Dr. Whitney Bowe shares her expertise on acne – how to treat it, how to prevent it, and whether popular social media posts offer a one size fits all solution.
As a dermatologist, I see the emotional and physical scars of acne in my office every day. This skin disease can be devastating in terms of self-esteem and confidence – its impact is very real. I have focused on acne for this very reason for many years in my practice and during my residency. Actually, as a dermatology resident, I studied the relationships between acne and emotions and published several papers on the topic.
Meanwhile, despite the fact that acne is the most common skin condition in the United States, its mental and emotional toll continues to be underappreciated.
However, there is now hope for recognition of this reality and a change due to a new study in the British Journal of Dermatology. Researchers from Canada used a very large United Kingdom database which tracked visits to primary care doctors. Remarkably, the sample size of acne patients involved 134,427 men and women (compared to 1.7 million controls without an acne diagnosis)! After an initial diagnosis of acne, the researchers looked for a subsequent diagnosis of major depressive disorder over the next 15 years. There was an increased risk of major depressive disorder within the first 5 years after an acne diagnosis, especially in the first year – 63% higher in patients with acne. The key word here is disorder; that is, levels of depression serious enough to interfere with daily functioning. Major depressive disorder is its own bona fide risk factor for many other diseases and is, of course, potentially life-threatening.
This study joins several other recent studies which have looked at acne patients over time — in 2016, researchers from New Zealand found that acne patients (in a study spanning 23 years) had a 45% increase in anxiety disorder risk. My acne patients are also much more likely to struggle with either anxiety or depression, as demonstrated in these studies.
Clearly, skin disorders are NOT just skin deep. In fact, the skin and the brain are intimately connected, and as dermatologists, we need to evaluate each patient in an integrative, comprehensive way if we truly want to determine the best course of treatment. I have been taking a comprehensive approach to my patients for years, asking about their stress levels, sleep patterns and coping mechanisms in addition to examining their skin, and this study only provides even more evidence supporting this approach. I want to bring this discussion to the forefront. It’s a reality that many people live with every single day and cannot and should not be ignored.
Antioxidants are absolutely essential when it comes to radiant, healthy skin. Let’s start with what antioxidants do: antioxidants pack a powerful punch to fight free radicals. Free radicals are like bullets or missiles, and they destroy everything in their path. They are highly reactive forms of oxygen whose effects can damage cell membranes and other structures in the body, including DNA and collagen. Free radicals come from both normal metabolic processes such as exercise and respiration, but they also come from external sources such as pollution and the sun. When you are exposed to a lot of free radicals, it means you are suffering from oxidative stress, and too much oxidative stress can lead to premature aging, skin cancer, and chronic skin conditions like acne. The take home message here: we do not like free radicals.
Enter antioxidants! Antioxidants help squelch and neutralize free radicals so they stop them from damaging your skin. Studies show that antioxidants not only slow down the development of wrinkles and age spots, but they also fight against skin cancer and even keep inflammatory skin conditions under control—conditions like acne, eczema, rosacea, and psoriasis. The take home message here: we love antioxidants!
When it comes to addressing skin conditions, antioxidants are key! For example, because antioxidants help control inflammation, if you’re prone to any skin issue rooted in inflammation- which can mean eczema, rosacea, or psoriasis – they will help relieve those stubborn conditions.
Antioxidants are also proving to be helpful in combating acne. New evidence suggests that free radicals and oxidative stress play a role in the initiation of acne. It is now documented that people with acne tend to have lower levels of cellular antioxidants and higher levels of markers of oxidative damage. We are learning that inflammation is actually one of the very first steps in the acne process. One theory is that free radical damage to skin’s natural oil, or sebum, appears to be a match that lights the inflammatory process. The process is called “lipid peroxidation,” or “sebum oxidation.” If we can stop this process from happening, could we possibly prevent acne from spinning out of control? Based on this exciting new knowledge, I recommend my acne-prone patients in particular make sure they are getting plenty of antioxidants.
And last but not least, numerous studies have demonstrated that antioxidants can slow down or even reverse signs of aging including fine lines, wrinkles, and brown spots. They do so primarily by protecting the skin from the ravages of sunburn, inflammation, and DNA damage.
So, it’s clear that antioxidants are important for your skin’s health. But, the question I get all the time in my office is – what’s the best way to get them? Should you use antioxidants topically through skincare products or orally through what you eat?
The answer is: BOTH.
Antioxidants are unstable, and they get used up very quickly, especially if you produce or are exposed to lots of free radicals. So it’s critical to replenish your antioxidant stores both internally and externally morning and night, and even more frequently if you engage in intense exercise, live in an urban center with lots of pollution in the air, or expose your skin to the sun.
For specific product recommendations, keep your eye on my Dr. Whitney’s Picks page and sign up for my VIP newsletter because I will be sharing much more on this topic with my VIPs!
QUESTION 1: What helps with acne scarring?
