Hyperpigmentation results in flat, darkened patches of skin that are light brown to black in colour, and can vary in size and shape. Types of hyperpigmentation include age spots, melasma, and post-inflammatory hyperpigmentation and even lentigo maligna, a form of skin cancer. Hyperpigmentation is one of the biggest skincare concerns today, so if you do have them, know that you are not alone. Read on as Dr Teo Wan Lin addresses your concerns on hyperpigmentation and pigmentation products.
Q1: Do most brightening products target only the top layer of the skin?
It is important to understand from a dermatologist perspective that pigmentation develops from primarily the layer of the skin we call the epidermis. The epidermis itself is further divided into layers, the bottommost layer is known as the stratum basale. It is important scientifically to distinguish that references to the top layer of the skin are actually not accurate because the top layer itself is further divided into five different layers. That being said, the origin of pigmentation is typically from the melanocytes. Melanocytes refer to pigment producing cells – this originates from neural crest cells during the development of the central nervous system via the process of embryogenesis. Pigmentation commonly localises to the stratum basale.
Q2: What are the differences between pigmentation products and brightening products?
In terms of brightening products, one does not use the word brightening in dermatology. However, I understand that it’s a colloquial expression of a topical, that when applied leads to removal of pigmentation, i.e. referring to pigmentation products. This would commonly fall under the category of active ingredients that inhibit the production of melanin, a process we call melanogenesis.
Q3: Do most brightening or pigmentation products make you more sun-sensitive?
I think it’s not to say most. If you were to just zoom in on the synthetic skin lightening pigmentation products, then yes. This is because the most prominent would be hydroquinone and retinoids, both of which could be sun sensitising. Tretinoin which is a form of retinoid and hydroquinone, primarily from its irritating side effects. Having irritated skin means you could be more susceptible to sun damage. On the other hand, botanical or nature derived ingredients that have been scientifically proven to help pigmentation, tend to have little to no side effects. For example, there are certain microorganisms like fungus or kojic acid, that is derived from a fungus in nature, which are helpful in inhibiting melanocyte activity.
Q4: What are the active ingredients in these brightening and pigmentation products?
Most of the active ingredients are tyrosinase inhibitors. Tyrosinase is an enzyme that is actively involved in the production of pigment. Brightening and pigmentation products refer to any active ingredient that has been proven to inhibit the process of melanin formation and melanocyte activity. This would include evidence-based ingredients such as hydroquinone. Hydroquinone has both an epidermal and dermal action when it works in certain conditions such as melasma. In melasma, it is important to emphasise that pigmentation can be both superficial i.e. the top layers, or deep i.e. the dermal layers.
Q5: When pigmentation products advertise that they can effectively treat the cause of hyperpigmentation, are we supposed to believe that?
I think it’s really any descriptive that brands can choose to use. The important thing is the active ingredients the product consist of and the ingredient’s validity based on credible sources. You can carry out a short literature review on the ingredients on a scientific database i.e. Pubmed funded by National Institute of Health (NIH) in the US. If it’s an active ingredient that is scientifically proven, you’ll be able to find more than one paper on that ingredient.
Do note that skincare and cosmetics are not regulated by any authority. The Food and Drug Administration (FDA) in the US and Health Sciences Authority (HSA) in Singapore essentially regulates the incorporation of toxics and banned substances in skincare. They however do not validate claims in skincare. Hence, it is important to first research active ingredients listed in the pigmentation products.
Q6: Do pigmentation products tackle the root of hyperpigmentation or simply “slough off the top layers”?
I believe “sloughing off the top layers” refers to epidermal cell turnover which is the turnover rate of the topmost layer of your skin. There are some active ingredients e.g. glycolic acid, which is a type of AHAs that works well for pigmentation due to its ability to interfere with epidermal cell turnover. Topical retinoids also work by regulating epidermal cell turnover, though via different mechanisms. It targets various pathways in the skin to increase skin elasticity, increase collagen formation as well as decrease deposition of pigmentation.
Q7: Are the causes of pigmentation on the face and other areas of the body the same? What are the different types of pigmentation?
It is common for a layperson or a non-dermatologist to assume that an area pigmentation vs another area is the same. But to dermatologists, pigmentation itself is a very broad topic and there are 20 or 30 different types of pigmentation. The common ones are mostly cosmetic, thereabouts 4 or 5 types of pigmentation. The most common type of pigmentation is sun spots which is known as solar lentigo. Solar lentigo is dependent on age, genetics and amount of sun exposure. Another common type of pigmentation is ephelides, ephelides are genetically coded freckles which are more common in individuals with red hair.
The other common type of pigmentation in people of coloured skin would be melasma. Melasma is categorised into different types, depending on the various depths of the deposition of the pigment as well as the location of melasma. Other causes of pigmentation would be post-inflammatory hyperpigmentation (PIH) – a mark is left from a pimple or a surgery. PIH has to be treated differently from melasma, solar lentigo and ephelides. There are other types of pigmentation and even autoimmune diseases such as lichen planus. Lichen planus leads to hyperpigmentation of the skin. It is dangerous for anyone to assume that it’s a cosmetic problem and try to treat that with aesthetic dermatology treatment.
Q8: How do I eradicate dark spots and pigmentation on my face?
Firstly, it is important to get a correct diagnosis and knowing when the pigmentation becomes dangerous. It is crucial to not assume dark spots on your face to just be an aesthetic problem that you can burn or laser off. Dermatologists are trained to distinguish between various types of moles which are not obviously cancerous. Thus one should seek professional help before any assumptions are made.
A typical red herring would be a condition known as lentigo maligna. Lentigo maligna has been infamously diagnosed by dermatologists as an cosmetic pigmentation issue. However, it is a fairly aggressive form of skin cancer, melanoma. Melanoma has the ability to spread to your lymph nodes and if discovered at an advanced stage, at the very minimum, it causes severe disfigurement due to the extent of surgical resection needed. At worst, it can lead to mortality.
Q9: Lipodisq has been incorporated safely and efficiently to deliver potent skincare actives into deep layers of the skin. What are your views on nanoparticle drug delivery?
Lipodisq is a nanoparticle delivery system that is patented by a cosmeceutical company in the UK. To my knowledge, it is something which certain cosmetic manufacturers also utilise in the formulation of their products including pigmentation products to increase the cutaneous absorption of active ingredients.
In terms of nanoparticle drug delivery, I would say data is very much limited to the commercial interest that is driving the technology and hence the patent protections as well. Accordingly, I currently do not know of studies by the international dermatology community that independently verify these claims Nonetheless, from what we see with literature provided by the parent company that has researched this technology, the data does seem interesting and the technology itself, a safe and sound form of topical delivery.
For many people, blackheads, whiteheads and pimples are a normal part of puberty. However, for some, acne can be a stubborn problem that occurs well beyond their teenage years. This is known as Hormonal Acne. Hormonal acne are characterized by painful and unpleasant pimples. It most commonly appears in adult women ages 20 to 40. In this article, I will be sharing about the science behind hormonal acne and the recommended treatment option.
Hormonal acne is characterised by flare ups during specific periods in the menstrual cycle. Individuals with hormonal acne often present with large painful cysts around the chin and jawline area. Mild hormonal acne is often a normal physiological occurence. However, more severe forms may be directly related to an underlying gynecological problem known as polycystic ovarian syndrome (PCOS). In Polycystic Ovarian Syndrome. Other symptoms may include irregular menstrual cycles, excessive facial hair growth, weight gain in addition to adult acne.
2. Who suffers from hormonal acne?
Sufferers of hormonal acne tend to be adult females who find that the acne persists beyond puberty. In my knowledge, there has not been any clinical epidemiological study performed by dermatologists on the incidences of hormonal acne. However, in my practice, out of 10 adult women that I see, a good 60 or 70% would report an influence of their menstrual cycle on their acne.
3. When should I see a dermatologist for my hormonal acne?
Finally, at the earliest onset of a flare up consisting of more than 5 pimples a month should warrant a visit to a dermatologist. This is especially if one does not have a history of having acne. The earlier the start of treatment, the lower the chances of morbidity from scarring. Acne has severe psychosocial effects as well. Dermatologists recommend that acne treatment should be commenced earliest as persistent acne flare ups cause emotional distress.
4. What is the best treatment option for hormonal acne?
The best treatment option for hormonal acne is to first visit an accredited dermatologist. A clinical evaluation will be conducted to inspect for any other clinical signs suggestive of a more severe underlying gynecological issue such as PCOS. Early detection and concurrent treatment of the underlying PCOS is key to effective control of hormonal acne.
The attending dermatologist will subsequently determine the acne treatment regime based on the appearance of the acne itself, rather than on the fact that it is hormonal acne. If it is predominantly nodules and cysts, treatment will likely be escalated to an oral medication isotretinoin (also known as Oratane or Accutane).
However, most hormonal acne patients have moderate severity, comedonal type acne with occasional painful cysts. These individuals start treatment with an oral contraceptive pill that has cyproterone acetate in addition to the estrogen component. Cyproterone acetate has been proven to block the male hormone testosterone. This is helpful in treating hormonal flare ups of acne. This may also be administered with oral antibiotics which can help reduce inflammation in cases of moderate-severe acne.
