Acne, Bad Behavior, and Tobacco Tax – PediaCast 044

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  • A Discussion on Acne with Dr. Suzanne Spadafora
  • Chili Sauce Linked to Botulism
  • Food Industry Makes Marketing Pledge
  • When Bad Behavior is Good
  • Little League Elbow
  • Tobacco Tax Hike
  • Teenage Self-Injury Rates
  • Benefits of Drama Club


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Announcer: This is PediaCast.


Announcer: Hello, moms, dads, grandmoms, grandpops, aunts, uncles and anyone else who looks after kids. Welcome to this week's episode of PediaCast, the pediatric broadcast for parents. And now, direct from Birdhouse studios, here's your host, Dr. Mike Patrick Jr.

Dr. Mike Patrick: Hello, everyone and welcome to this week's edition of PediaCast. It's episode 44. I'd like to welcome everyone to the program. This is Dr. Mike coming to you from Birdhouse Studio. And a special warm welcome to those of you who are visiting us for the very first time who have found us because of our nomination in the People's Choice Podcast Awards in the Education category.


And those of my regular listeners who nominated PediaCast, I want to extend a thank you. And now it's time to actually vote, so make sure that you head on over to the Podcast Awards site. You can vote every day. So once every 24 hours you can vote for PediaCast. Again, that's in the Education category, and there is a link in the side bar at

And if you click on that link it'll take you to the nomination… or, not the nomination, the voting page. There's a slate of lots of good podcasts there. In fact, you may want to check out, there are links to the actual podcast pages as well as their feeds and you may find some podcasts that you didn't know about before because they're a great group of programs.

So again, don't forget to go to and click on the Podcast Award link in the side bar of the page. And again, you can vote for PediaCast and lots of other good shows once every 24 hours for the next two weeks. So I encourage you to do that, and again a warm welcome to those of you who have found PediaCast for the first time and are visiting us now.


So what's this show all about? In a nutshell, basically we do news, we answer listener questions. We talk about a little bit of research, a bit of facts, parent's and child health. And this week, we're actually kicking off a new segment called our in-depth segment. We're going to have an interview with Dr. Suzanne Spadafora, a dermatologist practicing in Virginia. And the topic this week is acne.

And we really geared it at a level that not only parents can understand, but I think a lot of teenagers out there who have problems with acne would probably be very interested in this discussion as well. So if you have a teenager at home, you may want to have them tune in and listen to our in-depth segment which will be coming up in a little while.

Okay, don't forget, if there's a topic that you would like us to discuss or if you have a question or comment for us, it's easy to get a hold of us here. Just go to and click on the Contact link. You can also email or call the voice line at (347) 404-K-I-D-S. That's (347) 404-KIDS or 5437.


Also one bit of information. The Manic Mommies are having a Manic Mommies Escape. And of course I think it's important for mommies, whether they're manic or not, to sometimes get away and the Manic Mommies are providing an opportunity to do that. And if you haven't checked out that information, again there's a link in the side bar at that'll take you to the Manic Mommies site that tells all about their escape.

One more bit of a business, I guess I should say, before we get to the News Parents Can Use segment. And that is we have a new friend here at PediaCast, and it's called, B-U-N-D-L-O. And of course we'll have a link in the Show Notes.


But basically what Bundlo is is an online blog, photo album and journal for your baby. And really, it's sort of the Web 2.0's answer to the traditional baby book. Don't worry, it's password protected so the only people who you want to have access will have access to it. But really, it's a place just to sort of outline what your baby's doing and to put the photo album up with pictures and also keep a journal when they said their first word, when they got their first tooth. Just basically like a baby book but online and you can share with the family immediately who might be far away.

Now why is this important for PediaCast? Well, Bundlo has been kind enough to give us three lifetime plans to give away for absolutely free. Now they already have a free plan, so you can actually go to their website and check it out. But they also then have a Basic level, a Standard level and a Premium level. And really the difference between the levels is how much storage that you get in terms of being able to put pictures up on the website.


And so they are giving us a free lifetime membership at each of those levels, not the free one, but at the Basic, the Standard and the Premium levels. And we're doing this to celebrate the kickoff of our in-depth segment.

And how we're going to do this, it's pretty easy. Each interview that I do, the interviewee is going to release or let you know a code word for the next four episodes. And really, all you have to do is write down the code word each episode for the next month, and then the code words all put together will form a phrase that you'll have to put in the right order.

Email in your answer when we get to that part, and then we will basically pull three people at random who are not affiliated with PediaCast in any way. And it'll be completely random and then those will be the winners of the three lifetime subscriptions.


Now if you don't have a baby at home, that's okay because if you do this and win, you could assign your prize to anyone that you'd like. So that will be coming up. And our first code word, we'll let you know what that is during our in-depth segment with Dr. Spadafora on acne a little bit later on in the show.

Also, one other thing I came across this week is a site. It's kind of like Digg, except for parent news stories and parent sites. It's called Mother Approves. I've not been in contact with them at all, I just wanted to share this with you because it's really seems like a neat idea. They're at, and we'll put a link in the Show Notes for you for that.

Okay, we better get moving on because we have a lot to get to today. Don't forget the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions of formulate treatment plans for specific individuals. So if you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands-on physical examination. Also your use of this audio program is subject to the PediaCast terms of use agreement which you can find at


And with that in mind, we'll be back with News Parents Can Use right after this short break.


Dr. Mike Patrick: Our News Parents Can Use is brought to you in conjunction with news partner, Medical News Today, the largest independent health and medical news website. You can visit them online at


Chili sauce linked to botulism. Last week, federal health officials warned consumers to throw away certain cans of hotdog chili sauce after linking the product to the first cases in decades of botulism affecting US commercial-grade canned foods. This week, the manufacturer of the chili sauce added several more products to the list, including beef stew, corned beef hash, barbecue beef and chip… [laughter] creamed chipped beef gravy. Never used that before.

The warnings come after four people required hospitalization for complications of botulism. Contamination by the botulism toxin is extremely rare for a commercially-canned product. Centers for Disease Control and Prevention medical epidemiologist Dr. Michael Lynch said the last such US case dates back to the 1970s. According to Lynch, the roughly 25 cases reported each year typically involved foods canned in the home.


The victims, two each in Texas and Indiana, were seriously ill but expected to survive. The Texas case involved children who are siblings and the Indiana case involved an adult couple. The products were made by the Castleberry Food Company owned by Bumble Bee Seafoods. The company based in San Diego had no immediate comment.

Robert Brackett, director of the FDA's Center for Food Safety and Applied Nutrition, says expert investigators are on the scene at the Castleberry plant in Augusta, Georgia where the products were canned.

Botulism is a muscle-paralyzing disease caused by a toxin made by a bacterium called clostridium botulinum. Brackett urged consumers to discard any of the recalled cans without opening them because the toxin is so potent if you get it on your hands or it sprays in your face it can make you ill.


Typically, commercially-canned foods are heated long enough into high-enough temperatures to kill the spores. "It's been a triumph for food safety that canning is safe, that's what makes this so unusual,… Lynch said.

Symptoms of botulism include double or blurred vision, drooping eyelids, slurred speech, difficulty swallowing, dry mouth and muscle weakness that moves down the body. Eventually, paralysis can cause a person to stop breathing and die unless supported by a ventilator. Most victims eventually recover after weeks to months of care. And we'll have a link in the Show Notes to the complete list of affected products.

The food industry pledges to make healthy food to market healthy food, but will it make a difference? The recent pledge by a group of major food companies to market only healthy foods to kids may have little effect on the diet of the nation's children, so says Kelly Brownell, director of Yale University's Rudd Center for Food Policy and Obesity.


Brownell said research is likely to show a small amount of overall television programming will meet the industry's self-imposed criterion, that 50% of the targeted audience for a specific program is younger than twelve. According to Brownell, the majority of children's marketing exposure comes from programs where young children are not the predominant audience. He also questions the industry's self-imposed definition of which foods are acceptable to market to children.

Brownell calls for an independent review of the impact of the industry plan on marketing to children and on their diets. He says this is a small but positive step to protect children from a tidal wave of messages to eat foods high in sugar, fat and salt. The danger is if the progress stops here and that the public and legislators feel the industry has fully discharged its civic responsibility.


