revolving doorI remember back in middle school when I started getting acne and asking my mom to take me to the dermatologist. I always felt better after seeing the dermatologist. He or she always wrote me a prescription for a medication which was supposed to clear me up. I tried oral antibiotics, topical antibiotics, retinoids, sulfur, and a few other prescriptions. Inevitably, they didn’t work, and I’d come back for another prescription, this time hoping that this one would actually clear me up. What all of these dermatologists failed to tell me is that most prescriptions only work to clear up acne to a degree.

As the researcher for Acne.org, I read hundreds of clinical trials and studies on acne each year. The latest article I just read was to test the “…efficacy and tolerability of tazarotene foam, 0.1%, in the treatment of acne…” Like most other articles on prescriptions for acne, the conclusion to this study sounds familiar: “Tazarotene foam, 0.1% significantly reduced the number and severity of acne lesions after 12 weeks and had a safe and acceptable tolerability profile.” That sounds great, doesn’t it? But when you read the article, you find that the decrease in acne lesions hovers around 50%. Sure, results are scientifically significant, but is someone with 20 zits on their face going to be happy with 10? That is still full fledged acne if you ask me. In my opinion, dermatologists should communicate clearly that most prescriptions will help improve the skin, but will not clear you up.

1 exception: Accutane (isotreinoin) completely clears acne in most people who take an adequate dosage for a long enough period of time, but comes with side effects, some of which can be long-term and some of which can be severe.

1 other exception: When used within The Acne.org Regimen, 2.5% benzoyl peroxide will also completely clear the skin, and does so without any severe or long-term side effects. It’s refreshing to be able to tell people what dermatologists were never able to confidently tell me. The Acne.org Regimen will clear you up. Completely.

References:

  • Feldman SR, Werner CP, Alio Saenz AB. “The efficacy and tolerability of tazarotene foam, 0.1%, in the treatment of acne vulgaris in 2 multi center, randomized, vehicle-controlled, double-blind studies.” Journal of Drugs in Dermatology. 2013; 12(4): 438-46.

LowDoseA typical full dose of Accutane (isotretinoin) is 40-50mg per day and the typical length of treatment is 15-20 weeks in order to achieve the recommended cumulative dose of 120mg/kg of bodyweight over the course of a cycle. However, as the years go on, researchers have been conducting more studies on low-dose Accutane (isotreinoin) to see if they can get the same results with less side effects. Generally speaking, the research is showing that even at a low dose of 20mg per day, people see good results, albeit not as impressive as when the full dose is used, and also with a higher incidence of relapse.

However, one recent study published in Advanced Biomedical Research is particularly interesting. In this study, they gave patients a low dose of 20mg per day but kept the patients on this low dose for quite a long time (10-22 months) in order to achieve the usual recommended cumulative dose of 120mg/kg of bodyweight. 96.4% of patients “demonstrated complete clearing of their acne, defined as no acne or occasional isolated lesions.” Relapse was low as well. “In a 5-year follow-up, relapse accrued in…7.9% of patients.” Side effects were, “…mild, and only 6 patients (out of 146) discontinued study medication because of severe adverse events.”

This is the first study where patients receive a low dose of isotretinoin, but are kept on this dose until the cumulative dose reaches the full 120mg/kg. Results from this study look impressive, and relapse rates are low. The authors admit, however, “The only pitfall is it is longer than 10 months duration of treatment period.”

Perhaps it is time to take a second look at how Accutane (isotretinoin) is administered.

References:

  • Rasi A, et al. “Efficacy of fixed daily 20mg of isotretinoin in moderate to severe scar prone acne.” Advanced Biomedical Research. 2014; 3: 103.

pdt-1-1Traditional at-home light therapy, which must be performed daily with tabletop red and/or blue light, produces very few side effects but also tends to produce disappointing results. However, dermatologists are now using light therapy on patients in their offices in a different way with better results but with more pronounced side effects. The procedure is called photodynamic therapy (PDT). The first step is what makes PDT different from at-home light therapy. A photosensitizing agent is applied to the skin. This primes the skin to react to the light that is applied. Next, red and/or blue light is shone on the skin for 15-20 minutes. Due to the power of photosensitizing agents, the reaction with the light creates more side effects and can include severe pain during the procedure and a full week of downtime afterward. The entire procedure is repeated 3-5 times at 2-4 week intervals, and is normally reserved for moderate to severe acne.

