne are consistent no matter the ethnicity of the skin. With the right regimen, acne in Latino people can be treated extremely well. There is a regimen based on benzoyl peroxide here on acne.org which works remarkably well for Latino people. Another option is Accutane.

The bottom line The most important goal is prevention. Preventing acne will prevent post-inflammatory hyperpigmentation and potential scarring. Once you get your acne completely cleared up and are actively preventing new lesions from forming, you may embark on one of the methods of treating hyperpigmentation.

HOW TO TREAT ACNE

White Skin

Overview Acne is an extremely common skin disorder in Caucasian adolescents and adults. According to Cutis, a peer-reviewed clinical journal for dermatologists, “During visits by white patients, the...most common [diagnosis] recorded [was] acne.”1 Upwards of 95% of Caucasian people experience acne at some point in their lives.

What is different about white skin

People with lighter skin tend to have a higher incidence of nodules and cysts, the more severe types of acne lesions. Caucasian people also tend toward dryer skin, making drying and peeling medications more of a challenge. White people must also contend with more noticeable lesions when they do break out. The acute redness and inflammation that directly surround an acne lesion stand in stark contrast to light skin tones. However, when it comes to the red spots that acne leaves behind, white people tend to have less of a struggle. While white people do experience post-inflammatory hyperpigmentation—a fancy term for these marks—they experience them less often than their darker-skinned counterparts. Also, these

marks tend to fade more quickly on lighter skin. However, Caucasian skin, just like any other ethnicity, can scar.

How to treat acne in white skin No matter the ethnicity, acne develops and is treated the same way, and with proper medication is easily treatable.6 Options include topical treatment as well as Accutane.

The bottom line Prevention is key. Preventing acne will not only improve quality of life, it will help prevent potential scarring.

HOW TO TREAT ACNE

TREATMENT FOR SEVERE NODULAR OR CYSTIC ACNE People with nodules or cysts should be treated by a dermatologist. For patients with severe inflammatory acne that does not improve with mediceines such as those described above, a doctor may prescribe isotretinoin, a retinoid (vitamin A derivative). Isotretinoin is an oral drug that is usually taken once or twice a day with food for 15 to 20 weeks. It markedly reduces the size of the oil glands so that much less oil is produced. As a result, the growth of bacteria is decreased.

Advantages of Isotretinoin Isotretinoin is a very effective medicine that can help prevent scarring. After 15 to 20 weeks of treatment with isotretinoin, acne completely or almost completely goes away in most patients. In those patients where acne recurs after a course of isotretinoin, the doctor may institute another course of the same treatment or prescribe other medicines.

Disadvantages of Isotretinoin Isotretinoin can cause birth defects in the developing fetus of a pregnant woman. It is important that women of childbearing age are not pregnant and do not get pregnant while taking this medicine. Women must use two separate effective forms of birth control at the same time for 1 month before treatment begins, during the entire course of treatment, and for 1 full month after stopping the drug. You should ask your doctor when it is safe to get pregnant after you have stopped taking isotretinoin.

Some people with acne become depressed by the changes in the appearance of their skin. Changes in mood may be intensified during treatment or soon after completing a course of medicines like isotretinoin. There have been a number of reported suicides and suicide attempts in people taking isotretinoin; however, the connection between isotretinoin and suicide or depression is not known. Nevertheless, if you or someone you know feels unusually sad or has other symptoms of depression, such as loss of appetite, loss of interest

in once-loved activities, or trouble concentrating, itâ&#x20AC;&#x2122;s important to consult your doctor. Talk to your doctor or pharmacist about the side effects of isotretinoin. You can also visit the Food and Drug Administration (FDA) website2. To determine if isotretinoin should be stopped if side effects occur, your doctor may test your blood before you start treatment and periodically during treatment. Side effects usually go away after the medicine is stopped.

What is Isotretinoine? (also known as 13-cis retinoic acid) first marketed as Accutane by Hoffmann-La Roche, is a medication primarily used to treat cystic acne. Rarely, it is also used to prevent certain skin cancers (squamous-cell carcinoma), and can be used in the treatment of brain, pancreatic and other cancers. It is used to treat harlequin-type ichthyosis, a usually lethal skin disease, and lamellar ichthyosis. It is a retinoid, meaning it is related to vitamin A, and is found in small quantities naturally in the body. Isotretinoin is primarily used as a treatment for severe acne. The most common adverse effects are a transient worsening of acne (lasting 2â&#x20AC;&#x201C;3 weeks), dry lips (cheilitis), dry and fragile skin, and an increased susceptibility to sunburn. Uncommon and rare side effects include: muscle aches and pains (myalgias), and headaches. Isotretinoin is known to cause birth defects due to in utero exposure because of the moleculeâ&#x20AC;&#x2122;s close resemblance to retinoic acid, a natural vitamin A derivative which controls normal embryonic development. In the United States a special procedure is required to obtain the pharmaceutical. In most other countries a consent form is required which explains these risks. Women taking isotretinoin must not get pregnant during, and for 1 month after isotretinoin therapy. Sexual abstinence, or effective contraception is mandatory during this period. Barrier methods by themselves (such as condoms) are not considered adequate due to the unacceptable failure rates of approximately 3%. Women who fall pregnant whilst on isotretinoin therapy are generally counselled to have a termination. Isotretinoin has no effect on male reproduction. In 2009, Roche decided to remove Accutane from the

