Dr. Teo Wan Lin is the host of a beauty podcast- Dermatologist Talks: Science of Beauty, which covers the latest in skincare active ingredients, dermatology news and beauty technology. Listen to her podcast here.
In this Conscious Beauty blog series which ties in with the launch of my podcast- Dermatologist Talks: Science of Beauty- I will be sharing about skincare tips in common dermatological conditions. Do you suffer from facial redness or flushing? Facial erythema can be caused by acne, rosacea, eczema and even autoimmune diseases like lupus. Most commonly, facial redness is due to rosacea. It is a disorder where the skin’s blood vessels are abnormally active leading to persistent skin inflammation. This article will focus on dermatologist rosacea skincare tips, medical therapies, as well as the role that a rosacea skincare routine has to play in treatment.
Rosacea Symptoms, Signs and Diagnosis
Rosacea is a dermatological condition characterised by the tendency of one’s skin to become flushed or red. This can happen in the presence of certain triggers or when the disease is advanced, it may present as persistent redness. It is a condition affecting many in Singapore. It can also be fully treated by a dermatologist.
How does the skin look like? Firstly, there is persistent flushing, which presents as redness on the face. In skin of color, the redness may not be obvious. However the individual over time develops skin textural changes, which can become disfiguring. Irregular skin texture, enlarged pores and eventual skin thickening are medium to long term complications of untreated rosacea.
In general, onset of the skin inflammation occurs when one is between 30 to 50 and tends to affect fair skinned individuals from a Celtic or Scandinavian ancestry. It is also seen commonly in Chinese people in Singapore.
Rosacea is diagnosed visually, examining the skin around the nose and eyes, and from asking more questions. Before giving you a diagnosis, your dermatologist would have to rule out other medical conditions that can look like rosacea. Medical tests can help to rule out conditions like lupus and allergic skin reactions.
Family history: It is more likely for you to get rosacea if you have a family member who also has rosacea. It is possible that people inherit the gene for rosacea.
Immune system: Research has found that many people who have acne-like rosacea, or papulopustular rosacea, react to a bacterium called bacillus oleronius. This reaction causes their immune system to overreact.
Intestinal bug: H Pylori is a bug that causes infections in the intestine. This bug is also common in those with rosacea. There is a hypothesis about the Helicobacter pylori bacteria colonizing the gut of rosacea patients, which explains why treatment with metronidazole can be effective in treatment.
Skin mite: Demodex is a mite that lives around the nose and cheek areas on the skin. This is where rosacea often appears. Studies have found that people with rosacea have large numbers of this mite on their skin.
Processing of protein: The protein cathelicidin usually protects the skin from infection. How the body processes this protein may determine whether a person gets rosacea.
Topical treatment can include brimonidine, metronidazole and azelaic acid. However, these have irritating side effects.There is increasing evidence to support the use of cosmeceuticals, which do not have side effects, for the adjunct treatment of rosacea. At TWL Specialist Skin & Laser Centre, our dermatologist uses cosmeceuticals for the treatment of mild to moderate rosacea, in combination with oral treatment where necessary. Anti-inflammatory oral antibiotics may be required for papulopustular subtypes i.e. tetracycline, erythromycin, to reduce skin inflammation. In severe papulopustular variants, isotretinoin may be required. Light therapies and lasers may be of value as adjunct treatments.
Rosacea Skincare Tip #1 Respect the Skin Barrier When Cleansing and Moisturising
We’re going to talk about the role of the skin barrier in rosacea.
The skin barrier is best thought of as the physical “wall” that separates the external and our internal cell environment. An intact skin barrier protects from external allergens and environmental damage. An individual with rosacea may have associated eczema, making face redness worse. This can be pre-existing childhood eczema or due to external factors such as harsh drying skincare.
When you suffer from a dermatological condition like rosacea, it is important to have it treated by an accredited skin specialist. Your rosacea skincare routine affects skin barrier function. When it is intact, there is less inflammation and facial redness will improve.
