Chapter 12 It is the rare doctor who can teach all that is needed in the short time allotted. The patient who can remember all the details necessary to carry out the instructions is even rarer. Handouts are essential in managing all skin disorders. Proper handouts, kept relevant and up-to-date, reflect the standard of care provided in physicians’ offices. These are ours. They are available at www.acnemilk.com and are updated as new information becomes available. Acne is caused by a blockage of the duct leading to the skin surface from the oil glands. This blockage occurs because of sex hormones (mainly the male ones—chemicals called androgens). These hormones are present in both men and women. They regulate the activity of the oil glands and the lining cells of the ducts in the pores on the face and upper back and chest. They are particularly good at turning on and plugging up these ducts in persons with a family tendency to develop acne. The duct clogs with too many lining cells, and this results in a plug of material that is either open to the surface as a blackhead (called a comedo) or closed and visible under the surface (called a whitehead). Within this blocked material are trapped hairs and skin cells and bacteria and yeast. The bacteria and yeast increase in number, the wall leaks, and eventually the body’s reaction to these materials is a pustule (pimple). If the whole pore shatters, there is an explosion of pore wall material, bacteria, yeasts, white blood cells, and other foreign material under the skin, and a deep red acne papule is created. A blackhead takes three to four months to be formed from the initial plugging of a pore; pustules or papules take about 6 months. Because acne is due to sex hormones and growth hormones as well, it onsets at puberty, in girls from 9 to 11 years and boys from 11 to 13. Eighty percent of teens “grow out” of acne by 18–22 years. About 10% of women and 3% of men go on to have adult acne. Acne occurring to a marked degree in women over 22 or 24 years of age is often due to a persisting minor hormone imbalance, ovarian or adrenal, and it is sometimes necessary to investigate the hormone system. Most acne settles in the late teens or early 20s as these hormones stabilize, but long-term stress is also a factor and other hormonal influences can make acne worse. Nicotine is a contributor. Birth control pills (BCPs) with a tendency to a male hormone–type balance (such as Ovral and Lo-Ovral) should be switched to a BCP that helps block male hormones. Ocella/Yasmin is the best for this; Gianvi/Yaz is good for smaller women; and there are some other alternatives. Oil-based cosmetics can make acne worse. Dairy products (containing numerous hormones from the pregnant cows that produce the milk) play a role. Milk, cream, butter, cottage cheese, cheese, pizza, yogurt, ice cream, protein powder shakes, and milkshakes are all best totally avoided. Skim milk is even worse than 2% or whole milk. Recent work strongly suggests that a low-glycemic-load diet (low sugar, and low levels of simple carbohydrates) will also help clear acne faster. It is really important that harmful habits are discontinued—these are little habits such as absent-mindedly picking, touching, rubbing, or pinching your face. These trigger flares of preexisting acne. Pressure causes the contents of the pores to leak into the tissue surrounding the pore, and this starts the hot inflammatory lesions known as cysts or “blind pimples.” Picking worsens acne and leaves scars—often the scar from the picking is worse than that produced by the acne itself. Therapy is aimed at five things: PLEASE NOTE: Picking or squeezing is generally forbidden. “Acne surgery” is best done by your dermatologist unless you have had special instructions. THIS TREATMENT TAKES TIME. IT IS NOT A FAST CURE. It takes three to four months to slow oil gland production. You will need to work at this daily for months to clear and years to stay clear. The things that cause acne do not disappear quickly and so the treatment is prolonged. With good advice, good medicines, and your regular care, you should do well. Wash with Dove® Beauty Bar for Sensitive Skin (Fragrance Free), Cetaphil® Cleanser for Normal and Oily Skin, Ivory®, Oil of Olay®, or Neutrogena®. Just use soapy hands. Then rinse, repeat, and rinse again until “squeaky clean.” Be thorough, but do not scrub. Avoid face cloths. Be sure to rinse well, especially around the ears and hairline. Twice or three times a day is usual.Alcohol swabs may be used after exercise to remove oil and sweat, but a soap-and-water shower would be better. One of the Proactiv® products is a mild 2% benzoyl peroxide version, but Acne Free® is even cheaper. PersaGel 10® and ZapZyt are other OTC BP products. Both are cheap and effective for overnight application to “hotspot” pimples. The expensive prescription varieties seem to be no better. If you are using two or more products, you may choose which is for morning, for evening, and for night. Some degree of irritation is expected. If you are uncomfortable, slow the therapy a bit—but DO NOT STOP. If