Below the Surface
by Michael Q. Pugliese, licensed aesthetician
Understanding acne is one of the biggest challenges skin care professionals face because it is a complicated condition caused by many influences, including internal and external factors. Acne manifests on the outside, but there are also many things happening on the inside that contribute to this condition.
THE IMPACT
Acne is a problem that affects millions of people of all ages across the globe. The American Academy of Dermatology reports acne is the most common skin condition in the United States, affecting up to 50 million Americans annually. Not only does acne affect a person's skin, but the effects on their confidence and comfort are massive motivators for people to seek help.
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According to Precedence Research, the global acne treatment market size is expected to reach $15.18 billion by 2032. In the same study, it was noted that the North American acne treatment market is currently valued at $4.35 billion. The breakout and blemish business is so big that many stand-alone acne treatment centers are popping up and proving to be profitable business models.
There is no denying acne is complicated and difficult to understand. There are several factors, including hormones, genetics, diet, and lifestyle, that contribute to a perfect storm for acne to form. Beyond whether someone washes their face and applies proper skin care at home, these other intrinsic, or internal factors, remain a key player in acne formation.
TYPES OF ACNE LESIONS
As complicated as acne is, so are the different types of acne. There are generally three main types of acne: comedonal, papules and pustules, and nodulocystic. It is important to note that a client can have all three types of acne at the same time, and each type requires specific treatment.
Comedonal
Comedonal acne is the result of clogged pores and mostly happens when there is too much oil, bacteria, or skin cell production. A closed comedo or “closed pore” is known as a whitehead. A blackhead, also called an open comedo, means “open pore.”
These breakouts can also happen due to hormonal changes. Hormonal acne can emerge in early adolescence with the fluctuations of hormones during puberty and can continue into adulthood where some sufferers endure menopausal related hormonal acne.
Papules & Pustules
Papules and pustules are considered inflammatory acne, where small red bumps form on skin due to pores getting blocked and infected. This can also be caused with hormonal fluctuations.
Cystic Acne
Cystic and nodule acne lesions are more severe, causing deep, painful cysts that are usually red, inflamed, and filled with bacteria, sebum, and pus. Cystic acne can occur because of hormonal imbalances as well. Treating cystic acne is difficult and complicated because of the intrinsic factors that cause it.
GRADES OF ACNE
While many treatment plans must be tailored to the individual and may involve a combination of treatment options, acne is commonly categorized into grades to standardize conditions and treatment plans.
Grade I
Grade I is the mildest form of acne. There may be minor pimples, but they will be small and appear occasionally in small numbers. Blackheads and milia may be found, commonly on the nose and chin, sometimes in great numbers, but no serious inflammation is present in Grade I.
Grade II
Grade II is considered moderate acne. The presence of blackheads and milia is greater than Grade I. Formation of papules and pustules can be observed. Lesions will appear with greater frequency and general breakout activity will be more obvious. Slight inflammation will be apparent. Lesions can progress down the face onto the cheeks, shoulders, and back, particularly in males. Activity will also be seen on the forehead, cheeks, and jawline.
Grade III
This type is severe. Skin is more prominently red and inflamed and covers a larger area of skin. Papules and pustules have developed in greater size and number. Nodules can also be observed. The chance for scarring increases, as infection can spread more rapidly and deeper.
Grade IV
Grade IV is the most severe form of acne, also referred to as cystic acne. Skin will display numerous papules, pustules, and nodules in addition to cysts. The amount of inflammation is heavily pronounced and will generally feel painful for the person. Lesions are deep, pus filled, and can result in scarring.
- C. ACNE & SKIN
Cutibacterium (c. acnes) bacteria is a normal resident on skin, particularly in areas with high-sebaceous gland activity, and it is often seen on the face, chest, and back. It usually exists harmlessly on skin's surface without causing any issues.
While c. acnes are a normal part of the skin microbiome, it can contribute to the development of acne – especially when conditions are favorable for colonization. Combined with excessive sebum production, sluggish dead skin cells, and clogged hair follicles, an advantageous environment for c. acnes is formed. This bacteria is anaerobic, meaning they thrive without oxygen present, so when the follicle is blocked, it creates a perfect storm for inflammation.
When c. acnes colonize, they metabolize sebum and produce various substances, like fatty acids and inflammatory molecules. This inflammation can trigger an immune response, resulting in even more inflammation, which can compound the acne issue and exacerbate the condition further.
