Guido R. Zanni, PhD

People of all ages can develop acne, but many treatments are available.

Your skin is covered with many tiny holes, commonly referred to as 

, which contain oil glands that help to keep skin and hair moisturized. During puberty, hormones can cause the skin to make too much oil, resulting in clogged pores, also known as 

. If the top of a pimple is dark, it’s called a 

Acne symptoms include redness around pimples and small red bumps. If a clogged pore breaks open, additional swelling and red bumps can occur; acne that is deep in the skin can be especially painful.

 Most pimples occur on the face, but can also appear on the neck, back, chest, and shoulders. Acne and acne scars often result in depression and stress.

	Several factors can trigger acne. As previously mentioned, hormonal changes in adolescence increase the skin’s oil content. Likewise, high humidity, sweat, and stress also aggravate acne. Certain medications can contribute. Additionally, some scientists believe genetics plays a role: if a parent had acne as a teenager, his or her children are likely to have acne.

	People of all ages, including babies and elders, can develop acne. Even people in their 30s, 40s, and 50s can develop acne.2,3 Up to 80% of people between 11 and 30 years of age have acne outbreaks,

 with 27% having severe acne, often leading to scaring.

 During adolescence, acne is more common in boys; in adults, acne is more common in women. By 40 years of age, 5% of women and men still have acne.

	Diet, as a cause of acne, has been controversial. Chocolate, pizza, and nuts do not appear to cause acne, while there is some evidence that diets high in refined sugars and dairy products may be related to acne. There is a stronger connection between skim milk and acne compared with other dairy products: people who drink 2 glasses of skim milk daily have a 44% greater chance of developing acne. White bread, rice, potatoes, and pasta may likewise play a role.

			Minimize psychological stress and embarrassment.

	Most dermatologists use a combination of treatments that can be expensive and require multiple sessions before results are noticeable. Even with treatment, there is no guarantee that a person will be acnefree. Table 2 lists several medications used to treat acne.

 If OTC products do not get the desired result, dermatologists can prescribe stronger medications. Most of these medications help break down blackheads and whiteheads by unclogging skin pores. All medicines have side effects, and your doctor or pharmacist will discuss these with you.

	Acne scarring ranges from mild to severe, the latter being associated with deep tissue scars. Laser skin resurfacing, dermabrasion, chemical peels, and the use of fillers are 4 procedures used to treat acne scars. Laser skin resurfacing removes skin layer by layer, with precision, so that skin cells formed during healing give the skin a tighter, younger-looking surface. Dermabrasion, also called 

, removes layers of skin, as well. Chemical peels involve applying a chemical solution to the skin to make it “blister” and eventually peel off; the new skin revealed is usually smoother than the old skin. Fillers, which are injected, “plump” up scars and bring them closer to the surface, thereby making them less noticeable. The effects of fillers last between 6 and 18 months.

 Acne surgery is another treatment option. The surgery involves lifting the scar to make it less noticeable. Over time, some acne scars fade.

	Your doctor may use medications to prevent scarring. Bellafill was recently approved to treat acne scars. Isotretinoin is also very effective in treating and preventing scars; however, because isotretinoin can cause birth defects, it is not used in pregnant women.

	Acne, left untreated, can lead to scars, depression, and stress. Early treatment is critical to obtain the best results and minimize or prevent scarring.

Dr. Zanni is a psychologist and health-system consultant based in Alexandria, Virginia.

			Acne. US National Library of Medicine website. www.nlm.nih.gov/medlineplus/ency/article/000873.htm. Accessed January 7, 2015.

			Under the microscope. Centers for Disease Control and Prevention website. www.cdc.gov/bam/nutrition/microscope.html. Accessed March 25, 2015.

			10 myths and facts about adult acne. WebMD website. www.webmd.com/skin-problems-and-treatments/acne/features/10-myths-and-facts-about-adult-acne. Accessed January 7, 2015.

