Chapter One: skin under siege

"My little nephew, who's only two, turned to me and said, 'Auntie, can I connect the dots on your face?' He didn't know what he was saying, but I was totally humiliated.

I used to wake up crying because I'd feel a new lump on my face every morning."

Amanda, age thirty-one

No matter what your skin color or type, whether you're eight, eighteen, thirty-eight, or sixty-eight, you can get acne. You may have one pimple or a hundred, but the process is the same. Acne vulgaris is the most common
and often the most debilitating skin disease that exists. Over 90 percent of
all people on earth suffer from it at one point or another. So even if you didn't get it as a teenager, chances are extremely high that you'll experience it later in life. It's a rare human indeed who manages to get through life without a single zit!

Before we explore acne in detail, let's learn a little bit about the organ it
affects: the skin.

all about skin

Even when it is covered with acne, your skin is still a marvelous organ. It reflects who you are and how you feel, and it keeps you safe. It has an almost magical ability to repair itself, and we certainly almost always take it for granted. (Except, of course, when plagued by acne.) Constantly replenishing itself, the skin covers a whopping twenty square feet and constitutes 15 percent of our total body weight. In the three layers of one square inch of skin you'll find:

• 19 yards of blood vessels

• 65 hairs

• 78 yards of nerves

• 100 sebaceous glands

• 650 sweat glands

• 1,300 nerve endings

• 20,000 sensory cells

• 129,040 pores

• 9,500,000 cells

Epidermis -- Top Layer

The first living layer of the skin is the epidermis. This microscopically thin layer is seven to ten cells thick and in a young adult completely renews itself every twenty-eight days. Nearly 95 percent of the epidermis is composed of new cells called keratinocytes. The remaining 5 percent is made up of the cells that produce melanin, the substance that gives skin its color, and the all-important Langerhan cells, which work with the immune system to help fight infections.

As keratinocyte cells age, they flatten out and eventually lose their nucleus, becoming horn cells. These horn cells create the stratum corneum, the outermost layer of skin. Even though the stratum corneum consists of dead, overlapping horn cells, like shingles on a roof, it serves a vital function as our first line of immunological defense between the outside world and our bodies.
The renewal rate of the epidermis diminishes with age. As a result, the stratum corneum becomes thicker and the pores pack up with dead skin cells, which makes them look larger.

Dermis -- Middle Layer

Most of the skin's volume is found here. The dermis is composed of collagen and elastin fibers; nerve endings that sense temperature and pressure; blood vessels supplying nutrients to keep everything replenished and renewed; sweat glands, which function to cool you down, and erector pili muscles, which contract, causing you to shiver and making your hairs "stand up" (these functions keep you at a stable 98.6 degrees Fahrenheit); hair follicles; and those pesky oil glands, which produce the sebum that keeps skin soft, pliable, and waterproof. However pesky they are, you can't live without those oil glands (although when your acne is bad, you certainly wish you could!).

Subcutaneous -- Bottom Layer

Here lie lots of fat cells. These fat cells are good fat cells. Without them, you'd lack insulation and protection for your fragile organs. Also rooted in these fat cells are most of your hair follicles. The hair follicle and the attached sebaceous, or oil, gland share the space known as the pilosebaceous gland (pilo means hair and sebaceous refers to the sebaceous, or oil, gland). The pore is the passageway from the base of the hair follicle to the surface of the skin. Sebum, an oily substance composed of free fatty acids, cholesterol, triglycerides, and wax, is released from the sebaceous, or oil, gland into the pore and travels to the skin's surface to keep it pliable and protected. Without sebum, your skin would look as dry as dust.

what kind of skin do you have?

From a dermatologist's viewpoint, contrary to all those surveys published
in women's magazines, just about everybody has combination skin. Human bodies are constructed with the greatest density of oil glands in the T-zone -- the nose, cheeks, chin, and forehead -- so that even if you have dry spots, you will most likely also have oily spots.

