Written by Kathleen Carney from December 2019 Dermascope Magazine
Acne is a disease of the sebaceous hair follicle. Each follicle contains tiny hairs and multi-lobed sebaceous glands. In non-acneic skin, sebum travels up the follicle and out to the skin’s surface. Acne presents itself when sticky sebum and dead skin cells become trapped within the follicle. The sebum attracts the propionibacterium (acne bacteria). Enzymes from the bacteria digest and split the sebum into free fatty acids, which are irritating to the skin. These free fatty acids cause pain and inflammation.
The secret to controlling acne is to stop the impaction from forming in the follicle. There are three keys to stopping acne from forming: eliminating acne aggravators, consistently using appropriate homecare products and prescription medication only if absolutely required, and regular professional treatments.
ELIMINATING ACNE AGGRAVATORS
Key number one is for clients to eliminate acne aggravators. Acne is genetic. Aggravators help set the environment for acne to occur or get worse. There are four types of aggravators, including topical, ingested, environmental, and internal. Acneic skin is sensitive skin. For milder cases of acne, sometimes eliminating the aggravators may help the client achieve clear skin. Most often, professionals will need to incorporate products for home use, as well as professional treatments to achieve clear skin. In severe cases, the acne sufferer may need prescription medication.
Avoid Topical Acne Aggravators
If a client has a genetic predisposition to acne, their skin is sensitive. Sensitivity can range from mild to severe. The microcomedones in their follicles are waiting for something to set them off. Potential topical acne aggravators are things applied directly or indirectly to the skin and include the following.
Skin, Hair, and Cosmetics Products: Comedogenic ingredients can block the follicle and lead to acne. This type of acne is called acne cosmedica. Ingredients are categorized as highly, moderately, or non-comedogenic. The first comedogenic tests were done on rabbit ear skin. Rabbit skin is more sensitive than human skin, so they clog pores faster. Human skin testing is more expensive, less controversial, and more accurate, but it can take up to six months for results. It is important to remember that ingredients are listed in descending order, according to the amount used in the formulation. If a comedogenic ingredient appears towards the end of a label, the product might be okay. Mildly comedogenic ingredients are usually not a problem when used in diluted concentrations. Comedogenic ingredients are not as terrible if used in cleansers or products that are applied and then quickly washed away, so they are not left on the skin to cause problems. The skin care professional should advise the client to be aware that the oils in certain hair conditioners are meant to cling to hair and will also cling to skin, which can cause acne problems.
Laundry Products: Laundry detergents and fabric softeners may cause breakouts. To be on the safe side, encourage clients to use only “free” products like Cheer free, Tide free, and other products.
Friction, Rubbing, Sweating, and Constriction: Acne formed by friction, rubbing, overheating, and sweating is called acne mechanica. If a person has the genetic predisposition for acne, it can be set off by mechanical irritation from helmets, headbands, bra straps, and so on. Sleeping on only one side of the face, resting one’s head in their hand, and shouldering a telephone can also cause friction, resulting in acne. Cleansing sweat away as soon as possible is important.
Avoid Ingested Acne Aggravators
Many things that are routinely ingested can be problematic for acne sufferers, as well. Acne aggravators can be food, drinks, supplements, recreational drugs, and medications.
Foods and Supplements: A high glycemic diet and inadequate levels of vitamins, antioxidants, fiber, omega-3 fats, zinc, and water may lead to the development of acne. Too much iodized salt can cause flareups for clients also. It is advisable for acne sufferers to create a food diary to see if eliminating potential triggers helps clear their skin.
Medications: Corticosteroids are man-made drugs that resemble cortisol, a hormone that the adrenal glands naturally make. Sometimes, increased acne is a side effect of these medications. These medications are given to women for endometriosis. Hormones given to women with fertility problems or menstrual difficulties can also aggravate acne.
Birth Control Pills: The same birth control can have different effects on different women. There are some exceptions but, for the most part, androgen (male hormone) dominant birth control pills usually worsen acne, while female hormone dominant birth control pills containing estrogen usually help clear acne. It is important to note that a severe acne flareup often occurs about 90 days after discontinuing the pill and about 90 days after pregnancy. This is due to hormonal fluctuations. Sometimes the body is able to correct itself and clear the acne, but sometimes the acne may continue for years.
