Going Clear: Advanced Treatments for Adult Acne

The Adult Acne Epidemic

Welcome to the new era of acne, where more and more people experience breakouts for the first time as adults—sometimes even into their fifties and sixties. How lucky that we get to worry about aging and acne simultaneously! According to the Journal of American Academy of Dermatology, 54% of women over the age of 25 have some facial acne. And research at The International Dermal Institute indicates that the type of acne that arises in adulthood is different than that which plagues teenage years—adult acne is more likely to be inflammatory with lesions primarily located around the mouth, chin and jaw line, and with fewer comedones (whiteheads).

Kristina Holey + Marie Veronique

This research supports the findings of Kristina Holey, facialist extraordinaire and co-creator of the Kristina Holey + Marie Veronique collection. Kristina’s typical client presents with symptoms that fit the description above: some type of atopic dermatitis (frequently perioral), jawline acne and facial redness, dryness and irritation. If this sounds familiar, join the growing throng—and keep reading for good news.

About two years ago, Kristina brought to my attention the repeatability of the symptom clusters she was seeing in her clients, and I started noticing how many of my customers were similarly afflicted. We were looking at near-epidemic levels of a distinctive type of adult acne among, predominantly, thirty-something women. Many of our clients were additionally stressed by treatments that seemed to be aggravating their problems. All too often, mainstream treatments, such as steroid therapy, benzoyl peroxide and antibiotics, deliver short term gain at the price of undesirable long-term consequences. Not surprisingly, treating symptoms while ignoring causes can create issues: steroids suppress inflammation for a time but can also trigger the inflammation to return with a vengeance, making the successful treatment of conditions like rosacea almost impossible. Benzoyl peroxide controls Propionibacterium acnes, but prolonged use can cause skin photosensitization and accelerated aging. And the ever-popular antibiotics disrupt microbial balance, which will likely create more inflammation over time.

Kristina and I decided we needed something that didn’t presently exist, so for two years, we worked to develop products specifically aimed at treating the various manifestations of adult acne we were seeing. We began by searching for underlying causes that conventional treatments were not addressing. The problems adults were experiencing didn’t fit the usual etiology of acne vulgaris found in teenagers, where excess sebum and dead skin cells clog pores, leading to Propionibacterium acnes over-colonization and the spread of infection and inflammation. Adult acne tended to be more of a mixed bag: while there was sometimes congestion related to hormonal jawline breakouts, the perioral dermatitis and overall inflammation without the lesions suggested other contributing factors. To complicate matters, adults often come to us with a combination of skin conditions in addition to their acne (such as rosacea) which made treatment more challenging than with teens, who generally have more resilient, uniform and oily skin.  

In observing hundreds of people, we developed a few conjectures:

• Jawline acne suggests hormonal involvement related to clogged pores and P. acnes overgrowth.
• The presence of atopic dermatitis suggests barrier impairment.
• Inflammation might be related to severely disrupted microbiomes, both skin and gut, related to prolonged overtreatment, as well as other factors.

From these hypotheses, we created products and protocols that sought to alleviate the “new” adult acne in its various and sundry manifestations. We wanted to give adult acne sufferers more choices than the antibiotics and benzoyl peroxide that are still being used today, as they were forty years ago, but above all we wanted to broaden the scope of investigation into effective acne treatments centered around adults.

The different types of adult acne, and ingredients that help

Hormonal acne

Virtually all acne formation is linked to hormones, so most of us notice at least a little at the onset of puberty, when hormones begin triggering sebum production that can lead to infection and inflammation. Men produce enormous amounts of testosterone and one of its by-products, sebum, during their teenage years. Once the puberty storm settles down, their skin tends to clear up, though they may continue to have mild break-outs because they have more sebaceous glands in their skin than women. Women, on the other hand, have to deal with fluctuating hormones. Different periods in their lives, such as puberty, pregnancy, perimenopause and menopause, can turn previously clear skin into a landscape of clogged pores, whiteheads, blackheads and blemishes.

How to tell if it’s hormonal acne:

1. It’s cyclical—you have breakouts that show up at regular times during the month, and other times your skin is quite clear.
2. Acne breakouts are specific to certain parts of the face, like the jawline.
3. The pimples appear in clusters and are pus-producing, as in teenage acne.

Ingredients that regulate sebum:

• Retinol, which reverses photoaging damage while clearing up acne, is every adult’s best friend (except if you are pregnant or nursing). Retinols regulate sebum production and lead to smoother skin with fewer wrinkles.   
• Vitamin B5 (pantothenic acid) applied topically, in addition to vitamin B5 oral supplements, can help adults struggling with hormonal breakouts by regulating sebum breakdown.

