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.
- Brandstetter AJ, Maibach HI. “Topical dose justification: benzoyl peroxide concentrations.” Journal of Dermatologic Treatment. 2013; 24(4): 275-7.
Acne rosacea is a different disease from acne vulgaris (run-of-the-mill acne). However, since symptoms often overlap, I like to keep on top of rosacea research as well. A few years ago I read a truly fascinating study which found that the guts of people with rosacea had a much higher incidence of bacteria colonization with a type of bacteria called H. pylori (helicobacter pylori), the same bacteria that is responsible for the majority of stomach ulcers. Of the people who had this bacteria, 20 of 28 of them appeared to be cured by using a powerful antibiotic to specifically kill the helicobacter pylori bacteria. I got so jazzed from the possibility that perhaps H. pylori could also affect acne vulgaris that I went to the doctor and had him order an H. pylori test for me. The test took hours and involved me blowing into a detector every few minutes. My results: Negative. I didn’t have any H. pylori in my gut.
Another study has since been conducted in Nepal. The researchers found that 17 out of 26 rosacea patients they studied had colonies of H. pylori in their gut.
This evidence is so compelling that rosacea researchers are starting to look at the possibility that rosacea is simply a skin manifestation of an internal disease of the gut.
Might another existing or still undiscovered gut bacteria cause or aggravate acne vulgaris? I would so love to know.
- Parodi A, et al. “Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its eradication.” Clinical Gastroenterology and Hepatology. 2008; 6(7): 759-64.
- Ghattarai S, et al. “The study of prevalence of helicobacter pylori in patients with acne rosacea.” Kathmandu University Medical Journal. 2012; 10(40): 49-52.
Scientists 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.
- 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.
Medical science is still not close to deciphering what causes acne, but it’s not for lack of trying. Here I will summarize 9 recent studies that I have read which attempt to get to the bottom of it. Keep in mind that we have no definitive conclusions, just ongoing research. Warning: Big words!
Oxidative stress. Scientists published an article in the Journal of Drugs in Dermatology considering the role of oxidation as something that “may be an early event that helps to drive the acne process.” Could it be skin oil (sebum) oxidizing that causes acne? Could antioxidants help?
Growth hormone and IGF-1 (Insulin-like growth factor 1). A study in Iran attempted to evaluate the power of growth hormone and IGF-1 to affect male hormones and thus increase the severity of acne. “The mean serum levels of GH and IGF-1 of severe acne patients were significantly increased when compared with mild-, moderate acne patients, and healthy controls.” A second Turkish study further evaluated the link between IGF-1 and acne. Again a significant link was found between IGF-1 levels and acne severity.
Staphylococcus aureus (S. aureus). You may have heard of this in regards to “staph infections.” In the journal North American Journal of Medical Sciences, researchers looked at the Staphylococcus aureus levels in acne patients vs. healthy controls. Results were inconclusive. “S. aureus was detected in 21.7% of the subjects in acne, and in 26.6% of control groups.”
Altitude. An article in the European Journal of Pediatrics looked at 6,200 boys. Interestingly, they found that “the acne frequency decreased with the increasing of the altitude where the boys lived.” Why this might be the case we don’t know.
Inflammation. Three articles looked at inflammation more closely. The first in the Journal of Drugs in Dermatology further elucidates the particular sequence of inflammation that leads to acne lesion formation. “An important facet of the new paradigm is that a specific follicular pattern of innate inflammation occurs before and during follicular hyperkeratinization. Moreover, this inflammation persists during the resolution of the macular phase after inflammatory lesions flatten toward the end of their life cycle.” A second article in the Journal of Drugs in Dermatology further states this point, “Newer research has shown that inflammation may precede comedo formation. Gene array analysis of acne lesions has elucidated newer inflammatory mediators…” A third study, again published in the Journal of Drugs in Dermatology drives home the point, “Recent evidence suggests that subclinical inflammation is the primary event in lesion development and that inflammation persists throughout the lesion life-cycle. Therefore, all types of acne should be considered ‘inflammatory’ acne.”
