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Clear Reflections | How teenagersóand adultsócan attack acne head on. | by Noelle Robbins

Acne is a scourge that shows no mercy, striking young people as early as age 9, just when appearance starts to mean so much. Most teenagers experience some acne at one time or another and, once entrenched, it can refuse to budge, rebuffing a mighty assault of potions and pills. And sometimes, even when our teen years are decades behind us, acne can rear its ugly head—again.

Whether a single pimple here or there, every now and then, or a full-blown breakout, it is—according to physicians—all acne. The condition starts with sebaceous glands surrounding the hair follicles on the face and upper trunk, which release sebum, an oily, waxy substance that lubricates hair and skin. This is not a problem until the flood of adolescent hormones triggers several important changes: a growth of the glands, production of stickier, thicker sebum, and skin cells that clog the pores. Whiteheads are clogs below the skin surface. Blackheads occur when oil reaches the skin surface, darkening upon exposure to air. Both can lead to more serious problems when a bacterium—Propionibacterium acnes—infects and inflames the sebum clogs, which erupt into pimples on the face, chest, back, and shoulders.

Peter James of Orinda, a passionate athlete who excels in baseball, loves surfing and tennis, and experiments with rap music, was 14 when acne first hit. “I never tried to hide my acne,” he says. “I never had self-esteem problems. But my zits were very painful.” He tried cleansing with mild, non-oily soap and, to avoid dry irritated skin, following up with an oil-free (“noncomedogenic” in dermatologist’s lingo) and fragrance-free moisturizer. “I tried washing my face more, and washing my hair more when it got sweaty from sports,” James says.

He also took a closer look at his diet. Although the myth that chocolate and greasy foods cause acne was busted long ago, eating fresh fruits and vegetables made sense to him. But eating better had no effect on his breakouts. The next step was a course of oral antibiotics prescribed by his primary care physician. He ended up with an out-of-whack digestive system and an upset stomach, but not a clear face.

Finally, James and his mother, Maria, decided the time had come to consult a specialist, and he was referred to Orinda dermatologist Kristin Walker. According to Walker, her new patient was already on the right track: His twice-a-day cleansing routine was exactly the protocol she recommends. But that was just a beginning. Like many dermatologists, Walker takes a combination approach to attacking acne. “We often start with a topical twice a day,” Walker says. She advises nonprescription preparations in the form of pads, creams, or gels containing Benzoyl Peroxide 5%, which kills the acne bacterium. In addition, she may suggest treatment with Retin-A, which improves the skin’s ability to shed cells. Walker, like some of her colleagues, also offers facials for patients with acne. “This is not a spa facial,” she says. “It is a deep cleansing to unclog pores and prevent scarring.”

Once initial anti-acne regimes are in place, Walker says, “we hit it hard with oral antibiotics.” Complexions don’t clear overnight; it can take four to six weeks to see results. “And,” Walker warns, “it may get worse before it gets better.” She advises tapering off antibiotics after a few months, following up with topicals, and monitoring flare-ups.

Today, James regrets that he didn’t take a more aggressive approach early on, avoiding pain and scarring. The good news is that acne is no longer a big issue in his life. “I saw some improvement in two to three weeks,” James says. “In six months there was drastic improvement.”

In addition, the treatments Walker prescribed are known to have relatively few side effects. In James’s case, the antibiotic he received was milder than the one his primary care doctor had prescribed, so he didn’t experience gastrointestinal distress. (Patients on antibiotics may want to ask their medical providers about taking probiotics—supplements or foods like yogurt that are rich in beneficial intestinal bacteria—to minimize potential digestive upsets and yeast infections.)

James still follows a routine that includes a topical gel in the morning and Retin-A at night. And he still experiences occasional flare-ups, but is not overly worried. “I think I am probably more concerned than he is,” says his mother. “Most teenage boys are not very forthcoming about their feelings, so I wonder if it bothers him more than he lets on.” James recently, and somewhat reluctantly, returned to the dermatologist to start another round of antibiotics. But he is optimistic about the immediate and long-term benefits of facing down his acne.


