But for those of you who never had teenage acne or who had some teenage acne problems and outgrew them, it is a real shock to start having breakouts in the mid twenties to late thirties.
This is not shocking to dermatologists; they are consulted frequently by women well past their teenage years who have acne problems. Statistics support the notion that adult acne is a very common problem—50 percent of the females who consult dermatologists about acne are in the twenty-five- to forty-five-year-old group. And many dermatologists feel that this problem is on the increase. It needs to be understood better by those women who have it.
Adult acne can usually be controlled with proper skin care and the intelligent use of over-the-counter medications. And, if that is not enough, dermatologists have expertise and access to prescription medications that will certainly help.
Let us define our terms in the way that dermatologists do. Do you really have acne, or just little breakouts? The word "acne" conjures up a picture of a really bad complexion problem, but it should not. Dermatologists use the term "acne" to cover a broad range of complexion problems, from the very minor to the very severe.
ACNE LESIONS
Blackheads (open comedones) are, visibly enlarged pores filled with a plug of dead skin cells and skin oil. The top of a blackhead is often dark, but in blonds and redheads it may be light-colored.
Whiteheads (closed comedones, milia) are, like blackheads, a compacted mass of dead skin cells and skin oil in a pore. But the top is closed by a thin layer of skin. They are just little white bumps under the surface, best seen by slightly stretching the skin. Pustules, pimples. These are small inflamed (red) bumps with pus in the top. Papules, pimples. Another small inflamed bump, but this one does not have visible pus in the top of it. Cysts, zits, bumps. These are larger, deeper, tender lesions. Often they are so deep in the skin that they may never come to a
head, never develop visible pus. These are the ones that are most likely to leave scars.
So, from the dermatologist's perspective, just about any kind of small or large bump, whether few or many, constitutes a verdict of acne. That's the way it is; do not be insulted if someone says you have acne. Just read on to learn more about acne and what you can do about it.
CAUSES
Blackheads, whiteheads, pimples, pustules, and cysts all probably spring from the same fundamental causes. There are three basic parts to the cause of acne:
1. Active oil glands. By definition, acne is a disorder of active oil glands. The activity of oil glands is determined by heredity and hormones.
2. Blocking or plugging of oil ducts and pores. The small channel through which oil gets to the skin surface may become blocked by a mixture of dead skin cells and oil. Acne problems do not often occur on skin areas where pores are visibly large. That is probably because of a large pore just does not get blocked easily. Acne very often occurs on the chin area of women past teenage, probably because the oil glands are big there but the pores are very small, and therefore easily blocked.
3. Bacteria normally present on everyone's skin may enter the blocked pore and cause it to develop into a pimple, pustule, or cyst.
So now that you know that those breakouts are called acne, that a large number of mature women have acne, and about some of the basic definitions of acne lesions; read on to learn about the various factors that predispose to acne, and may be involved in your own case. Then action can be taken to correct the problem. The last part of this section is about what can be done on your own about the problem—about skin-care routines and medications for acne—and what dermatologists can do.
Acne Means Oily Skin
Acne is, by definition, a disorder of active oil glands. It has been proven scientifically that acne occurs only-to individuals who have fairly high oil-secretion levels. Just remember: Acne means oily skin in the areas where the acne problem is.
A Changing Skin at Age Thirty
Many women undergo a significant skin change sometime between ages twenty-five and thirty-five. This is a change in oil glands, toward bigger, more active oil glands—toward oilier and therefore more acne-prone skin.
Women have been told for so long that their skins are drying out at age thirty that they have a difficult time believing they could possibly be getting oilier at this time. Though not well documented scientifically, this change toward oilier skin is very often noted by dermatologists.
Some signs of this change toward oilier skin:
Pores become larger—and we know that big pores mean big oil glands.
Seborrheic dermatitis develops in the scalp (dandruff and itching) and on the face. These problems, though often interpreted as dry scalp and dry skin, are really a result of oily skin.
Acne breakout problems often develop at about age thirty. That should be the most compelling argument yet. For, again, it is a fact that acne occurs only in oily skin.
