Acne 2018: an update

Why worry about acne?

Besides of the social stigma carried by acne among adolescents, other skin problems may follow. People with darker skin are likely to see hyperpigmentation follow acne, and scarring will probably follow nodular acne.

From my book, here is the short story about acne.
Just because a skin condition is common, that doesn’t mean that it isn’t serious. What happens to one’s skin happens in front of the world, and acne is a good example. Acne affects a large proportion of the population, but again, just because something is common, that doesn’t mean it isn’t serious. Serious acne can ruin a teenager’s life.

Though acne is a normal skin condition, what’s significant about it is that it makes us so unhappy. And while advertising promises miraculous results, the companies that produce the ads clearly stand to benefit by painting pretty pictures to catch desperate people. There are no miracles to be found in the real world. There is no easy solution, or cure, for acne. The good news is that we know enough about acne to control it, and this is a great achievement.

The skin care industry continues to introduce new products, but whatever the name of the new products that will perform miracles on your skin, it always comes back to salicylic acid and/or benzoyl peroxide. So the old saying is fitting: nothing new under the sun. Usually, there is a stinging ingredient (menthol or a derivative) added to make you think that something is happening. These stinging ingredients can only make things worse, because stinging has no beneficial effect on the acne lesion and at high concentration they can increase inflammation.

If there is a danger in the usual anti-acne products – it’s that fast buck companies don’t care about the long-term health of their clients’ skin. They will use benzoyl peroxide even if repeated use of a product with this ingredient will aggravate acne and age the skin prematurely. Benzoyl peroxide decimates the natural bacterial flora of the skin and ages skin by flushing it with a strong oxidant that will promote DNA mutations and other issues.

Pores and acne

One of the effects of this not-very-useful sebum is acne, so I can see why the popularity of pores is so low.

Pores get larger and more visible during adolescence, when hormones increase sebum secretion. Pores can get clogged with sebum, keratin, and dead cells, resulting in an environment lacking in oxygen and favorable to the growth of the acne bacterium, Propionibacterium acnes. The products of bacterial metabolism cause the inflamed pimples characteristic of acne. This is a real problem and one that adequate skin care can prevent and correct. A comedo may be closed by skin – whitehead – or open to the air – blackhead. Being open to the air causes oxidization, which turns the lipids at the top of the “plug” black or brown?

It is now 2018. What is new about acne?

We, humans, are always looking for the easy fix, something that will cure all ailments. Maybe a vitamin, which has the double advantage of low price and no prescription required, will do it. But once and again, evidence shows that vitamin C will not cure the common cold and vitamin D will not strengthen bones. Easy fixes are good for advertising but they are usually not real.

What bad news do I bring you this time? I am here to tell you that there is still no cure for acne. This is not surprising, because acne is such a complicated condition, where several factors come together to put an end to the beautiful skin of childhood.

What are the factors? To happen, acne requires the following:

1) increased sebum production (under instructions from androgens) which provides food to the acne bacteria and contributes to seal the pore, providing an anaerobic environment that promotes some bacteria over others. The acne bacteria is a sure winner.
2) excess growth of the sebaceous glands also under instructions from androgens.
3) pore obstruction from increased keratinocyte desquamation and proliferation, which mixed together with increased sebum, makes a great sealing plug.
4) Propionibacterium acne colonization, and
5) inflammatory cell infiltration.

The news: growth factors and more

The news: bacteriologists changed the name of the acne bacterium from Propionibacterium acnes to Cutibacterium acnes. This doesn’t help much, right?

Another news: nutrition may actually affect acne. Not through “be good, avoid chocolate and you will be OK”. It looks like for some people, the glycemic index of foods do matter. This is because

Also: there is a genetic component to acne. If the genetic background predisposes the person, the onset of androgen action on the body during puberty can trigger development of acne. This may not help you at present but will aid in understanding of what are the mechanisms underlying acne, eventually leading to improved therapy.

Present strategies
The strategies available to control (not cure) acne are basically the same as they were 10 years ago. Some chemical analogs are added from time to time, like with retinoids, but the basics are unchanged. Let’s revisit them. PLEASE note that many of the following are strictly prescription medicines, and with good reason, because they can have serious side effects and drug interactions.

a) Antibiotics (topical, oral) to control the growth of the acne bacteria
b) Strong oxidants (benzoyl peroxide) as antibiotics
c) Hormone modulation, antiandrogens: sprironolactone, finasteride, oral contraceptives, antiandrogenic progestins
d) Inhibitors of sebum production (sebum is food for the acne bacteria) through hormonal manipulation
e) Normalizers of skin keratinization like topical retinoids, salicylic acid, azelaic acid and oral isotretinoin
f) Anti-inflammatories like oral tetracyclins and topical retinoids. Antibacterials will also decrease inflammation by decreasing the growth of inflammation promoting bacteria.

The present strategies to control acne carry big problems. For example, antimicrobial therapy begets antimicrobial resistance of P. acnes. Many bacterial strains we find in acneic skin are now antibiotic resistant. Also, some retinoids can’t be used on women that may become pregnant.
But, more than anything else, acne is very hard to control, especially in some individuals.

If you acne is giving you trouble, you can try to control it with some over the counter medications but please avoid those known to age and irritate skin.

Skin Actives uses some special ingredients that, as formulated, may help you do what other products can’t, while at the same time keeping your skin healthy.

What can Skin Actives Scientific do for you?

We use ingredients that help control acne, especially when formulated synergistically and when taking into account all the strategies known to help with acne. We also use ingredients that may not be available to other companies yet, some of them standardized botanical extracts and others product of biotechnology. What matters to us is effectiveness and safety, not whether they are natural or not. This is what should matter to you too. It is also important to know that all the ingredients we use are allowed by the FDA to be employed in skin care products (a.k.a. cosmetics), no prescription is required.

Some examples:

Oleuropein, wild yam and niacinamide have anti-inflammatory properties. Salicylic acid, salicin, and retinyl acetate normalize keratinization. Nobiletin decreases sebum production. Coleus oil, galangal and granulysin decrease acne bacteria. Nobiletin, zinc and EGCG decrease sebum secretion. Yeast beta glucan is an immune response enhancer, making your skin more able to battle the acne bacterium. Saw palmetto, zinc and EGCG act as inhibitors of 5 alpha-reductase activity.

As always, don’t look for the miracle ingredient among them. They work well together – but it is not magic or miracles, just good biochemistry.

Remember to avoid strong skin cleansers: irritation, caused by strong detergents, alcohol or abrasives will not prevent acne, but it may very well change the immune response of your skin making acne a more likely outcome.

What can your MD do for you?

Ask your doctor if you have impaired management of glucose. Your doctor may decide to prescribe Metformin, and maybe acne will improve in parallel with glucose management.

If the acne is bad, your MD may refer you to an endocrinologist for testing. Your genes may be responsible for a mismanagement of hormones in your body and this could be corrected, especially if there are other worrying symptoms like hirsutism or menstrual cycle disruption.
Sometimes, some oral antibiotics may help with acne and inflammation, your MD can help you with this too.

And, in the meantime, remember that it is basic science that elucidates how things work and what happens with things don’t work properly. This is why we need funding for research in universities and centers of excellence. The pharmaceutical industry is good at bringing innovations to the public after they are created by academics and university researchers.