HOW TO TREAT ACNE

US market after juries had awarded millions of dollars in damages to former Accutane users over inflammatory bowel disease claims. Other common brands are Roaccutane (Hoffman-La Roche, known as Accutane in the United States before July 2009),[D 1] Amnesteem (Mylan),[D 2] Claravis (Teva),[D 3] Absorica (Ranbaxy),[D 4] Isotroin (Cipla), and Epuris (Cipher). Medical uses Isotretinoin is used primarily for severe cystic acne and acne that has not responded to other treatments. Acne treatment usually begins with topical retinoids (e.g.tretinoin, adapalene), in combination with topical antibiotics (e.g. clindamycin, erythromycin) or antiseptics (e.g. benzoyl peroxide-containing preparations), followed by oral antibiotics (e.g. doxycycline or minocycline). In women a cyproterone acetate-containing contraceptive pill can be useful if there are no contraindications. In cases of hormonal acne, such as in women in their 20s and 30s with cyclical acne, often a course of isotretinoin can permanently improve acne obviating the need for lifelong hormonal manipulation.[medical citation needed]

Prescribing restrictions In most countries, isotretinoin can only be prescribed by dermatologists or specialist physicians; some countries also allow limited prescription by general practitioners and family doctors. In the United Kingdom and Australia, isotretinoin may be prescribed onl y by or under the supervision of a consultant dermatologist. Because severe cystic acne has the potential to cause permanent scarring over a short period, restrictions on its more immediate availability have proved contentious. In New Zealand, isotretinoin can be prescribed by any doctor but subsidised only when prescribed by a vocationally-registered general practitioner, dermatologist or nurse practitioner.

In the United States, dispensing of isotretinoin is by an FDA-mandated website called iPLEDGE. iPLEDGE has applied to isotretinoin prescriptions since 1 March 2006. Under it, dermatologists must register their patients on the system before prescribing isotretinoin. Pharmacists must then verify the prescription on the iPLEDGE website before dispensing isotretinoin. The website allows no more than thirty daysâ&#x20AC;&#x2122; supply of the drug to be prescribed or dispensed; and after issuance, another prescription may

not be written for at least 30 days (even in the case of lost prescriptions). Prescriptions expire from iPLEDGE if not picked up from the pharmacy seven days after issuance. Physicians and pharmacists must verify written prescriptions on the system before filling an isotretinoin prescription. Due to the teratogenic effects of isotretinoin, iPLEDGE makes additional requirements of female patients filling prescriptions for the drug: women with child-bearing potential must commit to using two forms of effective contraception simultaneously for the duration of isotretinoin therapy and for a month immediately preceding and a month immediately following therapy. Alerts continue to exist against purchasing isotretinoin online. Most other national health services emphasise that isotretinoin is a teratogen, but do not impose the same stringent conditions on the dispensing process as the United States does. In Mexico and Brazil the use of the drug is restricted: official identification and a signature must be provided by the patient before an isotretinoin prescription will be filled by a pharmacist. Clinical guidelines for most countries recommends or mandates that the dispensing physician monitor patients, or provide instructions to the patient’s regular doctor for monitoring. As part of the monitoring, patients’ blood is periodically re-tested throughout treatment for blood lipids, pregnancy, and several other factors. Women, diabetics, and patients with liver problems are particularly at risk and will be monitored especially closely.

Dosage 10 mg capsule The dose of isotretinoin patients receive is dependent on their weight and the severity of the condition. Highdose treatments are administered between 0.5 mg/kg/ day to 2 mg/kg/day (usually at 0.5 to 1 mg/kg/day, given as a single dose with food). Usually a course will last 8–10 months. A second course may be required. Efficacy appears to be related to the cumulative dose of isotretinoin taken, with a total cumulative dose over each course of 120–150 mg/kg used as a guideline.

Nearly all patients achieve initial clearing of acne during

HOW TO TREAT ACNE

a normal course of isotretinoin therapy. 90% of patients achieve excellent clearance of their acne after a cumulative dose of 150 mg/kg. Lower-dosage treatments, such as 10–20 mg/day (approximately half the high dosage treatments above), can also be effective, with greatly diminished side effects. However, such lower dosage courses may be associated with higher relapse rates, requiring additional courses, especially if not taken for sufficient time. Usually, a starting dose of 20 mg is taken with the largest meal of the day. After a few months, the dose is increased, e.g. to 40 mg/d. If side-effects permit, a higher dose such as 60 mg/d can be prescribed although daily dose rarely exceeds 60 mg. If 20 mg capsules are supplied, patients may take (for example) 20 mg one day, then 40 mg the next to provide an average daily dose of 30 mg/d. In most cases, isotretinoin achieves a complete clearing of acne during a standard-dose 12–16 week course. Some patients’ acne will respond to a course before recurring, necessitating multiple courses of treatment.

