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The Mechanisms and Pathogenesis of Hormonal Acne (Acne Excoriée)

Hormonal acne (sometimes known as acne excoriée or “picker’s acne”) is a specific breed of acne that almost exclusively effects people born biologically female. It is characterized by tender bumps that are often large and can occur deep in the skin. These bumps often appear to be “headless” and are commonly labeled as cystic acne lesions.

mụn-trứng-cá-nội-tiếtHormonal acne almost exclusively appears on the jaw line, chin, and lower cheeks unlike common acne, which tends toward the T-zones of the face (forehead, nose, and upper cheeks). It’s difficult to cover with cosmetics and is almost always a point of embarrassment, shame, and pain for those who suffer from it.

It affects roughly 25% of the biologically female population and is actually increasing in prevalence.

It is often unaffected by topical products that are marketed to help acne sufferers due to the cause being the fluctuation of female hormones. Fortunately, there are treatments that can help, so let’s talk a bit about what actually causes hormonal acne, some things to try before seeing your doctor, and what you can expect when seeing a doctor for hormonal acne.


Recognizing the Cyclical Nature of Hormonal Acne

Before I get into the meat of this post, I first want to talk a bit about the cyclical / re-occurring nature of hormonal acne.

Acne is often a chronic disease, with hormonal acne affecting nearly one in every four women throughout their lifetime. This prolonged course of outbreak, healing, and relapse is not only frustrating, it is also psychologically and socially damaging to the sufferer. These effects are often swept aside or neglected all-together, leaving sufferers to feel ostracized and silenced. Of course, this pattern just re-inforces itself: sufferers feel dismissed, neglected, or lied to, which leads to feeling like it should not be discussed at all, which leads to feeling isolated and ashamed, which leads to feeling dismissed, neglected, or lied to… and so on, until you find yourself avoiding outings with friends, dates, or mirrors.

Worse, hormonal acne is physically painful, which creates a constant reminder of the lesions that you feel are ruining your very life. Anxiety, depression, and social withdrawal are not uncommon and have all been reported in individuals with acne and acne scarring. Physical scars and persistent hyperpigmentation are not uncommon and often expensive or difficult to treat, which can mean that even after the acne is gone, the memory is still there.

If you have found yourself suffering from acne, regardless of whether it is hormonal acne or not, it is important to remember that you are not alone and that the right doctor can change your life. Please do not feel ashamed of your skin to such an extent that you are reluctant to see a medical professional.

And if you are feeling anxious, depressed, withdrawn, or suicidal, I urge you to speak to a therapist. Some insurers, while not accepted in office, will refund you a percentage of the amount of mental health visits after a deductible is met (for example, my last insurer would cover up to 70% of each visit if I mailed them a claims form and the receipt for my therapy visit). Therapists are there to listen – without judgment – to whatever you are going through, and merely provide guidance on how to overcome the painful feelings within.


The Formation of Hormonal Acne

As anyone with hormonal acne knows, it is a disease that is cyclical in nature, meaning it comes and goes. To understand why this is, I’ll be talking very briefly about the menstrual cycle.

Understanding the Menstrual Cycle

The length of the average menstrual cycle is about 30 days and consists of four different stages:

  1. Menstruation: The first day of the menstrual phase is the first day of your period. You may feel low energy, and your skin may begin to clear up as your period begins or starts to end.
  2. Follicular: The last day of your period is when the body begins to prepare for ovulation, the next stage of your menstrual cycle. Your estrogen spikes, your skin begins to clear, and you may have more energy.
  3. Ovulation: The egg is released into the Fallopian tube and travels into the uterus. You’re still riding high on estrogen during this time. You may feel very motivated and full of energy, and your skin might “look it’s best.”
  4. Luteal: The egg moves down the Fallopian tube towards the womb. Your body begins to produce progesterone to build the lining of the uterus. If the egg is not fertilized, estrogen and progesterone begin to drop and your body begins to break down the uterine lining. Your skin will start to break out, you may feel easily irritable, feel the most anxious or sad, and your breasts may swell.
acne

The hormones of the menstrual cycle, visualized

This temporary imbalance of hormones is what is often at the root cause of hormonal acne. More annoyingly, as a biological woman ages, her estrogen levels drop while androgens remains the same, making hormonal acne more likely. Of course there can be other drivers at play, the most common being polycystic ovarian syndrome or PCOS – a hormonal disorder among women of reproductive age.

Hirsutism.jpg

Hirsutism

Before you panic, PCOS has many symptoms other than hormonal acne. It is frequently accompanied by hyperandrogenism (excessive androgen hormones); excessive hair growth (hirsutism) around the face, chest, and neck; irregular periods; oily skin; infertility; obesity; and hair loss on the crown of the head that spreads outwards.

 

There are other diseases that can result in hormonal acne, such as growths on the adrenal or pituitary gland, but these are all extremely rare. Please see a doctor if you have any of the other signs of hyperandrogenism mentioned above.

The Role of Androgens in Hormonal Acne

While the pathogenesis of acne is constantly evolving, it is widely accepted that the key factors that play a role in the development of acne are follicular hyperkeratinization, microbial colonization with p. acnes, sebum production, and inflammation. I talked a bit about this in my post on retinoids.

To quote directly from the-dermatologist.com, which has a wonderful explanation the role of hormones in acne:

• Sebum is largely under hormonal control, and we know that androgen stimulates sebum production and proliferation by binding to the androgen receptor. In addition, 5-alpha reductase type I enzyme activity is present at the sebum site. This activity converts less potent androgens, such as testosterone and also androsterone, into dihydrotestosterone (DHT). This more potent hormone has a greater effect on sebum production. We also know that sebum levels remain relatively constant far into the adult years, so why does acne seem to spontaneously resolve in many people? In addition, why is it that some people who have oily skin don’t develop acne? This reiterates the idea that acne is multi-factorial.

We also know estrogens have an inhibitory influence — they increase the sex hormone binding globulin, which is what “soaks up” testosterone. Estrogens also feed back into the hypothalamus and pituitary glands. This decreases the release of gonadotropin-releasing hormone, and subsequently, gonadotropins. So, less androgen is secreted from the ovaries and adrenal glands.

Total testosterone is not the important value — free testosterone is more important. In general, the higher your sex hormone binding globulin, the lower the amount of free testosterone. The levels of free testosterone in males is 9 to 30 nanograms per deciliter, and in females it’s 0.3 to 1.9 nanograms per deciliter. So, again, if sebum was the only factor contributing to acne development and testosterone was the cause of this excess sebum, then all men, and no women, would have acne. Obviously, this isn’t the case.

In individuals with hormonal acne, the sebaceous glands seem to be particularly sensitive to DHT. Why these DHT-sensitive sebaceous glands tend to be concentrated in the jaw is not very well understood. However, it is well known that increased sebum excretion and alteration of lipid composition are all events associated with the development of acne.

Of course, as mentioned, acne is multi-factorial.

Insulin-like Growth Factor (IGFs) in Hormonal Acne

Another thing to consider is insulin-like growth factor, a hormone triggered by high glycemic loads, which can cause increased sebum production in some people.

Unfortunately, all of the studies performed on low glycemic load (LGL) diets have been small and relatively inconclusive. In the article “Dietary Regimes for Treatment of Agne Vulgaris: A Critical Review of Published Clinical Trials,” the authors note:

We found only 6 studies which performed an actual clinical intervention; all concerning HGL and/or chocolate, and only 3 of these gave significant results … Two of the studies showed a decrease in lesion counts with an LGL diet. Fulton’s trial from 1969 was the first clinical trial regarding dietary habits and acne (Effect of chocolate on acne vulgaris, Fulton, 1969). This study has later been criticized (Chocolate and acne: how valid was the original study, Goh W.). … This is an area that requires further research; in particular studies with larger sample sizes are required.

In short, your mileage may vary.

Dairy and Hormonal Acne

Dairy has gained a bit of a bad name in recent years. Fortunately for dairy-lovers everywhere, the data suggests that skim milk is the only dairy worth watching out for.

According to the American Academy of Dermatology (Guidelines of Care for the Management of Acne Vulgaris, 2016), a 2005 study of 47,355 adult women were asked to recall their diets as well as whether they had been diagnosed with acne. The strongest positive association with acne was with skim milk. “Specifically, women who consumed >2 glasses of skim milk a day had a 44% increased risk of reporting acne,” the researchers noted. Two follow-up studies were conducted, one on boys and one on girls, which again associated the intake of skim milk.

In another study involving 88 Malaysian subjects 18 – 30 years old, the frequency of milk and ice cream consumption was “significantly higher in patients with acne compared to controls. … No association was found with cheese or yogurt.” (Source)

This was replicated once more in 2012, when a study involving 563 Italian subjects, 10-24 years old, found “that the risk of acne was also increased with milk consumption. The association was more pronounced with skim milk, and again, no association was seen with cheese or yogurt.” (Source)

Treatment of Hormonal Acne

Some of the treatments for hormonal acne mimic those of traditional acne, such as retinoids. However, there are some distinct differences that are unique to hormonal acne, namely in the treatment of hormones (or rather, the blocking of androgens with anti-androgens).

Retinoids and Antibiotics

Retinoids are usually one of the first lines of treatment, usually in combination with other medications. You can read all about retinoids and combination treatments in two of my posts, which go further in detail about the how and why for these treatments:

Birth Control (Combination Oral Contraceptives)

Combination oral contraceptives (COCs) were first approved by the FDA in 1960. “They work by preventing ovulation and pregnancy by inhibiting gonadotropin-releasing hormone, and subsequently, follicle-stimulating and luteinizing hormones.” (Source) In the absence of these hormones, ovulation does not occur. To quote the American Academy of Dermatology once again:

There are currently 4 COCs approved by the FDA for the treatment of acne. They are ethinyl estradiol / norgestimate, ethinyl estradiol / norethindrone acetate / ferrous fumarate, ethinyl estradiol / drospirenone, and ethinyl estradiol / drospirenone / levomefolate. The mechanism of action of COCs in the treatment of acne is based on their antiandrogenic properties. These pills decrease androgen production at the level of the ovary and also increase sex hormone binding globulin, binding free circulating testosterone and rendering it unavailable to bind and activate the androgen receptor.

A 2012 Cochrane metaanalysis assessed the effect of birth control pills on acne in women and included 31 trials with a total of 12,579 women. Nine trials compared a COC to placebo, and all of these COCs worked well to reduce acne. The progestins included in these 9 trials were levonorgestrel, norethindrone acetate, norgestimate,
drospirenone, dienogest, and chlormadinone acetate. Seventeen trials compared 2 COCs, but no consistent differences in acne reduction were appreciated based on formulation or dosage of the COC. Only 1 small study compared a COC to an oral antibiotic; no significant difference in self-assessed acne improvement was identified.

The risks of birth control should be weighed against the risk of the condition being prevented. For example, a meta-analysis evaluated 25 publications reporting on 26 studies that focused on oral contraceptives and venous thromboembolic events (VTEs, such as venous thrombosis). The analysis conclused that all COCs increase the risk of VTE compared to placebo. To put the risk into perspective, the baseline risk in non-pregnant, non-users of COC is 1-5 per 10,000. Users have a risk of 3-9 per 10,000. Pregnant women are at an increased risk, with 5-20 per 10,000, with postpartum women at a risk of 40 and 65 per 10,000.

Spironolactone

Perhaps the most effective and common treatment for hormonal acne is spironolactone, a potent antiandrogen medication that decreases testosterone and inhibits testosterone and dihydrotestosterone (DHT) in skin. It has not been approved by the FDA for treatment of acne. There are multiple studies backing it’s effectiveness however.

Two small, placebo-controlled prospective studies showed statistically significant improvement in acne severity and sebum production at doses ranging from 50 to 
200 mg daily. A retrospective chart review of 85 patients treated with spironolactone 50 to 100 mg daily, either as monotherapy or as adjunctive therapy, revealed that 66% of women were clear or markedly improved with favorable tolerability at 
these lower doses. (Source)

Spironolactone is well-tolerated, with the most common side effect being diuresis (frequent urination). Those taking spironolactone may be advised to avoid high-potassium foods, such as low-sodium processed foods and coconut water. Some doctors may order potassium testing for those taking spironolactone.

