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Excerpt of Power To The Patient by Isadore Rosenfeld M.D.
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If none of these treatments work, consult your skin doctor, who might recommend topical lotions of antibiotics such as clindamycin, erythromycin, or products that contain sulfacetamide for mild acne. Apply them once or twice a day to the affected skin.

If these antibiotics are not successful, the next step is tretinoin (Retin-A). This preparation, which requires a prescription, is especially good against blackheads and white-heads because it unclogs the ducts and allows the oil to flow freely to the skin surface. It also lightens dark spots caused by old acne lesions. I prefer the gel or cream; the liquid can be irritating. Start with a tiny amount of the weakest strength (that's 0.01 percent for the gel and 0.025 percent for the cream) every couple of days and work your way up gradually as needed. Too much causes peeling, dryness, and irritation. Keep away from strong sunlight when using it and wear sunscreen in sunny weather. Tretinoin will irritate your skin at first, but you will see some improvement in two to three weeks, although maximum effect may take three or four months. Differin and Tazorac are related products.

Azelaic acid cream is a new, effective, and well-tolerated topical preparation recently approved for the long-term treatment of mild to moderately severe acne. Apply it to the affected area once or twice a day. It works very much like Retin-A and also prevents thickening, pigmentation, and discoloration of the top skin. Try it if the topical antibiotics don't work.

When the acne does not respond as well as you'd like to any of these topical applications, you may need to take oral antibiotics in low doses on an ongoing basis, sometimes for as long as a year or more. Your doctor will recommend any of the following, all of which slow the growth of the offending bacteria: tetracycline (taken with a full glass of water on an empty stomach), erythromycin (harder on the stomach; although it's safe, it makes the skin more sensitive to sun, so cover up in bright sunlight or use sunscreen), minocycline (my preference), and doxycycline (also very popular). Unlike tetracycline, the latter three can be taken with food. However, take them hours apart from iron or antacids, both of which can interfere with their absorption. Pregnant women should not take tetracycline because it can discolor the teeth of their newborns.

For maximum effect, the various topical therapies can be taken together with oral antibiotics.

There is something new and effective for adult women with acne. It's called Diane-35, a low-dose oral contraceptive that combines estrogen and cyproterone; the latter neutralizes the androgens that are responsible for the increased production of sebum. This preparation takes six to twelve months to work, and the acne is apt to return when the drug is discontinued.

When all else fails and acne is severe, you may need isotretinoin (Accutane) orally, but never if you're pregnant or of childbearing age unless you use appropriate contraception—without fail!—because it can cause birth defects. Accutane works by preventing the sebaceous glands from producing oil and can permanently shrink them. Even the most severe and resistant cases usually respond within weeks to Accutane. As many as 40 percent of patients can be cured by 1/2 mg per kilo of body weight taken for five to six months. Always take this drug under the close supervision of a dermatologist. And while you're doing so, check your cholesterol and triglyceride levels; they can be increased by Accutane. Be careful with your diet during the treatment period. Never take vitamin A supplements with Accutane. Also, because it makes the skin fragile, never use it to remove hair and don't get a facial peel.

If you have been scarred by acne, several cosmetic and/or dermatological treatments are available. These include dermabrasion, in which the superficial layers of the skin are planed down, the new Cooltouch laser, and chemical facial peeling. Pitting scars, however, do not usually respond to these measures. If you require such treatment, insist on a second opinion from a dermatologist as to which approach is best for you.

Copyright 2002 by Isadore Rosenfeld, M.D.