The title of my PhD is “The clinical and cost effectiveness of essential oils and aromatherapy for the treatment of acne vulgaris: A Randomised Controlled Trial”. More than half of my waking life is spent either reading about acne vulgaris (acne), hearing peoples experiences of acne, or writing about acne (the other 40% is spent being a domestic goddess, but I digress…) So, it annoys me when some blog authors (which are more commonly accessed than research) offer reconstituted fiction, sold as fact. When I read these articles, I understand that the author is not very well read, and clearly has no expertise in the subject! So today, I want to write about acne.
I want to be clear – this post is not going to cure your acne; it is not even going to offer any tips. I just want to write about what I know, what I am doing, and what I hope to be able to offer the sufferer* sometime in the near future. Acne is not simply a “cosmetic” issue; and it is a lot more than an adolescent problem that will pass; it is a very complex, multifactorial, chronic skin condition that can have serious and long term psychosocial effects. It can affect people in a lot of different ways and sometimes, very deeply. If you are one of these sufferers, I can empathise with your situation. I hope that this blog will help you to understand acne, and also help you to make decisions about how you treat it.
Acne is experienced by the vast majority of people at some point in their lives (1), and it is most prevalent amongst the 15-18 year old age group. For many the symptoms may ease towards the end of adolescence but for others, symptoms will continue beyond their teenage years, or commence (adult onset) in their early 20’s.
There is no clinical definition of acne and as a result a person may be unsure as to whether they are experiencing acne or whether they have a couple of pimples. In the academic literature, mild acne is variously defined as being, for example, one or two pimples, or less than 20 pimples, or less than 50 pimples; sometimes it is only described as mild, moderate or severe. It is not very clear – in fact, it is confusing.
Acne is the result of 4 physical processes. The jury is still out as to what actually triggers acne and this is the subject of debate amongst authors in the academic press:
- Inflammation: mediators (CD4+ T-cell response) causing inflammation (and redness) are released into the skin – although the “role” of inflammation is unclear (2).
- Hyperkeratinisation: a disorder which causes the dead skin cells to remain in the hair follicle, causing it to become blocked; this is due to an excess of keratin, a natural protein found in the skin.
- Increased sebum production: sebum is the oily substance that prevents hair and skin from becoming too dry. Sebum production will peak twice in early life – the first is just a couple of hours after birth (some babies experience neo-natal acne) and again around age 9 (adrenarche) to 17 years.
- Propionibacterium acnes: the colonisation of P.acnes is implicated in acne, however, it is probably not the trigger (2,3); P.acnes is found on everyone’s skin and the amount found in the hair follicle does not correlate to the amount of inflammation experienced by the acne sufferer. It is also interesting to note that this bacteria is not present in the case of neonatal acne.
There are many physical presentations of acne; you have seen them and so I will not go in to detail. However, it is important to note that these symptoms can often be painful. Rarely, people may experience the most severe form of acne, known as acne fulminans (most commonly found in teenage boys); these people will often experience fever, weight loss and musculoskeletal pain; less frequently, they may require lengthy hospitalisation (4).
So, what causes acne? Recent research concluded that most people attribute acne to poor diet, stress and poor hygiene. I think we should break this down a little and take a look at what is fact and what is fiction:
- Hormones: Yes, hormones are implicated. People go to a great trouble and expense to determine what is “wrong” with their endocrine system if they are experiencing the symptoms of acne. Acne is present in neo-nates and adolescents, and it is a symptom of Polycystic ovary syndrome – all times of hormonal change or upheaval. But it is not the full-stop in the conversation. We all experience hormonal change, why then do some experience symptoms while others do not?
- It is genetic!: Many authors describe a familial link for acne. Yes, acne is a genetic, heritable condition. But, how is this helpful? I sometimes indulge in a little reading around twin research – I find it fascinating to read about the familial traits of health conditions. However, we don’t yet know which genes are implicated in acne, and we don’t have a gene therapy. So, is this actually helpful for the sufferer of acne? And the cases of identical twins where one experiences acne and the other doesn’t tells me that it may be simpler to deal with the environmental triggers…
- Diet: There is no definitive answer, yet, but I think it probably does. And we have some theories which are worth testing. Eg, Cordain et al (2002) longitudinal study of Papua New Guinean and Peruvian nonwesternised populations found no acne amongst the population (mainly traditional hunter-gatherer) being observed. This is a significant finding, however, it cannot be confused with causation – we cannot assume that because we see something happening, that it is the cause; in these populations, we must also consider genetic factors; it is shared genetic factors that can dictate how a person looks and the similarities within a group or a culture; it is therefore conceivable that these factors may also affect skin health. But it is worthy of further testing. Also, just how appealing is a traditional hunter-gatherer diet to western adolescents??? Perhaps a low GI approach may be a little more teen-friendly? High GI foods cause a spike in blood sugar levels which will affect hormones and as we have noted above, hormones have a role in acne. Smith et al (2007) (5) conducted a study and their findings suggested that a low GI diet may have a positive impact on symptoms, but that further, larger studies are necessary. Another dietary link is between dairy and acne; Adebamowo et al (2008) conducted a large (4273 participants) prospective study of dairy intake of adolescent boys; they found that there is a positive correlation between acne and the intake of skim milk, but there is no correlation between acne and the fats found in whole milk.