There is no consensus on what may be causing this change toward more active oil glands. It is logical to postulate that changing hormone patterns are the cause. Small changes in the relative amounts of male and female hormones can cause large changes in oil glands.
There are lots of birth-control pills on the market, and they contain different hormones, at different dose levels. Their effect—good or bad—on acne problems depends not only on what the pill contains but on the hormone and oil gland complexities of the woman taking the pill. Acne breakout problems may improve or worsen when birth-control pills are started. Some types of birth-control pill usually help an acne problem; other types may, in susceptible individuals, aggravate or even cause an acne problem.
Birth-control pills contain two hormones—an estrogen and a progesterone. Those pills containing a relatively high dose of estrogen are usually better at controlling acne than those with a low estrogen dose. Those higher-dose pills also cause more of the usual pill side effects.
For the acne-prone patient the type of progestin hormone is important—norethinodrone and norgestrel have some male-hormonelike activity, and pills containing it are usually not recommended by dermatologists for the acne-prone woman. Birth-control pills containing ethynodiol diacetate as the progestin seem to be better at helping the faces of acne-prone women, because that type of progestin does not have significant male-hormone activity.
Starting birth-control pills. When a woman begins taking birth-control pills that are the wrong kind for her, her face may break out quickly—in a matter of weeks. When the right kind of pill is started, she usually will not break out at all. But if the pill is being taken to help a preexisting case of acne, she probably will not notice improvement for a long time—three or four months. It takes that long to modulate hormone levels.
Stopping birth-control pills. Most of the breakout problems associated with birth-control pills seem to happen upon stopping the pill. The reason for this is that while a woman is on the pill, her natural hormones have been suppressed; when the pills are stopped, the natural hormones start up again, and often seem to be "out of balance." Until the natural hormones have settled back to normal (which may take several months), acne problems may be a real bother.
Hormone Problems and Acne
Recent scientific studies are shedding more light on the problem of acne in women past teen age. Although these studies do not all seem to agree with each other, the general truth that comes from them is that a significant percentage of women who have acne past teen age do have hormone abnormalities—higher than normal levels of male-type hormones. These levels are almost never high enough to cause obvious masculine changes but are high enough to cause acne. These women are "normal" enough in the hormone department to have normal female hair patterns, to have regular menstrual periods, and to be fertile.
A very few women, though, do have hormone levels so far from normal that they show obvious physical changes in addition to acne: excessive hair growth in typical male areas such as the beard region (even male-type baldness can appear), absence or abnormalities of menstrual periods, and infertility. Women in this category must definitely be under the care of a physician—endocrinologists and gynecologists are specialists in this area—as these may be signs of serious physical problems.
What tests can be done? When abnormalities of hormones are suspected, appropriate testing can be done to determine the problem. Gynecologists, dermatologists, and other physicians can have these tests done for you. They have only recently become generally available. These are blood tests for male hormone levels and they are expensive.
New facts are being discovered in this area each year. You must rely upon a physician expert in this area to help guide you about whether hormone tests and hormone treatments are appropriate for you.
Cosmetics and Acne
Cleansers, moisturizers, bases, foundations, blushers, and even sun-screening lotions may cause previously clear skin to break out; all may make a very minor acne problem into a major one. It is a fact that the wrong cosmetic and skin-care products used on acne-prone skin can cause or worsen acne. Dermatologists call this problem "acne cosmetica" and see it every day. The constant call to moisturize, moisturize, moisturize is responsible for a lot of pimples! One of the most important messages in this book: Do not moisturize acne-prone areas or the face. Do not use moisturizing foundations, moisturizing blushers, or anything else moisturizing on acne-prone areas of the face. Fortunately, at least a few cosmetic makers are finally coming around tc understand this problem and are providing better cosmetic and skin-care products for acne-prone women.
The problem of just how cosmetics promote acne is complicated. Dermatologists and cosmetic manufacturers alike are far from understanding it completely. Tests have been devised to try to determine whether a cosmetic ingredient or formula is likely to cause acne problems. Lists of particularly offensive chemicals are available; at least some, if not most, cosmetic manufacturers avoid using them.
