Acne: The long and the short of it.
(Or: Things I have learned treating acne in two states, two New York boroughs, and three continents).
By Marie Leger, MD PhD
Working and teaching in Queens, Manhattan, Ghana, Botswana, Reno, and Costa Rica, I have experience with many kinds of skin. We are all about science and evidence-based medicine at Entière, but we also have years of collective experience. Here are a few things I have learned over my last decade (gasp!!) treating acne patients.
Acne is a chronic disease. Isotretinoin, better known as its trade name Accutane, is our most effective acne treatment for scarring and nodulocystic acne, and it can sometimes be a “cure.” But even after a course of Accutane, about a third of patients will still have active acne. I often meet patients who have completed a course of Accutane in high school, are well controlled for several years, and then suddenly in their twenties or thirties their acne comes back. For these patients, a variety of approaches can help—including newer topical regimens, sometimes repeating isotretinoin, hormonal therapies, evaluating diet and lifestyle, and regular attention to larger cysts and scarring.
New Yorkers are in a big hurry. And inflammatory acne and the spots it leaves behind take time to improve. When I suggest that my New York patients wait things out, they look at me like I’m nuts. I use a lot more adjuvant acne treatments in Manhattan than I have in other practice settings. These include injections, hydroquinone or cysteamine to help dark spots fade more quickly, vascular lasers to make red spots go away more quickly, and sometimes the light device Forever Clear BBL (which uses blue light, yellow light, and heat) which can be used along, but also helps early in treatment while waiting for another therapy to take effect.
Sometimes during the first month taking Accutane, patients flare. In Reno, more of my patients flared A LOT the first month on Accutane than anywhere I’ve ever worked before. Being a curious person, I wondered….was this due to sun exposure from summers on Lake Tahoe and snowboarding? Was it because of the young male teenage patient population I seemed to primarily work with there is known to have more recalcitrant acne? Who knows. A Reno friend and colleague who trained in Chicago noticed the same thing. I learned a lot of humility, treating acne in Reno. I learned to start Accutane SLOWWWWLY in young men and in patients with particularly inflamed acne and to use prednisone when needed. Also, there is some literature suggesting that the antihistamine Xyzal prevents flares. I’ve also started putting patients on this for the first few months. So far… no flares!
Post inflammatory hyperpigmentation—or the dark spots that linger months after inflamed pimples disappear—often bothers people more than acne itself. Most common in patients with darker skin tones, it can make acne look active and skin blotchy even when acne is controlled. For this reason, I try treat acne more assertively in my patients prone to hyperpigmentation.
It is really rewarding to be able to offer acne scar treatment. Before working at Entière, I didn’t have access to so many devices (microneedling!) and lasers (Genius radiofrequency microneedling! Halo! Profrac!). Because of this, I used to refer acne scarring patients out, which often delayed treatment. Being able to treat and prevent scarring acne as well as to simultaneously treat patients’ scars has been extremely fun.
Patients with Central and South American ancestry can scar in a unique way. I noticed this working in Elmhurst Queens. Another former NYU resident then described the phenomenon in a paper he published from his experience working at Bellevue Hospital in New York City. (Dr. Levin and I trained there.) The characteristic little firm bumps on the nose and chin associated with acne I’ve seen are difficult to treat, so I tend to be more aggressive early on when my patients showing this kind of scarring.
Microdosing Accutane is a great option for people worried about getting too dry, too achy, or too sunburned on regular doses of Accutane. The jury is still out as to how it measures up to conventional higher dosing (two different recent reviews came to different conclusions), but it is certainly true that lower dose isotretinoin is effective and much easier to tolerate. While this approach requires a longer treatment course and longer-term use of effective birth control for patients who can get pregnant, it is a great option for people worried about side effects on isotretinoin.
To summarize, acne can be a chronic disease. Age, race/ethnicity, and genetics all affect how it shows up, and the nuances involved in treating it. Figuring out the right approach for my patients is so satisfying!