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Kristen

Skincare Ingredients: Tretinoin, Adapalene, and Tazarotene

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. 

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.

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. In addition, as the lesions mature into a microcomedone, the walls of the follicle become patchy and thin.

acne_histology

Why this occurs is not very well understood, but it is thought to be due to hormones, abnormal lipid compositions, or microbial factors.

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 gammy 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% or .3% creams and .1% lotion
    • Available in .1% gel over-the-counter in the US
    • 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.
    • Can be used to treat psoriasis
    • Stronger than adapalene (Differin)
    • 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.

1-s2.0-S0190962215026146-gr1_lrg

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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Review: Paula’s Choice Azelaic Acid Booster

by Kristen
Review: Paula’s Choice Azelaic Acid Booster

DSC_1754Before I boarded the plane in Northern California, I was flipping through my Facebook when I was served an ad for a new Paula’s Choice product: the Azelaic Acid Booster. Of course, as an azelaic acid devotee, my interest was piqued. I flipped through the ingredients and quickly realized I had used this product before, shipped and sold to me from the EU in the silver packaging of the RESIST Skin Transforming Multi-Correction Treatment.

Up until recently, you could have this product shipped to you from the EU, but as a commenter on my blog noted, you can no longer have this product imported into the US. This was fairly upsetting, as the product works quite well (better than The Ordinary’s Azelaic Acid suspension, in my experience) and combines AzA (10%), BHA (2%), and skin-brightening licorice root – a wonderful combination for fighting acne and post-inflammatory hyperpigmentation at the same time.

I’ve already seen some people asking about this new product, so I figured I’d so a quick review on it in case you are considering taking the plunge!


Product Overview

First off, I wanted to show the ingredient list alongside the new ingredient list for the Azelaic Acid Booster, which is now being sold on the US Paula’s Choice website.

Azelaic Acid Booster Ingredients

Water (Aqua), Azelaic Acid (skin-soothing, antioxidant, exfoliant), C12-15 Alkyl Benzoate (emollient), Caprylic/Capric Triglyceride (skin-replenishing), Methyl Glucose Sesquistearate (emollient), Glycerin (skin-replenishing), Cetearyl Alcohol (texture enhancer), Glyceryl Stearate (texture enhancer), Dimethicone (hydration/texture enhancer), Salicylic Acid (exfoliant), Adenosine (skin-restoring), Glycyrrhiza Glabra (Licorice) Root Extract (skin-soothing), Boerhavia Diffusa Root Extract (skin-soothing), Allantoin (skin-soothing), Bisabolol (skin-soothing), Cyclopentasiloxane (texture enhancer), Xanthan Gum (stabilizer), Sclerotium Gum (stabilizer), Propanediol (hydration), Butylene Glycol (hydration), Phenoxyethanol (preservative).

RESIST Skin Transforming Multi-Correction Treatment Ingredients

Aqua, Azelaic Acid (skin brightener/antioxidant), C12-15 Alkyl Benzoate (texture-enhancing), Caprylic/Capric Triglyceride (hydration/skin replenishing), Methyl Glucose Sesquistearate (texture-enhancing), Glycerine (hydration/skin replenishing), Cetearyl Alcohol (texture-enhancing), Glyceryl Stearate (texture-enhancing), Dimethicone (hydration), Cyclopentasiloxane (hydration), Propanediol (hydration), Salicylic Acid (Beta Hydroxy Acid, exfoliant), Butylene Glycol (hydration), Sclerotium Gum (texture-enhancing), Xanthan Gum (texture-enhancing), Allantoin (skin-soothing), Bisabolol (skin-soothing), Glycyrrhiza Glabra (Licorice) Root Extract (skin-soothing), Adenosine (skin-restoring), Boerhavia Diffusa Root Extract (antioxidant), Phenoxyethanol (preservative).

DSC_1758

Ingredients as listed on the tube

The ingredients are exactly the same, just arranged differently. This is probably due to the FDA’s packaging requirements (specifically the Fair Packaging and Label Act of 1967), which requires that all ingredients in order of concentrations up to 1% be listed in order of concentration, rather than the actual formula. Admittedly, I have not purchased a tube of the Azelaic Acid Booster, so I can’t tell you for certain that it has the identical feel and results, but I do feel pretty confident in assuming that it is the same product formula for both.

 

 


Ingredient Breakdown

I’ve written an entire post on the benefits of Azelaic Acid (AzA), so please feel free to check it out if you want to know all the details, but in general, AzA is an anti-inflammatory, anti-bacterial ingredient that is frequently used in acne and rosacea treatments, especially with sensitive skin types that are more prone to irritation from ingredients like benzoyl peroxide (BP) and tretinoin (Retin-A). In one study I cited, 20% AzA combined with glycolid acid (AHA) has been shown to be just as efficacious in treating mild-to-moderate acne as .025% tretinoin. In another study, it was shown to be as effective as 5% BP as well as 1% clindamycin.

It is also bacteriostatic, repressing the ability of bacteria to reproduce, which may be why it is anti-inflammatory. In addition to these characteristics, it is also a tyrosinase inhibitor, with a special affinity for abnormal melanocytes, making it ideal in treatment of melasma or post-inflammatory hyperpigmentation (PIH). In fact, it is much safer and typically more preferred to hydroquinone, which is a skin lightener that tends to target all skin cells and has created concerns due to potentially causing tumors in mice. In an open study comparing 20% AzA twice daily to 4% hydroquinone, it showed to be just as effective if not more effective than the hydroquinone in reducing mild melasma.

