OMG, my face is a disaster! My acne is worse than ever. PLZ help me!

Desperately,

Your Patient

Many of my patients email me; this is the most common email I am getting this week. Why is everyone’s acne flaring up all of a sudden? It’s because of this simple formula: [High School Stress + Hormones = Acne].

Acne results when your pores clog, trapping sebaceous oils and bacteria deep in the skin. When you’re under stress, your body releases cortisol, a hormone that helps you stay alive in life or death situations. High school, however stressful, is not usually life or death, but your body doesn’t know that, and it reacts as if it were.

Two side effects of increased cortisol are increased sebaceous oil production and increased inflammation in your skin. The result: big, red pimples in the middle of your face that make you now wish you were dead.

If you have painful, cystic acne bumps, then your dermatologist can inject the worst ones with steroids to reduce the inflammation and to flatten them out quickly — “Nurse! Give me a syringe with Kenalog. Stat!” (Who said I don’t do emergencies?) Steroid injections can, however, cause atrophy or dimpling in your skin, which can last for months — much longer than the original pimple.

• Spot treating acne is difficult at home. Tretinoin products such as Retin-A, Differin, or Tazorac do not work if applied to acne spots.
• You can pop a pimple; however, unless it has a white head, squeezing usually just makes a little pimple into a big pimple.
• Apply a spot acne treatment such as Neutrogena Rapid Clear Fight and Fade Gel. The mild acids in it help dissolve a pimple when applied directly.
• Use a spot cover-up or concealer that has salicylic acid in it. Yes, guys, it is OK for you to apply a dab of cover-up. Use your sister’s.
• If you have a little extra cash lying around (humor intended), then acne zappers like Zeno can help. They apply heat directly to the pimple killing the bacteria and hastening recovery. Or just use your iPhone, (I’m sure they will have an app for that soon, right?).

Remember that school is stressful, so eat well, sleep well (preferably not in calculus class), and exercise regularly. These will decrease your stress hormones and help keep you acne free.

Disclaimer: I did not receive any free products or reimbursement from any products mentioned in this post; these are my unbiased suggestions.

Photo: John Steven Fernandez

Argh! You cleaned out your high school locker years ago and now you have acne pimples on your jaw this morning. You’re not alone — 1 in every 5 women over 25 has acne.

Adult acne, in contrast to the teenage type, occurs more often in women. For some women, this is the first time they had acne; we call this late-onset acne. For other women, their acne never stopped from childhood into adulthood; we call this persistent acne. Many of my women patients have other names for adult acne, but they cannot be printed here.

It Must Be Hormones

We like to blame everything on hormones. In the case of acne, hormones contribute, but they are not the only factor. Stopping birth control pills causes a change in hormones and is  a cause for acne in adult women. Similarly, using progestin-only birth control pills affects hormones in such a way as to cause breakouts. Pregnancy is a time of dramatic hormone fluctuations and for some women, dramatic acne. Similarly, menopause can trigger outbreaks. Despite these known hormonal triggers, most women who have acne do not have hormonal imbalances (they are normal fluctuations in hormones). Foods or supplements that claim to balance women’s hormones don’t. So save your time and money, they won’t help your acne.

You Can’t Scrub Acne Away

Exfoliating to open pores can help, but only when done in moderation. Harsh scrubs or repeated microdermabrasion will irritate the skin and make acne worse. Instead, use mild chemical exfoliators such as salicylic acid or glycolic acid which are found in many women’s cosmetics and in acne treatments. Products that contain benzoyl peroxide also help to exfoliate and will treat adult acne.

Don’t Give Up Your Scharffen Berger Chocolate

Although myths of chocolate and pizza causing acne have been disproved, it is true that consuming cow’s milk (which contains hormones) as well as eating a diet high in carbohydrates (which causes inflammation) can contribute to acne. Eating chocolate once and a while, especially good chocolate, will not cause or worsen your acne.

Cosmetics Cause Acne

Many skincare products contain ingredients that clog your pores, triggering acne. Pantene shampoo as well as many hair conditioners have been known to cause this problem. Also, sunscreens are notorious for causing acne. If you notice that your acne is worse around your hairline or that it has flared since you started sunscreens, then try changing your products; it might be all you need to clear up your face.

Photo: Foundphotoslj (flickr)

Post written by Dr. Benabio Copyright The Derm Blog 2009

Everybody is talking about the blue light. It is the latest gadget for treating acne (and admit it, we LOVE gadgets).  But can you really treat acne by simply shining a blue light on your skin?

Acne is caused by bacteria that flourish in the pores of your skin. Clogged pores on your skin fill with oily sebaceous material. These warm, oily pits are breeding grounds for P. acnes, the bacteria responsible for acne. Overgrowth of the bacteria leads to inflammation and eventually (quite) noticeable pimples on your face.

