The Skin Saga: Breaking Blemish

By John, Skincare Contributor

John describes himself as eccentric–you might find him having a conversation with himself or making “A Beautiful Mind”-like movements while doing so. He’s a stickler for accuracy, so you might find him correcting one thing or another! His goal is to answer questions and provide unbiased, meaningful, and insightful information.

At 21, he is an aspiring dermatologist and will return to school next fall to get those plans moving. John enjoys singing, playing piano, hitting volleyballs, playing video games, and chatting with friends. Some day, he’d love to try more adventurous activities, like skydiving and mountain climbing! Check out his blog, The Triple Helix Liaison!

The Skin Saga: Breaking Blemish

Currently, I have very oily, acne-prone, mildly sensitive skin that occasionally flakes and feels dehydrated in certain areas, like around the nose, mouth, and eyes.  I hope to one day have very pale, perfectly-formed, diamond-hard skin that will occasionally shimmer and radiate when exposed to sunlight!  This post will chronicle the stages of acne and explain how and what ingredients treat those stages.

Formation

A combination of factors including irregular polarization of the keratinocytes, excess sebum production from heightened androgen activity, and inflammation of the hair follicle lining, contribute to the formation of comedones, either as blackheads or whiteheads.  The ingredients that block or inhibit this step include the following:

  • Topical retinoids (tretinoin, adapalene, tazarotene): Topical retinoids function by reducing the positive and negative polarities of keratinocytes, which will allow for more even and normalized natural exfoliation. They do so by decreasing the levels of transglutaminase, an enzyme that cross-links the trans-membrane proteins present on keratinocyte surfaces.

Recommendations: Besides the brand-name and generic prescription treatments such as Retin-A, Differin, and Tazorac that are available from your doctor, the Peter Thomas Roth Retinol Fusion PM ($65.00), which allegedly contains 1.5% retinol, a precursor of tretinoin that is roughly 20 times weaker, is a fantastic option and I can personally attest that it provides significant results without much irritation. Note that “weaker” only refers to the ratio of retinol that undergoes esterification to become retinal and ultimately tretinoin. The word has nothing to do with the molecule itself because the skin cannot use retinol, only tretinoin.

  • Oral retinoids and contraceptives (Accutane, Ortho TriCyclen, Estrostep, and Yaz): Oral retinoids and contraceptives function by reducing sebaceous gland activity. Less sebum means lesser chances of clogs or plugs forming. This may be surprising but retinoids are actually types of hormones because there exist various receptors (RARs and RXRs) throughout the body that are activated by the presence of such chemicals. So while they are distinct, oral retinoids and contraceptives do have overlapping characteristics. Oral contraceptives function by reducing the amount of circulating androgens; they stimulate the production of sex hormone-binding globulin, which inactive testosterone.

Fun fact: Ever wonder why many women experience acne once they reach menopause? It’s because their estrogen levels plummet, which means they can no longer hide the effects of the androgens still present (at now comparatively higher levels). Estrogens exhibit anti-inflammatory properties by decreasing neutrophil chemotaxis (meaning they inhibit and slow down the immune system), while androgens do the opposite. I guess that explains why men love to fight!

  • Hydroxy acids (Glycolic, salicylic): This family of ingredients was already discussed in detail during my last post; they will only be covered briefly here. They function by loosening follicular impactions and inducing exfoliation.

Recommendations: Paula’s Choice makes excellent salicylic and glycolic leave-on products with varying degrees of concentration that employ different vehicular bases for corresponding different skin types. Alpha Hydrox makes several good ones as well. They are just less cosmetically elegant in my opinion.

  • Regarding cleansers with hydroxy acids: Most hydroxy acids require a certain pH range to function properly, which is determined by the acid’s pKa and molecular electronegativity. Now, when pH = pKa that signifies that equal amounts of the free acid and salt form are present in the solution (50/50). Only the free acid form will allow for meaningful exfoliation. Now, even if a cleanser is in an appropriate pH range, which many are not, it  still won’t function optimally because the pH of water is seven. The pKa of glycolic acid is 3.83; salicylic acid’s is 2.97. When you emulsify your cleanser with water and spread it onto your face, the pH will undoubtedly increase. By how much? It depends on how much water you use and if your cleanser is a buffered solution. You will be getting suboptimal or nonexistent treatment for your condition. Cleansers only stay on your face for what, thirty seconds? However, if you are currently using cleanser with a member of the hydroxy acid family in it, continue to use if you enjoy it, but I would advise against purchasing one expecting to see major results.

Learn more about the infection, inflammation, and eruption stages! 