you are worried, call the office. Pills and capsules (antibiotics): Doxycycline is used most often and, like minocycline (Minocin), it can (and should) be taken with food. Tetracycline very expensive and cannot be mixed with food, milk, or antacids—they neutralize it, so take pills one hour before or two hours after eating, with water (one full glass) only. For easily upset stomachs, Doryx® (and its generic) is best but it is expensive. Side effects are rare with all of these, but diarrhea longer than three days or a vaginal discharge or itch may be due to yeast and must be reported. Phone the office. Malassezia is worse with all antibiotics. Sunburn may occur with less sun exposure than usual, especially with doxycycline, so be careful (skiers and vacationers take note). If doxycycline is taken with the evening meal, this risk is reduced almost to zero, but be sure to take it at midmeal with a large glass of water. Pregnancy means “stop the pills”. Completely. No questions. Do not take any ’cycline with isotretinoin (Accutane® or generic). If another doctor orders penicillin for you, stop the ’cycline. Ketoconazole: 200 mg tablets–two tabs are taken in a single dose weekly for Malassezia yeast infection. Sunlight: If you are using any ‘cycline and/or retinoids (see above), the treated areas may be more easily sunburned than before. It is very important to use a sunscreen when taking either tetracycline or doxycycline—minocycline is less photosensitizing but has other side effects. The best chemical sunscreens are Anthélios L 60® or Vichy® Capital Soleil. The best nonchemical full-spectrum sun blocks are Vanicream® 35 and 50+ or the CoTZ group. Never “bake” in the sun. High skin temperatures make acne worse. Stay cool. Cosmetics and moisturizers: Lipstick, eye shadow, mascara, and powder blush are permitted. Safe cosmetics include any Almay® product and any product that bears the word “non-comedogenic.” You can apply your moisturizer and/or makeup and/or sunscreen on top of Differin® or Tazorac®. Use Almay®, Vanicream®, Cetaphil®, or any “non-comedogenic” product. Medicines: Report all medications to your doctor, even aspirin and vitamins and supplements and health foods and naturopathic therapies. More information: Milk and milk products cause acne because milk contains hormones that “turn on” oil glands. The cows that give the milk are pregnant and milking most of their lives. These hormones are not injected into the cows—they are natural hormones that cows make during every “menstrual” cycle—but during pregnancy these hormones are produced at high levels and so are found in all cow milk, pregnant and nonpregnant. There is no such thing as “hormone-free” milk. The confusion was caused by a company in the United States that sold a hormone (BST or rBGH) for injection into cows to make them produce more milk. Some milk producers (both organic and not) have made the point that they do not use this injection, by advertising that the milk is “hormone-free.” It obviously does not contain the injected hormone, but all the natural cow hormones are still in the milk. We do not know yet what the injected hormones do to the levels of natural cow hormones in milk. No. Lactose intolerance has nothing to do with acne, and “organic” simply means that the pesticides and insecticides the cows are allowed to be exposed to in their food are less toxic than usual. The “organic” cows are healthier and have higher levels of natural hormones, and so they are likely worse for acne. There are two ways to handle dairy restriction: The first (and simplest) way is to just stop consuming all milk, cream, cheese, ice cream, butter, sour cream, cream cheese, cottage cheese, cheeseburgers, pizza, yogurt, and protein powders or bars or shakes containing casein or whey—anything that contains a significant amount of milk or milk solids. It is best to avoid “anything that comes from the south end of the cow.” Goat milk and goat cheese are not alternatives, because they are not hormone-free, either. The second way is to find dairy-like substitutes for whatever you are missing. Soy-based products are the most convenient and include substitutes for milk, creamer, chocolate milk, yogurt, ice cream, cheeses of various types, and even butter. Almond, coconut, rice, pea, mixed vegetable protein, and hemp products also can be useful. You don’t need to eat soy or other substitutes, just stay away from cow dairy. Oil gland pores are plugged by the overproduction of the cells that line the pore—basically a “traffic jam” happens in the pore. This overproduction is caused by hormones, and there are three sources. The first is ovaries or testicles, the second is from stress, and the third is dairy products. These three “stack up” on each other, and when the amount of hormone present is enough to plug up the pore, acne is started. Some lucky people just do not have the gene for acne, but just about everybody has a different level of hormone where this happens (this is the acne threshold). Many young women pass this threshold just before their period every month, others stay above the