Last week's publicity about Accutane, the acne medication that can cause severe birth defects, underscored something many Americans know first-hand: Adults get acne, too. Indeed, dermatologists say a significant proportion of so-called "teen-age acne" lasts far beyond adolescence.
"For a sizable number of acne sufferers, particularly women, the condition persists into their twenties, thirties or even later," writes Dr. Nelson Lee Novick, chief of the dermatology clinic at Mt. Sinai Medical Center in New York, in his new book "Saving Face."
"Some outgrow it only to have it recur later on. A patient of mine who had acne in her forties complained to me that she was convinced she was destined to go straight 'from acne to wrinkles.' "
On top of that, adults are prone to a second kind of acne that usually first appears after the age of 30 -- and that results not only in the pimples and cysts of adolescent acne but in other skin problems as well.
Unlike common acne, which is called acne vulgaris, adult-onset acne tends to be a chronic condition that actually gets worse over time. This chronic acne, called acne rosacea or sometimes just rosacea, is especially resistant to treatment.
It is also relatively rare. Estimates are that acne vulgaris accounts for 6 million physician visits a year; acne rosacea accounts for just 400,000.
Rosacea looks very much like plain old acne. More than 80 percent of rosacea patients, according to a survey done by Curatek Pharmaceuticals, develop papules and pustules similar to those seen in acne vulgaris, except without the blackheads and whiteheads. In 27 percent of patients, the papules and pustules are the only component of rosacea, said John Presutti, vice president of Curatek.
But usually the skin problems of rosacea go beyond pimples. The majority of rosacea patients also develop redness and inflammation of the face, Presutti said. In addition, rosacea can lead to a proliferation of broken blood vessels in the face (telangiectasia); irritation around the eyelids (blepharitis); eye problems (conjunctivitis, iritis and keratitis); enlargement of the oil glands (sebaceous hyperplasia) and enlargement and reddening of the nose (rhinophyma), a complication most prominently associated with acne rosacea's best-known victim, the comedian W.C. Fields.
Unlike teen-age acne, acne rosacea can be aggravated by certain foods and drinks. Alcohol, caffeine, pork, spicy foods and hot beverages have all been known to promote rosacea outbreaks. Reducing or eliminating these items from the diet can sometimes help relieve the problem, Novick said.
Treatment of rosacea has to date been limited mainly to oral antibiotics. The topical preparations used for acne vulgaris have little benefit for acne rosacea. Accutane has also proved helpful.
But by the fall, Presutti says, Curatek expects to market a new topical gel for acne rosacea, MetroGel (metronidazole), an antibacterial drug that has been shown to improve appearance in about three quarters of the patients who use it.
Over-the-counter creams, gels and lotions may not help acne rosacea, but they often are enough to keep teen-age acne under control. These compounds may contain sulfur, either alone or in combination with resorcinol (as in the preparations Rezamid and Clearasil's Adult Care), which helps skin peel, inhibits bacterial growth and often covers up pimples already formed. Novick especially likes Vlemasque, a sulfur mask that is washed off after half an hour on the face, which he says can treat "the pustules, abscesses and acne cysts of moderately severe and severe inflammatory acne. Most patients not only find the mask soothing but enjoy the fact that they do not need to keep a medication on their faces overnight."
Other OTC preparations use salicylic acid to loosen and soften blackheads. Stri-Dex Medicated Pads and Saligel are two such products. Benzoyl peroxide, available at low doses without a prescription (in Clear By Design, Fostex BPO, Neutrogena's Acne Mask and other products), kills bacteria and stimulates peeling along the hair follicles, thus unclogging the pores.
When a patient comes to a dermatologist for acne treatment, these over-the-counter creams and lotions generally have been tried and found wanting. At that point, doctors often treat acne with some heavy medical and surgical artillery: Retin-A, hormones, antibiotics (given either orally or topically), acne surgery and -- for the most recalcitrant cases of severe, cystic acne -- the controversial Accutane.
Retin-A, which has made a splash of its own in recent months for its ability to reverse the aging effects of sun exposure, has been used for acne since 1971. But Retin-A does not work for all kinds of acne -- indeed, it can make some acne worse instead of better.
According to Dr. Douglas Robins, a Silver Spring dermatologist and associate clinical professor of dermatology at George Washington University, Retin-A is only effective in acne with a predominance of whiteheads and blackheads. It is less effective in treating papules, pustules and cysts.
"If you try Retin-A on someone with inflammatory acne or with acne rosacea, you might actually do more harm than good," Robins said. One common side effect of Retin-A is inflammation and reddening of the skin.
Hormones sometimes help, because acne is thought to worsen in the presence of high levels of the male hormones. Indeed, acne-prone women sometimes find that their skin breaks out on the so-called "mini-pill," which has a higher proportion of male hormones than the high-estrogen birth-control pills. For that reason, some dermatologists recommend high-estrogen birth-control pills to their patients who want to use the pill for contraception.
"But I strongly advise against hormonal manipulation solely for the purpose of treating acne," says Novick. "I don't like the whole body to suffer for the sins of the face."
The whole body is affected, though, in the most common treatment for both acne vulgaris and acne rosacea: oral antibiotics, which kill bacteria involved in pimple formation. Dermatologists now try to wean patients off antibiotics within a few months of improvement of the skin lesions, since chronic use is thought to be related to the development of antibiotic-resistant strains of bacteria. In addition, tetracycline -- the most commonly prescribed anti-acne antibiotic -- makes women more prone to vaginal yeast infections and can interfere with the contraceptive effectiveness of the birth-control pill.
While patients are taking acne medication, some dermatologists also perform acne surgery -- essentially, lancing cysts and papules -- to minimize scarring. This can hasten recovery by bringing to the surface lesions that might have taken weeks to erupt.
Antibiotics eventually work in more than 80 to 90 percent of acne patients, dermatologists say. For those with recalcitrant cystic acne -- probably less than 10 percent of patients -- Accutane can be used.
Acourse of Accutane lasts no longer than 20 weeks, Robins says, after which almost all his patients experience "a long-term remission" -- at least six months without outbreaks, and sometimes much longer than that. Robins says he occasionally puts patients back on 20-week courses of Accutane a second and even a third time when the acne returns.
Aside from the risk of birth defects, Accutane has a long list of other possible complications, such as blood fat abnormalities, bone and joint pain, and dryness of the mouth, genitals and skin.
"No one goes onto Accutane as a casual thing," Robins says. "A five-month course costs about $700 to $800, and the list of possible side effects, quite apart from the birth defects, is scary.
"But the more severe acne patients eventually scar, and that has psychological implications for the rest of their lives. They can't afford to wait too long before they get their acne under control."
Robin Marantz Henig is a Washington free-lance writer.