Adverse effects Increasingly higher dosages will result in higher toxicity, resembling vitamin A toxicity. The following are adverse drug reactions from Roche’s UK product information for Roaccutane as of October 2010 Research suggests vitamin E supplementation in the form of alpha-tocopherol reduces the toxicity of isotretinoin treatment in subjects with cancer and myelodysplastic syndrome. In contrast, a randomized study in 82 subjects taking isotretinoin (1 mg/kg/day) for acne vulgaris found no difference in the incidence or severity of side effects in the group taking an additional 800 IU/day of vitamin E in the form of d-l-alphatocopherol. A study in 2007 found a significant decrease of growth hormone (GH) levels from 0.9 mU/L to 0.3 mU/L after three months of isotretinoin treatment. And a study in 2010 found that isotretinoin treatment decreases insulinlike growth factor-1 (IGF-1) levels.

Possible permanent effects Stunted growth An Accutane medication guide approved by the U.S. FDA in 2010 states that the drug “may stop long bone growth in teenagers who are still growing.” Several reports state that premature epiphyseal closure can occur in acne patients receiving recommended doses of Accutane.

Inflammatory bowel disease Several scientific studies have posited isotretinoin as a possible cause of Crohn’s disease and ulcerative colitis in some individuals. However, a study looking at 45,000 patients showed no association between isotretinoin and inflammatory bowel disease (Ulcerative Colitis and Crohn’s Disease).[46] The authors concluded, “Because inflammatory acne in children and adolescents carries a high psychological burden, clinicians should not be discouraged from prescribing this drug owing to a putative association with IBD.”

Eye changes Decreased night vision and keratoconjunctivitis sicca (dry eyes) has been reported to persist in some patients after discontinuation of isotretinoin therapy.

Hyperostosis Hyperostosis has been reported in patients receiving treatment with isotretinoin.

Skin The most common side effects are muco-cutaneous: dry lips and skin. Regular lip balm and moisturizer is recommended. Sometimes, however, the dose needs to be decreased to reduce these side effects. The skin becomes more fragile— especially to frictional forces—and may not heal as quickly as normal. For this reason waxing of hair, tattooing, tattoo removal, piercings, dermabrasion, exfoliation, etc. are not

HOW TO TREAT ACNE

recommended. Treatment of acne scars (e.g. with fractional laser such as “Fraxel”) is generally deferred until 12 months after completion of a course of isotretinoin. Acne usually flares up 2–3 weeks into the treatment and is usually mild and tolerable. Occasionally this flareup is severe, necessitating oral antiobiotics such as erythromycin. A short course of oral prednisolone may be required. Some dermatologists favour a few weeks pre-treatment with oral antibiotics before commencing isotretinoin to reduce the chance of a severe flare.

Psychological effects The association between isotretinoin use and psychopathology has been controversial. Beginning in 1983, isolated case reports emerged suggesting mood change, particularly depression, occurring during or soon after isotretinoin use. A number of studies have been conducted since then of the drug’s effect on depression, psychosis, suicidal thoughts and other psychological effects. Recent reviews of the studies and reports have found that an association has not been proven, with varying opinions on the likelihood of an association. A 2008 review found that based on clinical studies and case reports, “the link between suicides and severe depressions has not yet been clearly demonstrated.” A 2009 review found that evidence strongly suggested a link between the use of isotretinoin and psychopathology, but did not establish a causal link. It recommended that “clinicians should be on the alert for potential psychiatric side effects following treatment with isotretinoin, especially in vulnerable populations.”

The U.S. Food and Drug Administration recommends that: All patients treated with isotretinoin should be observed closely for symptoms of depression or suicidal thoughts, such as sad mood, irritability, acting on dangerous impulses, anger, loss of pleasure or interest in social or sports activities, sleeping too much or too little, changes in weight or appetite, school or work performance going down, or trouble concentrating, or for mood disturbance, psychosis, or aggression. Patients should stop isotretinoin and they or their caregiver should contact their healthcare professional right away if the patient has any of the previously mentioned symptoms. Discontinuation of treatment may be insufficient and further evaluation

may be necessary. - U.S. Food and Drug Administration, “Isotretinoin (marketed as Accutane) capsule information”. Postmarket Drug Safety Information for Patients and Providers. Retrieved 28 February 2014.

The U.K. National Health Service, in its guidance on side effects of 20 mg isotretinoin tablets, includes the following as “rare” side effect (more than 1 in 10,000 users):

Thoughts of committing suicide, behavioural problems or worsening of behavioural problems including: aggression, feeling anxious, mood changes, depression or psychosis or psychotic-like behaviour you or your carer must seek medical advice if you become depressed or if your depression worsens. - National Health Service, “Side effects of isotretinoin”. NHS Choices. Retrieved 28 February 2014.

