Benzaclin

Dr. Shupack: The treatment of acne starts with skin care.

Dr. White: And proper cleansing could be considered the most basic step in skin care. You wash gently, with no vigorous scrubbing.

Dr. Berson: It is an important part of treatment. I use different cleansing modalities depending on the patient.

Dr. Brand: Before I start giving prescriptions, I discuss skin care, and I tailor the cleansing modality and the way I start treatment based on what the acne looks like. For example, if it's a teenager with a significant inflammatory condition, I might add a gentle benzoyl peroxide (BP) cleanser. If it's a patient with a lot more comedonal presentation. I may go with a gentle glycolic acid, alpha-hydroxyl acid cleanser.

Dr. Shupack: But what if the patient says. "Doctor, I have combination skin. Do I use one cleanser in the middle of my face and another on my cheek?"

Dr. Brand: I just determine which the predominant presentation is and go with that.

Dr. Shupack: You can also tell the patient, "That's why I'm giving you a combination of products."

Dr. Brand: It's important to find out what patients are already doing for treatment by the time they come to your office. Many people use harsh abrasive scrubs and/or very drying astringents, and it's important to inform them that they need something non-drying and gentle. They need to learn that less is often more.

If you have patients with very oily skin, they are clearly going to need a different kind of cleanser to begin with than someone whose skin is on the dry side. You especially need to advise people that since all acne medications are potentially drying and irritating, you don't want to exceed their tolerance with a cleanser that's too harsh.

Dr. Shalita: Exactly. If you are going to put somebody on a retinoid and a leave-on product containing BP, you really want to use a very gentle cleanser.

Dr. Brand: If they get too irritated, they won't use their acne medicines. You want to make sure they are in compliance with the medication, so give them a gentle, mild cleanser.

Dr. Shalita: I am not the least bit opposed to using emollients. There are a wide variety of emollients available today.

Dr. Shupack: But don't they clog the pores?

Dr. Shalita: There are wide varieties that are noncomedogenic and, even more important, nonacnegenic--there's a difference between the two. All you have to do is look at the animal model to see that it is nonacnegenic and noncomedogenic. Not everybody does that, because they don't use the animal models anymore. I believe they use cell models. In any event, there are plenty of those products. If you are using a topical retinoid, it will overcome the mild comedogenic effects of anything else that you are putting on, so unless you are using something potent like coal tar, you are not going to have a problem. This is very important because it enhances patient compliance.

Dr. Brand: As you say, it's important to emphasize to people that they can use a moisturizer if they need to. And they should probably include some sunscreen in the moisturizer as well if they are using a topical retinoid.

Another point that comes up is hair care products. If people use products that are greasier and then don't wash their hands before putting on makeup, it can aggravate their acne. When making recommendations about particular cosmetics, it's important to educate people about what the terminology means, and then to point them in the right direction. Most large, reputable cosmetic brands are generally well tolerated; users should look for the words 'oil-free,' 'noncomedogenic,' and 'nonacnegenic'.

Dr. Berson: I agree with that, as long as you are using a noncomedogenic, nonacnegenic product. When I see the occasional patient who has a hairline exacerbation with a shampoo product, I usually recommend that he or she use a standard shampoo that doesn't include conditioner, and then add the conditioner separately to the area away from the face and not on the hairline. That usually solves the problem.

Dr. White: I agree that gentle cleansing and mild cleansers are advisable when you are giving the patient drying medications. But I find that early adolescents like and do well with liquid cleansers containing salicylic acid. Even in the hot summer months, they can use a toner or astringent with salicylic acid, perhaps on their oilier areas. I find that if they can tolerate it along with their medications that may be a helpful adjunct also.

Dr. Berson: I also like products that have a mild glycolic acid. It's the same idea but a different modality.

Dr. Shupack: Do we really need special cleansing products when potent therapeutic products such as BenzaClin[R] are available? Why bother with all of the rest?

Dr. Shalita: In point of fact, if I have somebody who is on a topical retinoid and a BP combination product, I have him or her use the gentlest cleanser they can use; I don't use any special products.

Dr. Shupack: Things like pore-minimizing lotion are a big waste.

Dr. Shalita: Those are really marketed for people who have 'acne-prone' skin. For example, a woman is getting one pimple on her chin premenstrually every month as well as an occasional blackhead. So, she goes to some salon periodically to get a facial cleansing, and the laying on of hands makes her feel better. They may use one of the exfoliating lotions that contain a mild salicylic acid or glycolic acid in it to loosen up the acne, even though the patient is not undergoing active treatment. Then there are a variety of other products for the acne-prone. You may be using only one simple product and want to complement it with a stronger one. For example, there are patients who can't tolerate a topical retinoid and a leave-on BP product, although more and more can tolerate it with the aqueous formulation. For them, I'll possibly use a BP cleanser, so they're still getting the benefit of the benzoyl peroxide, and some of the newer BP cleansers have enough substantivity so that the antibacterial activity lasts overnight. Now, that's not my first-line therapy; it's for somebody who's not tolerating my preferential therapy, which is the leave-on product.

Dr. Shupack: Now, what about consumer patients who have been so indoctrinated by magazine reading that they absolutely refuse to give up using a line of products that has been sold to them for $500? Do you try to reeducate them, or do you just shrug your shoulders and say my treatment is more powerful than all of the above, and let them do whatever they want?

Dr. Shalita: I let them do whatever they want. I give them the information I think they should have, and try to educate them, and if they're still going to do what they want to do, fine. However, if they're running into a problem with it or it's going to conflict with whatever I'm recommending, I'll tell them, "Look, you have a choice. You can follow the regimen I give you, which I believe will help, or you can choose not to follow it. All I can do is advise you how to take care of your problem. The rest is up to you."

Dr. White: By the time they arrive in my office, they have tried the usual over-the-counter products, the ones they've seen advertised on TV.

Dr. Shupack: Or they've been to other dermatologists or GPs.

Dr. White: That, too. So, with whatever product or treatment or line of cosmetics that they've been using, they still have acne when they come to my office.

COPYRIGHT 2004 Journal of Drugs in Dermatology, Inc.
COPYRIGHT 2005 Gale Group