UNDERSTANDING ANDROGENS
Androgens are a group of hormones that exist in all people but are generally found in higher levels in males. Testosterone is the most well-known androgen; however, there are several types including androstenedione, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEA-S), and dihydrotestosterone (DHT).
While androgens are necessary to help with bone density, muscle development, puberty, red blood cell production, and sexual function, they also cause an increase in sebum production, which can, in turn, be the catalyst in acne lesions forming. Androgens may also enhance follicular hyperkeratosis, which is a thickening of the outer layers of skin.
Acne And…
Menstruation
A study published in the Archives of Dermatology in 2004 showed 63% of acne-prone women experienced premenstrual acne flares, with a 25% increase in total lesions. Normally, the increase in acne comes about seven to 10 days before the onset of menstruation because of progesterone and testosterone increases and often subsides when menstruation begins.
Pregnancy
During the first trimester, human chorionic gonadotropin (hCG) spikes, while progesterone and estrogen levels remain low. As such, breakouts are common during this time. The second and third trimester human chorionic gonadotropin dips, with a spike in estrogen and progesterone, and acne generally clears.
Medication
Certain medications, such as corticosteroids, androgenic progestins (which have similar properties to androgen and are found in some birth control pills), and certain anti-convulsants, can cause hormonal imbalances and contribute to acne development.
PCOS
Many women with polycystic ovary syndrome disorder (PCOS) have high androgen levels, often resulting in severe acne because of the hormonal imbalances associated with the condition.
MEDICAL INTERVENTION
There are many treatment options when it comes to acne, ranging from medical interventions prescribed by a physician to over-the-counter products for milder cases. In many circumstances, due to the complicated cause of acne, a multifaceted approach is necessary to achieve control.
In cases where acne Grades III and IV are present, medical intervention is often necessary. Some of the most common treatments prescribed by doctors are oral medications, topical medications, and laser and light therapy. When it comes to medical treatments, the need to be supervised by a physician is necessary due to the inherent side effects of the drugs.
Topical Retinoids
There are many prescription gels, creams, and ointments, like tretinoin and adapalene, that are designed to help increase cellular turnover and reduce inflammation. They also can cause dryness, redness, peeling, and skin irritation at the application site. These side effects are generally mild and resolve with continued use. Anyone on topical retinoids should also avoid the sun, waxing, and any other more invasive treatments.
Topical Antibiotics
Bacteria, like c. acnes, respond to antibiotic drugs like clindamycin or erythromycin. By controlling bacterial growth, these topical antibiotics reduce inflammation and help reduce acne lesions. As with any antibiotic use, bacterial resistance is a concern with prolonged use.
Oral Antibiotics
In severe cases, oral antibiotics may be a given. These drugs include tetracycline and doxycycline. Some side effects can include nausea, diarrhea, and gastrointestinal issues. Similarly to topical antibiotics, the bacteria may become less responsive to oral antibiotic treatment over time, making it less effective as the bacteria grow resistant to the medication.
Oral Contraceptives
Individuals sometimes find that oral contraceptives help manage acne due to hormone regulation. Oral contraceptives reduce the level of free testosterone in a woman’s body by coaxing the ovaries and adrenal gland to produce less testosterone. Oral contraceptives increase the level of sex hormone-binding globulins (SHBG), which inhibit the conversion of free testosterone into dihydrotestosterone (DHT). In short, there is less dihydrotestosterone in the body, so it lessens the favorable conditions for acne to exist.
The progestin component of oral contraceptives lower androgen levels. While they are generally well-tolerated, some side effects can include irregular bleeding, mood changes, nausea, and, in some cases, blood clots.
Isotretinoin
Isotretinoin is a potent medication used for the most severe cases of acne. While generally effective in drying up sebaceous glands, it also dries out the rest of the body. Side effects include dry skin, lips, and eyes, and muscle and joint pain. It can also cause birth defects if taken during pregnancy. It requires regular supervision due to potential liver and blood lipid level changes.
Hormonal Therapy
Anti-androgen medications, such as spironolactone, are used to help regulate the levels of androgens in the body, which reduces sebum production and inflammation. These medications are primarily prescribed to those who have a direct connection to hormonal acne, such as in clients with polycystic ovary syndrome. Side effects may include breast tenderness, headache, nausea, and mood changes. Anti-androgen medications are generally not recommended during pregnancy.
