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Growing Stronger Together is a podcast for people who care about children.
Growing Stronger Together was developed by faculty at East Tennessee State University, including members of the ETSU Health Department of Pediatrics, the ETSU Center for Early Childhood Learning and Development, and the ETSU Child and Family Health Institute.
East Tennessee State University is located in the beautiful Appalachian Highlands. We appreciate the financial support provided through a Community Health Improvement Site Investment from Ballad Health’s Department of Population Health.
Dr. William Dodd (00:02)
I'm your host, Dr. William Dodd, from the East Tennessee State University Health Pediatrics Adolescent Medicine Clinic.
This podcast is not intended to provide medical advice. If you or a loved one are working through medical problems related to today's topic, please consult a personal physician. I have no conflicts of interest to disclose.
Today we have a discussion on a topic that nobody likes... Acne.
Welcome to the Growing Stronger Together podcast. I'm your host, Dr. William Dodd with ETSU Health Pediatrics. And today I'm joined by one of our second year residents, Katie Seale. Dr. Seale attended Carson Newman University and then LMU for medical school. ⁓ She came on to join us here at ETSU ⁓ for a pediatrics residency and she wants to be a general pediatrician and treat a
variety of age ranges, including adolescence. And today we're going to talk about a really important topic for adolescents. And a lot of people think it's a minor condition, but we're going to talk about, you know, some of the ways it can go wrong and some of the ways it's a really important condition to bring up and treat. So welcome to the podcast, Dr. Seals.
Dr. Katie Seale (01:35)
Thank you so much. Thanks for having me.
Dr. William Dodd (01:37)
Alright, so acne. Why is acne an important thing that we treat in our patients?
Dr. Katie Seale (01:46)
So acne is a very common skin disorder seen in a lot of our adolescent, possibly young adults. About 85 % of teenagers will have some form of acne and it can persist into their twenties and thirties. A lot of our teenagers find their acne flares to be pretty distressing and can lower self-esteem in that population. And some of our teenagers even go on to have acne and depression due to their acne flares.
lowering their self-esteem and they have lots of worries about their appearance at school and what their peers are going to think about them or say about them and that effect on the mood is why it's so important for us to discuss when we see a teenager in our office.
Dr. William Dodd (02:34)
Yeah, absolutely. you know, if you look at medical, the spectrum of medical problems that we treat, I mean, there are very few problems that are as ubiquitous as acne. You know, 85 % is a huge chunk of the population. Even, you know, seasonal allergies, I don't know percentage wise, but I would guess about 60 to 70 % of people maybe deal with seasonal allergies at some point in their lives. You look at
I guess tooth decay, probably most people deal with that, but acne's right up there with kind of problems that everybody deals with to one extent or the other and that can really impact our lives. ⁓ But, you know, getting down to the basics, how does acne form?
Dr. Katie Seale (03:19)
There
are four main processes that contribute to acne formation. The first one is excess sebum production. Sebum is one of the oils produced by the sebaceous glands under our skin surface, and that keeps our skin from drying out. This can be exaggerated greatly by hormones during puberty called androgens. So that's why we see a big jump in acne around the ages when we see puberty.
and teenage. The second formation is hair follicles plugging with this sebum and excess skin cells. So our follicles can get kind of clogged. ⁓ If you've heard on TV or commercials about clogged pores, this is what they're talking about.
And the third process is bacteria Colonizing those follicles or those pores so back to you can get in there with the sebum and skin cells and aggravate things and then the fourth process would be our body's inflammatory response to the bacteria in the follicles and redness tenderness and swelling that we can see With those acne lesions once they get real
aggravated.
Dr. William Dodd (04:39)
And you know, just looking at this process, first, you know, the body making too much of the sebum, that oily fat on the skin, then the follicles getting plugged, then acne getting in, or bacteria getting in there, and then your body fighting bacteria like it naturally does. I have so many patients where they'll come in, the adolescent has acne.
The parent will say, they need to wash their face. I've been telling them to wash their face They're just not washing their face, but you can't wash off hormones. You know, it's kind of like a Tough situation. I think a lot of kids need Poking and prodding to kind of be responsible and turn into responsible hygienic adults but Agnes one of those things that sometimes there's not a lot you can do about it without you know treating some of these other underlying causes like
the effects of hormone on the skin or the bacteria that gets in there. And let's talk about the bacteria a little bit. know, the type of bacteria that colonizes acne. I think as a doctor, we have in our minds like a spectrum of bacteria. There are really bad ones like staph aureus or pseudomonas that can be
resistant to lot of medicines and cause like heart infections and deep abscesses and just infections that are very difficult to treat. Bacteria that causes acne, is that difficult to treat or like one that doesn't get as resistant?