This formula also contains 2% salicylic acid (BHA), a derivative of salicin. It is oil-soluable, making it more effective at penetrating to the areas most effected by acne. Like it’s cousin, AHA (frequently found in the forms of glycolic or lactic acid), it helps to break apart the corneocytes that do not shed properly, which ideally prevents breakouts from occurring. It is not as photo-sensitizing as an AHA and in many people it is not nearly as irritating, even being characterized as “soothing” or “anti-inflammatory” (perhaps due to the fact that it serves as an active metabolite of asprin). Unfortunately, according to the 2016 “Guidelines of Care for the Management of Acne Vulgaris” from the Journal of the American Academy of Dermatology, “clinical trials demonstrating the efficacy of salicylic acid in acne are limited.”

This product also contains licorice root extract, which I talked a bit about in my review of Kikumasamune Sake Skin Lotion:

Licorice root extract is similarly a tyrosinase inhibitor as well as an anti-irritant – with some studies signalling that it may be able to absorb UVA and UVB rays. It is more effective than kojic acid and some studies put it at 75x more effective than ascorbic acid (though Dr Dray raises some interesting points regarding the efficacy of L-AA). “The chief constituent of licorice root is glycyrrhizin, present in concentrations that range from 5 to 24 percent depending on the variety of licorice used.”²


DSC_1565My Experience

I went through about half of the tube of this product before shelving it, as I felt like it aggravated the erythema in my rosacea, as most BHA products do. I’ve always avoided the areas around my nose, where I get the most flushed, and with this product I did have to apply the product there to deliver the benefits of AzA to my rosacean-prone areas.

It does have the exact same side effects as Finacea, tingling and itching upon first use (this eventually goes away, but is much worse if you are new to AzA), but this felt very assuring to me that it contained the amount of AzA that it is advertising (10%).

It also feels quite similar to Finacea Gel, but feels perhaps a bit smoother and spreads a touch easier. It also has a very Finacea-esc scent that is difficult to describe if you’ve never used azelaic acid products before. It is not strong by any means, nor does it linger, but I am very attuned to the scent after years of using Finacea.

DSC_1568Unfortunately, I don’t have much acne these days to tell you whether or not it is ideal for acne, but I did feel like my pores looked a bit clearer and smoother while I was using it, though not markedly better than when I use 2% BHA Liquid. Nor do I have much scarring and hyperpigmentation to be able to say for sure whether this formula helped with lightening any dark spots.

Other than the erythema, my skin did not have any issues with the formulation, and felt no more hydrated or irritated than when I use my regular Finacea.

It did feel much more efficacious than the Ordinary’s Azelaic Acid 10%, which I used briefly a couple of months back. To compare, the Ordinary’s AzA is suspended in a very powdery, primer-like silicone formula, which I wasn’t the biggest fan of. I also didn’t feel like it really did much, and I didn’t feel any of the itchy tingle of the AzA on application.

All-in-all though, if you do well with BHA and are looking to add AzA to your routine, I think this is a wonderful product.

To Purchase in the US – $36 USD + Shipping for 1 fl. oz
To Purchase in the EU – € 36,00 ($41.97 USD) + Shipping for 1 fl. oz.

 

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Blog Notes – Week of July 8-13, 2018

by Kristen
Blog Notes – Week of July 8-13, 2018

Hi guys,

Some updates on the blog posts this week! I frequently go back to update old posts in an effort to keep them current, concise, and ensure that they have the best information as I learn new things. Consider this like blog patch notes.

I am out a majority of this week and into next, so I wanted to give you guys a little update.

One more note before below: I may be switching to 1 Patreon, 1 Regular post a week. This is because it is quite hard to do 3 really heavily researched posts a week and is leaving me with a bit of brain drain on my days off. I have more notes about this below under PATREON.

Blog Changes

  • SHE’S GOT THE LOOK: Updated the entire look of the blog!
  • SPAM: People who were subscribed to my blog via email received a large number of emails on July 5, 2018. This was due to me updating the front-end of the blog, which pushed several fake “posts” out as demos. This was a function that I wasn’t aware of, and so it spammed my Twitter account as well as my blog subscribers. The site was not compromised. It was my own error. I’m so, so sorry to those effected. I know the last thing you need is more spam.
  • PATREON: I’ve begun creating written Patreon content. Patreon content will appear “protected” and be shown with a Patreon logo. Patrons will receive access to these pieces, which will be deep-dives on specific topics pertinent to skin, ingredients, and research. It will not be replacing my regular content, as I know many people who enjoy the blog are unable to pay for content, and that’s okay! Patrons can find all Patreon-specific content either on my Patreon page OR at the top of the blog, under Patreon Content. I really appreciate the support. 🙂
  • SOCIAL MEDIA: You can find my social media at the top, in the menu, on the far right, as well as at the bottom of the blog. If it does not appear for you, turn off your ad blocker (I am not running ads anyway :)). I’ve thrown my Instagram, Twitter, Twitch (yes, I stream video games sometimes), and Reddit (gulp) there.
  • WHAT ABOUT IT: I’ve ditched my About page since I have a fancy, floating sidebar with an About.

Post Changes

Evaluating Your Routine: Hydroxy Acids

Totally Normal Features of the Skin: Sebaceous Filaments

  • Updated with lots of fresh information on the origin of the term “sebaceous filament,” switched around the title, and updated the information on whether or not you should use pore strips (do they “stretch” the pore?!).