Hormonal acne, like other forms of acne, is always treated with topical anti-inflammatory creams in addition to oral medications. An antibacterial cleanser is essential. I have moved away from prescribing chemical antibacterial agents like triclosan to natural derivatives. My patients use a Honey Cleanser Formula made with medical grade honey. Medical grade honey is naturally anti-bacterial and anti-fungal.
Individuals who suffer from extensive comedonal acne around the hairline may actually have concomitant fungal acne- a condition known as Pityosporum Folliculitis. Acne-prone individuals tend to have excess sebum (oil) production, and this also predisposes to increased fungal growth. Malessezia, which is the yeast organism responsible for fungal acne, overgrows in individuals with excess sebum production. This is worsened by humid weather.
Physical therapies such as blue light and lasers help hormonal acne. Blue light helps to suppress the acne bacteria, propionebacterium acnes which is responsible for acne flare-ups.
Lasers such as the carbon laser are semi-ablative, meaning they do not directly traumatise the surface of the skin but still help to resurface gently. These can also help to control sebum production by directly shrinking oil glands. The results are cumulative, meaning that the more sessions undergone, the greater the effects of sebum reduction.
In terms of answering your question as to the best treatment option for hormonal acne, it is important to highlight that acne is a medical condition rather than a cosmetic one. It is caused by a myriad of factors working together. Firstly, our personal genetics, the second being inflammation which is influenced by genetics as well.
Hormonal fluctuations in females during the menstrual cycle indicates that certain individuals are more sensitive to circulating amounts of testosterone than others. Hormones trigger off increased oil production- which aggravates acne inflammation. Bacteria also play a role in acne. Individuals with acne have higher counts of propionebacterium acnes. Diet plays a role as well, with dairy products and foods high in saturated fat causing flare-ups of acne.
With this, one can then medically target several of these processes in the treatment of hormonal acne. There is no one single method. It has to be addressed holistically. If you have primarily hormonal acne that is caused by PCOS, taking an oral contraceptive pill and treating the underlying hormonal issue would help to resolve the skin problem. However, 80-90% of the adult females I see have a combination of factors causing their acne. We have to approach the treatment holistically, addressing all these processes.
5. How can I prevent hormonal acne?
Truth is, many individuals are predisposed to developing adult acne because of their genetics. Singapore’s humid climate is not helpful for acne sufferers, as the moist environment encourages growth of bacteria. Secondary skin infections like gram-negative folliculitis cause pustules and inflammation.
From what I observe, most adult acne patients start treatment too late. Prevention is always key. If you have greasy skin or are prone to hormonal flares of acne, a good skincare routine is helpful. For removing all the dirt, grime and makeup, I advocate double-cleansing. This helps overall to reduce the bacteria load your skin. Cleansing encourages a good balance of good bacteria, eliminating bad bacteria on one’s skin.
Individuals who have hormonal acne tend to get gram-negative folliculitis, a secondary bacterial infection caused by bad bacteria on the skin. Using a well formulated anti-acne pimple cream is also important. This helps to treat inflammed papules and can prevent progression to acne cysts. I have moved away from prescribing topical antibiotics (which lead to bacterial resistance with time) to botanical derived anti-inflammatory active ingredients such as Chlorella Vulgaris, an algae extract which directly blocks sebum production. Natural moisturising factors such as amino acids also helps to reduce inflammation.
The use of antioxidants serums such as vitamin C reduce bacterial counts and can improve acne as well as acne scars. I regularly prescribe hyaluronic acid serum which helps to regulate oil production. An underrated active ingredient is polyglutamic acid, an active ingredient which can hold 4-5 times more moisture than hyaluronic acid itself. The Mineral Booster which I formulated for problem-skin has predominant polyglutamic acid content and is very effective for moisturising throughout the day, over/under makeup. It is an excellent humectant with additional natural moisturising factors which enhances the skin’s natural repair barrier without a heavy cream formula which can increase facial oiliness.
“How do we avoid acne breakouts?” As dermatologists in Singapore, this is the commonest question we get asked. Certainly not a surprise, considering over 90% of the world population is affected by acne at one point or another in their life. Yes, acne is not a problem unique only to Singapore, which has a constantly hot and humid climate that some may try attribute their less-than-ideal complexion to.
Whilst the climate could play a role in proliferation of the P. acnes bacterium responsible for acne breakouts, the underlying cause of it is actually multi-factorial and intertwined with one’s genetics. Given the pervasiveness of acne, there are naturally burning questions surrounding what we can do to get rid of pimples that have popped up and how do we prevent them from reoccurring, which we discuss below.
Pimples that have come to the surface have two possible outcomes. One outcome would be the pimples going away, so the pus and all the debris get extruded out within two to three days. The pimple flattens out and leaves a mark and eventually it fades. The other possible outcome, which is undesirable, would be having the pimple grow bigger and bigger. This becomes cystic acne and may feel as being very deep under the skin. The pimple may also become part of broader acne breakouts, with multiple cysts and may even be painful. It is therefore a no brainer that we want to prevent the second outcome.
The crux here is to understand that having just 1 or 2 pimples a month is classified as physiological acne. This can actually be very well managed with over the counter topical acne creams. However, if you have anything more than five pimples a month, there is a need for prescription medications. Be it in the form of creams or oral medications, because otherwise, you will likely end up in an inefficient cycle, find that the problem keeps recurring and never goes away.
If you have anything more than 5 pimples in a month, it means that under your skin, you have at least 20 pimples gradually rising to the surface. These embedded pimples take turns to come out. That is why some people struggle with having acne which never seems to go away. The pimples do not appear overnight, contrary to popular belief. Micro-comedones, which are little bumps under your skin, rise to the surface of skin through the process of inflammation. These could take 1 to 2 weeks to appear. In the interim, over the counter (OTC) acne medications may be useful in resolving some bumps, especially where there are fewer bumps.
There are plenty of OTC active ingredients we know traditionally for treating acne. These include benzoyl peroxide, salicylic acid, and some people use sulphur based solutions. However, in my opinion, these only work for very mild acne. I personally do not prescribe any of these in my practice anymore, because they cause irritation and very often the side effects outweigh the benefits. Furthermore, you can get a lot of sensitivity, redness, burning and stinging sensations.
If you have more than 5 pimples a month or experience acne breakouts, you have at least moderate to severe acne. This warrants a visit to your dermatologist for comprehensive management of your acne condition. The following are some tips which I would dispense to those having mild acne breakouts, and also applicable as adjuncts during acne treatment and maintenance thereafter.
1. Use anti-inflammatory creams on acne breakouts
In place of the traditional acne treatment ingredients, I am now proposing anti-inflammatory pimple creams that are composed of bioactive viable botanical ingredients. One such cream is the Blemish Spot Cream, which I have formulated using an algae extract and amino acids. This is instead of the traditional harsh chemical ingredients which work by drying out the skin.
With studies in more recent years, we understand more about acne being an inflammatory condition, which is genetically determined. Accordingly, we work towards reducing inflammations. Therefore, certain amino acids like serine and methionine, that help to repair wounds and reduce inflammations, would be effective. If you think of your pimple as an injury to the skin, which it really is, you want the skin to heal faster. By the same principles, the raw materials supporting wound healing, i.e. amino acids, have the effect helping the pimple to resolve.
In addition, lipid extracts from the algae chlorella vulgaris is also a critical anti-inflammatory constituent. A 2015 study showed that these extracts have tremendous efficacy in inhibiting human inflammatory mediators, with nearly 80% inhibition in some permutations, thereby reducing the pathogencity of P. acnes in causing acne breakouts.
Another key ingredient in the Blemish Spot Cream cream tackles oil production. Oil production significantly worsens acne, causing it to become more inflamed. The abundance of oil also becomes a perfect breeding ground for bacteria, to even cause secondary bacterial infections. In this light, we use extracts from the Argania spinosa tree, colloquially known as argan oil, to reduce oil gland activity. Apart from regulating oil production, sterolins (a form of plant fats) in argan oil also has a potent anti-inflammatory effect from dampening overactive antibody immune responses.
Botanical-based anti-inflammatory creams have in fact increasingly taken the place of prescription antibiotic ointments in our practice. You may have heard of clindamycin, clindoxyl and erythromycin gels which are topical antibiotics that kill surface bacteria. The antibiotic gels, however, have demonstrated limited success in suppressing acne inflammation. Furthermore, I think it is important to highlight that these lose efficacy after a maximum of 3 months. This is because the body gradually develops resistance against topical antibiotics and should be closely managed by your dermatologist.
A more sustainable second category of prescription medication would be retinoid creams. Retinoids belong to the vitamin A group of topicals. Different trade names exist, although by and large the mechanism of action is similar. Essentially, retinoids such as tretinoin work by treating the microcomedones under the surface of the skin.
They accelerate the rate of cellular turnover of the skin, thereby bringing up to the surface microcomedonic bumps in the first one to two months of treatment. This is before they start to suppressing the growth of such microcomedones. However, these are not without side effects, such as redness and irritation which may occur during the course of treatment and needs to be monitored by your dermatologist.