threshold for years because of milk and milk products, and others cross the threshold with stress (first-year college is the most common stressor in late teens). By removing dairy from your diet, you will usually be able to get down below your personal threshold, making your acne much less with time. This threshold is also influenced by your family history, so if one or both of your parents had acne, your threshold will be lower, making acne risk higher. The “zero-milk” diet has three phases. First is the total restriction phase. That means NO DAIRY AT ALL. That is what “zero” means. It is essential to minimize the production of new plugs in the pores, and this lasts at least six months. With proper therapy, you are expected to clear during this time. Second is the maintenance phase, and it lasts through all the teen years into the early 20s. During this phase, zero dairy intake is best, but some patients can have a little bit. Third is the cautious reintroduction phase, usually possible in the early 20s. But, depending on individual thresholds, some acne patients can never return to dairy. For males, there is no generally accepted anti-hormone therapy. Unfortunately, there is almost nothing to be done about stress hormones in males or females. Young women have the option of controlling their ovarian hormones with BCPs. We prefer to call these hormone control or acne control pills, but they are all the same as BCPs, really, and are given for medical reasons. The products we prefer are not only the least “male” of all “birth control” pills, but the best, drospirenone, also blocks the acne-making hormones coming from other sources (like the stress glands). Most young women with previous acne have almost no acne after six to 12 months on this “pill,” especially if they stop all dairy. Remember first of all that there are hundreds of thousands of growing teens in this country, and millions in the world, who are either genetically lactose intolerant or allergic to milk. They do not drink milk but grow up just fine. It also helps to realize that cows have big strong bones and healthy teeth, produce milk during most of their lives, and also produce a calf every year—with its own bones—yet they drink no milk and take no calcium supplements in nature (although when they are being “factory milked,” they get supplements). It is also a fact that it is very difficult to design a low-calcium diet for those few medical conditions that require it. It is far more important for maintenance of bone health to make sure you have regular bone-stressing exercise, a healthy diet containing adequate sources of calcium, a normal amount of estrogen in your body if you are female, and an adequate intake of vitamin D. We recommend Vitamin D3 only, 2000 IU daily, taken with food, as both safe and wise. We consider 2000 IU daily a minimum. Others consider it maximum. There are studies that suggest that consuming dairy products may be associated with breast cancer, ovarian cancer, and prostate cancer. Further studies are necessary, but if you have a family history of any of these kinds of cancer, you should consider avoiding dairy intake. Dairy also reduces women’s fertility, favors the conception of twins, is associated with greater weight gain during pregnancy, leads to larger unborn babies, and increases the risk of difficult deliveries and Caesarian sections. Enjoy your new face! Take a look at: With Thanks to Dr. James Baumgaertner Isotretinoin (originally marketed as Accutane®) is a powerful oral acne medication that has been on the market in the United States since 1982. It is a synthetic retinoid and it is closely related to vitamin A. Isotretinoin is a natural part of the metabolic cycle of vitamin A in our bodies—we all have a low level of isotretinoin in our blood, but obviously not enough to keep acne away. Isotretinoin is dramatically effective for all types of acne, including severe scarring cystic acne and even (in very low doses) hidradenitis suppurativa. There is simply no better treatment for resistant acne. Drs Danby and Margesson have both been practicing dermatology for over 38 years, and isotretinoin is the only medicine that we would categorize as a real miracle drug. Before isotretinoin became available in 1982, dermatologists had no consistently effective treatment for the most severe forms of acne. Despite the use of dangerous cortisone pills, sulfa medicines, chemical peels, ultraviolet light, X-ray therapy, surgery, and high doses of various antibiotics, severe acne would frequently continue unabated. Patients suffered for years with painful nodules that would scar their faces and severely damage their fragile psyches. Isotretinoin changed all that. Over the last 32 years, millions of people all over the world (and 700,000 per year in the United States) have successfully and safely used isotretinoin to clear their resistant acne. Perhaps more importantly, isotretinoin has converted thousands of reclusive, depressed young adults with ravaged faces into clear-faced, smiling, outgoing, and self-confident individuals. Isotretinoin is not just a face