Dr. Katie Seale (06:21)
The typical bacteria in acne ⁓ are pretty risk. And it's not, you know, the big, scary that we think of with like staff or Marissa that are typically ⁓ resistant to treatment. So ⁓ we do use antibiotics ⁓ and we'll get into that when we talk about treatment of acne, but a lot of times we really only have to use topical treatments for acne.
Yeah. The mild type. Absolutely. So these bacteria are typically pretty responsive to treatments and we don't always have to go as far as systemic antibiotics for these teenagers.
Dr. William Dodd (07:06)
Yeah,
absolutely. I always think of it as the weakest bacteria there is and you know sometimes a little bit of treatment makes a huge difference. you know just looking at these, this process of how acne forms, does that lead to like different types of acne in patients?
Dr. Katie Seale (07:26)
does.
⁓ There are two big types of acne. The first one would be non-inflammatory acne. So what you would call probably our mildest type. these non-inflammatory lesions are called comedomes. That's the medical lesions. And these are pretty much your clogged pores ⁓ with sebum and the excess skin cells. And you may have heard on TV or commercial
about whiteheads than blackheads. So these are what those people are talking about. So you have your whiteheads, which are open lesions and your blackheads, which are closed lesions. And these are your mildest types of acne lesions, which is a non-inflammatory. The second group would be your inflammatory group. There are multiple different types of lesions characterized by their size and their contents.
about and the most common would be a papule.
These are your small raised bumps. They're typically a little bit red and sometimes tender to touch. ⁓ Your second group would be pustules. So these are pretty much like a papule. They're raised in red, but these are filled with white yellow pus. So if you were to scratch ⁓ a bump on your face and it pus comes out, that would be a pustule instead of a papule. The third type would be a nodule.
So these are large raised red bumps and these are typically very tender in your papule or pustule and larger than your papules. And then as a whole, kind of talk about cystic acne as our most severe form. This is composed of very large deep nodules that are red, very tender, but these nodules are also filled with pus.
Dr. William Dodd (09:11)
Mm.
Yeah, and which one of those tend to cause, you know, scarring problems, which I think is what a lot of people are worried about.
Dr. Katie Seale (09:37)
So your inflammatory group typically tends to cause some scarring. Usually the larger the lesion, the more likely it's going to scar. So more likely your nodule or your cystic type of acne is going to be more scarring. Sometimes you can have very small scars with papules or pustules, but usually the nodules are going to scar them out.
Dr. William Dodd (10:01)
Yeah, and I'd also like to point out here like if you have a pustule or a nodule and there's like a fluid-filled lesion on your face, there's a real temptation to squeeze it and you know pop the pimple as commonly said but ⁓ that's really bad for scarring. It just pushes all that inflammatory bacteria under the skin, spreads the inflammatory response, you know the
the best way to treat acne is keeping it from happening in the first place. yeah, when we're diagnosing it, how do we diagnose it or how do we grade acne?
Dr. Katie Seale (10:40)
So there are many different severity scales or ways the doctors grade acne, but each of them take into account the location of that acne, the types of lesions that they see and the number of lesions that are present. Generally mild disease consists of non-inflammatory like we talked about with minimal number of those inflammatory lesions. So it's typically non-inflammatory if it's mild.
And then severe disease consists of much more inflammatory lesions and sometimes we can see scarring like we just discussed.
But regardless of the severity scale, the effect on self-esteem and mood should be taken into account like we mentioned before. ⁓ I've had lots of teenagers that they have mild acne, but it's very distressing to them. So it's very important even if it is just mild, if they are distressed by it, it's definitely.
Dr. William Dodd (11:43)
Yeah, and I've seen teenagers with acne that I would have been proud to have as a teenager and they're very upset by it. But there are like very big studies, know, thousands of people with acne and teenagers with acne in these studies and they show...
pretty consistently that acne has effects on self-esteem, it can have effects on school performance, it can even have effects on family relations, because, you know, if you're feeling stressed out and bad about yourself, I think that's bad for everything. ⁓ you know, if I'm a teenager and I have acne and I'm worried about it, I walk into the drug store, I look around, I can buy, you know, $100 worth of a treatment system with pretty packaging that...
may not have any sort of effective medicine in it. ⁓ How do we treat acne as doctors?
Dr. Katie Seale (12:43)
Yeah, so we'll get into that. ⁓ Sometimes we treat it by severity and then sometimes we focus on what type of acne that we're looking at. So we'll talk about severity first and all of the prescription and over-the-counter things that you use. So patients with mild acne are typically treated with topical creams or gels. These are typically a topical retinoid or a benzyl peroxide. Both of these
creams can be purchased over the counter without a prescription. So topical retinoids have various over-the-counter names. They can be tretinoin, diferent gel,
Retin-A and adaptolyne. So you could see any of those names over the counter and those are pretty much the same. They're a retinoid. And then your topical benzoyl peroxide is all brands that you can get over the counter such as CeraVe, Clean and Clear has some and so does Panoxyl. So you can get both of those either as a prescription from your doctor or you can just look over the counter your spells.