When bad behavior is good. At very young ages, children's defiant behavior toward their mothers may not be a bad thing. This defiance may, in fact, reflect children's emerging autonomy and a confidence that they can control events that are important to them.

These are the findings of a new study conducted by researchers at the University of Texas at Austin and the University of Michigan. The study is published in the July-August 2007 issue of the Journal Child Development.

To understand how very young children react to being controlled by their parents, the researchers videotaped 119 mostly middle class mothers as they interacted with their 14- to 27-month old children. Mothers who were asked to have their children avoid a set of attractive toys and when play time was over, to get their children to help them clean up the mess that they had made.

Based on the taped interactions, the researchers coded children's behaviors, categorizing them as being cooperative, defiant or simply ignoring the request to stop playing and clean up. Children were most likely to be defiant and least likely to ignore requests when their mothers had fewer symptoms of depression and when children were positively interested in their mothers during the interaction. In the end, these children also tended to be highly cooperative.


Children with mothers who had symptoms of depression were more likely to simply ignore requests and less likely to respond with defiance. The researchers suggest that these children do not develop confident assertion with their mothers, learning instead to be overly passive in the face of obstacles.

These results imply that at ages when parents first ask children to conform to requests and commands, active resistance is not a sign of problems in child development or in relationships between parents and children. To the contrary at these very young ages, children's active resistance may reflect a healthy confidence in their ability to control events.


"Although a year or two later high defiance may be a problem, we found that at this age, defiance appeared to be a positive development,… according to Theodore Dix, Associate Professor of Human Development and Family Science at the University of Texas at Austin and the study's lead author. It increased with age and was associated with variables known to predict favorable outcomes for children.

Okay, how about little league elbow, is your child at risk? Over the top. Don't Aim. Push off the rubber. If these phrases are all too familiar to you while at a ball game, they could be causing more harm than good. Sports Medicine specialist, Dr. Raphael Longobardi, of the University Orthopedic Center in Hackensack, New Jersey, is seeing more athletes, younger than ever coming in with overused injuries, particularly Little League elbow due to the pressures of pitching and the increase of organized sports beyond a regular season.

Little League Elbow is an injury to the growth plate inside the elbow joint, most commonly due to excessive throwing. The age group most affected are young athletes between 10 and 15. The combination of the joint being immature and the increased competition and intensity level at that age definitely increases the chance of injury to the growth plate in the elbow and sometimes causing it to separate.


In some cases, if not detected early, the condition may require surgery, explains Dr. Longobardi. Although the symptoms gradually build up, the elbow eventually becomes sore to the touch. The most characteristic symptom is when the player experiences pain with throwing the ball, decreased velocity or distance and sometimes diminished effectiveness. A clinical exam and an x-ray will confirm the diagnosis.

When there are many age guidelines to follow in regard to pitching and throwing, coaches and parents need to be aware of proper ways to prevent overused injuries including, but not limited to, proper warm ups such as stretching, running and easy, gradual throwing and a trained teacher or coach to help supervise a team.


Parents should pay close attention to their kids because a loss of enthusiasm by your child or continuous rubbing of the elbow area could be a warning sign of pain. Dr. Longobardi adds, "ignoring these symptoms and signs can dramatically affect a child's chance to continue playing baseball or softball. If an injury is overlooked today, it can result in future damage that could be more difficult to correct down the road….

And Senate panel approves a huge tobacco tax and an overwhelming majority of 17 to 4 and in defiance of a threatened veto by President Bush, the US Senate Finance Committee approved the bill that expands child health care using a large increase in tobacco tax. Most of the Republicans on the committee joined the Democrats to vote in favor of the bill.

The current legislation for the State Children Health Insurance Program is due to expire at the end of September. If passed by Congress, the new bill would entitle another 3.2 million children in low-income families to receive state-funded health insurance. These families can afford medical insurance but don't qualify for Medicaid because their earnings are just above the cutoff point. If passed, the bill would bring the overall number of state-insured children to grow around 10 million.


President Bush has said a number of times he is against the bill because it expands the government's role in health care and is financed by a huge tax increase. He favors a system of tax breaks to encourage uninsured people to take up private insurance.

The Senate panel voted to provide an additional $35 billion to finance the expanded program, bringing the total spending to $60 billion over the next 5 years. President Bush's approval is for a $5 billion increase to continue the program without expansion, with a total spend of $30 billion over five years.

The committee-approved bill calls for a considerable rise in tobacco tax to pay for the expanded program. The tax would go up from the current $0.39 on each pack of cigarettes to $1.00 per pack. Cigars would attract an even greater increase with premium cigars that are currently taxed at $0.05 being taxed at $10.00 each.


Senators in favor of the bill said the tobacco tax would also discourage smoking, particularly among teenagers, while those against the tax said the increase was well, in a word, ridiculous. According to her report by Reuters, Senate Majority Leader Harry Reid of Nevada, Democrat, said the Senate would approve the bill later this month in defiance of Bush's threat to veto it. He said they we're going to fight for it because, "this is important….

A New York Times report said that Republican Senator Charles E. Grassley of Iowa co-author of the bill, called Bush's plan unrealistic and he couldn't see how only a $5 billion increase in child health funding would enable it to continue doing what it does now.

The report quotes another bill co-author, Democrat Senator John D. Rockefeller IV of West Virginia as saying that Mr. Bush and his Health Secretary, Michael Leavitt, were being pretty belligerent in their criticism of the bill.


Another proposal in the bill would remove the waivers brought in by the Bush administration that allow some states to use money from the program to cover adults who don't have kids. Republican Senator Pat Roberts of Kansas said the new bill would allow states to help low-income families buy private insurance and he said he was proud to support the bill.

A new $1.2 million television campaign has been launched by healthcare workers lobbying support for the legislation in the house. They want Congress to push for higher tobacco taxes as a way to reduce smoking as well as increase health coverage for uninsured children. Getting the bill through Senate may not be as straightforward as some might imagine. The original proposal in the Senate committee by the Democrats was for $50 billion increase so the current $35 billion is a compromise.

However, the Democrats are adamant about pursuing the original $50 billion and some are saying that if they're trying to do this in the Senate, it could make the situation fragile because many Republican senators will be nervous about approving an increase that is significantly above what the Finance committee approved.


Republican Senator Charles E. Grassley summed it up nicely when he said, "I hope they understand it takes 60 votes to get anything done in the United States Senate….

And teens are harming themselves at a higher rate. Non-suicidal self-injury, the deliberate direct destruction of body tissues without suicidal intent is a relatively common occurrence for adolescents in high school, a new study suggests. Led by researchers at the Miriam Hospital and the Warren Alpert Medical School of Brown University, barely half of the teen studied endures some form of self-injury in the past year, that's frequently biting, cutting, hitting and burning the skin. The research is published in the August 2007 issue of Psychological Medicine.

"The findings are important because it suggests that self-injury is more prevalent among adolescents in the general population than previously thought…, says lead author Dr. Elizabeth Lloyd-Richardson, a psychologist at the Miriam Hospital and Assistant Professor of Psychiatry and Human Behavior at Brown University.


If this is the case, it's essentially a wake-up call to take better notice of these behaviors in the community and learn how to help teens manage stress without harming themselves. Researchers decided to explore the frequency and breadth of self-injury by teens in the community because little is known about self-harming behavior in this particular population.

"Although self-injury is commonly encountered in in-patient and out-patient psychiatric and other institutionalized settings, little research has looked at self-injury in the community samples,… says Lloyd Richardson.

A total of 633 high school students ages 9 to 12 from schools in… I'm sorry, grades 9 to 12, that makes a little difference, from schools in the Southern and Midwestern United States voluntarily and anonymously participated in the study by completing a survey administered by the researchers.


The survey asked the participants whether they purposefully engaged in 11 different self-injury behaviors in the past year, and if so, the frequency of occurrence. In addition, the survey assessed the motivation for engaging in self-injury behavior.

We were surprised to find that 46% of the teens in the study reported injuring themselves in the past year on multiple occasions. Furthermore, 60% of these or 28% of the entire sample endorsed moderate to severe forms of self-injury including cutting the skin, burning the skin, giving oneself a tattoo, scraping the skin or using a pencil to "erase the skin….

The researchers note that it's important to distinguish between minor and moderate severe forms of self-injury since severe forms of self-injury may be predicative of more serious outcomes.