Recreational Drugs: Even though there are reports that state that smoking marijuana lowers testosterone, most acne sufferers experience major improvement when they refrain from smoking marijuana. This might be because marijuana first raises testosterone and then lowers it and the fluctuation is stressful to the follicle. “Smoker’s acne” is usually a non-inflammatory breakout commonly found on the cheeks.
Sunlight: The ultraviolet rays of the sun irritate the skin, whereby the skin responds by producing replacement cells. How the follicles respond to these replacement cells determines the effect on the skin. For the majority of acne sufferers, the additional replacement cells pose no problem. A flareup in acne after sunbathing may also be the result of using comedogenic tanning products or an increase in heat and humidity. Sun-improved acne may be a result of the relaxation experienced while sunbathing, in addition to the extra sleep obtained. In addition, the darker color may provide a cover-up effect for lesions and red spots. The sun damages and prematurely ages the skin by breaking down the collagen layer and may even lead to skin cancer. The same is true for ultraviolet radiation from artificial sources.
Seasons: Testosterone levels in humans reach their high in October and their low in May. This is triggered by the changing lengths of the day and the amount of time the body is exposed to ultraviolet light. This seasonal pattern is most obvious in areas with dramatic seasonal climate changes. Not all acne sufferers notice a seasonal pattern, but some report a flareup period during the spring. If a pattern does exist, treatment can be stepped up to stay ahead of the body’s hormonal cycle.
Climate: It is not known for sure why heat and humidity aggravate acne. It might be because the stratum corneum, which absorbs moisture from the environment, can swell up to 300% when immersed in water. This swelling could lead to a breakdown in a vulnerable follicle wall. The only time steaming is beneficial to an acne sufferer is prior to extractions. This is because it temporarily softens the skin and increases blood flow, making extraction easier. Extractions are much easier after, along with an aggressive benzoyl peroxide homecare peeling treatment regimen.
Occupation: For some acne sufferers, the aggravators can be chemicals they work with. It is important for them to protect their skin, change their clothes frequently, and cleanse their skin immediately following work.
Night Employment: Disrupted sleep cycles can aggravate acne. Sleep is important for the body to remain healthy. The body naturally wants to sleep at night when the sun goes down. Anytime the body is put in an unnatural situation, it creates stress for the body, and for the acne sufferer, leading to acne.
Avoid Internal Acne Aggravators
By far, stress is the number one condition for aggravating an existing acne condition. This is because when a person is under stress, the body suffers first at its weakest link, and for the acne sufferer, the weakest link is the sebaceous follicle. Stress does not always have to be bad. In fact, the body needs a certain amount of stress for individuals to live healthy, happy lives. But, when the body is plagued with too much stress or lacks the ability to efficiently deal with stress, it becomes distressed and unable to defend itself from disease. Here are some factors that cause stress and can aggravate acne.
Irregular Sleep Patterns: The body is designed to go to sleep when the sun goes down and to awake when the sun comes up. Upsetting this biological clock seriously aggravates the acne condition.
Overtaxing the Body: Exercise is good for the body, but too much is overtaxing and stressful to the body. Sometimes acne sufferers will have to make a choice between overtaxing their bodies in stressful sports or a clear complexion.
Strong Emotions: Fear, anger, and anxiety, whether appropriate or not, are stressful. Long-term and bottled up emotions are particularly stressful. These emotions can lead to serious health problems because they exhaust the body.
Hormones: Pregnancy often induces acne flareups and is usually worst in the first trimester. Also, 90 days after the birth, the mother’s acne can flareup because it lacks the estrogen it was receiving while pregnant.
Menstrual Cycle: Flareups are caused by fluctuating hormones. Although testosterone is traditionally blamed for monthly acne breakouts, researchers now feel the hormone responsible for the third week acne flareup is progesterone. There is a rapid increase in progesterone at exactly the same time the premenstrual acne breakout begins. The best way to treat monthly flareups is to do a peel mid-cycle and increase benzoyl peroxide application until the beginning of the menstrual cycle.