Dr. William Dodd (13:56)
Yeah, and usually the medicine, the topical medicine that I would start with as an outpatient simply because it's on that first line list and it's easy to titrate and it works would be a medicine called tretinoin. But you're right, there is an over-the-counter equivalent called adapalene. ⁓ And it's also very effective. It's not that expensive compared to some of these systems out there.
I always recommend if patients interest doesn't cover the Tretinoin that I'm prescribing, I would try the adapalene over the counter as a first line agent for like acne that's not severe, severe. But what, what about if, if it doesn't or, or sorry, what are their, one other point with the benzoyl peroxide, ⁓ that stuff's it's, it's effective, but it's also a bleaching agent and it'll ruin towels and sheets and
Whatever a kid puts their face on. So I always warn parents about that too, because that can create more stress around the situation. That's in some over-the-counter formulations as well. what about when you're, let's say you try topical agent or severe acne, where do you move to next?
Dr. Katie Seale (15:15)
Yeah, so with moderate and severe acne, we typically do a combination of our topicals like we just discussed, and then we add in some systemic antibiotics like we had talked about before. These antibiotics are used for the target bacteria. ⁓ and this group is called tetracyclines. ⁓ they're an antibiotic that we typically use is doxycycline. This medicine's used for lots
of different things but we use it a lot for acne as well. ⁓ So we typically move into adding a systemic agent if just topicals are not effective for these kids.
Dr. William Dodd (16:02)
Yeah, And antibiotics, you know, these are antibiotics that you take for months too, right? So it's a, it's a big step up in treatment because I think anybody who's been on antibiotics knows they, they affect your gut.
know, doxycycline is usually pretty well tolerated, but it's still, it can cause some stomach upset. If it gets caught in your esophagus, it can cause ulcers. It can cause some photosensitivity type reactions or rarely like allergic type stuff. So it's not a treatment without consequences. What if the system
Dr. Katie Seale (16:38)
to talk to them about that too. Yeah, some risk benefit. important to talk to them about that too because a lot of people don't really think about the side effects that may come from that. So having that shared decision making with them and parents is really important before you make that big jump.
Dr. William Dodd (16:59)
And let's talk about an even bigger jump. Where do we move if let's say antibiotics don't work, it's severe scarring type acne, what medicine will work?
Dr. Katie Seale (17:12)
So at that point, we would be moving on to Accutane and probably a dermatology referral at that point. A lot of times we continue our topicals and our systemic antibiotics until we get to that dermatology appointment just to have them covered. But that's when they start talking about Accutane or IsoDrapnoin for that.
Dr. William Dodd (17:39)
Yeah, and I also tried knowing really strong medicine, you know, it'll cure acne almost invariably. Why is it such a big deal?
Dr. Katie Seale (17:49)
So it's very harsh on the body. ⁓ A lot of teenagers have very dry, flaky peeling skin. They have layers of their epidermis peeling off. ⁓ You have to do pretty frequent blood work to monitor the levels in your body. ⁓ I think it's every three months at least you have to go back to your blood work.
⁓ And it's very important if we're talking about girls to make sure that they have one to two forms of birth control at that time because it's very harmful if you were to get pregnant while you are on Accutane for the fetus.
Dr. William Dodd (18:36)
Yeah, absolutely. It's one of those medicines that's so dangerous for causing birth defects.
Dr. Katie Seale (18:43)
Mm-hmm.
Dr. William Dodd (18:44)
And I've had so many patients who are on Icetretinoin and they're being monitored at dermatology and one lab or another just gets way out of whack and we've got to figure out what to do about it. It can affect everything. It can affect liver. It can affect blood. It can affect kidneys. It can affect cholesterol and lipids. Just any body system.
is potentially at risk from isotretinoin. And it's not like, you know, it's not a highly dangerous medicine. It's not like chemotherapy or something, but it is more dangerous than a lot of medicines that we prescribe like antibiotics or that sort of thing. ⁓ Isotretinoin is just hard on the body. So it's a big decision as to whether to take that step and...
get on that medicine, but for a lot of patients, it's the only medicine that's going to work, the only medicine that's going to prevent that scarring and help that adolescent lead a happier life during their adolescent years as well. Dr. Seale, that was a fantastic acne overview. I really appreciate your putting all this together and I've enjoyed our discussion.
Dr. Katie Seale (19:50)
Yeah, of course.
Dr. William Dodd (20:05)
Thank you for joining us.
Dr. Katie Seale (20:06)
Yeah, thank you so much for having me. It was my pleasure.