Acne, Uncategorized

Adult acne- what’s the deal with that?

Acne is one of the most common reasons for visiting a dermatologist. Everyday I see several patients with acne, and many of these are adult women. It is a myth that only teenagers suffer from acne. About 35% of women will suffer from acne at some point in their adult life- which just isn’t fair- to be fighting acne and wrinkles at the same time!

Why do we (I say we because I am part of the unlucky thirty five percent) get acne as an adult? The theory is that most adult female acne is related to fluctuating hormones. If you think about it- our hormones fluctuate as adults frequently. There are normal monthly fluctuations and then you add fluctuations due to birth control, pregnancy, post pregnancy, pre-menopause and menopause, it is a wonder that anyone has clear skin! 

Fortunately there are many treatment options for acne. When considering treatments in adult women it is important to remember that our skin is aging and traditional acne medications may be too harsh. 

One category of topical treatment, Retin A (also called tretinoin), is very good for light acne and is also anti-aging, win-win! With Retin A I am very careful to prescribe the appropriate strength, as it can be drying and irritating to the skin. I usually prescribe a low strength and recommend applying a small amount (such as a fingertip) over a moisturizer and starting application every other night (or even every third night).  It is important to use Retin A at night because it is in-activated by sunlight. It is also VERY important to use sun protection if you use Retin A because it will make your skin very sensitive to the sun.

Other topical treatments that are commonly used for acne are topical antibiotics and medicated washes (salicylic and glycolic are my favorite for mature skin).

If your acne is cystic (those big deep, red ones), scarring and more severe then we consider oral medications. Oral antibiotics can be used to clear the skin and then creams are used to keep the skin clear as oral antibiotics are not meant to be used long term. If someone needs a longer term treatment, an oral medication called Spironolactone can be very helpful. Spironolactone is a blood pressure medication that is used off label for acne, it works by blocking the effect of male hormones (women have male hormones too and they are part of the reason we get acne) at the level of the skin. Spironolactone works very well for some women- but it is not a cure- it only works when it is being taken. 

Which leads me to our most powerful medication for acne, Isotretinoin (commonly called Accutane). Accutane is our only cure for acne. Most people who complete a course of Accutane are cured of acne. Accutane can be a difficult medication to take due to lab testing and office visits, but it can be life changing for people whose acne is severe, scarring, resistant to other treatment or just persistent for many years. I prescribe Accutane frequently for both teenage and adult patients.

I recommend calling your dermatologist if acne is a concern for you, there are many treatment options to help you achieve clear skin!


My daily skincare routine

Wow- two posts in one day, a record for me! This post is for Miranda who requested an outline of my daily skincare routine. My routine is fairly simple and it changes depending on the season and if I have had (or planning) a peel or other treatment (microneedling and Resurfx are my go-to maintenance treatments).

The products are in the order of application unless otherwise stated. In general you should apply thinner (serums) products first and use moisturizers last. The exception are medicated products – which should be applied first (except Retin A can be put over other products to decrease intensity).

My Daily Routine

Early AM (Pre workout)

Splash water then Skinceuticals Retexuring Activator serum OR Elta AM Moisturizer

Morning (Post workout)

Splash water in the shower,  Finacea foam (for rosacea prevention), Neocutis Journee Bio-restorative Day Cream with Broad spectrum SPF 30 (workday) OR EltaMD UV Clear SPF 46 (weekend). If my face is feeling dry I will add Neocutis Biocream after the Finacea. If my complexion needs a little smoothing I’ll add a little Chanel Perfection Lumiere Foundation.

My morning routine involves 2-3 products. I wait a few minutes between applying the products. In general you want to put on medicated products or serums first.


Wash with Perfect Cleanser or Cetaphil Gentle Cleanser , Finacea foam, Neocutis Lumiere Eye Cream, Neocutis Biocream.

2-3 days per week I use Skinceuticals retinol (.5 or 1 %) OR Perfect A (prescription strength Retin A with Vitamin C). I apply retinol under the moisturizer because it is not as strong. I apply the Perfect A over the moisturizer to decrease intensity.