Results tend to be far better and longer lasting than light therapy alone when the procedure is done correctly. What is “correct” is up for debate, but science is pointing us more toward red light, which penetrates the skin more deeply. Other considerations are also important. Check out the new Photodynamic Therapy (PDT) page of acne.org for the full story on this new therapy.

sodium-l-ascorbyl-2-phosphateI read three studies recently on Sodium L-Ascorbyl-2-Phosphate (SAP), which is a topically applied vitamin C derivative. It is an antioxidant which is showing statistically significant acne clearing over time. It seems to clear the skin about as much as other topical prescriptions. This sounds impressive, but keep in mind that most topical prescriptions only clear the skin 40-50%. This is why The Regimen is so important because it completely clears the skin, which is what people really want. But I digress…

The three studies I read were in the International Journal of Cosmetic Science, Cosmetic Dermatology, and the Journal of Cosmetic Dermatology. They all used 5% SAP and show around 40-50% clearing of acne after 8-12 weeks with very few side effects. SAP has a good safety profile. Only a very small percentage of participants in the studies withdrew because of adverse effects even at a relatively high 5% titration.

Why might it work? Squalene is the most abundant fatty substance in the skin. Some scientists hypothesize that acne may be partly due to squalene oxidation. SAP is an antioxidant. Next, it may help reduce inflammation, which can not only help calm acne, but may also help prevent scarring to some degree and also help clear hyperpigmentation a bit faster.

I am always trying new ingredients in Acne.org products, and this is on my list to also try. I’ll let you know if and when it makes it into one of our products.

References:

  • Ikeno H, Ohmori K. “Open Study Comparing Sodium L-Ascorbyl-2-Phosphate 5% Lotion Versus Adapalene 0.1% Gel for Acne Vulgaris.” Cosmetic Dermatology. 2007; 20(6): 368-372.
  • Ruamrak C, Lourith N, Natakankitkul S. “Comparison of clinical efficacies of sodium ascorbyl phosphate, retinol and their combination in acne treatment.” International Journal of Cosmetic Science. 2009; 31: 41-46.
  • Woolery-Lloyd H, Baumann L, Ikeno H. “Sodium L-ascorbyl-2-phosphate 5% lotion for the treatment of acne vulgaris: a randomized, double-blind, controlled trial.” Journal of Cosmetic Dermatology. 2010; 9: 22-27.

il-1The question, “Is acne an autoimmune disease?” has always lingered in the back of my mind. An article in Swiss Medical Weekly recently looked into how an over-active immune response could be the culprit in chronic skin inflammation. Since we know that acne is largely an inflammatory disease, could this play a part? The authors state, “The skin is our largest organ, which is exposed to and protects the body from microbes, pathogens and several irritants. However, the skin can…be a site of excessive immune responses resulting in chronic inflammation, autoimmunity or autoinflammation.”

Our skin, like other organs of our body, is pretty amazing. It provides defense against a multitude of pathogens. However, in the case of acne, might it be overreacting to perceived pathogens and creating an unjustified inflammatory response in the form of excess oil and/or hyper-proliferation of skin cells? The key may be in researching inflammasomes that detect pathogens and the cytokines that these inflammasomes activate, specifically interleukin 1 (IL-1).

I have not come across much research on acne and autoimmunity, but if any of you come across some good hard science on this topic, please send it my way.

Also, have any of you gone on immune suppressing medications (i.e. Humira) and seen your acne symptoms change? I’d be curious to hear from you.

I noticed there is also a thread on the forum discussing this as well. Feel free to add your comments there as well.

References:

  • Contassot E, Beer HD, French LE. “Interleukin-1, inflammasomes, autoinflammation and the skin.” Swiss Medical Weekly. 2012; 142:w13590.

