For acne that just won’t go away…

Question:  My acne is so bad I’m desperate to try Accutane – but I’ve heard scary things about its side effects. What’s the truth about this medication and how can I get rid of this acne once and for all?

Sick and tired of acne? Try Isotretinoin
Sick and tired of acne? Try Isotretinoin

Answer: First of all, the brand “Accutane” is no longer available so we should speak about it using its generic name which is isotretinoin. Isotretinoin is an acne medication that does resolve acne in most patients once and for all.

Isotretinoin is more mainstream than you think. While we do use it for severe acne and acne that just doesn’t resolve after we’ve tried many other well-known combinations of medication, both topical, oral and in combination; we also use it in  patients who need to have perfect skin such as models, actresses, those in the public eye and in patients who are (frankly) really sick of having to deal with and look at their acne on a daily basis.

Although isotrentioin is approved only for severe cystic acne, it is really useful in less severe forms of acne to prevent the need for continuous treatment and repeated office visits those patients require. In my opinion, oral isotrentioin is warranted for severe acne, poorly responsive acne (acne that improves by less than 50% after 6 months of therapy with combined oral and topical antibiotics), acne that relapses off oral treatment  or acne that induces scarring and  psychological distress.

Isotretinoin is the only thing that I can tell you will cure a patient of acne. Generally speaking, a patient who we have treated with isotretinoin will almost certainly never break out to the same degree again. Most patients are pretty clear for usually up to 5 years after finishing the course. For those with acne and rosacea, oral isotretinoin has been shown to induce a full remission in many cases.

How I prescribe isotretinoin

I usually start patients at a half-dose  (20-40 mg daily) to decrease flare-ups of the cystic acne and then increase it on a monthly based on the patient’s response. A higher dose based on a patient’s weight, increases the likelihood of a prolonged remission. While a usual course may be around 5 months, sometimes I extend the length, again,  based on the patient’s response.

The major advantage to choosing isotretinoin treatment is reliability in almost all patients.

A course of isotretinoin leads to a remission that may last many months or years. Approximately 40-60% of patients remain acne-free after a single course of isotretinoin. About one-third of patients who relapse will need only topical therapy; the others sometimes need oral therapy. I often retreat patients with isotretinoin again because it is reliably effective and we can predict their side effects.

What you can expect while taking isotretinoin

Isotretinoin is a potent teratogen (affects a developing fetus) and causes severe birth defects if taken while a woman is pregnant. For this reason the medication is tightly regulated; both the prescriber and the patient need to be registered with the iPledge program in order for us to write the prescriptions and for the patient to receive them. What is important to remember is that use of isotretinoin does not  affect future pregnancies; however, pregnancy is absolutely contraindicated while the patient is taking isotretinoin.

Although you may experience any of the physical side effects such as dryness, inflammation of the lips (chelitis), nosebleeds (epistaxis), sensitivity to the sun (photosensitivity), itchy skin,  and many others, most are extremely manageable.

There have been many claims of adverse events from patients while taking this medication, so we monitor patients thoroughly during their course of treatment. These include elevations in blood cholesterol, gastrointestinal disorders, liver enzyme elevations, psychiatric disorders, visual and hearing impairment and others.
However, in all my years of prescribing the medication, I have rarely stopped the drug because of the side effects.

I do tell patients taking isotretinoin to:

  • Avoid the sun due to hypersensitivity
  • Avoid waxing and electrolysis due to skin sensitivity
  • Use two effective forms of contraception

The truth is, when the patient is thoroughly monitored and all precautions are managed, isotretinoin is an extremely effective option for patients with the worst cases of acne and for those patients who acne is negatively affecting their lives.

I’ve even taken it myself – twice!



Prescription retinoids versus drug-store retinols

Question:  I’ve seen plenty of products in the drug store skincare aisle that contain retinol and say they reduce the appearance of fine lines while balancing an uneven complexion. Is this the same as the Retin-A products I can get by prescription?

Read drug store retinol cream labels looking for vitamin A!

Read drug store retinol cream labels looking for vitamin A!

Answer: While they are both derivatives of Vitamin A, called “retinoids,” and used to promote faster skin cell turnover, they are not the same.

All retinoids have been well-studied, tested and been proven effective and powerful for treating skin issues ranging from acne to many signs of aging, including sun damage.

But there is a marked difference between retinoid products you get only by prescription and the retinol products you see on drug-store shelves.

Retinoid products are prescription-only skincare products containing the most commonly-known natural vitamin A derivative, tretinoin which comes in name brands such as Atralin, Retin-A (and Micro) among others.  These proven prescription products increase the rate of cell turnover to uncover healthier skin-whether it’s reducing fine lines or evening out the texture or color of your skin.  Common side effects include dryness, redness, cracking,  irritation and skin peeling. There are two other prescription strength (lesser known) prescription retinoids-tazarotene (Tazorac) and adapalene (Differin).

If you find, during the dead of winter, that dryness, peeling, redness and cracking are more pronounced, simply reduce the usage of your prescription retinoid to just once per day, or every other day or even every two or three days until side effects are diminished. By the way, winter weather and drier indoor heat may be exacerbating your already winter-dry skin, if you need to use them less don’t worry, the powerful retinoids still do their job!

