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FAQs:
What is Acne?
Acne is a common skin condition that happens when hair follicles under the skin become clogged. Sebum—oil that helps keep skin from drying out—and dead skin cells plug the pores, which leads to outbreaks of lesions, commonly called pimples or zits. Most often, the outbreaks occur on the face but can also appear on the back, chest, and shoulders.
Acne is an inflammatory disorder of the skin, which has sebaceous (oil) glands that connects to the hair follicle, which contains a fine hair. In healthy skin, the sebaceous glands make sebum that empties onto the skin surface through the pore, which is an opening in the follicle. Keratinocytes, a type of skin cell, line the follicle. Normally as the body sheds skin cells, the keratinocytes rise to the surface of the skin.
When someone has acne, the hair, sebum, and keratinocytes stick together inside the pore. This prevents the keratinocytes from shedding and keeps the sebum from reaching the surface of the skin. The mixture of oil and cells allows bacteria that normally live on the skin to grow in the plugged follicles and cause inflammation—swelling, redness, heat, and pain. When the wall of the plugged follicle breaks down, it spills the bacteria, skin cells, and sebum into nearby skin, creating lesions or pimples.
For most people, acne tends to go away by the time they reach their thirties, but some people in their forties and fifties continue to have this skin problem.
What is Cystic Acne?
Cystic acne is a type of inflammatory acne that causes painful, pus-filled pimples to form deep under the skin. Acne occurs when oil and dead skin cells clog skin pores. With cystic acne, bacteria also gets into the pores, causing swelling or inflammation. Cystic acne is the most severe type of acne. Acne cysts are often painful and more likely to cause scarring.
What is Fungal Acne?
Fungal acne is a common skin condition that occurs when hair follicles become infected with a fungus called Malassezia yeast. The condition is also called Malassezia folliculitis or Pityrosporum folliculitis. Fungal acne causes clusters of small, itchy, red bumps (papules) on your skin. Sometimes, the bumps get a bit larger and turn into whiteheads, small pockets of white or yellow pus (pustules).
Is Acne a Disease?
Acne is a skin disease involving the oil glands at the base of hair follicles. It affects 3 in every 4 people aged 11 to 30 years. It is not dangerous, but it can leave skin scars. Treatment depends on how severe and persistent it is.
Who Does Acne Affect?
Acne usually affects everyone at some point in their lifetime. It’s most common among teenagers and young adults undergoing hormonal changes, but acne can also occur during adulthood. Adult acne is more common among women and people assigned female at birth (AFAB). You may be more at risk of developing acne if you have a family history of acne (genetics).
Who Treats Acne?
A general healthcare provider or a dermatologist can diagnose and treat acne. If you have stubborn acne that doesn’t improve with treatment, a dermatologist can help.
Where on My Body Will I Have Acne?
The most common places where you might have acne are on your:
- Face.
- Forehead.
- Chest.
- Shoulders.
- Upper back.
Oil glands exist all over your body. The common locations of acne are where oil glands exist the most.
Does Stress Cause Acne?
Stress won’t give you acne if you’re not already predisposed to it, but it can make acne worse by causing levels of certain hormones to temporarily increase. When your fight-or-flight response is activated, the body releases stress hormones, such as cortisol and androgens. These hormones increase your skin’s oil production, which can exacerbate acne.
Stress, anxiety, and fear might also worsen acne by triggering the production of cytokines, tiny proteins that stoke inflammation, including inflammation of the area around sebaceous glands, the glands that produce oil. Stress-related disruptions in healthy habits play a role, too. When you’re anxious, you may not sleep or eat as well as you normally do, which can worsen acne.
Can Acne Cause Scars?
Yes, sometimes acne can cause scarring. This happens when the acne penetrates the top layer of your skin and damages deeper skin layers. Inflammation makes your acne pores swell and the pore walls start to breakdown, which causes skin damage. Scarring can be a source of anxiety, which is normal. Before treatment, your healthcare provider will determine what type of acne caused your scars. There are several treatment options available for acne scars.
How Long Does It Take for Acne to Go Away?
On average, it can take between one to two weeks for acne pimples to clear up on their own. With medicated treatment and a good skin care routine, you can speed up your body’s healing time to make acne go away faster. For severe acne, it can take several weeks for your acne to go away, even with treatment.