Isotretinoin (Accutane)

The last resort drug, oral isotretinoin has been used in the United States for the treatment of acne for over 30 years. It is prescribed in cases of treatment-resistant acne or acne that produces severe distress to the patient.

The side effects are well-known to most acne-sufferers as well as prescribers. The most prevalent side effect is extreme dryness, particularly of the mucous membranes and lips. Other side effects that have been noted include inflammatory bowel disease (IBD), depression/anxiety/mood changes, cardiovascular risks, bone mineralization, concerns of scarring, and S aureus colonization.

The AAD on IBD:

While 2 studies have shown a potential relationship, more recent analyses suggest no association between IBD and isotretinoin ingestion. The most convincing article suggesting an association between isotretinoin and UC was directly refuted by a later analysis of the same database. Therefore, the work group agrees with
the position statement of the American Academy of Dermatology that the ‘‘current evidence is insufficient to prove either an association or causal relationship between isotretinoin use and IBD.’”

On depression/anxiety/mood changes:

Changes in mood, including depression, suicidal ideation, and suicide have been reported sporadically in patients who are taking isotretinoin. To date, no studies to suggest an evidence-based link between isotretinoin and depression, anxiety, mood 
changes, or suicidal ideation/suicide exist. Multiple studies have shown no evidence of depression from isotretinoin on a population basis.

On the contrary, most studies have shown isotretinoin to improve or have no negative effects on mood, memory, attention, or executive functions. However, given the prevalence of depression, anxiety, and suicidal ideation/suicide in the general population, and especially the adolescent population who may be candidates for isotretinoin therapy, the prescribing physician should continue to monitor for these
symptoms and make therapeutic decisions within the context of each individual patient.

Fortunately, hormonal acne often requires a much lower dose than traditional Accutane treatments, which has a decreased rate of side-effects and increased rate of tolerability and satisfaction.

Isotretinoin is often only prescribed in combination with an oral contraceptive due to the high rate of congenital malformations. Because of this, iPLEDGE (US only), a risk-management program, was implemented. The FDA has since mandated that all patients receiving isotretinoin treatment enroll in and adhere to the iPLEDGE program. Regardless, roughly 150 isotretinoin-exposed pregnancies still occur in the US each year.

Isotretinoin is very lipophilic (oil-loving) and should be taken with food.


Caring for Hormonal Acne at Home

Whatever route you take, it is important to stick with a bland routine that does not aggravate inflammation in the skin. Simple moisturizers, cleansers, and sunscreens are often recommended.

Reducing stress, a herculean task, seems to help many people who suffer from hormonal acne. While entirely anecdotal, meditation is an excellent way to relieve and manage stress for many people who suffer from chronic illnesses.

Getting ample sleep, limiting sugar intake, and other inflammation-reducing practices may also help you.

Whatever you decide, it is important to keep in mind that hormonal acne comes from within, which means that it often needs to be treated from within by a doctor. I’ve been asked from countless women what I recommend for their hormonal acne and unfortunately, my answer is always the same: You often cannot treat it topically. It must be treated internally.

Do you suffer from hormonal acne? If so, what has helped you? Let me know in the comments below!

 

 

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Skincare Ingredients: PHAs (Polyhydroxy Acids; Gluconolactone and Lactobionic Acid)

I first read about PHAs a few years back when I was looking for gentler chemical exfoliants for my rosacean skin. As with many people who have atopic dermatitis, acne, or rosacea, traditional glycolic acid (and even the gentler forms of AHA such as lactic acid or mandelic acid) can be rough. It stings, burns, and can cause aggressive flare-ups of redness that domino into other reactions. With rosacean skin specifically, I referred to this as “status cosmeticus” or cosmetic intolerance syndrome. Unfortunately, those with delicate skin still find themselves needing a form of exfoliation. This is where PHAs can be helpful.

There are lots of claims about PHA floating around the Internet, so to break all of the noise down into a short list, the key claims of PHAs are:

  • Less irritating
  • Humectant (water-binding properties)
  • Barrier-strengthening
  • Photoaging benefits comparable to AHAs
  • Not sun sensitizing

Note: Several studies that I found around PHAs were sponsored by Neostrata, a skincare company that uses PHAs as a flagship ingredient. This does not mean that these studies are not valuable, as many studies done by private companies are very useful, but it is worth disclosing.


There are two main types of polyhydroxy acids (PHAs): Gluconolactone and Lactobionic Acid.

Gluconolactone is a derivative of gluconic acid, an organic compound found in mammals that breaks down carbohydrates. It is frequently produced from corn and is most often  used as an exfoliant, though it sometimes moonlights in your ingredient lists as a preservative. It’s sister, lactobionic acid, is a sugar acid and is formed from gluconic acid and galactose, a monosaccharide.

There are several places online that consider PHAs to be just as effective as AHAs but without all of the irritation of AHAs. This is largely due to it’s greater molecular weight.

Molecular weight is a factor that comes up frequently when considering the efficacy and irritation potential of a product. I’ve even mentioned it before when discussing various types of “gentler” AHAs such as mandelic acid and lactic acid.

To be able to determine whether an ingredient or compound can penetrate the skin, the “500 Dalton rule” is referenced most frequently, which states that compounds of molecular weights equal to or below 500 Daltons can pass transcutaneously. The following is a chart of the various weights of the three most popular AHAs against the two most common forms of PHA with water as a point of reference:

Molecular Weight of AHAs vs PHAs
INGREDIENT DALTON (mw)
Water 18
Glycolic Acid (AHA) 76
Lactic Acid (AHA) 90
Mandelic Acid (AHA) 152
Gluconolactone (PHA) 178
Lactobionic Acid (PHA) 358

The 500 Dalton rule is why some ingredients – such as the collagen in your anti-aging cream – are more of a marketing ploy than actually beneficial to the “anti-aging” of your skin.

This irritation due to the lower or higher molecular weights can be felt almost immediately by some people, typically in the form of redness or stinging. In such cases, higher molecular weighted ingredients (such as PHAs) are preferable. In one small, twelve-week, controlled-use study, Caucasian women with mild to moderate facial photodamage were enrolled in a study that compared PHAs (n=30) to AHAs (n=27). At the end of the study, “irritation grading and subject self-assessment showed that the PHA regimen was better tolerated than the AHA regimen. Stinging and burning were significantly worse for subjects in the AHA treatment group at both week 6 and week 12, and degree of sensitivity was rated worse for the AHA regimen as well.” (Source)

pha_irritation

PHAs are also highly humectant, particularly lactobionic acid, which may be calming to irritated skin and weakened skin barriers. One study that outlined the various types of hydroxy acids states the following about BAs (bionic acids such as lactobionic acid):

BAs are hygroscopic materials that readily attract and retain water, forming a gel matrix when their aqueous solution is evaporated at room temperature. The transparent gel contains certain amounts of water, forming a clear gel matrix. Formation of a gel matrix may add protective and soothing effects for inflamed skin. Indeed, formulations containing BA are well tolerated and help calm skin when applied after cosmetic procedures that weaken the skin’s barrier, including superficial HA peels and microdermabrasion. (Source)

Another study found that this water-loving property may be particularly valuable for those with rosacea who are using azelaic acid (AzA). In a 12-week, single-site, investigator-blinded, randomized, Neostrata-sponsored study of 66 patients with mild-to-moderate type 2 rosacea:

Improvements were seen in skin sensitivity, dryness, texture, smoothness, and overall skin condition with statistical significance (p<0.05) in the patients using the dermatologist-recommended regimen (Group 2) compared to those using their own self-selected regimen (Group 1). … 

Draelos also noted an appreciable clinical improvement in background erythema in patients using the dermatologist-selected regimen and postulates that this improvement in background erythema may be a result of improved SC function from the gluconolactone in the formula. Gluconolactone is a PHA that exhibits humectant properties, which can improve SC barrier function temporarily by inducing a swelling of corneocytes as discussed previously(Source)

As with all things and rosacea, your mileage may vary. Rosacean skin is extremely sensitive and many may find PHAs to still be too irritating for their skin. Patch testing is advised.

In addition to usage with AzA, PHAs can be formulated and used in conjunction with oxidative drugs such as benzoyl peroxide (BP) “to help reduce irritation potential and erythema [redness] caused by the oxidative drug.” (Source)

PHAs have also proven useful at preventing skin irritation and reducing trans-epidermal water loss (TEWL). One study compared four different types of hydroxy acids (glycolic, lactic, tartaric, and gluconolactone) with skin barrier function and irritation. After four weeks, a 5% sodium lauryl sulphate (SLS) patch test was performed. The gluconolactone-treated sites showed “significantly lower TEWL” at both 24 and 48 hours after the patch test was performed. (Source)

The percentage of acid content in PHA products seems to matter little when comparing the hydration levels in the skin. A small study (n=10) compared the effects of a 10% lactobionic acid (LA) peel to 30% LA peel in a split-face test. They concluded no noticeable differences in the participants hydration levels. (Source)

pha_antiagingPHAs are also touted as having “anti-aging” benefits, specifically improving the appearance of the skin. One Neostrata-sponsored study comparing PHAs to AHAs that I referenced above concluded a “relative equivalence of AHAs and PHAs in treating photoaged skin … both regimens provided significant antiaging benefits to skin as measured by clinical evaluations…”

PHAs can also prove valuable in boosting the dermis-thickening benefits of tretinoin, thus reducing fine lines and wrinkles. According to one journal:

In summary, PHA-containing products were used in combination with retinoic acid in treating adult facial acne and were found to be well tolerated. PHAs plus retinyl acetate (pro-vitamin A) in a cream base exhibited significant antiaging skin benefits such as skin smoothing and plumping. … Finally, PHA-containing products were shown to be compatible with African American, Caucasian, and Hispanic/Asian skin and provided significant improvements in photoaging in these populations. (Source)

This is consistent with findings in vitro and in vivo showing the increased production of collagen, hyaluronic acid, and fibroblasts in the dermis due to extended periods of application of glycolic acid.

PHAs may also improve the effects of hydroquinone and assist in reversing hyperpigmentation and photoaging. One example:

1-s2.0-S0738081X09001564-gr8_lrg.jpg

Adult man with hyperpigmentation and photoaging at (left) baseline and (right) after twice-daily use of an α-hydroxyacid (AHA)/polyhydroxy acid (PHA)/bionic acid (BA) skin care regimen for 12 weeks. Use of the skin care products resulted in significantly less hyperpigmentation and improved radiance. The product regimen included: 20% AHA/BA cleanser, 10% PHA/BA SPF 15 cream for daytime use, and 15% AHA lotion for nighttime use. (Source)

It is also worth noting that PHAs, particularly gluconolactone, do not increase sun sensitization, making them a good choice for those who are unable to use sunscreen but are still looking for some form of chemical exfoliation.

… an in vitro [test performed outside of the body] cutaneous model of photoaging demonstrated that gluconolactone protects against ultraviolet (UV) radiation. These findings were attributed to the ability of gluconolactone to chelate oxidation-promoting metals and trap free radicals. In addition, pretreatment of skin with gluconolactone does not lead to an increase in sunburn cells after UVB irradiation, as has been shown to occur with glycolic acid; this is thought to be due to its antioxidant effects. (Source)

Just as with AHA, PHA must be formulated at the proper pH in order to be effective. Similar to glycolic acid, the effective pH of PHA is 3.8. The lower the pH value (the more acidic), the more free acid is available to exfoliate the skin, meaning that formulation is important.

When purchasing a PHA, look for a leave-on product as opposed to a wash-off product, which will give it more time to activate on the skin. Products that are already formulated with combination therapies may also be valuable to reduce the number of steps in your routine as well as ensure there are no ingredients that can interfere with the penetration or efficacy of the active ingredients (such as PHA).