saver; it is also a real lifesaver. Although isotretinoin is a truly miraculous drug, it does have some well-known and potentially serious side effects. Virtually all medications, including Aspirin, penicillin, Tylenol, and even vitamin pills, have potential side effects. For comparison, there are 70,000 emergency room admissions (and 100 deaths) each year in the United States from Tylenol. Isotretinoin has come under increased scrutiny over the past few years by the public, the media, and the US Food and Drug Administration (FDA) because of charges that it may have induced serious depression in some patients. Tragically, a number of patients (about 40), while on courses of isotretinoin, committed suicide. Of course, many individuals over the last two decades who were not on isotretinoin also became depressed and some of these (about 100,000 between the ages of 18 and 24) even committed suicide. What was scientifically unclear until June 2005 is whether or not there might be a real increased risk of depression and mental status changes in people on isotretinoin compared to similar people not on isotretinoin. In a study published in the Archives of Dermatology, the authors concluded, “The use of isotretinoin in the treatment of moderate-severe acne in adolescents did not increase symptoms of depression. On the contrary, treatment of acne either with conservative therapy or with isotretinoin was associated with a decrease in depressive symptoms.” This has been our personal experience and that of thousands of other dermatologists. In a previous study published in the Archives of Dermatology (Jick SS, et al. Accutane use and risk of depression, psychotic symptoms, suicide, and attempted suicide. Arch Dermatol 2000 Oct;136:1231–6), 7535 acne patients treated with isotretinoin were compared to 14,376 acne patients treated with oral antibiotics. “There was no evidence that use of isotretinoin is associated with an increased risk for newly diagnosed depression, other psychiatric disorders, or suicidal behaviour.” Nevertheless, despite this large study, we personally think it is still possible that isotretinoin could be a factor in the development of depression in a very small subset of patients. There are certainly documented cases of patients who have developed depression while on a 20-week course of isotretinoin. Some of these patients noted improvement in their depression when the isotretinoin was stopped, and some later noted worsening of their depression when isotretinoin was reintroduced. This certainly suggests to us a possible cause-and-effect relationship in this small subset of isotretinoin-treated patients. This is called an idiosyncratic response. It is unpredictable and is very rare. There are also reports of depression developing three or more months after coming off of isotretinoin. We know that isotretinoin is completely out of the body approximately two weeks after stopping the drug, and so these reports suggest to us a coincidental relationship rather than a cause-and-effect relationship. We fear that individuals who happen to develop depression many months or even years after taking isotretinoin may now try to blame isotretinoin for their condition. Does isotretinoin cause depression? It is unlikely; however, what is certain is that depression can and does occur in some young people and it can, unfortunately, lead to some very serious, and sometimes fatal, consequences. Therefore, it is vitally important that all persons, and particularly those who are prescribed isotretinoin, should be carefully observed by family, physicians and friends for signs or symptoms of altered mental status, particularly depression. If such changes are noted, isotretinoin should be stopped immediately and appropriate therapy should be initiated at the earliest opportunity. Because of the FDA’s increasing concern over these potential psychiatric side effects, an isotretinoin “Medication Guide” was produced and distributed by the manufacturer in January 2001. The FDA and the original drug manufacturer (Roche Laboratories) directed that all patients who were to receive isotretinoin must be given this guide. The FDA also mandated that pharmacists provide this information sheet every time an isotretinoin prescription was filled or refilled. Subsequently, this was replaced when the iPLEDGE program was introduced. The FDA, the drug manufacturers, and all dermatologists want to be sure that every patient who is placed on isotretinoin understands all of the drug’s potential side effects.
The handouts
12.1 Acne
TREATMENT
Warning
12.2 The “zero-dairy” diet
Why avoid milk products?
What about hormone-free milk?
Is lactose-free milk or “organic” milk ok?
What are the options?
How do the cow hormones make Acne?
How long do i need to do this?
What else can I do for my hormones?
What about my calcium intake?
What else does dairy hormone do?
12.3 The risks and benefits of isotretinoin
Introduction and History
Side effect concerns
Isotretinoin medication guide: “Be Smart” booklets and the iPLEDGE rules
Our concerns
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