For body cream I use Cetaphil (in the tub). For hands I use Cetaphil or Neutrogena Norwegian Hand Formula. I use Cetaphil Gentle Cleanser as body cleanser.

This routine changes occasionally when I am trying a new product or after a treatment (then I use only Cetaphil cleanser and biocream or even vaseline).

If you have seen my purple product sheet in the office- be assured I have tested/used all the products.

Hopefully this is helpful, thanks for the idea Miranda!


Retin A and Retinols

Everyday I prescribe or recommend retinoid ( Retin A or retinol ) products to my patients (and my friends and family). After sunscreen it is the number one anti-aging compound. Retin A and retinol are synthetic forms of vitamin A. Retinoid compounds have been shown to help improve fine lines and wrinkles and are first line treatments for acne. They also improve the texture and clarity of the skin by exfoliating the top layer of dead skin cells. Most of the studies have been done with prescription strength tretinoin, but many non prescription retinols can also give good results.

Some types of prescription Retin A you might recognize:
1. Tretinoin: generic retin A in three strengths .025, .05, .1
2. Tazorac: a very strong retinoid. Available in gel and cream form
3. Retin A Micro, Atralin, Renova and more: brand name tretinoin. Some brand names have improved delivery systems that decrease irritation and peeling. Atralin is my favorite. The downside is they are expensive.
4. Differin: a gentle retinoid for teen acne

Non prescription retinol products may vary in the concentration or delivery, but can be less expensive (ROC Brand) and cause less irritation. I never thought I could use Retin A because my skin was too sensitive. I started using skinceuticals 0.5 retinol and after six months I could use a prescription strength a few times per week.

The downsides to Retin A and retinol products:
1. Irritation, redness and peeling. This is normal and expected. There are ways to avoid and minimize this side effect. Start out using a low strength tretinoin or retinol and use it only 1-3 times per week (at night). Use a moisturizer over your retin A at night and in the morning.
2. Sun sensitivity. This is also normal and expected. Retin A removes the dead layer of akin cells- which is why your skin looks brighter. But dead skin cells protect the skin from sun exposure. Minimize sun exposure when using Retinoid products, wear sunscreen at all times and wear a hat when outside for prolonged time. I recommend stopping all Retinoid products one week before going on a sun or ski vacation.
3. Increased sensitivity to products and waxing. Again, the dead skin cell layer (which causes your skin to look dull) helps protect the skin from irritating products and procedures. Stop all retinoid products a week before waxing or a peel. Also keep in mind that your skin may be more sensitive to new products (especially plant based or chemical sunscreen)

4. Cost. Retinoids can be expensive, especially brand name prescription and high end retinol products. The expensive products are beneficial for people with sensitive skin, as the delivery systems are more advanced and help prevent some of the problems mentioned in #1. Generic tretinoin is very affordable with a large tube costing less than $100. This tube will last you 6-12 months and is a good investment. When you get the prescription from your doctor, ask for a paper prescription and then go to This website allows you to enter the name of the prescription and your location. It will give you the lowest cost pharmacy. You will be surprised at how much the cost varies between pharmacies.

5. They work slowly. You must have patience when using retinoids. You will see results over months to years, not days. Stick with the program and you will see the results.

Retinoids are products that should be part of your nightly skincare (at night because they are in activated by sunlight)- however, you may not be able to use them every day. The retinoid regimen that I follow varies by the time of year and my activities. In Seattle the climate is very mild and I can use a retinoid product (either Retin A or retinol) several times per week. If I lived in a dryer or colder climate I would not be able to use retinoids in the winter because my skin is sensitive. I don’t bring retinoid products on ski or sun vacations.  Generally, I use a retinoid product every other day. Some days this is a prescription strength (either Atralin .05% or Perfect A cream .1%) but usually no more than twice per week. On the alternate days I use a retinol product (Beauty Pacifica Super 3, Skinceuticals .5 or 1% Retinol or Neocutis Retinol). I have sensitive skin so I always use a moisturizer over my retinoid. If my skin starts showing signs of irritation (burning, peeling, redness) I stop using all the retinoid products until the signs resolve. I stop using all retinoids at least a week before any peel or laser procedure.


I hope this post has given you useful information on retinoid products. I welcome questions and comments. Ask your dermatologist for a prescription today!