In your rosacea skincare routine, gentle cleansers are recommended. For foaming cleansers-these can be amino- acid based or formulated with lower SLS (sodium laureth sulfate) content. SLS- free cleansers usually contain alternatives like ammonium-laureth sulfate. Laureth sulfates can all strip the skin of moisture. SLS-alternative foaming cleansers can be natural emulsifiers, such as soy-based or honey. Medical-grade honey is purified and retains bioactive properties. It is a broad-spectrum anti-microbial. It inhibits bacteria, fungi and also moisturises the skin.
The function of gentle cleansers for rosacea can be two-fold. First by emulsifying the dirt, oil and grime in a lather which is then rinsed off. Second, the best cleanser leaves a beneficial residual effect on skin. It continues to act after the cleanser is washed off. This is possible with medical-grade honey cleansers that have a natural humectant property, trapping water under the skin’s surface. This reduces trans-epidermal water loss (TEWL).
If you wear makeup, double-cleansing is recommended. The type of cleanser to remove makeup has to effectively dissolve oil-soluble makeup pigments. An oil cleanser or a oil-in-water cleanser (usually formulated as a milk cleanser) will be gentler on your skin then a micellar formulation.
Rosacea Cleansing Tips Explained by a Dermatologist
Gentle skincare is key. The goal of a rosacea skincare routine is to maintain integrity of skin barrier while avoiding agents that cause inflammation/flushing. Non-soap cleansers with synthetic detergents (pH 4.0-6.5) are better tolerated than traditional soaps (pH >6.5). Avoid harsh topicals such as toners, exfoliating agents and astringents. In erythematotelangiectatic rosacea and facial erythema (flushing), telangiectasia, eczema-like features such as skin sensitivity (burning or stinging sensation), dryness and scaling can be present. The redness can also affect other areas e.g. scalp, ears, neck and chest.
Repair the skin barrier while undergoing rosacea treatment. Facial redness can be caused or worsened due to facial eczema. If you have itch, swelling and skin flaking, you may have dermatitis, which can co-exist with other dermatological conditions.
The Best Type of Moisturiser for Sensitive Skin
Moisturisers in your rosacea skincare routine should target barrier repair. The best moisturiser for sensitive skin and rosacea is one with ceramides. Ceramide-dominant moisturisers with an optimal lipid ratio help to replenish dehydrated skin. The gold standard moisturiser is formulated as a Prescription Emollient Device with additional anti-inflammatory ingredients. Hyaluronic acid and polyglutamic acid are additional hydrating molecules that do not leave a greasy feel in a tropical climate like Singapore. Polyglutamic acid is more effective than hyaluronic acid in attracting water molecules, but can be more expensive.
Rosacea Skincare Tip #2 Anti-Oxidants Target Inflammation
Inflammation occurs in rosacea. In papulopustular rosacea, inflammatory papules and pustules are present in addition to persistent face redness. Phymatous rosacea is a subtype of rosacea that shows thickened and coarse skin. Enlarged pores (dilated hair follicles on facial skin) may be a sign of rosacea, due to tissue overgrowth. Irregular skin texture can be due to nodules. These changes can get worse as one ages. Cosmeceutical skincare containing anti-oxidants fight inflammation in a healthy skincare regimen.
Importantly, skin inflammation in rosacea should be treated medically. This is because the end stage of persistent inflammation is a condition known as rhinophyma. Rhinophyma is disfiguring and surgical methods, including fractional CO2 laser resurfacing, may be required treatment when the disease is advanced.
Dermocosmetics are the latest development in cosmetic dermatology. There is evidence supporting botanical anti-inflammatories in skincare formulations.