Bowel Detoxification: There does seem to be a correlation for some acne sufferers between constipation and acne. If this seems to be a possibility, flax seed tablets are available in most health food stores.
CONSISTENTLY USING APPROPRIATE HOMECARE TREATMENTS AND PRODUCTS
Key number two is for the client to consistently use appropriate homecare and products. The goal for acne sufferers is to keep their skin hydrated, exfoliated, treated, controlled, protected, calmed, and iced.
Hydrated: Hydration keeps the skin flexible and makes extraction easier. Dehydrated skin tends to clog easier.
Exfoliated: Exfoliation products with both alpha hydroxy acids, which work on the skin’s surface, and beta hydroxy acids, that work both on the surface but are also able to penetrate inside the follicle, will help keep the follicles unroofed. This will help prevent clogging inside the follicle.
Treated: Benzoyl peroxide is often considered one of the most effective treatments for treating acne. It kills the P.acnes bacteria. Benzoyl peroxide and salicylic acid are approved by the FDA for over-the-counter treatment of acne. Proper usage can not only treat acne but can prevent it. Extractions are much, much easier if the skin care professional waits for seven days after daily benzoyl peroxide usage.
Controlled: Over-cleansing and scrubbing of the skin can lead to increased oil production. Using a gentle cleanser is better when trying to control sebum production. A clay mask can also help control excess oil.
Protected: Clients should protect skin from free radicals and sun damage with a good sunscreen of at least SPF 30 every day and reapply as necessary. An oil-free moisturizer applied over a hydrating gel can provide extra protection and seal in all the beneficial hydrating ingredients.
Calmed: Irritation and redness lead to inflammation. Inflammation leads to destruction of skin cells, so ingredients and products need to be calming and soothing. Non-comedogenic, gentle ingredients, such as aloe vera and green tea, are perfect for calming irritation.
Ice: Applying ice to freeze the skin will cause protein peptides to break apart and travel to the area of infection and have an antibacterial effect inside the skin. Ice is excellent for inflamed acne and for those pesky under the skin impactions.
Products and Ingredients for Acne
The following are beneficial products and ingredients that are best to include in an acne fighting homecare regimen.
Gentle Water-Based Gel Cleanser: Cleansing skin is important for removing makeup, oils, and bacteria and to keep the follicles from becoming clogged.
Salicylic Acid Toner: Salicylic acid is a beta hydroxy acid that can be used over the counter at 2% or below to keep skin exfoliated both on the surface and inside the follicle, so there is less chance of the follicle becoming clogged. Salicylic acid is related to aspirin, which has anti-inflammatory properties, so it can be less irritating to the skin than other acids.
Benzoyl Peroxide: Benzoyl peroxide is an effective treatment for acne because it removes dead skin cells to keep pores from becoming clogged and will penetrate into the follicle and destroy bacteria. Benzoyl peroxide releases oxygen into the follicle. The bacteria that causes acne is anaerobic, which means it cannot live in the presence of oxygen. Benzoyl peroxide is very drying to the skin, so it is best to let skin gradually acclimate to it. It is important to note that benzoyl peroxide can bleach fabric and hair. Skin will also be more sensitive to the sun, so sunscreen is a must.
Hydrocortisone: Hydrocortisone lotion can be used to soothe dryness and irritation that sometimes accompany benzoyl peroxide usage. Clients should only use it when absolutely needed to avoid the skin becoming acclimated to it.
Alpha Hydroxy Acids: Alpha hydroxy acids can be used over-the-counter at 10% or less. They exfoliate by dissolving the intercellular glue that holds cells together. This signals the skin to make more cells, thereby increasing cell turnover, which can help heal existing acne lesions. Exfoliation of the surface cells also helps keep the follicle openings clear.
Sulfur: Sulfur can reduce inflammation and sebum by dissolving surface cells. Since it smells like rotten eggs, it is usually blended with ingredients that will counteract the smell.
