pathogenesis and treatment of acne and rosaceaA new book hit the market recently called Pathogenesis and Treatment of Acne and Rosacea. The biology dork in me is excited to chomp it up. This is a perfect time of year too. At my latitude here in San Francisco, from April through October you can get tons of vitamin D from sitting in the sun, and I absolutely love sitting in the sun. So, I’m going out back to start reading this thing. Anybody want to join me in reading this thing!? I’d love to hear your input if you want to be in the world’s nerdiest book club with me 😉

ZapA 2012 article published in the International Journal of Dermatology attempted to evaluate whether using a tiny 1.5mm long electrical needle to zap sebaceous glands (pores) might be able to permanently disable these glands and thus prevent acne. Only 12 patients were studied, so replication is of course needed, but the initial results are quite interesting. The researchers treated each patient 3 times at 1-month intervals for 30-60 minutes per treatment. During treatment, the researchers inserted the needle into each active lesion for about half a second and sent 40 watts of electricity into the gland.

The results: “All of the subjects…showed a reduction in inflammatory and non-inflammatory acne lesions after three selective electrothermolysis treatments.” A month after the final treatment mean inflammatory acne was reduced 98.14% and non-inflammatory acne was reduced 83.09%. What is perhaps most interesting is that 1 year after the final treatment, only 2 out of 12 patients relapsed.

Side effects: “All patients reported transient post-treatment erythema (redness), which faded after a few days.”

Quite interesting indeed. I noticed no other studies have been performed on this method, but I would like to see this studied more widely.


  • Lee JW, et al. “Selective sebaceous gland electrothermolysis as a treatment for acne: a prospective pilot study.” International Journal of Dermatology. 2012; 51(3): 339-44.

Head in HandsI’ve read or overheard countless times the faulty warning, “Be careful not to touch your skin because you can move bacteria around and cause acne to spread.” On the myths page here at I dispel this myth. What is really happening is when you touch your skin–especially when you touch it roughly and frequently–you are physically irritating the skin. This physical irritation is what can lead to acne symptoms.

Let’s get into a little bit of the science behind this. Now that the genome of acne bacteria (P. acnes) has been decoded, we know that there are three types: I, II and III, and two subtypes, IA and IB. Recently, a group of researchers took a close look at acne bacteria in both people with acne and “healthy” controls. They published the results in the British Journal of Dermatology. One of their major findings is that the presence of P. acnes bacteria on the surface of the skin was almost identical between people with acne and controls: 40.4% vs. 40.0%. They also looked inside inflammatory acne lesions (papules and pustules) and what they found there was that a certain subtype IA was markedly increased, while other types and subtypes were decreased.

The researchers conclude: “…we suggest that distribution patterns of P. acnes over the skin surface at the phylotype level do not support its involvement in the initiation of comedogenesis or inflammation…However, type IA P. acnes…might be more closely associated with inflammatory acne lesions.”

This is pretty cool stuff. The more we understand exactly which types of bacteria are involved in which types of lesions, the better we might be able to specifically target them in the future. In the meantime, there is no reason to feel that if you touch your skin you are “moving bacteria around” and causing acne.


  • Kwon HH, et al. “Analysis of distribution patterns of Propionibacterium acnes phylotypes and Peptostrepococcus species from acne lesions.” British Journal of Dermatology. 2013; 169(5): 1152-5.

korean questionnaire 2Korean researchers gave 136 acne patients in Korea a questionnaire to gauge the patients’ understanding of proper skin care and determine their skin care habits. They then published the results in the International Journal of Dermatology. The results are almost exactly what I would expect from patients inside the United States or anywhere else in the world for that matter. The researchers state, “We doctors have put so much effort into fine-tuning laser parameters and dosages of medication in the past that we might have underrated the role of the patient.”

The questionnaire answers highlight several problems, including excessive face washing. A full 42.7% of respondents wash their face excessively, with 28.7% washing “vigorously until it feels silky,” and 14% washing “until I cannot detect sebum at all.” Physical irritation of the skin is one of the major factors that keep people entrenched in a cycle of acne. One of the easiest and best ways for these respondents to immediately improve their acne would be to wash lightly with a gentle cleanser for only a short period of time.

Next, the researchers asked respondents to answer what they thought caused acne. The most common answer was stress at 27.2%. Excessive sebum production came in tied for second with diet at 14.7% and insufficient cleansing was next at 14%. A few things stand out here. First, while stress is an aggravating factor, it is nowhere near as causal as excessive sebum. Next, insufficient cleansing is rarely a cause of acne. The contrary is true. Overly cleansing causes far more acne symptoms than insufficient cleansing. The scientific community is still gathering evidence on diet to determine if diet is as much of a causal factor as the respondents thought.

After looking at the answers to this questionnaire the researchers state, “This study showed that our patients may be making a great deal of errors and that we may be neglecting them. To effectively treat and prevent further breakouts, appropriate skin care is imperative in patients with acne.” In other words, it is extremely difficult for acne patients to see the results they desire when they are actively practicing bad habits such as over-cleansing the skin.

The moral of this story is similar to many others when it comes to acne. First, be gentle. Do not scrub your skin. Wash only twice a day and wash exceedingly gently for only a short period of time. I recommend 10 seconds or less. Then, don’t expect miracles from the vast majority of acne treatments that your doctor might prescribe. Only a few treatments provide complete clearing of the skin.

Props to these researchers for gathering this information and for responding to it so honestly and clearly. Dermatologists need to better educate patients to stay gentle with their skin if acne clearing is desired.


  • Navarete-Solis J, et al. “A Double-Blind, Randomized Clinical Trial of Niacinamide 4% versus Hydroquinone 4% in the Treatment of Melasma.” Dermatology Research and Practice. 2011.

niacinamideI have written about niacinamide (AKA nicotinamide), the active component in vitamin B3, for a couple of years now. Evidence shows it can help significantly reduce acne through its anti-inflammatory effects. However, the more I look into this ingredient, the cooler it becomes. The latest double-blind study I found in the journal Dermatology Research and Practice has researchers administering 4% niacinamide to patients with melasma or dark patches of skin from sun exposure. Melasma is much more common in women and is an extremely prevalent condition experienced during pregnancy. The reason I find this particularly interesting is because people with acne often experience dark/red spots after acne lesions heal, also called hyperpigmentation.

The study pitted 4% Niacinamide against 4% hydroquinone for the treatment of melasma. Results were similar. “Good to excellent improvement was observed with niacinamide in 44% of patients, compared to 55% with HQ.” The lightening effect of niacinamide took a little longer to exhibit itself and was evident at 8 weeks versus 4 weeks for hydroquinone.

As far as side effects go, “Treatment with niacinamide showed no significant side effects and was well tolerated.” This is in contrast to “moderate adverse effects” in 18% of the hydroquinone patients.

I am in the process now of trying niacinamide in products because of the breadth and depth of compelling research that exists now on this simple yet effective ingredient. I’ll let you know how that goes.


  • Navarete-Solis J, et al. “A Double-Blind, Randomized Clinical Trial of Niacinamide 4% versus Hydroquinone 4% in the Treatment of Melasma.” Dermatology Research and Practice. 2011.

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, 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 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 Regimen will clear you up. Completely.


  • 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.

Low DoseA 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.


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

photodynamic therapy with red lightTraditional 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 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 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.


  • 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.


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