For those with mild acne, the potent anti-inflammatory properties of the Blemish Spot Cream will be handy in resolving acne breakouts. This is especially when the pimples are not yet fully inflamed and in clinical practice for such cases, has demonstrated particularly quick spot resolution of comedones. For those undergoing acne treatments or maintenance post treatment, the Blemish Spot Cream may also be used for prevention of acne breakouts around acne-prone areas.
2. Use an anti-bacterial cleanser
I think for acne it is very important that you use an anti-bacterial cleanser. For the ladies, double cleansing works in this method – oil soluble pigments such as those from makeup, especially eyeliner, mascara, eye shadows pigments, need to be dissolved in either a micellar formulation or a oil based emulsion. The oil-in-water emulsion forms a milky formula which is what I usually recommend to my patients because this is much gentler on skin.
The second stage of cleansing is where acne-prone skin would benefit from if done correctly. An anti-bacterial face wash in the past to us meant using a chemical such as triclosan. Triclosan, while effective in preventing acne breakouts, has had some controversy in its use. Although not definite yet, it has some reported effects on the human hormonal system and that is why I have also stopped prescribing that. Instead, we use a medical grade honey cleanser which helps to emulsify the grim, dirt, and it forms a foam which is not based off a very strong lathering agent like the laureth sulphates.
We are using the natural emulsifying lathering properties of honey and the same would go with a product such as soya. The great things about these natural emulsifiers is that they form a layer of what we call a humectant after you wash it off. This is so that while your skin feels clean after a wash, it is not dehydrated. The humectant layer in fact stays on the rest of the day and helps to form a healthy skin barrier between your skin and the environment to help prevent the onset of acne breakouts.
3. Healthy diets go a long way to prevent acne breakouts
The other aspect that should not be neglected would be your diet. I find that if you have problem skin and we start you on treatment, almost everybody will get well as long as they comply with treatment. However, the rate of recovery as well as the sustainability of the positive effects of treatment is significantly better in the group where they are conscientious with their diet.
We now know that diets high in trans fat, i.e. deep fried foods, dairy products, sugary foods, are pro-inflammatory which means that it can exacerbate your underlying acne conditions to cause acne breakouts. I tell my patients to stay away from that and also take an anti-oxidant rich diet. It is very hard to imagine that we are not what we eat. The same goes for skin, an organ that needs to be respected along with whatever nutrition that goes to your skin, which occurs via 2 ways.
Firstly, nutrition to the skin is topically applied and to me that is the most significant such as in the form of antioxidant cosmeceuticals. The second means, by consumption, is for the healthy functioning of all your tissues. This is for it to fight the daily assaults of free radical formation from environmental pollution, uv exposure, biological ageing. It is critical that have your supply of anti-oxidants in diet and all these do not have to be found in supplements which may be controversial, in terms of the amounts that have to be ingested in a sustainable manner.
We should perhaps instead look towards a healthy natural anti-oxidant rich diet. Do include lots of blueberries and even olive oil. Olive oil in our diet has been proven both by cardiologists as well as within the dermatology research community to have positive anti-ageing effects on the heart as well as on the skin. These factors do add up eventually for healthy skin that is free of acne breakouts.
In the current COVID-19 situation, people might think that there is no need to pay attention to stay at home skin care, since staying home is the safest environment for the skin. Whilst it’s true that the home environment is generally a lot more conducive than the outdoor environment for skin, such as avoiding onslaughts from the sun’s ultraviolet, there may be some lesser-known “dangers” to your skin while staying home. In this article, we seek to explore these lesser known stay at home skin care “dangers” and some tips to keep them at bay.
Stay At Home Skin Care “Dangers”
First of all, when indoors and leaving the air conditioning turned on all the time, you may not be paying attention to the ambient humidity. The combination of a dry environment caused by the air conditioner as well as the fact that it is a lot cooler than our usual climate, can increase a phenomenon known as transepidermal water loss. This essentially refers to evaporation of our skin’s innate moisture levels to the environment and this can cause a bit of dry skin in individuals who otherwise have normal skin. For people who are prone to dry sensitive skin, this constant indoor air condition environment may be severe enough to trigger an attack or flare up of eczema.
The other thing in the entire context of us staying home all the time, would be there is definitely less physical activity than if we went about our daily activities. This is especially so for people who are dependant on domestic help, for example, then they may be extremely sedentary during this stay home period and lack of exercise is not good for the skin as it is for the human body as a whole. The skin, like any organ, relies on perfusion or circulation and blood flow to deliver nutrients to it, and even more so, being the largest organ in the human body.
Furthermore, if you are gaining a lot of weight without exercise, that is detrimental to your skin in the long run because fats cells secrete testosterone. Testosterone is the male hormone that causes people to be more prone to acne and greasy skin. Finally, if you are always looking to snacking when you are at home, do bear in mind that if you are eating a lot of deep fried snacks like potato chips or sweets like chocolates and dairy, all these can increase your risk of inflammatory skin conditions, in particular conditions such as adult acne.
Stay At Home Skin Care Tips
The situation of the COVID-19 pandemic and us having to spend a lot of time at home, is a good opportunity for us to pay attention to what is first of all essential, efficient and sustainable, rather than “oh you know I got more time now I’m just going to add on a million and one things to my stay at home skin care regime”. It could be very opportunistic for beauty brands to advise anything otherwise. Therefore, from a dermatologist’s perspective, my advise doesn’t change whether it is in the time of a pandemic or in an ordinary day.
The basic principles are if you are suffering from a skin condition, please get it treated by an accredited dermatologist, rather than going around trying all sorts of different products or googling to see on beauty forums what people use or DIY methods. This is because none of these will work if you truly have a persistent skin problem, that is, anything lasting more than 2-3 weeks and is recurrent or chronic.
If you don’t get that out of the way, no matter how wonderful your skincare regime is, you’re not going to see results. In fact, it would be a blind process trying to encourage somebody to do a stay at home skin care regime, just because they are spending more time at home.
If you have healthy skin or say you are experiencing a little bit of ageing and want to optimise what you do for your skin, it is a good time for people to realise that facials, medispas and even what we consider therapeutic treatments such as cosmetic lasers or HIFU (High Intensity Focused Ultrasound) technology for aesthetic purposes, are not essential services. In a time such as now, these aesthetic services will not be available and are therefore not sustainable.
On the note of sustainability, it is important to see that whatever is science based and is a topical will fare better as stay at home skin care. If you are able to apply the topical yourself, the good news is that you are in full control of it and you do not need anyone else to apply it for you. Nonetheless, it is important to be a voice of discernment in this case so we hopefully can help people on this topic of science-based topicals, or cosmeceuticals.
Cosmeceuticals are cosmetics infused with pharmaceutically bioactive ingredients. There is currently limited regulatory control on cosmeceuticals, so it is important to do your brand and ingredient list research. As a general rule of thumb, we would recommend including plant antioxidants, so look out for an ingredient such as centella or portulaca oleracea which is something that we have included in all of our antioxidant skincare formulations.
In addition, we recommend as basics for stay at home skin care, the use of a stabilised vitamin C serum and a ceramide-based moisturiser. Stabilised vitamin C, such as sodium ascorbyl phosphate, is effective in conferring would healing benefits to skin even at concentrations of 5% or less. This is whilst avoiding the pitfall of skin irritation as with raw un-stabilised ascorbic acid, which is often formulated in higher concentrations at >10% to counter the ease of degradation in atmospheric oxygen. Ceramides, on the other hand, are like to the skin, the cement used to stick brick walls together, and help maintain healthy skin barrier function to regulate water loss which any good moisturiser should.
There is no point in using just serums blindly in a stay at home skin care routine, because at some point in time you do need a cream. This is so even if your skin is very greasy and the key thing is to avoid occlusive creams like paraffin and vaseline. Instead, go for a moisturising cream well formulated with ceramides, which will be helpful even if you have greasy skin. In fact, to treat the greasiness on skin, moisturisers play an important role to target the underlying seborrhea, often a form of reactive seborrhea whereby the skin produces even more oil because of stripping away of its natural oils.
Conversely, with a good moisturiser that hydrates the skin, the skin would gradually learn to produce less oil and become less greasy. For intense hydration and oil control on greasy skin, a well formulated Hyaluronic Acid serum in the range of 1% concentration is essential and would prove essential in stay at home skin care. Do note most commercial brands have concentrations of hyaluronic acid much lower.
A good cleanser also plays an important part in any stay at home skin care routine. If you are wearing makeup, makeup removal is done either with a micellar formulation or an oil based emulsion which essentially both function to dissolve pigments, and the same with mascara, eye makeup and lipstick. However, when staying at home and not really putting on makeup, the second layer in cleansing the skin is probably more important and it may be worth looking closely into the function of your cleanser’s ingredients.
In our practice, we recommend a Honey Cleanser. Honey is naturally anti-bacterial and the cleanser further contains an Arnica Montana flower extract that soothes and calms the skin. The cleanser is also gentle on the skin, and avoids the use of skin-drying surfactants such as sodium laureth sulphate which strips away the skin’s natural oils.
