Choosing between contradictory foliculitis treatments

[iamthepatient]

I'm 27 old male and I have a moderate severity acne. I've been to two doctors and got a drastically different feedback from them. I'm fighting with the issue for a very long time so desperately searching for resolution.

My skin is unfortunately a combination of being oily, sensitive and having stiff facial bristles. And, as obvious from my question title, my skin is also acne-prone: almost everywhere above the navel. Head, forehead, upper back and shoulders typically have some rashes and occasional breakouts happen but they're not painful or itchy and they don't really bother me most of the time.

Recently (within the last year) things got worse with my chest. There were quite large red bumps that took more than a week to heal and typically had some white pus(?) inside. Also, the things got worse with my face: mostly cheeks, neck, area near mouth and nose. I shave all of the affected facial areas (except nose of course but nose is my most oily part of the skin so I assume that is the main reason). Also, my chest is quite hairy if that adds useful information.

So, with all that said, I went to a dermatologist who said that my diagnosis is chronic foliculitis and gave me a 3 month treatment plan that I 100% followed:
* a cleanser gel for face and chest twice a day and before shaving (they position themselves as a product for sensitive skin and I must say the skin really feels well after it; can't estimate its therapeutic properties though)
* an anti-irritating cream after shaving
* 3-month application (both face and chest) of the medicine based on Adapalene and Benzoyl Peroxide

But it didn't quite help:
* the chest state really became better but now in a month after the end of treatment I'm still having a few bumps there (I mean that they still happen not that they can't cure for a month); it's not as bad as it was a few months ago but I'm concerned
* facial state didn't improve a lot; I've recently read a lot about shaving and slightly changed my shaving routine to shave mostly in hair growth direction on cheeks and chin; in parallel, the state of cheeks got better but chin and area near mouth didn't (I'm shaving with a 5-razor Gilette cause thought it should shave fast and gentle but now that I'm reading about shaving it looks like 2-razor options are better but Internet is inconclusive; my doctor just said that quality cartridge blades are better than electric razors).

So I went to the same doctor again and got two changes to the treatment plan:
* 2 month course of doxycycline orally (2 pills for 10 days, 1 pill for 20 days, 0.5 pill for 30 days)
* 2 month course of clindamycin on face
* apply anti-irritation cream in the morning (not just after shaving)
* keep only cleanser for chest

I felt uncomfortable with such an amount of antibiotics so decided to get a second opinion before starting this treatment plan. The other dermatologist said that doesn't see reasons to take oral antibiotics, that I should stop shaving but use a trimmer instead and then some quality aftershave balm that should also be used after cleanser (I'm a bit confused on this cause I thought that aftershave means only after shaving) + some additional cleanser once in two days that is a combination of benzoyl peroxide and clindamycin. The second doctor also said that I should not apply cream after shaving because it's bad for oily skin.

So I'm very much confused now because these treatments don't have anything in common except clindamycin. I like the second approach because intuitively less razor contact with skin, less irritation and maybe infection. But I'm also concerned that I might have a bacterial infection that the first doctor implied by suggesting antibiotics course and that this might get worse.

Any advice regarding these treatment plans or any alternative ideas will be very highly appreciated. Thank you very much in advance. I'm really looking forward to your answers.

[Honey0416]

The white pus seems to be a fungal infection. But your is severe, and due to the shaving the hairs have turned back into the skin and cause the redness and inflammation. You can use head and shoulders with pyrithione zinc or Nizoral shampoo. Then take some cortisone cream and some anti fungal cream like lotrimin AF is best and apply twice a day. Ohh the shampoo is used kinda like a mask for 10 min if it irritates 5 minutes and u rinse it off. That was happening to me and I struggled for months and after 4 failed dermatology appointments I discovered the answer on my own..

[Paxiled]

Any time you take an antibiotic for something that won't actually kill you, there are big risks.  One is making the problem chronically worse, as they will only work while you use them and then you go back to being who you were before but possibly worse as antibiotics kill off beneficial organisms that protect us from such things.  While acne is annoying, it won't kill you, so antibiotics would only be appropriate if the acne was getting in the way of your life.  You also have to consider that the products doctors recommend for cleansing often have a lot of synthetic additives in them and are often also antibiotics in part, so again, temporary relief with the possibility of more long-term harm.  As for nose being oily, oily skin usually is where we get acne, so that's not it.  It might in fact be that the nose sticks out and gets a lot of sun, and ultra-violet light dries out the acne.  When I had acne when young it went away pretty much in the summer because I got a ton of sun, which is now not recommended because of skin cancer, but it was a lifestyle where and when I grew up.  If you really want to experiment, try radically changing your diet, to start with.  Avoid dairy, wheat, sugar, chocolate, and the like and see if the problem gets a lot better.  If it does, you have a food problem.  And try using more gentle natural cleansers that keep you clean but don't add to the problem.  You want to keep those pores from getting clogged, so stay away from anything with petroleum derivatives in it, and watch the oily foods you eat -- just the good fats, not the bad ones, avoid fried food, etc.  If that works, it will keep working, not stop as  soon as you stop the medication.  If it doesn't work, nothing lost.  Some people just are unfortunate in that they have very sensitive skin that needs a lot more care than others.  My brother was one of those, and he grew a beard to avoid the problem, at least on his face.  Get out in the sun when you can.  Peace.

[iamthepatient]

Thanks for your response, @Paxiled.
I try to follow a healthy diet (kinda what you wrote: less sugar, more wholegrain stuff, less white wheat, almost no fried food etc.), didn't notice effect from reducing dairy. Growing the beard (or switching from shaving to trimming) is maybe the way to go. Still hoped to get some opinions so thanks again for yours.

[iamthepatient]

Thanks for your response, @Paxiled.
I try to follow a healthy diet (kinda what you wrote: less sugar, more wholegrain stuff, less white wheat, almost no fried food etc.), didn't notice effect from reducing dairy. Growing the beard (or switching from shaving to trimming) is maybe the way to go. Still hoped to get some opinions so thanks again for yours.

[Paxiled]

Reducing won't work.  Only eliminating completely will tell you if you're having reactions to certain foods.  Less, almost won't cut it if you're trying to figure out if it's what you're eating.  A lot of people think they eat a healthy diet but actually don't, but in your case it's not health so much as what might be an allergy or intolerance to certain foods that causes inflammation that contributes to your acne.  I have no idea if that's involved, but it's just one thing that affects some people.  It's very hard to do but if it works, and this was my point, if you can find something you can change without using medication you might actually fix the problem.  You don't mention your age, but you're shaving, so you're not most likely a teenager anymore, but this does pretty much go away at some point for most of us as we age, although never completely -- I'm 68 and yeah, I still get pimples here and there.  Peace.

[iamthepatient]

Thanks for your comment.