Common college: Acne

[“Common College” is a twice a month column on medical issues particularly pertinent to college students, ranging from infectious disease to mental illness. This information is not meant to be used in place of a doctor’s care.] 

There’s no nostalgia for our awkward middle school years, and even less if our past is speckled with pubescent pimples. For many college students, acne remains an unfortunate mark of the present. Whether it’s blackheads, whiteheads, or the regular old red pimple, most people would agree that while there’s a wide variety of types of acne, there’s no such thing as a good zit.

“All acne starts with the pores getting a little bit sticky or plugged up, and that then forms a comedone,” said Jennifer Gardner, a UW assistant professor of dermatology. “There’s a little keratin plug within the pore, and then that causes a closed space, which is a great place for sebum, which is the natural oils your body makes.”

This sebum blockage encourages bacterial growth and leads to more inflammation as the bacteria and sebum clog the pore, Gardner said. This leads to the traditional blackheads and whiteheads, but may precipitate more severe forms of acne.

“The blackheads and the whiteheads are what we would call in dermatology, ‘comedonal acne,’” Gardner said. “The whiteheads are technically called closed comedones, and the blackheads are called open comedones.”

Comedones tend to appear on the forehead and nose, but can appear on other parts of the face as well. They are typically treated with a topical retinoid cream, prescribed by a dermatologist, but over-the-counter cleansers like salicylic acid or benzoyl peroxide are also useful.

“Beyond comedonal type of acne, we see a lot of inflammatory acne that is more pink or red papillae, or bumps, … that are focused on the face, the neck, the chest, the shoulders, and back,” Gardner said. “Those are sometimes, for lack of a better word, juicy, and are the ones that are hard to keep your hands off.”

Although it may be tempting, picking and popping zits can cause scarring. This scarring often appears as red marks that remain long after the actual acne has been resolved, and is known as post-inflammatory hyperpigmentation. While these scars are not acne itself, Gardner says many patients are also bothered by their presence.

This more severe form of acne is often also treated with a retinoid cream, a topical vitamin A treatment that increases the presence of collagen and cell turnover. This works effectively on severe and minor acne, although it can be rough on the skin during the first applications.

Other options include using a dual treatment of a comedolytic cleanser, like benzoyl peroxide, with clindamycin, a topical antibiotic, for a synergistic effect. The benzoyl peroxide also helps slow down any antibiotic resistance the bacteria may develop. A more systemic approach may also be necessary, which could involve a temporary course of oral antibiotics.

All of these these topical treatments tend to be less effective on deep acne, known as nodulocystic acne.

“The more cystic or deeper papules or nodules can form cystic acne, which can be very painful,” Gardner said. “They can be long-lasting and take a long time to resolve, and often leave scarring. Those patients with a lot of inflammatory acne or nodules, I really think about treating more aggressively to prevent scarring, which can be life-long once it’s settled in.”

If oral antibiotics fail, or the patient can’t stop taking the antibiotics without having recurring acne, the next step is Accutane, a pill taken orally, one to two times a day for several months, which Gardner says is one of the most effective medicines for treating deep acne.

For female patients with cystic acne, the cause may also be hormonal, particularly if it appears along the jawline or chin. If that’s the case, treatment should target the hormonal, rather than bacterial cause. Oral contraceptives, or other hormonal medicines, such as spironolactone, are often prescribed in that case, Gardner said.

While keeping the face clean to prevent acne is important, Gardner warns against over-washing. She recommends gentle scrubbing, just once or twice a day.

As for unhealthy food habits leading to acne, Gardner says there’s no conclusive evidence yet, but there has been a renewed interest in the past decade among researchers. In spite of that, among her patients, Gardner says many have tried to cut out certain foods, such as dairy.

However, if your acne is significantly affecting your day-to-day life and confidence, Gardner recommends visiting a dermatologist, no matter how mild it may seem.

“[Visit a dermatologist] anytime, if it bothers you,” Gardner said. “There’s a lot we can do from very mild acne to very severe acne.”

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