The texture, pore size, and oiliness/dryness of your skin is in large part determined by your genes and regulated by your hormones. There's nothing you can do about your body's natural inclination to be dry or oily. You can, however, do something about how the environment in which you live affects your skin. For example, it's easy enough to humidify (or dehumidify) the air inside your home.

Equally important is the fact that your skin changes as your body ages. You can have oily skin as a teenager and dry skin as an adult. Be aware that as these changes take place, your skin care needs change, too. We often see women still using the same products after age thirty, which may not be the optimal treatment plan for their skin.

What if your skin is mostly dry?

You can still have dry skin even when it's covered with acne. If you look at the surface layer of the dead cells in the epidermis (the stratum corneum), they're superhydrated in high-humidity environments and desiccated in dry ones. Drinking gallons of water won't necessarily plump up your skin in Arizona -- you'll just be spending much more time in the bathroom. And as you age,
circulation naturally slows down, hormones dwindle, oil production diminishes, and the surface dead cell layer thickens and fissures, allowing water loss from the skin. The result is that your skin won't be as moist as it was when you were younger. Some medications also dry out skin, most notably Accutane.

Using humectant agents (moisturizers) can help relieve dry skin. So can humidifiers. Air conditioners and forced-air heating systems tend to zap the moisture out of the air, so be judicious with their use.

What if your skin is mostly oily?

"My skin's too oily -- make it stop!" We hear that all the time from our patients. Unfortunately, there's no little faucet we can turn off or on to decrease or increase oil flow. Oil production constantly changes. For instance, one month your skin might be oily the week before your period; the next month it might not. And, you may have oily skin and terrible acne or oily skin and no acne. Oily skin is not a life sentence for acne or even necessarily a symptom
of acne.

Living in a hot, humid climate will stimulate oil gland production. Exercise, stress, and androgenic (masculinizing) hormones, such as testosterone or DHEA-S, will also increase oil flow.

Oily skin generally needs no moisturizers except on the eyelids. Oil absorb-
ers; loose, oil-free powders; and medicated, clay-based masks will help absorb excess oil. However, frequent facial washing (in excess of two to three times a day) may eventually result in increased oil production, because when the surface of the skin is excessively stripped of lubrication, the oil glands' response to perceived dryness is to produce additional oil.

Why Is Dryness/Oiliness So Important?

Knowing that the layer of dead cells (the stratum corneum) in the epidermis is crucial to healthy skin, we became interested in trying to stabilize, protect, and repair the barrier function it provides. Any assault to this top layer increases the skin's susceptibility to infection and environmental irritants. This can produce a range of skin conditions, from impetigo to herpes eczema to contact allergic dermatitis.

One enduring myth about acne is that the best form of treatment is to strip all the oil off your skin. Drying the skin's surface with ingredients like rubbing alcohol leaves the skin parched and irritated, with greater susceptibility to infection while failing to treat the acne process. Perhaps you've even tried to clean your skin with harsh scrub soaps that contain apricot or walnut pits, which can tear your defenseless cells. You look raw and red. Your skin peels. It itches. It doesn't heal properly, and your acne doesn't go away. As a result, your acne may take longer to heal and leave scars behind.

In chapter 5, you'll see how an acne treatment program can be gentle
yet effective, maintaining a healthy balance of dryness and oiliness in the
epidermis.

Do You Really Have Sensitive Skin?

Many of our patients tell us that they have sensitive skin. In truth, the vast majority of people do not have sensitive skin even though they think they do. The clinical definition of sensitive skin is skin that has a noticeable reaction with product application. It turns red, itches, tingles, or burns. Or all four.

There are two causes of sensitive skin: environmental and genetic. Environmental factors causing sensitive skin are usually product-derived. Most people tend to use more than one product on their face, and in each of the products there are often ten to twenty different ingredients. The more products you layer on, the more ingredients you are exposed to, and the more likely you are to create a sensitive skin response. When you strip your skin of its barrier function, irritated skin often follows.

