A Dermatologist’s Guide To Clear Skin
If you have ever suffered from acne, you are not alone. I have acne. I have had acne since age 12. As a teenager, I tried every scrub and over the counter acne product with little or no relief. As a medical student, I tried Proactiv for months with minimal improvement in my acne. When I entered my dermatology residency one of my attending physicians pulled me aside and told me the following: “You have got to clear up that acne. People will not trust you when you say that you are a dermatology resident and you have acne!” It was something that was very hard to hear, but I realized that he was right. It took me a few years to figure it out, but I finally did. I cured my acne, and I have published journal articles and made national presentations about acne. Now people travel near and far to have me help them with their acne. Many have seen other dermatologists, and have tried many over the counter and prescription medications with no improvement in their skin. I want to empower you and encourage you to believe that clear skin can be yours. You CAN clear your skin once and for all. In this blog, I will talk about the first and most important step… making the right diagnosis!!
Step 1 – Making A Diagnosis. All acne is not created equal.
A single pimple or a face (or back) full of them, most people can relate. Acne is the most common skin condition in the United States, and most likely, worldwide. 80 percent of people in the world will suffer from acne at some point in their lifetime. The first step is to make the right diagnosis. Not all bumps on the face or back are acne. You could have rosacea, or even folliculitis (stay tuned for more information about these conditions in future posts). However, if you are fairly certain that you have acne, there is still a diagnosis to be made. You have to figure out what kind of acne you have! Once you diagnosis the type of acne you have, figuring out how to treat your acne can be relatively easy.
A basic anatomy lesson tells us that the sebaceous gland is attached to a hair follicle. When that follicle is obstructed (usually by dead skin cells), the oil doesn’t have a way to get out. This creates a comedone, otherwise known as a whitehead or blackhead. There is an bacteria that lives on our skin called P. acnes. When you have a blocked pore, these bacteria begin feeding off the oil and skin cells and give off toxic free fatty acids that perforate the base of the follicle and release toxins into the dermis. The body reacts with an inflammatory response and a part of this response results in the formation of a pustule. Acne can be triggered by hormonal changes. The sebaceous glands that re attached to the follicles secrete more oil in response to certain hormonal triggers. This is why women may notice more breakouts at certain time of the month. This is also why teenage males may have worse acne than teenage females. This is because it is actual the male hormones known as androgens that trigger sebaceous glands. Lastly, acne can also be influenced by a few other things, including genetics, certain foods, and stress. Physical irritation can also generate an inflammatory response resulting in pimples.
Let’s review the different types of acne!
Type 1: Comedonal
A fancy name for a plug of oil and dead skin cells within the hair follicle, or pore, this type of acne
appears as a small bump but generally is not red and swollen. Often you will hear these referred to blackheads and whiteheads and your case can be mild or severe. Comedonal acne is typically found on the chin and forehead but can form anywhere there is a pore (including face, neck, shoulders, chest, thighs and back).
Especially common during the preteen and teen years (but can happen at any age), comedonal acne tends to run in families (if your parents or siblings had it, you’re more likely to have it too) and people with oily skin are more prone to it. Non-Surgical Nose Job
Type 2: Inflammatory
Do you tend to wake up with new spots despite a regular skin regimen? This is inflammatory acne.
Clogged pores can be the cause but inflammatory acne is a response by your body to the clogged follicle. Inflammatory acne occurs when acne blemishes become inflamed, forming papules and pustules (pimples and zits). In more severe cases, deeper and larger pus filled lesions called nodules may form. While it may be tempting to pop these new spots, it’s important not to as this can result in scarring.
Inflammatory acne tends to be more common in men due to higher testosterone levels leading to more oil production.
Type 3: Cystic
Cystic acne (also called nodulocystic acne) is the most severe form of acne vulgaris. Breakouts become deep and inflamed and blemishes form cysts that become very large and painful.
Cystic acne can affect anyone but is much more common in teenage boys and young men and it does seem to run in families. This type of acne is severe and needs to be treated by a dermatologist.
Type 4: Hormonal acne
This type of acne is a bit harder to define. As I mentioned, the hormones called androgens stimulate sebaceous glands to squirt out more oil– the more active the sebaceous glands, the happier the p.acnes bacteria. If you go through hormonal fluctuations related to menstruation, or pregnancy, or menopause, or because you have a condition called Polycystic Ovarian Syndrome, you may have times when the androgens are stimulating your skin to make inflammatory acne. This acne usually has a specific pattern, and likes to present as painful bumps around the chin and jaw line.
Are you following me so far? If not, let me summarize it.
- Almost all acne starts off with a blocked follicle called a COMEDONE – aka Whitehead or black head. This type of acne is called COMEDONAL ACNE
- A bacteria on the skin called P.Acnes loves to eat those dead skin cells covered with all the oil from your sebaceous glands just like cheese on a pizza!!! (and who doesn’t like cheese pizza) If the bacteria really go to town on those blocked pores you get pustules, white pus filled bumps on your face, or large inflamed bumps on your face. This type of acne is called INFLAMMATORY ACNE
- If the inflammation is severe, your body may try to wall it off forming an acne cyst. This type of acne is called CYSTIC ACNE
- Hormones called androgens stimulate your sebaceous glands to make more oil. More oil is like more cheese on the pizza for those pesky bacteria. For a certain subset of people, usually women in their late 30s and early 40s, this creates a certain pattern on the face. This acne is called HORMONAL ACNE.
Images are not patients of Vibrant Dermatology and are here for example only. Images source: American Academy of Dermatology.
Treatment of mild forms of acne can usually be accomplished with over the counter products. Once you can understand the type of acne that you have, you can identify the best treatment option for you. Each type of acne will require a different treatment option. Stay tuned for the next post in this series where I will cover over the counter treatment for specific types of acne.