If you use tretinoin (Retin-A), adapalene (Differin), or tazarotene (Tazorac), you may also want to space out your product usage, using PHAs during the day and your retinoid at night. As with anything though, do what is best for your unique skin type.

Do you use a PHA product? If so, what are your favorites? Let me know in the comments below!

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My First Four Months on Differin .1%

On June 28, I placed an Amazon.com order for the 15 gram tube of Differin .1%. I was nervous, apprehensive, excited.  I’ve had a rough history with retinoid products, which I talked a bit about in my guide to visiting a dermatologist.

As I’ve gotten older, I’ve felt the desire to  incorporate a retinoid into my routine for the benefits of improved cell turnover. As I talked about in my previous post on retinoids, adapalene is the most gentle of the retinoids, and .1% is the lowest dosage.

Ultimately, my goal is to be able to use .025% tretinoin (tretinoin remains the gold standard in dermatology for “anti-aging” benefits), but I felt that adapalene would be a good way to ease into this and make the transition a bit less irritating. While I’m not there yet, my first few months on Differin have been pretty painless, truth be told, and my skin looks better than ever.


My Skin Profile

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My skin on a very good day (and my hair on a very bad day), without retouching, before embarking on Differin

My skin is in relatively good shape. For some background, I’ve burnt very badly twice in my entire life – both times as a child – and have worn sunscreen in some capacity since I was 12 or 13. I’ve been blessed with pretty good acne genetics and only see acne flares around times of stress, excessive tiredness, autoimmune disease flare-ups, hormones, and of course, product changes. In fact, I’d say that products are the number one reason for most of my acne woes, as many of you who read this blog may already know. The longer or more complex the ingredient list, the more likely I am to avoid it at all costs.

Unfortunately, where I did not win the genetic lottery is in my rosacea. While it is blissfully mild due to catching it pretty early, it is persistent. It frequently creates small bumps along infraorbital triangle of my face (the area beneath the eye, above the nasolabial folds, and right beside the nose) as well as pockets of flushing. Even on my best days I have a bit of a rosy complexion. It does not cover well with makeup due to the flaky nature of the skin in this area, due to the rosacean redness.

My cheeks are the most sensitive portion of my face with my forehead being the least sensitive. Even makeup removing wipes feel too harsh and abrasive against my skin many times, and I can only use a very soft washcloth on my skin once a week.

My skin responds to irritation with acne breakouts. If I’ve pushed it too far with acids: acne. If I’ve pushed it too far with retinoids: acne. If I push it too far with physical exfoliants or a washcloth: acne. These breakouts are always tender, firm, under the skin bumps that linger for days to several weeks and leave flat scars.

I scar pretty easily, even in spots that I do not pick. For example, I am still fighting away hyperpigmentation on a spot that appeared on my cheekbone back in March of this year. Arbutin, azelaic acid, and other melanin-suppressants do not seem to do much for me in this regard.


The First Few Weeks

For the first three weeks, I went extremely slow. I applied every third night with the following routine:

AM

  • Apply sunscreen
  • Apply makeup

PM

  • Cleanse makeup and/or sunscreen with Clinique Take the Day Off Balm
  • Pat eyes and beneath my jaw dry with towel, leaving face wet.
  • Apply HadaLabo Premium Lotion generously to wet skin
  • Apply Cheryl Lee MD Lotion to skin while it is still damp
  • Allow lotions to dry about 20 minutes
  • Apply pea-sized amount of Differin .1% all over

I stopped usage when I experienced excessive tenderness during the day and resumed usage the next day. I experienced light peeling that was only visible when base makeup (like foundation or concealer) was applied. Some small breakouts surfaced on my forehead, near my hairline, and along my jaw. Breakouts resolved quicker and did not leave marks.

After around three weeks, I noticed that my skin peeled less and seemed less sensitive, so I bumped up usage to every other night. This is where I stayed under about month four.


Every Other Night

After the initial “every third night” period, I was able to bump up usage to every other night. This was where I was for quite awhile.

Initially, bumping the frequency caused slightly more peeling, but this was the only side-effect I noticed, and it began to subside around the seven week mark. I followed the same routine of application after moisturizing.

I noticed that my skin started to look glowier, healthier, more even-toned, and pigmentation began to subside a bit quicker. Makeup glided on easier, foundation looked better, and the pockets of flakes around my infraorbital triangle weren’t quite as bad. My rosacea also appeared to flare up slightly less.

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Makeup-free selfie from August 11

Everything was going great until I tried to adjust my usage to every night.


Achieving Every Night Usage

Around the middle of August, shortly after the above selfie was taken, I decided that my skin felt ready for every night usage. It was not.

Within three nights, I began to break out in small spots around my forehead and chin. My nose became very tender to the touch. I tried to exclude my nose from this nightly ritual for awhile, but the rest of my face quickly joined the rebellion. After five nights, I eased back and skipped two days of usage entirely to allow time to heal. I went back to using it every other night for roughly two more weeks. Unfortunately, the breakouts did not subside. My skin almost seemed to be reverting back to pre-Differin times with clogs and breakouts.

Around September 1st, I tried again with the same pre-Differin routine in place. This time, my skin responded perfectly. The breakouts healed within days, the small clogs in my pores began to roll out with my nightly oil cleanse, and my nose didn’t even feel excessively tender. There was not even a peel in sight. Just smooth skin.

 

I’m a little over three weeks into this routine of every night and my skin feels no different (irritation wise) than it did at every other night.


Takeaways

While many people feel that application of Differin or other retinoids on dry skin is paramount, my experience has actually been opposite. As someone with extremely irritation-prone skin, moisturizing before applying my retinoid (and gradual introduction) has unquestioningly been the biggest factor of success. For me, application on dry skin always lead to redness, peeling, and excessive breakouts, possibly due to the increased TEWL and more compromised nature of the skin barrier post-cleansing.

I’ve also moved extremely slowly and patiently, unlike in the past where I had bum-rushed my way into retinoid usage. This was also a factor in reducing irritation and subsequent breakouts.

One note is that I haven’t really experienced any dryness. In fact, the Differin base seems fairly moisturizing to me. Again, I attribute a lot of this to the application of moisturizer after cleansing and before using Differin.

I imagine I’ll be able to introduce tretinoin at some point early next year – maybe by late this year – but for now, things are going great.

Have you tried using Differin .1%? How do you use it and how long was your breaking in period? 

 

 

 

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The Curious Case of Self-Care

by Kristen
The Curious Case of Self-Care

It was a Wednesday afternoon, a day after the big article hit about my former employer. I had barely slept the night before, my mind churning endlessly on thoughts and feelings of my own and the hundreds of strangers that had reached out to me throughout the day. I had spent that Tuesday at a museum, surrounded by family, checking my Twitter every few minutes to read ten, fifteen, twenty, or thirty new messages. They were pouring in and I could not keep up. It was largely supportive messages like, “Thank you for speaking out,” and “You’re so brave. We’re with you!” Regardless of all of this love, my legs barely worked due to the tremors that were freezing my muscles and choking the breath out of me. I had to sit down several times when I began to get light-headed and thought I was going to pass out.

I have a complicated history with my previous employer and my therapist has told me several times that what I experience is post-traumatic stress disorder or PTSD. It means that I am filled with dread each time I drive past the building, fear at each notification on my phone (particularly those that begin with, “Can we talk?”), and am brought back to the mental space of terror that I thought had been put behind me when I quit.

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My vanity in it’s natural, honest state

Exhausted, I sat down at my vanity and studied my face in the small, round mirror. It looked tired. Dry, dark circles filled out the space beneath my eyes; my cheeks were blushed from intermittent crying the night before; my skin just looked lifeless due to the small quantities of water I had drank the day before and the even smaller amounts of food I had eaten.

I picked up my tube of sunscreen (Altruist SPF 50, for the curious, which I’ve been testing for a few weeks now) and squeezed out a generous dollop. I smeared some on each cheek, then my forehead, with remainders blobbed to my nose and chin. Then I began to massage it in with slow, methodical strokes. I watched to see if it pilled in my hair or eyebrows, smoothing small streaks out with a light touch of my ring finger. I applied a second layer much the same way, focusing on my cheekbones where I tend to accumulate the most sun spots.

I looked at my face. The sunscreen was glycerin heavy and had a generous sheen, making my skin look smoother, healthier, and instantly more moisturized than it was just a few minutes earlier.

I picked up an eyebrow spoolie and brushed through my brows, noting the sunscreen particles that caked to the bristles. Carefully, I began to brush the hairs upwards and reached for the eyebrow pencil on my vanity. I drew in the shape at the bottom of my overgrown brows followed by the top. The tail of my brows came last. Another spoolie – cleaner than the first – brushed through, smoothing the harsh edges and blending the product through. DSC_1888

I set everything down and to the side before reaching for my concealer. Opening the pot, I tapped a small finger in to pick up a small amount of product that I pressed onto the blemishes on my upper lip, nose, forehead, and scar on my cheek – all part of the early break-outs from introducing Differin.

Eyelashes came next, my elbow steadied by the small surface of my messy vanity. I pressed the curler as far down my lashes as I could, blinking a few times to capture all of the lashes that otherwise escape the edges of the dutiful device. A few firm, but gentle squeezes, walked out from the root, and my eyes instantly looked less tired – transformed instantly by a device that can only be described like a medieval torture tool (someone close to me once affectionately described my curler as an “eyeball polisher.”)

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I pulled out the drawer containing my mascara – pink, magenta, and black tubes lining the recesses – and plucked from it a hot pink tube of Japanese mascara. It was the most tear-proof mascara I owned. A few quick swipes and wiggles assured me that my eyelashes would remain curled and inky black all day, regardless of whatever catastrophe I could come up with.

I powdered down my skin of the sunscreen sheen, pressing the puff into the loose powder cap before applying it to my skin.

I leaned back from my mirror and that is when I noticed something incredible: I was calm for the first time in twenty-four hours. I could breathe normally. My mind had stopped rushing through innumerable rabbit holes. I felt completely, utterly, unequivocally normal.


Retail Therapy

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What pores?

In our very consumerist society, it is easy to want. It is especially easy to want when you are not only surrounded by advertisements promising unrealistic, airbrushed results, but also the sheer number of testimonials from average people who have had incredibly promising experiences with potentially unremarkable products. This leads everyone to feel a compulsion to look for the Next Big Thing, the next Holy Grail, the next product that will be Even Better.

We all have wants and needs, and we are all looking for happiness, but frequently, all of this noise and information just serves us to make us more unhappy. Countless people come into skincare community subreddits looking to overhaul their entire routines, and indeed, when you visit Amazon, you can see that the “Customers Also Bought” section beneath CeraVe Cream contains many favorites of skincare communities, such as Thayer’s Rose Witch Hazel, Aztec Secret – Indian Healing Clay Mask, CosRX Acne Pimple Patches, Innisfree cleansers, sunscreen, and Stridex in the red box. Hell, I know that a good chunk of people that read this blog as well as other blogs like it are looking for solutions to the things that make them unhappy, whether that is acne or visible nose pores. I know I am absolutely guilty of trolling YouTube, MakeupAlley, Reddit, and blogs in a desperate attempt to find that next cutting-edge ingredient that will hide dark circles, give me long eyelashes without downsides, or make my skin glow “from within” (this phrase drives me the most crazy, as a woman who cannot tolerate many antioxidant products, which are considered the “holy grail,” if there ever was one, of “lit from within” ingredients, especially when this is considered the truest marker of skin health in many online spaces).

In the pursuit of these market-driven flaws of self, I’ve told myself time and time again that I am not partaking in these unhealthy consumerist mechanisms, but “self-care.” I’ve purchased perhaps tens of thousands of dollars in makeup and skincare alone, far outpacing any of the other collections I have, all in a pursuit to try the new thing, to find a new holy grail, or solve my dark circles once and for all.

