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Ep. 14 From the Archives: Acne 101

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Ep. 14 From the Archives: Acne 101

Jan 07, 2022
While the Skincast crew is working on some brand new episodes for the new year (with new guests!), enjoy this look back at tips from Dr. Johnson and Dr. Tarbox for dealing with acne. They offer up simple techniques and recommend affordable products that can make a big difference in minimizing acne's impact on your skin.


Dr. Tarbox: Hello and happy holidays from Skincast. We’re taking a little break to refresh ourselves over the holidays, but don’t worry we’ll be back soon with more information on how to take the very best care of the skin you’re in.

Dr. Johnson: We are working on some brand new episodes — hopefully with some fun guests — so we will see you then!

Dr. Tarbox: Hello and welcome to "Skincast." This is the podcast that helps you understand how to best take care of the skin you're in. You wear your skin your entire life. It is the most expensive garment you will ever wear so you want to take great care of it.

My name is Michelle Tarbox, and I am a dermatologist and a dermatopathologist. I'm an associate professor at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas, and I love helping people take better care of their skin. And joining me is my co-host...

Dr. Johnson: Hey, this is Dr. Luke Johnson. I'm a pediatric dermatologist and general dermatologist with the University of Utah.

Dr. Tarbox: So today we're going to go over acne basics. Acne is a common skin condition that affects most people at some point in their lifetime, and utilizing a few simple techniques you could really help minimize the impact of this condition on your skin.

Dr. Johnson: So acne is super annoying. I had pretty bad acne when I was a young lad. I still get the occasional pimple even though I'm 40. Really seems unfair. But when I, you know, became a dermatologist, we learned about what causes acne. And actually, I remember being a teenager sitting in my dermatologist's office and looking with fascination at the posters on the wall about the causes of acne.

So, in dermatology, we consider acne a disease of the hair follicle unit. So one of the first things that happens is that the hair follicle gets kind of blocked up with sticky skin cells. And the hair follicles are often connected to oil glands, and the oil glands produce oil. The special term for this kind of oil is sebum. And so since the sebum can't get out of the hair follicle because the hair follicle is blocked up, the hair follicle gets all kind of filled up with this sebum.

Dr. Tarbox: And one of the interesting . . .

Dr. Johnson: Who likes to eat sebum? Bacteria like to eat sebum. So bacteria come to eat it, and then that creates an inflammatory reaction from your immune system and that sort of really gets the whole ball rolling down the hill.

Dr. Tarbox: That's actually one of the things I like to think through as kind of fascinating that these bacteria, which are called Propionibacterium acnes — they're named after the condition that they cause — are almost like little farmers of the oil that they eat. So they actually make our skin cells more sticky to each other so it plugs up the hair follicle more, and that actually makes a little reservoir of oil that these bacteria can use as a food source.

Dr. Johnson: And you might wonder why this tends to get worse around adolescence. And hormones play a big role as you might guess. A lot of the hormones make your oil glands crank out more oil and they make your skin a bit stickier so it makes the whole thing worse.

Dr. Tarbox: Whenever you have that backup of oil, it can actually break open the edges of the hair follicle and then that skin oil and possibly those bacteria and the dead skin cells get into the part of our skin that's not supposed to have foreign bodies in it. So if you've ever had a splinter and it got inflamed and red and irritated, you know how much our skin doesn't like things that don't belong there. And that oil is just as inflammatory.

Dr. Johnson: I think it's helpful to understand why acne shows up because then we can understand how the treatments work. So the treatments for acne affect some of those factors that cause the acne to begin with. And our best treatments are those that can affect more than one of those factors at the same time.

Dr. Tarbox: Here on "Skincast" we are not sponsored, but we are going to mention specific trade products because it makes it easier for patients to find them and I think that it's a little bit less complicated than people scouring an ingredient list looking for a specific and very technical chemical name.