Laser Therapy
Laser therapy can be highly effective in treating acne if used correctly. The latest in laser technology allows for quick 30-minute treatment to help clear mild to severe acne, working by shutting down sebaceous gland activity, thus limiting the favorable conditions for acne to thrive. Generally speaking, laser therapy can cause temporary redness, swelling, and increased sensitivity to sunlight. In rare cases, more severe side effects, such as infection, scarring, or pigmentation changes, may occur. It is worth noting that all side effects vary from person to person, and some may discontinue after consistent use. It is always important to refer clients back to their physician if they have any concerns regarding their medical treatments as it is not the professional's role to offer medical advice.
THE ROLE OF THE SKIN CARE PROFESSIONAL
Professionals can play an integral role in helping clients improve their acne. As seen in Acne Grades I to II, teaching them about proper homecare, providing extractions where necessary, and offering in-spa treatment options can help clear their skin.
Proper Homecare
Many times, clients with acne want a cleanser that strips their skin of any oiliness because it makes them feel like they are removing the acne. However, if skin is stripped of its natural barrier, the human body can go into overdrive to produce more. Finding the perfect balance is essential. A gentle cleanser that contains salicylic or mandelic acid is a great choice for clients because it helps unclog pores and reduce bacteria.
Clients may also resist the need for a moisturizer because they do not want to feel greasy. Educating clients on the benefits of a moisturizer is essential, because not only is a moisturizer going to help skin with hydration levels, it is going to help maintain the barrier function to protect against bad bacteria as well as target acne when using an acne-fighting formulation. These formulations work to exfoliate skin, reduce oil accumulation, and kill bacteria.
Every skin care professional should have a go-to spot treatment to recommend to all clients. It is inevitable a breakout will happen, and they will want a quick solution. Spot treatments are applied directly to individual breakouts and contain ingredients like benzoyl peroxide or sulfer to reduce inflammation.
PROFESSIONAL TREATMENTS
Peels
Chemical peels designed to exfoliate dead skin cells, speed up the cell turnover rate, unclog pores, and reduce acne lesions are a great in-spa treatment to offer clients. They can range from superficial to medium-depth and can target active breakouts and soften scarring. Popular peels for acne include both alpha and beta hydroxy acids, as well as a combination of both to treat active acne and prevent future breakouts.
Enzymes
Enzymes are gentler than chemical peels and scrubs but are still effective in treating acne. In skin care, many enzymes are derived from botanicals like plants and fruits. Popular botanical enzymes can include pineapple, papain, and trypsin. Protease enzymes, like trypsin, break down proteins on skin's surface and help smooth and soften skin's surface. Enzymes are effective in desquamation, and when combined with other anti-inflammatory ingredients in formulation, the fight against inflammation can be particularly helpful. Enzymes are most functional when they are wet and warm, so laying damp 4x4s on the area or using a hot towel can be effective in maintaining moisture.
Oxygen
Oxygen treatments are another great choice for professionals, because, as mentioned previously, c. acnes bacteria thrive in an anerobic environment. When oxygen is introduced to skin, it forces the pores to open, and the acne is killed.
Extractions
Extractions can be incredibly helpful in clearing the pores to help pimples heal. Proper extraction techniques are necessary to ensure scarring, additional inflammation and breakouts, and post-inflammatory hyperpigmentation do not occur. Microcomedones, blackheads, and whiteheads are usually safer to extract as opposed to cysts and nodular acne that contain a high level of inflammation that prevents the removal of all contents and, in turn, may contribute to more trauma to skin.
Clearing acne involves addressing many factors, including cellular turnover, sebum production, bacterial colonization, and hormonal imbalances. Often, a combination of interventions is needed to help control bacteria, increase exfoliation, reduce inflammation, and regulate hormone levels. Acne is complicated, but professionals who know the contributing factors and what is going on underneath the surface of skin are better prepared to help clients combat it.
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Michael Q. Pugliese, an informed educator, writer, and asset to the skin care industry, became the third-generation CEO of Circadia by Dr. Pugliese in 2006. His dedication and leadership to the brand has grown to achieve international recognition and distribution worldwide. This global expansion has created a skin care regime for every skin type in the world. Pugliese’s compelling lectures honor the tenets of modern skin science discovered originally by his grandfather. By following in his grandfather’s footsteps, he has been driven to deliver a clear message on skin care to all of his clients and fellow educators in the industry.