And I’m not alone. According to statista.com:

In 2016, the global cosmetic market grew an estimated of four percent in comparison to the previous year. Skincare, hair care, make-up, perfumes, toiletries and deodorants, and oral cosmetics are the main product categories of the cosmetic market. Skincare was the leading category, accounting for about 36 percent of the global market. Hair care products made up a further 23 percent, while make-up accounted for 18.2 percent in 2016. Skin care has been forecast to remain the most profitable product category, as its market value is projected to grow by 20.1 billion U.S. dollars between 2014 and 2019. As of 2016, Asia and Oceania was the industry leader, accounting for approximately 40 percent of the global market. Between 2016 and 2021, the Asia Pacific mass beauty market is projected to grow by nearly 14.9 billion U.S. dollars in sales.

The production of cosmetics and beauty products is controlled by a handful of multi-national corporations – L’Oréal, Unilever, Procter & Gamble Co. , The Estee Lauder Companies, Shiseido Company, and Lancôme to name a few. As of 2016, the French cosmetics company L’Oréal was the leading beauty manufacturer in the world, generating about 28.6 billion U.S. dollars in revenue that year. The company owns the leading personal care brand worldwide, L’Oréal Paris, valued at 23.89 billion U.S. dollars in 2017 . The market leader was also one of the leading companies in cosmetic innovation , registering a total of 314 patents in 2015.

The cosmetic industry has benefited from the increasing popularity of social media channels such as Instagram and YouTube. These platforms are not only highly influential amongst certain groups, but create a demand for beauty products and help fill the gap between cosmetics brands and consumers. As of 2015, nearly half of the beauty videos on YouTube were tutorials. These tutorials aim to teach the viewers something about beauty, whether it is how to use a particular type of product or create a style of make-up, for example. Beauty vloggers and other independent content creators in fact produce the majority of conversations and social media buzz surrounding beauty brands on YouTube – 97.4 percent as of June 2016 – with makeup videos accounting for just over 50 percent of the makeup content videos on YouTube. (Source)

As women and men, we frequently turn to cosmetics to comfort us. Just look at the theory of the “Lipstick effect,” which is the theory that lipstick sales increase in times of social distress or discomfort. In a New York Times article, “Hard Times, but Your Lips Look Great,” the chairman of Estee Lauder noted that lipstick sales increased after the 2001 terrorist attacks in the US, despite the deflated economy.

The waters around this have become even muddier as Internet brands latch onto these very personal feelings, advertising themselves to you as a concerned friend, not a global, multi-billion dollar conglomerate.

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I’m sure I’m not the only one who has used as well as seen the term “treat yo self” thrown around during times of difficulty or anxiety. I’m positive I’m not the only one who has spent hundreds at the Sephora sale on yet another expensive skincare product or pricey makeup palette in the pursuit of “retail therapy” after a hard day. And I know for sure that I am not the only one who feels more self-conscious (and thus, a “need” to fix them) at the size of my pores or the zit on my upper lip when I see photo-retouched ads, despite knowing that they were retouched.

But are we actually participating in “self-care,” or are we just filling our lives with more noise and ultimately, a feeling of disappointment when whatever we purchase cannot fill the hole of socially-constructed “need” in ourselves?

This is a question that I ask myself each time I pick up a new product, and frankly, while it has saved me a lot of money, it has also made me feel outside of the “in” groups on skincare spaces. The pressure is always there.


As soon as my PC turns on, an old browser window pops up. It’s my YouTube homepage, which is flooded with recommendations like, “3 Days of Foundations,” “New Skin Smoothing Concealer,” “Skincare Routine 2018,” and “Travel Skin Care Empties.” Most of these are in caps, vying for my undivided attention and clicks. It’s a list curated by the browsing habits that I’ve found myself in during the last two weeks.

I’ve talked briefly about my anxiety, depression, and panic disorders before on this blog, but I’ve never really talked about why skincare – and makeup, by extension – have been important to me, nor have I really explored the truest sense of caring for one’s self.

For those who have never experienced mental illnesses, it can mean that you disassociate from your body (imagine an experience where something happened that seemed so surreal to you that you felt like you left your body and were looking down at the situation – this is disassociation). It can mean that you catastrophize the smallest of situations into the largest of catastrophes (“I can’t remember this term for the exam” -> “My life is over. I’m a failure. I’ll always be a failure that no one will ever love.”). It can mean that you neglect showering for days or weeks at a time while your mind shouts at you about how worthless you are.

It’s extremely difficult to pull yourself out of these mental distortions and for me personally, it results in persistent tremors and panic attacks that become a bit of a self-reinforcing cycle.

I’ve seen many people on Reddit and elsewhere describe how skincare or even makeup “saved them.” Indeed, we are creatures of habit, and routines are extremely important to our own sanity and mental health. I had always discounted these experiences to just that: routines that had given people something to look forward to and build upon in times where it is impossibly difficult to hold onto anything concrete. That skincare and thus, caring for one’s self translated to growing into other healthy habits, such as cooking or just eating meals consistently – something that is challenging when you are fighting an uphill battle against your own mind.


Still Breathing

As I sat back from my vanity, an epiphany hit me. Something so obvious and so “duh” that I couldn’t believe I hadn’t seen it before. For years, I had spent so much money and time on skincare and makeup – something that I still love deeply to this day. Indeed, the last few times I moved, I had to carefully pack and insure my makeup and my tenderly curated skincare collection. Both were more precious to me than anything else that I took with me in the long trip from Texas to California. Both held not only significant monetary value but also emotional value.

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Both were my escape from my mental illnesses. Both were some of my most important tools of the truest form of self-care. Whether I had felt shaky or simply sad, both had given me comfort, steadiness, and assurance, regardless of if I was mixing lipstick or facial oils.

At each nexus point in my life, I have found comfort in my routine. The steady rhythm of application drowning out the doubts and fears that screeched in my mind. Each dotting of Differin, each emulsified mixture of oils, each methodical measurement of sunscreen. The texture of the product rubbed through my hands, the redness of my rosacea rescinding. The appearance of my reflection that assured me that I was not only okay, but safe.

This is the comfort I derive from skincare. This is the passion that drives me to write, to care, to learn, and to educate. This is my version of “self-care,” and one that I think is much more honest and pure than anything that someone can try to sell you.

 

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A Bit of a Real-Life AFK

by Kristen
A Bit of a Real-Life AFK

You may have noticed my silence over the past few weeks and I wanted to explain why, but first I wanted to thank you for bearing with me and continuing to follow me, despite my silence.

Over the past month, my life has imploded, to put it mildly. On August 7th, I was a named source in an article about sexism experienced at my previous employer, Riot Games. At the time of publication, I came out with my experiences in both a tweet thread that was retweeted 811 times as well as a follow-up story I published on Medium. In the aftermath, I’ve had literally hundreds of friends and strangers reach out to me to thank me for my bravery (which feels really weird to say as someone who never thought they were particularly brave) and honesty. I’ve seen my name published on Newsweek and my experiences referenced on ESPN. It’s been surreal, but mostly anxiety-inducing for me.

On top of this, I’ve been taking the time to care for other women and non-binary people who have been abused by this industry. It’s incredibly important to me to be an advocate as well as a support to these people right now, as we have all been re-living trauma that has been stuffed down our collective psyche’s for far too long.

As you can imagine, this has been incredibly emotionally and mentally draining. I’ve struggled to write and write well, so I’ve opted to just not write at all and to take the time to rest when I can.

I promise I will be back at it in a few weeks, so never fear – I’m just taking some much-needed time to heal.

Thank you so much for your love and support,

 

-K

 

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A General Guide to Cleansing and Caring for Your Body Post-Shower

Over the past few weeks, I have been testing some new ideas when it comes to body skincare. For most of us who love skincare, we invest oodles of money into our faces. From fancy washes to serums to exfoliators to creams, we carefully read every ingredient, study the texture of each serum, and examine our faces way too closely in the mirror each morning, looking for overnight improvements.

But most of us are not nearly as discerning about our body care. Sure, we might purchase the slightly more expensive body wash in cleanser aisle at Target or splurge on a fancy body butter from time to time, but for the most part, when it comes to our bodies, we don’t really care as much. We frequently abuse our body’s skin with hot showers we refuse to give up, soap it down with a fluffy loofah, towel off, and go on about our day.

In short, we don’t invest much time nor effort in the skin of our bodies until it itches, flakes, peels, scars, or bruises. Then we slather on some expensive miracle cream and hope it gets better overnight before we forget about it all over again.

Fortunately, caring for the body to achieve the best skin of your life is pretty easy, but it does require some sacrifices and changes be made, most of which begin right in the shower.


Stop Taking Hot Showers

I can hear the screaming now. I know, hot showers objectively feel great. They’re soothing and for many of us, a time to unwind and relax. Over the past month, I have transitioned the shower handle from as high as it will go, practically cooking me, to a bit more middling. I do not take cool showers or even lukewarm showers by any means, but I don’t take ones that leave me red anymore, either.

The reason for this is that hot showers strip the skin’s natural lipids much easier and quicker than cooler water and they make any cleansers that are used much more stripping by shrinking the size of the micelles produced by your cleanser, which allows for deeper penetration into the skin. This produces inflammation and dryness.

This is probably the toughest transition of them all, and I know, I know – you can pry my hot showers from my cold, dead hands. I get it. Thankfully, when you start to take cooler showers and begin taking care of your skin, hot showers feel hotter and a bit more unpleasant – almost like a burn. I don’t know why this is necessarily (perhaps a thinner layer of protective dead skin cells), but it has made the transition much easier for me.

Bonus: My hair is softer and my rosacea is less angry, too.


Put Down the Soap

The earliest recorded use of soap dates back to 2800 BC, in ancient Babylon. By the late 18th century, European and American companies began to promote the connection between cleanliness and health. As the use of soap became common and hygeine improved, the population of pathogenic microorganisms shrunk.

By 2018, most of us wash our clothes frequently, sleep in (relatively) clean sheets, wash our hands after using the bathroom (I hope), and have access to showering or bathing in clean water. Most people also do not interact with harsh chemicals or use products like bug spray often.

Because of the general cleanliness of most people’s lives and homes, it is unnecessary to use soap on your body with such high frequency. Our bodies have much fewer sebaceous glands (oil glands) than our faces or scalp and sweat is largely water-soluable (washes with water). As such, most of us do not need to use soap on our bodies (sans genital regions) every day.

I first began to explore this when I was watching one of Dr Dray’s vlogs where she admits to not using soap on her body and rants that the use of soap these days is largely beneficial to padding the pockets of companies that manufacture the products, such as Unilever or Bath and Body Works. Intrigued, I decided to nix soap (except for soaping my bottom, of course) and see what would happen.

In fact, I’ve used soap twice over my entire body in one month and both times were to remove sunscreen or other chemicals, like when I sprayed fungicide all over my tomato plants and the wind blew it back onto my body (ew). I do not smell any different (according to myself as well as people who are around me every day) nor do I feel any less clean than I did when I was using soap at each shower.

So the rule of thumb here: Soap is only needed for removing chemicals – such as bug sprays, sunscreens, or chemicals you may interact with at work (if you get them on your body) – or if you have a condition that requires cleansing, such as folliculitis or athlete’s foot.


When You Do Soap…

… use gentler soaps. Sodium lauryl sulfate is the enemy of healthy skin, particularly if you take hot showers, as it is one of the smaller molecular weight surfactants that can produce micelles that can penetrate the stratum corneum of the skin. Bar soaps (except for Dove body bars, which are synthetic soaps and not what is called “true soaps”) should also be ditched due to their high pH values that strip the skin and make it more difficult for the skin to readjust to it’s natural pH after showering.

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Some of the products in my shower

I picked up a bottle of CeraVe Hydrating Body Cleanser to experiment with, and it does indeed feel much less stripping than my usual liquid Dove and Olay. It is also not scented, which… while scented body products are nice, the scents don’t usually linger long after they’ve been washed away and the fragrance only serves to further irritate dried out skin.

If you can find a sulfate-free and fragrance-free body wash, this is ideal for use during the few times you need to use soap. Most health food stores contain such products.