We can’t emphasise enough the importance of using a good cleanser and cleansing regularly. Even if you’re not outdoors, don’t get exposed to pollutants or don’t sweat, know that your body naturally produces some oil. This is the case even if you think your skin is very dry, and excess oil on the skin surface contacts and oxidises with particulates in your house environment, which is how clogged pores are formed.
There could also be lots of indoor pollutants and the indoor environment may not actually be necessarily much better than the outdoors.Very limited studies have been done with indoor pollutants like benzenes, volatile agents, formaldehyde emitted from your furniture, paintwork etc and how these affect the skin. Nonetheless, it is postulated that these will generate some form of free radical formation on the surface of your skin, which contributes to skin ageing. Keeping your skin clean and moisturised is no doubt an important part of cosmeceuticals in a stay at home skin care routine.
Do you have pigmentation on your face that you wish to remove? Is it melasma, an age spot, a freckle, sun spot (solar lentigo) or evening a skin cancer? Perhaps it is a scar mark left behind by previous eczema, or pimples. We at TWL Skin, are a specialist dermatologist centre accredited by the Ministry of Health, Singapore. In this article, we ask Singapore dermatologist Dr.Teo Wan Lin about the best methods to treat pigmentation, in this case, melasma. If you do have a problem with pigmentation, we do recommend you seek a proper consultation and diagnosis by an accredited dermatologist. You can find an accredited dermatologist here
Be sure to check your doctor’s credentials to ensure you are seeing a true skin specialist. All dermatologists will be accredited by the Ministry of Health and you can search for them here.
What are some common remedies for melanoma pigmentation?
One common remedy would be the Cysteamine 5% cream (Cysteamine Cream®, ScientisPharma). It is used to lighten the skin in many hyperpigmentation disorders. It can be applied regardless of the amount of sunlight exposure. It is suitable for all skin phototypes, however, a slight burning sensation may be experienced at the areas applied.
What type of cosmeceuticals are available to treat melasma pigmentation?
Cosmeceuticals for treating melasma include phenolic compounds such as hydroquinone, mequinol, arbutin, vitamin C and vitamin E. Vitamin C may play a role as it is devoid of any side-effects, can be used alone or in combination therapy.
Controlled studies with vitamin E show insufficient evidence of effectiveness in treatment of specific dermatologic disorders. However, there is a large body of experimental evidence proving its photo-protective effects. More information on the role of Vitamin C in treating hyperpigmentation can be found here.
There is a recent safety concern regarding the use of hydroquinone for pigmentation. What is your view on it?
Hydroquinone can cause DNA damage as demonstrated in studies done in rodent models and cultures. This carcinogenic effect has raised concerns regarding its use. Due to this, the International Agency for Research on Cancer has placed hydroquinone as not classifiable as to its carcinogenicity in humans. The Food and Drug Administration (FDA) has even proposed banning over-the counter skin bleaching agents containing hydroquinone. However, it should be kept in mind that these studies were based on oral and parenteral doses and there have been no clinical studies or cases of skin cancer or internal malignancy related to topical use.
I would recommend using cosmeceuticals instead, such as the one in my range, the Radiance Fluide. It contains niacinamide, vitamin E, extracts of grape seed, aloe vera and plant antioxidants which all inhibit the activity of tyrosinase. This results in decreasing skin pigmentation, vitamin C which is a stable variant known as sodium ascorbyl phosphate. I have a new concept pharmacy where we incorporated a mask bar, vials of the cosmeceutical ingredient alpha-arbutin, is very effective at removing skin pigmentation and also goji berry extracts.
The key is we are limited by how much the skin is able to absorb the topical so the premise of the mask bar is to incorporate these customizable mask essences into a reusable sheet mask which increases the absorption of the cosmeceutical ingredients leading to better efficacy. The material that we have used is actually derived from proprietary plant technology. it is from the roots of a plant that has grown roots that is able to absorb enormous amounts of moisture and hold reservoirs of these micronutrients.
It is also ecologically friendly, it is grown from sustainable sources and it is also biodegradable. Unlike the commercial mask sheets which are extremely wasteful, the great thing about this mask is that it is reusable. You just wash it with anti-bacterial honey cleanser and you can use it up to 5 times with a different mask essence each time.
More information on the use of cosmeceuticals vs hydroquinone for treating hyperpigmentation can be found here.
What treatments would you recommend for melasma pigmentation?
In terms of a treatment that can deliver quick and long-lasting visible results, there is no easy answer. For prescription medication such as retinoids and hydroquinone, the effects are often dramatic and fast. However, in terms of how long-lasting it is, it really depends. I usually make the switch from prescription medication to cosmeceuticals after a maximum treatment duration of 3 months. The prescription items always have side effects and using hydroquinone for longer than 3 months can lead to a condition called ochronosis which is paradoxical hyperpigmentation due to the use of hydroquinone.
In terms of long-lasting results, I feel that it is important to reinforce a skincare regime with cosmeceutical active ingredients. Even if you have been given the prescription item by your dermatologist, beyond 3 months, you really should get started on anti-aging cosmeceuticals which contain active ingredients like arbutin, kojic acid, niacinamide and plant-derived antioxidants like grade seed and aloe vera. These have all been proven to help in inhibiting the process of the skin producing pigmentation. In addition, one should never forget the use of a medical-grade sunscreen being the cornerstone of prevention and maintaining the results you have achieved with any treatment.
In my practice, my patients with hyperpigmentation, if its melasma or post-inflammatory hyperpigmentation, they undergo a q switched laser known as 1064 q switched laser toning device and this is in combination with either prescription medication (retinoids and hydroquinone) and also cosmeceuticals like vitamin C and medical-grade sunscreen of SPF 50 which blocks against UV A and UV B.
For targeted legions such as sunspots and freckles, I use a wavelength 532nm laser which helps to remove the pigment spots after just a single session although multiple sessions are usually required to completely remove it. Again, the recovery process is heavily dependent on the skincare because how the laser works is by injuring the skin and prompting the skin cell to try to heal perfectly so as to remove the pigmentation.
In the absence of antioxidants topical skincare, it is unlikely that the results will be favorable. If sun protection is not used, the problem is very likely to recur again. Then again, I tell my patients whatever sun spots or pigmentation they develop now is not due to sun exposure in the last year or even in the last 2 years. It is probably way before that. Thus, the importance of starting a good skincare regime as early as possible.
On the restrictions on using brightening or whitening products, I think that it is important for any of these conditions to be revealed first by an accredited dermatologist. This is because what is just a brown spot to you, to the beautician, may actually turn out to be a skin growth, some early form of skin cancer. They start off as being pigmented spots and it is really terrible to just treat it as a cosmetic concern. An accredited dermatologist can pick that up.
There are some very dangerous skin cancers such as melanomas, a variant which is known as lentigo maligna, which really looks like pigmentation to a lot of doctors and to the laypeople. Dermatologists are trained to pick that up and it is actually a dangerous form of melanoma.
Nevertheless, over the counter brightening and skin- whitening products, if they have gone through the correct authorities such as the Health Sciences Authority or DFTA, they would not contain prescription medications that are prohibited to be in the over-the-counter preparation. The importance of this is that if you use prescription medication such as retinoid steroid or hydroquinone which is a bleaching agent without medical supervision, you are at high risk of developing skin irritation known as dermatitis which is a form of eczema. This inherent risk occurs even if your skin is normal without any underlying problems.
In fact, it can get very serious. You can get skin toxicity due to exposure to both the chemical ingredient and sunlight, you can get paradoxical darkening.Above all, there are some countries in the world such as South America and some parts of Asia, where there is easy access to potent topical steroids for people who want to lighten their skin. This is first of all, extremely dangerous because potent topical steroids can cause permanent skin thickening. There will be dramatic results in the first couple of weeks but afterwards, the damage will be irreversible and it is a very bad idea for anyone who wants to pursue skin lightening in that way.
Also, if you have underlying skin conditions like eczema, acne and a condition whereby you lose pigment on your skin due to an auto-immune disorder known as vitiligo or any long term medications, it is very important for you to check with an accredited dermatologist whether it is safe for you to use any of the prescription medication.
The popularity of skin lightening and brightening products is very much tied to the Asian definition, the traditional definition, of beauty which includes having very fair skin which is really not common in other parts of the world. I guess it is really about the marketing and the skincare manufacturers who targeted this vulnerability and insecurity of a lot of women. My standpoint is if you do have hyperpigmented spots, there are ways to treat it medically. If you are looking for a topical that can lighten your skin, I feel that it is not sustainable because we are all with a certain amount of pigment on skin and this is protective.
Living in a country like Singapore where we have 100 percent of UV rays right at the equator, we also have this natural protection with the melanin we have to fend off the sun UV ray which can lead to skin cancer. Rather than trying to change your skin color, I feel that it is important to appreciate your skin tone.