Minor forms of self-injury consisted of behaviors such as pulling out hair, biting the self or picking at areas of the body to the point of drawing blood.


Moderate to severe self-injurers were more likely than minor self-injurers to report a history of psychiatric treatment and hospitalizations, suicide attempts and current suicide ideation.

Results from the study also indicated that the most common reason teens in the study engaged in self-injury included to get control of the situation, to stop bad feelings and to try and get a reaction from someone.

This suggests that adolescents are engaging in self-injury for several reasons including both regulating their own internal emotional states and trying to manage situations in their environment.

Once thought of as a phenomenon only found in teens with mental health issues, the results support the notion that many adolescents in the community are self-harming as a way to cope with emotional distress.

Accordingly, interventional efforts should be tailored to the individual and contribute to building alternative skills for positive coping, communication, stress management and strong social support.


While there remains few proven treatments for self-injury, understanding the specific motivations behind an adolescent's behavior, namely to influence the behaviors of others as well as to manage their own internal emotions as the study shows, allows for the development of an individual treatment plan that could help prevent future episodes.

In this study, no gender, race or age differences were noted in overall self-injury rates. However, the researchers suggest that future studies examine self-injury in nationally-representative samples. They also recommended exploring how self-injury and its function may change over time given additional exposure, as well as changes in interpersonal and intrapersonal variables.

Lloyd-Richardson adds, "For example, a question that arises is if long-term exposure of repeated self-injury leads to a decreased fear threshold in teens and therefore greater attraction to suicide and death. The answer could lead to significant changes in how we initially treat adolescents who start to exhibit self-harming behavior….


And finally, a theater program strengthens teenage emotional skills. A unique study found that adolescents' emotional skills were strengthened through a high school theater program. This study appeared in the July and August 2007 issue of the Journal of Child Development.

Adolescents face formidable challenges in emotional development to become functional adults. They must learn to manage the emotions that unfold in complex social interactions, including those in collaborative work groups, yet little is known about the day-to-day circumstances of adolescent emotional development.

Researchers at the University of Illinois Urbana-Champaign conducted open-ended interviews and observations to gain an in-depth understanding of one's setting, a high school theater program. 10 teenagers were interviewed every two weeks over a three-month period while the theater group rehearsed the musical. Two adults who led the production were also interviewed bi-weekly.


In addition, the researchers observed the actual rehearsals. And during the rehearsals, teenagers reported frequent emotional experiences including disappointment, anger, anxiety and exhilaration.

The researchers found the program to provide a culture that helped the children learn to respond constructively to events and feelings associated with different emotions. The adults provided models and helped the teens cultivate strategies to manage strong feelings. The youth learn from repeatedly using these strategies to employ positive emotions to motivate their work. They also learned how to manage their own and others' negative reactions.

The theater setting supported this process by putting the youth in situations in which emotions were likely to occur because the expectation of hard work created stress and tension. Moreover, intense feelings were accepted and discussed openly with a climate of concern for others. The adults and youth alike stated shared beliefs about the importance of the emotional experience, and the adolescents drew on the models and ideas of the culture as they learned about the dynamics of a wide range of feelings in themselves and in the group.


The researchers also found young people were actively engaged in the process of emotional learning, and in the theater setting they were proactive and willing to manage emotional situations, evaluated experiences and put to use the insights they had gained and actively drew on the ideas and assistance of adults and peers.

"The development of emotional intelligence is important to adult, work and family life, but many people arrive in adulthood with incomplete emotional skills,… according to Reed W. Larson, Professor of Human and Community Development at the University of Illinois Urbana-Champaign and the study's lead author. These preliminary findings suggest how, under the right conditions, adolescence strengthen these skills. Although further research is needed, youth programs in schools that provide these conditions may be more likely to facilitate emotional learning.


And that will wrap up our a little bit lengthy new segment this week, but there are a lot of good stories there and I had trouble cutting them out.

So we're going to take a break here for a few seconds and then we will be back with our very first in-depth segment. The topic is acne, and our guest will be Dr. Suzanne Spadafora. We will be back with that interview right after this.



Dr. Mike Patrick: Alright, welcome back to the program. This week, we're going to do an in-depth segment, and we're going to discuss acne. Acne is the most common skin disorder in the United States. It affects more than 17 million Americans each year and results in 4.8 million patient visits each year.

In fact, some say 10% of all patient encounters with a primary care physician is because of acne. And the number patients over the age of 25 with late-onset or persistent acne is also increasing. So it affects 8% of 25 to 34-year-olds and 3% of 35 to 44-year-olds. So it's not only a problem for teenagers, but also one for many young parents out there as well.

And today, I have the honor of being joined by Dr. Suzanne Spadafora. She's a dermatologist practicing in Virginia. So welcome to the program, Dr. Spadafora.

Dr. Spadafora: Oh, thank you very much, Dr. Mike. Thanks for having me.

Dr. Mike Patrick: Sure. Now acne, I would assume, is something that you see in the office from time to time.


Dr. Spadafora: Pretty much every day. [laughter] Sometimes almost every other visit.

Dr. Mike Patrick: Right, I tell you, in our office in a primary care setting it's really something that we see often too. And it's not just something that… you know, causes, issues of when they come in. But it can really have some long-lasting effects too, can it?

Dr. Spadafora: Absolutely, absolutely. Especially with any scarring, that can be permanent. As well as the self-esteem on the patient and how much time they spend having to deal with their acne using the medications, they're concentrating on working on it.

Dr. Mike Patrick: Right. I think in order to really understand how you treat acne, I think first, you have to really sort of understand what it is sort of at a cellular level. And we'll try to keep this as simple as we can but at the same time, if you really understand what's going on with acne, helps to understand why we do the different treatments for it, right?

Dr. Spadafora: Absolutely. Do you want me to go over a couple of the things that contribute to acne?


Dr. Mike Patrick: That would be great.

Dr. Spadafora: Sure. If you want to break it down there's usually four things when I teach my patients that contribute to it.

The first thing is going to be your oil glands, also known as your sebaceous glands. And that's what is our natural moisturizer on our skin. And initially, we you first start getting acne and you get the whiteheads and the blackheads, that's because your oil glands are getting plugged up.

Second thing is going to be hormones, specifically when you testosterone level goes up. That will often cause the oil gland to secrete more oil. And as a result, you get the oiler complexion, especially around puberty.

Third thing is going to be the acne bacteria. And the acne bacteria is also known as Propionibacterium acnes, but I just refer to it as the acne bacteria. And that is usually on our skin. It really, really loves the hair follicle and the oil gland, which are one-set unit. And it loves to live around there. And the oilier your skin is, the more it grows and drives and it eats the oil.


And that leads to the fourth thing. It's when it starts infecting that gland and having its way with all the oil that's on your face or on your back and chest. Then as a result, you get inflammation. So that's the fourth component that contributes to acne. With inflammation, you start seeing your white blood cells and other things that fight that acne bacteria infection coming in and causing the pus bumps.

Dr. Mike Patrick: Right. Now what about plugging up of those, the hair follicle or the gland. Are there — anything that teenagers in particular do that [laughter]… also, from like an external point of view that may contribute to that process?

Dr. Spadafora: Yes. For example, there is something called acne mechanica, where if you are using something very occlusive, something that blocks your pores, that can contribute to it. We see during football season, the chinstrap acne and the shoulder pad acne going on in our football players.


Also, if you're using a lot of hairsprays or really, really heavy, heavy caked on make-up, that can also clog your pores. So that's why we always advise our teenagers and adult women that you're going to look for oil free or noncomedogenic. Comedone means the whitehead or the blackhead. So that contribution of the blocking of the pores is something that contributes to it.

However, there's also a couple of things that a lot of teenagers ask me about like the diet and does that affect it? Is it because I'm eating chocolate? And that's one of the myths. I will go ahead and diffuse early on. Food does not have anything to do with it. And I would like to think that it could be just because when people are stressed, their acne will flare. We know for sure that stress definitely makes it get worse.

And when they are stressed, they tend to eat a lot of comfort foods. One person might nail it down to the chocolate or some other oily substance that is very, very comforting for them, but it's not really a cause of the acne per se.