Some cosmetic manufacturers are becoming more aware of this problem and are searching for noncomedogenic cosmetic and skin-care formulas. "Noncomedogenic" means that a chemical or mixture does not cause comedones (blackheads) when applied to skin in laboratory tests. Currently the inside of the rabbit ear is the most used test area. Research is in progress to find a better way to test for the cornedogenicity or acne-causing potential of a cosmetic product.
But, unfortunately, the tests for cornedogenicity are not good enough yet—-products that pass the tests still cause breakout problems on some faces. As of the time of this writing, a label or advertising claim of "noncomedogenic" does not guarantee safety. But it does at least mean that the maker of that product is trying.
The most comedogenic products put on very acne-prone faces can cause noticeable problems quickly—within weeks; relatively less offensive products put on slightly acne-prone faces may not cause problems until the product has been used for three to six months. And there are all degrees between these two extremes. Therefore, it is difficult sometimes to decide if cosmetic products are causing problems at all. But the truth is that they often are. The problem is further compounded by the fact that women in general are using more cosmetic products that ever before, and most women around age thirty are using more cosmetic products than when they were younger. There are more imperfections to cover up. They see little facial lines and are convinced by beautiful cosmetic ads and incorrect skin-care" advice that they need more and more moisturizing products.
Important: Do not moisturize acne-prone areas of the face. This applies to the use of moisturizers and moisturizing makeup foundations. Even if they are labeled "noncomedogenic," they may not be safe. There is more on specific recommendations for skin-care products and cosmetics for the acne-prone face in later posts.
Other Factors That Cause Acne
Acne is such a common problem in the teenage years and beyond, that it has to be considered simply normal. Most individuals who have acne breakout problems are never able to ascertain a specific cause, such as hormone imbalance, birth-control pills, improper cosmetic and skin-care practices, etc. Having acne breakouts may just be the way it is for an individual's skin.
Here are some other factors that seem to cause acne breakouts, or at least aggravate acne:
- Heat and humidity.
- Exercise, with the resulting perspiration.
- Premenstrual hormone changes.
- Stress, with the resulting hormone changes.
- Diet. So much has been written and discussed about dietary influences on acne! Frankly, there has never been much presented in the way of proof of any of it. Chocolate, coffee, cola, nuts, butterfat, greasy foods, rich foods, foods high in iodine—all of these and more have been implicated in acne. The best approach is to understand that there are wide variations among individuals. Those who feel or know for sure that certain food substances aggravate their acne problems should simply avoid those things.
TREATING THE ACNE BREAKOUTS
If hormones or birth-control pill problems are suspected as the cause, a physician should be consulted and testing done if appropriate. Dermatologists, gynecologists, and endocrinologists all share expertise in this area.
If the acne problem is not so severe, home treatment may suffice, using good medications available without a doctor's prescription. More severe or unresponsive cases should definitely be under the care of a dermatologist.
But, whether treatment for acne is being done at home with nonprescription medications or under a dermatologist's supervision, the proper understanding of and approach to treatment is essential. Acne medications, prescription or nonprescription, do several things:
Dry and clear pimples. Kill the germs that are waiting to cause new pimples. Unblock (by their peeling action) blocked pores. Prevent blocking of pores. Prevent acne breakout.
Acne Cleansers
Soaps that contain sulfur and salicylic acid. These are nonprescription items that help acne by their drying and peeling action. Soaps and liquid cleansers that contain benzoyl peroxide. There are prescription-only and nonprescription products available. They help by their drying, peeling action, and they also kill skin germs.
Cleansers that contain granules. These contain just granules and "soap," or may contain sulfur, salicylic acid, or benzoyl peroxide. They are strong and are appropriate only for very oily, nonsensitive facial skins.
Alcohol-based acne cleansers. These contain alcohol and sometimes other solvents and chemicals. They remove oil, dead skin cells, and germs. They are fine to use, but some can be too drying on sensitive skin.