I have actually written about skin tones about, there are cool, neutral and warm skin tones. Somebody who is very fair tends to be of a cooler skin tone than somebody who is darker with a warm skin tone. There are colors that you wear, it could be lipstick colors or the clothes you wear, that would bring out the best radiance in your complexion. Rather than trying to bleach your skin through unhealthy methods, I think that it is important to note a few things.
Firstly, if you have pigmentation disorder, do get it checked up by an accredited dermatologist and there will be medically-sound therapies that will help to treat it. Second, to maintain healthy radiance skin, it is good to start on a good cosmeceutical regime. Masking is an important concept that can help to deliver the lightening agents to your skin in a more effective way. Click here to find out more about the Dr.TWL Custom Mask Bar System.
Finally, wear colors that are complementary to your skin tone to look healthy and radiant.
What is the difference between brightening and whitening products?
Let’s define these two terms as scientifically as possible. Brightening would refer to an overall increase in skin radiance and luminescence whereas whitening is more targeted towards removing pigments.
For the brightening effects of skincare and topicals, one would be looking at the physiological pathways targeted by these products. The most common and scientifically-researched route is via a mechanism known as cellular torque. The use of oligopeptides such as that which is in the radiance emulsion moisturizer helps to convince the skin cells to regulate themselves such as to remove excessive pigment.
For whitening products, I would be looking more towards prescription medications such as hydroquinone which is essentially inhibiting the pigment cells, the melanocytes, from producing melanin. There are other non-prescription cosmeceutical ingredients that can achieve a whitening effect such as alpha arbutin.
The other difference aside from the effects are the active ingredients. I think it is very important to note that most whitening products that are advertised by cosmetic brands are not allowed to contain prescription medication. These products are not known to bleach the skin but rather can lead to some inhibition of pigment production such as inhibiting the enzyme tyrosinase. They are meant to be applied over a larger area to even out skin tone pigmentation rather than specific whitening products such as hydroquinone which I would only apply to the affected areas to avoid bleaching of normal skin.
Acne in teenagers and adults is a troubling condition, affecting one’s self-esteem and confidence levels. In my clinical practice as a dermatologist, acne vulgaris, colloquially known also as pimples, forms at least 50% of the daily load of patients I see. There are many aspects to be addressed within the dermatology consultation.
This varies from the cause of pimples, to questions about effective acne treatments, DIY formulas, over the counter acne creams and prescription medications. I have sought to share as many of these treatment pearls in the following article as comprehensively as possible, and hope it can help shed some light on the best acne treatments available.
Dr. Teo Wan Lin is an accredited dermatologist and an expert on cosmeceutical skincare research and development. She is the author of “Skincare Bible – Dermatologist’s Tips for Cosmeceutical Skincare” which was published July 2019 by leading bookstores Barnes & Noble, Baker & Taylor and Apple Books and available in bookstores islandwide from January 2020. She is the founder of Dr.TWL Dermaceuticals, a specialist cosmeceutical skincare line with evidence-based active ingredients for anti-ageing and skin health. Dr. TWL Pharmacy is the only full fledged online specialist dermatologist compounding pharmacy in Singapore and is jointly headed by a trained pharmaceutical engineer for strict quality controls.
Why do pimples form and what exactly is happening to your skin when a pimple forms
Pimples is the colloquial term for Acne Vulgaris. This refers to an inflammatory condition of the skin that presents with blackheads and whiteheads, otherwise known as closed comedones and open comedones respectively, inflamed papules as well as acne cysts. The cause of Acne Vulgaris is multifactorial.
First of all, it is determined by one’s genetics. Individuals with a family history of acne tend to have a higher chance of developing acne. This is brought on by the onset of puberty which leads to the secretion of the male hormone, testosterone. Testosterone, in turn triggers oil production in both men and women. That being said, sebum, the oily substance secreted by your sebaceous glands, is essential for the entire process of acne formation.
The third thing that occurs due to one’s genetics, is the process of inflammation itself which leads to comedone formation. All pimples whether whiteheads or blackheads arise first as microcomedones under the surface of the skin.
When they reach the surface of the skin, they become visible. The process that drives this is a mix of genetics, the presence of sebum as well as some form of dysregulation of the process of follicular keratinisation i.e. the way your skin retains dead skin cells around your skin pores.
Aside from genetics, there is also the involvement of a bacterium known as Propionibacterium acnes – a heavy commencer in individuals who suffer from acne. Finally, a lot of acne flare-ups can be due to the secondary bacterial infection of existing acne bumps known as gram-negative folliculitis. This tends to present with pus-filled papules and tend to have a yellowish tip.
I have observed that I always get acne in the same spot
While I do hear this coming from my patients quite often, i.e. “I always get this one pimple now and then on my cheek, chin, forehead…”, there is no scientific answer to this. From my personal experience, this could be due to one of the following. Firstly, if you tend to pick at your pimples, there is a condition known as acné excoriée. The entire name of this condition in french is acné excoriée des jeunes filles meaning acne excoriée of young girls.
There is an element of this compulsive picking of acne and this is the main reason why I find my patients having acne at the same spot. They constantly pick at it so even when it is healing, it does not get the chance to heal and picking introduces secondary bacterial infection.
The second reason why is because you are suffering from some form of acne that is related to occlusion. Some people wear helmets or face masks. If acne develops around that area, it is a type of acne known as occlusion acne. It could also be due to the application of comedogenic, hair waxes etc.
The third thing, if you are talking specifically about acne on the chin, you have to consider perhaps it is not acne at all. There is a condition known as perioral dermatitis. Perioral dermatitis looks very similar to acne and if you are seeing a non-specialist, it is very easy to be confused. This is because the bumps look very similar to acne, except that it is a mixture of eczema and inflammation, acne bumps, or it could even be acne rosacea.
All about Acne Creams
When you apply a pimple-clearing product to your pimple, what happens to the spot? What are some of the ingredients that you’d want to look out for in a pimple product, and what should you avoid? Are pimple drying lotions ok for the skin and how do they work?
If you find yourself searching online for answers to these questions, you are not alone. These are some frequently asked questions by sufferers of acne and I shall seek to clarify them here. There are a few categories of pimple-clearing creams. The first being the good old-fashioned creams that simply dry out the skin and reduce sebum production.
Pimple Drying Medications
This category would include topicals that contain the following active ingredients: benzoyl peroxide, salicylic acid, calamine lotion, sulfur-containing lotions. In some mild cases these creams may lead to an improvement in acne itself.
Pimple Creams Containing Antibiotics
The second category of acne treatment creams would be those containing antibiotics. The commonest antibiotic-acne gels would be those which contain clindamycin or erythromycin as an active ingredient.
These work on the premise that a lot of cystic acne is caused by secondary bacterial inflammation. As with all topically applied antibiotics especially in a chronic skin condition like acne which is not primarily due to skin infection, there is a huge problem with using topical antibiotics.
Topical antibiotics work well in a short-term simply because the skin has never been exposed to it. But very quickly the body learns to identify the antibiotic and develops resistance.
This is particularly concerning because the resistance doesn’t just take place in the skin level. Exposure of the topical antibiotics on the skin level leads to resistance systemically as well. For example, it could lead to antibiotic resistance when one is older.
The main thing about antibiotics is that it is a mere short-term fix and does not work after some time. There are other combinations of antibiotic gels, such as clindamycin combined with benzoyl peroxide which is the active ingredient present in the OXY pimple cream. The benzoyl peroxide component has been proven to reduce the emergence of bacterial resistance.
Prevention Creams – Retinoids for Acne Treatment of Whiteheads and Blackheads
The third category of pimple creams which I consider more preventive rather than treatment sort of cream is the retinoid category. These are the vitamin A derivative creams. We have heard of creams like tretinoin and adapalene which may have differing trade names. Both these creams are Vitamin A derivatives and they work via preventing microcomedone formation.
However, when you apply these creams, you should not apply it to inflamed active pimples as this can worsen the inflammation process. Rather they should be used in conjunction with active acne treatments prescribed by a dermatologist which is proportionate to the severity of your acne as preventive treatment. When you start applying a retinoid cream for example, you only get to see the result 2-3 weeks later.
A Dermatologist’s Recommendation of the Ideal Pimple Cream – New Generation Anti-Inflammatory, Anti-Sebum Pimple Creams
The fourth category of acne treatment creams is actually what I actively advocate now and which we have formulated in a highly effective Blemish Spot Cream under Dr.TWL Dermaceuticals. It is targeted at reducing inflammation itself. I am very convinced that botanicals have a prominent role to play in cosmeceuticals.
Cosmeceuticals are no longer just confined to the realm of having anti-ageing properties but are also adjuncts for the treatment of many medical skin conditions. I have used botanicals extracts successfully in the treatment of rosacea for example.
For acne, I incorporate an algae extract from chlorella vulgaris which actively reduces the oil gland activity. This is combined with amino acids such as methionine and serine that help to heal the skin when you apply it. The main thing is that when you try to dry up an active pimple, very often you get more inflammation as you are burning the skin around it.
What you need to do is to try to get the pimple to heal as quickly as possible. This is so that you minimise the risk of scarring. At the same time, this also treats the underlying problem of acne pimples which keep forming.