Dr. Mike Patrick: Right. And I think that's an important point, because it's one of those things where, and we've talked about this in some previous episodes not too long ago, about how sort of myths get perpetuated without any good scientific basis for it. I think that's definitely a good one because so many people do associate chocolates and greasy foods with acne. But that's just not the case, right?

Dr. Spadafora: Oh, yes. And it's funny because this comes up so often that it's usually a battle between the parent and the teenagers. Either the parents are going in to the teenagers for eating too much pizza or chocolate. And then they look at me for affirmation, and then I can only say I'm sorry, but I can't back you up on that one. There is no scientific evidence to show it for acne.

Dr. Mike Patrick: At least for the acne, right? But you could, you still should… [Laughter]

Dr. Spadafora: Yes, exactly.

Dr. Mike Patrick: Right, right, exactly. Now what about… you were talking about stress. There is a link between stress and outbreaks?


Dr. Spadafora: Yes. And the idea is, when you're stressed, your adrenal gland puts out a hormone called cortisol. And cortisol has a little bit of a cross reactivity with the testosterone receptor. And as a result, cortisol can cause your oil gland also to work a little bit more and then give you the greasy complexion that causes the plugging up of the oil gland and ultimately, the acne bump and the pus bumps.

So that's what the thought is if life's stress occurs. And that I see notoriously with my kids here coming back home from college. For example, the students here are coming back and haven't had much time number one, to do their acne regimen; and number two, are just stressing out for more exams at midterms or at the end of the year.

Dr. Mike Patrick: Sure, sure. Now what do you think, in terms of… I'm a pediatrician and you're a dermatologist, at what point should the individual teenager move from self-treatment of their acne to asking their doctor for help? And then at what point should a dermatologist become involved?


Dr. Spadafora: Well, basically I would start off as a teenager myself, I'm not myself right now. But if I were a teenager, you start off with the simple whiteheads usually. And those you can address with over-the-counter products, usually those that contain salicylic acid. And also benzoyl peroxide, which is over the counter, will be able to help with those a little bit.

Also from the smaller bumps, if you don't have too many of the red bumps or too many of the pus bumps on your face, back or chest, you can use over the counter. But if those are not working for you and you've given it a good try of at least six to eight weeks, then it's time to move on and ask your primary care doctor.

You know, look if there's something over-the-counter that I can… I'm sorry, something by prescription I may be able to use to help this get better. And that's when you would probably intervene.


A lot of the primary care doctors who see patients before they refer to me had already started their patients on topical medications that are antibiotics such as clindamycin or sulfa antibiotics. These are things that will already be started by a pediatrician. And if they're still not getting any better or if a patient is already starting to get a lot of scars associated with their acne or requiring high doses of antibiotics by now in order to get their acne under control, that's when a dermatology referral is needed usually.

Dr. Mike Patrick: Okay. Now let's talk a little bit about each of these treatments, because I think it's interesting to sort of put them under the magnifying glass and just talk a little bit about why certain things work. And you mentioned salicylic acid. So why don't we start with that one. What exactly does that do?


Dr. Spadafora: Salicylic acid is basically, they call it keratolytic, which means that it helps to unplug the clogged pore, basically. That's the easiest way to explain it. And in whiteheads and blackheads, those are your clogged pores. It remove the top layer of keratin that's plugging up the pore and as a result, it brings the oil up to the surface.

Dr. Mike Patrick: So it just helps to dissolve the keratin that's plugging the pore, so you help with that portion?

Dr. Spadafora: Exactly.

Dr. Mike Patrick: And then benzoyl peroxide I guess would be the next one. And the over-the-counter percent is 2.5% I believe. But then there's also…

Dr. Spadafora: Actually, yeah, you can get it up to 10%. It's just that a couple of the drug manufacturers want to keep it by prescription. So you'll see sometimes a 4.% benzoyl peroxide that's a brand name by prescription, but you can get a 10% benzoyl peroxide in something like Oxy Wash or Clearasil.

Dr. Mike Patrick: Okay, and then what does that do?


Dr. Spadafora: It's an antibacterial. It has great efficacy against the acne bacteria. And of the topical antibiotics you can use, that's the only one, as far as I know, that has no resistance associated with it.

Dr. Mike Patrick: So it's really good at killing the P. acnes that you were talking about?

Dr. Spadafora: Uh-hmm, absolutely.

Dr. Mike Patrick: So this is a good combination? You're with benzoyl peroxide and salicylic acid. You're addressing two of the main things that contribute to acne formation, the bacteria that's there, then the plugging of the glands.

Dr. Spadafora: That's right.

Dr. Mike Patrick: Now I also… we should point out that with the benzoyl peroxide, there are some issues. I know it can bleach hair and fabric. And is there a photosensitivity for the benzoyl peroxide or is that just with the antibiotics?

Dr. Spadafora: No, not with benzoyl peroxide.

Dr. Mike Patrick: Okay.

Dr. Spadafora: It's more so with the… we'll get to probably to the category of what we call retinoids, as well as some of the oral antibiotics.

Dr. Mike Patrick: Okay, sure. So we'll get back to that. And then with drying of the skin, sometimes you see that if it's used too zealously.


Dr. Spadafora: Uh-hmm. Yes. Almost or anything that you put on your skin for acne could cause some type of irritation or even a rash if you're allergic to it. But benzoyl peroxide, and even salicylic acid are among the more irritating ones.

Dr. Mike Patrick: Okay. And then there's a product out there which I and our community, I guess, has not really been pushed in terms of people coming to me about it. But you certainly see it in the magazines. It's this Proactiv, it's like a three-step system. Do you know what I'm talking about with that?

Dr. Spadafora: Uh-hmm.

Dr. Mike Patrick: And personally, I've looked at the ingredients, because at their website I was just kind of browsing around checking it out. And they have a little link to look at their ingredients, and it looks like it's pretty much just 2.5% benzoyl peroxide. [Laughter]

Dr. Spadafora: Right, that's the active ingredient. And you know one of my little things that make me think of why it works so well for a lot of patients is the insurance companies won't usually pay for it since it's over the counter. So if you've invested your own money to pay the $40 a month, I think it's what it is for their regular program to buy the product, then you're more likely to be motivated to use it.



Dr. Mike Patrick: Sure.

Dr. Spadafora: Mom and dad just paid their co-pay and they're nagging you to use it.

Dr. Mike Patrick: Right.

Dr. Spadafora: You have a little bit more motivation if it's hitting you in the pocketbook.

Dr. Mike Patrick: That's a great idea.

Dr. Spadafora: Plus they have a very good marketing campaign if they get somebody like Jessica Simpson advertising for them. And you're more likely to watch the commercial.

Dr. Mike Patrick: Right, right. So they've got the marketing down. [Laughter]

Dr. Spadafora: Yes, absolutely.

Dr. Mike Patrick: We need to hire them for PediaCast.


Dr. Mike Patrick: So let's say they've tried benzoyl peroxide and the salicylic acid. Oh, one other over-the-counter thing, cleansers with triclosan in it. Have you come across using that much?

Dr. Spadafora: Yes, and I find that that does not work so well for the acne bacteria.

Dr. Mike Patrick: Okay.

Dr. Spadafora: But it actually has efficacy against other types of bacteria, one of which you're familiar with called methicillin-resistant staph aureus, at higher percentages. But independent of acne, I don't find it good for this particular problem.


Dr. Mike Patrick: Okay, great. So at that point, if you've done the salicylic acid and benzoyl peroxide and you're not getting anywhere, then it's time to see your doctor. And then the topical retinoids, I guess, will be the next category and the topical antibiotics I guess too. So if you could address those, that'd be great.

Dr. Spadafora: Yeah. People probably heard of or a lot of people have heard of Retin A, which is the original retinoid that was out on the market many years ago. And since then, they've come along with the brand names Differen and Tazorac, manufactured by other companies.

And the purpose of retinoid is they're derivatives of vitamin A that help you unplug the oil gland also. We were talking about how salicylic acid helps. Well this vitamin A type of product also is able to open up the passageway where the oil travels from the oil gland up to the surface of the skin and normalize it.


So in addition to drying out the current pimple that you have, it also will keep your pores open. So it's preventative too. And on top of that, they also have the benefit of lightening up the dark spots of the scars that some people would consider scars where the old acne region has been but it's taking forever and a day for that redness or pink to go away.

Dr. Mike Patrick: Okay, so that's the retinoids. They're a derivative of vitamin A, I believe, is that…

Dr. Spadafora: That's right.