Then there is the genetic factor. Twenty percent of babies develop eczema, also called atopic dermatitis, within the first six months of life. Atopic dermatitis is often accompanied by allergies, asthma, and hay fever. By the time children are twelve, most outgrow atopic dermatitis. However, because the skin of people with atopic dermatitis may remain somewhat immunologically compromised, the risk of developing skin sensitivity is greater. Patients with a history of atopic dermatitis in childhood are especially prone to eyelid dermatitis, hand eczema, and keratosis pilaris (tiny red bumps on the back of arms) as teenagers or adults. These patients may also be intolerant of some topical acne preparations.

Many people with rosacea, another genetic condition, have sensitive, reactive skin. For more information on skin sensitivity, see chapter 13.

what is acne?

Acne is complicated. Many factors are involved in its creation. It is, however, most influenced by genetics and hormones. These hormones, known as androgens, stimulate a four-step process in the skin.

Step 1 Abnormal keratinization in the pore leading to a plug (clogged pores)

Step 2 Overproduction of oil (sebum)

Step 3 Overgrowth of p. acnes bacteria

Step 4 Inflammation (swelling) as a reaction to the bacteria and its by-
products

The bump that appears on your face is actually the final step in a process that began two weeks before. Even though that painful bump on your face looks bad and feels worse, the real damage is happening underneath the skin. The secret to controlling acne is to get down deep in the pore -- to stop the acne process before bumps are visible on the skin's surface.

Step 1: Clogged Pores

Normally, skin cells are in a continuous, gradual state of renewal. As the old cells die, they mix with your skin's natural oil and are sloughed off, making room for fresh, new skin every thirty days.

But sloughing doesn't always happen as it should. Sometimes the dead skin cells don't shed evenly or cell turnover slows down (as it does when we age, for example). When this happens, skin cells become "sticky." These sticky cells combined with oil clog your pores. A plug called a comedo (comedones is the plural) is formed inside the hair follicle. It's like a cork in a bottle. The corklike plug traps oil and bacteria in the follicle.

Step 2: Overproduction of Oil (sebum)

Hormones, known as androgens, stimulate oil production in the sebaceous glands, which are attached to your hair follicles. Normally, the oil (sebum) flows freely to the surface of your skin. But if your hormones tell your sebaceous glands to get moving, they'll churn out sticky oil, which results in potentially clogged pores and a wonderful environment for bacteria to grow.

Step 3: Bacterial Attack

Once your pores are clogged, an anaerobic bacteria naturally growing on your skin called Propionibacterium acnes (p. acnes for short) proliferates and starts feeding on the trapped oil. It likes the oxygen-free atmosphere deep in the pore. The overgrowth of p. acnes digests the entrapped sebum, breaking down the oil molecules into smaller particles. When a tiny bit of these broken-down oil molecules leaks outside the follicle, your body is going to respond.

Step 4: Inflammation

The body's response to the bacterial invaders and the oil by-products is a swarming army of red and white blood cells sent to contain the infection, attempting to wall off the follicle. The end result? Intense swelling and inflammation experienced as pimples, bumps, pain, and suffering. Otherwise known as acne.

Different Kinds of Comedones

Though all acne starts the same way, the lesions may look different on your skin.

Whiteheads

If the plug stays below the surface of the skin, it's called a closed comedo, or a whitehead. The white debris is composed of trapped sebum and dead white blood cells.

Blackheads

If the plug enlarges and widens the pore, it's called an open comedo, or a blackhead. Blackheads are not caused by trapped dirt, even though that's what they look like, and you can't wash them away. The black spots are from a buildup of melanin, the dark pigment in your skin, and oxidized oil.

Different Kinds of Pimples

(For more photographic examples, go to www.unblemished.com.) Acne can be noninflammatory or inflammatory. Noninflammatory acne consists of blackheads and whiteheads. Inflammatory acne occurs from an immune response to the bacteria and plug. The degree of inflammation determines the different kinds of pimples, the severity of acne, and ultimately the potential to scar.
The different kinds of pimples are:

Papules

Papules are small, pink, domed bumps. They are tender to the touch.