Moisturize Immediately After Showering

You know those clickbait titles like, “The one simple trick that changed my skin forever,” usually followed by, “Doctor’s hate her”? This is my one simple trick that changed my skin forever.

Ever since I was a child, I’ve heard from every dermatologist (and allergist, surprisingly) that I’ve visited that I should be applying moisturizer directly out of the shower, onto wet skin. The reasoning for this is that water removes water, so when you towel off after a shower, that water ontop of your skin takes water in your skin with it. By applying a moisturizer directly onto wet skin, you’re not only sealing in this water that would otherwise be stripped, but you are also providing water for the humectants in the product (such as glycerin) to work best.

If you take nothing else away from this post, take this. It has completely changed my skin for the better. It’s soft, supple, and hydrated. It no longer looks dry or scaly, my KP is nowhere to be found, and even shaving feels less irritating.

Admittedly, moisturizing after a shower feels a bit odd. The first time I stepped out of the shower, armed with CeraVe Moisturizing Cream, I steeled for a strange and chilly experience. And it was, but then I got used to it, and my skin began to improve practically overnight. I started noticing other changes, too – my hyperpigmentation from old scars started to fade and when I shaved my legs for the first time since switching my routine around, not only were they perfectly smooth without that kind of patchy skin roughness that seems to follow even the best leg shaves, but they didn’t even burn.

See, I have very sensitive skin, and for me, shaving is a bit of a ritual since my skin can get very irritated. I would soak in a bath, slather on shaving cream (I use Cremo), wait a few minutes, and then shave with a fresh blade on a razor. Then I’d quickly dump my legs back into the water, where they’d tingle and burn slightly. When exiting the shower, I’d towel off and then race to put on a soothing cream, like Aveeno. Unsure if this was brought on by the addition of moisturizing post shower or the removal of soaping during the shower, I nixed my ritual of lotioning myself down for a week and shaved again. Immediately, my skin felt irritated and I had that weird roughness that is a combination of missed hairs and dry, dead skin. I added moisturizing back in, and sure enough, all was well again.

I have been asked if you can do this with lotions like AmLactin, which contain AHAs, without reducing the efficaciousness of the product, and so I tried it. Turns out that it does not reduce how effective the product is, an in fact, helps it to absorb quite a bit quicker in some instances. So never fear – moisturize away!

I also began to do this for my face and just started to apply actives (BP, AHAs, BHAs, Differin, etc) on top. As usual, I’d leave occlusives for last, but simply applying my HadaLabo Premium with some of my facial lotion (Cheryl Lee MD) really improved my skin’s texture, softness, and ability to heal quicker. I’m also happy to report that not only did it not reduce the effectiveness of my actives, it seemed to reduce how much my skin would get irritated by said actives if I had otherwise dried my face and waited to apply them before applying my moisturizers. This is not entirely surprising, as healthy skin is not only more efficient, but reducing water loss reduces the amount of irritation that can be caused in the skin by otherwise irritating products.

This tip also makes it easier to layer essences or hydrating toners, as in many Asian beauty routines, since the first layer sinks in relatively well due to the amount of water on the skin, allowing for more (and less sticky layers) to be applied on top.

Moisturizing after the shower can feel a bit slimey, so I recommend either dripping dry for a minute while applying your facial products or toweling off specific areas, like your back, the back of the knees, and stomach. From there, apply your cream of choice liberally all over. You may find you want to use less or more, depending on your tolerance for the sensation.

After moisturizing, I wrap myself up in a robe and walk around or read while “soaking in.”


Making it Into a Routine

I’ll admit: none of this feels super easy. Ditching hot showers was hard, nixing soap was strange at first, and moisturizing immediately after felt slimey. However, I am advocating all of these things because they work. There is a reason you hear all of these things again and again, and it isn’t to rob you of the joy of a hot shower or the scent of your body wash. It is because it is absolutely the best way to solve persistent dry skin, irritation, and vastly improve conditions like keratosis pilaris and eczema.

Here’s my routine:

  • Shower
    • Apply Clinique Take the Day Off Balm before jumping into shower. Get in, rinse off.
    • Wash hair, put in conditioner and do the rest of my routine
    • Shave
    • Cleanse my ahem bottom with soap on a sponge
    • Rinse out conditioner
  • Moisturize
    • Wrap hair in towel
    • Towel off eyes, lips, back of knees, and back.
    • Apply HadaLabo Premium Lotion all over face and neck
    • Wait a few seconds and apply a second layer of HadaLabo Premium, mixed with jojoba oil and moisturizer, if feeling extra dry. Apply any extra along neck and chest.
    • Apply AmLactin generously all over. If I’ve shaved my legs that shower, I apply CeraVe Moisturizing Cream to them as AmLactin immediately after shaving can burn my legs. Apply a second layer of AmLactin to my KP-prone arms and legs once I am done with the rest of my body.
    • Wrap up in a robe. Read a book or surf Reddit while moisturizers soak in.

And that is pretty much it. That routine alone has not only cut 5 minutes out of my showering time, but has also softened my skin all over, improved previously unpleasant experiences like shaving, and made my dry skin disappear.

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Using Differin .1% at Home Effectively for Mild-to-Moderate Acne

On July 8, 2016, Differin .1% Gel was approved by the FDA for over-the-counter sale. This is a big deal in the treatment and management of mild-to-moderate acne at home, as it is the only prescription strength retinoid available in every major drugstore (and Amazon!) in the US. Bonus: it’s cheaper than most people’s co-pays (including mine) used to be. Unfortunately, it’s still kind of a mystery on how to use it properly for your skin, as there is a ton of misinformation out there on the world wide web and the tube basically tells you to just use it every day after washing your face.

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Mild-to-Moderate Acne


General Retinoid Tips

In my last post, I talked a bit about the different types of retinoids available as well as some brief usage tips. In short:

  • Wear SPF 30-50 every day while using any topical retinoid, including Differin.
  • Avoid the eye area (lid and thin undereye) as well as the lips and areas next to the nasal passages.
  • Apply a pea-sized amount. Dr. Dray demonstrates this amount below. It is quite literally roughly the size of a pea.
  • Apply after cleansing and moisturizing your skin, once your moisturizer has dried down. Don’t use overly occlusive moisturizers before Differin application, like heavy oils.
  • Do not introduce new products right before or while using Differin. The reason for this is that if you begin to break out from the new product, it can be misinterpreted as breaking out from the Differin.

If you do best by watching videos, Dr. Dray has an excellent video on this process.

 


Starting Differin

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The American Academy of Dermatology’s prescribing information for Differin (adapalene).

When you first start using Differin, you’ll want to ween your skin into it. While some skin is very tolerant and can withstand every night almost immediately, for more sensitive skin types this can be a bit more of a process.

  • Tolerant Skin. If your skin is quite tolerant of topical therapies and rarely shows signs of irritation and peeling, feel free to begin applying a pea-sized amount of  Differin once a day, at night, after cleansing and applied over your moisturizer as Dr. Dray demonstrates above. If your skin begins to feel tender or like it is burning, even after application of a bland moisturizer, cut down to usage every other day.
  • Normal/Sensitive Skin. If your skin is sensitive or relatively normal, apply a pea-sized amount of Differin every other night (Monday, Wednesday, Friday, etc.), after cleansing and applied over your moisturizer, as demonstrated above. If your skin begins to feel tender, even after application of a bland moisturizer, cut down to every third night.
  • Very Sensitive Skin. If your skin frequently shows signs of irritation to new products, particularly things like AHA, BHA, or vitamin C serums, or if you have rosacea, you may want to start by applying a pea-sized amount, over moisturized, clean skin every third night. This is where I started. After a few weeks, your skin should be able to tolerate every other night without excessive burning, tenderness, or peeling. If it does, cut back to every third night.

If your skin starts to feel a-okay with every third night or even every other night, try to bump up frequency. The goal is to be able to use it every night, but if your skin never feels comfortable at that point, that is okay – use it as frequently as you can. Remember that for everything, everyone’s skin is different and beautiful. Your mileage may vary.

What to Expect

  • Some tenderness. My skin is more sensitive to being scratched, hot water, scruffy beards, and chemical filter sunscreens, particularly sunscreens with avobenzone.
  • Micro-peels. Wearing makeup will be a challenge during the adjustment period (about two months) of using Differin. Your skin will look and feel smooth, but application of foundation will show very fine peeling all over the skin. This is okay and normal. If your skin is ever showing thick “sheets” of peeling from a retinoid, you should back down on usage. Your skin should never be shedding like a snake from a low percentage retinoid.
  • Slightly more breakouts. My skin isn’t particularly prone to acne, though I do get small breakouts from time to time. Experiencing slightly more breakouts for the first few weeks is normal and fine. They should not be extremely aggressive or much worse than the breakouts you were experiencing before, particularly if your acne is mild.
  • Dryness. My skin became slightly drier with the introduction of Differin. To compensate, I apply moisturizer more frequently throughout the day and on nights I am not using Differin, I apply my Rosehip oil and Jojoba oil, which I do not use on the nights I apply Differin (too occlusive).

Combining Therapies at Home

Referring back to my post I made previously once again, all retinoids (and frankly, all acne treatments) are best when used as a combination therapy all over the affected area (in this case, the face).

Benzoyl Peroxide (BP)

BP is not a new drug. First shown to be effective against acne in 1934 (though not explored as a treatment for acne until the 1960s when William Pace began to treat patients with a precipitated sulphur cream that contained BP), it is now often prescribed as a treatment for mild-to-moderate acne in conjunction with topical retinoids, particularly adapalene (Differin). The FDA has permitted use of benzoyl peroxide in OTC concentrations of 2.5-10%.

It has keratolytic, moderate comedolytic, and antibacterial properties, “which include the reduction of P. acnes and Staphylococcus aureus on skin.”¹ It is a largely vehicle-dependent drug, meaning that the formulation matters. One journal notes this: “Many formulations incorporate BP crystals that vary in size and do not necessarily fully dissolve completely or at the same rate. Larger crystals that are not capable of settling into the follicular ostia due to their size may randomly rest on the skin surface for more prolongued periods of time, thus producing scattered foci of ‘hot spots’ that may present as patches of cutaneous irritation.”¹

In addition, in three double-blind studies 2.5% BP gel was been found to be just as effective as 5% and 10% preparations with fewer side effects due to the lower concentration of the drug.

To combine with Differin at home, I recommend finding it in a wash, such as PanOxyl, or Differin’s brand “Daily Deep” Cleanser, which contains 5% Benzoyl Peroxide. Feel free to use BP in this form twice a week or every other night – whichever you and your skin are most comfortable with. This is a form of short-contact therapy (an effective way to use benzoyl peroxide with less side effects) that can also be done with gels or creams as well, especially if cleansers are too drying for your skin. In one study on short-contact therapy:

Short contact therapy utilizing a 2 minute skin contact time with BP 9.8% emollient foam used once daily over a 2 week duration was highly effective in reducing the quantity of P acnes organisms on the back and provided comparable colony count reduction to “leave on” therapy using BP 5.3% emollient foam. (Source)

For gels or creams, I sound like a broken record about this brand, but I do genuinely love Paula’s Choice BPO formulations. I have a small, travel-sized tube of their 5% formulation (which is not more efficacious than their 2.5%, but I had to test it!) and I love it. Unlike most BP formulations that crust up and sit as a film on the skin, the PC BP spreads easily and sinks in. Acne.org also has a pretty wonderful formulation of 2.5% BP that I used many years ago.

An additional note about BP is that is must be used all over to be effective as a combination treatment. While it is frequently billed a spot treatment product, BP really shines when it is allowed to treat acne before it becomes a problem, by blasting P. acnes and unseen microcomedones. This is why infrequent short-contact therapy is ideal, as the whole face can become quite sensitized when you’re new to Differin.