For some acne patients, the road is not so smooth. Riitta Gluskin of Orinda tells a harrowing tale about her son Adam’s two-year fight to vanquish the condition. Like James, Adam Gluskin—a track-running, guitar-strumming, highly social teen—sought relief via organic foods, topical skin preparations, and oral antibiotics that gave him stomachaches. When these techniques proved ineffective, says Gluskin, they escalated the attack with alternative treatments—homeopathy, expensive oils, expensive facials, and expensive clays—none of which were covered by the family’s health insurance plan. Finally, mother and son faced the fact that the only thing they hadn’t tried for his intractable acne was a highly controversial drug—Accutane.

Accutane—a prescription medication that Walker describes as “a very high dose of Vitamin A in oral form”—sends shudders of fear through responsible parents and suffering teens alike. Known side effects can include depression and suicide if a patient is on anti-depressants. Also, Walker notes, “It can cause liver damage and increase cholesterol, which means frequent lab tests, and birth defects, which means teenage girls must undergo frequent pregnancy tests or take oral contraceptives during their treatment.” Other possible side effects include muscle and joint pain, inflammation of the gums, bloody noses, and hair loss. Needless to say, it is not a protocol that dermatologists recommend lightly. And even for patients who accept the risks, Walker says, “It is not a miracle drug. It can take four to six months to see results and some patients may take a second course or still have occasional breakouts.”

Despite its many downsides, however, Accutane can produce positive results in acne cases that have not responded to other treatments, by shrinking sebaceous glands, cutting sebum production, reducing acne bacteria on the skin, and slowing skin cell production. Having exhausted all other options, Gluskin decided Accutane was worth a try—but kept the potentially risky treatment a family secret.

For her son, the decision paid off. Six months into treatment, the teen experienced significant clearing, and was taken off the medication. “He told me, ‘I’m so happy,’” Gluskin says. “After two years of feeling guilty and of trying to protect his health, and of Adam being so brave, using Accutane was worth it for the happiness it brought him.”

Over time, Gluskin grew less hesitant to reveal the source of her son’s acne turnaround. “My acne really bothered me socially,” says Adam Gluskin. “I was really self-conscious. Even knowing the risks, Accutane was the best thing I ever did.” His mother concurs. “After the positive results, without the horrible side effects, I now tell most friends right away,” she says.


Most acne first appears between the ages of 10 and 13 and lasts five to 10 years, according to the website AcneNet, sponsored by the American Academy of Dermatology. During those teen years, boys are more likely than girls to have severe outbreaks that linger longer.

However, teenagers are not alone in experiencing the embarrassment and physical discomfort of acne breakouts. And when acne strikes adults, usually from ages 20 to 40, women are twice as likely as men to be afflicted. Nearly 50 percent of all women, and a quarter of men, experience adult acne. Once again, hormone fluctuations—associated with the menstrual cycle, pregnancy, and pre-menopause—are a major culprit.

Karen Peters, a naturopathic doctor who practices at East Bay Naturopathic Clinic in Albany, treats adult patients suffering from skin blemishes. She cares for them, like her other clients, with a holistic approach that may incorporate traditional medicine but emphasizes nutritional and herbal or botanical treatments. “I don’t treat acne,” she says. “I treat people.” The condition of the skin reflects the overall health of the body, she believes.

A key to quelling acne, Peters says, is supporting a patient’s elimination and detoxifying systems to assure optimal hormone balance. “Liver function, bowel movements, kidney function, sweating, and breathing all remove toxins from the body,” Peters says. “Skin problems are often a sign of constipation or food sensitivities, with dairy products a common trigger.”

