John R. Tkach, M.D.
300 North Willson, Suite 203B
Bozeman, MT 59715
(406) 587-5442


Patient Information Sheet

Let me share with you some information about acne. I believe that if you know what's going on with your skin, the treatment will work better.

We do not know what causes acne, but we do know some things. Most of the time, acne eventually improves and even can go away. I cannot tell you when it will go away. It could be 6 months or 10 years or never.

Our goal is to find an agreeable and effective treatment that you can use yourself and rely on to control your acne. If the medicine does not work, you are not getting your money's worth out of it. If a medicine works, but you don't like it, you won't use it. I cannot guarantee that I can please you, but I think I can. I want to.

This is control and not a cure. If you stop using the medicine, the acne will come back. If it is any consolation, everybody tends to get some acne.

What Happens in Acne?

Normal Follicle

Normal Follicle

There are little hairs on your face. If you look in a mirror with light coming from the side, you can see this fuzz on your nose, tiny hairs. This is normal. If we look at the skin in cross section under the microscope, it looks similar to this drawing of a normal hair follicle. The hair follicle produces the tiny hair. Associated with these small hair follicles are surprisingly large oil glands that make an oily material call sebum. The sebum empties into the hair follicle, flow out its opening, and onto the surface of the skin. This is what makes your skin oily. It's normal.

The wall of the hair follicle is line by a thin layer of dead skin. Normally, these cells are supposed to be shed gracefully a few cells at a time. In acne, the dead skin cells stick together and form a clump of dead skin in the opening of the hair follicle.



You can see them as little brown or black dots that we call blackheads. The dark color is due to melanin, a natural body pigment, and oxidized lipids. Melanin is what gives color to your suntan and moles. Acne is not due to being dirty. You cannot wash it away any more than washing away a freckle. In fact, if you wash over 5 times a day, it may make acne worse. Excessive washing and abrasive scrubs irritate the skin without helping the acne. That interferes with using the medicines that do help. So, when you wash your face, use a mild soap. Ask me for free starter sample. Liquid soaps tend to be milder than bar soaps.



Sometimes the little plugs of dead skin form deeper down under the opening of the hair follicle in the follicle neck. When you look in the mirror, you may not be able to see a blackhead, but just a little bump. We call these whiteheads.

Whiteheads and blackheads plug up the opening of the hair follicles, and the oil cannot escape. The oil gland does not know this, and it continues making oil. The trapped oil accumulates in the hair follicle casing it to swell up like a balloon. A bump occurs under the blackhead or whitehead.

This continues until the hair follicle cannot hold any more oil. Then the oil erodes through the wall of the hair follicle, leaks into the tissue, and irritates the skin producing a pimple with pus, a pustule.



If you look in the mirror, you will see them in different stages of development from time to time. Pinching them out is undesirable because sometimes the plugs of dead skin are stuck in so tightly that you cannot force them out. Forceful squeezing tends to drive the pus deeper under the skin to produce more inflammation.


If we could prevent the formation of new blackheads and whiteheads or peel them away faster than they form, that would solve a lot of the problem. There are two medicines we use to do this. Retin A and benzoyl peroxide.

Retin A works by preventing the formation of new blackheads and whiteheads. Because of the way it works, it may take 4-6 weeks to see results. Do not be discouraged if your acne does not improve in 2 weeks. When Retin A works, it usually works well. The problem with Retin A is irritation. But there are some ways to get around this.

Benzoyl peroxide works by peeling away the blackheads and whiteheads faster than your body makes them and by inhibiting the growth of bacteria. You get results in 2 weeks.

Acne medicines can irritate the skin. It is not an allergic reaction. The trick is to find the highest concentration (strength) that works well without causing irritation. You just have to try it to find it. Sadly, the drug companies do not give out free starter samples for most acne medicines anymore.

Avoiding Irritation

A good way to avoid irritation is to apply the medicine while your skin is dry rather than wet. If you will apply the acne medicine to the acne areas while your skin is dry, the medicine gets into the hair follicle openings where you want it 8 time better than into the space between hair follicles, where you don't want it. If, on the other hand, you apply the medicine while your skin is wet, it will get into the space between the hair follicles 10 times more than into the hair follicle openings. That causes more irritation than benefit.

I suggest applying the medicine at bedtime. You do not need to wash your face first, but if you do, let it dry fir 10 minutes before applying the medicine. It helps to apply the medicine at bedtime to avoid irritation from sun exposure. Use a sunscreen like Neutrogena Ultra-Sheer Dry-Touch SPF 100 in the day to avoid sunburn.

Retin A tends to be irritating initially and then the skin adjusts to it. I suggest using it every third night the first week. Put a dab the size of a green pea on your forehead, chin, and each cheek bone area. Rub it in well until it disappears. If you are putting on more that will rub in, you are putting on too much.

If it is not too irritating at the end of 1 week, then the second week use it every other day for a week. If that is tolerable, the third week, try it every day. But don't start off every day. Build up a tolerance. For benzoyl peroxide, start every other day. You are letting your skin adjust to it.