History Building on the discovery that vitamin A can inhibit sebum production at toxic dosages, the retinoic acid derivative isotretinoin (13-cis-retinoic acid) was developed in 1982 by Hoffmann-La Roche. Dr. Gary Peck is credited with discovering its use for the treatment of cystic acne, as well as disorders of keratinization, such as lamellar ichthyosis, Darier’s disease, and pityriasis rubra pilaris. In addition, he demonstrated its chemopreventive properties in patients with basal cell nevus syndrome, also known as nevoid basal cell carcinoma syndrome and Gorlin’s syndrome. In fact, within one year of attaining the U.S. patent for discovering the use of isotretinoin in the treatment of acne, he received the Inventor’s Award from the US Department of Commerce and a Meritorious Service Medal from the US Public Health Services in 1983. In 2003, he was honored with The Discovery Award by the Dermatology Foundation in “recognition of extraordinary scientific accomplishments that have had a profound influence on the specialty of dermatology and have gained the respect and admiration of the world scientific community”. In February 2002, Roche’s patents for isotretinoin expired, and there are now many other companies selling cheaper

HOW TO TREAT ACNE

generic versions of the drug. On June 29, 2009, Roche Pharmaceuticals, the original creator and distributor of isotretinoin, officially discontinued both the manufacture and distribution of their Accutane brand in the United States due to what the company described as business reasons related to low market share (below 5%), coupled with the high cost of defending personal-injury lawsuits brought by some patients prescribed the drug. Generic isotretinoin will remain available in the United States through various manufacturers. Roche USA continues to defend Accutane and claims to have treated over 13 million patients since its introduction in 1982. F. HoffmannLa Roche Ltd. apparently will continue to manufacture and distribute Roaccutane outside of the United States. Among others, actor James Marshall sued Roche over allegedly Accutane-related disease that resulted in removal of his colon. The jury, however, decided that James Marshall had a pre-existing bowel disease. Several trials over inflammatory bowel disease claims have been held in the United States thus far, with many of them resulting in multimillion dollar judgments against the makers of isotretinoin. In 2009 Roche decided to pull Accutane off the market, stating at the time that the move was related to market pressures and the high cost of defending Accutane lawsuits.

HOW TO TREAT ACNE

5. HABITS TO MAKE BETTER SKIN It’s the night before the big event, and you’re completely prepared. The perfect outfit? Check. Great haircut? Check. Beautiful, healthy, glowing skin from taking such good care of it day after day? Check. Wait a minute, is that a zit? Are you kidding me? For some of us, pimples are a rare occurrence. But for those of us who aren’t so lucky, it can seem like a constant fight to keep the battleground of our faces clear from dermatological disaster. So we think it’s time you began winning the war -- which is why we’re arming you with our top five ways to clean acne-prone skin.

HOW TO TREAT ACNE

HOW TO WASH YOUR FACE RIGHT WAY Medical science has achieved significant breakthroughs in the treatment of acne. However, gentle cleansing must precede topical treatment in order to prevent irritation, because irritation can lead to more breakouts.

Choosing your cleanser Look for the terms “oil-free” and “non-comedogenic” (nonpore clogging) when selecting a facial cleanser. You know you’re on the right track when references to “mild”, “non-irritating,” and “non-overdrying” are mentioned as well. If you have inflammatory acne, the most common variety that comes with redness, you’ll want to avoid any scrubbing cleansers as well. Simply choose a gentle liquid cleanser with no scrubbing agents, beads, or balls.

SALICYLIC ACID is used on the skin to treat common skin and foot

Many acne cleansers also include other medications. For instance, Neutrogena Acne Wash Oil-Free Cream Cleanser has 2% salicylic acid in it. Clean & Clear Continuous Control Acne Cleanser contains 10% benzoyl peroxide. You may unwittingly be layering medications this way, and over-medicating the skin can cause irritation and perpetuate the acne cycle.

(plantar) warts. Salicylic acid helps cause the wart to gradually peel

How to remove make up

off. This medication is also used to help remove corns and calluses.

1. Gently use milk cleasing to remove make up

This product should not be used on the face or on moles, birthmarks, warts with hair growing from them, or genital/anal warts.

MIL K

Salicylic acid is a keratolytic. It belongs to the same class of drugs as aspirin (salicylates). It works by increasing the amount of moisture in the skin and dissolving the substance that causes the skin cells to stick together. This makes it easier to shed the skin cells. Warts are caused by a virus. Salicylic acid does not affect the virus.

fac i a l c l ea n s e r

It helps to reduce irritation from make up remover.

OIL-FREE

2. Clean with gentle liquid ‘oil-free’ and ‘non-comedogenic’ facial cleanser Neutrogena or Clean

non comedogenic

& Clear wash cleaser recommanded.

3. Use daily expoliating cleanser or skin to avoid pore clogging Some acne appears from the defunction of dead skin cell fall. Gentle Expoliating is needed.