To use a cream or gel as short contact therapy, use it over your moisturizer, before washing your face. If this bothers you, wash your face very gently first, removing any makeup or sunscreen, and patting dry with a towel. Apply a thin layer all over, let sit for two minutes, and rinse away. Apply your moisturizer while skin is still damp to prevent TEWL (trans-epidermal water loss) and let dry completely before applying a thin layer of Differin (about 20 minutes, if you are using it on the same day you use Differin).

To use a benzoyl peroxide cleanser, follow the instructions on the bottle, after removing any sunscreen and makeup with an oil-cleanser. Apply your moisturizer immediately after, while skin is still damp, to prevent TEWL and let dry completely before applying a thin layer of Differin.

If your skin feels particularly raw or chapped from the introduction of BP, cut down on frequency, use it on the “rest” day that you aren’t using Differin, or remove it all together to let your skin heal before re-introducing. Please note that these instructions are not for use with Duac, a prescription topical combining clindamycin and benzoyl peroxide.

Salicylic Acid (BHA)

Salicylic acid (SA) is in a class of ingredients known as hydroxy acids, which I’ve referenced before on this blog. SA is a lipophilic (oil-friendly, meaning it is ideal for oilier skin types or in conjunction with oily products) compound and found in a plethora of products. While frequently considered as the oil-friendly version of AHA, it differs from AHAs in how it exfoliates the skin (desquamation, keratolytic) as well as it’s ability to prevent the formation of comedones (comedolytic). To quote a journal that overviews the many OTC treatments for acne:

[On AHA] At lower concentrations, AHA functions as an exfoliant, interrupting corneocyte adhesion in the upper SC by interfering with formation of ionic bonds. As a result, AHAs promote individual corneocyte desquamation and decrease corneocyte clumping, both of which lead to smoother skin texture and decreased visible scaling and flaking; a decrease in follicular hyperkeratois promotes resolution and prevents formation of AV lesions, especially comedones.

[On BHA/SA] Due to its desmolytic properties, salicylic acid promotes individual corneocyte desquamation, thus simulating natural exfoliation, and exerts moderate comedolytic activity. The desmolytic and comedolytic properties of salicylic acid are concentration-dependent. In fact, salicylic acid is not keratolytic. Rather, it exerts its effect on SC desquamation by breaking the bonds created by corneodesmosomes, also called the “rivets” or “staples” of the SC, which sustain the adherence between contiguous corneocytes. … The “physiological” desquamation provided by salicylic acid provides smoother texture and appearance to the skin and can give the illusion of decreased pore sizes.

The journal goes on to add: “Unfortunately, lower concentrations of salicylic acid may provide only a modest desmolytic [the process of breaking down carbon-to-carbon double bonds, such as between skin cells] activity, thus producing minimal therapeutic effects.” In shorter terms, your mileage may vary.

Over the counter formulations can appear in 0.05% to 5%, while higher concentrations of SA are reserved for prescriptions and chemical peels.

These features make it less ideal (and much less studied) than BP for combination therapy with Differin, especially in lower percentages or untested formulations, but for some it may prove useful or even better than BP.

To use it with Differin, look for unscented washes or leave-on applications and use on clean, moisturized skin, before applying Differin or every-other-night, when not using Differin. Many people like Stridex pads due to their wide availability, but the formulation can be irritating to some. My personal favorite is (again – I swear I am not sponsored, I just really love their active ingredients) Paula’s Choice 2% BHA Liquid (Extra Strength, if using her acne line). CosRX also has a couple products, if you prefer Asian beauty products.

For cleansers, there are fewer options. Clinique has one that is fairly pricey and Dr. Dray loves the classic orange, oil-free Neutrogena cleanser in the pump (not the bar!). Use after removing makeup, following the directions on the bottle, and immediately apply your moisturizer to prevent TEWL. Once dry, apply a thin layer of Differin.

The risks with BHA combination therapy are largely the same as BP – redness, dryness, tenderness. If you begin to feel any of these effects, cut down on the frequency of usage of BHA before cutting back on Differin. If needed, remove the BHA entirely until your skin heals.

Glycolic Acid, Lactic Acid, Mandelic Acid (AHAs)

AHAs or Alpha Hydroxy Acids are a group of products that include glycolic, lactic, mandelic, and fruit acids. While the exact mechanism of these ingredients is rather poorly understood, it is known that they exert some effect by thinning the stratum corneum (SC) – the upper most layer of the epidermis – as well as dispersing basal layer melanin and increasing collagen synthesis in higher concentrations.

As mentioned above, AHAs can be helpful for some conditions of hyperkeratinization where the epidermal thickening impairs the SC permeability, resulting in skin fissures (microfissuring and macrofissuring). The most extreme examples of macrofissuring is usually seen on hands or feet, where the skin may split or “fissure.” At low concentrations (below 8%), AHAs disrupt the corneocyte adhesion. To re-iterate from above:

At lower concentrations, AHA functions as an exfoliant, interrupting corneocyte adhesion in the upper SC by interfering with formation of ionic bonds. As a result, AHAs promote individual corneocyte desquamation and decrease corneocyte clumping, both of which lead to smoother skin texture and decreased visible scaling and flaking; a decrease in follicular hyperkeratois promotes resolution and prevents formation of AV lesions, especially comedones. Higher concentrations of AHAs (8-10%) can lead to both epidermolysis and thickening of the dermis.

For some, this action can prove helpful when used in conjunction with retinoids, which most frequently cause peeling and dryness.

To use with Differin, look for low percentages to start with (4-8%) and in leave-on products. Glycolic, while the most effective form of AHA, is quite irritating to some skin types due to it’s ability to work quickly. Mandelic and lactic acid are especially gentle forms of AHAs due to their larger molecules that penetrate slower and may allow some people to use AHAs when they otherwise wouldn’t be able to.

To start, add them to your routine on your off-nights and work up tolerability from there. Some people also find value in using short-contact therapy with AHAs – particularly glycolic – though this limits their efficacy, particularly with forms that penetrate much slower, such as mandelic acid.

Some popular brands of AHAs are Paula’s Choice (8% Glycolic Gel), Pixi Glow Tonic (note: this contains several plant extracts, which can be very irritating), Nip + Fab pads (also contain fragrance and plant extracts), The Ordinary (7% Glycolic Solution as well as 10% Lactic), Stratia (10% Mandelic), and as CosRX (Glycolic Acid).

It is not advised to use an AHA in a cleanser, as it is often not on the skin long enough to create noticeable differences.

Azelaic Acid (AzA)

A natural component of everyone’s skin, azelaic acid (AzA) is also a viable combination therapy, and there are increasingly more products available over-the-counter that contain this ingredient. While AzA is not frequently prescribed for acne, it can be very helpful for some skin types, particularly those that are very sensitive.

Unfortunately, there are no good studies around AzA when used with Differin, but there are studies around AzA in comparison to clindamycin and BP. Specifically, one study showed it to be as effective as 5% BP as well as 1% clindamycin in a randomized controlled study with 351 patients (BP gel) and 229 patients (clindamycin).

Azelaic acid 15% gel proved to be as effective as BPO and clindamycin with median % reduction of the inflamed lesion (papules and pustules) of 70%, and 71% respectively. The azelaic acid gel was well-tolerated, the side effects (local burning and irritation) were distinctly less than with BPO but more pronounced than with clindamycin. Despite these side effects, the treatment was well-accepted by the majority of patients. (Abstract, source)

AzA is also bacteriostatic, meaning that it can suppress the ability for bacteria to reproduce, which can help inflammation. It also suppresses hyper-proliferation of keratin, which is a factor in acne.

Unfortunately, it does take time to work and the side-effects when initially starting off can be aggravating. The most common side-effects are itching and stinging as well as mild dryness or peeling. This tends to resolve within 4 weeks. This can be difficult to push through. As someone who uses AzA, I can say that the initial itching upon application canfeel very intense and aggravating to deal with, though icing my skin helped me push through the worst days. Your mileage may vary.

To use AzA with Differin, I recommend trying to use it in your “off” nights, when not using Differin. If your skin tolerates this fine, feel free to use it every night.

There are a few trustworthy AzA topicals available over-the-counter in the US. Paula’s Choice makes one that contains 10% AzA and 2% BHA, which I reviewed. The Ordinary also makes a 10% AzA, though it feels quite powdery and silicone-y, which some people dislike. Garden of Wisdom is another option, especially for people sensitive to many ingredients. Their product is an 8% serum that receives a lot of love, though I have never used it myself.

Another option is Melazepam Cream (20% AzA). However, I want to mention that this formula contains two oils, which may inhibit some of it’s efficacy. Specifically, in a study involving 15% AzA, waiting until after moisturizing seemed to result in greater penetration of AzA in all moisturizers tested except for one, which contained an oil (macadamia nut oil). It was surmised that this was due to the occlusivity of the oil. Another potential issue is that Melazepam is made in Israel – something that may concern some consumers.

Sulfur

Topical sulfur is another option, though hard to find and frequently found in masks and other short-contact products. Sulfur exhibits antimicrobial properties and has been used for hundreds of years to treat AV as well as seborrheic dermatitis. It is frequently found in formulas up to 10% in combination with other products, particularly resorcinol, which is thought to be antibacterial, antifungal, and keratolytic.

Unfortunately, topical sulfur frequently causes mild irritation and sensitization, and has limited popularity.

Queen Helene’s Mint Julep Mask is a popular product with sulfur, as well as the ProActiv mask. I would advise anyone using the Mint Julep Mask in particular with Differin to be cautious, as the clay (kaolin) can be very drying to skin that is already dry and peeling, and the fragrance content is fairly high, making it a potentially extremely irritating choice of treatment.


Whatever you decide, it is important to be consistent and not treat either the Differin or the combination product as a spot treatment. While this is a popular way to avoid irritation and sensitization, it only treats the symptom, not the disease, which is to say that it is only treating the comedone once it has surfaced as a larger issue rather than treating the root of the problem: the formation of microcomedones.

Differin takes roughly twelve weeks to see full results, and products like AzA can take even longer. Whatever you decide, stick with it and listen to your skin by backomg off when it feels a bit more sensitive and moving up slowly in application when you feel you’re adjusting.


Sources

  1. Over-the-counter Acne Treatments
  2. The effect of benzoyl peroxide 9.8% emollient foam on reduction of Propionibacterium acnes on the back using a short contact therapy approach
  3. The role of benzoyl peroxide in the management of acne vulgaris
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Skincare Ingredients: Tretinoin, Adapalene, and Tazarotene – part one

Note: This post is meant to discuss topical retinoids as ingredients.  I will be writing an additional post on how to best use Differin .1% (OTC) at a later date, as I am two weeks deep into using it now. In addition, this post only covers the effects of topical retinoids in acne. Please stay tuned for more posts about retinoids and wrinkles and scarring!

Topical retinoids are one of the most common treatments for acne – both during treatment and for maintenance, after the acne is considered to be resolved. During treatment, they are most often prescribed in combination with other products, such as benzoyl peroxide (BPO), where they show the most efficacy.

While the pathogenesis of acne is constantly evolving, it is widely accepted that the key factors that play a role in the development of acne are follicular hyperkeratinization, microbial colonization with p. acnes, sebum production, and inflammation. Additional factors have been suggested by the American Academy of Dermatology (AAD), such as “neuroendocrine regulatory mechanisms, diet, and genetic and nongenetic factors all may contribute to the multifactorial process of acne pathogenesis.” To understand how retinoids can improve acne, you need to first understand some of the mechanisms of acne, particularly follicular hyperkeratinization.

According to William J Cunliffe (Acne: Diagnosis and Management, 2001):

Acne lesions do not usually occur in a follicle bearing a terminal hair [hairs found on the scalp, for example]. The hair acts as a wick allowing sebum to drain from the pilosebaceous canal. In contrast, in the pilosebaceous follicles the hairs are small and vallus in nature and often do not reach the surface. They are ineffective wicks and do not therefore prevent the retention of follicular contents. Histological examination of the pilosebaceous canal reveals that much of the duct comprises an epidermis-like structure undergoing cornification [the final stage of keratinization for the skin cells], the cornified material occupying the more central part of the canal. … The horny cell layers [the stratum corneum is frequently referred to as the horny layer] … soon desquamate [shed] into the central part of the canal to form a heterogeneous [diverse] mass together with sebum and bacteria. … Thus the horny cells distend the pilosebaceous canal, first producing a microcomedone and then a clinical lesion. It is not known why some lesions remain closed comedones (whiteheads) and why other lesions progress to open comedones (blackheads). As the comedones enlarge, the sebaceous gland may atrophy but sebum continues to be produced until the glands are totally replaced. 

