3 must do steps to get rid of acne

What is acne?

Acne (or as health care providers like to call it “acne vulgaris”) is the medical term for zits and pimples with blackheads or whiteheads (comedones). It is the most common skin condition, and I dare say psychosocial condition. Other conditions such as folliculitis (inflammation of hair follicles), or rosacea can have pimples or zits, but they do not have comedones (blackheads and white-heads).

Acne appears when pores get clogged with dead skin, oils, or a buildup of bacteria. The skin gets inflamed, red, and the resulting swelling can block nearby pores causing the acne to spread.

In my opinion, the biggest problem with acne is its timing, since it occurs out of the blue during the most sensitive years of life- puberty and early adulthood. This may cause poor self-esteem, depression, anger, and other social issues.

 

This is summarized by Sulzberger and Zaidems in their article: “Psychogenic factors in dermatological disorders”. Med Clin North Am 1948;32:669.:

“There is no single disease which causes more psychic trauma, more maladjustment between parent and children, more general insecurity and feelings of inferiority and greater sums of psychic suffering than does acne vulgaris.”

This statement from 1948 still holds true today.

How can I make my acne better?

Before we answer this question you need to understand that acne is not just a skin problem, but is a sign of a more complex health issue. The brain-gut-skin connection theory is an old theory that is gaining traction in recent scientific publications.  It states that whatever affects your brain or gut, will also affect your skin as well.   This is especially true with acne. Therefore, using just the skin medicines will not solve the problem.  You have to also take care of your mood and your nutrition.

 

STEP ONE. IMPROVE YOUR MOOD AND YOUR SENSE OF WELL-BEING

Be active, go outside, and please try to keep your chin up! Though sometimes you feel sad and lonely you have to keep going and do not hide! Hiding will only make you feel worse. Here is the story my father told me from his high school days:

 

There was a pleasant freshman girl that had a horrible accident in her early childhood- she lost her right hand in a car crash. But unlike most people would do she did not hide that arm at all.  She would make gestures with her handless arm more than with her normal arm. Other students were left with no other choice but to accept her situation as something normal and not something to be ashamed of. She eventually married one of the most popular boys in school and had a productive and happy life with four children. My father met her at the 10-year reunion dinner and asked her how come that she had not been hiding her handless arm. She simply answered that her parents instructed her not to hide her handicap at all, and to do just the opposite, to accept it like it is nothing. By doing so she made it to become nothing to her and to the others. In contrary, if she had started hiding it, everyone around her would have started feeling uneasy and uncomfortable being around her, and that would have ultimately caused her to end up being alone. 

 

Isn’t this the best way to deal with any imperfections? This story teaches us an important lesson: Even when things seem to be out of our control (an irreversible handicap in this case) they are still very much under our control. You can’t control what happens to you but you can control how you react to it. Remember that and make the choice similar to the girl’s choice from the story above.

 

If you are unhappy with how you look due to acne, or due to any other possible perceived imperfection there are two important things to remember. First, you can control it.  Second, you are not alone. Various studies and surveys in the U.S. and abroad show that 80-90% teenagers are unhappy with their looks. So power through and live your life to the fullest! But again remember, you are not alone.  We at DermBoard know that we can help you with your acne.

 

OK let’s get to work:

  • Be active! If you are watching TV, stand up once in awhile, perhaps during ads, and walk around the room or do some other exercise. You could even get a pedometer to motivate yourself and track your progress.
  • Get out of your apartment, home, or workplace by walking around the block even if it’s just for a few minutes.   Try and see the beauty in everything around you, connect with those around you by giving them a compliment or talk about anything such as how beautiful the day it is.
  • Connect with others – talk about your issues freely, since more often than not people will try to help you, and even if they do not help, you will be relieved just by sharing your worries. But do not forget to share good things and your advice as well, and listen to others, they will appreciate it, and will want to hang out with you more often.
  • Focus on today. Today is the most important day of your life; not yesterday (it’s gone!) and not tomorrow (it hasn’t happened yet.) What happened – happened, it is gone and you have to LET IT GO. Try to learn something from it to improve today. Look to future, because your experiences will enable you to turn it into a better today.
  • Meditate! Simply close your eyes and don’t think about anything for 10 seconds several times a day. Just be.
  • Get rest! Sleep 7-8 hours a night. Also, try to squeeze in a 20-minute nap during the day. Find a dark and quiet place, set your alarm clock for 20 minutes, lie horizontally and cover with a blanket. You don’t even need to fall asleep; some quiet time will do just fine. Sleeping and napping are stress-killers.
  • Increase your intake of omega-3 fatty acids (fish oil), they are associated with improved mood (check out Carlson fish oil on Amazon.com), but only if your healthcare provider approves it.
  • Have a cup of green tea a day (adults only, and if permitted by your healthcare provider) – it will increase your energy levels and will improve your mood.

 

STEP TWO. IMPROVE YOUR NUTRITION! YOU ARE WHAT YOU EAT!

  • Eat foods that are closest to their natural state (e.g. eat whole apples, not apple sauce; eat strawberries, not strawberry jam etc.).
  • Eat foods that are not processed, and that your great-grandmother would recognize as food.
  • Eat foods with omega-3 fatty acids (raw nuts, fish oil, whole milk with DHA etc.) because they will decrease the redness and inflammation of your skin.
  • Eat green leafy vegetables and fresh fruits because they will remove toxins from your body.
  • Eat yogurts with active cultures or use supplements with Lactobacillus since they will replace bad bacteria in your gut, and reduce inflammation (including redness of your skin) and constipation.
  • Try to eat whole, raw nuts (peanuts, walnuts, almonds, pecans etc.) as snacks- they will keep you well fed; allowing you to have better control of your weight while decreasing redness and inflammation of your skin.
  • Try not to eat highly processed foods (e.g. as a rule avoid foods that have more than 6 ingredients), they may make you overweight.
  • Try to avoid eating starchy or sugary foods on regular basis, since they may worsen your acne, and may make you overweight.
  • Try to avoid any sugary drinks since they may worsen your acne, and may make you overweight; instead drink plain water plus one cup of green tea a day (if it is permitted by your healthcare provider).
  • Try not to consume skim milk- it has been associated with worsening acne! We are designed or evolved to drink whole milk, and guess what – consumption of whole milk is associated with better weight control. You also may try to get milk with omega-3 fatty acids (e.g. DHA).
  • In general try to eat more foods that come from farms, not food or food imitations that come from factories.

STEP THREE. SKIN CARE:

  • Wash your face no more than twice a day using a gentle non-soap facial skin cleanser, or acne cleansing pads containing salicylic acid (pads are preferred by most teenagers due to ease of use) with a gentle circular motion to remove dead skin and unclog your pores. Again, be patient and be gentle. There is no overnight cure of acne.
  • Avoid picking, or squeezing pimples. This is a classic advice that you can find everywhere. If you pick and squeeze pimples in an uncontrolled, impulsive fashion with your fingernails you are setting yourself up for worse acne. Ideally you should not do it at all, but if you really have to, and the pimple is really making you unhappy, then wash your skin, wash your hands, sterilize a sewing needle over a fire, wipe off any char from the needle with rubbing alcohol, and gently go with the tip of the needle through the tip of the pimple (tip-to-tip method). Try not to nick normal skin and cause excessive bleeding. Gently press the skin with your knuckles about 1/4 of an inch away from the pimple in attempt to empty it, then leave it alone. Finally, wipe the area with rubbing alcohol. However, always make sure not to squeeze any pimple within the so-called “danger triangle of the face”, which is an area from the corners of the mouth up to the bridge of the nose, including entire nose and areas inside of it. If you squeeze a pimple in this area, you may push pus into brain circulation, which may cause life-threatening brain infections.
  • Use non-comedogenic skin products. Use loose mineral make-up, and avoid pasty, or pressed make-up, as  it may clog your pores. Check everything that goes on your skin for the “non-comedogenic” claim. Go by your own experience and by pure common sense- if you feel that something that claims to be non-comedogenic makes your acne worse, then stop using it.