			Questions and answers about acne. National Institute of Arthritis and Musculoskeletal and Skin Diseases website. www.niams.nih.gov/Health_Info/Acne/default.asp. Accessed January 7, 2015.

			Jaggi R. Acne vulgaris. Medscape website. http://emedicine.medscape.com/article/1069804-overview. Accessed January 7, 2015.

			Katta R, Desai SP. Diet and dermatology: the role of dietary intervention in skin disease. 

			Acne: role of food remains controversial. American Academy of Dermatology website. www.aad.org/dw/monthly/2011/september/diet-and-acne. Accessed January 7, 2015.

			Acne: tips for managing. American Academy of Dermatology website. www.aad.org/dermatology-a-to-z/diseases-and-treatments/a---d/acne/tips. Accessed January 7, 2015.

			Acne scars: treatment and outcome. American Academy of Dermatology website. www.aad.org/dermatology-a-to-z/diseases-and-treatments/a---d/acne-scars/treatment-and-outcome. Accessed January 7, 2015.

			Marotta R. FDA approves new acne scar treatment. 

 website. www.pharmacytimes.com/product-news/FDA-Approves-New-Acne-Scar-Treatment. Accessed January 7, 2015.

Articles

Acne: More than a Cosmetic Problem

Lifestyle and dietary factors are the leading causes of hyperlipidemia.

Consider this: Fats and oils accounted for approximately 45% of calories consumed in the 1960s; during that decade, 13% of adults were obese and less than 1% had diabetes. Current data indicate that fats and oils account for 33% of calories consumed today, yet 34% of Americans are obese and 11% have diabetes.

 Clearly, attempts to increase the awareness of cholesterol in the United States have not been tremendously successful (Table 1).

Numerous factors fuel hyperlipidemia, but lifestyle and diet are the leading culprits. Likewise, certain medications (eg, some birth control pills, diuretics, b-blockers, some antidepressants, and HIV medications) can negatively impact cholesterol levels.

For the past 10 years, treatment guidelines for hyperlipidemia have advocated a treat-to-target approach. The clinical goal was to treat patients until they reached the recommended target cholesterol level (Table 2).

New guidelines from the American Heart Association, American College of Cardiology, and the National Heart, Lung and Blood Institute were published in 2014.

 The most significant change is that patients are no longer treated simply to reach specific target levels. This shift is based on insufficient evidence that better outcomes are associated with designated target cholesterol levels. For example, there is no evidence that a patient with coronary disease who has a low-density lipoprotein (LDL) cholesterol level of 78 mg/dL will have a better outcome if his or her target LDL level decreases to 70 mg/dL. The new guidelines do not abandon the importance of lipid levels, but treatment targets are now defined as a percentage from baseline readings.

Today’s guidelines define 4 groups of patients for primary and secondary prevention of hyperlipidemia and, for each group, a recommended intensity level for statin therapy (Table 3). Statin therapy is now considered the first-line treatment for lowering cholesterol levels. Other cholesterol-lowering agents such as fibrates, bile acid sequestrants, and niacin are reserved for patients who are statin intolerant or for when statins fail to reach the desired outcome.

These groupings more accurately define patients who are most likely to benefit from statin therapy. As with all guidelines, patient groupings help guide clinical practice but do not replace clinical judgment. Table 4 defines high-, moderate-, and low-intensity statin therapy.

The guideline that is generating the most controversy is treating patients with LDL cholesterol levels ranging from 70 to 100 mg/dL and whose risk for heart disease exceeds 7.5%. Critics question the role of treatment for those with low LDL cholesterol levels. They also note that the coronary risk score is heavily weighted by age, blood pressure, and smoking status.

 Readers can access the American Heart Association’s online risk calculator at https://www.heart.org/ gglRisk/main_en_US.html.