To treat a 37-year-old patient, a female photographer who travels extensively, Peters started with the contents of the woman’s kitchen. As a teenager, the photographer had been troubled by acne, and although the condition improved over time, breakouts continued into adulthood whenever she got her period. Eventually, she turned to antibiotic therapy, but it had little long-term effect. “First we changed her diet— increased seasonal vegetables, fiber, and whole grains,” Peters says. “I diagnosed a dairy intolerance, and added probiotics, and herbs for liver support.” After four weeks, the photographer reported better digestion and increased energy. With Peters’s guidance, she went on to incorporate healthy fats into her diet and increase her vitamin B intake—and finally started to experience slow, steady progress toward a clearer face, chest, and back. Another plus? Fewer premenstrual symptoms. “It does take time and patience,” says Peters. “Skin clears as a side effect of better body health. You need to treat skin internally—from the inside out—to have long-lasting success.”


For those not inclined to seek skin care in the doctor’s office, other options do exist. “I love working with acne,” says Shelley Rosenfeld-Brooks, owner of Conscious Skin & Body Care in Alameda. “I had acne from age 13 to 30, and felt crippled psychologically. All the commercials and magazine ads for acne products made me feel like my skin was just plain dirty, that I was doing something wrong.” Rosenfeld-Brooks’s goals for her acne clients are two-fold: To deep-clean and exfoliate dead cells, unclog pores, and calm overly dehydrated, irritated skin; and to teach them about nontoxic products to use at home, like lotions and sunscreens free of mineral oil, lanolin, artificial ingredients, or alcohol. “Skin needs the ideal balance of moisture,” Rosenfeld-Brooks says. “We need oil to protect our skin. But when skin is too dry, oil glands overproduce to compensate.” Like all acne professionals, she counsels patience. “It can take three to six months, or even a year, to see results. You should see a difference in your skin after the first treatment but overall clearing of acne depends on home care and lifestyle choices.”

Emmeline Brocca, 28, of Oakland, is one of Rosenfeld-Brooks’ regular clients. “Since I was a teenager, I have had very oily skin, and a lot of acne on my face, neck, and chest,” she says. “I tried a dermatologist, but I have no insurance and prescriptions are very expensive. And the acne kept coming back. Plus,” she adds, “I prefer a natural approach.” For the past year and a half, she’s used products recommended by Rosenfeld-Brooks twice daily at home, and she schedules a monthly facial. Not only have the treatments cleared her face, she says, but her scarring is significantly reduced as well.

No one treatment is right for everyone; no single approach can promise to instantly erase acne, and some alternatives are riskier than others. But even for the toughest cases, there is hope for a reflection in the mirror of clear, healthy skin.

Noelle Robbins is The Monthly’s health columnist.



Banishing breakouts: Pimples are no picnic, but state-of-the-art treatments help teens (adults, too) heal problem skin. Photo by Ron Sumners Graphics Inc.



Pimple Producers
Chocolate and french fries may not cause acne, or make it worse. But here are some things that might:

• Genetics
• Surge in male hormones during puberty for boys and girls, and for women later in life
• Monthly cycles, pregnancy, and pre-menopause
• Stress and poor sleep
• Oily cosmetics and soaps; grease on the job; sweat from heat and exercise
• Food sensitivities

Abolishing Acne
• Never pop, squeeze, or pick; it increases risk of infection and scarring.
• Avoid harsh, drying soaps and scrubs, and don’t rub, which increases irritation. Use mild cleansers, gently, twice a day. Wash hair to remove oil and sweat.
• Use oil-free cosmetics, skin, and hair care products—look for “noncomedogenic” or “nonacinegenic” on the label.
• Use topical acne medication (either over-the-counter or prescription) under makeup and continue use after skin clears. Taper off gradually.
• Follow doctor’s orders, but report side effects immediately.
• Eat a healthy diet rich in fresh fruits, vegetables, whole grains, and fiber.
• Be patient. Improvement is usually seen in six to eight weeks, with significant results in six months. Treatments can reduce scarring during and after acne breakouts.

American Academy of Dermatology;
Naturopathic Dermatology;
Accutane information; and The PDR Family Guide to Prescription Drugs (Three Rivers Press).