How Does Acne Affect My Mental Health?
Acne can cause disruptions in your mental health because it affects your appearance and self-esteem. Often, acne development is out of your control if hormones cause it. This can create stress, which can influence future breakouts. Acne can be challenging for teenagers and young adults. If your acne causes you to feel anxious or it prevents you from participating in social activities with your friends and family, talk to a healthcare provider or a mental health professional.
Can Acne Be Prevented?
Acne is caused by normal hormonal changes that happen during puberty. This makes prevention of acne very difficult, or even impossible. However, avoiding substances that can cause acne may help. This includes certain medicines (such as corticosteroids, lithium, and barbiturates), mineral or cooking oil, or certain cosmetics. Also, daily shampooing helps prevent oil and grease on the scalp from getting on your face or back. Early treatment of acne may prevent it from getting worse and causing scars.
How Common is Acne?
If you have acne, know that you’re not alone. Acne is the most common skin condition that people experience. An estimated 80% of people ages 11 to 30 will have at least a mild form of acne.
What are the Symptoms of Acne?
Symptoms of acne on your skin include:
1. Pimples (pustules): Pus-filled bumps (papules).
2. Papules: Small, discolored bumps, often red to purple or darker than your natural skin tone.
3. Blackheads: Plugged pores with a black top.
4. Whiteheads: Plugged pores with a white top.
5. Nodules: Large lumps under your skin that are painful.
6. Cysts: Painful fluid-filled (pus) lumps under your skin.
Acne can be mild and cause a few occasional pimples or it can be moderate and cause inflammatory papules. Severe acne causes nodules and cysts.
What Causes Acne?
Clogged hair follicles or pores cause acne. Your hair follicles are small tubes that hold a strand of your hair. There are several glands that empty into your hair follicles. When too much material is inside your hair follicle, a clog occurs. Your pores can clog with:
1. Sebum: An oily substance that provides a protective barrier for your skin.
2. Bacteria: Small amounts of bacteria naturally live on your skin. If you have too much bacteria, it can clog your pores.
3. Dead skin cells: Your skin cells shed often to make room for more cells to grow. When your skin releases dead skin cells, they can get stuck in your hair follicles.
When your pores clog, substances plug up your hair follicle, creating a pimple. This triggers inflammation, which you feel as pain and swelling. You can also see inflammation through skin discoloration like redness around a pimple.
Types of Acne
Acne causes several types of lesions, or pimples. Doctors refer to enlarged or plugged hair follicles as comedones. Types of acne include:
1. Whiteheads: Plugged hair follicles that stay beneath the skin and produce a white bump.
2. Blackheads: Plugged follicles that reach the surface of the skin and open up. They look black on the skin surface because the air discolors the sebum, not because they are dirty.
3. Papules: Inflamed lesions that usually appear as small, pink bumps on the skin and can be tender to the touch.
4. Pustules or pimples: Papules topped by white or yellow pus-filled lesions that may be red at the base.
5. Nodules: Large, painful solid lesions that are lodged deep within the skin.
6. Severe nodular acne (sometimes called cystic acne): Deep, painful, pus-filled lesions.
Severity of Acne
Dermatologists rank acne by severity:
Grade 1 (mild): Mostly whiteheads and blackheads, with a few papules and pustules.
Grade 2 (moderate or pustular acne): Multiple papules and pustules, mostly on your face.
Grade 3 (moderately severe or nodulocystic acne): Numerous papules and pustules, along with occasionally inflamed nodules. Your back and chest may also be affected.
Grade 4 (severe nodulocystic acne): Numerous large, painful and inflamed pustules and nodules.
Foods and Diets that Cause Acne
According to a 2021 review, certain foods or diets may have an effect on acne:
1. Low glycemic index diet. Cutting back on foods with a high glycemic index, such as refined carbs and added sugars, could help reduce acne lesions.
2. Milk products. Consuming certain milk products, like milk and ice cream, seems to worsen acne for some people. However, cheese, as well as nonmilk dairy products, don’t seem to worsen acne.
3. Fat and fatty acids. Omega-3 and omega-6 fatty acids may help reduce acne breakouts.
4. Vegan and vegetarian diets. While vegan and vegetarian diets can offer plenty of health benefits, little evidence supports them specifically for the treatment of acne.