Dr. Mike Patrick: It's interesting trivia for folks out there. And then the topical antibiotics. We've talked a little bit about the Triclosan and some of the over-the-counter things. But of course there are better ones.

Dr. Spadafora: Back in the day, there used to be a lot of use of erythromycin topically. And there's still a few of primary care doctors and occasionally some dermatologists who would still use topical erythromycin.


But unfortunately, there's been a lot of resistance developing by the acne bacteria to that medication. So as a result, there's a lot of use of topical clindamycin instead. And that brings me to a relatively good point in that a lot of the products that are out now by prescription which have clindamycin in it have also benzoyl peroxide mixed in it on purpose. So that you get a two-for-one with the medicine.

And the reason why is they try to minimize your chances of developing resistant bacteria if you use benzoyl peroxide in addition to the clindamycin. So you have two things fighting the acne bacteria as opposed to one.

Dr. Mike Patrick: Sure. And I know this is kind of the gold standard treatment, I think, for pediatricians today when you get to the point when over-the-counter stuff is not working. I know that in my group, a lot of us use BenzaClin, which is the brand name of one of them that has benzoyl peroxide and clindamycin in it. And boy, I have a lot of teenage patients that just swear by it. As soon as they're about ready to run out of it they're on the phone wanting their refills because it really seems to work pretty well for a lot of folks.


Dr. Spadafora: Yes, yes.

Dr. Mike Patrick: But then there are those who it doesn't work for or it does for a while and they have episodes where things really get a lot worse. And then when we start talking more about oral medications for it. And I guess the first one to think about would be the oral antibiotics. And I'll tell you, when I usually at this point, I think in my younger days of practice I was a little more quick to prescribe oral antibiotics for acne. And I think now I'm a little bit quicker to just go ahead and do the dermatology referral if we get to that point. So with the oral antibiotics or what are the choices out there and some of the concerns?

Dr. Spadafora: Well, you have your tetracycline class of oral antibiotics which is pretty much the first line, and that includes tetracycline, doxycycline and minocycline. The next one, sometimes people will use oral erythromycin. And then you also have the sulfa medications, brand names known as Bactrim, Infectra.


Finally, some of the docs will use the penicillin category of medication such as Keflex or Cephalexin is the other name for it, for a second reason, the third line. Occasionally, we'll have some patients who are unqualified to use some of the even stronger oral medications, which we'll talk about later.

But they may be put on something like called azithromycin or Zithromax, which is a cousin to erythromycin. But that's more of a rarity that we'll go so far as to use something, because we do like to try and favor antibiotics for the other types of diseases that are out there and not always be prescribing them indiscriminately.

Dr. Mike Patrick: Right, right. And I think that moms and dads are becoming more sensitive to that as well because when there's anything where we, like with recurrent urinary tract infections with little kids you put them, the standard's still is to put them on an oral antibiotic for a long period of time.


And I guess you'd probably get the same thing with using oral antibiotics for acne over a long period of time that there's more, I guess, awareness about not wanting to create resistant bacteria.

Dr. Spadafora: Yes, yes, that's one of the concerns. And also with the tetracycline category of medication, especially with minocycline, there is a very rare side effect where it's called a lupus-like syndrome. Patients can get fevers, joint ache, sometimes a rash. And that can occur after you've been on it for over a year at the higher doses of these medications.

And those are a couple of ways that I tell my patients, this is not something that we want you on for a long term if we don't have to. There are side effects down the road from being on it. Also, in the tetracycline class, it can cause liver irritations so I really often check liver function panel after a year if I have a patient who has to be on it for greater than a year, which is more an exception rather than the rule.


Dr. Mike Patrick: Right. And then there is photosensitivity issues too with tetracycline, with that class of antibiotics.

Dr. Spadafora: Yes, and sometimes we'll switch especially if it's like you're a long-distance track, it's a long-distance runner's track season and you know they're going to be out or it's your lifeguard who's working on the summer somewhere down in Florida or something. I might just switch them or try to get them off their oral medications if possible because I'd rather have them break out a little bit as long as they're not getting scarring type of acne than get back sunburned only to see me 30y ears later for skin cancer.


Dr. Mike Patrick: Right, exactly. Now before we even do Accutane, which is kind of the big daddy here. What… who's the elephant in the room, what about hormonal treatment?

Dr. Spadafora: Uh, yes. That's a good choice. It's only available to women because of the –that it comes in birth control pills. And we obviously don't want to be putting our boys, our teenage boys on birth control pills.


Dr. Mike Patrick: Right.

Dr. Spadafora: But the idea behind how it works is there are certain birth control pills out there that have a progesterone component, that's one of the female hormones. And progesterone that comes from a female's body will often also stimulate the oil gland the way that testosterone can and you'll get more secretion of oil.

But the ones that are in a couple of oral contraceptives such as, there's one called Yaz that came out recently with the FDA indication; Ortha Tri-Cyclen's been out on the market and the one called Estrostep. These all have FDA indications for acne, as well as a few that are not labeled specifically for acne but work such as Desogen or Alesse.

Anyway, these work because of the fact that they are not as stimulating to the oil gland the two weeks right before a woman is going to get her period or a girl is going to get her period. Girls are women who say, "Yeah, I tend to break out right before my period…. Well they have a certain distribution of acne, especially around the lower face, around the beard-neck area that breaks out. They're very, very good candidate for oral contraceptives.


And I also try to find a reason why else to put them on an oral contraceptive. Are you having heavy periods? Are you having irregular periods? If I don't have to, I'd prefer not to put 14 or 15-year old on an oral contraceptive. And of course that opens up the entire talk if I have to give the this doesn't protect you against sexually-transmitted disease if you ever become sexually active type of talk with this teenager, which is not always comfortable when it's a 14-year old, but it's still something that you actually the responsibility to talk about when you prescribe a medication like that.

Dr. Mike Patrick: Yeah, definitely. Right.

Dr. Spadafora: There's also something called spironolactone, which we will prescribe also in some women, but we'll do it in conjunction with using a birth control pill. And spironolactone also works because it blocks the testosterone receptor and also keeps you from getting that surge of acne right before your period too.


The only thing is it also tends to lower blood pressure; it's sometimes used as a diuretic. Actually a lot of times it's used as a diuretic, so it makes people pee a lot. And young women and young girls tend to have lower blood pressures to begin with, so it's not one that I will use often in the teenage population. More so my adults's acne, women, more so for the moms of our patients.

Dr. Mike Patrick: Sure. Yeah, we see a lot of those teenagers who stand out too fast and kind of black out a little bit because of a low blood pressure, so I could see that. You don't want to make that worse.

Dr. Spadafora: Right.

Dr. Mike Patrick: Let's talk a little bit about Accutane, because I think… when I send someone to see the dermatologist for bad acne, that ends up more often than not, being what they get on and really helps just tremendously. But of course there's a lot of issues with that. So let's talk about Accutane.


Dr. Spadafora: Sure. So Accutane, I think the best way to describe it is a great medication for acne but it has a lot of side effects, and also very bad reputation because of some of the side effects that are associated with it.

And the two most important ones that always come up, and this is the reason why the FDA has restricted its use so much and there's a lot of hoops you have to jump through and registration processes that you have to through in both the person who'd prescribing and the person who it being put on Accutane is the fact that women who get pregnant on Accutane, their babies will have birth defects associated with them, very serious birth defects.

And so it's required by the FDA that girls and women who are sexually active be on two forms of birth control for a minimum of 30 days before they start the medication, as well as another 30 days after they discontinue the medicine in order to prevent any pregnancies. And they're doing monthly pregnancy tests throughout the entire course, which is usually, on average, about a five-month course for patients.


Dr. Mike Patrick: Do you get a lot of parents that are resistant to that? Like, "There's no way my kids this is going to happen to them. They're not sexually active…. Or do they usually understand? And I know that they have to go along with it to get it. But do you get resistance to that?

Dr. Spadafora: No, not really. They're very, very accepting. And I say to them that I kick out all of my parents for my teenage girls who are under 18. Unless they want them to stay, that's fine. If the patient wants them to stay, that's alright to talk about it. But I tell the parents it's my policy to ask the patient's parents to leave the room in order to interview the girl by herself to find out if she has ever had sex before or she is planning on being sexually active. And also, is it something that she discusses with her parents or is comfortable with her parents knowing.