Blue light therapy started as an office-based procedure only. Patients with acne would see their dermatologist for treatment. The physician would often apply a sensitizer to the skin called Levulan about 30 minutes before the procedure. Then the patient would sit in front of a blue light source called Blu-U for several minutes. This was repeated several times each week for about 6 weeks.

The therapy worked well. The sensitizing agent penetrated the skin. When treated with the blue light, it absorbed the energy from the light, killing the bacteria and frying the sebaceous glands, decreasing the oil production. It is, indeed, the ultimate dermatologist’s gadget.

So what’s the downside?

First of all, it is expensive. Each treatment costs about $200. A complete course of 8 treatments costs about $1,600. Although it is effective in improving acne, the results might not last, and you may need to continue treatments to keep your acne under control.

A second problem is that the Levulan sensitizes you not only to the blue light but to any light. As a result, you have to be extremely careful about sun exposure for 48 hours after your treatment. Failure to protect your skin after applying ALA can result in a serious sun burn.

A third problem is that the treatment hurts. The combination of the sensitizing agent plus the light treatment will give you a stinging sensation. For most people the treatment is tolerable, but some people find it too uncomfortable to stand.

We now know that light by itself actually kills bacteria; the bacteria produce a natural substance that is similar to the ALA. As a result, the bacteria absorb the blue light and are obliterated. Cool, huh?

Because the sensitizing agent is not necessary, you no longer have to go to the doctor’s office to get treated.  Several companies have developed hand-held blue light devices that you can use yourself at home (Woo-hoo, your own personal acne gadget!).

Recent studies have shown that blue light-only treatments are effective in treating acne. What’s the downside here? Again cost might be a factor. A hand-held blue light acne unit might cost about $250 to $300. 

The main problem is that you have to use it. In order for the light be be effective, you have to hold it against the skin for about 3 minutes everyday. That might not seem like much, but if you have several areas, like both cheeks and forehead to treat, then it could take about 10 minutes each day.

Considering that the average person brushes his or teeth teeth for just 46 seconds, 10 minutes is a long time. 

Photo: Freaksanon (flickr)

Many of my patients ask me about Proactiv. You know, the stuff that makes Vanessa Williams, Jessica Simpson, Kelly Clarkson, Sean Combs, Brooke Shields, Elle MacPherson, and Jennifer Love Hewitt beautifully blemish free. Patients want to know if Proactiv really works. I’ll address that here, but first, here’s a short intro on acne.

If you have acne, then you are like most people. Acne is common — about 85% of teenagers develop it and many adults, especially women, have acne in their 20’s, 30’s and even later. Proactiv is an acne treatment system, designed by two dermatologists, that uses non-prescription medications to clear up acne. It was designed with adult women in mind, but is used by millions of teenagers all over the world. Proactiv does not cure acne (nothing does), but it does work. Here’s how.

The basic Proactiv solution is a three part system comprised of a cleanser, a toner, and a lotion. There are several add-on products, but the acne treatment is in this three part system. In order to understand how Proactiv works, you have to first understand what causes acne.

Acne is a skin disease where red bumps, clogged pores, and tender cysts develop in the skin. It is sometimes painful and almost always embarrassing. The bumps you see on your skin today began about 2 weeks ago. Each acne blemish starts as a clogged pore. These pores are the opening of hair follicles. The skin cells at the surface of some of the pores do not shed normally. Instead, they stick together, clogging the pore. When the pore is clogged, the natural oils from the hair follicle accumulate in the pore, building up pressure and creating an airtight, warm environment for bacteria to grow. Bacteria build up in the blocked pore; as a result, white blood cells accumulate to attack the overgrown bacteria. The combination of blocked sebum, bacteria, and white blood cells (pus) lead to tender red bumps that we call acne.

The Proactiv system works to stop this process. The first step is to use a cleanser. The cleanser has tiny beads that help to physically exfoliate the dead skin cells, unblocking the pores. The cleanser also contains benzoyl peroxide. This is a powerful oxidizer that both exfoliates the skin as well as kills bacteria (similar to hydrogen peroxide).

The second step is to use a toner. The toner contains glycolic acid. This is a natural acid found in citrus fruits. It also works to exfoliate the skin and to unstick sticky-cells. It is a chemical exfoliant and compliments the physical exfoliant in the cleanser.

The third step is to use a repairing lotion. In actuality, it is another dose of benzoyl peroxide, now in lotion form. Again the benzoyl peroxide helps exfoliate the skin and kill the bacteria.

Although there are other anti-inflammatories, moisturizers, and botanicals in Proactiv, the main treatment is from the exfoliants and the benzoyl peroxide.