Acne Medications
Benzoyl peroxide lotion and gels. These are the choice of most dermatologists. They kill germs, and the stronger ones cause beneficial drying and peeling. There are prescription-only and nonprescription products available. They come in strengths from 2.5 to 10 percent. There are tinted products (good for covering and spot-treating a bump) and products that dry clear (best for use over the whole acne-prone area—and you must use medications that way if you want to prevent new bumps). They can bleach any colored fabric they touch, and can cause allergic reactions in some individuals.
Sulfur (and salicylic acid or resorcinol) lotions and gels. These medications are fine to use but in general are not as effective as benzoyl peroxide medications. They are especially useful for individuals allergic to benzoyl peroxide. They are available as tinted or clear products. The tinted ones are good for covering and drying an acne bump.
Retinoic acid medications, Retin A. These are prescription-only products and must be prescribed by your doctor. These medications are used as the mainstay of acne treatment by some dermatologists.
Antibiotic lotions and creams. These are also prescription-only products. They are recommended by many dermatologists.
Acne masks. Two products, Neutrogena Acne Mask and Vlem-asque (both available without prescription), are often recommended by dermatologists. They do a nice job of medicating and cleansing. They can be a part of nearly every acne-control program.
Antibiotic capsules and tablets. These drugs are of immense value in treating acne. Tetracycline, minocycline, and erythromycin are the primary ones prescribed. Some seem quite safe for long-term use, some not so safe. Some are quite expensive, some quite inexpensive. Let your dermatologist guide you in the appropriate use of these prescription drugs.
13 Cis-retinoic acid, Accutane. This powerful medication is relatively new and is truly a wonder drug for severe acne. It is expensive and has side effects, but it is so effective that it should be considered by anyone with severe or otherwise unresponsive acne problems. In some cases it permanently cures the acne tendency. It must not (absolutely not) be taken if there is a chance of becoming pregnant while taking it, for there is a very high risk of damage to the developing fetus. Severe birth defects may result.
Zinc. Zinc supplements have been said to help acne in some cases, though convincing evidence is lacking. Ask your dermatologist about this, and do not take zinc without a doctor's supervision.
Vitamins A and E. There is no question that vitamin A is helpful in some cases of acne. Its effect is enhanced if it is taken along with vitamin E. The problem, though, is that the dose of vitamin A required to really help acne is fairly high. Taking high doses of vitamin A, or even moderate doses for too long, is risky, for toxic effects can be severe. Like 13 Cis-retinoic acid, vitamin A can cause birth defects. Do not take these vitamins for acne without specific instructions from your dermatologist.
ACNE TREATMENT—DAILY ROUTINES
If your facial skin is troubled by occasional or constant outbreaks, start doing something about it now. Use available nonprescription medications on a regular daily basis, or consult a dermatologist and use the prescribed medications on a regular daily basis. It is ever so important to remember that daily treatment is the key in preventing any type of acne outbreak.
Cleansing—night and morning. Use fairly strong cleansing measures: medicated cleansers if your skin is not too sensitive, and scrubbing cleansers or scrubbing grains or pads if your skin is very oily and not sensitive. Never scrub hard. Use warm water, not hot. Use cleansing masks such as Vlemasque or Neutrogena Acne Mask, and astringents or fresheners, if you like. Never fail to use a lathering cleanser even if your skin is sensitive. Mild ones are available. (See "Acne Products")
Moisturizing. It is risky to moisturize acne-prone skin areas. It may be better to tolerate a little surface dryness in the effort to avoid pimples. Even the so-called oil-free and noncomedogenic moisturizers are not entirely safe. When women really learn this, they will not spend as much time and money at the dermatologist's office!
Medicating. You should always medicate overnight and morning and night if you can. Start with a relatively mild acne medication (benzoyl peroxide preferred), and then increase the strength of the acne medication as your skin can tolerate it. A little drying and peeling is needed for good effect. Medicate every day, even if your face is clear—this helps prevent new outbreaks. (See 'Acne Products," below.)
