Acne is one of the most common skin diseases in the United States, affecting millions. Acne is an inflammatory disease of the oil glands of the face, chest and back. It occurs most commonly during adolescence and has various modes of manifestation. It can appear as whiteheads or blackheads, pimples, or cysts. If not treated timely and appropriately, it can result in pitted or depressed scars. Although acne is not a life threatening disease, it can have significant emotional and psychological consequences. There is now an effective solution against Acne. There are many different treatments for acne. These include topical creams such antibiotic, Retin-A and Benzoyl Peroxide. Oral treatments are effective as well, including oral antibiotics, Accutane, spironolactone, or even oral contraceptive pills. Chemical peels, photodynamic light therapy, red light and blue light are also effective methods for controlling acne. Electric face brushes like Clarisonic will remove the dirt and unplug the pores, leading to less acne breakouts. There are many options and every patient is unique and will respond to different medications, so developing a customized plan that fits one’s own acne situation is critical.

Acne - Conditions

What is the most common type of acne that you see in the clinic?

There are many different forms of acne. They are comedones, which either whiteheads and blackheads. These could be anywhere on the face, but very typically they occur on the forehead. The reason for this is that anything that blocks the oil glands on the forehead will lead to these acneiform comedonal lesions. These include bangs in females and hats in males. Dr. Behnam recommends cutting the bangs in order to prevent the blockage of oil glands on the forehead and prevent the formation of comedones, whitehead and blackheads on the forehead. If a patient wears a baseball cap, then it is recommended to stop wearing one.

The other form of acne is red pimples on the face. This is known as erythematous papules. Comedones, whiteheads and blackheads could progress to a red erythematous papule. These are typically sometimes tender and sometimes they might have pus in them. There are many different degrees of acneiform papules. It could range from mild-to-moderate and moderate-to-severe. Each one of these acneiform papules is full of inflammation as well as bacteria. Our main treatment method is to give antibiotics, which are anti-inflammatory in order to reduce the inflammation. If not treated aggressively and appropriately, the inflammation may cause damage to the collagen within the skin and will lead to depressed acne scars on the face. In addition to the red pimples, there are also cystic acne that could occur on the face.

These represent as large cysts throughout the face. When the patient presents  with cystic acne, typically the most appropriate recommended treatment is Accutane. The cystic acnes are the most common ones that could lead to depressed scars, so early and aggressive treatment is necessary.

What are the most common treatments for whiteheads and blackheads?

Comedones known as whiteheads and blackheads may occur anywhere on the face. These comedones may progress to become red pimples. The most effective treatment for comedones are the Retinoid creams, such as Retin-A (Tretinon) or Differin (Adapalene). By using these medications, they will essentially unplug and exfoliates the face and prevent comedones from appearing on the face. In clinical studies, after a 6 weeks course of using these Retinoids there is about 30% to 40% improvement of comedones on the face.

How to apply Retin-A and Differin?

Retin-A and Differin are applied very sparingly every night. If too much is applied, they can cause significant drying and irritation. In addition, Retin-A and Differin will make your face sensitive, so it is important to wear moisturizers on a regular basis as well as sunscreen in the morning. Dr. Behnam highly recommends his patient’s to use them sparingly and only use a pea-sized amount all over the face. He even sometimes start his patient on an every-other-night regimen and then slowly titrate them up.

There are many different strengths of Differin and Retin-A, so it is important to look at your patients and see how sensitive they are. The patient who has blond hair, blue eyes and fair skin are more sensitive than the patients who have darker hair, dark-color eyes and olive skin tone. Typically for the sensitive patients, Dr. Behnam typically starts with Differin 0.1% or Retin-A 0.04% Microgel. The patients who are Middle Eastern or have olive skin tone, they may start with Differin 0.3% or Retin-A 0.1% every other night. Again everybody is different, so please consult your dermatologist for the appropriate regimen of treating your acne in Santa Monica.

How do you treat red pimples on the face?

Red pimples are classically treated by using a combination of topical antibiotic creams, topical retinoids and oral antibiotics. Clinical studies have showed that topical retinoids like Retin-A or Differin not only help with comedones but also with a red pimples on the face. In addition, topical clindamycin, which is a topical antibiotic, may also be added to the regimen in order to reduce red pimples. Clinical studies have shown that topical clindamycin if used alone by itself would lead to resistance of bacteria on the face. So it is very important to use a topical benzoyl peroxide along with the topical clindamycin. This is why medications like BenzaClin and Duac are on the market. These are combination of benzoyl peroxide and clindamycin.

They are very effective and will lead to resolution of red pimples on the face without causing resistance of the P acne bacteria. In patients that have moderate-to-severe red pimples on the face, it is very important to add an oral antibiotic to regimen. The class of antibiotics that is traditionally used in dermatology is the tetracycline family. The most commonly used antibiotic from the Tetracyclin family is Doxycycline 100 mg. It could be used once a day or twice a day. There are brand name medications of doxycycline in the market such as Monodox or Doryx. Doryx and Monodox are typically used once a day as appose to the generic doxycycline, that is used twice daily.

The brand named medications also have less side effects of upset stomach. Dr. Behnam always highly recommends that doxycycline be taken with food and never on an empty stomach; otherwise, it will cause upset stomach. Also these  indications will cause the patients to become sun sensitive, so wearing a sunscreen is very important. Typically, during the summer month, Dr. Behnam may switch the patients to minocycline antibiotics because it tends to make the patients less sensitive. Minocycline at high doses may cause vertigo or dizziness.

