My Doctor Online The Permanente Medical Group

Over-the-Counter Treatments

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There are several commonly used over-the-counter products that you may have already tried for mild acne symptoms: 

• Benzoyl peroxide
• Salicylic acid
• Alpha-hydroxy acids

Benzoyl peroxide

Benzoyl peroxide is a topical antibacterial medicine that is very effective in killing the bacteria that cause acne. It can be used on the face, chest, and back. It is commonly used for mild acne and is effective for milder forms of comedonal and inflammatory acne. There are combination products (topical antibiotic and benzoyl peroxide) that may limit the development of antibiotic resistance.

Benzoyl peroxide is available in solutions, creams, gels, and washes ranging from 2.5 to 10 percent concentration. Concentrations greater than 5 percent are no more effective and can increase skin irritation.

Be cautious, as benzoyl peroxide can bleach clothing and hair. Irritation usually appears as redness, dryness, stinging, and peeling of the skin. Some people develop an allergic reaction and cannot use this product, but that is rare.

Salicylic acid

Salicylic acid is a beta-hydroxy acid that is similar to the chemical found in aspirin (acetyl-salicylic acid). It helps to reduce the stickiness between the cells and the development of whiteheads and blackheads.

If you have oily skin, this medication can penetrate deeper into your pores and oil glands and may be more useful. This medication comes in many forms including washes, creams, and gels. You should not use a concentration higher than 2 percent. Higher concentrations are available for other skin conditions such as warts and psoriasis.

Alpha-hydroxy acids

Alpha-hydroxy acids are weak acids obtained from fruits and other plants (glycolic acid from sugarcane) or milk (lactic acid). These work by breaking down the dead cells on your skin and clearing out the blackheads and whiteheads. They are available in concentrations of up to 10 percent.

Prescription Treatments (Retinoids)

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For mild acne, consisting of mostly whiteheads and blackheads and rare acne pimples that are not responding to over-the-counter medicines, we may prescribe topical retinoids. However, do not use retinoids if you are breastfeeding, pregnant, or planning to get pregnant.

This medication works by unplugging clogged pores and reducing the formation of new whiteheads and blackheads. Sometimes, during the first few weeks of treatment, your acne can get a little worse before it improves. Here are some tips for using retinoids:

• Apply to your skin at night before you go to bed, about 20 to 30 minutes after washing your face with a mild cleanser.
• Cover all acne-prone areas of the face (if you have acne there), not just over existing acne pimples.
• To lessen chances of dryness and flaking, apply a pea-sized amount for the entire face. Avoid delicate areas under the eyes and around the nostrils.
• If dryness and irritation occur, use retinoids every third night for a few weeks, then switch to every other night for a few weeks, working up gradually to using nightly.
• Use retinoids consistently to help prevent additional acne from developing.
• Do not combine retinoids with any other treatments unless we specifically tell you to do so.
• Use sunscreen (SPF 30 or higher) every day.

It may take 2 to 3 months before you see the benefits of this medication.

The 3 most commonly prescribed topical retinoids are:

• Tretinoin (Retin A or Retin A micro) is the most commonly used topical retinoid. It is available in several concentrations from 0.025 to 0.1 percent. The different formulations include creams, gels, and solutions.
• Adapalene (Differin) is available in two concentrations of 0.1 and 0.3 percent in a cream or gel formulation.
• Tazarotene (Tazorac) is a newer retinoid available to treat acne. It is the strongest topical retinoid and is used when the others are not working. It is available in two concentrations of 0.05 and 0.1 percent in a cream or gel formulation. 

Isotretinoin

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Isotretinoin used to be known as Accutane, a brand name that has been discontinued by the manufacturer. Isotretinoin is used for the treatment of severe nodulocystic acne that has not improved with any other treatments. It controls acne by unclogging skin pores and shrinking oil glands. It is made from Vitamin A (a retinoid). Treatment usually lasts for 4 to 6 months.

Isotretinoin has many side effects. The most severe is its ability to cause defects in a developing fetus in pregnant women. Because of its effect on the fetus, this medication cannot be used by pregnant women. To avoid severe side effects such as birth defects and to ensure that all patients are well informed on its usage, the FDA has implemented a program called iPLEDGE.

iPLEDGE has very strict requirements regarding how isotretinoin can be prescribed. We will discuss this program in detail if you are a good candidate for this medication. Other potential side effects of this medication include:

• Dry eyes
• Chapped lips
• Hair loss
• Increases in liver enzymes and cholesterol
• Muscle and joint pains
• Mood changes leading to depression and increased risk of suicide
• Development of inflammatory bowel disease 

Given the number of risks, treating acne with isotretinoin should not be taken lightly and should include a detailed discussion of each of the side effects.

Prescription Medications (Antibiotics)

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We may recommend topical antibiotics if you have mild acne that is not responding to over-the-counter medications.

These medicines work by reducing the overall numbers of P. acnes bacteria on your skin. They also reduce inflammation, which plays an important role in acne. Some common types of topical antibiotics include:

• Clindamycin and erythromycin are the most commonly used. These antibiotics may also be used in combination with benzoyl peroxide.
• Combination products containing benzoyl peroxide may limit the development of antibiotic resistance.
• Other topical antibiotics used for the treatment of acne include azelaic acid and sodium sulfacetamide/sulfur.
• For pregnant women, erythromycin and azelaic acid are the two topical antibiotics we recommend.

Oral Antibiotics

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We may add oral antibiotics to your acne treatment if your acne:

• Is moderate to severe.
• Is not responding to topical treatments.
• Involves large areas of your chest and back that cannot be easily treated with topical treatments alone.