5. Probiotics. While probiotics — found in yogurt, other fermented foods, and supplements — could help improve acne, experts have yet to find conclusive support for probiotics as an acne treatment.
Topical Acne Medications
Your healthcare provider may recommend using a topical acne medication to treat your skin. You can rub these medications directly onto your skin as you would a lotion or a moisturizer. These could include products that contain one of the following ingredients:
1. Benzoyl peroxide: This is available as an over-the-counter product (such as Clearasil®, Stridex® and PanOxyl®) as a leave-on gel or wash. It targets surface bacteria, which often aggravates acne. Lower concentrations and wash formulations are less irritating to your skin.
2. Salicylic acid: This is available over the counter for acne as a cleanser or lotion. It helps remove the top layer of damaged skin. Salicylic acid dissolves dead skin cells to prevent your hair follicles from clogging.
3. Azelaic acid: This is a natural acid found in various grains such as barley, wheat and rye. It kills microorganisms on the skin and reduces swelling.
4. Retinoids (vitamin A derivatives): Retinol, such as Retin-A®, Tazorac® and Differin®, which is available without a prescription, breaks up blackheads and whiteheads and helps prevent clogged pores, the first signs of acne. Most people are candidates for retinoid therapy. These medications aren’t spot treatments and must be used on the entire area of skin affected by acne to prevent the formation of new pimples. You often need to use these for several months before noticing positive results.
5. Antibiotics: Topical antibiotics like clindamycin and erythromycin control surface bacteria that aggravate and cause acne. Antibiotics are more effective when combined with benzoyl peroxide.
6. Dapsone: Dapsone (Aczone®) is a topical gel, which also has antibacterial properties. It treats inflamed acne.
Oral Acne Medications
Oral acne medications are pills that you take by mouth to clear your acne. Types of oral acne medications could include:
1. Antibiotics: Antibiotics treat acne caused by bacteria. Common antibiotics for acne include tetracycline, minocycline and doxycycline. These are best for moderate to severe acne.
2. Isotretinoin (Amnesteem®, Claravis® and Sotret®): Isotretinoin is an oral retinoid. Isotretinoin shrinks the size of oil glands, which contributes to acne formation.
3. Contraceptives: The use of certain contraceptives can sometimes help women and people AFAB who have acne. The U.S. Food and Drug Administration (FDA) approved several types of birth control pills for treating acne. Some brand names include Estrostep®, Beyaz®, Ortho Tri-Cyclen® and Yaz®. These pills contain a combination of estrogen (the primary AFAB sex hormone) and progesterone (a natural form of steroid that helps regulate menstruation).
4. Hormone therapy: Hormone therapy is helpful for some people with acne, especially if you experience acne flare-ups during menstruation or irregular periods caused by excess androgen (a hormone). Hormone therapy consists of low-dose estrogen and progesterone (birth control pills) or a medication called spironolactone that blocks the effect of certain hormones at the level of your hair follicles and oil glands.
Types of Acne Therapies
If topical or oral medications don’t work well for your acne or if you have scars from your acne, a healthcare provider may recommend different types of acne therapies to clear your skin, including:
1. Steroids: Steroids can treat severe acne with injections into large nodules to reduce inflammation.
2. Lasers: Lasers and light therapy treat acne scars. A laser delivers heat to the scarred collagen under your skin. This relies on your body’s wound-healing response to create new, healthy collagen, which encourages growth of new skin to replace it.
3. Chemical peels: This treatment uses special chemicals to remove the top layer of old skin. After removal of the top layer of skin, new skin grows in smoother and can lessen acne scars.
How to Get Rid of Acne Scars
Acne scars are stubborn, and no single treatment is best for everyone. One or a combination of the following approaches might improve the appearance of your skin, depending on your scar type, your skin type and the severity of the scarring.
1. Home skin care. Using sunscreen can help limit the contrast between unscarred skin and a scar. Some medicated creams, such as those containing azelaic acid or hydroxyl acids, might help too.
2. Soft tissue fillers. Injecting collagen, fat or other substances under the skin can plump the skin over indented scars. The goal is to make the scars less noticeable. Results are temporary, so repeat treatments are needed to retain the effect. This method has little risk of changes in skin color.
3. Steroid injection. Injecting steroids into some types of raised scars can improve the appearance of your skin.
4. Laser resurfacing. This approach is increasingly popular and is often used on scars that were once treated with dermabrasion. This technique has an increased risk of side effects for people with darker skin or a history of keloids.