Proactiv is effective for many people with acne. The main reason why it works is because people actually use it. The system is designed to be used everyday and over your entire face. The whole concept is for you to be “proactive” about treating your acne. It is also a good product because the benzoyl peroxide, which is one of the most effective treatments for acne, is a mild strength, only 2.5%. At this strength, the benzoyl peroxide is mild enough to not be too irriating, but strong enough to treat your acne, especially since it is used in two products and applied twice a day.

Photo: Specialkrb Flickr.com

Tea tree oil is an essential oil that has antiseptic properties. It has been used as a natural antifungal and antibacterial agent. You might have heard that teat tree oil can help treat acne because it kills acne-causing bacteria. However, unlike benzoyl peroxide and retin A, there is not much evidence that tea tree oil is an effective treatment for acne.

There are only two published studies on the use  of tea tree oil for acne. The first was done about 10 years ago in Australia. It showed that 5% tea tree oil is comparable to 5% benzoyl peroxide. The tea tree oil took longer to work, but appeared to be less irritating than the benzoyl peroxide. The second study, which was done in Iran, showed that 5% tea tree oil was more effective than a placebo in treating acne. Comparing tea tree oil  to a placebo, which is essentially comparing it to non-treatment, is not the same thing as comparing it to another acne-fighting treatment. It’s likely that tea tree oil has some effect on acne but it has never been shown to be better than traditional acne therapies.

In contrast to other acne treatments, however, tea tree oil is an increasingly common cause of skin allergies. Like other fragrant oils such as balsam of Peru, tea tree oil can trigger an allergic contact dermatitis in people who are sensitive. This can range from a minor itchy rash to a full scale blistering eruption.

Tea tree oil is also toxic if swallowed. If consumed, even in small doses, it can cause reduced immune function, abdominal pain, diarrhea, drowsiness, confusion, or even, in rare instance, coma.  If applied in the ears, it can lead to hearing loss. It has been shown to be toxic to animals when applied to a large area of skin. Tea tree oil can affect hormones as well. One study published in The New England Journal of Medicine showed that repeated application of topical products containing tea tree oil (and lavender oil) could cause prepubertal gynecomastia, a rare condition resulting in enlarged breast tissue in prepubscent boys. Tea tree oil is not recommended for pregnant or nursing mothers.

Because tea tree oil is a naturally occurring substance, it tends to get good publicity, but it’s probably only an average or below average product for acne. Oftentimes people believe that since tea tree oil is natural, it must be safe and better for you than traditonal acne treatements. It’s not true. Remember, turpentine (a related tree oil that is used to strip paint) is also natural, but it doesn’t mean it’s good for you.

Photo: Shek Graham

All over the counter acne treatments work by using two basic ingredients –

1. An antibiotic to kill acne-causing bacteria and 2. A peeling agent to unclog your pores.

Proactiv® is a widely popular acne kit available by mail; it’s a nice combination of washes, toners, and lotions. If you can afford it, Proactiv is an effective treatment for mild acne. Its active ingredients are 2.5% benzoyl peroxide (the antibiotic) and glycolic acid (the peeling agent).

You can recreate the same acne therapy by buying the ingredients separately. For example, if you used CVS Acne Gel ($3.99) and Aqua Glycolic Toner ($12.28) daily you are using the same active ingredients as Proactiv. The only real difference is the cost:

Proactiv: $40 to $60 (depending on the extras)

Do-it-yourself-activ: $16.28.

Over a year you could save over $250. Remember that any acne therapy only works if you are “proactive;” that is, you must use it faithfully everyday for 2 to 3 months to see results.

Photo: Marissa Cap

In theory, eating foods high in antioxidants like blueberries or acai berries, or applying topical antioxidants like vitamin C should soak up free radicals. However, in reality, consumed antioxidants do not concentrate in the skin (no matter how much Mona Vie you drink) and topically applied antioxidants degrade too quickly to have any effect (despite what they tell you in the infomercial).

To make matters worse, most antioxidants applied to the skin don’t penetrate the dead, outer skin and so cannot have any effect on the living skin below (sort of like trying to clean a window that is dirty on the outside by applying cleaner on the inside). That may change soon.

A group of physicians at Duke University is working to find a way to apply potent topical antioxidants which are stable, penetrate the skin, and have measurable damage-protecting abilities. Through years of research, they found that popular antioxidants such as vitamin C and vitamin E do not live up to their claims, and have little if any actual antioxidant properties when tested on the skin. Recently, however, they found that when vitamins C and E are combined with a special antioxidant derived from ferns called ferulic acid, the antioxidants stabilize each other and really do work.