Evidence demonstrates that intense and comprehensive hyperlipidemia counseling results in greater changes in behavior. Counseling should begin with an assessment of the patient’s understanding of hyperlipidemia, including LDL cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides. The pharmacist can explain the difference between good fats and bad fats. If the patient is taking cholesterol-lowering agents, the pharmacist can review side effects and discuss the new guidelines, emphasizing that there is no “magic” number.

It is also important to emphasize that a healthy diet and exercise may be sufficient to reduce cholesterol without medication. Daily caloric intake from fat should range from 25% to 35%, and calories from saturated fat should be less than 7%. Replacing trans fats with polyunsaturated fats is the most effective measure for improving blood lipid profiles.

 When exercise is combined with a diet low in saturated fat, LDL cholesterol levels can be reduced by 7% to 15% and triglycerides by 4% to 18%, with a 5% to 18% increase in HDL cholesterol. Online Table 5 provides additional counseling guidelines.

Dr. Zanni is a psychologist and healthsystem consultant based in Alexandria, Virginia.

TABLE 5: COUNSELING FOR PATIENTS WITH HYPERLIPIDEMIA

				·         Emphasize that medication to lower cholesterol is not a license to eat an unhealthy diet.

				·         Review the consequences of high cholesterol, including heart attack, atherosclerosis, stroke, and vascular disease.

				·         Recommend frequent cholesterol screenings. Some guidelines recommend screening beginning at age 20. Others recommend the first screening for men at age 35 and for women at age 45.

				·         Discuss tobacco cessation. Quitting smoking can increase HDL up to 10%.

				·         Encourage physical activity.

				·         Stress weight reduction. For every 6 pounds lost, HDL increases by 1 mg/dL.

				·         Motivate patients to read food labels.

				·         Recommend limiting intake of saturated fats by cutting back on red meat and full-fat dairy products and increasing omega-3 fatty acids (eg, cold-water fish, walnuts, canola or soy bean oil, flax seeds).

1. Fats and cholesterol: out with the bad, in with the good. Harvard School of Public Health website. www.hsph.harvard.edu/nutritionsource/fats-full-story/. Accessed November 17, 2014.

2. Cholesterol fact sheet. Centers for Disease Control and Prevention website. www.cdc.gov/dhdsp/data_statistics/fact_sheets/docs/fs_cholesterol.pdf. Accessed November 17, 2014.

3. HIV and hyperlipidemia. AIDSinfo website. http://aidsinfo.nih.gov/education-materials/fact-sheets/22/66/hiv-and-hyperlipidemia. Accessed November 17, 2014.

4. Dugdale III DC. High blood cholesterol levels. MedlinePlus website. www.nlm.nih.gov/medlineplus/ency/article/000403.htm. Accessed November 17, 2014.

5. Mayo Clinic Staff. Cholesterols levels: What numbers you should aim for? Mayo Clinic website. www.mayoclinic.org/diseases-conditions/high-blood-cholesterol/in-depth/cholesterol-levels/art-20048245. Accessed November 17, 2014.

6. Stone NJ, Robinson JG, Lichtenstein AH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association. Task Force on Practice Guidelines. 

7. O’Riordan M. New cholesterol guidelines abandon LDL targets. Medscape website. www.medscape.com/viewarticle/814152. Accessed November 17, 2014.

8. O’Riordan M. ACC, AHA update guidelines for the treatment of high cholesterol. Available at www.medscape.org/viewarticle/813659?src=emailthis. Accessed November 6, 2014.

9. Kelly RB. Diet and exercise in the management of hyperlipidemia. 

10. Mayo Clinic Staff. HDL cholesterol: How to boost your ‘good’ cholesterol. Mayo Clinic website. www.mayoclinic.org/diseases-conditions/high-blood-cholesterol/in-depth/hdl-cholesterol/art-20046388. Accessed November 17, 2014.

11. Hyperlipdemia. Southern Illinois University School of Medicine. www.siumed.edu/surgery/vascular/hyperlipidemia.html. Accessed November 17, 2014.

