Acne Treatment

I am 33 years old and have been dealing with acne since my teens.  It has gotten to the point that I am completely frustrated and it has affected my self-confidence tremendously.

A brief description of my condition is as follows:

My acne would be considered mild to moderate.  My major issue is whiteheads.  They are located on my nose and forehead.  These whiteheads are small, very deep and definitely visible (but, they are not inflamed and red).  I have tried leaving them alone.  But after 6 months I finally get fed up and have a medical aesthetician remove them.  She uses a fine needle to open the pore and extract them.  When extracted they come out as a firm white mass.  Although this procedure removes the whitehead, it results in very visible inflamed skin for a few days.  So it's a matter of choosing between the lesser of two evils.  Leave the whiteheads alone and live with them or have them extracted only for them to return within a couple of weeks.

I have worked with numerous dermatologists over the years and none of my efforts have been successful.  

The skin regime I have been following for the last 6 months is as follows:
1) A maintenance dose of Accutane (40 mg  taken every other day).  I have been on this dosage for about a year and a half.  I get regular blood work done and my results are well within the acceptable ranges.  Without this dosage my face is incredibly oily and my acne is much more severe.
2) Oral Batrim-DS twice a day (I have tried the tetracycline family of antibiotics and they haven't worked as well)
3) Cleocin lotion in the morning and afternoon.  (I have tried a wide array of topical prescription and OTC antibiotics in the past and none has really been successful).
4) Differin gel at bedtime.  (I have tried Retin-A and Tazorac but neither has shown results significantly better than Differin and they are more harsh on my skin)
5) Wash with Plexion cleanser in the morning and use Cetaphil cleanser in the afternoon and evening (Plexion more than once a day really dries out my skin)

As you can see, I'm pretty much a slave to my acne.

I have tried every popular acne treatment and none has been a successful long-term solution.  To date, the treatment that has worked the best is Accutane.  I have had two major courses of Accutane.  The first when I was 20 years old and the second when I was 27 years old (both treatments were for 40mg per day for 6 months).  In both cases, the Accutane worked very well but my acne returned within a few months after ending the treatment.

My question is:  Would a more potent course of Accutane be a viable option for me to consider?  If so, what is the typical recommended duration and dosage for someone like me (I am a 5'9", 180 lb. male in excellent physical condition).  If not, what other recommendations do you have?

Thank you for your help.

[Alan Rockoff, MD]

Whiteheads are very frustrating but hard to treat.  Topical retinoids (like Differin) help somewhat, but mechanical extraction is usually needed.  Accutane sounds like overkill to me.  It's not clear from your post whether it's even working--you seem to be on it chronically, but you still have the problem.  If it is working fairly well, I suppose you could consider a full-dose regimen (60-80 mg/day) for 20 weeks. but I wouldn't be enthusiastic about that since the condition is likely to relapse, and chronic Accutane, even at low doses, may be associated with bone changes.

I would recommend retinoids, facials, and a dose of tolerance of imperfection.

Dr. Rockoff