In short, the hair of the face is too short and too fine to drain sebum (oil) effectively, which allows the follicles to retain its contents, including skin cells that line the hair follicle that would otherwise be shed normally. This forms a clumpy mass of sebum, bacteria, and shed skin cells, which turns into a microcomedone and from there, a closed or open comedone. Why this occurs is not very well understood, but it is thought to be due to hormones, abnormal lipid compositions, or microbial factors.

In addition to this, it has been found that the follicular cells in patients with acne is more irregular. This favors retention of shed cells. As the lesions mature into a microcomedone, the walls of the follicle become patchy and thin.

acne_histology

However, this has become the basis for retinoid usage, and has placed retinoids at the core of topical therapy for acne due to their comedolytic behavior, which allows them to resolve the precursor to lesions (microcomedones), as well as their mild anti-inflammatory properties.


An Introduction to Retinoids

Retinoids have been used since the 1960s, when they were discovered to have tremendous effects on disorders of keratinization. They work by binding to specific receptors on the cells, and each retinoid binds to a different set of retinoic acid receptors. In tretinoin, they bind to alpha, beta, and gamma receptors, while tazarotene and adapalene selectively bind to beta and gamma receptors. This is what makes each retinoid’s activity on the skin (as well as tolerability) a bit different.

Again, to quote William J Cunliffe:

The activation and inhibition of certain steps of gene transcription results in changes of different pathways. These pathways include proliferation, differentiation, inflammation, and sebum production. … Some retinoids such as tretinoin increases the mitotic activity of the ductal keratinocytes …

In short, these ingredients are cell-communicators that can result in changes to the skin, such as increased cell turnover, reduced sebum production, and more normalized cell shapes.

All retinoids are vitamin A derivatives. There are three major types of topical retinoids available today, which include:

  • Tretinoin (Brand name Retin-A)
    • The first topical retinoid and the gold standard.
    • Available in gels or creams, and is now in less irritating microsphere formulations such as Retin-A Micro.
    • Available in gel and cream .025% and .1% strengths
    • Also available in combinations with topical clindamycin (.025% tretinoin/1.2% clindamycin phosphate)
  • Adapalene (Brand name Differin)
    • One of the best studied retinoids for combination treatments with BPO. Much better tolerated than tretinoin in most cases.
    • Available in .1% gel over-the-counter in the US
    • Available in .1% or .3% creams and .1% lotion
    • Available as combination a with BPO (Epiduo, .1% adapalene, 2.5% BPO)
  • Tazarotene (Brand name Tazorac)
    • Potentially more efficacious than tretinoin at treating papules and open comedones.
    • Stronger than adapalene (Differin)
    • Can be used to treat psoriasis
    • Available in gels, creams, or foams in .05% and .1% strengths

They all carry many of the same side effects of peeling, dryness, erythema (redness), and irritation, and the higher the concentration of the retinoid, the higher the risks of side effects become. In 2016 Guidelines for the Management of Acne, the AAD also notes about combinations with BPO:

Some formulations of tretinoin (primarily generic products) are not photostable and should be applied in the evening. Tretinoin also may be oxidized and inactivated by the coadministration of BP. It is recommended that the 2 agents be applied at different times. Tretinoin microsphere formulation, adapalene, and tazarotene do not have similar restrictions.

Topical retinoids have also been associated with photosensitivity and all people who are using them should use at least SPF 30-50 every day to avoid burns and sun damage, which reverse many of the benefits of retinoids. You should also avoid the eye area, including lids and beneath the eye, as well as the lips and the areas next to the nasal passages. Dr Dray recommends using Vaseline on these areas and calls it “greasing the orifices,” which I quite like.


A Note About Antibiotics and Topical Antibiotic Usage

Since many of the retinoid studies I am about to discuss are those which have been conducted in combination therapies (over 16,000 studies have been published around combination therapies), I think it is both unavoidable to discuss antibiotic resistance and its effects on how doctors are now prescribing topical acne treatments.

As you probably already know, antibiotic resistance is a growing public health concern in virtually all parts of the world. While antibiotics have been considered a fantastic treatment for acne for a long time, primarily due to their anti-inflammatory effects, nonantibiotic agents, particularly BPO, has been advised for combination treatments due to the highly effective nature of BPO to kill p. acnes without creating bacterial resistance.

Antibiotic resistance can change the outcomes of acne treatments, and in a 1998 review, there was a “clear association between poor therapeutic response and antibiotic-resistance propionibacteria [p. acnes].” (Source) The Global Alliance to Improve Outcomes in Acne (which I will be abbreviating to GAIOA from now on) also notes that resident flora has a “memory” “and retains resistance variants long after antibiotic therapy is discontinued.” Worse, this can lead to other complications down the line:

Patients with acne are often treated with multiple antibiotics and their flora is exposed to a significant selective pressure for resistance development. Margolis et al found that patients with acne treated with antibiotics had 2.15 times greater risk of developing an upper respiratory tract infection compared with patients with acne who were not treated with antibiotics. In addition, there have been an increasing number of reports of infections caused by P. acnes, including arthritis, endocarditis, endophthalmitis, and adenitis. … several researched have termed P. acnes infections ‘an emerging clinical entitity’ and ‘an underestimated pathogen.’ 

To put this into perspective, one 12-week study involving 208 patients with acne treated with topical erythromycin showed erythromycin-resistant staph on the face increase from 87% to 98% while the density of the organism increased significantly.

Because of this, it is suggested that most clinicians only prescribe short-round antibiotic usage – 3 to 4 months – and only if absolutely necessary. For the patients who do require antibiotics, especially longer term antibiotic usage, it is very important that your doctor monitor your progress in order to prevent resistances.


Evidence for Combination Therapies

Combination therapies involving retinoids plus an antimicrobial agent have been used since the 1970s, with many early studies showing that retinoids, when used in addition to antimicrobials such as topical BPO, were much more effective than those who were using the antimicrobials alone. While early studies were mostly conducted with topical tretinoin plus oral tetracycline, 67% of patients vs 48% of those treated with tretinoin alone and 41% of those treated with tetracycline alone had “good to excellent” outcomes.

Combination therapies are most broadly recommended for people with mild to moderate acne, as per the AAD:

1-s2.0-S0190962215026146-gr1_lrg

Most modern combination treatments combine clindamycin and BPO along with a topical retinoid. This combination not only increases the likelihood of a positive outcome, but also decreases the development of resistant strains of bacteria due to topical antibiotics.


Treatment with Combination Therapies

For all of the following therapies, I have included the prescribing information as provided by the American Academy of Dermatology (2016). You should always follow your doctor’s instructions, but I also know some of you may be acquiring these prescription drugs without a doctor for any number of factors, and I feel like you have a right to this information. Please use it responsibly.

Adapalene (Differin and Epiduo)

In 2007, a study of Epiduo (0.1% adapalene and 2.5% BPO) was conducted. According to the GAIOA, “It is thought that adapalene and BPO have synergistic actions, because BPO is the most potent bactericidal agent against p. acnes and adapalene, like other retinoids, is comedolytic and anticomedogenic.” A double-blind study of adapalene/BPO in 517 patients with moderate to moderately severe acne also showed significantly lower lesion counts than patients treated with the vehicle alone (the formula the drug is carried in) or placebo.

The once-daily fixed-dose combination formulation of adapalene/BPO has also been evaluated during 12 months in 452 patients with acne. The fixed-dose combination had good safety with only mild to moderate adverse events that typically occurred in the first 1 to 2 months after initiation of therapy and resolved spontaneously. 

The regimen of adapalene plus BPO and clindamycin products has also been studied, with reduction of lesions apparent as early as week two.

adapaleneadapalene_bpo

Tazarotene (Tazorac)

While Tazorac (or “Taz”) has not been formulated in a combination product like Adapalene (Epiduo), it has been studied in combination with BPO and 3.0% erythromycin/5% BPO. In a study of 440, investigator-masked, randomized, parallel group study, tazarotene plus erythromycin/BPO was “significantly more effective” than other regimens including tazarotene, such as tazarotene and clindamycin.

taz

Tretinoin (Retin-A, Retin-A Micro, Veltin, Ziana)

Tretinoin is one of the most widely studied of the retinoids, and has significant evidence to back it up in use with combination studies.

Bowman reported the results of a controlled trial comparing three treatments: (1) clindamycin/BPO gel; (2) clindamycin/BPO gel plus tretinoin 0.025% gel; and (3) clindamycin/BPO gel plus tretinoin gel 0.025% plus clindamycin. In this study, the triple combination was most effective in reducing inflammatory lesions (69%) followed by clindamycin/BPO (66%), then tretinoin plus clindamycin (52%); non-inflammatory lesions also were reduced to the greatest extent by the triple combination (61%), then clindamycin (50%). All 3 treatments were well-tolerated, although there were more adverse events in the triple combination group compared with the other groups. (Source, page S15)

tretinointretinoin_clind


Maintenance with Topical Retinoids

At this time, Adapalene is the most well-studied topical retinoid for maintance therapy once the acne has been considered “resolved.” This may be due to its reputation as one of the gentlest of the retinoids. In general though, retinoids are the preferred maintenance therapy due to their ability to prevent development of new acne lesions and resolve existing lesions quickly.

In a study on the efficacy of topical retinoids in the role of maintenance of acne, the following changes were observed:

retinoid_stopped

In a 16-week, randomized, vehicle-controlled maintenance study, patients who enrolled all originally were diagnosed with severe acne and only 28% of patients had moderate acne and 72% had mild or minimal acne or were clear at the time of the maintenance study. By the end of the study, more than 90% of patients were able to maintain their clearing while on adapalene maintenance therapy.

While the following graphs are a bit tough to read, they all should give you a general idea of the efficacy of retinoid maintenance therapies:

fig10fig11Fig9

The GAIOA concludes that maintenance therapy is an important tool for minimizing the likelihood of relapse, given the chronic nature of acne, with topical retinoids considered the best tool for this. They go on to state:

The majority of studies reported to date have lasted 3 to 4 months and show a trend toward continuing improvement with topical retinoid maintenance therapy and relapse when patients stop treatment. Clinical experience indicates that a longer duration of maintenance therapy is likely to be beneficial for many patients. Ongoing research will help to define the optimal duration of therapy and, perhaps, refine patient selection. Some patients with significant inflammation may need to be treated with a combination of retinoid and antimicrobial agent. This should be further studied.

The fact that microcomedones are subclinical and not apparent to the naked eye underscores the need to apply topical therapies to the entire affected area.
This, in turn, suggests that any agent used for maintenance therapy must be well tolerated. The current studies are well done and interesting; however, future studies should include comparison of several maintenance regimens in different patient populations.


Some Guidelines

Here are some things to conclude from this post:

  • Topical retinoids are very effective for treating acne, especially when used in combination with antimicrobials.
  • Prescription antimicrobials and retinoids need to be used on the entire effected area for efficacy and should not be used as spot treatments.
  • Adapalene is the most gentle of the retinoids.
  • Retinoid use should be maintained after treatment for acne has concluded.
  • Sunscreen should always be used with retinoids.
  • BPO should only be used with microsphere tretinoin, tazarotene, and adapalene.
  • Many generic forms of tretinoin are photo-unstable (break down in UV light) and should be used at night.

Sources

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Acne, Purging, Irritation, and Gram-Negative Folliculitis

I’m about to say something that could upset skin communities everywhere: I don’t really believe in purging. Before you panic, let me explain.