2.5% benzoyl peroxide Researchers at UCSF Medical School recently published a review article in the Journal of Dermatological Treatment which took a look at all available evidence on the dosing of benzoyl peroxide. They took a look at 8 studies in all. The authors concluded:

“There appears to be insufficient data…to document use of a higher concentration than 5% or even 2.5%.”

Regarding side effects, the authors note:

“There does appear a difference in the number of side effects according to the dose titration. The 2.5% formulations had a significant lower rate and lower severity of burning, erythema (redness) and peeling…”

They go on to further conclude:

“To increase compliance and thus the efficacy of the therapy, a lower titration of 2.5% should be preferred.”

Those of us who use benzoyl peroxide regularly have noticed this first hand. 2.5% works just as well or better than higher percentages because it does the same job as higher percentages without all the unnecessary irritation that can perpetuate acne cycle.

For best results, stick with 2.5%, and use it within The Regimen.

References:

  • Brandstetter AJ, Maibach HI. “Topical dose justification: benzoyl peroxide concentrations.” Journal of Dermatologic Treatment. 2013; 24(4): 275-7.

ADHDScientists recently took a look at 55,825 outpatient dermatologist visits from 1995-2009 and found that “In comparison to other dermatologic disorders, acne was over two times more likely to be associated with ADHD.” They controlled for age, sex, ADHD medications, and other mental disorders. A second look at 5240 patient visits showed similar results: “Our results…reveal a significantly high prevalence of ADHD in acne patients…”

These are retrospective studies, and even the authors themselves call their findings preliminary and say, “These findings need to be confirmed in clinical samples of acne patients.” However, if it turns out to be true, why might this be the case? Might both acne and ADHD be worsened by similar dietary factors? Perhaps it is the fidgeting of people with ADHD that causes increased irritation of the skin and thus acne.

Side note: Interestingly, eczema has also been associated with ADHD before.

References:

  • Gupta MA, Gupta AK and Vujcic B. “Increased frequency of Attention Deficit Hyperactivity Disorder(ADHD) in acne versus dermatologic controls: analysis of an epidemiological database from the US.” Journal of Dermatological Treatment. 2014; 25: 115-118.
  • Gupta MA, Gupta AK and Vujcic B. “Cormirbidity of acne with attention deficit hyperactivity disorder: Results from a nationally representative sample of 5240 patient visits for acne from 1995 to 2008.” Journal of the American Academy of Dermatology. 2012; 66(4): AB86.

Green Tea in Skincare

We use licochalcone, a Chinese licorice root extract, in Acne.org Moisturizer and Acne.org AHA+ (10% glycolic acid). This is what gives both products their characteristic yellow color. I chose licochalcone because it is powerfully calming to the skin and works especially well on irritated, acne-prone skin. It targets inflammation and has antioxidant properties and has proven its efficacy over the years that it has worked so well within the Acne.org line of products. However, it is extremely expensive ($6000 per kilogram), and some people don’t love the yellow color it imparts. Because it is such a specialized ingredient, we are also at the mercy of cyclical weather changes and potentially unreliable harvests in the few places where this particular species of licorice is grown.

For these reasons, I have kept my eye out for another comparable calming ingredient with research to back up its use on acne-prone skin. Green tea, or more particularly, the major polyphenol within green tea called EGCG, is one of the strong top contenders. I have been intrigued with green tea for several years now, but the more I look into it the more I’m liking what I’m seeing. Researchers performed two more studies within the last two years on EGCG and its effect on acne, both with promising results. The data is showing that EGCG not only produces anti-inflammatory effects, but may also help reduce skin oil (sebum) production.

Any change to Acne.org products takes lots of time to study, mock up, and ultimately implement, and I am still not 100% convinced that I can’t find anything even better than EGCG, but I’m intrigued to say the least.

