It starts with Clearasil, then moves on to stronger stuff: birth control pills, antibiotics, Retin-A, or the nuclear option, Accutane.
These days, there's an arsenal of treatments for that common adolescent scourge, acne vulgaris, and the beleaguered teenager may be forgiven for thinking that it will all go away when she hits adulthood.
More and more women are battling breakouts along with their wrinkles these days, and while there is no cure for either, some promising treatments are on the horizon, from subantimicrobial treatments -- low-dose antibiotics -- to vitamins and light therapy.
Research by a joint team at the University of Pittsburgh and the University of California at Los Angeles has found that the "good" bacteria and "bad" bacteria found on people's skin and in their intestines can determine whether they have acne or not.
But don't expect a miracle cream just yet, said Huiying Li, one of the lead researchers in the study.
"We've still got years of work to do before anything appears on the market," she said. There are, at any one time, 40 million to 50 million people suffering from acne, and it's not clear why the number of adults are growing, said a report from the American Academy of Dermatology -- perhaps just more adults seeking treatment.
Adult acne affects 45 percent of women aged 21 to 30, 26 percent of women aged 31 to 40 and 12 percent of women aged 41 to 50, according to a Massachusetts General Hospital study in 2012.
Moreover, acne vulgaris, driven by hormones, mostly disappeared by age 18, but these days lasts on average to about age 28, said Lisa Pawelski, a dermatologist based in Monroeville.
For some women, that type of acne never goes away, but it does become less severe. For others, it comes as a nasty surprise just when they're preparing to battle aging skin.
Jean Camp was lucky enough to have a clear complexion as a teenager but now, at 32, is suffering from a different type of acne known as papulopustular rosacea -- pink bumps, or papules, and pustules, more commonly known in acne lingo as whiteheads.
She even remembers the date she realized she had it: March 1, 2010.
"I have people asking me what's wrong with my face," said Ms. Camp. "I can never wear makeup, because it doesn't cover up the pimples and only irritates me more. I don't think it's fair."
These two different kinds of acne can be determined by location: teenage acne vulgaris can be all over the face and back, while the adult version is mostly along the jawline. And the rosacea form can be found mostly across the center of the face, on the cheeks and around the nose.
"Wrinkles and acne are the diabolical duo," said Suzan Obagi, assistant professor of dermatology at the University of Pittsburgh School of Medicine and director of the UPMC Cosmetic Surgery and Skin Health Center. Certain treatments present a special challenge with older skin, she said, which is thinner and drier and can respond poorly to the high concentrations of benzoyl peroxide teenagers slather all over their faces.
Sitting in her sunlit offices in Shadyside, she sees no shortage of older women patients "who are not going to outgrow this kind of acne," and, perhaps fittingly, she is turning to light as one of her options.
She uses CoolTouch, a laser emitting non-ultraviolet wavelengths that have been shown to reduce breakouts while smoothing fine wrinkles. The CoolTouch laser is applied in gentle pulses over the skin, penetrating deeply enough to shrink oil glands and decrease their capacity to produce acne without drying out the skin.
"You have to hit the acne where it lives and sometimes that requires careful targeting," said Dr. Obagi.
There are other light technologies out there as well that work on adult acne, including Isolaz, which merges broadband light and gentle vacuuming to remove pore blockages, and some blue light and red light therapies, distributing blue light over the skin's surface to target bacteria, and short wavelengths of red light to reduce inflammation. Since no ultraviolet radiation is involved, cancer and wrinkles aren't a risk.
These new light therapies are usually tried after the tried and true -- or just tried -- medications are given a test run. Spironolactone, for example, blocks the effect of testosterone, a hormone that increases in women as they age and results in oilier skin, more facial hair growth and breakouts.
And there's tretinoin, the generic version of Retin-A, a derivative of vitamin A that helps with both acne and wrinkles, and isotretinoin, the generic version of Accutane. That pill's potentially severe side effects have been debated for years: While it causes birth defects in pregnant women, there is no direct scientific link to depression or suicide, and it is still considered the gold standard for severe acne treatment.
More recently, Dapsone, used to treat other skin disorders, including leprosy, has been shown to be effective as a topical antibacterial agent with anti-inflammatory properties, and Duac, another topical gel that combines benzoyl peroxide with an antibiotic called clindamycin.
Ms. Camp, of Irwin, feels as though she's tried them all -- antibiotics such as cephalexin, doxycycline, metronidazole, and other medications used for eczema, such as pimecrolimus cream, known as Elidel.
Even Oracea, a low-dose treatment that is chemically identical to doxycycline, didn't work. At a time when doctors are under pressure to stop dispensing so many antibiotics, given concerns about growing resistance to them, this form of doxycycline is too low a dose to have antibiotic effects, but since rosacea is not bacterial, this subantimicrobial dosing is promising for that kind of acne.
Cost, however, has been a factor for Ms. Camp, as it is for many adult acne patients who need more targeted approaches than young people. Her insurance covers some medications and not others: Elidel was out of Ms. Camp's price range, as were the brands Nicomide and Nicazel, both of which include niacinamide, also known as nicotinamide.
The generic form of nicotinamide is a member of the vitamin B group and was used for years as an effective tool against inflammatory acne. While co-payments for that drug were $20 a month under some insurance plans, it was pulled from the market in May 2012.
Now only the brands Nicazel and Nicomide are available, and are far more expensive, running between $70 and $80 a month, even if their discount coupons are used.
Ms. Camp also encountered another roadblock when her dermatologist, Dr. Pawelski, referred her to a Greensburg practice offering laser treatment, only to have it rejected by her insurer, UPMC Health Plan, she said.
Those laser treatments, while lasting, cost about $250 a session, and Ms. Camp says she needs four or five.
A spokeswoman for UPMC Health Plan, Gina Pferdehirt, said privacy regulations prohibit her from commenting on a specific case, however, "While our policy doesn't cover for cosmetic work we do cover what's medically necessary," she said.
For all the increasingly high-tech treatments out there, several recent studies have reinvigorated the debate about a very low-tech culprit -- diet, particularly carbohydrates and dairy products.
"I tell patients to cut out dairy, and some have reported an immediate improvement," said Dr. Obagi. "Sometimes, in the end, it's just about living in a healthy way -- and about eating fresh foods instead of chocolate."mobilehome - health
Mackenzie Carpenter: firstname.lastname@example.org; 412-263-1949. On Twitter at MackenziePG.