Are there different pimple creams best suited for the different types of acne (eg blackheads whiteheads, red swollen pimples)?
For tretinoin and adapalene which are the two main available form of vitamin A creams, these should not be used for red, painful, swollen acne treatment. They are best suited for comedonal acne which would be your blackheads and your whiteheads. For drying pimple creams, like benzoyl peroxide, salicylic acid, calamine lotion, I don’t recommend applying these to areas that have broken skin.
If you apply these to broken skin, the irritation and drying potential is just going to be multiplied. Potentially, you are going to end up with something that looks like a chemical burn. That is something much redder with a lot of peeling flaking and bad scarring.
Instead, I would recommend using an anti-inflammatory product with botanical-based extract that doesn’t contain anything irritating like salicylic acid. For example, the one we use is based on an algae. There is no issue applying this over areas with broken skin, although it also really depends on the formulation itself.
In addition, for a correctly labelled and medicated acne cream, i.e. not just a cosmetic product, there would be very clear indications of use available.
Does my skin ever get used to pimple-clearing products – is that why my pimple never seems to heal?
If you are using a medication like clindamycin and erythromycin, then yes because you develop real bacterial resistance which stops the medication from working. If you are using something which is drying such as the first category I spoke about earlier, or something anti-inflammatory, there is no evidence that your skin can actually develop a form of resistance to that. It is simply that the severity of acne has progressed or in the first place it wasn’t sufficient acne treatment.
Adult Acne Treatment
For patients with mild acne, they will have approximately 3-5 pimples every month and they tend to be of the teenager age group. Once you are past your teenage years, from the age of 21 onwards, it is a different ballgame of what dermatologists term as adult acne. If you still suffer from acne then, meaning having an average of more than 5 pimples every month after the age of 18, it is at the minimum, a case of moderate acne.
Moderate severity acne means that while you don’t have severe scarring or cystic acne, it is still very persistent and would need to be treated medically by an accredited dermatologist. In my clinical experience, moderate acne does not respond well to topicals only regimens. Topicals are only useful as an adjunct in the treatment of moderate acne.
On the other hand, using appropriate cleansers and pimple-clearing gels works well and is sufficient for mild acne. It may be a selection bias by default, given that attendances at a dermatologist practice would be moderate cases.
This is because the mild cases perhaps get treated at the GP level before they do get to us. Moderate cases of adult acne would need more treatment than just topicals. According to international dermatology guidelines, there are two options for the treatment of adult cystic acne.
Oral Acne Treatments
Firstly, the oral pathway for which I must emphasise that there are many oral medications that are safe and effective that have been widely prescribed by dermatologists internationally for decades. Examples of commonly prescribed medications include low dose oral antibiotics like doxycycline, erythromycin. These function primarily as anti-inflammatory medications to prevent comedone formation.
Minocycline is less frequently used these few years as it has been linked to a few rare cases of hypersensitivity syndrome, on top of potentially causing blue-grey skin discolouration.
Erythromycin in particular is safe for pregnant and lactating individuals. Oral contraceptive pills such as Diane-35 and Estelle-35 contains estrogen as well as cyproterone, which blocks androgen (testosterone activity). Androgens are male hormones that trigger off oil production, exacerbating adult hormonal acne.
Women with a history of irregular menstrual periods with cystic acne may have undiagnosed polycystic ovarian syndrome (PCOS). Such individuals will benefit from joint management of a dermatologist and a gynaecologist. Treatment of PCOS is with hormonal therapy, which will benefit adult acne treatment as well as preventing infertility.
Non-Oral Acne Treatments and Physical Therapies
Secondly, we have the non-oral pathway for acne treatment which involves physical therapies that have to be administered in a clinic setting. For example the usage of LED wavelengths, blue-light, two times a week for one month.
Blue light is therapeutic for treating acne that is especially worsened by the bacteria Propionebacterium Acnes. This has been proven to be effective in a regimen of twice weekly 30 minutes duration for a one month regimen.
Chemical Peels and Lasers for Acne Treatment – Can they be used independently?
Use of chemical peels and specific lasers like the carbon laser helps to shrink the oil glands of someone with active acne, especially in individuals that may not want to go on oral medications.
I always recommend those with persistent moderate acne to go for a short course of a safe antibiotic such as erythromycin or doxycycline in conjunction with any of these physical therapies. This is the most cost-effective option that targets inflammation that goes on in acne rather than blindly treating it from the surface.
For severe acne, you may suffer from deep painful cysts which often involve pus and bleeding and there will be a lot of scarring. The treatment for this is very straightforward, our first line is always this medication called isotretinoin.
The medication is also known as accutane or oratane which are brand names of the forms of isotretinoin available. Isotretinoin is an extremely effective oral medication which works essentially by shrinking your oil glands.
Without oil, your skin simply doesn’t produce acne. However, isotretinoin use does come with drawbacks like increased sun sensitivity, dryness of the lips and eyes. One also has to monitor your liver function and cholesterol levels whilst on isotretinoin.
A lot of patients in my practice have asked me to gauge the number of days to determine if an acne product works and my answer is simply this.
The Wound Healing Process of a Pimple’s Life Cycle
When a pimple forms it is best viewed as an injury caused by inflammation to the skin. You may go by the principles of wound-healing, especially when it only involves the top two layers of the skin (the epidermis and dermis).
Within the first 2-3 days of a cyst, there should be signs of pus draining. Should there be blood coming out of it, soon one should observe the redness and swelling resolving as well.
Acne That Does Not Heal
Acne may progressively accumulate and get larger instead of reducing in size. For example, the acne may get more painful, accumulate more pus and blood that doesn’t seem to be draining. When this occurs, one has to consider that there is an underlying cyst forming.
What is An Acne Cyst?
The formation of an acne cyst involves the collection of haemoserous material – blood, sebum, dead skin, keratin and debris. These substances subsequently get “cordoned off” by the body with a wall around it. This is part of the immune system’s response to inflammation. Acne cysts do not respond well to any topical treatment.
Proper Treatment of An Acne Cyst
Acne treatment of cysts involves a combination of the following. Firstly, an injection known as an intralesional steroid injection helps to reduce inflammation locally. It is injected right into the centre of the nodule and within 3 days, swelling will reduce the underlying swelling.
It is very important for the injection to be administered. This is because untreated acne cysts can lead to more severe problems like facial abscesses with drainage of pus.
Furthermore, it can spread to other parts of your face which is rare but has been documented. Concurrently, large painful acne cysts should be treated with an oral antibiotic such as amoxicillin, sufficient to treat the secondary bacterial infection that causes this reaction.
In the light of the Covid lockdown, our clinic is open to TeleDermatology services for acne treatment. This includes complimentary doorstep courier of prescription, contactless delivery within 3 working days. Same day delivery can also be arranged.
If you suffer from mild to moderate acne, you may try these over the counter cosmeceuticals proven for acne treatment.
Dr. Teo Wan Lin is an accredited dermatologist and an expert on cosmeceutical skincare research and development. She is the author of “Skincare Bible – Dermatologist’s Tips for Cosmeceutical Skincare” which was published July 2019 by leading bookstores Barnes & Noble, Baker & Taylor and Apple Books and available in bookstores islandwide from January 2020. She is the founder of Dr.TWL Dermaceuticals, a specialist cosmeceutical skincare line with evidence-based active ingredients for anti-ageing and skin health. Dr. TWL Pharmacy is the only full fledged online specialist dermatologist compounding pharmacy in Singapore and is jointly headed by a trained pharmaceutical engineer for strict quality controls. In this series “Dermatologist Talks” she shares her top tips on common skincare topics. In this article, she talks about chemical peels, are they necessary and are there any alternatives for those who wish to do it at home?
What is a chemical peel?
A chemical peel is the application of a high yet safe concentration of a certain acid on the skin. Superficial peels involve the use of acids such as salicylic acid and glycolic acid. They induce epidermal injury and the induced exfoliation is followed by dermal and epidermal regeneration from adjacent epithelium and skin adnexa, which results in improved surface texture and appearance of the skin. Superficial peels are most commonly used for mild skin disorders such as dyschromia, acne, postinflammatory hyperpigmentation, melasma, and actinic keratosis.
What are the benefits of a chemical peel?
Chemical peels exfoliate the dead outer layer of your skin and are mainly used to treat:
Acne (i.e Blackheads, whiteheads & pimples)
Chemical peels reduce inflamed lesions, loosen and reduce open and closed comedones (colloquially known as blackheads and whiteheads respectively). Chemical peels also lighten mild acne and facial scars from past blemishes. It can be used to compliment topical or oral medication to treat pimples and control acne breakouts.
Reduce fine lines under eyes, around the mouth and on the forehead.
Lighten mild acne and facial scars.
Reduce age spots, freckles, and dark patches (melasma) due to pregnancy or taking birth control pills.
Remove the sun-damaged outer layers, leaving you with smoother skin.
Chemical peels also increase the absorption of skincare products into the skin because the removal of the topmost layer of skin ensures that there are no dead cells impeding the penetration of products.