Micro Formulations

A new technology loads the medicines into microscopic little sponge-like beads that slowly release the medicine a few molecules at a time. This has two advantages. Almost all topical medicines work for about 45 minutes, and then they are gone. If you apply most forms of acne medicines to the skin once a day, you are getting treatment for only 45 minutes out of 24 hours. That's 3 % of the day. The micro formulations last 8 hours, 33% of the day. That's 10 times more treatment, even at low concentrations. Wow!

The regular formulations also are more irritating because you are applying a stronger concentration. It's kind of like flashing a flamethrower over your face. Well, may not that bad, but you get the idea.

Retin A micro comes in 0.04% and 0.1 %. Benzoyl peroxide micro is NeoBenz Micro. It comes in 3.5%, 5.5%, and 8.5%. I have seen NeoBenz Micro work miracles. It is best to start low and build up.

Deep Pustules and Cysts

Deep pustules are had to squeeze out. Cysts are impossible to squeeze out, so don't try. You may drive the irritating contents under the skin producing more scarring. It's not that the hair follicle openingis plugged up in cysts. There is no opening. These respond better to antibiotic pills like tetracycline, minocycline (super tetracycline), and sulf drugs. I don't like to use oral antibiotics unless we have to. Such medicines may cause increased risk of sunburn. Use a sunscreen. Doxycycline is more likely to cause sun sensitivity.

An effective emergency treatment for cyst is for me to inject them with very dilute Kenalog, a cortisone, and drain out the pus (irrigation). This is 75%-80% like to improve the cyst within 2-3 days. If you need emergency relief before an important event like a wedding or are just having particularly annoying cysts, call my secretary and tell her your need a brief visit for cyst injection. 15 minutes are usually long enough for those visits.

The treatment of last resort is Accutane pills used for four months. The cost ranges from $2,000 to $6,000 for the medicine alone for a four months course of treatment. See my separate Accutane information sheet. It is well worth reading. Accutane is approved for severe scarring cystic acne, but dermatologists are also using it for milder acne that is very stubborn and won't respond to the milder treatments. Usually, Accutane works so well, you do not need other treatment in the future. Sometimes ongoing mild treatment is needed, but usually not. There is a 10% risk that Accutane-responsive acne may come back after 2-3 years requiring a second course of Accutane.

Role of Sunlight

Sunlight in the summer improves most cases of acne. What they don't tell you is that, after 6 weeks of daily UV exposure, about 25% of people get worse blackheads and whiteheads again. We don't know why.

Azelex Cream

Many patients have profoundly benefitted from Azelex cream. The advantages are that it often works when nothing else works, and it tends not to be very irritating. I have seen Azelex work miracles.

Other Topical Creams

Differin (adapaline) is similar to Retin A. Some people really like it. Tazorac (tazarotene) is sort of like topical Accutane. That's not quite right, but it is close. Tazorac can cause birth defects during pregnancy. That's too risky for me. I don't prescribe it. Aczone is a topical preparation of an anti-leprosy medicine dapsone. Its effectiveness remains to be seen.

Benzaclin is a combination of benzoyl peroxide and clindamycin. The benzoyl peroxide helps the clindamycin penetrate better. There is also a topical clindamycin solution.

Birth Control Pills

In my experience, some BCP's are about 66% likely to help. As with pregnancy, some people get worse the first three months and then get better. Give BCP's 3 month before concluding about their benefit. Antibiotics taken at low doses should not interfere with BCP's.


Diet affects acne, in my experience, in only about one person out of 50. If your acne is aggravated by what you eat, you already have figured it out. The most common cause is xanthines like caffein in soft drinks, tea, coffee and chocolate. Chocolate is a complicated food. Some people have trouble with sweets and dairy products like whole milk, cheese, and ice cream.

Excoriated Acne

Some people are mysteriously compelled to stand in front of the mirror and to pick at their acne. Sometimes this is severe. I have been doing a study on this since 2004. People who pick at their acne tell me similar stories. They do not know why they pick. They cannot control it. They hate that they do it. It somehow calms them. No one has been able to help them. It is worse with stress.

I have gained some good experience treating excoriated acne using Rapid Reintegration Procedure. See the link on the bottom of the menu of my home page. When RRP works, there is no question about it. You will know right away. Picking is a symptom. The urge to pick comes when events in the present occur that are reminiscent of traumatic events in the past. It is accompanied by a feeling. By following that feeling, I can gracefully help you to resolve hidden traumas from the past. I love treating people with excoriated acne.

Give Yourself Credit

When your acne improves, you deserve the credit. You did the treatment. I sit in my office and hand you a prescription, a piece of paper, and give you the suggestion to go buy it and use it. That's not the same as applying a medicine every day or taking a pill. You did the work. You deserve the credit.

Acne is emotionally distressing. Don't suffer. Get it treated.

The information provided in these patient information sheets is offered for general informational and educational purposes only; it is not offered as and does not constitute medical advice. In no way are any of the materials presented meant to be a substitute for professional medical care or attention by a qualified practitioner, nor should they be construed as such.

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