Retinol products don’t require a prescription so you can buy them over-the-counter at the drug store or grocery store, without a prescription. Retinols are simply a synthetic, weaker version of a retionid and as such, they act more slowly than a retinoid. However, these products can be useful if you find prescription retinoid products too strong for your skin. They are also a good beginning step to starting your skin on a topical retinoid.

When choosing a drug store retinol product, check the ingredients list to make sure vitamin A is listed toward the top of the ingredients list. Also, in terms of packaging, look for an air-tight bottle that keeps the light out (exposure to light makes the products less stable and effective and more susceptible to bacteria growth.)

Other skin tips:

  • Reduce your skin’s exposure to hot-hot water.
  • Add a humidifier to rooms where you spend a lot of time.
  • Use an emollient (thick) cream to counter peeling and cracking skin.
  • Always wear sunscreen.


How to avoid and treat dark spots

Post-inflammatory Hyperpigmentation

How a Dark Spot Forms

Question:  All I had was a simple pimple – why did it leave such a dark spot and how can I get rid of it as quick as possible?

Answer:  Of course the answer’s not that simple! Everyone’s propensity to form a dark spot in response to anything that causes skin redness and swelling,  (medically called post-inflammatory hyperpigmentation) varies depending on skin type, ethnicity and racial group as well as the severity of the inflammation and its duration. That’s because the amount melanin (light-absorbing pigment) and type of melanosomes (pigmented skin cells)  have a significant impact on the formation of a dark spot in your skin.

To avoid dark spots from forming at all costs, it’s a good idea to first know what skin type you have. Your Fitzpatrick Skin Scale type depends on genetic disposition and your skin’s reaction to sunlight and tanning. Dark spot intensity and duration is linked to skin hue and more pronounced in skin of color, especially phototypes IV-VI. Click the link above to take the quiz and find out if you’re more at risk for developing dark spots, then read on.

What causes dark spots?

  • Any skin disease, infection or injury-producing inflammation
  • Acne
  • Insect bites
  • Razor bumps (pseudofolliculitis barbae or PFB)
  • Allergic or contact irritation (dermatitis)
  • Surgical or cosmetic procedures

Treat recurring conditions immediately!

The darkness, or intensity, of the spot, area or scar left behind depends on the duration of the inflammatory process underneath the skin and whether or not is has a chance to reach deeper tissues and cause damage. In response to a skin eruption or inflammation, melanin is over-produced at the site causing the skin-darkening. The longer the period of inflammation, the darker the postinflammatory hyperpigmentation response so action should be taken to avoid or intervene on any known causes of inflammation such as acne and PFB and treatment should be instituted as quickly as possible to stop the inflammation from damaging skin’s deeper tissues and causing the dark spot response. Skin conditions with a recurring nature such as acne or PFB intensify the hue of dark spots as do skin diseases that disrupt skin’s basal layer such as lichen planus, psoriasis eruptions and lupus)

Stay out of the sun!

In addition to any post-inflammatory response, UVA and UVB exposure also stimulate increased melanin production so limit sun exposure by walking on the shady side of street, wearing a hat, sunglasses and use sunscreen daily  on exposed, inflamed, irritated or healing areas. Sun exposure frequently darkens hyperpigmentation and chronic sun exposure may result in a longer resolution period of any dark spots.

Don’t let scabs form!

For any skin eruption (acne, insect bite), injury or surgery where the skin is open (no matter what the cause) never let a dry scab form and never pick at, squeeze or further exacerbate the inflammation! Acne surgery can be performed by medical professionals to  help acne heal faster to avoid skin damage and spots. Keep the area covered with antibiotic ointment until there is no crust at all and new skin is formed. And keep that area out of the sun the whole time it is healing and protected with sunscreen at all times until skin has returned to normal.

Rx for already-formed dark spots

Hydroquinone 4%:  This melanin-inhibitor is the most widley-used  active ingredient to fade dark spots. It is available at 4% strength by prescription only and at weaker concentrations (which you can try first) over-the-counter. Depending on the age and darkness of a dark spot, therapy may be required for 20 weeks, although you may see results much sooner than that.  If only used on one spot, sometimes a light ring of lighter skin surrounds the area like a halo, and this halo effect disappears when the hydroquinone is discontinued.  Do not use hydroquinone if it is a known allergen and watch out for any irritation or further discoloration (called exogenous ochronosis) in which case hydroquinone should be discontinued.

Azelaic acid:  An alternate, but slightly weaker ingredient for treatment if you’re allergic to hydroquinone. Similarly, kojic acid and glycolic acid are two more ingredients for hydroquinone-intolerant patients.

Combinations: We have even found that combinations, depending on your skin type and condition, including hydroquinone , and/or a corticosteroid, retinoid and Combinations are more effective than 4% hydroquinone alone. These can be prescribed if necessary by a dermatologic practitioner.

Chemical peels: Chemical peeling agents have been found effective in removing dark spots, but be mindful to start with the lowest concentration and then move upward because you want to avoid any additional postinflammatory hyperpigmentation caused by chemical peeling agents

Follow my advice and you will see spots fade and fewer spots form!