An article released this month in the British Journal of Dermatology took a look at the evidence scientists have boldly gathered from 1950 through 2010 regarding when and where acne bacteria tends to exist and in what amounts. The patterns they found are intriguing and seem to suggest that acne bacteria, known as P. Acnes, may not cause clogged pores.

Over the past 60 years, various researchers have taken biopsies of “normal” skin, acne prone skin, and inflamed and noninflamed acne lesions, and then counted the bacteria they found. It turns out that across the vast majority of the 14 studies of this nature, acne bacteria is not always present, even in active acne lesions. A small but compelling percentage of acne lesions are “sterile” and contain no bacteria whatsoever.

Faced with this kind of consistent evidence, the authors hypothesize that acne bacteria does not initiate acne. How could it, they seem to ask us to ponder, if it doesn’t exist in all acne lesions?

However, the authors go on to state that after a pore has become clogged, acne bacteria can make the situation worse through a number of means, including increasing the skin’s cell production, causing stickiness inside the pore, and kicking inflammation into higher gear, amongst others.

So what causes acne? Is it our body’s immune response? Inflammation? Genetics? Vitamin/Mineral deficiency? The search continues…but as we move forward, let’s keep this evidence regarding bacteria in mind.

Are any of you wondering why it seems like your moisturizer isn’t working as well as it used to? You’re not alone. Every year around this time people come to me complaining that their moisturizer just doesn’t seem to be as powerful as it used to be. “Aha!,” I’ve exclaimed, in the nicest way possible of course, “It is not your moisturizer! It’s just winter.” It’s true that people experience increased dry skin in the winter. But this year I decided to do a little more digging to find out exactly why. As it turns out, there is startlingly little scientifically sound explanation to be found, and myths abound.  As is often the case, it falls to us to sift through the nonsense and make some sense of this issue.

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First, let’s dispell the myths:

When weather gets cold, it gets dry. This is claimed so often and by so many “reputable sources” that I almost took it at face value myself. But when I decided to double check this pervasive claim, it completely fell apart. I looked at historical charts of humidity levels across the United States throughout the seasons.* It turns out that humidity levels show no particular trend from summer to winter. In fact, in many cities, even Northern cities, humidity levels are higher in the freeze of winter than in the bask of summer.

The winter is blustery and wind dries out the skin. Many of us can recall experiencing our share of cold, windy winter days, and could swear that we experience “windburn”, characterized by dryness, redness, and irritation after being outside on these blustery days. But a look at the evidence forces us to consider other possible causes. The only experiment I could find was performed all the way back to 1937, and was published in Popular Science. Scientists founds through using a wind tunnel that wind alone does not create “reddening or chapping” of the skin. Furthermore, upon browsing through historical wind speed charts, I found that that much like humidity levels, wind speeds show no yearly trend. There is no evidence of higher winds in the winter months. Regardless of all this evidence against the wind creating redness, dryness, and irritation, many sources not only talk about the existence of windburn, but will even explain why it occurs. The most widely used explanation is that wind removes surface lipids (oils) from the skin. Exactly how the wind performs this feat is conspicuously absent from all of these articles. Furthermore, if wind is just as strong in the summer, why don’t people seem to experience windburn as much in the summer? Another common explanation that attempts to explain windburn, which is the current explanation on Wikipedia, is that windburn is actually just sunburn caused by the wind removing surface lipids (oils) which help protect us from UV rays (another claim I am yet to find evidence to support). While the wind can remove some of these surface lipids year round, they say, the removal of the surface lipids in the winter coincides with a season when we do not protect our skin as valiantly from the sun. Thus the redness and irritation people experience is simply a sunburn. This explanation is incomplete at best, and completely misinformed at worst. Yet another explanation, albeit less frequently posited, claims that wind removes sweat, which normally helps filter UV rays. Again, how sweat helps filter UV rays is conspicuously absent.

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Whew. So, now that we have gone through the myths, the fact remains that many people experience dryer skin in the winter. Why? After looking at all of the available evidence, I have a hunch it can be attributed almost entirely to:

Artificial heat: Mother nature can heat up or cool down the great outdoors while keeping humidity levels steady, but when we heat indoor areas, this lowers humidity. When you look at the science of relative humidity (I won’t bore you), this is how it works. For an everyday example, notice how when you heat your bathroom while taking a shower there is less steam in the air. Since most of us live and work in artificially heated indoor environments in the winter, it’s likely we experience long-term exposure to lower humidity environments during the winter months. This dries out the skin, causing many of us to wonder why our moisturizer isn’t working as well as it used to. Back to my original point, “It’s not your moisturizer!” And introducing my new, improved answer, “You’re living in lower humidity indoor environments in the winter!”

