pdf of this article

For more information about skin conditions and their treatment, contact:



Gregory J. Wilmoth, MD
Eric D. Challgren, MD
Margaret B. Boyse, MD
Laura D. Briley, MD
Tracey Cloninger, PA-C

4201 Lake Boone Trail, #200
Raleigh, NC 27607
Telephone: (919) 782-2152



4201 Lake Boone Trail, #207

Raleigh, NC 27607
Telephone: (919) 863-0073

Acne Across the Life Span

Acne is a multifaceted disease involving the skin and the immune system, with many possible causes, many aggravating factors, and a number of different approaches to treatment that must take into account patient characteristics, whether the patient is 8 or 80.

Dr. Briley offers a patient light treatment and engaging conversation.

“When I am designing a treatment plan for a patient with acne,” Says Dr. Laura D. Briley of Southern Derma-tology and Cancer Center in Raleigh, “I am looking at the whole picture of the person in front of me. First of all, there’s the age of the patient. A teenager is more likely to have a poor diet high in processed foods and carbs—things that will contribute to acne. They are more likely to experience self-esteem issues related to their appearance, so something that will work quickly is optimal.

“Teenagers are also less likely to be consistent in their compliance with medication, so while a topical wash and antibiotic applied daily may do the trick, it will only work if they actually do it every day. So, for some, a simple pill once daily may be a better option. However, parents of teenage girls are sometimes uncomfortable with hormonal treatment—which is basically birth control—so that is something I must consider and discuss with the family. For adolescents, taking both the parents’ and child’s needs and goals into account plays a significant role in how I decide to treat.”

Sharper Tools in the Medical Toolbox

Medical research is a continuous process of discovery and learning, notes Dr. Briley. “And while progress in drug development can be painstakingly slow, when the eventual result is a new medication with higher efficacy than anything we’ve had before, millions of lives can be changed.

“The extent to which derma-tology really involves the immune system is a relatively recent understanding,” Dr. Briley says. “For a long time, as we began to realize that many skin conditions were primarily caused by a dys-functional or over-active immune response, the only treatments available were general immuno-suppressants. Someone with psoriasis, for example, would get corticosteroids, which would tell the immune system as a whole to calm down, be less active, but wasn’t specific to the cause of the disease. So, when the biologic class of drugs came out, they literally changed the whole approach to psoriasis. These were the first drugs to target the specific part of the immune system causing the problem, and the results in treatment far surpassed our highest hopes when using topical or oral steroid treatments.

“While biologics are old news now, they were a huge and still relatively recent breakthrough in the treatment of psoriasis and eczema. New biologic drugs continue to come out every year, giving even more opportunity for patient specific treatment. Tremfya, for example, came to market six months ago for the treatment of psoriasis, and Dupixent just arrived for the relief of eczema. Often one drug from this class will work wonders for one patient, but the next responds better to another. We don’t understand fully what makes the difference, other than knowing that everyone’s body, chemistry, and genetics are different. So it’s of huge benefit that new biologic medications continue to be developed and expand the medical tools we have available to help our patients.”

Another new biologic—Xolair— has made a huge difference in the treatment of chronic hives, a condition, Dr. Briley says, that is more common than one may think. “We typically think of hives as an allergic reaction to a medication or something your skin came in contact with. They usually last a few days, maybe weeks, and resolve. But for some people, hives are a problem they deal with every day, with no known cause.  For a long time, the only option was for these people to live on daily antihistamines, medications 10 times stronger than Benadryl—and you know how sleepy Benadryl can make you. With the introduction of Xolair, a once-a-month injection, my patients with this challenging condition no longer need the antihistamines. Many of them are able to take the monthly injections for a year and whatever has gone wrong in the immune system seems to resolve and they no longer even need the shot. It’s really quite an amazing improvement in our ability to treat these very trouble-some conditions, and hugely improve the quality of life for many of our patients.”

Then there are women in the 20s, 30s, and 40s, Dr. Briley continues, “who are experiencing hormonal acne, which is different from the acne of a teenager. Whereas in youth, acne was in the central face, superficial and eruptive, acne during this later time of life more often has a deep, cystic presentation along the neck and jawline. Here, the approach is generally hormone-based, but again there are factors to consider. What other medications are they taking? Are they trying to get pregnant? Are they taking fertility treatments? Some medications I may use would prevent pregnancy, some can cause harm or death to a fetus, so these are going to be very important aspects of my plan of care in this population.”

Non-Pharmaceutical Approaches to Care

“Stress plays a huge role in acne of all ages,” Dr. Briley notes. “Whether it’s physical or emotional, the physiological response to stress is inflammation, and acne is an inflammatory disease. So, stress at work or a flare-up in your Crohn’s disease—both are going to worsen existing acne. Everything is related.  I counsel patients to find good ways to manage stress, be it exercise, yoga, acupuncture, meditation—whatever works for them.”

And then there’s diet, notes Dr. Briley. “Again, controlling inflammation is key, so eating an autoimmune diet—one that minimizes inflammatory foods such as carbohydrates, sugar, processed and greasy foods—is going to help. Additionally, excess adipose tissue causes inflammation, so weight loss is another area in which I counsel my adult patients suffering from acne.”

Tying it all Together

Allison, a woman in her 40s, is an example of how stress, inflammation, and dermatological skin conditions are related. She has Lichen planopilaris, a condition, Dr. Briley explains, that causes periodic inflammation resulting in alopecia. “When Allison experiences stress,” Dr. Briley says, “areas of her scalp become inflamed, cupping the hair follicles, causing the hair to fall out and the follicle itself to close, never to open again. The result is areas of permanent baldness.”

Topical and injectable steroids helped control the disease, but it wasn’t until Allison realized the relationship between her flare-ups and her level of stress that she was able to really get it under control.

“After a few years of working with her,” Dr. Briley remembers, “Allison removed herself from a stressful home environment, started seeing a psychiatrist, and got on anti-anxiety medication. All of a sudden, her scalp began to heal. This is such a good example of how every part of the body is related and needs to be considered in any treatment plan for almost any condition. Anxiety medication is not what one would first consider for the treatment of a skin condition, but for Allison, that is what made the biggest difference.”