Decades ago, acne was seen as a rite of passage—albeit one that affected some individuals worse than others. (Who doesn’t remember their high school classmate who had the most severe acne?) Yes, there were treatments, some better than others, but oftentimes, it was trial and error coupled with the hope that a person would simply outgrow their acne.

We now know this doesn’t always happen and that acne can continue or even begin in adulthood for a myriad of reasons. That’s not the only thing we’ve learned about the pathophysiology and epidemiology of acne in the recent past, either. Armed with new information, innovative dermatologists are now approaching acne treatment and prevention in a much more proactive fashion largely by starting combination therapy early on and not relenting until a complexion is all clear.

New York City dermatologist Eric Schweiger, MD, is one of the vanguards in this new regime. He even scribed what can be considered a manifesto on the new thinking about acne and its treatment: 100 Acne Tips & Solutions: The Clear Clinic Guide to Perfect Skin.

Schweiger, an assistant clinical professor of dermatology at Mount Sinai Medical Center in New York City, is also the medical director of Clear Clinic, a facility where the main mission is to eradicate acne. The Clinic’s very décor projects this mission. Everything is white with cool blue accents—slick, smooth, and spotless. He is so confident that his multipronged, holistic approach to treating acne works that he has opened Clear Clinics in nine locations and launched a robust product line. Schweiger is also helping to move acne care into the 21st century with the Clear Clinic @ Home protocol, which allows patients to work with a Personal Acne Coach™ via video conferencing, telephone, or online chat.

He personally trains each of the physicians who staff the Clinics to make sure they are in tune with his all-hands-on-deck approach.

“If I use dual therapy from the beginning, people can see results faster,” Schweiger says from the flagship Clinic in midtown Manhattan.

All Clear

Bethanee J. Schlosser, MD, PhD, an assistant professor in dermatology and obstetrics and gynecology at Northwestern University Feinberg School of Medicine in Chicago, agrees that times have changed for acne patients and the doctors who treat them.

Yes, certain acne treatment mainstays—topical retinoids, topical antibiotics, and oral antibiotics—have been available for a few decades. But, “There has been a significant change in our understanding of the mechanisms by which the available medications work to improve patient’s acne, and we have recently come to appreciate the multiplicity of effects that some acne medications may have—ie, anti-inflammatory as well as antimicrobial effects of oral antibiotics; that topical retinoids normalize follicular keratinocyte differentiation but are also anti-inflammatory,” she explains. Schlosser is also a spokesperson for the American Academy of Dermatology (AAD).

That’s not the only sea change that has occurred in the way dermatologists think about and approach acne. “We have also come to better appreciate the chronic nature of acne for many patients and are placing greater emphasis on strategies to improve patient adherence with chronic medication use for acne. Improved patient adherence can be achieved through the use of combination products (antibiotic/benzoyl peroxide, tretinoin/clindamycin, adapalene/benzoyl peroxide) with once daily dosing regimens,” she tells Plastic Surgery Practice.

“We now know that most people don’t clear on single agent therapy, and for that reason, many of today’s topicals are actually combinations that are buffered so the irritancy is much less,” adds AAD spokesperson William D. James, MD, Paul R. Gross Professor of Dermatology at the University of Pennsylvania in Philadelphia.

The pendulum has also begun to swing back in favor of the drug formerly known as Accutane to treat acne at its most severe. Isotretinoin—brand names including Roaccutane (formerly known as Accutane) and Claravis—fell from grace due to risks associated with their use, including psychiatric problems, most notably suicidality; inflammatory bowel disease (IBD); as well as their known teratogenic effects. As a result of the risks and intense monitoring needed, many dermatologists were reluctant to prescribe this medication even to individuals who could benefit. Today, however, many skilled dermatologists are more willing to use this medication—when necessary.

“It a great drug for the right patent, and almost all patients will be clear in 6 to 9 months,” Schweiger says.