When I was in my 20s, I went through a period of acne that the Internet affectionately called “purging.” I talked about it a bit in my post on how to pick and prepare for your first dermatologist visit. It was a very painful period in my life that I was urged to power on through.

Again and again, I see people asking about purging, telling others they’re purging, describing the breakouts from a new cleanser as purging, and even popular YouTubers suggesting that antioxidants like Vitamin C made them purge for six months. I want to dispel this myth right here and now: Your skin does not purge and the idea of purging is a far overemphasized everywhere. In one of Dr. Dray’s videos on YouTube, she mentioned this as well and described most people’s reactions as irritation.

As I dug into this topic over the past few weeks, I could find no medical evidence at all to support this idea of prolonged breakouts from AHAs or BHAs, or even tretinoin. Irritation is referenced several times – peeling, redness, and dryness – and indeed doctors will tell you that your skin may show some signs of worsening for a short period before it gets better, but there is nothing to support the idea of long-term breakouts from products. This term also gets tacked onto regular products, such as moisturizers and cleansers.

On top of this, I’ve seen people refer to acne breakouts from products (such as cleansers and moisturizers) as an allergic reaction, which I dig into a bit below.

So to tackle this, I want to talk a bit about how skin works, the mechanisms of acne, the type of reactions to products, and a common form of folliculitis that is frequently mistaken for worsening acne.

Please keep in mind that this post is not intended to diagnose you, but instead to debunk commonly held misconceptions and ideas. If you feel like you identify with one of the skin conditions or reactions detailed below, please speak to your doctor.


The Anatomy of Skin and the Pilosebaceous Unit

The skin is divided into three major layers: the epidermis, the dermis, and hypodermis. The epidermis contains the skin cells we see and frequently consider our skin, and is the layer affected by topical products and environmental conditions. It is broken into four distinct layers, with new corneocytes starting at the stratum basal (the layer right over the dermis), where they split into two thanks to the magic of mitosis, and one cell stays while another drifts towards the surface (the stratum corneum), becoming full of keratin, bonded by NMFs, and flattened down, before they eventually live out their lives being covered in moisturizers and exfoliants, and then sloughing away to cover our belongings in dust.

apocrine-sweat-glands-2The skin is also made up of many glands, such as the sebaceous glands (oil glands) and sweat glands (two types – apocrine and eccrine). Eccrine glands are most common on hands and feet, while apocrine glands are attached to the hair follicle, along with a sebaceous gland. This makes up the pilosebaceous unit. These are most common on the face, and is what becomes inflamed and plugged up when you have acne or folliculitis.

Fun fact: Sweating does not “clean” pores out either. The sweat glands are positioned too far up to actually “push out” the build-up that creates acne deeper in the unit. The scent of sweat is largely due to the sweat mingling with the microflora on the skin.

The body naturally produces a makeup of natural moisturizing factors (NMFs), which act as natural humectants, as well as a mixture of other fluids such as sebum. I talked about this with more detail in my post on dehydrated skin. This mixture creates what is known as the acid mantle. Together, it works to keep skin cells sloughing away, invaders out, and moisture in. Unfortunately, for a variety of factors, skin might not be the most effective at one of its natural processes (such as hormones pressing the gas on sebum production), so acne develops.

Acne, a condition characterized by hyper-keratinization, occurs when sebum, bacteria (p. acnes, which lives on everyone’s skin naturally), and corneocytes that didn’t slough away naturally, build up in the pilosebaceous unit. This creates a comedone.

Comedones begin as microcomedones (comedo- means acne or blockage), which later balloon to create an inflammatory lesion. As they get larger, and especially if squeezed, they can erupt the wall of the follicle, leaking the infection into the surrounding tissues.

This is all important because in the past, I (incorrectly) thought that acne occurred anywhere in the skin tissue and was not exclusive to a follicle. Hopefully, if you also used to think this, now you know!


How Acne Products Work

Without getting too into the weeds (future post!), acne products largely work by disrupting or killing the acne bacteria (such as benzoyl peroxide, which kills p. acnes through the release of free oxygen radicals), normalizing skin cell turnover, and by reducing inflammation in the skin. Not all acne topicals are anti-microbial, anti-bacterial, anti-inflammatory, or cell-communicators, but they all are used for combating one or several of the mechanisms of comedone formation.

According to the American Academy of Dermatology (Source):

Commonly used topical acne therapies include BP, salicylic acid, antibiotics, combination antibiotics with BP, retinoids, retinoid with BP, retinoid with antibiotic, azelaic acid, and sulfone agents.

The process of reversing the mechanisms of acne (or at least slowing them down) varies by medication, but anecdotally, it seems that the quicker the brakes are applied, the more irritating the process is. For example, tretinoin is perhaps one of the quickest medications to act on acne (Adapalene takes roughly 12 weeks, for example), while azelaic acid appears to be one of the slowest.


Adverse Reactions and Irritation

An adverse reaction can be described as any unwanted effect associated with a treatment. Sometimes this can lead to new discoveries, such as the discovery that a particular medication for glaucoma made patient’s eyelashes grow longer, but many times it is just aggravating.

Basic Skin Irritation

Simple skin irritation is what most people think of when they think of “irritation.” It is redness at the site of application (though people of color can frequently see a decrease in color in their skin rather than redness) and usually occurs within 6-24 hours, though people with very sensitive skin may see a reaction within just a few hours.

Short-term use of anti-inflammatories and corticosteroids usually resolves the issue and rarely do medical professionals need to get involved.

Cumulative Irritation

Cumulative irritation is like a slow-burn irritant. It’s the product you put on for a few days and then one day – boom! Your skin reacts with redness and tenderness, like basic irritation. This is the most common with many topical prescription acne treatments that can cause redness, dryness, and peeling.

There can be several factors that cause this, from other ingredients in a skin care regime not mixing well with each other to skin simply becoming more sensitized and reactionary as time goes by.

Discontinuing use of the product and returning to a bland routine (cleanse, moisturize, sunscreen) as well as anti-inflammatories usually resolves this issue as well. If it is a topical prescription, contact your doctor for instructions.

Allergic Reactions

Allergic reactions are defined by almost immediate hypersensitivity and can be severe, with swelling, redness, hives, or anaphylactic shock. If the individual is less allergic, it can take 24 hours or more to present with itching, swelling, and redness. Mild reactions can be treated with Benadryl, while more severe reactions should be treated by a medical professional.

The primary differentiation between allergic reactions and other reactions is that allergic reactions usually last longer, can spread, and cannot be re-introduced once the reaction has resolved.


Gram-Negative Folliculitis

While many modern acne treatment guidelines dissuade the use of oral or topical antibiotics (eg, erythromycin and clindamycin) due to growing antibiotic resistance (Source), many people are still prescribed these treatments in combination with topical retinoids. In it’s place has come azelaic acid (which does not produce p. acnes resistance) and benzoyl peroxide.

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2016 AAD Guidelines for the Management of Acne Vulgaris (Source)

Besides antibiotic resistance, oral and topical antibiotics can also produce another unwanted side-effect: gram-negative folliculitis (p. acnes is gram-positive). According to Herbert P. Goodheart (Goodheart’s Photoguide to Common Skin Disorders: Diagnosis and Management), folliculitis, “in it’s broadest sense, may be defined as a superficial or deep infection or inflammation of the hair follicles.” This usually occurs when an irritant – either physical or chemical – is introduced to the skin that can aggravate the follicles.

Gram-negative folliculitis is an acne-like “rash” (referred to in some literature as a “pustular rash”) caused by bacteria. The term “gram-negative” simply refers to the staining pattern of the organisms. It usually appears in patients with acne and is often mistaken as worsening acne in those patients. It is also most commonly found around the mouth, under the nose, to the chin and cheeks.

While folliculitis is not limited to patients using antibiotics by any means (men frequently report folliculitis in their beard, for example, and pityrosporum folliculitis is a common form of fungal folliculitis typically found on the upper trunk of the body), gram-negative folliculitis specifically seems to most commonly appear in patients who are immunocompromised, have been on rounds of oral antibiotics recently, or given topical antibiotics like clindamycin. From the Journal of the American Academy of Dermatology:

This uncommon disorder presents as uniform and eruptive pustules, with rare nodules, in the perioral and perinasal regions, typically in the setting of prolonged tetracycline use. It is caused by various bacteria, such as Klebsiella and Serratia, and is unresponsive to many conventional acne treatments. Gram-negative folliculitis is typically diagnosed via culture of the lesions, and is generally treated with isotretinoin or an antibiotic to which the bacteria are sensitive. In cases of acne unresponsive to typical treatments—particularly with prominent truncal involvement or monomorphic appearance—pityrosporum folliculitis should be considered. Staphylococcus aureus cutaneous infections may appear similar to acne, and should be considered in the differential, particularly in cases of acute eruptions; a swab culture may be helpful in these cases.

According to William J Cunliffe (Acne: Diagnosis and Management, 2001), “Approximately 80% of patients with cases of Gram-negative folliculitis present with superficial pustules, while the remaining patients [20%] present with deep nodules and pustules. … The possibility of a Gram-negative folliculitis should be entertained if a patient develops a highly inflamed flare after doing well on antibiotics.”

Examples of antibacterial agents used to treat acne that gram-negative folliculitis bacteria are not sensitive to include:

  • Tetracyclines: doxycycline and minocycline
  • Macrolides: erythromycin and azithromycin
  • Clindamycin

It’s important to note that pityrosporum folliculitis is a separate disease – fungal in nature – and is not treated the same as acne or gram-negative folliculitis.

Anecdotally, this is the type of reaction I see the most when people start to viciously break out from a prescription acne product suddenly, along with skin redness and basic irritation. It usually comes on acutely – such as overnight or within 48 hours – is itchy, tender, and sore. Unfortunately, these characteristics sound a lot like acne to many people, especially those already suffering, and thusly, it is frequently mislabeled as “purging.”


Treatment Options

If you have experienced this kind of reaction, it is important to talk to your doctor about it, as they are the only ones that can truly help you – not the Internet. However, most cases are confirmed by sampling and culturing the lesions, and swab samples from the nose (where the causative bacteria lives) can be taken.

Doctors may advise you an antibiotic therapy, using antibiotics that the organisms are sensitive to (ampicillin and trimethoprim, specifically), though this treatment is not always successful. Isotretinoin, which suppresses sebum production in the pilosebaceous duct and dries out the mucous membranes (especially the nasal passages) is generally preferred (.5-1.0g/day) for 4 months.


Some Acne Guidelines

So in short, I don’t really believe in what is frequently considered purging. Yes, acne medications can frequently resolve comedones quicker, but they can also just as frequently cause irritations and other adverse reactions, particularly when used aggressively, which is often mistaken for other conditions.

With this in mind, here’s a few guidelines for products when treating your acne:

  • If you begin to break out from non-prescription products, it is just breaking out or irritation. Cleansers cannot “purge” acne, your moisturizer cannot “purge” acne, nor can your vitamin C “purge” acne. It is simply adverse reactions to the product (and an ingredient or combination of ingredients within) and your skin not getting along. Additionally, most OTC products (such as BHAs and AHAs) do not contain a high-enough percentage to worsen breakouts significantly but can irritate your skin.
  • If your acne becomes itchy or flares up immediately, as if overnight, call your dermatologist. This is especially important if you’ve been on oral antibiotics or using a product with topical antibiotics, including clindamycin combinations (ex.  Ziana or Veltin).
  • If your skin becomes tender, red, or burns upon contact with any products, such as cleansers or moisturizers, or even water, while on acne treatments, talk to your doctor. Your skin may be irritated and your prescription may be adjusted.
  • Gram-negative folliculitis is not fungal, it is bacterial. Unlike pityrosporum folliculitis, gram-negative folliculitis is not treated with fungal treatments.
  • Your skin may get worse for the first two or three weeks when using a prescription acne treatment. I feel like this period is where “purging” really got it’s name and is what it should be carefully confined to describing. If your breakouts last longer than this time period or get much worse, painful, or deep, particularly in locations around the cheeks, chin, and mouth, contact your doctor.

Sources

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