References:

  • Im M, et al. “Epigallocatechin-3-gallate suppresses IGF-I-induced lipogenesis and cytokine expression in SZ95 sebocytes.” Journal of Investigative Dermatology. 2012; 132(12): 2700-8.
  • Yoon JY, et al. “Epigallocatechin-3-gallate improves acne in humans by modulating intracellular molecular targets and inhibiting P. acnes.” Journal of Investigative Dermatology. 2013; 133(2): 429-40.

…we still have no clue.

After scouring the research from the last several years regarding sebum (skin oil), acne bacteria, gene transcription, and a bunch of other super techie stuff, the answer to what causes acne is…um…we still have absolutely no idea. Most diseases are tricky things, and acne is no exception. Scientists are really only still scratching the surface when it comes to nailing down what actually happens that starts the acne ball rolling.

Let’s take acne bacteria for instance. Over the past few years, scientists have located more strains of P. Acnes, the bacteria present in human skin. We don’t know which strains might be harmful and which might actually be helpful. Furthermore, we don’t know which of the secretions of which of the bacteria strains cause problems and why. Additionally, we don’t know if it’s the secretions that cause a problem or if certain strains of bacteria interact with cells in some other way, such as interacting with cell RNA, toll-like receptors, or inflammation. And, um…if these bacteria do interact with skin cells in some way, we don’t know whether it’s dermal cells, oil cells, or immune/inflammatory cells.

The story is equally muddled when you look at the immune response of the skin, the inflammatory cascade, cell signaling, et cetera, et cetera.

Regardless, it’s not all bad news. Some directions of inquiry are starting to look more interesting than others. For instance, scientists are starting to frame acne as an inflammatory disease and are focusing in on how to mediate the body’s inflammatory response in the skin.

With time, we may be able to better specify what causes acne, which could theoretically lead to a cure. Rest assured that I’ll keep on top of the latest research. In the meantime, The Regimen should work well to keep acne under complete control, and in more severe cases, Accutane is an option as well.

The more I learn about antibiotic therapy for acne, the more wary and less enthused I become. Due to overuse and misuse over the past twenty years, antibiotic resistance has become widespread throughout the skin of the world population. This is evidenced by the increasing ineffectiveness of both oral and topical antibiotics in clinical studies. Antibiotics never worked very well for acne, and now they work even less well.

According to a “Global Alliance to Improve Outcomes in Acne” published in the Journal of the American Academy of Dermatology, antibiotics should be avoided as the sole treatment of acne. Researchers agree strongly that if antibiotic therapy is used, it should be combined with other therapies. When you look at the superior effectiveness of these other therapies the question arises as to why someone would want to include antibiotics at all. For example, when one takes into consideration the fact that benzoyl peroxide kills 99.9% of acne bacteria on its own and does not create resistant colonies of bacteria, one has to wonder why so many prescriptions for antibiotic acne therapy–over 11 million per year–are still written. According to an article published in the journal Expert Opinion on Pharmacotherapy, “…evidence demonstrates that [topical antibiotics] are no more effective against inflamed lesions than [benzoyl peroxide], and are less effective against non-inflamed lesions…To date, [benzoyl peroxide], as both mono- and combination therapy, is the most evidence-based approach.” Other acne treatments exist, and while they may not be as effective as benzoyl peroxide, they easily outpace antibiotics.

The misuse of antibiotics can also cause antibiotic resistance in other skin bacteria, especially the bacteria known to lead to impetigo and folliculitis. If all of this weren’t enough, when we look at how gene mutations work in bacteria, we see that genes which allow for resistance to antibiotics are easily transferred from acne bacteria to other bacteria in the skin, thus further promoting unwanted antibiotic resistance in other skin bacteria.

If your doctor has you on antibiotic therapy for acne and nothing else, it may be time to have a talk with her/him. The authors of the expert opinion review also note that topical antibiotics should be used for no longer than 3 months and oral antibiotics for no longer than 6 months. So, if you have been on antibiotic therapy for a long time, it may also be time for an appointment with your dermatologist. Since poor compliance with antibiotic regimens are one of the main causes of antibiotic resistance, just make sure you do not stop antibiotic therapy on your own without consulting with your physician first.