By combining ferulic acid with the vitamin C and E, the researchers found that the antioxidants remain stable when applied and do not break down quickly. They then put their cream to the test; they applied the cream to people’s skin and fired a beam of skin-damaging ultraviolet light (a form of sunlight) at it. They then measured how red the skin got and biopsied the skin to see if the antioxidant cream did indeed protect cells from the ultraviolet radiation.

They found that the skin treated with the ferulic antioxidant cream had much less redness, many fewer damaged skin cells, and had less DNA damage as compared to the skin that was treated with a placebo cream.

Although there are countless creams that claim to make you look younger and protect you against damage, there are very few studies to support these claims. This study examined the actual antioxidant effect of a highly engineered cream and found that the combination of vitamins C, E, and ferulic acid does protect the skin from damaging oxidation.

Look for creams containing this triple combination of vitamins C, E, and ferulic acid, which I am sure will be available soon. They are probably filming an infomercial right now.

So here is this handsome kid who is the new star on campus with big red pimples all over his chin. Could his acne be related to football?

It is. Acne is common in teenagers, over 80% have some acne during these years. While we have dispelled some of the myths, like eating greasy foods makes acne worse, there are things in a teenager’s life that can exacerbate the problem: in this case, football equipment.

There is a skin condition called acne mechanica that occurs in areas where the skin is occluded. This often happens under athletic equipment. It is common in high school athletes, especially hockey and football players. When solid or nonbreathable materials, such as pads or straps, rest on the skin, it occludes the pores. Heat and friction under the material makes the problem worse.

It can be improved by applying a breathable fabric such as cotton between the equipment and the skin. Treating the skin with mild exfoliants such as salicylic acid acne washes or with antibiotics like benzoyl peroxide washes can improve the acne. Sometimes oral antibiotics are needed to clear things up.

A similar condition to acne mechanica is folliculitis. This inflammation of hair follicles can be difficult to distinguish from acne; it is treated in the same way. Anytime you have an infection of the skin it important to see a physician — sometimes red, pus filled bumps can be a staph infection such as methicillin resistant staphlococcus aureus (MRSA). MRSA infections are not uncommon in high school athletes and can spread in the locker room or lead to more serious infections.

My patient put a cotton pad under his chin strap and took oral antibiotics. His acne is already better. So is his pass rating; maybe its just coincidence, but I don’t think so.

Post written by Jeffrey Benabio, MD
Copyright The Derm Blog 2008, All Rights Reserved

Photo: Edward Leger

Rosacea is an acne-like condition seen in adults. It can take several forms, but commonly presents as pimples on the nose and cheeks. The study reports on a woman with mild rosacea who started taking oral cinnamon oil pills to treat her diabetes. Two weeks after starting the cinnamon pills, her rosacea became much worse.

When she stopped the cinnamon supplements, her rosacea improved. Interestingly, whenever she ate any type of cinnamon after this, her again rosacea worsened.

Using cinnamon to lower blood sugar and cholesterol levels has been growing in popularity. It’s thought that some properties of cinnamon might act like natural insulin in your body and might decrease your blood sugar levels. Clinical evidence for how effective cinnamon is at lowering blood sugar or cholesterol, however, has been minimal thus far.

Cinnamon certainly does act as a vasodilator, that is, it dilates blood vessels. As one of the main problems in rosacea is dilated blood vessels on the face, it’s likely that cinnamon could worsen these blood vessels and make rosacea worse. Dilated blood vessels can also lead to increased inflammation, which would also worsen rosacea.

This post is written by Jeffrey Benabio, MD

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Photo: Gio Jl

MILK CAUSES ACNE!

It makes for a great blog headline. But is it true?

Moms have been saying for ages that eating too much pizza, French fries, and chocolate is what causes acne. Until recently, we didn’t have any research to support or refute Mom’s theory. Now there are studies linking high glycemic diets (that is, diets high in sugar and simple carbohydrates) with acne; so it looks like Mom might have been right.

But the strongest relationship between diet and acne is actually with milk.

There are current studies showing that there is an association between drinking milk and having acne. In the May issue of the Journal of the American Academy of Dermatology, researchers found that drinking skim milk was associated with increased severity of acne in teenage boys.

Blockage of pores caused by hormone induced changes in your skin is a known cause of acne. Milk might contribute to acne, therefore, because milk contains hormones (androgens) that can act on your skin just like your natural hormones.

Does that mean you should stop drinking milk?

No. These findings, although interesting, do not prove that milk causes acne — many people who don’t drink any milk still get acne. But if you have acne and have difficulty controlling it with washes or other acne therapies, then you might consider cutting back on milk to see if that helps.

Remember, though, that milk is a good source of vitamin D and calcium which are critical for bone development in your early teenage years.

You might also like:

The Proper Way to Pop a Pimple

How Do Birth Control Pills Control Acne?

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Photo: William Morgan Hsu