Dr. Johnson: Yes, we have no commercial interests. This is just stuff we found that is good for our patients. And if you've got some acne, then there is some over-the-counter stuff that's fairly helpful. One of my favorites is a medicine called benzoyl peroxide. Not hydrogen peroxide. That's something else. This is benzoyl peroxide. It's in a lot of over-the-counter acne treatment products. So if you stroll down the acne treatment section in your local grocery store, you'll find benzoyl peroxide in various concentrations. Usually it's something like 4% to 10% that's present in cleansers, in spot treatment pads, in creams, and in various other formulations.

Dr. Tarbox: Benzoyl peroxide can be a great help when you're dealing with acne. One thing you do have to be thoughtful about is that it has peroxide in it. So if you've ever bleached your hair or thought about bleaching your hair, you might know that peroxide can lighten things. And it's true that if you have a benzoyl peroxide product on and it gets on a bed sheet or a towel or clothing, it can lighten or bleach the clothing. If you have fine light brown hair, it can also lighten your hair color around the hairline.

Dr. Johnson: Yeah. So this is one reason why I like it as a wash or a cleanser. I figure most people are washing their face anyway. Might as well put some medicine in there so you don't have an extra step to do. I say wash your face in the morning with this stuff because then they're not immediately putting their face on a pillowcase and discoloring their pillowcase. You do want to use white towels though or you'll have some messed up looking towels. That's the main downside with this benzoyl peroxide stuff.

It can also be a little bit irritating to the skin. In general, the lower percentage, the less irritating it is. So how sensitive is your skin? If it's not that sensitive, just buy whatever's cheapest, like I do, the generic brand. But if it's a little bit sensitive, there's a couple brands out there that are especially gentle. There's one called AcneFree. All one word. You might have to get it online. It's 2.5%. And then CeraVe makes a good one called Acne Foaming Cream Cleanser. It's 4% benzoyl peroxide. Also, very gentle.

Dr. Tarbox: I really like that CeraVe product, and I think that patients can do really well with benzoyl peroxide. Some people can't tolerate it, and, in that setting you can potentially use a milder wash made from something called salicylic acid, which is actually a relative of aspirin.

Dr. Johnson: Yeah, I do prefer benzoyl peroxide, but salicylic acid doesn't have this bleaching property and is usually present again in the same sorts of products that benzoyl peroxide is found in. Usually it's 2%. And if the benzoyl peroxide is just too irritating or you hate that half of your clothes are discolored, then salicylic acid is a decent option.

Dr. Tarbox: If you are aspirin sensitive, you would not want to use salicylic acid, and if you're pregnant, you would not want to use salicylic acid as it is a derivative of an aspirin-like chemical.

There's another wash that I really like for patients who have very sensitive skin that can't tolerate benzoyl peroxide or salicylic acid. This is a product from Cetaphil that actually has zinc sulfate in it, and it's an oil control acne wash.

Dr. Johnson: So there's our cleansers. Something else that's really nice that's over-the-counter is a medicine called adapalene. The brand name is Differin, D-I-F-F-E-R-I-N. Differin the brand makes several products now I think. So you want the one that's called Adapalene, is the medicine.

Until about five years ago, this was a prescription product that cost about $220, and now it's an over-the-counter product that costs $12. So a rare example of medication costs moving in the right direction. It comes as a gel, and you put a little blob of it on your finger. I usually recommend that people do it at night. And then you get that blob on your finger and you kind of dot it all over your face and then you rub it in everywhere.

So neither of these approaches is a spot treatment. Both of them go over your whole face because they help prevent acne from showing up as well as treat acne that's currently there.

Dr. Tarbox: If you're looking for adapalene over the counter, there are a couple different brand names. Differin is the original brand name, but you also can buy it as a La Roche-Posay product. That's a French company that retails products across to pharmacies in the United States. And the name of that line is Effaclar.

Dr. Johnson: I did not know that. It can also be a little bit irritating. Usually not too bad. But I usually tell people if it dries you out, just give your skin a break for a day or two, let your skin recover and then come back to it. Most people's skin will kind of get used to it. If you find that you're using it every night and it's not irritating you at all, well, you could probably step it up to a prescription strength version of the same thing.