Clay Masks: Clay can temporarily reduce oil production and soothe the skin. Applying a clay mask on top of benzoyl peroxide to spot treat impactions (overnight) can be helpful.
Soothing and Hydrating Masks: Collagen sheet masks can quickly increase the hydration of the skin in only 10 minutes, as long as no comedogenic ingredients are in them. They contain antioxidant and soothing ingredients and can benefit acneic skin.
Tea Tree: Results from a clinical study in Australia found that both 5% tea tree oil and 5% benzoyl peroxide had a significant effect in ameliorating the patients’ acne by reducing the number of inflamed and non‐inflamed lesions (open and closed comedones), although the onset of action in the case of tea tree oil was slower.
Azaleic Acid: Azaleic acid helps unclog pores and fade discolorations, while delivering antioxidant and calming benefits to the skin.
Vitamin C: Vitamin C can promote wound healing and help lessen post-inflammatory hyperpigmentation. Magnesium ascorbyl phosphate is the most stable vitamin C and, since it is a lipophilic molecule, it is easily absorbed into the skin.
Hydrating Gel: Many acne treatment products can dehydrate the skin. Dehydrated skin can perpetuate the acne cycle. Hydrating gels are oil-free, so they are perfect to use during the day under sunscreen and at night under an oil-free moisturizer.
Oil-Free Moisturizer: Oil-free moisturizers can help seal in the benefits of a hydrating gel without being too occlusive on the skin.
Sunscreen: Sunscreen is always important, especially when using products that can help acne, as many of these exfoliate the outer protective layer of the skin, leaving the skin more vulnerable to the sun.
Makeup (noncomedogenic – preferably pure mineral makeup): Many foundations are labeled as mineral makeup, but they also contain other ingredients, which may be comedogenic. Using a 100% pure mineral makeup is best.
Medications for Acne
There are also medications that can help acne sufferers:
Antibiotics: Prescription antibiotics kill the acne bacteria. If a client is seeking medical help for their acne, the only treatments that should be done are hydrating and calming facials.
Birth Control Pills: Birth control pills which contain the hormones estrogen and progestin help regulate hormone swings that cause cyclical acne and reduce excess oil.
Retinoids: Oral retinoids, known as isotretinoin, shut down the production of oil, thereby eliminating the source of what is keeping the cloggage together. Retinoids are derived from vitamin A. Topical retinoids not only smooth fine lines and wrinkles, but they also exfoliate the dead skin cells that cause clogs and lead to acne. Retinoids can make the skin irritated and extremely dry. Skin care professionals can help retinoid users by supplementing their skin with hydrating and calming treatments and products.
REGULAR PROFESSIONAL TREATMENTS
Key number three is the importance of getting regular treatments from a skin care professional who has advanced training in acne products and protocols. Although treatments are important, if a client cannot afford both homecare products and treatments, homecare is a must. The goals of professional treatments are to:
Extensively hydrate the skin to combat the drying effect of the acne treatment products.Thoroughly exfoliate the skin, so treatment products are better able to penetrate the skin. Enzymes are gentle, but effective exfoliators. Alpha hydroxy acid peels, such as glycolic, lactic, and mandelic, can provide even more exfoliation.Activate the body’s internal nourishing and self-cleansing mechanisms, the circulatory system, and the lymphatic system, through massage and masking. The circulatory system is responsible for the flow of blood, nutrients, oxygen, and hormones to and from cells. The lymphatic system transports lymph, a fluid containing infection-fighting white blood cells throughout the body.Properly extract the skin to prevent scarring, staining, and worsening of acne.Red and blue light emitting diode (LED) light therapy treatments are excellent for acne. Blue LED lights can kill the acne bacteria, while red LED lights can help heal the lesions and stimulate collagen for repair.High frequency generates oxygen, which also kills bacteria and calms inflammation.
In summary, the best way for a client to achieve clear skin is to keep the impaction from happening in the first place by avoiding acne aggravators, use proper homecare, and establish a treatment program with a professional skin care provider who is trained in advanced acne treatment and protocols.