SA has anti-inflammatory, antimicrobial and depigmenting properties. It is safe in skin of all Fitzpatrick phototypes. Because of SA’s lipophilic and comedolytic effects, it is particularly effective for comedonal acne.
What are the side effects of a chemical peel?
The side effects of the treatment tend to be mild and temporary. Most side effects subside after 3 days.
Scabbing of the skin (due to skin cells being removed)
Increased sensitivity to the sun
How is a chemical peel performed at your clinic?
A certified nurse will hand you a consent form for the chemical peel before proceeding to explain in detail what you can expect during the peel and the benefits. The peels we use in our clinic are: Lactic Acid, Salicylic Acid and Glycolic Acid. Before the procedure, your face will be cleansed and eye protection like goggles or gauze may be applied. During chemical peel, the nurse will use a cotton pad or brush to apply the chemical solution to your face. You may feel a slight stinging sensation however the nurse will assess the skin and monitor the reaction to the acid. Once complete, the chemical solution will be removed or a neutralizing solution will be added. The strength and peel times are tailored to individual patients skin type and needs. After the peel, we will apply AMINO ACID 360° MASQUE and leave it on for 10 minutes to soothe the skin. It contains a potent concoction of skin brightening Vitamin C which soothes inflamed acne and lightens scars. LARECEA™ Extract with lifting amino acids penetrate the epidermis to stimulate collagen regeneration, resulting in all round 360 degrees lifting effect for a youthful, smooth contour of face.
If I cannot make it down for a chemical peel at your clinic, would there be alternative treatments that can be performed at home?
Our online specialist skincare pharmacy Dr. TWL Pharmacy supplies custom compounded topicals powered by botanical actives, for various skin conditions delivered to your doorstep. This is also part of a teledermatology service integrated with the specialist skincare pharmacy, a unique service developed for our overseas patients and a current necessity given the healthcare situation worldwide. There is complimentary courier service locally and subsidised international shipping for our prescription medications.
The following are alternatives for home peels:
Our Dr. TWL Home Chemical Peel System– By Prescription via Teledermatology only. This system incorporates active peeling agents suitable for home use formulated by our in house team, with recovery serums and skin healing emollients included in the package. From $80 upwards depending on prescription and need. Please book in here for your consultation.
Home Medi-Facial Aesthetic Treatments with our Custom Mask Bar Service Our on-site skincare pharmacy is manned by trained technicians who compound topical prescriptives for skin concerns such as acne/greasy skin, pigmentation, scars and sensitive/eczema prone skin to be used with our newly launched FDA-approved skin devices for a full home facial experience. The SilkPeel, a state-of-the art microdermabrasion device with copper ion technology, suitable for antiageing and skin resurfacing is used with our prescriptive medifacial solutions and has been proven to have similar benefits as in-office chemical peels. For post-peel skin healing and tightening, the CollagenUP Wand utilises Radiofrequency technology with our MoistureMax Polysaccharide Mask Sheet for the Custom Mask Bar which delivers monthly mask essence vials with a complimentary 4L Beauty Fridge. Find out more about the science of our home medi-facials here
Meet with Dr Teo Wan Lin, an accredited dermatologist at TWL Specialist Skin & Laser Centre, for a thorough consultation to determine the most suitable treatment for your skin. Our consultations are now available via teledermatology here . Our online skincare pharmacy is also available for over the counter prescriptives to be delivered directly to your doorstep.
To book an appointment with Dr Teo, book directly here with our integrated online booking system, call us at +65 6355 0522 or email firstname.lastname@example.org for assistance. Alternatively, you may fill up our contact form here.
Wrinkles, sagging and pigmentation of one’s skin are signs of premature ageing. Due to this, skin tightening is a popular cosmetic procedure to improve one’s appearance. However, while surgery has long been able to restore a youthful appearance, many prefer non-surgical face lifting and skin tightening treatment because it provides immediate results with minimal or no downtime.
Dr. Teo Wan Lin is an accredited dermatologist and an expert on cosmeceutical skincare research and development. She is the author of “Skincare Bible – Dermatologist’s Tips for Cosmeceutical Skincare” which was published July 2019 by leading bookstores Barnes & Noble, Baker & Taylor and Apple Books and available in bookstores islandwide from January 2020. She heads up Dr.TWL Dermaceuticals, a specialist cosmeceutical skincare line with evidence-based active ingredients for anti-ageing and skin health. Its subsidiaries, the Pi- Cosmeceutical Custom Makeup Lab and the Conscious Mask Bar are part of the Conscious Concept Pharmacy launched in December featuring environmentally sustainable makeup and skincare materials. In this series “Dermatologist Talks” she shares her top tips on common skincare topics. In this article, she talks about non-surgical skin tightening treatments.
What are the alternatives to surgical skin-tightening?
1. Non-invasive skin tightening procedures
Unlike surgical skin-tightening, patients will not incur puncture wounds, incisions or raw skin after the procedure. Temporary redness and swelling, would usually be the only side effects of the procedure. When performed by a board-certified dermatologist, little risk of other side effects is involved. This procedure can be performed on almost any part of your body and the results of the procedure tend to appear gradually. Regarding the details of the procedures, a session takes approximately 1 hour or less. Some patients may face some discomfort during the procedure.
Common procedures include:
Heat produced by ultrasound treatments can stimulate collagen production. After one session, most people see modest lifting and tightening within 2 to 6 months. You may get more benefit from having multiple treatments.
A device is used against your skin to heat the tissue beneath. Most patients feel an immediate effect after the first session. Collagen production in the body takes time, the best results show in about 6 months. Some people benefit from having more than 1 treatment. The results from radiofrequency treatments can last 2-3 years when accompanied with appropriate skin care.
Certain lasers allow heat to penetrate into the skin without damaging the top layer of the skin. These lasers are utilised for skin-tightening treatments all over the body and can be especially helpful for tightening loose skin on the belly and upper arms. 3 to 5 treatments may be needed to get results, which gradually appear between 2 and 6 months after the last treatment.
2. Minimally invasive skin tightening procedures.
Although they are unable to give you the results of a surgical procedure like a facelift, these procedures result in more evident changes than non-invasive procedures. They require less downtime than surgery while carrying less risk of side effects. Patients will be sedated during this type of procedure and will have a few days of downtime.
A thin tube (or needles) is inserted into the skin which provides heat to tighten loose skin at a precise location. This procedure is often used to tighten the skin at the neck or upper arms. Results are noticeable in a month. In some research studies, patients see gradual tightening and lifting for close to 1 year. After the procedure, you’ll need someone to drive you home and you may need to wear a compression garment for 4 or 5 days. You’ll also need to care for the wound.
This is the most effective procedure for tightening loose skin. Unlike the laser treatment, this procedure requires some downtime. You’ll need to stay home for 5 to 7 days. Laser resurfacing gives you the fastest results. After you heal, your skin will appear tighter with less wrinkles within 2 weeks. Laser resurfacing can effectively tighten skin, usually showing more prominent results than any other skin-tightening procedure. Laser resurfacing diminishes fine lines, wrinkles, and dark spots on the skin, such as age spots. The tradeoff is that it requires downtime and has a greater risk of possible side effects, such as scarring.
Do skin-firming creams and lotions work?
Despite their promising claims, face-lift like results from a mere jar are highly unlikely. The result, if any, you see from a skin-firming cream will be subtle. These products tend to be good moisturisers at best resulting in plump skin and less noticeable fine lines and wrinkles. This result is temporary. To continue seeing any benefit, you need to apply the product every day. Dermatologists dispute the claim that a cream or lotion can lift sagging skin as these products are unable to penetrate the skin deeply enough to do this. Still, a small change may occur if the product contains a retinoid, such as retinol, which stimulates collagen production.
Who should avoid skin-tightening procedures?
Skin-tightening procedures should not be done on pregnant individuals, those with skin infections or patients with certain medications.
Meet with Dr Teo Wan Lin, an accredited dermatologist at TWL Specialist Skin & Laser Centre, for a thorough consultation to determine the most suitable treatment for your skin.
To book an appointment with Dr Teo, call us at +65 6355 0522, or email email@example.com. Alternatively, you may fill up our contact form here.
Sugar in diet is measured by the Glycemic Index (GI)– a value assigned to foods based on the effect they have on your blood sugar levels. Studies have suggested that diet, particularly dietary GI, may aggravate existing moderate-cystic acne. A high GI diet increases sebum production, contributing to acne formation. Additionally, high-glycemic foods can also accelerate aging theoretically via an increase in the breakdown of collagen fibers, a process known as glycation.
2. How exactly do low and high (GI) sugar in diet affect the body?
This is how sugar in diet works – carbohydrates with a low GI value are more slowly digested and absorbed, causing a lower and slower rise in blood sugar and, therefore, insulin levels. Conversely, consuming carbohydrates with higher GI translates to higher blood sugar and insulin levels. Insulin is a hormone responsible for the decrease in blood sugar levels. It also stimulates the synthesis of another group of hormones (known as androgens) which leads to high sebum production, a recognized correlation to acne severity.