Things I’m Working On

  • Body Care. I’m trying some new products and routines out to find the best and most comfortable routines for the body. I’ll be working on a post about that, since we frequently discuss facial care but not body care.
  • Adapalene. I’m trying out Differin again, so we’ll see how that goes! I’ll be writing a post on Adapalene in the coming weeks, similar to the AzA post.
  • Acne. I ordered a textbook a couple weeks ago that gets referenced a lot on places like acne.org. It has taken several weeks to ship out to me, and I receive it in the next few weeks, so when I do, I’ll be digging into that.
  • Rosehip Oil. The next oil on my list to write about. I use it all of the time and people swear by it. Personally, it does really well by my skin, so I’m excited to write about it.
  • Reviews!
    • HadaLabo Premium Whitening
    • CeraVe Hydrating Body Wash
    • Some old The Ordinary products

 

 

 

 

 

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Skincare Ingredients: Azelaic Acid

by Kristen
Skincare Ingredients: Azelaic Acid

Azelaic acid (AzA) is a very unique ingredient. It is a natural component of the skin as it is a byproduct of malassezia furfur yeast, which lives on everyone’s skin. Not to be confused with hydroxy acids, it is a dicarboxylic acid that can be derived from grains such as barley, wheat, and rye, but is usually lab-engineered due to its stability.

First approved by the FDA in 2002, it comes in multiple prescription topicals, from 20% creams (Azelex) to 15% gels and foams (Finacea), as well as over-the-counter products that I will talk a bit about at the bottom of this post.

AzA is an anti-inflammatory and anti-bacterial, and is frequently used in acne and rosacea treatment, especially with sensitive skin types that are more prone to irritation from ingredients like benzoyl peroxide (BP) and tretinoin (Retin-A). In fact, in one twelve-week study, when 20% AzA was combined with glycolic acid, it showed as being just as efficacious in treating mild-to-moderate acne while offering “superior tolerability and patient approval.”

We conducted a 12-week, multicenter, randomized, double-masked, parallel-group study of the efficacy, safety, and tolerability of azelaic acid 20% cream and glycolic acid lotion compared with tretinoin 0.025% cream and a vehicle lotion to treat mild-to-moderate facial acne vulgaris. Patients treated with azelaic/glycolic acid experienced a significantly greater reduction in the number of papules, as well as a greater reduction in the number of inflammatory lesions, than those treated with tretinoin. Overall global improvement was approximately 25% in both groups. In the physician evaluations, treatment with azelaic/glycolic acid was found to cause significantly less dryness, scaling, and erythema than tretinoin. Patients also reported significantly less dryness, redness, and peeling with azelaic/glycolic acid. Significantly more patients in the azelaic/glycolic acid group than the tretinoin group reported that they felt attractive. (Abstract, source)

It has also shown 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), with less irritation than BP (though more than with 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)

Due to the bacteriostatic (ability to suppress bacteria from reproduction) is thought to be why it is also anti-inflammatory.

In rosaceans, it has been shown to be potentially as effective as metronidazole (Metro-Gel and Metro-Cream) in treating subtype 2 (Papulopustular Rosacea) in addition to being more tolerable. It also sits at a higher pH range (4.8-5 pH), closer to our skin’s natural pH of 5.5¹, which may be an additional contributing factor to it’s tolerance, though nothing is for certain.

In 2015, it was also been approved for use in a foam vehicle in treatment of mild to moderate rosacea, where it has been shown to be even better tolerated than the cream and gel versions.

It is also a proven suppressant in hyper-proliferation of keratin, which is a factor in conditions such as acne. A small study (45 patients) shows that it may help conditions like keratosis pilaris as well due to it’s ability to reduce inflammation by inhibiting “the reactive oxygen species of neutrophils” (a type of white blood cell), though not enough to be considered significantly better than simply moisturizing.

Results: Of the 45 patients that enrolled in the study, only 24 patients were present at 3 month follow-up. 92% of azelex-treated skin and 83% of [Cetaphil Moisturizing Cream]-treated skin showed improvement in hyperkeratosis and/or erythema after 3 months of therapy. … This small study demonstrates that both azalex and cetaphil is effective in treatment of keratosis pilaris, and that one is not significantly better than the other in reducing the degree of hyperkeratosis or erythema. (Source)

It may also have some benefits for sufferers of perioral dermatitis (or “steroid rosacea,” as it used to be called). A small study of 10 children aged 3-12 suffering from PD were evaluated and treated with 20% azelaic acid cream.

Treatment with 20% azelaic acid cream led to complete resolution of skin lesions after 4 to 8 (mean 5.4) weeks in all patients. Transient exacerbation of skin condition with a peak between the 2nd and 6th day of treatment could be observed in three patients. Side effects of 20% azelaic acid cream were registered in six patients and were predominantly present in the first 2 weeks of treatment. Side effects were minimal and became rarer with ongoing treatment. No recurrences were seen within a follow-up period of 2 to 8 (mean 4.4) months. Treatment with 20% azelaic acid cream could provide an effective and safe alternative therapeutic option in children with nongranulomatous periorificial dermatitis. (Abstract, Source)

It is also a tyrosinase inhibitor, with a special affinity for abnormal melanocytes, making it ideal in treatment of melasma or post-inflammatory hyperpigmentation (PIH). In fact, it is much safer and typically more preferred to hydroquinone, which is a skin lightener that tends to target all skin cells and has created concerns due to potentially causing tumors in mice.² In an open study comparing 20% AzA twice daily to 4% hydroquinone, it showed to be just as effective if not more effective than the hydroquinone in reducing mild melasma.

In conclusion, this study suggests that 20% azelaic acid cream applied twice daily may be more effective than hydroquinone 4% in reducing mild melasma. However, because this was an open trial, it is suggested that further studies involving large groups of

patients be conducted to achieve a more conclusive result. (Conclusion, Source)

In another study involving AzA (15%), waiting until after moisturizing to apply AzA resulted in greater penetration of the AzA. This did not occur with all moisturizers however, and was only seen in moisturizers that lacked large amounts of occlusives. It should also be noted that in a small study, gluconolactone (PHA) was shown to be helpful when combined with Azelaic Acid 15%.³

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 can feel very intense and aggravating to deal with, though icing my skin helped me push through the worst days. Your mileage may vary.