So, Dr. Behnam typically restricts the use of minocycline to 100 mg once a day. If patients have a combination of various forms of acnes on the face, such as comedones, whiteheads, blackheads and red pimple, Dr. Behnam typically use a regimen of topical retinoid creams, topical clindamycin with benzyl peroxide as well as oral antibiotic. Typically, patients stay on this regimen for a few months. As soon as the patient gets better, Dr. Behnam then tapers down the oral antibiotic and continues the patient on the topical creams.

How to treat cystic acne?

Severe cystic acne is typically treated with Accutane. Accutane is a medication that is used in patients who have already failed other medications such as oral antibiotics as well as topical retinoids and other topical creams. Accutane is not for everybody. Accutane is also known as isotretinoin. It is a form of vitamin A that is taken daily typically for 5 months. In order to take Accutane in the United States, patient must be registered under a special program called iPLEDGE. Typically, your dermatologist will register you under this program.

So, it is very important to see your dermatologist. The reason for registering with iPLEDGE is because Accutane has become a restricted medication in the United States. One of the side effects of Accutane is that it may lead to birth defect if one becomes pregnant on it. So, it is very important that one does not become pregnant on Accutane. In fact, the whole purpose of the iPLEDGE program is to prevent pregnancy on Accutane. Patients on Accutane must either not be sexually active or if they are sexually active, they have to be on two forms of birth control, a condom and an oral contraceptive pill. It is dangerous to purchase Accutane over the internet or to purchase Accutane from outside of United States as this violates the iPLEDGE program.

Dr. Benham treats acne aggressively and does enroll patients in the iPLEDGE program. If you think you need Accutane, please see Dr. Behnam at his dermatology office in Santa Monica.Is benzoyl peroxide good for your skin? Benzoyl peroxide is a topical medication that is used to kill P. acne on the face. This is the bacteria that cause acne. It is typically combined with clindamycin. The reason for this is that in clinical studies, if clindamycin is used alone by itself without any benzoyl peroxide, it will lead to development of resistance of the P. acne bacteria on the surface of the skin. As a result the clindamycin will become ineffective. So these two medications are typically combined together such as Duac and BenzaClin. Overall, I think benzoyl peroxide is a great medication; however, one of its downfalls is that it could be too irritating.

There are many different strengths of benzoyl peroxide ranging from 2.5% to 10%. Dr. Behnam does not recommend the 10% Benzoyl Peroxide because the 5% will work as effective as the 10% one with less side effects. Dr. Behnam typically recommends PanOxyl, which is a topical benzoyl peroxide wash. The recommended use is once daily. This medication should not be used twice a day.

Does Proactiv work?

Most of my patients that come to my clinic have already tried Proactiv. Proactiv does contain some good ingredients. They have benzoyl peroxide and sulfur, which are some of the ingredients that are used when I am treating my patients. It could work for some patients, typically those patients that have mild acne on the face. However, when the acne is moderate-to-severe, then Proactiv does not work. It is important to see a dermatologist in order to get prescription strength topical and oral antibiotics.

Does Proactiv work on acne scars?

There are many different forms of acne scars. One form are depressed scars. Proactive does not work on depressed scars. The  reason is because a depressed scar has lost collagen in it. There is no active ingredient in Proactiv that will stimulate collagen production in those depressed scars. There are various other methods of treating depressed acne scars such as fractional CO2 laser, Fraxel, Active FX, SmartXide DOT, TCA CROSS technique, and subcision.

Does Proactiv work on blackheads?

Blackheads also known as comedones are typically treated with topical retinoids. These include Retin-A as well as Differin. These agents exfoliate the skin and unplug those pores and lead to resolution and improvement of the blackheads. In Dr. Behnam’s opinion, Proactiv does not work on blackheads or comedones because it does not have any of the exfoliating ingredients of retinoids.

Does exercise make acne worse?

The exercise itself will not make your acne worse. There are many patients that say after they started to aggressively exercise at the gym, the acne on their face has become worse. It is not the exercise; however, when one exercises, one sweats on the face. Leaving the sweat sit on the face will plug up the pores and that will lead to acne exacerbation. So, Dr. Behnam highly recommends to take a shower or wash the face within a minute after finish exercising. Dr. Behnam recommends using a special topical pad immediately after exercising in order to prevent the sweat from sitting on the face. This is very effective and patients absolutely love it. The pads contain salicylic acid and glycolic acid, two ingredients that will fight acne.

Is back acne hard to treat?

Yes, back acne is difficult to treat. Acne on the back is the most difficult acne to treat. Typically, oral antibiotics or even Accutane may be necessary to treat the acne on the back. Dr. Behnam typically puts the patients on doxycycline 100 mg once or twice a day along with topical clindamycin lotion once a day. He also recommends the patient to use a benzoyl peroxide wash, typically PanOxyl, once a day. Patients should not use PanOxyl more than once a day because that could be too irritating on the back.

Do lasers work for acne?

Photodynamic light therapy (PDT), including blue and red light, have a tradition of being used for the treatment of acne on the face. In the recent years, such laser modality has been combined with Levulan or Metvixia in order to improve its efficacy. Levulan is a type of chemical that gets absorbed preferentially by the oil glands. Once absorbed in the oil glands, it is activated by light and leads to the possible shrinkage of the oils glands. In Dr. Behnam’s clinic, the Omnilux laser is used. Several sessions with photodynamic light therapy will lead to significant improvement of the red acne lesions on the face.

The following is the protocol for using photodynamic light therapy (PDT) with Levulan for acne on the face.

  1. Clean the face with alcohol.
  2. Apply the Levulan on the face and incubate for about 30 minutes.
  3. Place the patient under the Omnilux red light for a specific duration of time.
  4. The face is cleansed, sunscreen is applied, the patient wears a hat and leaves the office.
  5. The patient is told to stay out of the sun for the next 48 hours as the Levulan chemical will make the face very sun sensitive.
  6. Please return to clinic in 2 weeks for additional treatment.