After remove make up

1. Wash your face only twice per day Morning and evening. Excess washing can cause irritation.

HOW TO TREAT ACNE

2. Use only your bare hands to wash, and wash for 10 seconds or less Washcloths and hand-held cleansing devices are unnecessarily irritating. Consider the act of washing as simply prepping your skin for medication, nothing more. Washing itself does not clear breakouts since dirt does not cause acne, so there is absolutely no need to scrub.

3 Pat dry

Do not rub dry. Rubbing the skin is irritating, and excess irritation can perpetuate the acne cycle. Gently pat dry.

HOW TO TREAT ACNE

HOW TO POP A PIMPLE Step-by-step instructions Common advice is to let your body heal a pimple on its own without popping. However, in the real world, it’s not great for your social life to go around with a bulging white zit for the world to see. Plus, when done properly, popping a pimple can be beneficial to the healing process. Reserve this technique only for pimples that are ready to be popped—all the way at the surface and white/yellow. After a shower is best, when the skin is supple, but popping can be successfully performed with dry skin as well.

1. Disinfect a needle with rubbing alcohol.

A basic sharp sewing needle is a good choice because sewing needles are strong and sharp.

2. Gently prick the pimple’s surface.

3. Take two tissues and wrap each of your index fingers with them.

+ Glycolic acid may help prevent a spot from fully developing.

GLYCOLIC ACID It may reduce wrinkles, acne scarring, hyperpigmentation and improve

4. Squeeze from the sides, confidently but gently, using a down-and-in motion.

many other skin conditions, including actinic keratosis, hyperkeratosis, and seborrheic keratosis[citation

Don’t force it. If the pimple is ready it will pop. If it doesn’t, leave it be. Stop if clear fluid or blood starts to come out.

needed]. Once applied, glycolic acid reacts with the upper layer of the epidermis, weakening the

5. Walk away from the mirror!

binding properties of the lipids that

Continuing to work at a lesion that is not ready to be popped

This allows the stratum corneum to

will most definitely introduce unnecessary irritation and can

be exfoliated, exposing live skin cells.

hold the dead skin cells together.

also increase the chance of scarring.

Highly purified grades of glycolic acid are commercially available for personal care applications.

Important It is very important to leave deep, painful lesions (cysts and nodules) untouched. Do not attempt to pop them. Instead, a effective option for these types of lesions is to see a dermatologist who can administer a cortisone injection, which will bring down swelling and potentially reduce or eliminate scarring. Often dermatologists will accept a quick “emergency” appointment for such matters.

HOW TO TREAT ACNE

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DUAL ACTION ACNE TREATMENT

MOISTURIZING CREAM

Effaclar Duo is a dual action acne treatment lotion that reduces the number and severity of acne blemishes. Penetrates clogged pores to clear blackheads and whiteheads. Contains:

Cetaphil Moisturizing Cream contains a superior system of extra-strength emollients and humectants clinically proven to bind water to the skin and prevent moisture loss. The result is long-lasting relief for even severely dry skin. The non-greasy formula is excellent for hands, feet, elbows, knees, and any other areas that require intensive moisturization.

• Micronized Benzoyl Peroxide [5.5%]: A Powerful acne medication in a unique micronized format to penetrate pores and clear blemishes.

• Intense and lasting moisture to replenish sensitive, dry skin — great for eczema and very dry skin

• Micro-exfoliating LHA [0.4%] for precise cell-by-cell exfoliation to smooth roughness and gradually even skin texture.

• Clinically proven to provide immediate, long-lasting hydration that soothes dry, itchy skin • Quick absorbing, rich, non-greasy • Fragrance-free, mild, non-irritating

HOW TO TREAT ACNE

6. AFTER CARE We’ve also heard that it’s all a myth. Many dermatologists will tell you there is no link between food and acne. They dismiss the idea because so much research is inconclusive. Also acne scars are usually the result of inflamed blemishes caused by skin pores engorged with excess oil, dead skin cells and bacteria.. The skin attempts to repair these lesions by forming new collagen fibers. These repairs usually aren’t as smooth and flawless as the original skin.

HOW TO TREAT ACNE

INNER BEAUTY Apple The best apples have several properties that make them excellent skin food. An apple is full of water, and balanced hydration is an important part of maintaining good skin. Apples are also full of fiber, which helps maintain good digestion - a crucial aspect of healthy skin. Add vitamins A and C, calcium, iron, phosphorous and potassium and you have a very compact and delicious food that promotes good health and appearance. In some instances, acne is caused by an internal disorder of some sort. Yes, touching your face with your hands will promote bacteria, as will the use of certain cosmetics or unhealthful hygiene practices. Allergies, stress and hormonal imbalances can also create acne. However, both ancient and modern medicines agree that much of what causes acne starts on the inside. Thus, a healthful, balanced diet for healthy skin with an emphasis on whole foods goes a long ways towards keeping zits at bay. The apple, a naturally cleansing fruit, is widely considered a crucial ingredient for good internal and external health. O m e ga -3 According to the American Academy of Dermatology, acne may result in low self-esteem, social withdrawal, anger and even depression. Omega-3 fatty acids, commonly referred to as good or healthy fats, have a wide range of benefits including improving inflammatory conditions such as acne. Unlike acne medications, which can aggravate the skin and cause other side effects, omega-3 fatty acids are a safe, healthy way to reduce or even eliminate acne breakouts.