Genetics and Lifestyle. An study performed in Italy and published in the Journal of the American Academy of Dermatology looked at family history, personal habits, diet, and menstrual history. Their conclusion: “Family history, body mass index, and diet may influence the risk of moderate to severe acne. The influence of environmental and dietetic factors in acne should be further explored.”
Thanks scientists for all your work! Hopefully we will keep getting closer to figuring out what causes acne so we can get to the root of it and wipe it out for good!
- Bowe WP, Patel N, Logan AC. “Acne vulgaris: the role of oxidative stress and the potential therapeutic value of local and systemic antioxidants.” Journal of Drugs in Dermatology. 2012; 11(6): 742-6.
- Saleh BO. “Role of growth hormone and insulin-like growth factor-1 in hyperandrogenism and the severity of acne vulgarism in young males.” Saudi Medical Journal. 2012; 33(11): 1196-200.
- Tasli L, et al. “Insulin-like growth factor-1 gene polymorphism in acne vulgaris.” Journal of the European Academy of Dermatology and Venereology. 2013; 27(2): 254-7.
- Khorvash F, et al. “Staphylococcus aureus in Acne Pathogenesis: A Case-Control Study.” North American Journal of Medical Science. 2012; 4(11): 573-6.
- Robeva R, et al. “Acne vulgaris is associated with intensive pubertal development and altitude of residence–across-sectional population-based study on 6,200 boys.” European Journal of Pediatrics. 2013; 172(4): 465-71.
- No authors listed. “Decoding Acne: Genetic Markers, Molecules, and Propionibacterium Acnes.” Journal of Drugs in Dermatology. 2013; 12(6): s61-2.
- Weiss JS. “Messages from molecules: deciphering the code.” Journal of Drugs in Dermatology. 2013; 12(6): s70-2.
- Stein Gold LF. “What’s New in Acne and Inflammation?” Journal of Drugs in Dermatology. 2013; 12(6); s67-9.
- Di Landro A, et al. “Family history, body mass index, selected dietary factors, menstrual history, and risk of moderate to severe acne in adolescents and young adults.” Journal of the American Academy of Dermatology. 2012 67(6):1129-35.
We recently donated to the Songs for Hope benefit for the Leiomyosarcoma Direct Research Foundation. They work to help develop treatments for this rare and aggressive cancer. Great job everybody!
Happy to help. If you’d like to contribute, check them out here: lmsdr.org
Prevalence: Acne is prevalent in Asians. According to an article in Pediatric Dermatology, “Acne remains one of the most common dermatologic diagnoses in children of all races.” The authors of this article found that the most common reason that Caucasians visit the dermatologist is acne, while the most common reason that Asians visit the dermatologist is dermatitis (inflammation of the skin), with acne not far behind. Another study in the journal Acta Dermato-Venereologica looked at people of all ages in six cities around China and found not suprisingly that younger people experience more acne, and that males had more acne than females. However, they also found that prevalence of acne was lower in Asians than in Caucasians and far lower in Asian adults than Caucasian adults (1% vs. 13%).
Hyperpigmentation: The literature echoes what I have always said, which is that prevention is key when it comes to the dark/red spots that acne leaves behind. According to authors of an article in the Journal of the European Academy of Dermatology and Venereology, “The primary treatment of PIH (post-inflammatory hyperpigmentation) is prevention and treatment of the underlying inflammatory condition.” The Regimen is the best way to topically prevent acne and it works remarkably well in people of Asian heritage. The authors go on to note, “In addition to prevention, there are a variety of medication and procedures used to treat PIH. Although topical skin-depigmenting agents remain the treatment of choice for PIH, lasers and light sources may be an affective adjunctive therapy or alternative for treatment failures. When treating PIH, any treatment options selected should be optimized and utilized carefully because the treatments itself may worsen the PIH.”