Where to splurge and where to save (on skincare products)

A benefit of my job is getting to try new (and free) products. But these are not the products that I use everyday. Just like everyone else, I chose which products to spend (money) on and which ones to save on. These are my splurge and save categories:

Where to save your money:
1. Face cleanser. Cleansers don’t stay on the skin very long and the bottles tend to go fast. Here are a few inexpensive washes that I like.
Cetaphil Gentle Cleanser: I always use for my kids and for my face during the winter or after procedures like laser or a chemical peel.
Neutrogena creamy salicylic acid cleanser: A gentle acne wash

2. Body cream and lotion. I don’t like scented body creams so all are non scented and come in a large size.
Cetaphil Moisturizing Cream
CeraVe Moisturizing Cream
Vanicream Moisturizing Cream

3. Hand cream. Again, I prefer non scented. These all hydrate and don’t leave hands greasy.
Neutrogena Norwegian Hand Formula
CeraVe Therapuetic Hand Cream

4. Shampoo and conditioner. I wash my hair EVERY day, so these go fast.
L’Oreal sulfate free line- they are all great, though some have strong scent and others are fine.
Neutrogena Moisturizing Shampoo and Conditioner
John Frieda line

And now for my Splurge products:
1. Serums. There are millions of serums, some are good, some are not. Serums spend time on your skin. I started using serums around age 30 and I think it has helped my skin age gracefully. I use an antioxidant serum in the morning and a glycolic serum at night. Sometimes I add a vitamin C serum for brightening or a vitamin B serum for extra moisture.
Skinceuticals CE Ferulic or Phloretin CF
Skinceuticals Retexuring Activator
Skinceuticals B serum
Perfect C Serum

2. Eye Cream. I have tried many eye creams and the only two I will use:
Neocutis Lumiere
Skinceuticals AGE Eye Cream

3. Moisturizers and day cream. I have very sensitive skin and am prone to breakouts, so I chose this category carefully.
EltaMd PM Moisturizer
Neocutis Journee with SPF 30 (I use every day)
Neocutis Biocream (great in dry weather and post procedure)
Neocutis Biogel (great in dry weather and post procedure)

4. Sunscreen. I splurge on face sunscreen and save on body- again because my skin is sensitive and breakout prone. I use the Neocutis Journee on indoor days and one of these on more outdoor days.
EltaMD UV Clear (good for breakout prone skin)
EltaMD UV Physical (a lightly tinted no chemical sunscreen)

5. Retinols and Retin A. These are the most important anti aging product, so if you only spend in one place- do it here. A prescription generic cream will probably cost 60-100 and last 6-12 months.
The Perfect A (.1 percent tretinoin and vitamin C)
Super 3 retinol

6. Bleaching creams. Some work, most don’t. Here are a few that work well.
Perfect Bleaching Cream (hydroquinone and kojic acid)
Neocutis Perle (non hydroquinone option)

I hope this post helps you determine where to save and where to splurge. Most people don’t need products from all of the splurge categories (so don’t get overwhelmed). If you are my patient reading this and still need or want help, my wonderful medical aestheticians (Amy and Rene) provide complimentary skin care consultation, so ask for an appointment when you call (206-860-4605).


Freshen up for fall

Now that fall is around the corner it’s time to erase those sun spots and fine lines that may have crept up over the summer. The summer is a tough time to undergo skin procedures that increase sensitivity to the sun. Now is the time to start a skin care program to have your skin shining by the holidays.

A few procedures and topicals to consider for the fall:

1. Peels. Peels are a great way to freshen up the skin. They can treat acne, brown spots and fine lines. Stay tuned for a future post dedicated to peels. Peels are what I miss most over the summer.

2. Laser and intense pulsed light. Often you need more than one treatment (over several weeks) for optimal results, so start early to have your skin ready for the holiday parties.

3. Laser hair removal. Skin cannot be tan for this procedure.

4. Retin A (and retinols) and bleaching creams. You may have taken a break for the summer. These creams take a few months to work so start soon (though start gradually because Retin A can cause skin irritation if you use it too often).

Now is the time to get back to the skin care regimen!