EPSON DSC pictureResearchers 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!

References:

  • 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.

featherlight touch
Lots of people will try a new skin care product and be sure it broke them out. They assume it is something in the product itself–a bad ingredients of some kind. However, people often miss a stealthy cause of breakouts: irritation.

Let’s say you are sensitive to acne on the back of your neck. You don’t normally use a sunscreen there but now that it’s getting sunny you started applying some sunscreen there each morning for the past week. Boom, you broke out. You are certain it is the sunscreen. What else could it be!? Well, it could be the irritation when you applied it. Your neck has been accustomed to being left alone. And acne-prone skin loves being left alone. Then whamo, for the past week you have been slathering on sunscreen and not being gentle at all. What you don’t realize is that you have been irritating your skin on a daily basis.

The moral of the story: Consider irritation as a potential cause of breakouts, not just products themselves. And always apply any product with a featherlight touch.

Now go have some fun in the sun :)

For those of you who have tried The ZIIT Method, you know it works as long as you catch the zit early in its lifecycle. But why does it work? Is it the Zinc, Ibuprofen, Ice, or Treatment that is doing the most?

In order of ability to stop a zit in its tracks I would rank them like this:

1. [Tied for first place] Ice and Treatment (2.5% benzoyl peroxide followed by 10% glycolic acid)
2. Ibuprofen (or other NSAID)
3. Zinc

We know that early application of 2.5% benzoyl peroxide and 10% glycolic acid will usually stop a pimple from forming. However, ice is often overlooked for its anti-inflammatory prowess. Try and and you’ll see. Next time you feel a zit forming, even if it seems like it’s going to be a big painful one, try The ZIIT Method, and don’t forget the ice component.

A tip for how to apply ice:

Put a piece of ice in a ziploc bag:ice_ziit

Get yourself an eye patch from your local drugstore. They are cheap. I got this one for about $2.49.photo-74

Then hold it on the pimple for 5 minutes. photo-73

Do this twice a day along with the rest of The ZIIT Method and you will be surprised how much power you have over a menacing zit–as long as you catch it early.

20101212_200110_LactobacillusAcidophilus

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.

References:

  • 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.

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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!

References:

  • Seneschal J, et al. “Exogenous inflammatory acne due to combined application of cosmetic and facial rubbing.” Dermatology. 2012; 224(3): 221-3.

acne scarsI recently finished pouring through the last 2 years of acne scar research and have updated the scars page. It’s an evolving field. Here’s what I found:

Lasers are becoming more and more the go-to treatment for acne scarring. Fractional lasers, which treat only a fraction of the skin at once, are also becoming more popular for their ability to reduce side effects while still producing results.

Scientists are incorporating radiofrequency devices along with lasers and data is promising, while not earthshattering, that radiofrequency could help a bit.

Scar revision specialists have treated scars with fat injections for years with lots of success. However, recently, they are trying what they call autologous fibroblasts, which are cultured connective tissue cells from the person’s own body. This is also showing lots of promise.

Despite the advances, a person embarking on scar revision should not expect miracles, but should instead expect improvement. As always, data is showing that a combination of treatments (i.e. laser combined with subcision and augmentation) produces the best outcomes especially in more severe scarring. According to an article in the journal Dermatologic Surgery, “Severe grades of scarring often require a combination of filling agents for volume deficit, injectable agents for hypertrophic disease, neurotoxins to effect movement, and fractionated and ablative resurfacing for surface changes.”

Lastly, there appears to be vast confusion amongst dermatologists in the classification of acne scars. This highlights the need to carefully select a scar revision expert who is dedicated to and experienced in this specific area of surgery. If you decide to embark upon acne scar revision, do your homework and make sure you go with someone who specializes in acne scars.

Helpful links:
Acne.org Scar Forum: join in the discussion
Acne.org Scar Gallery: share your pictures

References:

  • Leheta TM, Abdel Hay RM, El Garem YF. “Deep peeling using phenol versus percutaneous collagen induction combined with trichloroacetic acid 20% in atrophic post-acne scars; a randomized controlled trial.” The Journal of Dermatologic Treatment. 2014; 25(2): 130-6.
  • Nirmal B, et al. “Efficacy and safety of Erbium-doped Yttrium Aluminium Garnet fractional resurfacing laser for treatment of facial acne scars.” Indian Journal of Dermatology. 2013; 79(2): 193-8.
  • Al-Dhalimi MA, Arnoos AA. “Subcision for treatment of rolling acne scars in Iraqi patients: a clinical study.” Journal of Cosmetic Dermatology. 2012; 11(2): 144-50.
  • Manuskiatti W, et al. “Comparison of fractional erbium-doped yttrium aluminum garnet and carbon dioxide lasers in resurfacing of atrophic acne scars in Asians.” Dermatologic Surgery. 2013; 39(1 Pt 1): 111-20.
  • Sardana K, et al. “Histological validity and clinical evidence for use of fractional lasers for acne scars.” Journal of Cutaneous and Aesthetic Surgery. 2012; 5(2): 75-90.
  • Bencini PL, et al. “Nonablative fractional photothermolysis for acne scars: clinical and in vivo microscopic documentation of treatment efficacy.” Dermatologic Therapy. 2012; 25(5): 463-7.
  • Maluki AH, Mohammad FH. “Treatment of atrophic facial scars of acne vulgaris by Q-Switched Nd:YAG (Neodymium: Yttrium-Aluminum-Garnet) laser 1064 nm wavelength.” Journal of Cosmetic and Laser Therapy. 2012; 14(5): 224-33.
  • Hedelund L, et al. “Fractional CO2 laser resurfacing for atrophic acne scars: a randomized controlled trial with blinded response evaluation.” Lasers in Surgery and Medicine. 2012; 44(6): 447-52.
  • Qian H, et al. “Treatment of acne scarring with fractional CO2 laser.” Journal of Cosmetic and Laser Therapy. 2012; 14(4): 162-5.
  • Huang L. “A new modality for fractional CO2 laser resurfacing for acne scars in Asians.” Lasers in Medical Science. 2013; 28(2): 627-32.
  • Kimura U, et al. “Biophysical evaluation of fractional laser skin resurfacing with an Er: YSGG laser device in Japanese skin.” The Journal of Drugs in Dermatology. 2012; 11(5): 637-42.
  • Cho SI, et al. “Evaluation of the clnical efficacy of fractional radiofrequency microneedle treatment in acne scars and large facial pores.” Dermatologic Surgery. 2012; 38(7 Pt 1): 1017-24.
  • Ong MW, Bashir SJ. “Fractional laser resurfacing for acne scars: a review.” British Journal of Dermatology. 2012; 166(6): 1160-9.
  • Wada T, et al. “Efficacy and safety of a low-energy double-pass 1450-nm diode laser for the treatment of acne scars.” Photomedicine and Laser Surgery. 2012: 30(2): 107-11.
  • Azzam OA, et al. “Fractional CO(2) laser treatment vs autologous fat transfer in the treatment of acne scars: a comparative study.” The Journal of Drugs in Dermatology. 2013; 12(1): e7-e13.
  • Lorenc ZP. “Techniques for the optimization of facial and non-facial volumization with injectable poly-l-lactic acid.” Aesthetic Plastic Surgery. 2012; 36(5): 1222-9.
  • Halachmi S, Amitai DB, Lapidoth M. “Treatment of acne scars with hyaluronic Acid: an improved approach.” The Journal of Drugs in Dermatology. 2013; 12(7): 3121-3.
  • Goodman GJ. “Treating scars: addressing surface, volume, and movement to expedite optimal results. Part 2: more-severe grades of scarring.” Dermatologic Surgery. 2012; 38(8): 1310-21.
  • Tenna S, et al. “Combined use of fractional CO2 laser and radiofrequency waves to treat acne scars: a pilot study on 15 patients.” Journal of Cosmetic and Laser Therapy. 2012; 14(4): 166-71.
  • Zhang Z, et al. “Comparison of a fractional microplasma radio frequency technology and carbon dioxide fractional laser for the treatment of atrophic acne scars: a randomized split-face clinical study.” Dermatologic Surgery. 2013; 39(4): 559-66.
  • Leheta TM, et al. “Do combined alternating sessions of 1540 nm nonablative fractional laser and percutaneous collagen induction with trichloroacetic acid 20% show better results than each individual modality in the treatment of atrophic acne scars? A randomized controlled trial.” The Journal of Dermatologic Treatment. 2014; 25(2): 137-41.
  • Lee SJ, et al. “Ablative non-fractional lasers for atrophic facial acne scars: a new modality of erbium:YAG laser resurfacing in Asians.” Lasers in Medical Science. 2014; 29(2): 615-9.
  • Shah S, Alam M. “Laser resurfacing pearls.” Seminars in Plastic Surgery. 2012; 26(3): 131-6.
  • Preissig J, Hamilton K, Markus R. “Current Laser Resurfacing Technologies: A Review that Delves Beneath the Surface.” Seminars in Plastic Surgery. 2012; 26(3): 109-16.
  • Mohammed G. “Randomized clinical trial of CO2 laser pinpoint irradiation technique with/without needling for ice pick acne scars.” Journal of Cosmetic and Laser Therapy. 2013; 15(3): 177-82.
  • Finlay AT, et al. “Classification of acne scars is difficult even for acne experts.” Journal of the European Academy of Dermatology and Venereology. 2013; 27(3): 391-93.
  • Kwok T, Rao J. “Laser management of acne scarring.” Skin Therapy Letter. 2012; 17(2): 4-6.
  • Sobanko JF, Alster TS. “Management of acne scarring, part I: a comparative review of laser surgical approaches.” American Journal of Clinical Dermatology. 2012; 13(5): 319-30.
  • Levy LL, Zeichner JA. “Management of acne scarring, part II: a comparative review of non-laser-based, nominally invasive approaches.” American Journal of Clinical Dermatology. 2012; 13(5): 331-40.
  • Munavalli GS, et al. “Successful treatment of depressed, distensible acne scars using autologous fibroblasts: a multi-site, prospective, double blind, placebo-controlled clinical trial.” Dermatologic Surgery. 2013; 39(8): 1226-36.