5. Other energy-based procedures. Pulsed light sources and radiofrequency devices help make scars less noticeable without damaging the outer layer of skin. Results are subtle, and you might need repeat treatments.
6. Dermabrasion. This procedure is usually reserved for more severe scarring. Your doctor removes the top layer of skin with a rapidly rotating brush or other device. Surface scars may be completely removed, and deeper acne scars may appear less noticeable. Potential severe side effects include scarring and changes in skin color.
7. Chemical peel. Your doctor applies a chemical solution to the scar tissue to remove the top layer of skin and minimize the appearance of deeper scars. You can repeat mild and medium peels to maintain results. You can have only one deep peel. Potential side effects include changes in skin color, especially with deep peels used on dark skin.
8. Skin needling. Your doctor rolls a needle-studded device over the skin to stimulate collagen formation in the underlying tissue. It's a safe, simple and possibly effective technique for acne scarring. It has minimal risk of discoloring the skin. Results are subtle, and you may need repeat treatments.
9. Surgery. Using a minor procedure called punch excision, your doctor cuts out individual acne scars and repairs the wound with stitches or a skin graft. With a technique called subcision, your doctor inserts needles under the skin to loosen fibers below a scar.
10. OnabotulinumtoxinA (Botox). Sometimes the skin around acne scars puckers. Injecting Botox relaxes the surrounding skin, which may improve the appearance of an acne scar. Results are temporary, so repeat treatments are needed to retain the effect.
How to Get Rid of Butt Acne
Butt acne shows up as pimple-like bumps on your rear end. These breakouts are not the same as the acne vulgaris that appears on the face and upper body, but some of the same treatment strategies may work.
Some suggestions for how to get rid of butt acne include:
1. Loosen Your Clothing
Yoga pants, leggings, skin-tight jeans, and other close-fitting pants can trap moisture against the skin and trigger folliculitis. Limit how often you wear tight pants or for how long you wear them. For example, change out of sweaty yoga pants as soon as you can after your hot yoga class.
2. Shower ASAP After Exercise
Sweat that gets trapped against the skin and then dries can be highly irritating to hair follicles. It can create the perfect place for bacteria to grow. Try to schedule workouts and other physical activities so that you can take a shower immediately after. Don't stop by the grocery store or the library until you've lathered up and changed clothes.
3. Steer Clear of Allergens
For people who are sensitive or allergic to them, certain perfumes and other chemicals in laundry detergents, fabric softeners, dryer sheets, and flushable wipes can trigger a rash on the buttocks.
4. Be Gentle on Your Skin
Just as acne can't be scrubbed away, folliculitis needs to be treated gently. But it can be helpful to gently exfoliate affected skin as long as it isn't inflamed or painful. Do not use Loofahs, Stiff-bristled body brushes and Other abrasive products. Choose a soft cloth or nylon body pouf.
5. Apply a Warm Compress
Warm moisture can soothe irritation and help release pus from whiteheads. Press a warm washcloth to your bottom or sit on one for 15 minutes at a time at least three times a day. Dipping the washcloth in a saltwater solution may be especially soothing. You can make one by adding 1/2 teaspoon of salt per 1 cup of water. Soaking in a warm bath or a saltwater sitz bath can be helpful too. Research suggests apple cider vinegar has antimicrobial properties. Add a few drops to your washcloth or a cup to your bath. This can help reduce staph bacteria that can cause infections and worsen breakouts. Thoroughly towel or air dry before you get dressed.
6. Use a Benzoyl Peroxide Wash or Gel
Although "butt acne" isn't typical acne vulgaris, some treatments for facial acne also work on mild butt breakouts. This includes small, fine bumps or a small number of inflamed pimples. Benzoyl peroxide is a common ingredient in acne medications. It's an antimicrobial that helps clean pores. It also has anti-inflammatory properties to soothe mild swelling. Look for a body wash, bar soap, cream, or gel spot treatment made with 5% to 10% benzoyl peroxide. Because it can bleach out fabrics, use white towels and wear white underwear when using benzoyl peroxide products on the skin.
7. Try Tea Tree Oil
Tea tree oil comes from a tree native to Australia. Some studies suggest it has antimicrobial and anti-inflammatory properties. These studies found out that tea tree oil may be as effective in treating breakouts as benzoyl peroxide. But it may not work as quickly.