Accutane: A 4-year retrospective study in The Journal of Dermatologic Treatment looked at how well Accutane (isotretinoin) worked for Asian skin. They concluded: “This study reaffirms the overall safety and efficacy of oral isotretinoin in Asian patients with acne vulgaris.” “Safety” is a relative term here since we know that Accutane can and will cause severe birth defects if taken when pregnant. If you are Asian and considering Accutane, do it only in close contact with a trusted physician.
- Eimpunth S, Waniphadeedecha R and Manuskiatti W. “A focused review on acne-induced and aesthetic procedure-related post inflammatory hyperpigmentation in Asians.” Journal of the European Academy of Dermatology and Venereology. 2013; 27(1): 7-18.
- Henderson MD, et al. “Skin-of-color epidemiology: a report of the most common skin conditions by race.” Pediatric Dermatology. 2012; 29(5): 584-9.
- Gan EY, et al. “Isotretinoin is safe and efficacious in Asians with acne vulgaris.” Journal of Dermatologic Treatment. 2012; 24(5): 387-91.
- Kundu RV and Patterson S. “Dermatologic conditions in skin of color: part 1. Special considerations for common skin disorders.” American Family Physician. 2013; 87(12): 850-6.
- Shen Y, et al. “Prevalence of Acne Vulgaris in Chinese Adolescents and Adults: a Community-based Study of 17.345 Subjects in Six Cities.” Acta Dermato-Venereologica. 2011; 92(1): 40-4.
Researchers published a very interesting study recently in The American Journal of Clinical Dermatology to gauge how accurate data from crowdsourcing is when it comes to the efficacy of acne treatments. The researchers asked 662 online acne patients to tell them how well their treatments were working and then compared this to results from clinical studies. I found a few interesting things.
Responses from the crowd seemed to vary quite widely with clinical studies. For instance, only 46% of respondents from the crowd reported any improvement from tretinoin (Retin-A) compared with 80% of subjects in clinical trials. 64% of the crowd reported improvement from Accutane (isotretinoin) compared with upwards of 90% of subjects in clinical trials. 41% of the crowd reported improvement from tetracycline oral antibiotic therapy compared with 57% of subjects in a clinical trial. 38% reported improvement from doxycycline oral antibiotic compared with 50% of subjects in a clinical trial.
You may be noticing a trend here. As the authors of this particular study note, “For most…treatments, medication with high efficacy in clinical trials did not produce high effectiveness ratings based on the crowdsourced online data.” Why might this be? Could it be due to the inaccuracy in respondent responses outside the parameters of a clinical setting? Or could it be because the people funding the vast majority of clinical trials are the companies who make the products? Lest I get too high on my high horse, I do not think it is always the case that data is skewed in favor of corporations and profits. For instance, over the past 20 years, hundreds of thousands of pieces of input from people here at Acne.org show Accutane (isotretinoin) producing improvement for way more than 64% of people.
Something I very often find disturbing from results of acne medications, whether the data comes from the crowd or clinical trials, is the poor efficacy of the medications themselves. Who wants to use a medication which only helps 50% of people improve, and only improve somewhat? This is why I want the world to know about The Regimen here at Acne.org. It reliably gets almost everyone completely clear. That’s the kind of results people want.
So where do we go from here? I firmly believe that the future of pretty much everything is in crowdsourcing, and medicine is no exception. We know from Wikipedia that when enough people get together to share their knowledge, crowdsourcing can be incredibly accurate and valuable. I think the same can be true for medical information as long as we achieve a critical mass of people inputting their data. That’s one of the big goals of Acne.org and I hope we see more of this in the future across the medical spectrum. Join Acne.org if you haven’t already and add your voice!
- Armstrong A, et al. “Harnessing the power of crowds: crowdsourcing as a novel research method for evaluation of acne treatments.” The American Journal of Clinical Dermatology. 2012; 13(6): 405-16.