 

How can I treat acne on my own?

Consider the above provided information, and if you have mild acne (which includes the vast majority of acne sufferers), you can use non-prescription acne products. The best would be to use a combination of products containing 2% salicylic acid (i.e. cleansing pads) and a benzoyl peroxide 2.5% leave-on cream. Use acne medications on the entire affected area, since in the majority of cases spot treatments simply do not work.  Benzoyl peroxide creams with higher concentration than 2.5% have not been shown to be more effective, and have instead been shown to be more irritating. Almost everyone gets some irritation with acne medications (non-prescription and prescription), but that subsides over a few weeks of usage. Though rare, some have severe reactions to acne products, so for the first 7 days you can try the product on a small area to see if you will develop irritation. If your acne does not improve after 3 months, or if you have moderate or severe acne, see your health care provider for personalized advice. Non-prescription medications can be continued in combination with prescription medication if approved by your prescribing healthcare provider. If you have severe nodulo-cystic acne (acne with at least pea-sized, deep knots), or if you have developed scarring, then immediately seek help of the closest dermatologist. 

What should I do if non-prescription medicines do not help?

For the majority of acne sufferers, using non-prescription medications is enough; however, for the minority, prescription medications are needed. Non-prescription medications can be continued in combination with prescription medication if approved by your prescribing healthcare provider.

The usually prescribed acne medications include:

  • Benzoyl peroxide (brand names Benzac, Brevoxyl, Triaz). Benzoyl peroxide is one of the oldest acne medications that kills bacteria without reported bacterial resistance, and is used to unclog pores. Benzoyl peroxide is readily available without a prescription in various concentrations up to 10%; however, concentrations higher than 2.5% have not been shown to be more effective and have been shown to be more irritating.
  • Antibiotics in the form of creams, gels, and liquids you put on the skin. Antibiotics kill the bacteria (Propionibacterium acnes) inside pimples and calm inflammation. These medicines include, benzoyl peroxide (the only over-the-counter antibiotic for treatment of acne in the US, and the only one without reported bacterial resistance), clindamycin (brand names: Cleocin T, Clindagel, ClindaMax, Evoclin), erythromycin (brand name: Akne-mycin), dapsone (brand name: Aczone), and others. They are used as a single medicine or in combinations such as:
  • benzoyl peroxide and clindamycin (brand names: Acanya, Benzaclin, Duac, Onexton)
  • benzoyl peroxide and erythromycin (brand name: Benzamycin)
  • or in combination with retinoids such as combination of  benzoyl peroxide and adapalene (brand name: Epiduo), or
  • clindamycin and tretinoin (brand names: Veltin, Ziana).
  • Vitamin A derivatives also known as retinoids such as tretinoin (brand names: Atralin, Avita, Retin-A, Retin-A Micro), adapalene (brand name: Differin), and tazarotene (brand name: Tazorac). They are in the form of creams or gels, and are usually applied before sleep on clean and dry skin over the entire affected area. These medicines keep your pores unclogged and reduce inflammation. Their most common side effects are skin redness and peeling, especially in the first several weeks.  To reduce the chance of these side effects, you should apply these medicines on dry skin (i.e. 30 min after washing) and before sleep. During the first several weeks you may use these medicines every other night until your skin becomes accustomed to them. You should not use these medicines if you are pregnant or planning to become pregnant, or if you breastfeed your baby.
  • Azelaic acid (brand names: Azelex, Finacea). Azelaic acid helps keep pores unclogged by decreasing the formation of comedones. It can also kill bacteria in pimples. Azelaic acid can also help improve dark spots on the skin caused by acne. However, it is usually used in rosacea.
  • Antibiotics you take in a pill or tablet – We usually use these temporarily to bridge the period until the creams/gels/lotions achieve their maximum efficacy (6-12 weeks), or until a more aggressive regimen with an isotretinoin pill (brand names: Accutane- discontinued, Absorica, Amnesteem, Claravis, Sotret, Zenatane)  is started. Our favorite oral antibiotics are doxycycline (we try to avoid it during the summer due to increased skin sensitivity to sunburns), and azithromycin (we usually use it during the summer months).  We tend to avoid other antibiotics if possible due to increased chance of side effects. These antibiotics kill bacteria but also reduce skin inflammation and redness.
  • Birth control pills (oral contraceptive pills) – examples are Ortho Tri-Cyclen, Yasmin and Yaz. Some acne (especially those that are worse along the jaw line and edges of the face) are hormonally induced, or hormonally driven. Many times female patients complain that their acne is worse around the time of their period; in cases like this, birth control pills may be helpful. It usually takes 3 periods before we decide if birth control pills have helped.
  • Isotretinoin pill (brand names: Accutane- discontinued, Absorica, Amnesteem, Claravis, Sotret, Zenatane). This medication is the most powerful acne medication. In about 80% of cases it cures acne, if used in overall concentrations of 120-150 mg/kg over 5-6 months. But it can also cause serious side effects and birth defects. Some of the feared side effects are depression and suicide which is controversial (i.e. some studies show cause and effect while others did not show this), but there are also other more common side effects such as skin dryness, chapped lips, eye dryness, abnormalities in liver function, headaches, high lipids in the blood, problems with vision at night etc.  Women who can get pregnant, and who want to take isotretinoin must follow very strict safety rules to avoid pregnancy. Everyone who is prescribed with isotretinoin must be enrolled in the Federal Government-mandated  “IPledge” program, which is primarily designed to prevent the pregnancies while taking isotretinoin.

