Acne Therapy in the 21st Century
Posted Mon, Feb 28, 2011

I recently attended the annual Southbeach Symposium which functions somewhat as the premier meeting of dermatology experts in the field of cosmetic dermatology, especially as it relates to lasers and physical therapies of the skin. Under the direction of Dr Mark Nestor this course has been the gold standard for the past 9 years providing objective scientific data on the validity of concepts and devices. Many topics were covered including acne, rosacea, the aging face and body, botox, fillers, and even pediatric dermatology, eczema, and psoriasis.
Acne was given a lot of attention as it deals with those most concerned with self image: the adolescents- and then everyone else who uses a mirror. Significantly, mirrors always lie as noted in the Snow White parable of the evil stepmother who asked the mirror each day who was fairest in the land. She might as well have asked who is the ugliest in the land as the mirror always reflects what the viewer wishes to hear (see). For 2011 there is general consensus that antibiotics are almost the last drug of choice for acne because of potential side effects chiefly concerning development of microbial resistance. (A study more than 50 years ago demonstrated that 70% of adolescents could clear their skin with topical agents available at that time and it has taken a half century to incorporate this knowledge into our treatment protocols.) Our chief strategies now involve topical agents which increase cell turnover; topical agents to degrease in the skin; topical agents to reduce inflammation; and light energy systems to reduce bacteria and the size of oil glands. Almost 90% of patients with acne can be treated in this manner.
Photodynamic therapy, in which a chemical, aminolevulinic acid, can be applied to the skin followed by stimulation with lasers or other light based devises, was lauded by all as almost always effective and a viable alternative to Acutane, which works reasonably well in severe acne but entails numerous side effects which can be severe if not controversial.
Perhaps more controversial are the newer low-strength estrogen birth control pills with anti-androgens which are used to reduce premenstrual flare ups of acne. While these agents reduce acne they also potentially reduce testosterone as well as estrogen stimulation to female genitalia which may have long-term consequences for genital skin integrity and subsequent sexual arousal. While I think I speak for most fathers in lauding anything that reduces sexual proclivity in our daughters and while most adolescent girls would rather have a clear face than be sexually active, this is not true for adult women; especially those premenopausal females who may feel they are being cheated by choosing between a clear complexion and a more satisfying sex life- which reminds me of one of Woody Allen’s parables of a Jewish woman complaining of her recent vacation in the Catskills “Acch, the food was so bad… and the portions were so small!” Thus there is concern regarding the long term effects of taking anti-androgens which I will discuss in another blog.
The take-away from this review of acne therapy is that most patients get excellent results with topical agents; some need light (laser) therapy; antibiotics are the last drug of choice; and Acutane remains good and bad depending on the eyes of the beholder.

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Edward Lack
Edward Lack MD is a board certified dermatologist and a board certified dermatologic cosmetic surgeon. He is President and Medical Director of MetropolitanMD, a multispecialty cosmetic surgery center in Chicago,which is unique in having a double board certified cosmetic dermatologic surgeon, a double board certified facial plastic surgeon, and a double board certified cosmetic plastic surgeon. Dr. Lack is also the Past President of The American Academy of Cosmetic Surgery.

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