Probiotics are bacteria which inhabit the intestines and help maintain a healthy balance. They are known to interact with bodily tissue which comprise the immune system. Probiotics could also be helpful in lessening systemic inflammation. We also know that people with acne tend to have more constipation, and, excuse the frankness, their poop has less healthy bacteria in it. So it’s intriguing to think that maybe probiotics could help.
At least two studies have been performed so far regarding probiotics and acne. The first found a significant decrease in total acne lesions when people were taking probiotics alongside minocycline vs. taking minocycline or probiotics alone. This is marginally interesting, but not groundbreaking. The second study had people applying probiotics topically to the skin and those applying 5% topical solution exhibited “an effective reduction in acne lesion size and (redness).” Again, this is somewhat interesting, but not earth shattering.
Lastly, since doctors continue to prescribe antibiotics for acne, even though I can see absolutely no reason why they continue to do this, these patients may benefit from probiotic supplementation post-treatment to get their gut back in check.
My bottom line with what we know so far is that probiotics probably can’t hurt and may help somewhat.
- Bowe WP, Patel NB, Logan AC. “Acne vulgaris, probiotics and the gut-brain-skin axis: from anecdote to translational medicine.” Beneficial Microbes. 2013; 25: 1-15.
- Jung GW, et al. “Prospective, randomized, open-label trial comparing the safety, efficacy, and tolerability of an acne treatment regimen with and without a probiotic supplement and minocycline in subjects with mild to moderate acne.” Journal of Cutaneous Medicine and Surgery. 2013; 17(2): 114-22.
- Muizzuddin N, et al. “Physiological effect of a probiotic on skin.” Journal of Cosmetic Science. 2012; 63(3): 385-95.
I remember when I first got acne. I tried to scrub it away by using a washcloth several times a day and rubbing as hard as I could. This resulted in what were probably hundreds of tiny pimples, on my forehead and hairline especially. It didn’t take me long to realize that harsh scrubbing was getting me nowhere.
I have never seen a scientific study specifically attempting to gauge how physical irritation of the skin can cause acne, however. It’s abundantly clear that it does, both from my own personal experience, and the experience of hundreds of thousands of us on acne.org. If you’re not convinced, just wear a face mask for a sport and you will see how hard it is to keep this area clear.
In a recent article published in the journal Dermatology, authors observe three female patients who presented with severe inflammatory acne “due to the association of two factors: facial friction with cosmetic agents.” These young women were rubbing their faces in a “compulsory manner” with their cosmetics.
The authors conclude: “Because cosmetic face friction as a cosmetic care becomes more and more fashionable, dermatologists should be aware of this severe clinical condition, which can occur in patients without a person history of acne.”
Hey, at least this is something. It would be cool to see some sort of controlled clinical trial performed on the effects of physical irritation alone on the severity of acne in the future. In the meantime, if you want to clear up your skin, stay gentle!
- Seneschal J, et al. “Exogenous inflammatory acne due to combined application of cosmetic and facial rubbing.” Dermatology. 2012; 224(3): 221-3.
A recent article in the journal Alternative and Complementary Therapies discusses herbal sunscreens and sun protectants. Of specific interest is an herb called golden serpent fern (Phlebodium aureum). Several studies have been performed, and an extract from the plant, when taken orally, appears to help protect the skin from damage. In one particularly intriguing clinical trial, people were able to stay in the sun almost 3 times as long with golden serpent fern than without. According to the authors of the article, “The data on golden serpent fern extracts look very promising for counteracting negative effects of UV exposure in healthy people wishing to avoid sunburn…”
I think it would be great to have something oral that could help protect against the sun. This would limit the amount of stuff people need to put on their skin, thus eliminating potential breakouts. The only problems is I cannot find a single place anywhere online to buy golden serpent fern.
1) Have any of you tried golden serpent fern? If so, did it work?
2) Any ideas on where I can get my hands on some?
- Yarnell E and Abascal K. “Herbal Sunscreens and Ultraviolet Protectants.” Alternative and Complementary Therapies. 2012; 18(3): 141-144.