- Stress: I say yes. While there is some debate about whether it is a causative factor, it is frequently identified as something – a period of time, an event – that exacerbates the symptoms. The skin and the central nervous system share a number of hormones, neurotransmitters and receptors; therefore, it is not out of the question to be able to describe a relationship between these factors and conditions of the skin – in this case, acne.
- Skin Hygiene: The most common misconception about acne is that it is caused by a lack of skin hygiene, and yet there is little evidence to suggest that cleaning the skin will limit blemishes. There is evidence, however, that over-washing, or rigorous scrubbing can irritate the skin and impact negatively on the symptoms. Over-washing may dry the skin and rigorous rubbing or using harsh exfoliants may irritate the skin and cause a general worsening of symptoms and may also cause scarring. Skin cleanliness should include washing twice daily with a gentle cleanser and no rubbing or scrubbing – avoid using a face-washer and exfoliants.
So, we know all of this – what can you do about it?
At the beginning of this blog said that I was not going to offer any tips or cure your acne – I feel that I should leave that to another blog when I can talk about my findings. I am going to offer up this, though –
In 2001, acne prescription product was worth around $US2 billion and the over-the-counter industry was worth more than $US6 billion. There are so many products out there ranging from over the counter washes, creams, and spot treatments to prescription topical creams, tablets and then there is the cosmetic approach with peels and light therapies. With all of this you will find people who will offer to cure your symptoms if you spend a lot of money; be careful, do your research. Check the ace forums, of which there are plenty (acne.org; healthboards; acne discussions; acne). They are full of conversations and consumer reviews about all of the different products. You need to work out what you think is best for your skin; you can seek advice from a medical professional, a dermatologist, or you can seek out a reputable skin specialist who may approach it from a more natural perspective.
Read about diet and stress – learning about these two environmental factors may do more than improve your acne.
And finally, be kind to you. There is a lot of academic writing about the psychological effect that this condition has on the person. Believe me, there are loads of people who understand acne is far more than something a teenager gets and who are working tirelessly to try and understand it more in order to offer you help. You are most certainly not alone.
“And like flowers in the fields, that make wonderful views, when we stand side-by-side in our wonderful hues..
We all make a beauty so wonderfully true.
We are special and different, and just the same, too!
So whenever you look at your beautiful skin, from your wiggling toes to your giggling grin…
Think how lucky you are that the skin you live in, so beautifully holds the “You” who’s within.”
Michael Tyler, The Skin You Live In
(1) Williams, HC, Dellavalle, RP & Garner, S 2012, ‘Acne vulgaris’, The Lancet, vol. 379, no. 9813, pp. 361-372
(2) Farrar, MD & Ingham, E 2004, ‘Acne: Inflammation’, Clinics in Dermatology, vol. 22, pp. 380-384.
(3) Dessinioti, C & Katsambas, AD 2010, ‘The role of Propionibacterium acnes in acne pathogenesis: facts and controversies’, Clinics in Dermatology, vol. 28, pp. 2-7
(4) Zaba, R, Schwartz, RA, Jarmuda, S, Czarnecka–Operacz, M & Silny, W 2011, ‘Acne fulminans: explosive systemic form of acne’, Journal of the European Academy of Dermatology and Venereology, vol. 25, no. 5, pp. 501-507
(5) Smith, RN, Mann, NJ, Braue, A, Mäkeläinen, H & Varigos, GA 2007, ‘A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial’, The American Journal of Clinical Nutrition, vol. 86, no. 1, p. 107
* The concept of suffering involves feelings of loss, physical pain; the person may feel a loss of their integrity, autonomy and humanity. The person who suffers may often feel alone and this can affect a person’s long-term physical, psychosocial, and spiritual well-being.