Cosmetics. Please reread previous posts—the part that discusses makeup for acne-prone skin.
ACNE PRODUCTS
CLEANSERS
Nonmedicated
Purpose Soap
Acne Aid Bar
Neutrogena for Oily Skin
Phisoderm (liquid and bar)
pHresh 3.5 (liquid)
Aveenobar (for acne)
Almay Oil Control Cleansing Lotion
Medicated
(BP: with benzoyl peroxide) Fostex Medicated Cleansing Bar Fostex 10% BP Cleansing Bar (BP) Oxy Clean Soap Oxy Wash (BP) Sastid Soap
SCRUB CLEANSERS
Oxy Clean Scrub (BP)
Pernox Medicated Scrub Cleanser
MEDICATIONS
Benzoyl Peroxide types
Oxy 5% and 10% (dries clear) Clear by Design 2.5% (dries clear)
Benoxyl 5% and 10% (dries clear) Persadox 5% and 10% (dries clear) Dry & Clear 5% and 10% (dries clear) Fostex 10% (BP) (dries clear) Noxzema Acne 12 (dries clear) Clearasil Vanishing Formula (dries clear) Oxy 10 Cover (tinted) Clearasil Tinted Formula Vanoxide (tinted)
Sulfur Types
Transact Gel (dries clear) Xerac Gel (dries clear) Phiso-AC (dries clear) Propa PH (dries clear) Rezamid (tinted) Acnomel Acne Cream (tinted) Clearasil Adult Care (tinted)
BLEMISH-SPOT COVERUP, MEDICATED
Almay Touch on Blemish Treatment Noxzema on the Spot (10% BP) Clinique Touch-Stick Lotion Clearasil Regular Tinted Stick Janet Sartin Blemish Fix
Germaine Monteil Medicated Cover Up Treatment
THE APPROACH TO ACNE TREATMENT
Acne medications should be applied to the entire skin area that is acne-prone, not just to acne bumps. Acne medications do help make bumps clear up more quickly; more important, they are being used to prevent new bumps.
Acne medications must be used every day. Acne medications do help prevent bumps. Logically, this means that the patient should continue to use them even when the skin is clear, to help keep it clear. It simply does not make sense to get the skin cleared up, then stop medicating until another crop of bumps appears.
Persistence and patience are required. To achieve good results, an acne patient must treat the problem consistently, daily, for a long time. It may take two or three months of daily treatment to see a really significant change in an acne problem. Good results may be seen sooner, but this should not be expected.
Important Comments and Cautions
Most acne medications cause some drying and perhaps slight peeling of the skin surface. This means that the medication is strong enough to do some good. The drying effect does not have to be severe to be helpful—just a slight "chapped" condition is the level of dryness needed. This drying effect is absolutely not harmful to skin. It will not produce wrinkles or any other harm to the skin.
One caution here: Brown- or black-skinned individuals should avoid extreme dryness from acne medications, as darkening of the treated skin areas may result.
Dryness from acne medications should not be counteracted by the use of moisturizers. Resist the urge if you want to stop having breakouts. Even "oil-free" or "noncomedogenic" moisturizers are not safe for acne-prone skin. Some facial areas are more sensitive than others. If those areas get too dry, do not treat them as often; continue the daily treatment of other areas.
The degree of dryness from acne medications will depend upon the strength of the medication, the frequency of use, your skin type, and the climate and humidity. Low-humidity climates and sensitive skin dictate mild medicines. Use common sense in your selection.
If an acne medication causes significant itching, swelling, or blistering of the face, you may have become allergic to something in it. Benzoyl peroxide is the most common cause of allergic reactions, but other types of medications can cause reactions, too. Fortunately, these reactions are fairly rare. Allergic reactions to acne medication can be easily taken care of by stopping all medicated products and applying, several times daily, a .5 percent hydrocortisone cream, which is available without a doctor's prescription. Your dermatologist can prescribe more powerful medications for even quicker clearing. When the allergic reaction has completely cleared, select a chemically different type of acne medication and proceed.
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