It takes about 24 weeks to work in cases of melasma and up to two months in acne cases.

One important note (mentioned by Dr. Dray in her wonderful video on AzA) is that it can lighten and “hide” some forms of melanoma, particularly lentigo maligna melanoma. This does not treat it or cure it, and can in fact hide the melanoma. Please get a skin check before self-treating abnormal dark spots with over-the-counter azelaic acid products.


Sources

  1. Disruption of the transmembrane pH gradient–a possible mechanism for the antibacterial action of azelaic acid in Propionibacterium acnes and Staphylococcus epidermidis
  2. Induction of Renal Cell Tumors in Rats and Mice, and Enhancement of Hepatocellular Tumor Development in Mice after Long‐term Hydroquinone Treatment
  3. A Guide to the Ingredients and Potential Benefits of Over-the-Counter Cleansers and Moisturizers for Rosacea Patients
  4. Dr Dray – Azelaic Acid
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Dehydrated Skin and How to Heal It

by Kristen
Dehydrated Skin and How to Heal It

Quick note before this post: you may have received a flurry of emails from the blog on Thursday evening. This happened when I was working on the new look for the blog, which unknown to me, began to email subscribers as well as push to my Twitter feed. I’m very, very sorry this happened. I did not expect nor want to blow up inboxes, but here we are. The good news is that the new look is done and shouldn’t cause anymore issue.

Dehydration is characterized by a lack of hydration in the cellular system and intercellular channels of the skin. It is not a skin type, but a skin condition. It does not discriminate between dry, oily, or combination skin types, and is frequently aggravated by lifestyle and skincare choices.

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The Epidermis

To understand skin dehydration, you need to first understand the role of the natural moisturizing factors (NMF) in skin hydration. The NMF is an invisible lipid composition that sits on the top layer of the stratum corneum (SC) as well as interwoven in the top most layers of corneocytes (skin cells), making up a part in what is considered the “acid mantle” of the skin. The term NMF first appeared in 1959, but was not universally adopted immediately. It is hydrosoluable (able to dissolve in water) and hygroscopic (able to retain water), composed of about 40% free amino acids, 12% pyrrolidone carboxylic acid (PCA), 12% lactates, 8.5% sugars/peptides/inorganic acids, 7% urea, 6% chloride, 5% sodium, and various small amounts of other materials.

It serves three major functions:

  1. Protecting skin from damage
  2. Encouraging desquamation (exfoliation of the upper most layer of corneocytes)
  3. Controlling permeability of the SC

The NMFs are very effective natural humectants, drawing moisture to the skin from the atmosphere, even at humidity as low as 50%. “Hydrated NMF forms ionic interacts with keratin fibers, reducing the intermolecular forces between the fibers and thus increasing the elasticity of the stratum corneum.”² This keeps the skin healthy and supple in appearance. It also serves to prevent excessive water influx (see the third major function above), such as when your skin wrinkles from being in the bath or shower for too long, which causes the corneocytes to shrink.

CAPD_xerosis

Xerosis

While it is often thought that the stratum corneum is “dead” tissue, it still requires water to function effectively. The NMF serves to provide for this, drawing and holding much of the water required. For example, enzymes that cause skin cells to exfoliate away naturally, by breaking the various bonds holding corneocytes together, need water to do their job effectively.

Reduction or stripping away of the NMF results in dry skin (known as xerosis), scaling, flaking, as well as fissuring and cracking (such as severely cracked and dry heels). It can also result in what we refer to as “dehydrated skin” (though this is not a medical term).


What Dehydration Feels Like

Dehydrated skin is one of the more difficult conditions to diagnose because it is frequently invisible. There are many “tips” online about how to diagnose dehydrated skin, such as pinching the back of your hand to see how quickly the skin snaps back into place. It’s important to keep in mind that this only serves to show if your body is dehydrated. Dehydrated skin usually has less to do about the hydration inside of your body and more to do with how we treat the skin topically or the atmosphere around us. This is why someone with dehydrated skin can pinch the back of their hand and see their skin immediately pop back into place, yet feel horrible irritation on their skin when applying a simple moisturizer.

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Crinkling upon tension

The skin usually looks dry, scaly, or flaky, and feels “tight” (such as after using a harsh cleanser). When pulled very gently, it can appear to crinkle (not to be confused with crepey skin, such as the skin appearance around joints), and can even look like it has a very thin layer of skin sitting atop the upper most layer of skin. It is usually most evident on the forehead or nose. It generally lacks “bounce” and suppleness. In some, it can take the form of crinkly but very shiny skin, usually due to abuse of skin remodelers like AHAs or BHAs.

Both dry and oily skin types can be dehydrated – dry skin because it struggles to hold onto moisture and oily because sufferers frequently use harsh cleansers or astringents to gain relief. According to Milady’s Skin Care and Cosmetic Ingredients Dictionary, “When oily skin becomes dehydrated, the surface layers of cells harden … and block oil secretion. The result is an entrapment of the oils under the stratum corneum layer. This is particularly detrimental in the case of someone with acne because it also results in the entrapment of the infection.”¹

Dehydrated skin also typically responds more viciously to active ingredients, such as BHAs, AHAs, sulfur, retinoids, and vitamin C. It can also respond to completely benign ingredients, creating a burning sensation or the skin feeling flushed and hot.


Causes of Dehydration

The most common culprits of dehydration of the skin is stripping cleansers, harsh soaps, and hot water, though a host of other causes can come into play.