The link between the medication and inflammatory bowel disease has also been largely discredited, James says. “The latest information tends to refute some of the association with IBD and Accutane, and people aren’t quite as scared to use it or prescribe it,” James says.

Lasers and Light

Although Schweiger was not plagued with serious acne during his teen years, he is tuned in to the psychological effects that acne can have on his patients. For these reasons, he is not afraid to bring out the big guns right away, often including lasers and other light-based treatments in his treatment protocol from the get-go.

There is no one-size-fits-all approach to acne at the Clear Clinic. Instead, it’s more about meeting the patient where they are and working with them until they are satisfied. “For patients looking for fast results and having a budget that allows for self-pay procedures, I am a big fan of blue and red light therapy for inflammatory acne and photodynamic therapy for moderate to severe acne,” he says. At Clear Clinic, these procedures are often combined with extractions and chemical peels to treat acne quickly and effectively.

Schlosser is more pragmatic about the early use of light-based technologies, including photodynamic therapy. “They can be beneficial for inflammatory acne lesions,” she says. But most insurance don’t cover the cost of such treatments, which can be prohibitive.

“Due to the lack of insurance coverage and associated cost, photodynamic therapy and laser treatments are often broached only after patients have tried and failed other treatment options (oral antibiotics, topical retinoids, benzoyl peroxide) or have contraindications to such medical therapies,” she says.

Breakthroughs in Acne Etiology

As treatment improves, there has also been a parallel rise in the collective understanding about causes and aggravating factors. For years, it was suggested that chocolate and fried foods could trigger a breakout, but this has been slowly and surely debunked by the medical literature. That said, foods high in glycemic index—ie, white carbs—might contribute to acne. “If you follow the South Beach or another smart carb diet, you may lose weight and get clear,” James says. “There is also a school of thought that dairy products—skim milk, in particular—can trigger acne in some.”

He agrees that tweaking a patient’s diet can help prevent acne. “There have been 15 or 20 studies that have looked at foods with a high glycemic index and dairy foods, and these foods seem to really play at least some part in pushing people into having more inflammatory acne,” he says.

The relationship between acne and the microbiome is also yielding some important clues on the pathogenesis of acne. This research has shown that P. acnes is a dominant species and the strains are very similar among people with acne. By contrast, the strains in normal individuals are much more diverse. “The will give us a lot of answers,” James predicts.

Previous dogma regarding acne pathogenesis held that the initial step in the formation of new acne lesions, the microcomedo, involved abnormal differentiation (maturation) of the keratinocytes lining the hair follicle, Schlosser adds. “Studies have recently elucidated that inflammation with release of a myriad of cytokines including Interleukin-1 (which seems to be integral to acne lesion development) precedes this abnormal differentiation,” she says. “P. acnes has been shown to interact with Toll-like receptor 2 to initiate and propagate inflammatory cascades seen in acne.” As such, she adds, antibiotic resistance and appropriate stewardship of antibiotic use have become increasingly prominent in all of medicine, including the dermatologic use of oral and topical antibiotics for acne.

The Final Frontier: Acne Scars

With breakthroughs in the understanding of acne and gains in its treatment has come a significant change in how dermatologists approach acne’s physical scars. “We don’t rely on punch excision or dermabrasion as much anymore, and now we have fillers which have helped a lot of people,” James says. In addition, Cynosure’s Picosure just received marketing clearance from the US Food and Drug Administration to treat acne scars.

Schweiger and a colleague recently published a study about the efficacy and safety of fractional CO2 lasers for the treatment of atrophic acne scarring. And he pioneered the Focal Acne Scar Treatment (FAST), which uses a high-intensity fractional CO2 laser to target just the scars on the first day of treatment, followed by an Erbium Fractionated laser treatment 1 month later to the whole face. FAST is often followed by platelet-rich plasma injections to enhance the result.

“In 2014, there is no reason that anyone should have to live with acne or acne scars,” Schweiger says.

 About the author

Denise Mann is the editor of Plastic Surgery Practice. She can be reached at [email protected]