Part 1 – Acne: What it is and What it Isn't

Despite being the most common skin condition in the United States with over 85% of people having experienced acne at some point in their lives, many are completely lost when it comes to managing this tricky condition. The more we try, the more defeated we can feel. Acne has been clinically linked to correlate directly with issues like anxiety and depression. These mental health issues require management right along with the acne and in many cases can contribute to it worsening.

Commonly Misunderstood Condition

Yet even with acne being as emotionally and socially crippling as it is, it is often downplayed. It’s often dismissed as “not a big deal” or as a “first world problem” or even as a result of being unhygienic. Even the vast majority of dermatologists considers this condition a cosmetic issue and dismisses it with the quick flip of a prescription pad and the verbal equivalent of a pat on the head.

The toughest part of acne is that it is a multifactorial condition which continuously changes in its distribution and severity. This makes the endless hunt for that one single thing that is causing it to often be in vain. To truly support and manage acne it is crucial that we understand it. Without that element we are destined to chase our tails in a constant effort to suppress it, often at the expense of our overall skin health.

Yes, it appears as though, despite acne being the most common skin condition in the United States, it is also perhaps the most misunderstood. Let’s take a look at some of the information out there and break down the areas which require support, as well as, touch on what not to do. 

Diet and the Skin - An Interconnected System

Despite there being an overwhelming amount of evidence linking diet to skin health and even directly linking it to acne, it would appear as though there is a large number of professionals who either don’t keep up with these rapid new developments or refuse to let go of old beliefs. Refusing to acknowledge the irrefutable role diet plays in the pathogenesis of acne helps no one, particularly the patient who chooses to believe the advice that they can continue to eat what they want without consequence.

A 2008 study showed what many had suspected up until this point; that a high glycemic load diet impacts the composition of the oil on the skin to the point that it contributed to acne. Science has indeed shown us that acne is an insulin driven condition. Milk consumption and hyperglycemic diets can in fact aggravate acne through the release and production of specific growth factors which ultimately influence androgen metabolism. This brings me to my next topic of the hormonal blame game. 

Hormonal Acne

The vast majority of women struggling with acne will regularly refer to it as “hormonal acne” and it is not uncommon for many professionals to do the same. In reality, all acne has hormonal influencers and the term “hormonal acne” in many cases is quite the misnomer. Acne is a genetic fault within our follicles which makes the skin hyper reactive to all of the factors mentioned here. All acne patients will be hormone sensitive, even when the hormonal fluctuations involved fall within normal ranges. The term “cyclical acne” would be a better referencing term or even “premenstrual acne”. Up to 78% of adult women with acne report a worsening of their condition in the days before menstruation and the rate of premenstrual acne flares has been found to be significantly higher in women over 30 years of age compared to younger women.

There are of course certain situations where acne is more specifically dependent on hormonal abnormalities including cases where hyperandrogenism or PCOS are involved. Despite these numbers, the large number of adult acne sufferers is often ignored within the realm of new product creation. I have personally heard very well respected cosmetic chemists teach that, when creating a product for acne, you generally want to test it on skin within the age range of 12- 24 because you won’t find much acne outside of that. This statement is false but highlights one of the many issues we see within the skincare industry when it comes to supporting acne.

Adult Acne vs Teenage Acne

During our teenage years, when many experience their first and some even their only go round with acne, the skin will be quite different than adult skin, specifically when compared to adult skin which is struggling with acne. More youthful skin is without a doubt more resilient. It allows for more leniency when treating it aggressively or in the abusive manner of many of today’s acne treatments. As we age, those same treatments may offer temporary relief, but it more commonly worsens the issue.

The first notable difference is that, during our youth, a sudden shift in hormones causes a surge of oil production yet many adults who suffer from acne will present with lipid dry skin raising the question of whether or not oil is a big player here. The issue then becomes people thinking they are producing excess oil when they are not.

Has your skin ever felt oily yet dry at the same time? When our skin barrier struggles we will rapidly lose water through the skin in the form of Transepidermal Water Loss (TEWL) (More on this can be found here. The problem here is three fold; common acne products and “solutions” often cause dryness and compromise the skin barrier leading to TEWL. TEWL closely resembles oil on the skin and people struggling with acne view oil as the enemy. They contribute to a damaging cycle as they try to correct what they see as excessive oil with drying products.

Using drying products on skin which is already losing excessive water makes inflammatory conditions such as acne much, much worse. This is often why we will see a product work for a bit but then as dehydration and inflammation levels rise, it will stop…all the while making the newer, more angry acne that much more difficult to suppress.

Are Comedogenic Ingredients Really a Problem?

Comedogenic or pore clogging ingredients are yet another contested piece of the acne puzzle. It is common to see people dismiss the critical role these ingredients play in the formation of acne. Chemists will claim that because these ingredients are tested in high concentrations to determine their comedogenic or pore clogging potential, then using them in lower concentrations would lower that comedogenic potential.