Skin Conditions

  • Atopic dermatitis
  • Irritant contact dermatitis
  • Psoriasis
  • Cutaneous lymphoma

Environmental

  • Seasonal changes
  • Dry air (low humidity)
  • Flowing air (especially wind)
  • UV radiation (tanning beds, the sun)
  • Overwashing
  • Age
  • Sunburn
  • Cigarette smoking and smoke exposure
  • Friction

Heredity Disorders

  • Ichthyosis vulgaris
  • Netherton syndrome

Hormonal

  • Hypothyroidism
  • Estrogen deficiency

Topical

  • Alcohol/isopropyl alcohol/SD alcohol/denatured alcohol
  • Drinking alcohol
  • Essential oils
  • Clay masks
  • Sodium lauryl sulfate
  • Bar soap
  • Astringents (particularly alcohol-based astringents)
  • Topical medications (e.g. retinoids)
  • Excessive AHA or BHA use

Caring for Dehydrated Skin

The most important thing when solving dehydrated skin is consideration of the products you use as well as your environment. This means paying special attention to the ingredients label when shopping, being cautious about what is applied to the skin, and what your home environment is like (and potentially limiting outside exposure to harsh wind and sun).

Since everything starts with your cleanser, this means picking a creamier cleanser or one with lower amounts of surfactants. I’ve done a whole post on cleansers, which you can find here, if you’d like to read about all the various types of cleansers and how they work. The long and short of it is look for either a wipe-off cleansers, such as Albolene; an oil cleanser that emulsifies (rinses clean) in water, such as my beloved Clinique Take the Day off Balm; a creamy cleanser, such as CeraVe Hydrating Cleanser or Aquanil; or a gentle sudsing cleanser, such as Paula’s Choice Hydralight or CeraVe Foaming Cleanser. Avoid washing with hot water, which reduces the size of the micelles (the molecules created from surfactants, which cluster together), allowing them to penetrate deeper into the skin and strip it further. You’ll also want to completely avoid bar soaps (pH is too high) and harsh cleansers that make your skin feel tight after cleansing.

A general rule of thumb is to look for mild surfactants, such as decyl glucoside, or multiple surfactants, like decyl glucoside, coco-glucoside, disodium cocoyl glutamate, disodium laureth sulfosuccinate, cocoyl methyl glucamide, sodium cocoyl isethionate, and lauryl lactyl lactate.

Moisturizers are also a cornerstone in treating dehydrated skin. Humectants are especially important. Some humectants to look for:

  • Glycerin – A well-established humectant, it is a clear, thick liquid that is usually sticky on it’s own. It is derived from combining water and fat, usually vegetable oil. It is not typically irritating, but it can be to some people in high concentrations.
  • Hyaluronic Acid (HA) – A component of glycosaminoglycan, it occurs naturally in the dermis of the skin and is thought to play a very important role in skin function. It is advertised frequently as holding up to “1000” times it’s weight in water (citation needed). When applied, “hyaluronic acid forms a viscoelastic film in a manner similar to the way it holds water in the intercellular matrix of dermal connective tissue.”¹ It needs application regularly to be effective, frequently breaking down in skin 24-48 hours after application (note: this is not the case with HA injections). It is best applied to damp skin, straight out of the shower.
  • Urea – While it is frequently considered more of a moisturizer or keratolytic (able to break down bonds on dead skin) ingredient, urea has humectant properties and can attract and hold moisture in the SC.

Healing Dehydrated Skin

Armed with the proper ingredients, skin can typically bounce back within about two weeks (14 days). Once healed, skin should be maintained with ingredients and products that are beneficial to the skin’s health.

While healing dehydrated skin, it is recommended to use the most bland routine possible and avoid trying new things and any active ingredients at all. It should go without saying that to heal dehydrated skin, you must drop the products that are creating the problem in the first place. If you must change out one or two products that you believe were causing your dehydration, do so slowly and one at a time, starting with any cleansers and then moving on to moisturizers.

Petrolatum is helpful to some people as well, but can cause problems for others. This is possibly due to it’s ability to diffuse into the intercellular lipid domain of the skin in some people, which interferes with recovery. Your mileage may vary.

It is also recommended to sleep with a humidifier if you are in a particularly dry climate. You want to shoot for somewhere between 40-60% indoor humidity, as this will prevent the humectants from drawing moisture from the deeper layers of the skin, which evaporates away.


Product Recommendations

Cleansers

Creamy cleansers are ideal for dehydrated skin types, and I have talked fairly extensively about cleansers, with recommendations, in other posts.

For cleanser recommendations, I highly recommend checking out my post about recommended products for rosaceans (and hyper-sensitive skin types).

Hydrators

When it comes to hydrators, I honestly believe that good HA serums can have the biggest impact on dehydrated skin types, especially those that combine several molecular sizes of HA with skin-identifying emollients like squalane (not squalene) and ceramides or other humectants, like urea. Fortunately, the Japanese brand HadaLabo makes several products that meet this criteria and do so inexpensively and without fragrance. The Premium variety is my personal “holy grail” product that I will never be without. You can find Japanese HadaLabo products (listed as simply “HadaLabo” below) on Amazon or in a local Japanese market, while the HadaLabo Tokyo products are marketed for the US marketplace (though contain virtually identical ingredients most of the time) and can be found at drugstores and some Ulta locations.

HadaLabo Goku-jyun Moisturizing Lotion (Normal Skin)

Water, Butylene Glycol, Glycerin, Disodium Succinate, Hydrolyzed Hyaluronic Acid, Hydroxyethycellulose, Methylparaben, PPG-10 Methyl Glucose Ether, Sodium Acetylated Hyaluronate, Sodium Hyaluronate, Succinic Acid.