Also, this is a retinoid. So there are components called retinol that are in a lot of over-the-counter sort of anti-aging products. And they also work. They're pretty similar to adapalene. They tend to be a little bit higher priced though. But the reason that they are in these anti-aging products is because adapalene and retinol and all these things are good not only for acne but also for scarring, for wrinkles, for dyspigmentation, so pigmentary changes in your skin. Basically, anybody who's not pregnant or breastfeeding should probably be putting one of these things on their skin.

Dr. Tarbox: Yeah, I love my topical retinoid. I don't leave home without it. Speaking of irritation, sometimes people, when they have bad acne or acne that they're frustrated with, will really kind of go after it with everything and the kitchen sink and they can end up really stripping their skin and making it too irritated and dry, which can actually make the acne worse.

Dr. Johnson: Yeah. So just as important as knowing what to do, things like benzoyl peroxide and adapalene, are knowing what not to do. So your poor little skin doesn't need astringents, it doesn't need scrubs, and it doesn't need things that are just too expensive. So sometimes I have patients who come in and they bring their Ziploc bag full of products that they've been using and I love it when people bring them, but it kind of breaks my heart that they've been spending 20 or 30 bucks on a benzoyl peroxide cleanser because you can buy one of those for 4 or 5 bucks.

So things don't have to be expensive, in fancy bottles, and advertised on television for them to work well. You just want to look for these ingredients — benzoyl peroxide, adapalene, retinol, things like that.

Dr. Tarbox: Sometimes patients will also over exfoliate. There are products that are coming off of the market because they have microplastics in them with those little beads that sometimes were included in products for exfoliation. And there are also products that have ground up walnut shells and things like that, which are pretty abrasive to the skin and can do more harm than good. If you want to gently exfoliate, a gentle facial brush that you keep clean and use with minimal pressure is a great alternative.

Dr. Johnson: So those are pretty good things that you can do over the counter. But what if you've done those or your teenage kid has done those and they've still got acne? Well, it might be time to go to a dermatologist. Another reason to go is even if you haven't tried those things, if somebody's acne is moderate or worse and all of those over-the-counter things just aren't going to be good enough, come to one of us. There's really good acne medicines these days. Really the only downside for our acne medicines is that they take a little while to work. So I am sorry if you are getting married next week. There might not be a whole lot that we can do. So come early. It usually takes our medicines about three months to really kick in, but after that, modern medicine does a pretty good job of treating acne.

Dr. Tarbox: Yeah, I always remind patients if your acne is leaving footprints, if it's scarring, you want to seek professional help because scarring is permanent and while we can do a lot of things to help improve those sort of scars that are formed over the years, like chemical peels and microneedling, it's better to prevent than to treat those scars.

Dr. Johnson: I would like to have a little myth-busting section of our podcast here because I think there's a lot of myths out there around acne. One of the main things that gets bandied about is diet. So there's been a fair amount of research into diet and acne, and I will admit that, before I read some of this research, I just didn't think diet mattered at all. Now I think that diet matters... just a little bit.

So the research says that if you have a high glycemic diet — so that's a diet where you eat a lot of like sugar and fat and carbs and things — that can make your acne a little worse. And for some reason, skim milk specifically has been associated with acne. Again, I think the effect is pretty mild. So if you have a high glycemic diet and you drink a bunch of skim milk, instead of having five pimples a month, you might get seven. So it's not really going to make or break things, but there is some data out there. So if you want to listen to your grandma and not eat that bag of Doritos, it might help your face a little.

Dr. Tarbox: Yeah, the skim milk connection is really fascinating, because when you have skim milk, it's had the fat taken out of it so more of that product is protein. And our hormones are proteins. Animals that aren't raised organically sometimes have extra hormones added to make them big and strong and overproduce milk, and those can affect some patients. If you are sensitive to that, going for the organic alternative or going for a vegan alternative may help you.

What about cleaning the skin, Luke?

Dr. Johnson: Well, I don't think cleanliness is as important as a lot of, well, to be honest, mothers and grandmothers seem to tell their children and grandchildren. Obviously, you should do something, but blackheads, for example, are not black because there's dirt in there. That's the sebum, remember the oil, and it just gets oxidized when it's exposed to the air and it turns black. So it's not dirt in the skin. And you don't need to be overly vigorous, as we've discussed, with these scrubs and things. So I think washing your face once a day with something gentle, especially with something with some acne medicine in it, like we've discussed before, is probably all you need to do. But having acne does not mean you are an unclean person.