And what about the cold? Strangely, none of the authors or reporters writing about winter and dry skin mention the effect cold air itself has on the skin. However, I have a hunch extreme temperatures may figure into a complete explanation of why some people experience dry skin in the winter. When we expose our skin to freezing temperatures, the skin reacts through natural protective methods, most prominently by withdrawing blood from the surface of the skin to protect core temperature. This is the first step which ultimately leads to the skin freezing which causes frost bite and cell death. My hunch is that perhaps even during shorter duration exposure to freezing temperatures which people sometimes experience on cold days, the skin still reacts through a more mild form of cell death. This mild cell death, while not as apparent as the blisters caused by frostbite, is evidenced by flakiness or dryness as the dead cells flake off. The redness experienced by many people after exposure to winter weather, while it would require further research for me to be more definitive, could be the result of cell death or simply the body returning blood to areas where it has been withdrawn.

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So, what can we do about it?

1.  Humidify your home/workplace. Install a humidifying system into your central heat. Alternately, if you use wood burning stoves or kerosene heaters, you can place pots of water on top and let the water evaporate, then repeat. You can always boil a large pot of  water on the stovetop as well, being careful to keep a close eye on it of course. There are commercially available electric stand-alone humidifiers as well. 60% humidity is a good general goal to shoot for. You can measure humidity with widely available humidity measuring devices which are available at most hardware stores, or you can be more relaxed about it and just notice how you–and your skin–feel. When the humidity reaches a comfortable level you will feel less dry and generally more comfortable. You should also notice less static electricity, less shocks, and less frizz to your hair. An easy way to tell if you’ve gone too far and over-humidified your space is if your windows start to pool water at their bases.

Perk: Adequately humidified air feels warmer than dry air at the same temperature. In other words, you can get away with heating to a lower temperature.

2.  Use more moisturizer: An extra pump or two of moisturizer each time you apply should help.

3.  Add jojoba oil: Since jojoba oil does not evaporate, 5-6 drops of jojoba oil added into your moisturizer each time you apply it will provide a boost of all-day moisture support.

*Yes, I know. There is more to the world than the United States, but…well, okay fine, I have no excuse. I’ll make a note to look outside the U.S. for my next research-related blog. :-)

keratinocytes: human skin cells

Thanks to modern medical science, we know that for some reason, acne follicles tend to overproduce cells, which in turn stick together and cause a clogged pore and ensuing zit. But why does this happen? Scientists have performed very few studies in an attempt to figure this out.

I just got through reading what was only the second study to ever attempt to scientifically understand what happens inside acne follicles vs. control follicles. Researchers from the University of Leeds in England performed the study back in 1994. Unfortunately, I think this control follicles were poorly selected. The researchers took biopsies of acne follicles from the upper back of patients who were an average age of 22. The control follicles were taken from the chest of people who were an average age of 41 during open heart surgery. In my opinion, the vast difference in age and location of biopsy between the acne follicles and control follicles largely discounts this study. Regardless, the researchers did make a couple of interesting points when discussing what might cause acne-prone skin to overproduce cells.

1) When sebum production increases, as it often does in acne-prone individuals, the sebum, as it leaves the follicle, takes with it too many of the cells lining the follicle wall. The follicle then reacts by overproducing cells to counteract this loss.

2) Linoleate (a.k.a. linoleic acid, an essential fatty acid) deficiency in sebum: Researchers have discovered that sebum in acne-prone skin contains less linoleate than normal. One hypothesis is that when sebum increases, linoleate content is diluted, and this decrease in linoleate signals overproduction of cells.

But in reality if you asked these researchers to tell you what cases acne, I think if they’d honestly reply, “well heck, who knows…”

The more you read about the potential cause of skin cell overproduction and clogged pore formation, the more complex it becomes. We have the hormone system to look at, sebum overproduction, the skin’s inflammatory response, systemic vitamin and mineral deficiency, bacteria over-proliferation, or a combination thereof…the possibilites are endless and the list goes on and on.

So, if and when science does finally figure it out, will we uncover a silver bullet? Or is the cause of acne a combination of factors? I’ll keep reading and let you know what I find. Please do the same if you can and let me know what you find out.

I recently came across an August, 2004 survey sponsored by Galderma Laboratories which presented some interesting findings regarding how parents view their son or daughter’s acne. It turns out their concern does not sometimes translate, and does not always reflect their teenager’s reality. Researchers surveyed 504 teenagers with acne along with 500 parents of teens with acne.

— 69% of parents claimed they were “supportive and understanding” about acne, but only 48% of the teens thought the same.

— 15% of parents said their teen experienced body image issues because of acne. 36% of the teens claimed they experienced body image issues.

— Only 1% of parents said acne caused problems with other family members. 18% of teens claimed problems, however.

— 9% of parents said their teens were “angry” as a result of acne. 25% of the teens said they were angry.