A lot of times the answer is the 15-year old who has had sex and her parents know nothing about it. But most of the time those girls say they're going to be abstinent. Occasionally, I'll get a feel, like spider senses that are tingling. And in cases like that, I might just go ahead and put them on oral contraceptives just to be on the safe side. And I tell my patients who have been sexually active before they're not allowed to have an oops while you're on Accutane. That's absolutely not allowed.

Dr. Mike Patrick: Right, right.

Dr. Spadafora: If I feel like I can't trust them to be abstinent for the entire course of it, then I'll go ahead and start them on an oral contraceptive. And the nice thing about it is since these helped with acne, parents understand that, "Oh yeah, this is going to help their acne too….

Dr. Mike Patrick: Right, right.

Dr. Spadafora: And I just let the parents know that this is my general policy for all patients, whether if it's a sexually active or not sexually active. But I'm one of the doctors who will allow patients to be abstinent and not have to be on the birth control.


There are some prescribers out there who absolutely require anybody who goes in Accutane who's a female be on the birth control pill, there's no ifs and buts about it. But I don't feel that way, that was the way that I was trained. And also for religious convictions too, sometimes people aren't… are reproach to birth control pill.
Dr. Mike Patrick: Do you have them sign a contract if you're going to go that route?

Dr. Spadafora: If we're going to do Accutane, yes, they have to fill out… as women, they have to fill out two consent forms. The first one talking about, "I understand all the things about the birth control issues…. The second one is just general things which lead us to our big second side effect I was about to mention, which is the depression issue.

Dr. Mike Patrick: Before we go to that, is it just the parent who signs the consent or does the teenager also sign?


Dr. Spadafora: Teenagers do and they have the initial right next to the every individual statement that they understand it. And if the parent… I'm sorry, if the teenager is under 18, the parent has to co-sign and co-initial all of the forms. And then I have to sign at the very bottom that we've talked about all of the things, the side effects. And it even talks about, I will come to my monthly visits or otherwise, I understand I will not be able to get my Accutane….

Dr. Mike Patrick: Okay. Okay, I'm sorry, I interrupted you.

Dr. Spadafora: Oh no, that's okay.

Dr. Mike Patrick: Then there's the depression, suicide issues that are out there.

Dr. Spadafora: Yes. In all of the large-scale population studies that have looked at this issue as to whether Accutane causes suicide, depression or mood swings. There has been no increased rate of suicide that has been shown, as well as no increase in depression or psychological problem. And that's in the large population studies.


However, when you look at the anecdotal evidence, some of the case reports that are out there, they're going to be people who have written about how teenagers go on a medication. They became depressed on the Accutane. They come off it, they're no longer depressed. And then they went back on it, re-challenged the drug as we call it, and the depression started up again.

And so those you have to pay pretty close attention to and it's still something that we will counsel our patients about, that even though it hasn't been proven, it's just something that you need to be aware of. And if you or your parents or your friends ever notice something like that or you're feeling not like yourself, then you need to make us or another healthcare provider or your parents aware about your mood swings or your depression.

And I wrote, I have had three patients out of probably 200 patients I've ever put on Accutane who have said they haven't felt like themselves or they just feel quiet while they're on Accutane. And all of them had said, I don't feel like killing myself or anything, but at the same time they did feel different while they were on it.


Dr. Mike Patrick: It does make you wonder though if there's something chemically in the brain that is making you feel that way and then that same thing is also causing the acne to flare up which is why they're being put on the Accutane.

Dr. Spadafora: Yes. And the other thing is you have to look at, as far as the depression among the general population. You're talking about patients who get bad, scarring acne and because that's the type of indication that you have for Accutane. They're the ones who get the big, huge fits and the knocks on their face and the pus bumps and the scars. And of course with a complexion like that, they have a good reason to be depressed or have low self-esteem. And so which one is the chicken, which one is the egg?

Dr. Mike Patrick: [Laughter] Yes.

Dr. Spadafora: That's one of the controversies with Accutane.

Dr. Mike Patrick: Right. But in either case, whether it's with Accutane or anything, teenagers should be encouraged to share their feelings and to let someone that they trust know when they have feelings for hurting themselves or hurting others.


Dr. Spadafora: Yes

Dr. Mike Patrick: Okay. Well, let's move on to the realm of the… I think we've covered pretty much all of the topical and oral treatments for acne. Can you think of any we've missed?

Dr. Spadafora: There's also some things, some older medicine like sulfur and sulfide. I still find some people use that, I still use it. Usually it's called sulfacetamide and sulfur combination. Sulfacetamide has some antibacterial properties the way that clindamycin does. And the sulfur is that keratolytic, so that's also unplugging the whitehead or the blackhead. And you will see that used. The only thing is in patients that have allergies to sulfa. That's obviously something that you don't want to be using in them.

Dr. Mike Patrick: Right. And what about light therapy? Do you subscribe to the blue light or the clear light therapy for acne? You see that a lot advertised too in magazines and on the internet.


Dr. Spadafora: Right. We don't have lasers and lights over at our practice per se. But I know some of my fellow dermatologists who do, which is that we don't have any place to put them really. But in any event, they do work.

And the idea is that the wavelength of light that you're using, whether it be like the blue light that's one of the visible light spectrum. And there's also lasers that work. What they're doing is killing the oil gland by hitting the water in the skin that surround the oil gland or they're killing the acne bacteria. So it's going to be either oil, the gland or the acne bacteria that's their target, and it does work.

The main thing about it is that it's nice because you don't have to be on an antibiotic indefinitely. It has staying power of about 6 months if you've gone through several treatments. But the downside is because it's still considered experimental by a lot of insurance companies, then a lot of patients are going to be paying out of pocket for this.


Dr. Mike Patrick: Yeah, it's pretty expensive.

Dr. Spadafora: Yeah, it's very expensive. There are very rare exceptions where they will say well, because this person has got everything including Accutane, then we'll go ahead and pay for this. But it's more of an exception rather than a rule.

Dr. Mike Patrick: In Accutane, is it expensive? Do you know?

Dr. Spadafora: It is. Usually, if you were to pay out of pocket for it, you could get a prescription that's probably close to between $100 to $200, depending on which one you're getting. There's different forms of the generic that are out there now and the brand name obviously is going to be very, very expensive. But yeah, it still is a pretty expensive course of medication.

Dr. Mike Patrick: It's pretty typical of insurance companies to say we'll pay for the expense of the thing that is more invasive. But something that may work and have less side effects, then we're going to give you a problem with that. [Laughter]

Dr. Spadafora: One thing I do want to emphasize about Accutane though, getting back to that, is that this is the only medication that could have a permanent sort of cure to your acne, where you could be free of your acne for the rest of your life sometimes. And that can occur in about 40% of your patients.


So it sometimes makes sense for them to spend that extra money upfront because down the road that means less treatments that they might have to pay for ongoing lifetime doxycycline versus a few patients or having to worry about building antibacterial resistance or antibiotic resistance in patients who might have to always be on a doxycycline-minocycline investment until they reach age 26 or who knows when their acne is going to burn out. It might be more sensible to go ahead and do five months of Accutane. We have a lot of patients who have reached that point.

Dr. Mike Patrick: Right, right. That's an excellent point. Because you do have to think about the long-term benefits of and its kind spreading that cost than over a much longer period of time.


Dr. Spadafora: Yeah, and I've had some patients who did it when they were teenagers. And they don't get any… they may get a resurgence of their acne later on, but they are in their 30s and having kids. So it has a pretty good staying power.

Dr. Mike Patrick: That's great. Now we've kind of talked about acne and assumed teenage patients or young adult patients. And of course as a pediatrician, we see a lot of acne kind of issue in new born babies too. You probably don't see very many of those.

Dr. Spadafora: Uh, no. Mostly my own, but…

Dr. Mike Patrick: And I guess, you've mentioned that the way that babies get acne is really pretty similar to teenagers. It's just that the androgen-type hormones that are causing it actually come from the mom crossing the placenta in the baby's body and then basically have the same kind of effect on the skin. But then by the time the babies are two to three months old, that's all gone away.