Pustules

Pustules are small, round, pus-filled lesions. They are swollen and appear red at the base, with a yellowish or whitish center.

Nodules and Cysts

Nodules and cysts are large, deep, and painful bumps filled initially with blood, then with pus. Nodules can linger under the skin's surface for weeks or even months and hurt so badly you aren't even tempted to squeeze them. Persistent nodules can harden into deep cysts. Both nodules and cysts may leave deep scars.

Different Grades of Acne

(For more photographic examples, go to www.unblemished.com.) Most people think of acne as juicy, red, nasty bumps. Yet blackheads, whiteheads, papules, pustules, nodules, and cysts are all part of the acne spectrum. Dermatologists have a grading system that helps determine the correct course of action. The number one priority of a dermatologist is to prevent permanent scarring, so moderate-to-severe category is managed most aggressively.

A dermatologist's second priority is to clear your acne so you look and feel better about yourself. In mild cases, permanent scars are not a worry, so there is more leeway in trying different topical products.

Due to fluctuations in hormones and other factors, the grading of your acne can change as you age -- over months, years, or even your lifetime. For example, a thirteen-year-old boy might have mild acne. If left untreated, by the time he's sixteen, his acne may become severe. Our grading system gives an instant checklist for appropriate treatment.

what causes acne?

Acne is not your fault. Acne is not caused by the food you eat or how often you wash your face. It's caused by a complex combination of factors on two sides of the equation.

The first side is genetic, and it is totally beyond your control. Those with a family history of moderate-to-severe acne are at greatest risk, and the onset is often in the early teen years. You can no more change your genetic destiny than you can permanently change the color of your eyes. The other side of the equation is what we call cofactors or promoters, which can exacerbate preexisting acne. We will explore both the genetic factors and cofactors that cause acne.

Genetic Factors

parGenetics

Genetic factors include: how easily the p. acnes bacteria proliferate on your skin; how much your body is inclined to produce a swelling response to the bacteria; how much oil your body produces; how easily your pores get plugged; and how quickly your skin cells turn over. These contributing factors to acne are all determined by your genetic makeup. In addition, if both parents had significant acne, your risk for developing acne is very high.

Hormones -- Female

How a woman's hormones are regulated changes throughout her lifetime. Fluctuations in estrogen levels (and also androgen levels) can cause acne. As a result, many women experience acne monthly, in sync with their menstrual cycles. Also, the flood of hormones released by the body during and after pregnancy can cause acne. When estrogen levels become more erratic during perimenopause and menopause, acne can appear once again.

Hormones -- Male

During puberty, everyone begins to produce hormones called androgens. Androgens cause the sebaceous glands to enlarge, which is a natural part of the body's development. The rate at which you produce sebum, or oil, within the sebaceous glands is affected by your hormone balance, which is often in flux, especially in women. When androgens stimulate sebaceous glands, too much sticky oil and too little shedding of the dead skin cells occur, causing that plug. Wham! -- here comes the acne. This explains why 90 to 95 percent of teens have some form of acne.

Cofactors/Promoters of Acne

(in descending order of importance)

stress

environment

medications

mechanical irritation

cosmetics and occlusive sunscreens

diet

Stress

You need only look at the faces of college students cramming for exams to see how stress can affect acne. Stress hormones, specifically cortisol, are released by the body and trigger increased oil production by the sebaceous glands. Stress also delays wound healing, so the breakouts last longer.

Environment

Outside factors, such as pollution, exposure to oil or grease in the workplace, dry air in your house, and high humidity outdoors, have an effect on your skin and can contribute to acne. Sun exposure and sunburn can cause acne to flare up. Even flying, by disrupting the body's circadian rhythm (naturally occurring sleep cycles), can stimulate an acne outbreak, to say nothing of what the dry air on airplanes does to your skin.