(more…)

golden serpent fernA 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.

Two questions:

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?

References:

  • Yarnell E and Abascal K. “Herbal Sunscreens and Ultraviolet Protectants.” Alternative and Complementary Therapies. 2012; 18(3): 141-144.

aczoneA smattering of members of acne.org have tried Dapsone, a prescription anti-inflammatory medication which is best known as an oral medication for treating leprosy but is also prescribed topically in 5% concentration by the brand name Aczone. When taken orally, Dapsone comes with a host of worrying side effects, but when administered topically for acne, patients tend to suffer very few side effects. That is all well and good, but from the research that is coming in, it doesn’t seem to work very well, at least in the short term. Two studies have been performed recently on topical Dapsone. The first was a 12 week study which reported a 39% reduction in inflammatory acne. This is obviously not ultra-impressive, but when you consider that the placebo group experienced a 32% reduction, it becomes even less earth shattering. The second study was also a 12 week study which reported a 49% reduction in women and a 34% reduction in men. This is somewhat better news for women but the medication was still unable to even cut acne symptoms in half.

Longer term therapy: I spoke to a dermatologist a few years back who likes to prescribe Dapsone to her patients and claims that results only come after about the 3 month (12 week) mark. Therefore, I would like to see a study performed for a longer period of time.

Combination therapy: While Dapsone alone may not provide for sufficient clearing of acne, it may be prescribed alongside other drugs such as benzoyl peroxide or topical retinoids.

Have any of you guys taken Dapsone for longer than 3 months? How did it go?

References:

  • Tan J. “Dapsone 5% Gel – A New Option in Topical Therapy for Acne.” Skin Therapy Letter. 2012; 17(8): 1-3.

I wanted to let you guys know where I’m headed with The Regimen and getting it out to the world and hear any feedback you have.

Sobering reality #1: Not enough people know about The Regimen. Yes, there are tons of people on Acne.org, and yes, probably at least a million people have tried it…probably quite a bit more, since I started sharing it in 1996. However, there are 300 million people in the US alone, and 7 billion around the world. So we’ve reached only a tiny fraction of people. This I think is a shame since The Regimen actually works when most other stuff doesn’t.

Sobering reality #2: Most people don’t want to have to learn a bunch of stuff just to do a facial regimen. While anyone who has tried The Regimen knows it works incredibly well and is actually very simple, I think it comes across as too complex when people first encounter it. I am going to try to simplify it. For example, while I do think waiting for your skin to completely dry after cleansing is the best way to go, if you don’t wait the 5-15 minutes, I think The Regimen will still work for you. So I’m going to remove the “5-15 minutes” language from this part of The Regimen. Instead, I’ll just be instructing people to cleanse, wait for their skin to dry, and move right on to Step 2: benzoyl peroxide. I will also be looking at how else I can simplify The Regimen.

Sobering reality #3: Acne.org products are superior to drugstore products. When I started sharing The Regimen, I didn’t make products for it. For the first 8 years of Acne.org I instructed people to use recommended drugstore products. Yes, it is possible to use drugstore products and get clear but it is not nearly as easy. We get people writing to our customer service saying they want to return a product because The Regimen is “not working” for them. Almost every time, these people who want to return a product are not using all 3 Acne.org products on The Regimen. They are using other over-the-counter cleansers, moisturizers, or cream based benzoyl peroxide that just doesn’t work as well as Acne.org products or have comedogenic ingredients. Once we get any of these people using all Acne.org products, they invariably clear up. I can’t help but think our “open-source” Regimen ends up hurting people instead of helping sometimes.
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Where I want to go from here: Ultimately, I’d like to “Apple-ify” The Regimen. When someone buys an Apple iPad, they just start using it. They don’t have to read a manual or watch videos on how to use it. They just press the button and voila. This is how I’d like The Regimen to work. You buy the products and that’s all you have to do. It needs to be patently obvious how to use them. This will require some creativity but I think we can get there.

As a final note, I will probably always have links to alternative products because some people in certain countries can’t even order Acne.org products. It will just be a matter of linking to these alternative products in a way that does not add to any confusion.

I also want to hear you guys weigh in on this before we start making big changes. What do you think?

image-2imageIf you order an Acne.org Cleanser, you will now get the new label design! We changed the names of a few of the products too. Acne.org Cleanser is now called “Gentle Cleanser,” because, really, that’s what it is. Acne.org Treatment will become simply “Benzoyl Peroxide (2.5%),” and our Acne.org AHA+ will become simply “Glycolic Acid (10%).” The names of Acne.org Moisturizer and Jojoba Oil will not change. Overall, we’re going for super straightforward in both the names of our products and the look of the packaging. We also added QR codes to the back of products so people can easily scan and learn exactly how to use them.

Right now only the Cleanser is being sent with the new label, but the other products will slowly start being sent with the new label design in the coming months.

Enjoy! And as always, definitely let me know what you think of it.