Dr. Spadafora: Yeah. Then there's actually a few studies that are thinking maybe it's not the acne bacteria that's doing it, but some people think that it's because of a yeast called pityrosporum that's on their skin that they're getting it. In any event, the nice thing about it is it'll go away on its own so you don't have to treat it.


Dr. Mike Patrick: And then you had mentioned, I think it was actually before we started the interview when the two of us were just talking. But there are some other more serious illnesses that can have acne as one of the symptoms of those illnesses. So if you do have that acne and you're at home trying to treat it and things aren't getting better, it's not only the cosmetic issues and the psychological issues. But it really, you could be ignoring a more serious problem.

Dr. Spadafora: Right, uh-hmm. But… go ahead.

Dr. Mike Patrick: Yeah, I was just… if you want to talk just real briefly about what some of those could be.

Dr. Spadafora: Yeah. One of the more common ones that you have to think about is if somebody has a sudden onset of acne or they're relapsing after they've been on a course of Accutane.

There's a condition out there called polycystic ovary syndrome which happens to have abnormal ratios of female hormones associated with it or high testosterone levels. And these patients can prevent with having bad acne that doesn't respond to a lot of the typical medications.


And one thing that's very typical for these women who get it is that they tend to have less than nine periods per year. So that's one of the quick screening questions to find out if this could be polycystic ovary syndrome. And if you are suspicious of that, then as a provider, I would go ahead and order a couple of labs for those hormones to find out if that is one of the things I should be thinking about.

So with the other ways that this polycystic ovary patient would prevent is facial hair too. They would start to getting areas where men normally get hair and start to develop the moustache area and they are often overweight. That's one thing.

Another thing that you have to think about also is could it be an adrenal gland tumor. For example, if it's a baby who is not resolving their acne on their own, when they're not responding to just simple topical antibiotics, the benzoyl peroxide.


You have to think about something called progenitor adrenal hyperplasia which the adrenal glands, which also put out some hormones, are working a little bit too hard. And as a result, one of the side effects is getting acne. So in a baby who may be having really, really stubborn acne that's not going away, that's something to consider.

There are ovarian tumors that are out there that can do it and then also some very, very rare syndromes that I won't go into too much detail about. But it's one of those things that you always have to keep in the back of your mind if you have a patient who is just not responding to typical treatments, is presenting what other systemic syndromes such as those irregular periods and the facial hair. So it's always something that a good clinician has to think about.

Dr. Mike Patrick: Right, right. And the differential diagnosis.

Dr. Spadafora: Uh-hmm.

Dr. Mike Patrick: Alright. Well, I really appreciate you stopping by and you have the honor of being our first real interview.


Dr. Spadafora: Oh boy, wow! I normally don't do like whenever the newspapers and the TVs ask to do the interviews. I never ever want to do them, but for something about being on the web, it's just really, really cool.


Dr. Mike Patrick: Yeah. I think so too. Well, thank you very much, again for stopping by. We appreciate it. And we have to end here with a… there's a promotion and we'll have talked about it before this interview on the program. But we are doing a code phrase that people have to pick out of the next four episodes. And so if you could let everyone know what this week's code word is, that would be great.

Dr. Spadafora: That's right. It is beat. B-E-A-T.

Dr. Mike Patrick: Alright. So beat. You have to write that down because there's going to be a code word for three more weeks and we'll talk a little bit more about what prizes we're going to be giving away in relation to that promotion.


Alright, so we'll continue on with the show. We still have our Research Roundup coming up and we will get to that right after this break.


Dr. Mike Patrick: And I'd like to take a moment to tell you about this week's sponsor, Mariner Software. Now it's important to me that I use and trust products that I recommend, and I have used one of Mariner's software products on my MacBook from the first day I took the computer out of its box. And I continue to use it everyday. This little beauty of a program is called MacJournal. And thanks to a new underlying blogging and podcasting architecture, journaling, as you know, it just got a whole lot more interesting.


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Okay, we do have some listener comments and questions for you. First one, this deals with a prenatal drug exposure, and the person who wrote in did not want me to reveal their name or their location. But this is what they had to say.

"Dear Dr. Mike. I'm a big fan of the show and as a sometimes stay-at-home dad, can hold my own during discussions with moms at the park, thanks mostly to you. Keep up the good work and keep it coming.

My wife and I fostered a child at birth from a troubled family in our state. It very quickly became apparent the biological family would be unable to ever care for the child, so we pursued adoption and were successful. The child is now 14 months old. I have a couple of questions and due to their sensitive nature, could you keep our names confidential?

First, what do you feel is an appropriate level of information to give the folks who are curious about a foster or adopted child's history? I'm sure you're aware of the kinds of questions and comments that arise.


But in our case, they run the gamut from the benign such as, "Is it hard to foster or adopt,… to the very caring, "Is there any chance of losing the child to the birth family,… to the unkind, "He sure doesn't look like yours,…, or "He must have been a drug baby…. And then there are those that are off the charts such as, "How much did he cost?…

Don't get me wrong, we're ecstatic about where we found ourselves and wouldn't change a thing. We also understand the questions probably come from a good place. Anyway, we'd love to hear your view.

Second, what kinds of problems develop over the years following prenatal exposure to drugs, alcohol or tobacco? In this case, there was likely methamphetamine exposure, poor prenatal nutrition and other related issues. However, other than the child being slightly premature and four pounds six ounces, there appears to be no ill effects to the exposures thus far. Oxygen and IVs were not required in the hospital despite the low birth weight, and the child has had excellent emotional, physical and mental development.


Our pediatrician says the child has the nest temperament of any of the children in her care, and she doesn't seem to be the type to give false praise either. The child is smart, funny, strong and very engaging. I know I'm biased, but it's really true.

I've done some research regarding prenatal drug exposure and there seems to be some re-evaluation going on regarding the studies done over the years. Evidently, they didn't differentiate between children raised in troubled homes and those were moved or raised by either extended families or put in foster homes.

Maybe it's wishful thinking, but it's starting to seem like the problems we'll face with this child won't really be any different than what any other family faces. Again we're happy no matter what, but we'd love to hear your opinion, John and Jane Doe….

Alright. Well first, with regard to people's comments. Boy, I tell you, it's tough because it's one of those things I think where a lot of people once they asked the question and it's out of their mouths they think, "Uh, man why did I ask that?… Then, of course, there are some people that are just clueless.


But of course, I mean really, they should mind their own business with some of the personal things. And I don't think that you have an obligation, really, to explain much to them other than this is your child and you'd rather not discuss those things. So I guess it depends too on your comfort level with talking about them. But it's your child, and once you've adopted them, they're yours and I wouldn't treat them like they're yours.

Now with regard to prenatal drug exposure, you bring up an excellent example of ways that research can be flawed. This is a difficult study to do. I mean the easiest way to know whether developmental issues were a result of prenatal drug exposure would be to look at identical twins who were both exposed to the same things inside mom, but then they were separated at birth and put in different environments.

Now certainly, you wouldn't want to do this on purpose just for the sake of designing a good study. So there really are not a lot of kids out there who have had that kind of situation where identical twins were separated at birth and then put in a good environment versus a bad environment.


So it's really hard to tell how much is prenatal and how much is postnatal environment exposure that makes the difference. Really, almost impossible to tell.

So the bottom line I think here is that even though we don't know for sure what kind of a long-term developmental outcomes happen with prenatal drug exposure, you can't take back the exposure and you'll never know what would've been different if they hadn't been exposed.

And you're doing something great by providing an environment for this child to have the chance to succeed that they may never have had anyway. And you could look at it this way too: if the child had not had this prenatal drug exposure, he or she might not be with you right now.


And then who knows what kind of environment the child would be in right now. So since you're in a position to provide a wonderfully stimulating environment, perhaps the prenatal drug exposure was ultimately a good thing because it helped them to be able to grow in an environment where they're a little bit more stimulated.

Wow. Not that I'm suggesting that babies be prenatally drug-exposed intentionally. But if you're going to look at the bright side I guess that's what it would be.

I'm not talking a lot about up-to-date research because honestly, I had a very difficult time finding any up-to-date research pertaining to this topic. It was a popular topic of research in the 1990s. But researchers have seemed to have lost their interests in studying the effect of prenatal drug exposure on later development. I think that's likely due to the difficulty of designing a good study.