Z inc

While the exact mechanisms are unknown, zinc most likely promotes healthy skin by carrying vitamin A to your skin and by regulating your bodyâ&#x20AC;&#x2122;s hormonal balance.Also, a recent study found that zinc facilitates apoptosis, or programmed cell death, which is a natural part of your skin renewing itself. If apoptosis is delayed, as in the case of zinc deficiency, skin cells stick together instead of dying and sloughing off like they should, which leads to clogged pores. So, along with other important dietary changes (such as eliminating dairy), also make sure youâ&#x20AC;&#x2122;re getting enough zinc.

Vi t a m in C The antioxidant properties of vitamin C (ascorbic acid) and its role in collagen synthesis make vitamin C a vital molecule for skin health. Dietary and topical ascorbic acid have beneficial effects on skin cells, and some studies have shown that vitamin C may help prevent and treat ultraviolet (UV)-induced photodamage. However, the effects of vitamin C in the skin are not well understood due to limited research. This article discusses the potential roles of vitamin C in the skin and summarizes the current knowledge about vitamin C in skin health.

Wat e r ncreasing the amount of water you drink is a great way to flush out internal toxins and hydrate your skin from the inside out. Though there is no definitive research that shows toxins lead to breakouts, researchers at the University of Missouri-Columbia found that having about 2 cups of water significantly boosted blood flow throughout the body and skin.

Gre e n Ve g e t a bles New skin cells are formed at the bottom of the epidermis and gradually find their way to the top. The layer of dead cells is then shed and new ones take their place. The ascent takes approximately four weeks, and with an appropriate diet of nutrient rich list of green vegetables you can have better skin within a month. Beautiful skin is the result of a body that is functioning properly. Flawless & well cared for skin is the outcome of a â&#x20AC;&#x153;skinâ&#x20AC;&#x201C;friendlyâ&#x20AC;? diet made up of a long list of green vegetables that help to keep our skin hydrated and toxin free. Acne is a widespread malady that occurs due to keratinization which is the creation of surplus skin cells. Instead of being shed, the dead cells remain, blocking sweat pores and sebaceous glands. Vitamin A, folate, & antioxidants which are the prime constituents of the following list of green vegetables, control the growth of skin cells, and help to regulate the skin cycle, keeping the glands and pores free of acne causing toxins

HOW TO TREAT ACNE RETIN-A (tretinoin) is a form of vitamin

HOW TO GET RID OF ACNE SCAR

A that helps the skin renew itself.

The Retin-A and Avita brands of

How to prevent hyper pigmentation

tretinoin are used to treat acne. The Renova brand of tretinoin is used to reduce the appearance of fine wrinkles and mottled skin discoloration, and to make rough facial skin feel smoother.

When using Retin-A avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Retin-A can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun. Avoid getting

Post-inflammatory hyperpigmentation, often described as dark spots or red spots that are left after acne lesions heal is a common difficulty that acne sufferers with nonCaucasion skin share.1-3 Hyperpigmentation is common among people of African, Asian, and Latino descent, as well as other forms of “ethnic” skin.4 Various forms of acne therapy are often mistakenly blamed for the creation of these marks, but it is the skin’s inflammatory process which creates them. These marks can take months, and in rare cases years, to fade.5 Although they are often referred to as “scars,” they are not permanent. Nonetheless, they cause many people intense distress. Often, people with hyperpigmentation describe this issue as more concerning than the acne itself.

Retin-A in your eyes, mouth, and nose, or on your lips. If it does get into any of these areas, wash with water. Do not use Retin-A on sunburned, windburned, dry, chapped, irritated, or broken skin. Also avoid using this medication in wounds or on areas of eczema. Wait until these conditions have healed before using Retin-A.

Use this medication for as many days as it has been prescribed for you even if you think it is not working. It may take

Absolutely do not pick at acne lesions. Properly pop a pimple, and then leave the lesion alone. Also, while it may seem intuitive to scrub marks away, harsh scrubbing will only prolong their duration and should be avoided. Next, wearing a sunscreen is a huge help in getting these marks to fade as fast as possible.1,4,6 But the best way to prevent the marks is to treat the acne itself, thus preventing future acne lesions and any hyperpigmentation that they might leave behind.7 Acne is treated the same regardless of skin color and responds extremely well to proper topical treatment. When acne is severe, widespread, and deeply scarring, Accutane is also an option.

weeks or months of use before you notice improvement in your skin. If you are using Retin-A to treat acne, your

How to treat hyperpigmentation

condition may get slightly worse for a short time when you first start using the medication. Call your doctor if skin irritation becomes severe or if your acne does not improve within 8 to 12 weeks.