Medications

Over-the-counter as well as prescription medications may have side effects that can affect the body's chemistry and hormones, leading to an outbreak of acne. (See table, Prescription Drugs That Can Cause Acne, page 28.)

Mechanical Irritation

Excessive rubbing or irritation to the skin, such as holding the telephone
too close to your chin or sweating in a football or bicycle helmet, leads to acne. Anything that chronically rubs on a certain part of your body -- a baseball hat worn backward with the strap pressing on your forehead, athletic shoulder pads, or even the strap of a purse across your shoulder -- can promote acne.

Cosmetics and Occlusive Sunscreens

Some cosmetics, including moisturizers and makeup, or other products,
such as occlusive (thick, blocking) sunscreens, can irritate your skin and cause acne because of their comedogenic, or pore-clogging, ingredients. Beauty treatments, such as waxing, often irritate the skin and may contribute to acne.

Diet

We don't believe that sugar, fat, or caffeine directly cause acne. Nor do we believe that eating greasy french fries or potato chips causes oily skin and breakouts. Current research shows that sugars contribute to internal inflammation throughout the body. Yet while acne is a disease of inflammation around hair follicles, it occurs even if you don't consume sugars and starches.

Remember, a pimple is weeks in the making, therefore the pimple you see today cannot be a direct result of the chocolate sundae you ate yesterday. That said, some people may be hypersensitive to certain foods. For example, foods containing excessive amounts of iodides, such as salt, seafood, and seaweed, are linked to acne. If you know that a specific food tends to worsen your acne, it's best to avoid it. To help you test whether your acne is food-related, keep a food diary to see if flares of acne correspond to dietary changes in the previous weeks.

acne myths and misinformation

Now that you know what really causes acne, let's put to rest all the myths and misinformation about it.

Acne Is Your Fault

False. Acne is not and never will be your fault. Acne is caused by a combination of factors. These include genetics, hormones, bacteria, overabundance of oil, the plugging of skin pores, your unique immune response to the p. acnes bacteria, stress, environmental factors, medications, excessive rubbing or irritation, cosmetics, and even traveling. It is not caused by how you wash your face (or with what) or by any of the foods you eat. Some people never break out; some never stop.

Acne Can Be Cured

False. There is not yet a cure for acne. It's a complicated condition. Even the prescription drug Accutane, the strongest oral medication for acne, does not provide a permanent cure. But you can help prevent and control mild to moderate acne blemishes once you start following our program.

If You Leave Your Acne Alone, You'll Outgrow It

False. Don't wait. It's so important to start treating breakouts early. Untreated, acne can get worse. For example, comedones (blackheads and whiteheads) can evolve into pustules and pimples. If it does get worse, it can leave scars -- physically on your face and emotionally in your heart for a lifetime.

Acne Is Just a Little Problem. Don't Overreact.

Stop Worrying About It

False. Almost everyone who has acne is embarrassed by it -- if not mortified and depressed. Acne not only lowers self-esteem, it often affects social behavior. It's hard to have a social life if you don't want to leave the house. Acne can even affect job performance, especially if you feel inhibited about being seen and judged by your peers.

Spot Treatments Will Cure Acne

False. Spot treatments may help dry up a newly visible pimple, but that pimple started forming weeks before you were aware of its existence. Instead of spot treatments, it's wise to preventively treat all acne-prone skin on a daily basis so breakouts can't get started in the first place. Think of treating acne as you think of brushing your teeth: Do it every day and prevent a problem.

Acne Is Caused by Eating Greasy Foods,

Chocolate, or Caffeine

False. Medical studies have found that diet -- including chocolate, pizza, potato chips, and french fries -- rarely affects acne.
However, if certain foods consistently make you break out with acne, it's common sense to try to avoid them. For example, for some who are supersensitive, eating foods with a high iodine content, such as shellfish, dried fish, and seaweed, may cause flare-ups, which may explain why the Japanese, who usually have a terrific, balanced, low-fat diet, still get acne. Some other studies theorize that the hormones in chicken, beef, and dairy products may precipitate early adolescent acne, but the jury's still out on that subject. If you're concerned, substitute other sources of protein and calcium for these products or try hormone-free, organic versions of them.

