I have acne. What am I doing wrong?

Many of my patients with acne say they feel as though they must be doing something wrong to be cursed with this disfiguring disease. Many suffer from guilt, ranging from lack of personal hygiene to having "bad thoughts" and thinking their acne is punishment.

Not true. Acne is caused by a genetic defect in your oil glands. Specifically, the opening of the hair follicle into which the oil gland drains is the problem. The pore is unable to properly shed the sticky cells that plug the opening and prevent the oil normally produced by your glands from coming to the surface.

As the plug enlarges, it manifests as a blackhead or whitehead.

Your oil glands are constantly producing oil, which provides an abundance of food for bacteria that normally live in these glands. As these bacteria feast on your oil, they break it down to free fatty acids that stimulate inflammation, which results in the dreaded pimple or "zit." Eventually, the whole hair/oil unit ruptures, spilling its contents into your surrounding skin, resulting in a robust reaction that causes a tender, ugly cyst. Unfortunately, these inflammatory lesions can result in permanent scarring.

There are many interventions that can help you battle your acne. Many patients can be successfully treated with topical agents only. Every patient should be on a topical retinoid. These are derivatives of vitamin A that help normalize the development of the sticky cells plugging up your pores.

Unfortunately, retinoids can be irritating. Remember, your acne may get worse before it gets better. What happens is that the blackheads and whiteheads come to the surface at once as the plugs are released. This is when many patients abandon therapy; instead you need to push through this challenging time.

Benzoyl peroxide is another powerful topical agent. It works primarily by killing the bacteria that are creating the irritating free fatty acids. These products, too, can be irritating. And they should not be applied simultaneously with the retinoid to avoid retinoid inactivation. A new formulation successfully combining these now exists.

Although topical antibiotics are frequently used, they are rapidly falling out of favor as resistant organisms frequently develop. This risk can be minimized by using topical antibiotics in combination with benzoyl peroxide.

For those with more severe acne, systemic agents may be necessary. The mainstay is tetracycline or a derivative. These cannot be used if you are pregnant, may make you sun sensitive and can cause stomach upset.

There are hormone therapies designed for female acne patients, as well. For really severe cases that are unresponsive to these conventional therapies, oral Accutane may be necessary. This is a controversial drug with high risk-benefit ratio, and it requires both the provider and patient to jump through many hoops before starting. It can cause serious birth defects and may cause depression.

Other modalities that can be used, but aren't covered by insurance, are chemical peels, Blu-U light, and the use of topical Levulan with advanced light sources. See your dermatologist to determine what treatment will serve you best.

Neil Alan Fenske is professor and chair

of the Department of Dermatology and

Cutaneous Surgery at USF Health.