Infection

These keratinocyte plugs (blackheads and whiteheads) and the underlying sebum are enticing meals for the bacteria (P. Acne) that’s present throughout the skin. They will amass at these sites in obscene numbers.  The ingredients that block or inhibit this step include the following:

  • Benzoyl peroxide:  Due to its weak oxygen-oxygen bond, benzoyl peroxide eliminates bacteria by generating reactive oxygen species (ROS). Note that long-term use of this ingredient will age the skin prematurely because of the ROS, which are free radicals.
    • Recommendations: Once again, Paula’s Choice has two benzoyl peroxide products (2.5% and 5%) that are excellent. Dan from Acne.org ($32.03) also makes an elegant gel formulation that is inexpensive and effective! Now, unlike with hydroxy acids cleansers, those with benzoyl peroxide are not pH dependent and can be quite effective at preventing infection, because they help eliminate any surface bacteria. However, cleansers with benzoyl peroxide won’t penetrate deeply enough to address any existing acne.
  • Topical antibiotics (clindamycin, erythromycin): These exhibit antibacterial and anti-inflammatory properties as they reduce the levels of free fatty acids produced by P. Acnes. Because these targeted antibiotics can produce resistant strains of bacteria, they can and should be combined with benzoyl peroxide to enhance efficacy since the latter generates ROS, which destroy non-specifically.  These are prescription medications and need to be prescribed by your doctor or dermatologist to ensure that they are appropriate for your skin.
  • Oral antibiotics (tetracyclines, macrolides): These function similarly as their topical counterparts because they target bioactive lipids generated from free arachidonic acid (AA) and act as various cyclooxygenase inhibitors, both of which plays an important role in the prostaglandin and leukotriene pathways. They’re like stronger versions of salicylic acid.
  • Sulfur and sodium sulfacetamide: The former functions by interacting with the cysteine content of keratinocytes, which will allow for the formation of hydrogen sulfide, which leads to the breakdown of keratin. The latter acts as a substrate blocker for para-aminobenzoic acid (PABA), which P. Acnes needs for growth and proliferation.
    • Recommendations: ProActiv makes a good sulfur mask that also contains anti-inflammatories. Products containing sodium sulfacetamide are typically available by prescription only.

Inflammation

Once the bacteria begin to feed at these keratinocyte plugs, they will release pro-inflammatory byproducts that can induce the expression of Toll-like receptors (TLRs), which are proteins that regulate aspects of the skin’s immune response. This will lead to increased redness and swelling; the physical manifestations at this stage are characterized as papules and pustules.  The ingredients that block or inhibit this step include the following:

  • Salicylic acid: In addition to its other benefits for acne, salicylic acid is also anti-inflammatory because it inhibits several AA cascades, like the ones described above, that induce inflammation.
  • Topical corticosteroids: These function by inhibiting the expression of several genes that code for inflammatory molecules such as cytokines, while inducing expression of anti-inflammatory ones such as MAPK phsophatase-1. However, this family of ingredients should be reserved for intense and very severe inflammatory conditions because while corticosteroids do inhibit inflammation, their mechanisms of action interfere with other cellular signaling that manifest with significant side effects such as skin atrophy, more acne, and lasting hyperpigmentation.
    • Recommendations: Although there are several OTC products with corticosteroids (hydrocortisone), I’d advise against using them because of the numerous side effects. Please see your doctor if you are thinking about using this group of ingredients.

Eruption

If left unchecked, these sites will become so highly inflamed that the hair follicle will rupture, releasing its contents into the dermis and allowing for further bacterial proliferation. Ever wonder how blemishes, more specifically cysts at this stage, get so large as to encompass areas the size of dimes? This is how.

At this point, although many of the enumerated ingredients can be used, the fastest way to get rid of cysts is to have them drained with a lancet by a qualified professional such a dermatologist or esthetician.

Some key points to remember:

  1. Only salicylic acid, benzoyl peroxide, and corticosteroids can actually treat inflammatory acne that’s already visible on the skin. All other treatments are designed to prevent future outbreaks.
  2. Acne is an INFLAMMATORY condition, which means additional inflammation is never a good thing. I recently had a reader ask me how long she should expect the “purging” process to last after switching to a new skin care product. With a few exceptions, acne should never get worse before it gets better, meaning that you shouldn’t be breaking out significantly more after using a new product. If you are, discontinue use of the product and find out what is causing your reaction. Worst case scenario: you have to search for a product with a different active ingredient to ameliorate your condition. As you can see, there are many!
  3. These steps are not clearly demarcated. For example the transitions from step 1 to step 2 to step 3 cannot be detected by the naked eye. Therefore, just because an ingredient is only paired with a single step doesn’t mean it can’t be used for the other ones.
  4. 4. Your skin is constantly going through the exfoliation process so you shouldn’t rely on a singular approach to combat your acne.  For example, if you only have blackheads and whiteheads, you’ll know that you don’t need benzoyl peroxide. If you have severe cystic acne and your doctor only prescribes clindamycin, and not benzoyl peroxide or a topical retinoid, you can ask why not. It’s all about making YOU feel more comfortable and secure in WHAT and WHY you are applying something to your skin.

Feel free to comment on anything! Maybe I got something wrong, or you would like to add something to what I said about hydroxy acids. Whatever it is, know in advance that it will be greatly appreciated! Also, if you would like to nominate a topic for my next post, let me know comments!

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