Sugar Causes Acne

False. An article entitled "Acne Vulgaris: A Disease of Western Civilization" was published in the Archives of Dermatology in December 2002. The writers concluded that there's an astonishing difference between Western and non-Western societies in terms of how much acne people get -- a difference that can't be due just to what's in the gene pool. They blamed acne on excess consumption of sugar in Western countries. However, critics of this study noted that the authors looked only at a small, genetically distinct tribe of natives in Papua, New Guinea, to represent non-Western societies. This tribe has a much later onset of puberty than other societies around the world, which means their hormones associated with acne kick in later in life. It is therefore not a representative group.

Finding out what causes acne onset will be a tremendous help in acne treatment all over the globe. But to blame acne on sugar alone disregards scientific research and clinical observation. It's been our experience that eliminating all sugar or fat in a diet doesn't eliminate acne. We do advocate a healthy diet filled with complex carbohydrates, such as vegetables, fruit, whole grains, and low-fat protein. We believe refined sugars and excessive fat should be kept to a minimum to maintain a healthy body weight. Unfortunately, however, making changes in your diet alone will not stop acne. So don't beat yourself up because you just had a chocolate brownie; it is not going to create pimples weeks down the road.

Drinking Tons of Water Will Flush the Acne Away

False. Drinking six to eight glasses of water each day is healthy for your body. But not even the priciest designer-bottle spring water can flush away acne. There's simply no proof that water can clean the skin from the inside out. Furthermore, while dehydration may temporarily make your skin look lifeless, it won't lead to breakouts.

Sun Exposure Will Heal Your Acne

False. Small amounts of sun exposure may appear to be helping your acne at first; the blue band of visible light helps to sterilize the p. acnes bacteria. Breakouts temporarily dry up and your new tan helps camouflage angry, red blemishes. But prolonged sun exposure eventually increases the plugging of your pores, producing blackheads, whiteheads, and small pimples. Plus the very real danger of skin cancer, to say nothing of premature wrinkling, cannot be overstated. Exposing your skin to the sun without sunscreen will never be a good idea. Its risks outweigh its very minimal benefits.

Acne Is Seasonal

False. Some people claim their acne is seasonal, worse, perhaps, in summer. While temperature and humidity may increase the oil production of your skin, for most there aren't seasons for acne. It's a year-round problem.

Sunscreen Causes Acne

False. A good noncomedogenic sunscreen will not cause acne. However, a heavy, occlusive sunscreen will attract and hold on to heat in your follicles, flaring inflammation and causing numerous small red bumps to form. This reaction is not true acne but a condition called miliaria.

Find an oil-free, noncomodegenic sunscreen formulated for acne-prone skin. The risk of skin cancer is simply too great to do without it. This is true for people of all ages and all races. Reapply it frequently if you are sweating in the heat or after you go swimming.

Also remember that acne medicines, such as benzoyl peroxide, Retin-A, and salicylic acid, may increase your skin's sensitivity to sun exposure. This is even more reason never to leave the house without first applying sunscreen.

Acne Comes from Not Washing Your Face Enough

False. Acne is not caused by dirt or uncleanliness. In fact, if you overwash your face or strip it with rubbing alcohol in an effort to feel clean, you can produce irritation. While face washing does remove surface oil, there is evidence that too frequent washing may stimulate oil production. Washing twice a day is more than enough to remove bacteria and aid in exfoliation.

Acne Is Caused by Oily Skin

False. It is possible -- and often common -- to have both dry skin and acne. You can also have both oily skin and no acne. Pores will become plugged and acne will form whether your skin is dry or oily.

Using the Right Cosmetics Will Cure My Acne

False. Some eager salespeople at the cosmetics counters may say anything to entice you into trying their line of new potions and creams. Buyer, beware!