8. Use Salicylic Acid Medicated Pads
Salicylic acid is a beta hydroxy acid that helps the skin shed cells more effectively. Pre-treated salicylic acid pads are ideal for dabbing this medication onto affected areas. Make sure you keep the medicine well away from your genitals.
9. Apply a Lactic Acid Lotion
Lactic acid is an alpha hydroxy acid. Just like salicylic acid, it helps to loosen and get rid of dead skin cells. It can be found in body lotions such as U-Lactin and AmLactin. If you apply it each day, it can help smooth rough, bumpy skin on all parts of the body. You can use it along with Benzoyl peroxide, Tea tree oil and Salicylic acid. Apply the lotion after the salicylic acid medication has completely dried. A more effective method is to use a salicylic acid or tea tree oil product in the morning and lactic acid at night.
How to Prevent Acne
There are many things a person can do to try to prevent pimples and other forms of acne, including:
1. Wash the face twice daily
Acne is rarely the result of a dirty face, contrary to popular belief. However, it is important to remove excess dirt and oil from the skin by washing regularly and after sweating. Many people prefer to use a mild cleanser and warm water. Applying an oil-free moisturizer after washing can keep the skin from becoming too dry. Overwashing the face may cause the skin to become dry, which can aggravate pimples. However, over-washing of the face can dry the skin out, causing oil overproduction. This can result in more acne.
2. Refrain from harsh scrubbing
Some people scrub the skin with rough cloth pads or washcloths. This can irritate the skin and cause inflammation, making acne breakouts worse. Applying a gentle cleanser with clean hands or a soft brush for use on the face can help prevent pimples.
3. Keep hair clean
If excess oil in the hair travels to the skin, it can worsen acne. Regularly washing the hair may stop acne from developing, especially close to the hairline.Haircare products that contain oil can also cause pimples on the head and hairline. Avoiding these products can lower the risk of developing pimples.
4. Refrain from popping or picking at pimples
It may be tempting to squeeze a pimple, but it can cause inflammation and scarring. To reduce the appearance of blemishes, use a topical treatment instead. They may take some time to work, but they can also prevent new pimples from forming.
5. Apply topical treatments
Over-the-counter treatments, such as creams or serums, can reduce breakouts, particularly when they occur in certain areas.
The following problem areas are common:
- the chin
- the nose
- the forehead
Treatments often contain salicylic acid or benzoyl peroxide. These products are not as potent as prescription-strength treatments, but they can help prevent mild acne and reduce breakouts.
6. Consider topical retinoids
Topical retinoids are products containing medicines derived from vitamin A, and dermatologists prescribe them to manage and preventTrusted Source acne. These treatments help to shed and produce new skin cells faster, which helps to reduce pore-clogging. Most topical retinoids are only available by prescription, including tretinoin (Retin-A, Renova) and tazarotene (Tazorac). However, some topical retinoids, such as adapalene (Differin), are available over the counter.
7. Talk to a dermatologist about antibiotics
Topical antibiotics can fight an overgrowth of P. acne bacteria in the skin. Examples of antibiotics that treat this inflammatory acne include erythromycin and clindamycin, which are available by prescription. Alone, these antibiotics can cause bacteria to become resistant to treatment. As a result, doctors will prescribe antibiotic treatments in combination with benzoyl peroxide to reduce the risk of developing resistant bacteria. A person can identify inflammatory acne by its discolored, irritated appearance. It can also be painful.
8. Talk to a doctor about hormone pills
In cases of female hormonal acne, birth control pills can help prevent breakouts by helping to regulate the hormones that may make acne worse. However, these pills carry risks, so it is essential to review the benefits and side effects before deciding. Spironolactone, a medication doctors use to treat high blood pressure, may also help in cases of severe female hormonal acne. However, spironolactone has many possible side effects, so it is best to speak with a doctor to discuss all options. Doctors do not recommend either of these medications for use in males.
9. Cut back on foods linked to acne
Doctors are not certain of the connection between foods and acne. However, a growing body of research suggests that some foods may trigger acne in certain patients. According to the American Academy of Dermatology, foods with a high glycemic index may increase the risk of developing acne or make acne worse. These potentially problematic foods are sugary and high in carbohydrates. Some examples include:
- cookies
- cakes
- pies
Dairy products, especially skim milk, may also increase a person’s risk of developing acne. A person may want to cut back on a particular food group to see if their skin improves.
