Acne: It’s No Friend of Anyone

I have wanted to cover the topic of acne since the launch of this blog, but it’s a topic with such breadth that I have been waiting for the right angle. Recently, I read an article about new acne guidelines that creates a perfect forum for discussion of this important issue.

According to the American Academy of Dermatology, acne is the most common skin condition in this country, and yet, misinformation about its treatment has skyrocketed (e.g., toothpaste as a pimple zapper is fiction). This February, the AAD issued a report entitled “Guidelines of Care for the Management of Acne Vulgaris” in the Journal of the American Academy of Dermatology, which lays out formal, evidence-based guidelines for treatment.

The report states that the best evidence shows that a combination treatment is the most effective.  This means a complimentary approach, including a topical treatment (e.g., retinol- and benzoyl peroxide-based) with an approved antibiotic and/or an oral contraception (for women), or in refractory cases when all others fail, isotretinoin (aka Accutane).

“Because acne is a skin condition that is a culmination of issues (such as oil production, clogged pores, bacterial overgrowth and systemic inflammation), it makes sense to treat it with a combination approach,” says Washington D.C. dermatologist, Elizabeth Tanzi, MD.  And while “combination treatment has been the standard for treating acne for a very long time,” these guidelines are “just formally reinforcing it,” agrees New York dermatologist, Neal Schultz, MD.

The new guidelines also call out some common treatments as being less effective and unproven. These range from in-office procedures, such as laser treatments and chemical peels, to natural therapies like tea tree oil and lifestyle modifications, such as dietary restrictions. These non-pharmacological, and often supplementary, treatments have long been controversial among dermatology providers, who often disagree on their utility. A reason for the discrepancy may be that relative to studies on pharmacological approaches, research on these alternative treatments is limited. The creators of the new guidelines found that collectively, the body of objective (non-observational), longitudinal studies performed have yielded varied results with little, collective statistical significance, rendering them less reliable.

One issue that complicates doing research on acne therapies is that investigators usually have to rely on patient testimony – and thus on their adherence and honesty -“Yes, I promise that I used the retinol cream every night this week and just as prescribed” – rather than on unbiased, hard data that they directly control and collect. The question of reliability of data is particularly called into question in the case of alternative therapies for acne, most notably diet. Compliance rates with any treatment are low, and eating habits take the cake when it comes to non-adherence. When a patient reports, “No, no, I haven’t eaten any carb-loaded foods all week, I swear,” or, alternatively, “I ate a bunch of junk food last week and that caused my breakout this week,” just how reliable is that information?

For instance, there is a growing body of literature on the potential link between a high-glycemic diet and acne, but, again, this is a connection that some professionals doubt due to the question of reported data reliability and the lack of consistent study findings. Further, diet alone, while it may help, does not seem to be a cure-all for acne. As a result, investigators must weigh the impact of other concurrent therapies or lifestyle changes. Teasing out the efficacy of any one therapy becomes virtually impossible.

Some praticing dermatologists argue that non-pharmacological treatments can make a difference for some individuals, and their use should be recommended on on a case-by-case basis. They argue that these should not be discouraged or negated by blanket, general guidelines. For instance, Dr. Schultz states, “I disagree about in-office treatments. Superficial peels (glycolic or salicylic or combination peels) are always helpful as is opening and injecting cysts (with cortisone) to relieve pain and heal faster.” Dr. Tanzi adds, “In my opinion, for certain acne-prone individuals, diet does play a role in the severity of their acne, particularly a high-glycemic diet for some people. But that’s why there is no single treatment to cure acne for everyone; there are different triggers depending on the person. There is no one-size-fits-all treatment for acne.”

And I really like that perspective on acne – there is no one-size-fits-all approach.