HadaLabo Goku-jyun Light Lotion (Oily Skin)

Water, Dipropylene Glycol Dimethyl Ether, Alcohol, Glycerin, Disodium Succinate, Hydrolyzed Hyaluronic Acid, Methylparaben, PPG-10 Methyl Glucose Ether, Sodium Acetylated Hyaluronate, Sodium Hyaluronate, Succinic Acid.

HadaLabo Goku-jyun Milk (Dry Skin)

Water, Glycerin, Hydrogenated Poly (C6-12 Olefin), Dipropylene Glycol, Caprylic/Capric Triglyceride, PPG-10 Methyl Glucose Ether, Behenyl Alcohol, Carbomer, Dimethicone, Disodium EDTA, Glyceryl Stearate, Hydrolyzed Hyaluronic Acid, Methylparaben, PEG-20 Sorbitan Isostearate, Phytosteryl/Octyldodecyl Lauroyl Glutamate, Propylparaben, Sodium Acetylated Hyaluronate, Sodium Hyaluronate, Stearyl Alcohol, Triethanolamine.

HadaLabo Goku-jyun Cream (All Skin Types)

Water, Glycerin, Diglycerin, Dipropylene Glycol, Squalane, Caprylic/Capric Triglyceride, Behenyl Alcohol, Carbomer, Dimethicone, Disodium EDTA, Glyceryl Stearate, Methylparaben, PEG-20 Sorbitan Isostearate, Phytosteryl/Octyldocecyl Lauroyl Glutamate, Propylparaben, Sodium Acetylated Hyaluronate, Sodium Hyaluronate, Stearyl Alcohol, Triethanolamine.

HadaLabo Goku-jyun Perfect Gel (All Skin Types)

Water, Butylene Glycol, Hydroxyethyl Urea, Pentylene Glycol, Glycerin, Squalane, PEG/PPG/Polybutylene Glycol-8/5/3 Glycerin, Triethylhexanoin, Ammonium Acryloyldimethyltaurate/VP Copolymer, Agar, Arginine, Dextrin, Dimethicone, Disodium EDTA, Disodium Succinate, Glucosyl Ceramide, Hydrolyzed Collagen, Hydrolyzed Hyaluronic Acid, Methylparaben, Phenoxyethanol, Propylparaben, Sodium Acetylated Hyaluronate, Sodium Hyaluronate, Succinic Acid, Triethyl Citrate.

HadaLabo Goku-jyun Premium Lotion (Dry Skin – My personal holy grail product)

Water, butylene glycol, glycerin, PPG-10 methyl glucose ether, hydroxyethyl urea, sodium acetylated hyaluronate (super hyaluronic acid), sodium hyaluronate, hydrolyzed hyaluronic acid (nano hyaluronic acid), hydroxypropyltrimonium hyaluronate (skin absorbent type hyaluronic acid), sodium hyaluronate crosspolymer (3D hyaluronic acid), aphanothece sacrum polysaccharide (sacrum), hydrogenated starch hydrolysate, glycosyl trehalose, diglycerin, sorbitol, pentylene glycol, triethyl citrate, carbomer, polyquaternium-51, PEG-32, PEG-75, ammonium acrylates crosspolymer, disodium EDTA, potassium hydroxide, diethoxyethyl succinate, disodium succinate, succinic acid, phenoxyethanol, methylparaben.

HadaLabo Tokyo Skin Plumping Gel Cream

water, hydroxyethyl urea, butylene glycol, glycerin, pentylene glycol, PEG/PPG/polybutylene glycol-8/5/3 glycerin, squalane, triethylhexanoin, ammonium acryloyldimethyltaurate/VP copolymer, agar, alpha-glucan, arginine, citric acid, dimethicone, dipropylene glycol, disodium EDTA, glucosyl ceramide, hydrolyzed collagen (marine), hydrolyzed hyaluronic acid, iodopropynyl butylcarbamate, methylisothiazolinone, sodium acetylated hyaluronate, sodium chloride, sodium citrate, sodium hyaluronate, triethyl citrate.


Sources

  1. Milady Skin Care and Cosmetic Ingredients Dictionary,  2014, M. Varinia Michalun
  2. Understanding the Role of Natural Moisturizing Factor in Skin Hydration
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A Guide to Visiting a Dermatologist

Up until my twenties, I saw the same dermatologist that burned off warts from the back of my hand when I was a child. He was the same dermatologist that saw my mom and even my dad, on the rare occasions that he would visit a doctor at all, but when I was 20, I was in need of a skin-punch biopsy for a diagnosis of a rare disease. My dermatologist was incredibly busy and couldn’t see me for weeks, which wasn’t ideal when I needed to be able to go the same day that I was having flare-ups, which were unpredictable. So I got a referral from my rheumatologist for a dermatologist he know that would be able to see me the same day, and I was taken immediately on a day I was having a flare-up.

Being as I had seen the same dermatologist my whole life and had generally pretty good skin most of my life, I stared at the documents I had been given to fill out while in the waiting room. I filled out everything, stating I was there for a punch biopsy, and lingered on the last page. At the bottom was the question, “What else would you like to discuss with the doctor today?” I lingered for awhile before finally writing, “the acne on my forehead.”

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Closed comedones

Like a large number of people, I had had closed comedones on my forehead since I had hit puberty. While they didn’t particularly trouble me enough to drive me into a dermatologist office before, I figured I might as well get the most out of my co-pay and my infrequent dermatologist visits (prior to this visit, I had seen my family dermatologist about a skin tag in my eyelashes at some point when I was 15-17, and eczema/atopic dermatitis when I was 13).

During the visit, I told the doctor about my forehead acne without much detail, and hoped she would know exactly what to do. She looked at me and said, “Yep! A retinoid will clear that right up! I’m gonna write you a prescription for Ziana. Just use this once a day, at night, after you wash your face! Sound good?”