    Some general advice on acne regimen for women

    If you want to get pregnant, or if you are breastfeeding, you have to talk to your doctor before you start any acne medication, since many of the medicines used to treat acne are not safe for babies.

    OK, my acne is gone, but it left scars, what now?

    The good news is that you live in the 21st century, so there are many good options to take care of your scars, from dermabrasion and chemical peels to sophisticated lasers (e.g. Fraxel). You should talk with your dermatologist to determine what would be the best approach for your particular case. There is a great overview of available treatments for acne scars by Dr. Davin Lim on his YouTube channel.

    For more specific questions on acne please send us your question using our blog below.

  • amy

    Hey doc,
    I’ve been using some cream with benzyl peroxide for my acne for about 3 weeks. It seems to be working for my acne (better), but I get some skin redness and peeling. What should I do? Do I continue my cream or something else? Please help!

    • Dr. T

      Dear Amy,

      Thank you for your question! Benzoyl peroxide is one of the best acne medicines, since bacterium that causes acne is not resistant to it; however, this medicine causes some mild irritation in the form of redness and mild peeling in the majority of users. Please make sure that the concentration of the benzoyl peroxide is not over 2.5%, since it will not work better and it is more irritating if above 2.5%. To reduce irritation and peeling everyone should use some good moisturizer with sunscreen in the morning such as Cetaphil Daily Facial Moisturizer with Sunscreen, SPF 50+ or Vanicream Sunscreen, Sensitive Skin, SPF 30. Also to reduce irritation you can apply benzoyl peroxide less often (i.e. once daily or very other day). This irritation usually subsides within a few weeks. In more resistant cases I sometimes recommend to my patients over-the-counter hydrocortisone 1% ointment for 2-4 days which helps in 95% of cases. But in about 5% cases people have a true allergy and then stopping benzoyl peroxide is the only remaining option. I do this with heavy heart since benzoyl peroxide is a really great acne medicine. I hope you will find this answer helpful. Please do not hesitate to contact me again if you need any additional info.
      Input form other users would also be most welcome.

      I wish you all the best and let’s keep fighting acne together!

      Best!

      Dr. T

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