Dr. Tarbox: That is such a good thing to tell people because sometimes there is a stereotype that goes along with bad acne especially. If I have an active young person that's a student athlete, I do like for them to cleanse their skin after exercising, and the product I really like for this is something called Simple Face Wipes because they're little pre-moistened towelettes in a little convenient packet that can go right in the gym bag and the patient can just wipe their face down after exercising or sweating and it helps to decrease that kind of post-exercise gunk that sort of stops up the hair follicles.

Dr. Johnson: When we think about acne, we're often thinking about teenagers, but acne can show up in other people too. It can show up in adults, especially women, in which case it's often hormonal and we do have hormonal treatments. So there is hope out there if you are such a woman. Come in and see us. We can do stuff. And then I can see it in fairly young kids too. So, from hormonal standpoint, puberty supposedly begins around age eight. And, you know, having a couple of little kids of my own, that's rather terrifying. But I have seen acne show up in, you know, eight years, nine years. Usually, it's pretty mild, but I have had some significant acne in kids as young as about 10.

Dr. Tarbox: There's another special form of acne that can happen in young women called acne excoriée, and it actually has a French name. It's acne excoriée des jeunes filles ,which means 'the picked-on acne of the young woman'. And this is usually occurring in young women who are a little bit stressed out, often successful, intelligent, driven young ladies that sort of express a little low-level anxiety by picking at the acne lesions often sub, kind of, consciously. So bringing that to your attention, if you are a person that picks at the skin lesions, is a good idea and you should remember that the little scars and the marks that are left behind after manipulating or picking at an acne lesion are going to last longer and scar worse than the acne lesion itself.

Dr. Johnson: Don't pick at your acne. There. You heard it from some dermatologists.

There are some other sort of special forms of acne. Most of the time, when we see acne, it's standard acne or what's called acne vulgaris. But there's a form of acne called acne mechanica. So if you're wearing something like a mask, for example, on a part of your skin, then that can further occlude those little hair follicles and make acne a lot more likely. So maskne is a form of this acne mechanica stuff. People who wear a lot of sporting equipment, you know, goalie masks and things or fencing masks, I've seen it or surgical caps. I've seen that in surgeons because it occludes their forehead and they get acne there. I see it in military recruits who have to wear backpacks a lot. They get it on their back. That kind of thing.

Dr. Tarbox: You can also get acne from products that are put on other parts of your body. So if you use heavily oil-based products on your scalp, over the course of the day the heat from your body will melt those products and it just sub-clinically trickles down from the hairline to the eyebrows and patients can have a flare of acne on that forehead region because of their hair care products.

Dr. Johnson: Apparently, according to the textbooks, acne is also worse if it's really hot or humid. I live in Utah, where it's really hot, especially today, but it's not humid. But it has its own special name — tropical acne. So if you are a military recruit in some tropical place, I hope your back does okay.

Dr. Tarbox: There's certain medications that can also cause acne. Steroids, either steroid hormones, like the male and female type hormones, or steroids such as glucocorticoids or prednisone can cause acne to worsen as can other kinds of medications that are sometimes used to treat seizure disorders.

Dr. Johnson: But if you are taking one of those medicines and you get acne, we can help. So, you know, if you need to take testosterone or you need to take other hormone replacement therapies and things, then it makes sense to come see one of us if the acne is giving you trouble.

Dr. Tarbox: And especially if it's an anti-seizure medication. Those are not medicines you want to mess around with. So, you know, you would continue to take those based upon the recommendation of the doctor that takes care of you for those and then seek the expert advice from a dermatologist.

Dr. Johnson: I hope that you guys found this helpful. And we want to thank our institutions. Thanks to the University of Utah and to Texas Tech. And if you are a real dermatology nerd, you might be interested to know that Michelle and I co-host another podcast, which is really targeted at people practicing dermatology, but hey, maybe you'll find it interesting as well. It's called "Dermasphere," D-E-R-M-A-S-P-H-E-R-E.