3. How much sugar is too much, or should we cut it out completely?
I think it is very important, as part of a balanced diet, to incorporate all elements of the food pyramid. In my personal view, the presence of sugar in diet with natural foods such as fruits and honey is not something that is harmful. In fact, these sugars are essential for our body’s nutrition.
The problem arises when sugar is consumed in excess or when it is consumed in the form of refined artificial sugars. This is because one can easily down a lot more sugar without feeling full, for instance when one consumes a cake or a baked item. On the other hand, the amount of sugars present in natural fruits will lead to one feeling full before one consumes a real excess of it. The key thing here is balance. In terms of the actual scientific evidence, there are some conflicting viewpoints regarding this issue.
The main thing is that excess sugar in diet can definitely trigger conditions, such as metabolic syndrome which comes with an increase in risk of cardiovascular mortality and other conditions like diabetes. Another thing to take into consideration is inter-individual differences in metabolism and genetics.
The lifestyle of the individual plays a part as well. For example, someone who is very athletic would naturally need more sugar in diet for metabolism. Meanwhile, someone who is sedentary needs minimal calories in their diet and having excess sugars will just contribute to calorie intake and in turn obesity which is a risk factor for worsened skin diseases. Overall, I would strongly recommend a well-balanced diet and the limiting of artificial sugars as there are innate health risks with high sugar diets which include an increased risk of developing diabetes and pre-diabetes.
4. Is eliminating added sugar in diet effective for rosacea-prone skin?
Medical studies have not conclusively proven the link between a high sugar diet and the worsening of existing conditions, such as rosacea and eczema. Most of the studies have been focused on the role of a high sugar diet for patients with existing moderate to severe acne.
Theoretically, high sugar content does promote an inflammatory state and both rosacea and eczema are linked to underlying inflammation. Although there is a theoretical possibility that it could lead to worsening of the condition, it is not proven at this juncture. In fact, a German study specifically ruled out the worsening of eczema due to a high sugar diet.
In my personal clinical practice, I have not observed any such links. I do not routinely advise dietary modifications for people with these conditions. For acne however, I do recommend reducing the presence of trans-fat, dairy products and high sugar foods simply because they can potentially slow down the recovering process. Nevertheless, treating acne with dietary modifications alone does not work. It is more of an adjunct to medical treatments.
5. What are some guidelines to follow, if people do decide to reduce their sugar intake? For instance, is there certain fruit we should avoid, is alcohol a no-go too?
First of all, take sweets in moderation. This includes candies and baked goods which are particularly high in sugar content. Secondly, be aware beverages contain sugars as well. I would stick to plain water and perhaps an occasional natural fruit juice that doesn’t contain added sugars. However, diet alone is not sufficient. It is important to understand that you would need some form of energy output instead of just input. I would recommend an active lifestyle with a minimum of three exercise sessions a week, each with a duration of at least 20 minutes.
“I am a strong believer that natural beauty reflects honesty and authenticity, an approach I take as a dermatologist— sharing the truth about skin. Our pursuit of beauty should always celebrate individuality over vanity, I always emphasise that beauty starts with an inner consciousness and empowerment, starting with a scientific approach towards skin health, building confidence and finding peace.”
Dr. Teo Wan Lin is an accredited dermatologist by the Ministry of Health and is the medical director of TWL Specialist Skin & Laser Centre, as well as the founder of Dr.TWL Dermaceuticals, a specialist cosmeceutical skincare line. Want to know the top aesthetic treatments performed by accredited dermatologists? She shares the top aesthetic treatments in her dermatology practice here.
Once I start doing aesthetic treatments, am I reliant on them forever? Will the results go away after some time?
Optimum Face Lift Results with Accredited Dermatologists
“I find two major pitfalls of aesthetic treatments administered in clinical settings– the first relates to the lack of understanding of the total face structure — each layer of ageing skin needs to be addressed individually and dermatologists are well-positioned as MOH-accredited specialists in skin to ensure that correct treatments are administered and combined to each individual’s specific skin age according to the Glogau Photoageing system, developed and used by dermatologists.” Dr. Teo Wan Lin.
Aesthetic Treatments – The Key to Sustained Face Lift Results
“The second pitfall is the lack of maintenance, a touch and go approach, especially without using cosmeceuticals together with aesthetic treatments, is not scientific. While it is a surefire way to fuel ‘repeat treatment sessions’ when signs of ageing quickly recur, I find it unsustainable as results always taper off. I do not use such an approach with my patients. Our joint goal is always, in-clinic treatments for a specific duration until we meet our target, and then home maintenance to maximise the longevity of the clinical results, ”emphasises Dr. Teo.
The Dr.TWL 360 Degrees Face Lift System
At TWL Specialist Skin & Laser Centre, an accredited dermatologist practice in Singapore headed by Dr. Teo Wan Lin, the favourite of many patients seeking aesthetic treatments is a potent full-face anti-ageing cocktail prescribed by her. All patients undergo a medical consultation and with an objective staging of their ageing process to determine the intensity, duration and maintenance of treatment periods.
What does the Face Lift treatment consist of?
The Dr.TWL 360 Degrees Face Lift System is a full face targeted aesthetic treatment which comprises the following
1. Epidermal/superficial dermal treatment
Beginning with microdermabrasion and an in-house formulated gentle chemical peel) performed by our dermatology staff nurses, lasting 45 minutes including preparation and recovery time.
2. Deep Dermis Stimulation and Muscle Relaxation
The second component is performed by Dr. Teo Wan Lin. It comprises deep laser lifting to stimulate bulk tissue heating and collagen growth. The epidermis is treated for superficial pigmentation and fine lines, wrinkles which are the earliest giveaway signs of ageing. Microinjected muscle toxins are then administered to further stimulate collagen production around the jawline and hairline for a relaxed, natural face lift effect.
“The SMAS is best envisioned as the curtain rail that holds the entire curtain up, it’s what holds up the entire facial structure. It’s important to lift this structure when one is anti-ageing the face because it’s really the support of the facial structure,” shares Dr. Teo. At her dermatology practice, she uses High-Intensity Focussed Ultrasound (HIFU), a Korean technology as well as radiofrequency to achieve a SMAS face lift.
4. Composite Eyelid lifting and Wrinkle removal
The eyes often giveaway one’s age. The reason for this is due to the thinner periorbital skin, as well as the natural facial expressions that cause brow furrows and crows feet. At our dermatology practice, plasma nitrogen technology is used for periorbital resurfacing for undereye wrinkles, sagging, and lid drooping, also known as a soft blepharoplasty.
This maintenance system includes a home medifacial regimen fulfilled by Dr.TWL Pharmacy’s Mask Bar, freshly delivered to your doorstep monthly for a 3-month maintenance regime, with freshly compounded face masks containing oligopeptides to further tighten and lift the dermis. The system includes a full-face set of QRASER lifting patches made of medical grade polymers that mimic the skin barrier and erase wrinkles. The CollagenUP Facial Wand which is a FDA-approved Radiofrequency lifting device is used with the Polysaccharide Mask to increase absorption of Oligopeptides, the star molecule of Dr.TWL Dermaceutical that stimulates collagen production with a tightening face lift effect.
This non-surgical face lift system is designed and tested for proven results by accredited dermatologist Dr.Teo Wan Lin at her practice TWL Specialist Skin & Laser Centre. The number of shots used for each treatment is titrated according to the individual’s specific need. For patients who wish to stay home, they can opt for the home medifacial component which is delivered to their doorstep by the clinic’s specialist skincare pharmacy.
For whom is this aesthetic treatment suited for?
People who want a non-surgical, long lasting approach to a face lift effect with minimal to no downtime. A single clinic session followed by a strict home maintenance regime for 3 months helps boost the efficacy of the treatment. Can be adjusted in intensity and frequency according to individual need.
How long will the treatment results last?
This is the very question the Home Mask Bar treatment was created to address. According to Dr. Teo, “I would like to say, for as long as you are diligent to comply. The in-clinic treatment session is completed in a single day, and results peak at 2 weeks. I have seen patients who have maintained the overall face lift results for as long as 2 years. Inter-individual variability exists, due to lifestyle and genetic factors, some individuals have extremely good responses. For those who are at a more advanced stage of photoageing, more frequent treatments should be instituted before attaining the ideal for maintenance.” The effect of regular use of the Dr. TWL 360 Degrees Face-Lift System is sustained improvement.
How many sessions of this treatment do I require?
The in-clinic full sessions can vary from single session to 3-6 sessions depending on the level of skin ageing. The aftercare home system should be used on a daily basis.
Who should not undergo this treatment?
Components such as deep laser toning will be omitted for individuals with photosensitive (sun-sensitive) skin conditions. It is important to consult an accredited dermatologist as he/she is well equipped to manage these medical conditions simultaneously with your aesthetic treatment.
How much does this cost?
Single in-clinic session (expect half-day, 4 hours including recovery time) $2799, with Home Mask Bar Maintenance at $180.50/month, and CollagenUp Facial Wand at $599. All prices before GST.
Dr.TWL 360 Non Surgical Face Lift was featured by Men’s Folio. Read the full article here.