If I Have Acne, I Can't Use a Moisturizer

False. Many people think that if they have acne, they can't use moisturizers. Actually, noncomedogenic moisturizers, the kind that don't cause clogged pores, are a must to hydrate parched, dry skin.

Acne Is Contagious

False. Acne is a noncommunicable disease. Even if you run your hands over the face of someone with the worst case of acne you've ever seen, you won't get any pimples as a result. You can no more catch acne than you can catch cancer.

Accutane Is the Miracle Cure for Acne

False. Accutane is the most successful drug used to treat acne, but it should be used only for severe cases, not mild ones. It works by shrinking oil glands for one to two (sometimes three) years, and it normalizes the cells lining the pore so plugging does not occur. A significant percentage of people who use Accutane need a second or third course of the drug, and most require topical skin treatments long term to keep their acne at bay. Accutane also has significant side effects, which require careful monitoring by your dermatologist.

For more information about Accutane, see page 53 in chapter 2.

Hair in Your Face or Hats on Your Head Cause Acne

False. Hair and hats by themselves can't cause acne. But using the wrong kinds of products on your hair or too much of them can exacerbate acne. We call this condition mousse abuse. Comedogenic, acne-triggering hair products, whether mousse, gel, pomade, or oil, can occlude (plug) pores near the hairline, creating fine blackheads and whiteheads. People who wear hats to hide their acne may inadvertently cause excess perspiration and irritation, triggering acne breakouts.

Blue Light Therapy Can Cure Acne

False. Blue light therapy is an interesting approach to the treatment of acne, but it's not a cure. Blue light is part of the rainbow of visible light (410 nanometers wavelength) emitted from a light source from a machine in a doctor's office. It works by sterilizing the skin for a short period of time, removing acne bacteria and temporarily improving acne when used in conjunction with traditional topical acne medications. As more dermatologists use blue light therapy, we'll get a better idea of how well it works or whether its expense and frequent visits will disappoint patients in the long run. Studies are ongoing, but it's simply too soon to tell.

We will discuss blue light therapy and radio-frequency treatments on page 60 in chapter 2.

acne scars

One of the most important reasons to be proactive about treating acne is the risk of scarring. The long-term effects of acne, both physical and emotional, can last much longer than breakouts, sometimes forever.

Most Acne Scars Aren't True Scars

Luckily, 90 percent of what many people view as scars aren't true scars. They are the pink or brown pigmentation spots that follow a healed pimple. The medical term for these spots is postinflammatory hyperpigmentation.

When a blemish heals, the normal process is for a flat red-to-pink spot (called a macule) to form, followed by a flat brown mark, then total fading. The red-to-pink spot can take two to three months to turn brown, and it can take anywhere from six months to a year before it generally fades away. It's a long time to wait. People of color tend to find the brown spots more disfiguring than the actual pimples that caused them in the first place. The good news is that postinflammatory hyperpigmentation is a treatable side effect of acne. Bleaching agents effectively get rid of brown spots and are safe and easy to use.

What Is a True Scar?

(For more photographic examples, go to www.unblemished.com.) A scar by definition is a permanent, deep-seated change in the skin. It is a visible reminder of injury and tissue repair. After an injury, white blood cells and an array of inflammatory molecules help fight infection and heal damaged tissue. But not all the damaged tissue can be restored. You cannot erase a true scar, not even with a laser. You can modify it, you can soften it, sometimes you can replace one kind of scar with another that is more easily camouflaged, but you'll never be able to go back to the clear skin you had before that pesky pimple.

As with acne, some people are simply more likely to scar, especially those with a family history of severe, scarring acne. Sometimes acne scars stay exactly the same for decades; others diminish with time. Unfortunately, those with the most severe forms of inflammatory acne, with deep nodular lesions, are also most likely to have scarring problems. True scars signify that your acne is moderate to severe. You need immediate professional help from a dermatologist.

