Isotretinoin (previously known as Accutane) is the most effective form of acne therapy and the only one that can actually result in a cure for your acne. After finishing a course 80 percent of people never see acne again. It works so well because it unclogs pores, kills bacteria, reduces oil production and reduces inflammation. It's taken as a daily pill. Isotretinoin has numerous rare and potential side effects that has made it a controversial choice, but for patients with severe acne there is often no other option. Patients taking isotretinoin must also be on highly effective birth control as the drug can cause birth defects. Isotretinoin can only be taken under close medical supervision.
Acne appears to be strongly inherited with 81% of the variation in the population explained by genetics. Studies performed in affected twins and first-degree relatives further demonstrate the strongly inherited nature of acne. Acne susceptibility is likely due to the influence of multiple genes, as the disease does not follow a classic (Mendelian) inheritance pattern. Several gene candidates have been proposed including certain variations in tumor necrosis factor-alpha (TNF-alpha), IL-1 alpha, and CYP1A1 genes, among others. The 308 G/A single nucleotide polymorphism variation in the gene for TNF is associated with an increased risk for acne. Acne can be a feature of rare genetic disorders such as Apert's syndrome. Severe acne may be associated with XYY syndrome.
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Although the late stages of pregnancy are associated with an increase in sebaceous gland activity in the skin, pregnancy has not been reliably associated with worsened acne severity. In general, topically applied medications are considered the first-line approach to acne treatment during pregnancy, as they have little systemic absorption and are therefore unlikely to harm a developing fetus. Highly recommended therapies include topically applied benzoyl peroxide (category C) and azelaic acid (category B). Salicylic acid carries a category C safety rating due to higher systemic absorption (9–25%), and an association between the use of anti-inflammatory medications in the third trimester and adverse effects to the developing fetus including too little amniotic fluid in the uterus and early closure of the babies' ductus arteriosus blood vessel. Prolonged use of salicylic acid over significant areas of the skin or under occlusive dressings is not recommended as these methods increase systemic absorption and the potential for fetal harm. Tretinoin (category C) and adapalene (category C) are very poorly absorbed, but certain studies have suggested teratogenic effects in the first trimester. Due to persistent safety concerns, topical retinoids are not recommended for use during pregnancy. In studies examining the effects of topical retinoids during pregnancy, fetal harm has not been seen in the second and third trimesters. Retinoids contraindicated for use during pregnancy include the topical retinoid tazarotene, and oral retinoids isotretinoin and acitretin (all category X). Spironolactone is relatively contraindicated for use during pregnancy due to its antiandrogen effects. Finasteride is not recommended as it is highly teratogenic.
How to Handle It: Think of these as bigger, pissed-off whiteheads. Your best bet, says Zeichner, is to stock up on benzoyl peroxide, which kills the bacteria. A spot treatment like Murad Acne Spot Fast Fix ($22) should do the trick. Also, try not to pop them — as tempting as that may be. Since they're inflamed, they're more likely to scar if you go the DIY route.
Several scales exist to grade the severity of acne vulgaris, but no single technique has been universally accepted as the diagnostic standard. Cook's acne grading scale uses photographs to grade severity from 0 to 8 (0 being the least severe and 8 being the most severe). This scale was the first to use a standardized photographic protocol to assess acne severity; since its creation in 1979, the scale has undergone several revisions. The Leeds acne grading technique counts acne lesions on the face, back, and chest and categorizes them as inflammatory or non-inflammatory. Leeds scores range from 0 (least severe) to 10 (most severe) though modified scales have a maximum score of 12. The Pillsbury acne grading scale simply classifies the severity of the acne from grade 1 (least severe) to grade 4 (most severe).
Efforts to better understand the mechanisms of sebum production are underway. The aim of this research is to develop medications that target and interfere with the hormones that are known to increase sebum production (e.g., IGF-1 and alpha-melanocyte-stimulating hormone). Additional sebum-lowering medications being researched include topical antiandrogens and peroxisome proliferator-activated receptor modulators. Another avenue of early-stage research has focused on how to best use laser and light therapy to selectively destroy sebum-producing glands in the skin's hair follicles in order to reduce sebum production and improve acne appearance.
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