Do parents care? Yes, it appears that they really do, even more than we might think.

Do parents understand? While parents do seem to care, they may not understand the full ramifications of acne. From this survey, it appears that parents underestimate the negative emotional effects of acne. This could be because teenagers are not forthcoming with their feelings, or because our modern hectic lifestyles leave little time for engagement.

Bottom line: While the results of this survey point to a chasm in understanding, I’m walking away feeling good about the findings as a whole. The bottom line for me is that parents really do care about how their kids are feeling, even more than kids might know. Sure, they may not understand how much acne bothers you, but the care is there. If you are experiencing acne, or are on the Regimen now and clear but are still carrying around some anger toward your parents for not understanding your plight, just keep in mind that you may be misperceiving the situation. Give your parents some slack. They probably care more than you think…even if they may not understand as well as they could.

[I am not providing a link to the survey because the link appears to be broken. From what I can tell, this survey was published on a web site called losethezits.com but the page appears to be down.]

A February, 2010 article in the JDDG (Journal of the German Society of Dermatology) entitled “FoxO1 – the key for the pathogenesis and therapy of acne?” came across my desk recently. For those of you out there who are medical researchers or just into this stuff, if you want to look into this with me, it would be cool to see if we agree with the author’s hypothesis.

Basically, what the author, Bodo Melnik, proposes is that lowered levels of Fox01 (a nuclear transcription factor) leads to all of the processes we see in acne formation: the androgen/acne connection, cell wall overgrowth, increased sebum, higher levels of acne bacteria, and ensuing inflammation. He proposes that environmental factors which upregulate Fox01, such as diet, retinoids, and antibiotics, may all work to a degree because of this Fox01 stimulation.

We know that acne has a genetic component, so it’s worthwhile to look at gene expression when attempting to gauge what causes acne, and how it might be treated. If in fact Fox01 turns out to be a key factor in acne pathogenesis, perhaps Fox01 therapy could be around the corner. It’s interesting to think about. I hope to see more study in this area.

Recently I made the decision that acne just needs to be cured. So I started research in that vein, and I found that in 2001, scientists started work on an acne vaccine. More specifically, it is an anti-P.acnes bacteria vaccine. Since P. acnes is the bacteria implicated in acne formation and is a major culprit in acne development, if we can somehow turn off its genetic expression, the hope is that we can prevent or cure acne.

A brief history of the vaccine: A company called Corixa worked with a French company to decode the 2.8 milion base pairs that make up the P. acnes genome back in 2001. They then started working on identifying antigens in order to create a vaccine. Glaxo Smith Kline acquired Corixa in 2005. From there, mention of the vaccine seemed to fall off the map, until an article published in 2008 in the Journal of Investigative Dermatology surfaced. The article outlined research at the University of California San Diego in which scientists developed vaccines against P. acnes and successfully used the vaccine in both mice and in the lab using human sebum (skin oil) cells.

The trail seems to end there again. I’m in the process of contacting the researchers at UCSD to get more information. I find this area of work fascinating. I’ll keep you posted on anything I uncover. For now, let’s not get our hopes up too much however. Acne development is multi-faceted. While P. acnes plays a part, it is unknown how much it directly causes the other factors in acne development such as pores becoming clogged, oil overproduction, or inflammation.

Cool news you guys. I’ve been working with Daniel, our intern, as well as a statistician, and a well known doctor to put together a “prospective dietary trial” on milk and acne. What is a “prospective dietary trial”? Well, it means basically that we’re going to ask people on Acne.org to stop eating and drinking dairy and to fill out surveys and take pictures to document changes in their acne symptoms. If we get enough people to volunteer and follow through, it could be seminal research on the topic. Pretty darn cool.

Daniel, our intern, has been amazing with all of this–big shout out to him. He’s basically running the show. But all of us can be involved too! I’ve decided to be a candidate for the study, which will be hard because it will mean no pizza, but I’ll do it in the name of science! I’ll let you all know when this starts and when you can sign up.

Rosacea: It’s not acne vulgaris, but it’s similar. I’d like to make a nice rosacea page to outline what it is, how it’s different, and appropriate approaches to therapy.

Free radicals: Questions I’d like to answer: Free radicals are necessary for bodily maintenance, but how much is too much? When are anti-oxidants best utilized?

Scarring: I have not looked into the latest scar revision techniques for a couple of years. It’s time! I’ll update the scars pages accordingly.

B5
: Despite the severe paucity of research on this topic, it keeps coming up, so I’ll delve as deeply as I can and make a page about it.

Hormones
: In particular, you guys keep asking me questions regarding masturbation and acne. As is often the case, there is zero research on this exact topic, but looking more widely at hormones may shed some light. I’ll see if I can’t make a hypothesis or two regarding this sensitive topic.