Acne appeared sporadically at first when Sophia Steinberg was in the eighth grade, but within two years she said her face, chest and back were covered with embarrassing lesions of cystic acne.
"I was very self-conscious, deeply insecure and anxious," Sophia, a Brooklyn high school student, told me. "I would wake up ashamed for my face. I felt so unattractive all the time. I had to use so much makeup and wear concealing clothing. I avoided doing presentations in front of the class. Acne kept me from feeling confident and developing my personal style."
The teenage years are challenging times for many youngsters even under the best of circumstances. But if the face they present to the world is marred by prominent lesions of acne, the ordinary emotional and social stresses of adolescence can be that much more difficult to weather.
As Dr. Andrea L. Zaenglein, professor of dermatology and pediatrics at Pennsylvania State University, reported recently in The New England Journal of Medicine, "The psychological effects of acne can be profound, and persons with acne are at risk for substantial, negative effects on quality of life."
In an interview, she said, "Acne affects how teenagers feel about themselves and can increase their risk of depression, anxiety and social isolation. Acne is very visible - the face is the first thing people see. It's not something a teenager can easily hide. Yet, kids don't always tell their parents how much acne is impacting them."
According to Dr. Robert P. Dellavalle, professor of dermatology at the University of Colorado in Denver, "Acne is one of the most debilitating diseases in dermatology. It's not a killer, but it can scar people literally and psychologically. If treatment can cure acne and prevent scarring, it may prevent the need for psychological services, which can be hard to come by."
Complicating matters are many myths and misunderstandings about what causes acne, and a general lack of knowledge about how well modern medical treatments can control it.
As many as 85 percent of teens are affected to some degree. Although most cases are mild and respond to simple over-the-counter remedies, others are more severe, long-lasting and in need of professional care, the sooner the better.
Too often, experts say, that care is delayed, resulting in persistent emotional and social distress and permanent scarring that may warrant cosmetic surgery, which is not covered by insurance.
Proper care is often delayed when people assume that things will soon get better. But Zaenglein said, "Acne can take many years to run its course. And women can be plagued by it well into adulthood." For still unknown reasons, dermatologists are seeing an increase in persistent acne in adult women, Dellavalle said.
Acne is a disease of the pilosebaceous unit - translation: the hair shaft, follicle and associated sebaceous gland and muscle. Under the influence of adolescent hormones, the glands increase their production of an oily substance called sebum that normally lubricates the skin.
Sebum is a food source for bacteria called Cutibacterium acnes (also called Propionibacterium acnes) that reside in the skin. As these bacteria proliferate, they attract white blood cells that can damage the follicle walls, forming debris and dead cells that result in pimples and sometimes pustules. Or the follicles may become plugged, forming blackheads or whiteheads.
Contrary to common belief, acne does not result from surface dirt or infrequent skin cleansing. In fact, irritation of the skin from too frequent washing or, for example, by rubbing with hands or by a hat covering the forehead, can promote acne, Dellavalle said. He recommended gentle skin care with a product like Cetaphil rather than soap. Washing should be limited to twice a day, Zaenglein suggested.
The influence of diet is controversial, largely theoretical and hard to test. Global studies suggest that a high-glycemic diet, one rich in refined carbohydrates and sugars can promote acne, as well as a host of other common Western ailments. A low-glycemic diet rich in whole grains and legumes seems to improve acne in teens and "is good medical advice for everyone," Dellavalle said. Acne is virtually unheard-of in populations that traditionally consume such a diet.
Dairy products may aggravate acne in some people, so teens who are big milk drinkers might try cutting back to see if their acne improves. Likewise, heavy consumers of meat and poultry, rich in the amino acid leucine, may be more likely to develop acne through a complex chain reaction that stimulates the skin's oil glands.
But the influence on acne of other dietary items like chocolate and fried foods is more myth than fact. Dr. Steven R. Feldman, dermatologist at Wake Forest University School of Medicine in Winston-Salem, North Carolina, told me that "within reason, diet doesn't have a big effect on acne." He suspects that most mistaken beliefs about diet stem from the fact that "when adolescent hormones kick in, teens get very hungry and coincidentally also get acne."
More important than restricting diet is getting the right treatment. Most mild cases respond well to over-the-counter remedies like benzoyl peroxide, which kills acne-fostering bacteria. It is often used in combination with adapalene gel, a topical retinoid now sold over-the-counter as Differin.
But Zaenglein advised against "messing around with over-the-counter remedies if acne is extensive or severe. It's better to treat it professionally right away to prevent scarring."
Antibiotics are also effective remedies, but to avoid bacterial resistance, they should be used for only a few months as "a rescue treatment while waiting for the effects of topical treatment to kick in," Zaenglein said.
Severe cases like Sophia's require a doctor's care and prescription medication. For cystic acne, Feldman said, "the big gun, isotretinoin, is often needed and is highly effective."
In girls and young women with acne, birth control pills, which reduce the fluctuation of hormones, are often helpful. An effective contraceptive is critical for those taking isotretinoin, since it can cause serious birth defects.
Though Sophia's acne was more challenging than most cases, it finally responded to a combination of the androgen blocker spironolactone and oral contraceptives, and she's now looking forward to a far less stressful senior year.
One of the most challenging aspects of acne treatment in adolescence is lack of compliance - getting teens to adhere consistently to an established regimen. The simpler the routine, the better, Zaenglein said. She recommends keeping acne medicine next to one's toothbrush to enhance its use.
Most important, Zaenglein said, is to "be patient - it can take six to eight weeks of consistent treatment to see an improvement."