Hyperlipidemia: Updated Guidelines Impact Counseling

Sore throats lasting longer than a week require medical attention.

Sore throat (also called pharyngitis) is typically caused by a viral or bacterial infection. An estimated 200 to 300 different strains of virus cause colds and sore throat.

 In up to 90% of cases, sore throat is caused by viruses linked to the common cold or flu. The other 10% of cases result from bacterial infections or some other medical condition. The bacteria that most commonly cause sore throat are streptococci. Infection with streptococcal bacteria is commonly called 

Sore throat can also be caused by irritants such as air that is low in humidity, smoking, air pollution, excessive yelling, postnasal drip caused by allergies, and breathing through the mouth. Injury to the back of the throat and stomach acid backing up into the throat and mouth are other causes of sore throat.

Although sore throat affects people of all ages, children aged 5 to 15 years, smokers, allergy sufferers, and people with compromised immune systems are at higher risk.

Sore throat symptoms are easily recognized. Your throat hurts and is irritated, swollen, or scratchy. Pain increases when you swallow. You may also have tenderness in your neck. Other symptoms that are commonly associated with sore throat are listed in Table 1.

If your sore throat is due to a virus, it should go away within 7 to 10 days. When a person has strep throat, however, throat pain starts out gradually and quickly becomes severe and constant. Swallowing may be difficult. You may also have a fever of 100°F or higher. Symptoms worsen at night.3,4,6 Strep bacteria can lead to other conditions such as infection of the tonsils, sinuses, skin, blood, or middle ear, as well as various inflammatory illnesses. 2 Seek immediate medical help if your symptoms include drooling, an inability to swallow, difficulty opening your mouth, difficulty breathing, redness or swelling of the neck, swollen lymph nodes, bleeding from the throat, or a fever higher than 101°F.

Unless sore throat is caused by a bacterial infection, antibiotics are not prescribed. Antibiotics do not kill viruses—the most common cause of sore throat&mdash;and have no impact on symptoms. Using antibiotics unnecessarily creates strains of bacteria that are resistant to antibiotics. Without antibiotics, 85% of patients will be symptom-free within about 1 week.

 lists recommended strategies for managing sore throat pain. If your symptoms do not improve within a week, contact your doctor.

If your doctor believes you have strep throat, he or she may do a rapid antigen strep test, which determines whether you have a strep infection. This test provides results within minutes but is not always accurate. Therefore, your doctor may also take a throat culture, which is considered more accurate, and send it to the lab for testing. Test results are usually available within 24 to 48 hours.

Antibiotics are effective in treating bacterial infections. Penicillin is the most common antibiotic prescribed for strep throat. If you have a penicillin allergy, your doctor may prescribe erythromycin. Your doctor most likely will give you a 10-day supply. It is critical that you take all of the medication even if your symptoms subside or go away. Soft stool and diarrhea are common side effects of antibiotics. Taking an OTC antidiarrhea agent should minimize these side effects. Along with killing the bacteria that cause strep throat, your doctor will focus on preventing complications from the infection. For example, untreated strep throat can lead to rheumatic fever, which causes heart damage along with kidney problems.

People with bacterial infections remain contagious for approximately 24 hours after they begin taking antibiotics. Consequently, if you have strep throat, it’s important to limit your contact with other people until you are no longer contagious. Table 3

 lists recommendations for preventing sore throat.

Up to 90% of all sore throats are caused by viruses and clear up within a week. Those with a sore throat lasting longer than a week should seek medical intervention.

Treating Sore Throat

Although very contagious, head lice can be treated and prevented.

Head lice are insects with 6 claws and no wings. Lice cannot hop or fly. Lice move by crawling. Their claws hold tightly onto hair. They are gray-white or tan and the size of sesame seeds. Lice feed on human blood 4 or 5 times a day. Lice live and breed within a quarter inch of the hair from the base of the scalp, especially near the ears and neck. Head lice may also thrive in eyebrows and beards. Lice are most active at night.