ANSWER: When it comes to acne scarring, there are many options that can smooth out those scars, but they usually work best when used as part of a personalized treatment plan. Topical retinoids are key to use at home, as they help to rebuild the collagen especially in atrophic scars (ones that appear depressed or have a shadow). If scars are raised (so called hypertrophic scars), then cortisone shots can make a huge difference. For ice pick scars, and many types of rolling scars, I usually combine lasers with microneedling and fillers. I use lasers like the Fraxel laser to resurface the skin. Microneedling is amazing for acne scars as well. I can combine microneedling with your own plasma (the so-called Vampire Facial), or I can combine microneedling with radiofrequency energy (the Endymed Intensif). Last, chemical peels can also help to slowly even out the tone and textural changes associated with acne sequelae. (more…)
Question 1: How do I get rid of cystic acne?
ANSWER: Cystic acne is usually a result of hormones, stress and diet. The cysts are deep, and often tender or even painful, and they tend to stick around for what feels like FOREVER! If you try to pop them, nothing comes out because they’re not connected to the surface. You usually end up making things worse. When the cysts resolve, they leave marks that can sometimes last for weeks or even months. Ok, enough doom and gloom. What can we do to treat or prevent cystic acne? Although the typical acne creams with retinoids and benzoyl peroxide can’t hurt, they don’t do much in cases of cystic acne. To treat cystic acne, it’s best to use a multimodal approach. First, diet and stress are key factors in this kind of acne. More on how to make some dietary and lifestyle changes that will help prevent cystic acne below. Second, many of my patients with cystic acne benefit from prescription hormonal medications such as birth control pills or a medication called spironolactone. If you’re going the birth control route, you should make sure your pill contains BOTH estrogen and progesterone. Progesterone only forms of contraception (the “mini pill,” implantable devices and even some IUDs can make cystic acne MUCH worse). Spironolactone has literally been a game changer in my practice. It’s a pill you take every day that blocks the effects of male hormones on the skin, and can dramatically clear up adult female acne. But I like to keep the doses low, and to do that, I need to make sure my patients are following the right diet and reducing their stress levels as much as possible. That’s one of the reasons I wrote The Beauty of Dirty Skin (link below). It’s easy to write a prescription, but diet and stress management is complicated! You can write chapters on those topics… so I did! Last, I like to tackle cystic acne using minimally invasive procedures in my office like cortisone injections, chemical peels and light based therapies.
Question 2: Is there anything other than Retin A, cortisone injections to treat? What preventative steps can be taken in terms of diet and lifestyle?
ANSWER: Cortisone injections can be amazing if you can get in to see a derm, but that’s easier said than done for most people! When it comes to diet, it’s essential to avoid skim milk, as this has been shown in a number of studies to trigger acne. But also beware of milk proteins that might sneak their way into your diet: whey and casein can play a major role in acne for some people, and they are commonly found in protein powders and “healthy” bars that are high in protein. High cortisol levels can also make cystic acne lesions explode all over your chin. It’s essential to start making lifestyle changes that drop those cortisol levels and keep them in a healthy range. One tip for doing that is incorporate regular exercise. Regular exercise reduces stress levels very effectively, and helps you sleep better (which in turn further reduces your stress hormone levels in your blood).
Question 3: Are regular treatments like peels or lasers something that should be considered to minimize future breakouts and/or reduce residual scarring?
ANSWER: Absolutely! My patients who can afford to get regular peels and light based therapies see a huge difference in their skin FAST. Salicylic acid chemical peels combined with Theraclear (also called Acleara) light treatments are incredibly effective and work FAST. In my practice, I use a number of lasers and devices to improve acne scarring and minimize pore size, including Fraxel, Endymed Intensif and Microneedling. However, these treatments can be costly and those costs can add up. Even without these therapies, if you use the right skincare products and make certain lifestyle changes (detailed in my book – The Beauty of Dirty Skin), you can achieve beautiful, radiant skin on any budget!
I wanted to share more insight into the food swaps for beautiful, clear skin that I discussed on GMA!
As I discussed on Good Morning America, a number of studies are now showing that if you drink dairy milk, you will be more likely to struggle with breakouts and acne. We believe this issue arises from a combination of hormones that are found in the milk as well as milk proteins like casein and whey. Skim milk has actually been found to show the STRONGEST link to acne flares.
SIMPLE SWAP #1:
Instead of SKIM MILK, choose ALMOND MILK OR COCONUT MILK. Both are low in calories and are delicious!
Whey Protein Dietary Supplemnents:
As I also mentioned on GMA, the vast majority of protein powders and nutritional bars are made with whey protein, which has also been shown to contribute to inflammation and acne in the skin. Many of my friends and even my family members drink shakes containing whey protein daily as part of their meal plan! However, many athletes who use whey powder in their shakes or eat protein bars made with whey are finding that they are breaking out on their faces, chests and back.
SIMPLE SWAP #2:
Instead of WHEY PROTEIN SUPPLEMENTS, opt for VEGAN OPTIONS. Many of the companies that make these dietary supplements now offer vegan alternatives which do not contain whey. Look for pea protein or rice protein!
If you are breaking out, you want to make sure to avoid refined carbohydrates like white bread, cornflakes, chips and pretzels.
SIMPLE SWAP #3:
Instead of REFINED CARBS, choose QUINOA, BARLEY or SWEET POTATOES. These choices are great for your skin and for your waistline!