Retinoids: Tretinoin (Retin-A®). This topical treatment can help fade marks.8 Azelaic acid (Azelex®) may prove even better because it may have a hypopigmentary (lightening) effect by inhibiting melanin (skin pigment).2-3,9 • Retin-A (Azelaic Acid) Hydroquinone: (Bleach Eze®). This is the only lightening treatment approved by the FDA. It is normally used at 4%. In higher concentrations it can cause “spotted halos” around marks. It may have other negative effects as well. The addition of ascorbic acid (Vitamin C) to a topical

hydroquinone treatment may help minimize the oxidation of hydroquinone.2-3 Also, the efficacy of hydroquinone may be increased by the addition of a retinoid and mid-potent steroid.10 Be certain to work closely with your physician or dermatologist if you decide to use hydroquinone.

TCA PEEL l is a body treatment technique used to improve and smooth the texture of the facial skin using a chemical solution that causes the dead skin to slough off and eventually peel off.

Peels: Salicylic acid peels, Jessner’s® peels, TCA peels, and mandelic acid peels are all mentioned in medical literature as treatments for hyperpigmentation. These peels must be administered by professionals.

But Personally, I don’t recommend this meditation. It’s has possibility to trigger to severe acne prone skin.

• TCA Peel Dry ice cryotherapy: Doctors will sometimes use application of dry ice to help the mark fade.

LACTIC ACID PEEL is just one type of chemical peel, but they are preferred by many -- again,

Lasers: If topical treatment does not suffice, doctors may sometimes elect to try laser therapy. Laser therapy tends to produce statistically effective results on par with topical treatment.

because of lactic acid’s reputation as a gentler alpha hydroxy acid. You can use peels to improve wrinkles, some types of acne and

In one article doctors also describe regular topical application of lactic, kojic, and glycolic acid as helpful.3

discolorations on your skin. Lactic acid isn’t a cure-all

• Lactic Acid Peel • Glycolic Acid Peel In the same article, a doctor spoke about how he uses a combination of hydroquinone/retinoid/corticosteroid to apply directly to dark spots.3

GLYCOLIC ACID PEEL is mild when compared with some of their more hazardous counterparts, and as a result the outcome might not be as

Nicotinamide is mentioned once in the literature as a helpful treatment for inflammation.

noticeable as you’d like. It’s typical that multiple peels will be necessary to achieve the desired result. The

Microdermabrasion: Performed at salons and estheticians’ offices, microdermabrasion helps remove the upper layers of skin cells. However, abrading the skin can cause irritation and perpetuate the acne cycle, and should be avoided in acne-prone individuals.

upside is that there are very few complications associated with glycolic acid peels.

HOW TO TREAT ACNE

REFERENCES

Thappa, Devindermohan; Adityan, Balaji; Kumari, Rashmi (2009). “Scoring systems in acne vulgaris”. Indian Journal of Dermatology, Venereology and Leprology 75 (3): 323–6. doi:10.4103/03786323.51258. PMID 19439902. Goodman, Greg (2006). “Acne and acne scarring – the case for active and early intervention”. Australian family physician 35 (7): 503–4. PMID 16820822. Purvis, Diana; Robinson, Elizabeth; Merry, Sally; Watson, Peter (2006). “Acne, anxiety, depression and suicide in teenagers: A cross-sectional survey of New Zealand secondary school students”. Journal of Paediatrics and Child Health 42: 793–6. doi:10.1111/j.1440-1754.2006.00979.x. PMID 17096715. Picardi, Angelo; Mazzotti, Eva; Pasquini, Paolo (2006). “Prevalence and correlates of suicidal ideation among patients with skin disease”. Journal of the American Academy of Dermatology 54 (3): 420–6. doi:10.1016/j.jaad.2005.11.1103. PMID 16488292. James, William D. (2005). “Acne”. New England Journal of Medicine 352 (14): 1463–72. doi:10.1056/ NEJMcp033487. PMID 15814882. Benner, Nicholas; Sammons, Dawn (2013). “Overview of the treatment of acne vulgaris”. Osteopathic Family Physician 5 (5): 185–90. doi:10.1016/j.osfp.2013.03.003. Harper, Julie C (6 August 2009). “Acne Vulgaris”. eMedicine. Retrieved 2009-12-21. Kong YL, Tey HL (June 2013). “Treatment of acne vulgaris during pregnancy and lactation”. Drugs 73 (8): 779–87. doi:10.1007/s40265-013-0060-0. PMID 23657872. Mahmood, SN; Bowe, WP (Apr 1, 2014). “Diet and acne update: carbohydrates emerge as the main culprit.”. Journal of drugs in dermatology : JDD 13 (4): 428–35. PMID 24719062. Ramos-e-Silva, M; Carneiro, SC (2009). “Acne vulgaris: Review and guidelines”. Dermatology nursing / Dermatology Nurses’ Association 21 (2): 63–8; quiz 69. PMID 19507372. Taylor, Marisa; Gonzalez, Maria; Porter, Rebecca (May–June 2011). “Pathways to inflammation: acne pathophysiology”. European Journal of Dermatology 21 (3): 323–33. doi:10.1684/ ejd.2011.1357. PMID 21609898. Dawson, A. L.; Dellavalle, R. P. (2013). “Acne vulgaris”. BMJ 346: f2634. doi:10.1136/bmj.f2634. PMID 23657180. Berlin, David J. Goldberg, Alexander L. Acne and Rosacea Epidemiology, Diagnosis and Treatment.. London: Manson Pub. p. 8. ISBN 9781840766165.