Head lice are very contagious. Lice are spread by direct contact with someone who is infested or by sharing clothing (eg, hats) with someone who has lice. Female lice attach their eggs firmly to hair. Lice eggs are called nits, which are usually yellow to white. Nits are extremely small and can be confused with dandruff. Nits hatch in 8 or 9 days. They reach adult size in 9 to 12 days after hatching.

 Lice live up to 30 days. Females can lay 50 to 150 eggs in their lifetime.

 If lice fall off the scalp, they die within 2 days.

Six to 12 million children, mostly between 3 and 12 years of age, get lice each year.

 It is more common in girls and in individuals living in crowded conditions. 

 Head lice is less common in African Americans.

How Can I Tell if My Child Has Head Lice?

The first symptom of head lice is intense itching. Other symptoms include a tickling sensation or a feeling that something is moving in the hair. Small red bumps on the scalp or neck may also be present (Table 1

 Constant scratching can result in open wounds and infections.

The cleanliness of a person or house has no role in spreading head lice.

Insect sprays should never be used. They may contain harmful chemicals.

 Lice tightly hold onto hair when underwater. Chlorine in pool water cannot kill lice.

Head lice are treated with OTC products containing pyrethrins. Rid and Nix are brand names of products containing pyrethrins (Table 2

). Common side effects of pyrethrins are skin irritation and the feeling that the scalp is burning and itchy. People allergic to ragweed or chrysanthemums should avoid pyrethrins.

Two treatments spaced 7 to 9 days apart usually get rid of lice. The second treatment is needed to kill nits that have hatched after the first treatment. Because products may not kill all the nits, you should continue to comb for nits for at least 2 weeks following the second treatment. Some lice are resistant to treatment. Your doctor can prescribe a cream, lotion, or shampoo that kills resistant lice.

 There is some evidence that tea tree oil and lavender oil are effective against lice.

 While the American Medical Association recommends tea tree oil, the National Institutes of Health does not recommend herbal treatments. 

If you want to avoid medications, the following methods are recommended for treating head lice.

Apply an oil (eg, cooking oil) or petroleum jelly to wet hair. Using a lice comb, remove nits and lice. Comb the hair for 30 minutes every 2 or 3 days for a 2-week period.

Remove all hair by shaving the entire head and neck. Lice die if they cannot attach to hair.

Teach your children about head lice and ways to prevent it (Table 3

The Centers for Disease Control and Prevention has easy-tounderstand information on head lice at www.cdc.gov/parasites/lice/ head.

		Madke B, Khopkar U. Pediculosis capitis: an update. 

		Parasites-lice-head lice. Centers for Disease Control and Prevention website. www.cdc.gov/parasites/lice/head. Accessed June 15, 2014.

		Smith CH, Goldman RD. An incurable itch: head lice. 

		Head lice. FamilyDoctor.org website. http://familydoctor.org/familydoctor/en/diseases-conditions/head-lice.printerview.all.html. Accessed June 18, 2014.

		Gholamnia Shirvani Z, Amin Shokravi F, Ardestani MS. Evaluation of a health education program for head lice infestation in female primary school students in Chabahar City, Iran. 

		Head lice: diagnosis, treatment, and outcome. American Academy of Dermatology website. www.aad.org/dermatology-a-to-z/diseases-and-treatments/e---h/head-lice/diagnosis-treatment. Accessed July 20, 2013.

		Treating head lice. FDA Consumer Health Information website. 

www.fda.gov/forconsumers/consumerupdates/ucm171730.htm

		Barker SC, Altman PM. A randomised, assessor blind, parallel group comparative efficacy trial of three products for the treatment of head lice in children: melaleuca oil and lavender oil, pyrethrins and piperonyl butoxide, and a “suffocation” product. 

		Tea three oil. MedlinePlus, National Library of Medicine website. www.nlm.nih.gov/medlineplus/druginfo/natural/113.html. Accessed June 15, 2014.