Unfortunately, it is uncommon for cosmetic chemists to have in-depth or hands-on experience with skin. That, in itself, causes a huge disconnect when it comes to the creation of new and innovative products, particularly for people struggling with acne. What they tend to “expect” out of a product in the lab, isn’t always going to be what we see with practical application. Even what they witness when testing these products is often limited to results they can achieve within a 14 day testing window. Anything outside of that perimeter is of little concern.  

When we look at the formation of acne, a microcomedone, undetectable to the naked eye, forms under the skin up to 8 weeks prior to the acne lesion being visible on the skin’s surface. This means that we can have a product which may support more rapid healing of existing lesions or “dry the skin out” with acids while supporting the formation of new lesions under the surface. This may lead to temporarily clear skin for a short period of time and is often a honeymoon period, but yet another area of disconnect.The actual time frame associated with acne formation is simply not something typically accounted for during the recommended testing period for an acne product.

An ingredient is comedogenic due to a chemical composition consisting of higher levels of free fatty acids which are irritating to the pore. This is what makes them comedogenic - or pore clogging if you will. Many people think that an ingredient physically goes into the pore and remains there causing the clog. In fact, it is the irritating nature of the chemical which causes a rash-like response inside of the pore.  

Think of how your skin behaves when you have a rash. It becomes irritated, dry and flaky. This is what occurs inside of the pore. Those flakes from that irritation are what cause the congestion. This means that even using a “low dose” of one of these ingredients, even once, can sometimes cause this response. When the goal is clear skin, the idea is to not play Russian roulette when we should be eliminating and controlling as many variables as possible to yield the best result.

Existing Acne Treatments - Why You May Want to Think Twice

Traditional acne treatments exist to suppress the symptoms of acne as discussed above based upon their recommended testing time. Read that again because it is important. They do not work in a supportive manner with the skin or the body. They have not been formulated to help aid in anything within the skin aside from the suppression of acne symptoms. Long term damage or issues which arise from the use of these products is abundant yet, with the main goal of these treatments being to suppress and relieve acne symptoms, they are often easily dismissed within the professional realm.   

The main medical treatments for acne include antibiotics, oral isotretinoin (also known as Accutane) and now a blood pressure medication used off-script known as spironolactone. Topical medical treatments include isotretinoin, salicylic acid and benzoyl peroxide. Treatment failures with systemic antibiotics occur in 80% of adult women, and recurrences after oral isotretinoin therapy occur in 15% to 30% of users.  

Both antibiotics and oral isotretinoin (Accutane) are well known for replacing one issue with another or to amplify the existing issue of acne by kicking the can down the road. There is a connection between the gut and the skin referred to as the gut skin axis. When we take antibiotics we will often see a temporary clearance in acne, but due to the issues antibiotics cause within the gut and the common problem of over prescription within the medical community, this can lead to a worsening of acne along with other future health issues. Furthermoredue to the large role biofilm plays in how resilient acne can be, long term antibiotic use is needed to see results. 

Accutane is something that is well known to cause many internal issues which have been very well documented and reported, but as a professional who works with a large number of acne sufferers, I would instead like to discuss what we see when this treatment fails…or even when it doesn’t. For many who go this route, they often hear about the associated dry skin while taking the medication. What many fail to realize is that this continues long after they have completed their rounds. 

While skin on Accutane is severely compromised to an often painful extent, post Accutane skin is chronically lipid depleted. The depletion of these lipids and the fact that the skin often can no longer synthesize them on its own means that the TEWL mentioned prior is chronically at an all-time high, bringing with it excessive inflammation levels. At best, this will mean premature aging. At worst, it means more acne. Yet, with skin unable to produce lipids, the skin also struggles to heal itself meaning longer lasting, more severe and often cystic acne. These are some of the toughest cases to treat because, not only do you have to intensively focus on the acne, but there is no barrier repair available. There is only ongoing intensive skin barrier support.   

Benzoyl peroxide (BP) is my personal least favorite treatment based primarily upon observational evidence but also due to clinical evidence of it being inflammatory, creating oxidative stress and depleting antioxidants within the skin.  It is common for the skin to experience difficulty recovering from excessive use of BP and to have a considerable amount of rebound acne on the long arduous path back to healthy skin. 

In my next article I will discuss the ways we can address these factors and how we can successfully manage acne and support acne prone skin.

About the Author:

Dru Pattan is a Licensed Esthetician who specializes in acne while taking a skin healthy approach to sustainably healthy skin known as Corneotherapy. She believes that we don't need to beat the skin into submission to make it comply. By monitoring the skin's needs and offering nourishment we are able to heal common ailments which can often seem lifelong and defeating.

Dru has been licensed since 2014 and has spent the majority of that time relentlessly hunting down advanced education within the industry. When she herself is not studying, she is offering education and support to clients and other professionals within the industry.