Spencer, EH; Ferdowsian, HR; Barnard, ND (Apr 2009). “Diet and acne: a review of the evidence.”. International Journal of Dermatology 48 (4): 339–47. doi:10.1111/j.1365-4632.2009.04002.x. PMID 19335417. Hay, RJ; Johns, NE; Williams, HC; Bolliger, IW; Dellavalle, RP; Margolis, DJ; Marks, R; Naldi, L; Weinstock, MA; Wulf, SK; Michaud, C; J L Murray, C; Naghavi, M (Oct 28, 2013). “The Global Burden of Skin Disease in 2010: An Analysis of the Prevalence and Impact of Skin Conditions.”. The Journal of investigative dermatology 134 (6): 1527–34. doi:10.1038/jid.2013.446. PMID 24166134. Arndt, Hsu; Kenneth, Jeffrey (2007). Manual of dermatologic therapeutics. Lippincott Williams & Wilkins. ISBN 0-7817-6058-5.[page needed] Anderson, Laurence. 2006. Looking Good, the Australian guide to skin care, cosmetic medicine and cosmetic surgery. AMPCo. Sydney. ISBN 0-85557-044-X. Thiboutot, Diane M.; Strauss, John S. (2003). “Diseases of the sebaceous glands”. In Burns, Tony; Breathnach, Stephen; Cox, Neil; Griffiths, Christopher. Fitzpatrick’s dermatology in general medicine (6th ed.). New York: McGraw-Hill. pp. 672–87. ISBN 0-07-138076-0. Boils (Skin Abscesses), medicinenet.com Lacz, Nicole L.; Vafaie, Janet; Kihiczak, Nadia I.; Schwartz, Robert A. (May 2004). “Postinflammatory hyperpigmentation: a common but troubling condition”. International Journal of Dermatology 43 (5): 362–365. doi:10.1111/j.1365-4632.2004.02267.x. “Frequently Asked Questions: Acne”. U.S. Department of Health and Human Services, Office of Public Health and Science, Office on Women’s Health. 16 July 2009. Retrieved 2009-07-30. Melnik, Bodo; Jansen, Thomas; Grabbe, Stephan (2007). “Abuse of anabolic-androgenic steroids and bodybuilding acne: An underestimated health problem”. JDDG 5 (2): 110–17. doi:10.1111/j.1610-0387.2007.06176.x. PMID 17274777. Chiu, Annie; Chon, SY; Kimball, AB (2003). “The Response of Skin Disease to Stress”. Archives of Dermatology 139 (7): 897–900. doi:10.1001/archderm.139.7.897. PMID 12873885. National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health (January 2006). “Questions and Answers about Acne”, p. 5. Bek-Thomsen, M.; Lomholt, H. B.; Kilian, M. (2008). “Acne is Not Associated with Yet-Uncultured Bacteria”. Journal of Clinical Microbiology 46: 3355–60. doi:10.1128/JCM.00799-08. PMC 2566126. PMID 18716234.

HOW TO TREAT ACNE

Lomholt, Hans B.; Kilian, Mogens (2010). Bereswill, Stefan, ed. “Population Genetic Analysis of Propionibacterium acnes Identifies a Subpopulation and Epidemic Clones Associated with Acne”. PLoS ONE 5 (8): e12277. doi:10.1371/journal.pone.0012277. PMC 2924382. PMID 20808860. “National Guideline Clearinghouse”. Guideline.gov. 11/12/2007. Check date values in: |date= (help) University of Nottingham Centre of Evidence Based Dermatology (2012). “2011-2012 Annual Evidence Update on Acne vulgaris”. p. 10. Retrieved 23 September 2013. Davidovici, Batya B.; Wolf, Ronni (2010). “The role of diet in acne: Facts and controversies”. Clinics in Dermatology 28 (1): 12–6. doi:10.1016/j.clindermatol.2009.03.010. PMID 20082944. Ferdowsian, HR; Levin, S (2010). “Does diet really affect acne?”. Skin therapy letter 15 (3): 1–2, 5. PMID 20361171. Bek-Thomsen, M.; Lomholt, H. B.; Kilian, M. (2008). “Acne is Not Associated with Yet-Uncultured Bacteria”. Journal of Clinical Microbiology 46 (10): 3355–60. doi:10.1128/JCM.00799-08. PMC 2566126. PMID 18716234.

HOW TO TREAT ACNE