Ingredients that clear clogged pores:

• Salicylic acid (generally derived from willow bark or other natural sources) is a beta hydroxy acid that works from the outside in to dissolve protein, and is very effective at clearing congestion.  
• Oils high in linoleic acid (omega-6 EFAs), can clear pores clogged with sebum associated with low linoleic acid levels.  The sticky sebum gets stuck in pores, inviting P. acnes overgrowth which can lead to acne.  Besides breaking up sebum, oils create a follicular environment that inhibits P. acnes growth. Omega-6 rich oils like safflower and sunflower are ideal; stay away from coconut oil, which can be comedogenic.

Atopic Dermatitis

Part of the dermatological canon is that barrier function impairment is one of the major causes of atopic dermatitis. The International Dermal Institute’s assertion that some sort of atopic dermatitis, especially perioral or seborrheic dermatitis, is increasingly a feature of adult acne leads to the obvious corollary: growing numbers of adults are suffering from barrier malfunction.  

The stratum corneum (SC), the top five layers of the epidermis, make up the barrier layer responsible for regulating moisture levels in the skin. Compromised barrier function is governed by a variety of factors: aging, daily wear and tear, external skin stressors such as over-exfoliation and use of antimicrobial products, and internal factors such as nutrient-poor diets. Topical ingredients that supply the SC with the building materials it needs to create and maintain its protective barrier suggest a partial solution to barrier malfunction.

How does dermatitis look different than hormonal acne?

1. Perioral dermatitis appears as a rash around the mouth that tends to be bumpy or scaly.  It can look like a red ring around the mouth or can occur around the eyes (periorbital). It is not characterized by pus-forming pimples that are characteristic of acne. 
2. Seborrehic dermatitis mainly occurs on the scalp, but for many people it can also appear as lines of red bumps along the scalp line or other places where there are hair follicles, like eyebrows and beards for men. Dermatitis is differentiated from hormonal acne in that it can be a chronic condition, and the bumps are not pus-forming. 
3. Atopic dermatitis is associated with the very dry skin that occurs when barrier function is inadequate. While dermatitis may be related to barrier malfunction stemming from genetic causes, PD in particular may be self-produced—originating from the overuse of products that disrupt microbial balance and dry the skin. 

Ingredients that improve barrier function:

• Sodium PCA and other compounds that make up NMF (the natural moisturizing factor) keeps SC cells plump and skin hydrated.
• Barrier lipids like cholesterol, ceramides and fatty acids.

Inflammation

Inflammation is the root of all evil, implicated in everything from arthritis to skin aging. We are seeing more and more dry, irritated and inflamed skin, which we attribute to the overuse of harsh exfoliants, skin products that contain strongly anti-microbial preservatives, anti-bacterial acne products and so on. Teenage skin can weather these daily insults, but adults too often end up with a variety of complaints, from rosacea to inflammatory acne—and adults with inflammatory acne, especially, do not want to dry their skin with harsh exfoliants or disrupt microbial balance by using too many anti-microbials.  

How do you know if its inflammatory acne?

1. It’s chronic rather than cyclical.
2. The breakouts are serious and the pimples may be cystic, indicating serious infection.
3. The pimples and the area surrounding them are red and inflamed and may even be painful to the touch.
4. It doesn’t go away, though sometimes it’s better than other times.

This is the most serious type of acne, and one that requires the attention of a dermatologist to resolve. Whatever treatment is recommended, these ingredients can complement it.

Ingredients that reduce inflammation:

• Retinol which, among all its other claims to fame, is also anti-inflammatory.
• Niacinamide (vitamin B3) applied topically helps adults deal with acne that looks less like breakouts and more like inflammation.  
• B vitamins, which no one ever gets enough of. Besides acne, skin conditions like sensitivity to sunlight, cracked lips, dryness, wrinkles, rashes, and hyperpigmentation can signal a B-complex deficiency.
• Probiotics: Topical applications of probiotics help balance your skin microbiome. Full-fat, organic yoghurt with active bacterial cultures can be used to cleanse the skin—its lactic acid gently exfoliates. To cleanse, spread tsp spread onto the face and rinse. To use as a mask, spread ½ tsp onto your face, leave on for 15 minutes, then rinse. A dash of nutritional yeast added to the mask supplies extra B vitamins, and a dash of turmeric helps to control inflammation. To moisturize, spread 1/4 tsp of yoghurt onto the face and leave on overnight.