And it did. Fast-forward and I was 6 months deep into a break-out that never ended, with spots that had heads the size of pencil erasers. I had become a hermit, ashamed of my skin, and barely able to sleep on my sides from the pain.

Everywhere I looked online told me it was “just purging,” and it would get better with time, but it never did. I even cried in public at an Ulta while on the phone with my boyfriend, lamenting that my face was ruined forever and there was no end in sight. Of course, like everyone going through an acne breakout, I assumed it was every skin product except the prescription I had been given by a doctor to make my acne better. After all, a doctor helps you, and I trusted the knowledge and nature of a doctor to have my best interest in mind. I believe I called the office once to ask what I should do, and they assured me it would get better in time.

Unfortunately, it turns out that by the time I started to figure out what was actually happening, it was all way too late. To this day, I have light pitted scarring in places from the 8 month moderate-to-severe zit explosion on my face that never ceased. It has taught me a lot and pressed me to learn a lot about how skin actually functions, and that I probably should not have used that tretinoin once a day, that I have very sensitive skin that still struggles to tolerate tretinoin, and that I should not have remained with a doctor who I began to trust less and less.

From this experience, I went on to many others with doctors who made me cry (one looked at my face and said when I woke up “looking like that,” I shouldn’t be using anything on my face because everything was breaking me out) and who I just couldn’t talk to before arriving on a doctor who was wonderful, specializing in people with auto-immune conditions and skin conditions.

Sadly, my experience doesn’t seem to be entirely an uncommon phenomenon, and most people don’t know how to talk to their doctor (dermatologist or otherwise). Being as I’ve seen every type of doctor – from cardiologist to rheumatologist to dermatologist – and on a semi-regular basis (I see a rheumatologist every three months for tests/check-ups), I figured I would help anyone else who is in the same shoes I was in my early 20s navigate the waters a bit.


When to See a Dermatologist the First Time

Many times on Reddit, I see people posting things like:

  • “What is this?”
  • “What does this look like to you?”
  • “What is on my mouth? HELP!”
  • “I don’t know what to do anymore”
  • “I’ve tried everything and nothing works”
  • “What should I try next?”

If you’ve hit the point where you feel like you are at the end of your rope, tried everything, or just can’t identify that weird rash, it is time to see a doctor. I know it is not always in people’s financial reach (particularly those of us in the US…), but there are many resources now for prescription strength topicals and a doctor’s care that don’t even require leaving the house or having insurance (particularly Curology).

If any of the following statements seem to identify with you, it is time to see a doctor:

  • Is your acne leaving indented scars?
  • Does it interfere with your day to day life on a regular basis (such as not wanting to leave the house or avoiding friends)?
  • Does it seem to be linked to your periods or hormonal shifts?
  • Did it onset very suddenly, without routine changes?
  • Is it spreading? Any skin condition that seems to spread, especially if it spreads rapidly, requires professional medical treatment.
  • Have you tried every fancy skincare product, every spot treatment, and dumped hundreds or thousands into skincare with no results?

Picking a Doctor

The worst doctor I ever saw was one my insurance picked out for me while the best was one I picked out for myself.

The first thing I suggest is asking your friends for recommendations. If you’re a redditor, you may be able to ask your local city subreddit for recommendations as well (though this can be tough if you are in a less populated city). Typically, your friends will be honest with you about why they went and their experience, which is what you want.

From there, search for the doctor online. Yelp can be a toss-up for quality of reviews – some people will give restaurants fewer stars for having to ask for extra napkins, for example. You also aren’t receiving the whole picture on why that person went to the doctor in the first place, what their history is, what their skin is like, or what their concerns are. Because of this, I trust Yelp a little less, but it can still be a good place to get a general idea of what people tend to go to this doctor for the most.

You can also search through their Vitals and HealthGrades pages. This is how I found the dermatologist I fell in love with. These pages tend to have better (albeit fewer) reviews and more information. Make sure you look for the doctor’s specialties, if they have any. Many doctors will specialize in one or two things, such as acne, rosacea, or melanoma. Try to find one that specializes what you’re interested in talking about.

Finally, don’t forget their own page. Some doctors will have their own Instagrams. This can be a good way to get an idea of what most people see them for, and what they prefer to talk about or specialize in. Keep in mind that doctors are just like anyone else, and will post the things they feel the most positively about.

Once you’ve combed through the exhaustive list of resources online, narrow it down to the doctor you feel the most sure about, and set up an appointment.


Your First Visit

Before your first visit, as things occur to you throughout the day, write down everything you’d like to discuss onto two sheets. Frequently, we forget everything we want to talk about or feel anxious about asking a “stupid question.” When the doctor asks, “Is there anything else?” I’ll admit that I’ve said, “Oh, no, that’s it!” when in reality, I have a burning question that I am just too ashamed to ask. When your doctor comes into the room, after introductions, hand them one of the sheets of questions, and let them know that you’d like to discuss what is on the list. This way, you have your list of questions in front of you in case you get anxious or forgetful, and they have your questions in front of them so you cannot dodge out of a question from shame last minute.

Make sure you include any relevant details you can think of. Habits, previous records (such as allergy records, GI records, etc. – bring your other doctor’s information in case your dermatologist’s office needs to request documents be faxed over), family history (cancer, autoimmune, skin conditions), and a thorough history of your medications and supplements. This means prescription drugs (topical and oral) as well as supplements like fish oil, turmeric, cranberry pills, lysine, etc. Include dosage, frequency, and what you’re taking them for. Write your current routine down and what hasn’t worked and why (couldn’t use this product because it was too drying or made my skin burn, for example).