More effective than topical antibiotics, oral antibiotics also reduce the number of bacteria and treat inflammation. We usually prescribe these for a limited time until your acne can be controlled with topical medication. 

Common types of oral antibiotics

The oral antibiotics we commonly use for acne belong to the tetracycline family. They include tetracycline, doxycycline, and minocycline. They are very effective and are usually well tolerated. Except for tetracycline, the other cyclines can be taken with food to reduce stomach upset. Some of these medications may make your skin more sensitive to the sun; use sunscreen on a daily basis if you take them.

Other oral antibiotics we may recommend include erythromycin, trimethoprim/sulfamethoxazole, clindamycin, and penicillins.

Hormonal Treatment

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Women may notice a flare-up in acne just before their period, and it is likely that hormones are playing a role.

Hormones can increase oil production in acne-prone skin. They may be one cause of your acne if you continue to suffer from moderate to severe acne after your teen years are over, or if you started to develop acne long after adolescence.

If this is the case for you, it does not automatically mean that you have abnormal levels of hormones. Your oil glands may be more sensitive to normal levels of hormones. If so, we may recommend a low-dose birth control pill that has been approved by the FDA to control adult-onset acne. We might also recommend oral antibiotics depending on your specific needs.

Polycystic ovary syndrome (PCOS)

Women who have severe acne, irregular menstrual periods, excess hair on their face or body, and hair loss on their scalp may have a hormone disorder known as PCOS.

If you think you might have this disorder, please talk to your personal physician or to us.

Laser and Light-Based Treatments

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Several laser and light devices are being studied for the treatment of acne. They are used to reduce the number of bacteria on the skin, shrink oil glands, and lessen inflammation. They have not been shown to be as beneficial as standard treatments.

Your Care with Me

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If you are having symptoms that concern you, your first contact will typically be with your personal physician, who will evaluate your health and symptoms.

If specialty care is needed, your personal physician will facilitate the process of scheduling an appointment in my department. If appropriate, she or he might contact me or one of my colleagues while you are in the office so we can all discuss your care together. If we decide you need an appointment with me after that discussion, we can often schedule it the same day or soon thereafter.

During your office visit, we may discuss your medical and family history and I will examine your skin. Usually, no special tests are needed. I will explain the findings of your exam and answer any questions or concerns you may have. We will discuss treatment options, and together we will create a treatment plan that is right for you.

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If you need to talk with me after your visit or procedure, please call my office. You can also e-mail me with nonurgent issues from this website whenever it is convenient for you.

If you have urgent concerns or issues while my office is closed, or need general medical advice, you can call the Appointment and Advice line, available 24 hours a day, 7 days a week. You will be connected with a nurse who can give you immediate advice.

If you are experiencing a serious problem or an emergency, call 911 or go to the nearest Emergency Room when the clinic is not open.

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Coordinating Your Care

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Having all of our Kaiser Permanente departments located together or nearby, including pharmacy, laboratory, radiology, and health education, makes getting your care easier for you.

Another major benefit is our comprehensive electronic medical record system, which allows all of the doctors and clinicians involved in your care to stay connected on your health status and collaborate with each other as appropriate.

When every member of the health care team is aware of all aspects of your condition, care is safer and more effective.

If you come to an office visit

• At the beginning of your visit, you will receive information about when you are due for your next test, screening, or immunization. We can discuss and schedule any preventive tests that you need. 
• At the end of your visit, you may receive a document called the "After Visit Summary" that will summarize the issues we discussed during your visit. You can refer to it if you forget what we discussed or if you just want to recheck your vital signs and weight. You can also view it online under Past Visits.
• To help you prepare for your visit, please see additional details under Office Visit. 

If I prescribe medications

We will work together to monitor and assess how your medications are working and make adjustments over time. Prescriptions can be filled at any Kaiser Permanente pharmacy. Just let me know which pharmacy works best for you, and I will send the prescription electronically in advance of your arrival at the pharmacy.

• Order them online or by phone. Order future refills from my home page or by phone using the pharmacy refill number on your prescription label.
• Have them delivered to you by mail at no extra cost. Or you can pick up your medications at the pharmacy. If no refills remain when you place your order, the pharmacy will contact me regarding your prescription.

If lab testing or imaging is needed

For lab tests, I will use our electronic medical record system to send the requisition to the Kaiser Permanente laboratory of your choice. For imaging procedures, we will schedule an appointment with the Radiology department. When the results are ready, I will contact you with your results by letter, secure e-mail message, or phone. In addition, you can view most of your laboratory results online, along with any comments that I have attached to explain them.

If I refer you to another specialty colleague

If we decide together that your condition would also benefit from the care of other types of specialists, our staff will help arrange the appointment(s) with one or more of my specialty colleagues.

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Convenient Resources for You

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As your specialist, I have a goal to provide high-quality care and to offer you choices that make your health care convenient. I recommend that you become familiar with the many resources we offer so that you can choose the services that work best for you.

My Doctor Online is available at any time that is most convenient for you. From my home page you can:

Manage your care securely

• View and compose secure e-mail messages.
• Manage your prescriptions.
• View your past visits and test results.
• View your preventive services to see whether you are due for a routine screening or updated immunization.

Learn more about your condition

• Read about causes, symptoms, treatments and procedures.
• Find interactive health tools, videos, and podcasts to help you manage your condition.
• View programs to help you decide on or prepare for a surgery or procedure.

Stay healthy

• Locate health education classes and support groups offered at every medical center.
• Explore interactive programs, videos, and podcasts that focus on helping you stay healthy.
• View your Preventive Services to see whether you are due for a routine screening or updated immunization.

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