There are two kinds of true acne scars: those caused by increased tissue formation and those caused by tissue loss.

Keloids

Increased tissue formation scars are called keloids. For those who are genetically susceptible, the body doesn't heal pimples properly but instead produces excess collagen, which forms into lumpy, fibrous, red-brown nodules, often linear in shape. Keloids aren't painful but can feel almost rock-hard. One tiny pimple can suddenly trigger the body to go haywire and create a rambunctious overcompensation response, forming a keloid. Although African Americans tend to be the most prone to keloids, we've seen them in people of all races, and of all ages. Keloids are most common on the chest, back, shoulders, and jawline in people under age forty.

Keloids can be very difficult to treat. Cutting them out usually causes them to grow back larger. Instead, we try cortisone injections to flatten them or to help reduce redness. See a dermatologist the minute you start to see keloids form.

Scars caused by tissue loss are more common and take many forms:

Dell scars are shallow, sunken depressions in the skin with fairly smooth edges, making your skin appear to have waves or ripples.

Ragged-edged scars have sunken depressions with ragged, uneven edges.

Ice-pick scars are usually found on cheeks. They're small, deep holes with jagged edges and steep sides. They can evolve over time into depressed fibrotic scars, which also have sharp edges and steep sides but are larger and firmer at the base.

Atrophic macules are soft marks with a depressed base. Blood vessels just below the surface of the scar may make them appear purplish when they are recent, but this discoloration usually fades to pale ivory.

Follicular macular atrophy is more likely to occur when acne has appeared on the chest or back. These small, soft white lesions resemble whiteheads but are true scars and may persist for months, years, or remain permanently.

For more information on treating scars, see page 62 in chapter 2.

Scar Prevention

Firefighters always say that the best way to stay safe in a fire is to prevent it from happening. The same is true with acne scars. Stop the acne and you'll stop the scars before they've had a chance to form.

Another method to prevent acne scars is to stop picking! The more inflammation you prevent, the less likely you are to scar. Unfortunately, pimples are an invitation to pick. But picking and squeezing -- with fingernails, pins, you name it -- can cause permanent damage. Picking not only worsens the pimple you're attacking; it makes the surrounding skin even more irritated and swollen, triggering new eruptions. A severe form of picking, called Acne excoriée des jeunes filles, often leaves incurable, disfiguring gouged-out scars and holes in the face. (For more information, see the section on compulsive picking on page 83 in chapter 3.)

Another common complaint from adult women is the sudden proliferation of chin hairs along with acne nodules. This invites aggressive tweezing and digging at the hair that worsens the acne and may lead to scarring. If you can afford it, laser hair removal or the prescription hair-growth retardant, Vaniqa, can be very successful. Take away the reason to pick and you'll stop picking.

A pimple that's bothering you today will go away faster if you let it be. If you pick and poke and prod and squeeze it, you may be reminded of that pimple forever.

Acne in the Media and on the Internet

We're thrilled that more and more information about acne (and rosacea; see chapter 13) is being published so everyone can better understand this disease. However, we're concerned about all the myths and misinformation available to anyone who surfs the Internet. There are many wonderful websites filled with facts to help you learn about skin and acne, but there are also many run by frauds and the disgruntled. Chat rooms can be great, especially for teenagers who see them as safe places to vent and talk about what products worked and which ones they liked and didn't like. But there are also chat rooms devoted to Accutane and other controversial drugs, for example, that can be filled with people who may have had bad experiences and therefore assume that the drug is harmful for everyone and should be banned. When this happens, we lose the opportunity to treat and heal -- as well as comfort -- people who are convinced, through reading and believing misinformation on the Internet, that we can't help them.

So search the Internet all you like, but be smart about what you read. Use it for the helpful psychological support it can provide, but read the medical information on personal websites with a grain of salt. If it sounds too good to be true -- like an amazing herbal cure for acne -- it probably is.

Copyright © 2004 by Rodan & Fields Inc.