I did find a very good information sheet from It's adoptive hyphen families dot com. It's called Prenatal Drug Exposure: What Parents Need to Know. And it did look like it had some pretty good, fairly up-to-date information on that sheet. So I will put a link in the Show Notes to that.

Okay, next up in the listener's segment, too many vitamins? This comes from Laura in Las Vegas.

"Hi, Dr. Mike. Happy first birthday to PediaCast. I first heard you on Manic Mommies and thought you were great. I left you a review on iTunes….

Thank you very much for doing that. By the way, I think I had 80 the last time that I was talking behind the mic and I wanted to try to get over 100 reviews in iTunes. And as of right now, we're up to 93. So I got 13 more reviews in the last week, thank you very, very much. But we still haven't topped 100 yet. So if you haven't done that, please do.

Okay, Laura says, "I am a first time mom of a nine-month-old son, and I have a question for you. If my son is drinking formula and eating baby cereal and taking vitamin drops that were prescribed by his pediatrician. Could he be getting too much of any of the vitamins?


I've heard that too much vitamin A can be dangerous. I haven't caught up on all the past PediaCast episodes, so I'm not sure if you've already covered this. Thanks, Dr. Mike. Looking forward to future shows….

Too much of any vitamin can cause issues, and in particular, the fat-soluble vitamins, which would be like vitamin A, D, E and K. Because the body can store those vitamins in a fat tissue, it's a little bit easier to overdose on those particular vitamins. Whereas the water-soluble vitamins are less likely to be an issue because basically you pee out the excess pretty quickly after you take it. So the Bs and the Cs, you're less likely to have an issue with in terms of overdose, but it's still possible.


Now minerals, especially iron, can actually be deadly in large quantities. And this is really why vitamins are put in child-proof containers and why they should be kept out of reach of children. Now having said that, the amount of vitamins in infant formula combined with the proper amount of a prescribed supplemental vitamin, really should not be a problem at all. After all, your doctor wouldn't prescribe it if he thought it was going to be dangerous.

And obviously, your doctor knows if you're using a formula that also has vitamins in it. So the amounts that we're talking about as dangerous are extremely high and would normally only be encountered in a true overdose kind of scenario or if you were giving a child a particular vitamin supplement that only had that vitamin in it. That's not a good idea.

So unlike prenatal drug exposure, there are lots of good sources on the importance and the dangers of vitamins and mineral supplements for kids. And in the Show Notes, I put some links to some great articles that talk about those things. One is from Dr. Greene, the other one is from WebMD, and I even put a link to something from Oprah. So look at the Show Notes for those things.


Next up, ozone. And this comes from Jessica in Memphis. "Thanks for your podcast, it is so wonderful to hear the why behind all of your advice. I know you were the one who can answer my question.

I live in the South, and we are having a hot, dry summer. Quite often, on the morning weather report, the weatherman will say it is an orange ozone day, meaning ozone levels outside are at a dangerous level and at-risk people should avoid outdoor activity. Should I keep my children indoors on these days?

I have a five-year-old boy and a 19-month-old girl. My son is prone to sinus trouble but neither have any asthma or breathing problems. I don't want to expose them to unhealthy air but I hate keeping them inside so often too. Thanks for all you do….

Okay, so what is ozone? Well, ozone is basically three oxygen molecules bound together, so it's O3. Oxygen in its normal state in the air usually is two oxygen molecules bound together. So O2 is oxygen, O3 is ozone.


Now there's a large concentration of ozone in the upper atmosphere, and there it's a good thing because that's what we call the ozone layer. It absorbs harmful UV radiation from the sun. Basically the UV or ultra violet energy from the sun breaks O3,or ozone, into O2, or oxygen, and just single O's which wind up making more O3.

So there's basically a cycle of ozone breaking apart and then back together and then breaking apart and then back together, and that just helps to absorb UV light and helps to protect us from the DNA damage and cancer-causing abilities of UV radiation. But here we aren't really talking about the ozone layer, we're talking about ozone in the lower atmosphere, which is the stuff we breathe.


Now ozone forms when sunlight hits pollutants in the air. So the pollutants are hydrocarbons and nitrogen oxide, and this result from industrial pollution and car emissions. So this is going to be a bigger problem in large cities and industrial centers.

So what does the ozone do? Well, it enters the lungs and it reacts with the molecules in the lining of the airway. So basically, it reacts, turns into O2 and a single O, but it does that by reacting with molecules that are normally in the lining of the airway. And this ends up causing cell damage which results in inflammation.

And the more ozone exposure, the more damage it does. And those who already have lung problems are going to be the ones who are most affected because you're basically adding insult to injury. So those who already have asthma, emphysema, cystic fibrosis, these kind of things, you're going to have more trouble if you are exposed to large quantities of ozone.


I would pay attention to ozone warnings for your area and if there are warnings, I would limit outdoor play, especially if your child has underlying lung problems. Now ozone levels tend to be at their highest, at least in the United States from May to September, because there's more UV radiation at that time.

And they also start building up mid-morning and then peak in the afternoon. So early morning and early evening hours would be the safest time to be outdoors in terms of the ozone. Now of course, that's when mosquitoes are most active. [Laughter] Maybe they’re trying to avoid the ozone too. [Laughter]

But with mosquito exposure, then you worry about the West Nile virus and the encephalitis viruses that mosquitoes can carry. So you see, there's always something to worry about, right?

The bottom line is, physical activity is important, playing outside is important. But you want to be smart, you want to know your child's history and pay attention to warnings. I think like other areas of life, really, moderation here is the key.


Does your county have an ozone problem? To find out, you can look in the Show Notes, and we have a link to a county-specific ozone problem map of the United States and it's current as of June of 2007 put out by the Environmental Protection Agency. And if your area or your county is on the list, well you're in good company because well, the Ohio County where Birdhouse Studio lives is squarely a problem area on the map. So I feel your pain.

Alright, well we are running late. We're going to skip our Research Roundup this week. I had one put together, but we're running over, so we'll save it for next time.

So we will wrap up the program and we'll do so right after this break.



Once again, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for a specific individual. So if you have a concern about your child's health, call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also, your use of this audio program is subject to the PediaCast Terms of Use agreement, which you can find at PediaCast is licensed under an attribution, non-commercial, no derivative works creative commons license. And for more information on this copyright license, please visit and click on the Creative Commons link at the bottom of the page. If you're interested in using PediaCast material for a commercial project, please email for details.


Thanks go out to our news partner, Medical News Today, and this week's sponsor, Mariner Software. Also website and feed artwork are brought to you by Vladstudio. And I have had lots of email regarding that artwork here recently. And I would like to remind you, if you go to or click on Vlad's link in the sidebar of our website, it'll take you to his site and you can purchase prints and posters of his work, which would make excellent decorations for nurseries.

Also thanks go out to all of my loyal listeners by subscribing, listening and contributing to PediaCast. You keep this project going. And of course, thanks to my family, Karen, Katy and Nick for all that you do.

Don't forget, if you have a topic that you would like us to discuss or you have a news story or a line on some research or just really want to contribute to the program in any way, simply go to and click on the Contact link or email or call the voice line at (374) 404-KIDS, (374) 404-K-I-D-S.


Promotional materials are available on the Poster page. PediaCast Shop is open for your shopping pleasure, and actually, we'll probably throw in some t-shirts also with this contest that we're having. So in addition to the Bundlo prizes that I've talked about earlier, we will also probably be giving away some t-shirts as well. So make sure you write down those code words as they come up in the future programs over the course of the next month.

As always, iTunes reviews are important. But even more important now, don't forget the Podcast Awards are going on. You can vote once in every 24-hour period. And to get to the voting slate, you just click on the Podcast Awards link in the sidebar at

PediaScribe, the blog, that is my lovely wife Karen's doing. And probably my favorite story and when it's been one of the more popular one's this past week was Making Memories with Your Kids: Be Crazy, Be Unpredictable. We'll have a link to that in the Show Notes.


Alright, let's move on to this week's music. This is brought to you by IODA Promonet. The label is Electo-Fi Records. And if you like this song, there is a link to download this particular song, absolutely free, for your personal use as a DRM-free mp3 file. And if you really like the music and you would like to support the artist by purchasing the entire album, there's a link for that as well.

So this is Gary Primich. It's Riding the Dark Horse is the name of the album, and the title is Daddy, Let Me Hitch A Ride, pretty good song.

So until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long, everybody.



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