Take pictures of your skin in a well-lit condition on its worst days. This can be a huge help to your doctor when determining what the correct diagnosis is. Also, this helps to establish a pattern, which is crucial. Note what you were using or what changes may have taken place around the time of the photos.

Before they leave, make sure you ask how to apply the prescription topicals they recommend or if you should take any oral medications that are prescribed with or without food (and if you can take it with fruit juices like grapefruit juice, which causes issues for some oral medications). If you forget, ask your pharmacist! They are specialists in drug usage and interaction, potentially even more so than your doctor, and are required by law to ask if you have any questions about the medication.

Remember that you are paying to be there and the doctor wants to help answer your questions. After all, they went through years of medical school to help people.

Bullet pointed list for ease:

  • Write down all concerns onto two sheets. One for your doctor and one for you.
  • Write down habits.
  • Gather any relevant previous medical records (especially for any endocrine disorders, allergies, PCOS, or other hormonal conditions). If you no longer have the records (ex. diagnosis at a young age), then just make sure you note it and about at what age you were diagnosed.
  • Gather any other doctor’s information (name and phone number) in case your dermatologist needs documents faxed to their office.
  • Gather your family history on both sides (usually most doctors are just looking for direct relatives, like parents and siblings). Autoimmune, cancer, skin conditions, etc.
  • Write down all oral medications, dosage, frequency, and why you’re taking them.
  • Write down all supplements, dosage, and frequency.
  • Write down current routine.
  • Write down what you have tried and what hasn’t worked as well as why (skin sensitizing, burning, dryness, etc.)
  • Ask them how to use the topicals they prescribe.
  • Ask them if you should take any oral prescriptions with food and if it is safe to take with fruit juices, if you consume fruit or fruit juices, particularly grapefruit.

One last tip is to not wear makeup! They need to see your bare skin. Wearing sunscreen and moisturizer is fine, but make sure they can see your skin clearly.


Following Up

Follow up with your doctor frequently and if you have any concerns. Make the follow-up appointments in the office, while you’re there, and put the appointment in your phone calendar so you don’t forget. Take a card so you have their current phone number in case you have any questions.

Don’t be afraid or ashamed to follow-up, either. Perhaps the worst part of any skin condition is the shame aspect that is frequently attached. Many people with skin conditions report avoiding interactions with people, and feeling an extremely low sense of self-esteem. This can impact not only how we see ourselves in the mirror, but our inclination to be an advocate for ourselves.

If you’re feeling at all like your skin (or maybe not even your skin – something else that has happened to you) has severely impacted your life and your self-esteem, consider talking to a therapist.

While not specifically acne-related, I went through abuse in my childhood and trauma in my teen years. This left me with CPTSD (complex post-traumatic stress disorder), panic disorders, generalized anxiety, and a propensity to tunnel down into the deepest, darkest holes of depression. I had always known that seeing a therapist (and psychiatrist) would be good for me, but I didn’t even go to my first visit until I was 26. I was petrified of opening up to a stranger, having them “analyze” me, feeling like a specimen or a spectacle, and isolated.

My first visit to my therapist was maybe a little awkward because of that. I talked openly about my life, but I didn’t really dig deep into the things I felt were troubling me the most. I continued like this for maybe six months, seeing my doctor every other Friday, talking about life and getting his perspective on things I was dealing with in my day-to-day.

But then one session, I brought up some of the feelings that had been bothering me all week, and it just started to flow out of me like a broken dam. It was life-changing. I walked out exhausted from the tears, but feeling brave, safe, and honestly, not at all as “crazy” as I once perceived myself to be. Finally having a diagnosis for the mental pain I was suffering was possibly one of the most re-assuring and comforting experiences of my entire life, and allowed me to step away from the pain and see it more objectively.

Therapy isn’t cheap, and I understand that better than anyone, but it shouldn’t be something you are afraid of. If you want to try talking to a therapist, but you aren’t able to afford office visits (check with your insurance – some insurance providers will reimburse you the cost with a receipt + a reimbursement claims form) or feel too nervous to sit down with a doctor outside of your own comfort zone, there is online therapy. One of the ones I see recommended the most is betterhelp (though I have never used it myself).

Please, do not be afraid. It can change your life and liberate you in ways you may not have even thought possible.

 

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A Small Update

by Kristen
A Small Update

Hi all!

As you might have noticed, there was no post today. I’ve been battling what has felt like a stomach bug on and off for about two weeks now and this weekend I was super exhausted and didn’t have the energy to write. I’m sorry about that. 🙁

I will also be out of town for the better part of next week on half work, half vacation. I will try to put some content in the pipeline for you guys during that time, but it may only be one or two posts.

Additionally, I will be picking winners for the Reader’s Survey by the end of the month. I’ve gotten great feedback from you all and I really appreciate you taking the time.

I’ve also swapped to written content for my Patreon, as you may have already noticed. It is not replacing my usual content or anything, so don’t fret, nor do I have plans to put existing content features behind a paywall. Instead, I will be trying to write very deep-dive content for my Patreon that is a companion or supplement to the content you see here. Last week, I started with the anatomy and physiology of the skin, specifically the two major glands of the skin (three, if you want to count the two types of sweat glands) as well as how each layer of the skin breaks down.

I’ve also updated my post on Kiku High Moist Skin Lotion with some additional information about licorice root extract, which I missed the first time, as well as some studies on sake that a wonderful Redditor on /r/AsianBeauty gave me. I’ll always do my best to keep old content updated and relevant as I learn new things, and to let you guys know what has changed.

Thank you for hanging around! I hope you have fun plans for the Fourth if you’re in the US. If you aren’t, I hope you have a beautiful week without too many bumps in the road.

  • Kristen, Skinologist
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