10. Wear sunscreen when going outdoors
Too much sun has many damaging effects on the skin. Sunburn can also lead to an overproduction of oilsTrusted Source that make acne worse. However, a person should ensure their sunscreen is noncomedogenic and safe for use on the face.
11. Consider light or laser therapies
A dermatologist may recommend photodynamic therapy to treat acne and pimples. In photodynamic therapy, a medical professional applies a topical solution that makes the skin more susceptible to light. Following this, they will target the acne area with a focused light source. This can destroy dead skin cells and bacteria. There are many other light and laser therapies that can reduce the appearance of acne blemishes and pimples through similar means.
12. Avoid skincare products that contain oil
Skin care products containing oil can clog the pores. This can worsen acne symptoms and increase the likelihood of developing pimples. Using topical products, such as moisturizers and sunscreens that do not contain oil can help to reduce the risk of blocking pores. People refer to products that do not contain oil as noncomedogenic.
13. Refrain from excess exfoliation
Exfoliation is the process of removing dead cells from the skin. While some exfoliation can help improve acne, too much can worsen breakouts. This happens when a person removes too much natural oil from the skin. The skin may compensate by producing more oil, which clogs pores and produces more pimples. If a person exfoliates too much, the skin may become irritated or feel very tight after washing.
14. Reduce stress
Stress often causes inflammation, which can make breakouts worseTrusted Source.
Below are some means of reducing stress that may help to prevent acne:
- meditating
- exercising
- doing yoga
- relaxing before bed by reading or taking a bath
- spending time in nature
- engaging in hobbies
15. Keep facial care products clean
To keep the skin as clean as possible, people should clean makeup, facial sponges, and brushes regularly with soap and water to prevent bacteria buildup, which could lead to breakouts. Make sure that brushes dry completely before use.
Risk Factors for Acne
Risk factors for acne include:
1. Age. People of all ages can get acne, but it's most common in teenagers.
2. Hormonal changes. Such changes are common during puberty or pregnancy.
3. Family history. Genetics plays a role in acne. If both of your parents had acne, you're likely to develop it too.
4. Greasy or oily substances. You may develop acne where your skin comes into contact with oil or oily lotions and creams.
5. Friction or pressure on your skin. This can be caused by items such as telephones, cellphones, helmets, tight collars and backpacks.
Acne Myths
These factors have little effect on acne:
1. Chocolate and greasy foods. Eating chocolate or greasy food has little to no effect on acne.
2. Hygiene. Acne isn't caused by dirty skin. In fact, scrubbing the skin too hard or cleansing with harsh soaps or chemicals irritates the skin and can make acne worse.
3. Cosmetics. Cosmetics don't necessarily worsen acne, especially if you use oil-free makeup that doesn't clog pores (noncomedogenics) and remove makeup regularly. Nonoily cosmetics don't interfere with the effectiveness of acne drugs.
When to See an Acne Specialist
If self-care remedies don't clear your acne, see your primary care doctor. He or she can prescribe stronger medications. If acne persists or is severe, you may want to seek medical treatment from a doctor who specializes in the skin (dermatologist or pediatric dermatologist).
For many women, acne can persist for decades, with flares common a week before menstruation. This type of acne tends to clear up without treatment in women who use contraceptives. In older adults, a sudden onset of severe acne may signal an underlying disease requiring medical attention.
The Food and Drug Administration (FDA) warns that some popular nonprescription acne lotions, cleansers and other skin products can cause a serious reaction. This type of reaction is quite rare, so don't confuse it with any redness, irritation or itchiness that occurs in areas where you've applied medications or products.
Seek emergency medical help if after using a skin product you experience:
- Faintness
- Difficulty breathing
- Swelling of the eyes, face, lips or tongue
- Tightness of the throat
Sources:
The content herein is provided for general informational purposes only and is not a substitute for professional medical advice, diagnosis or treatment. Medical information changes constantly, and therefore the content on this website should not be assumed to be current, complete or exhaustive. Always seek the advice of your doctor before starting or changing treatment. If you think you may have a medical emergency, please call your doctor or 9-1-1 (in the United States) immediately.