As a rosacea skincare tip, active ingredients such as Gingko Biiloba, Camellia Sinensis, Aloe Vera, and Allantoin are beneficial in treatment. Gingko Biloba works for redness because of active terpenoids. Gingko reduces blood vessel hyperactivity through its anti-inflammatory effect. Polyphenols are powerful antioxidants that fight free radicals. Green tea known as camellia sinensis is a source of polyphenols that are anti-inflammatory. It has been shown to reduce UVB-induced inflammation. Bioactives in aloe vera include aloin, aloe emodin, aletinic acid, choline and choline salicylate which are anti-inflammatory. It can also balance the skin microbiome. Allantoin is a derivative of glyoxylic acid from the comfrey plant. It is a humectant and attracts moisture, restoring barrier function in patients with facial redness.
Common Misdiagnoses of Rosacea
Acne rosacea is the commonest subtype seen in dermatologist offices. It commonly occurs over the nose, forehead, cheeks and chin. An accredited dermatologist will be able to correctly diagnose, based on clinical examination, as well as symptoms derived from history taking. It mimics acne and can be mistaken for pimples. It is also possible for early rosacea to be misdiagnosed as facial eczema coexisting with acne, because of the background redness. The papule-pustular variant can appear with acne-like bumps, cysts, or nodules. The facial redness is due to visible blood vessels, also known as telangiectasia.
The flushing and skin swelling can look like sensitive skin or eczema. It also mimics the enlarged pores of oily skin-types, when in fact the thickened skin is due to rosacea. Flaking, redness and red bumps around the mouth can be due to perioral dermatitis. It can affect the eyes, resulting in blepharitis, where one develops red and irritated eyes. This can be confused with findings of ocular rosacea- dryness, irritation and a foreign body sensation. Other dermatological conditions that can mimic rosacea include seborrheic dermatitis, lupus erythematosus, polycythaemia rubra vera and carcinoid syndrome which are less common. Steroid-induced acne may be a consideration if there is a history of using steroid creams on the face.
Rosacea Skincare Tip #3 Sunprotection
While it has multifactorial origins, lifestyle factors affect rosacea significantly. Sun exposure, consumption of alcohol, emotions, spicy foods, medications, menopausal hot flushes, exercise and stress can trigger flare ups.
Sun protection is an essential component of a rosacea skincare routine. It is critical in treatment of all facial redness which is photosensitive. The cheeks are the most affected. As it is now covered by a face mask in a post-COVID19 world, sunblock may not be a practical measure of photoprotection. I have suggested in my research paper on maskne that UPF50+ biofunctional textiles be used as primary photoprotection with a face mask design. This means there is no need for reapplication.
However, as a rosace skincare tip, sunblock can also cause facial stinging in rosacea patients. A UPF50+ textile provides maximum broad spectrum UV-protection without any risk of skin irritation. For uncovered areas like the forehead, neck and upper chest, a broad-spectrum sunscreen is necessary. To prevent stinging, look for a sunscreen that is dermatologist-recommended. Also, UV-blocking ingredients such as titanium oxide and zinc oxide function as physical blockers are less sensitising. Look for additional protective ingredients such as dimethicone, cyclomethicone to prevent irritation from sunscreen ingredients.
Dermatologist’s Tip: Top Rosacea triggers
Various environmental or lifestyle factors can exacerbate rosacea. Heat, sunlight, stress, hot or cold weather, exercise, alcohol, spicy foods and certain skin care products. Emotions can also increase the frequency of disease flares. To reduce flushing after encounter with stimuli, applying cool compresses and transferring to cool environments may be helpful. Cold therapy can be harnessed for its anti-inflammatory effects.
Rosacea Skincare Tip #4 Cosmetic camouflage
The use of cosmetic products such as green colour correcting concealers can help. Cosmetic camouflage is a recognised intervention as part of rosacea treatment. Green-tinted concealers or foundation helps to camouflage facial redness. This can be followed by a flesh-coloured facial foundation to achieve a natural look. I develop a line of color-correcting concealers in my skincare makeup line that helps with concealing.
Dermatologist’s Tip: Best Concealer for Rosacea? It’s Green
Based on color science, green neutralises red, a color on the opposite end of the colour wheel. Cosmetic camouflage is an important part of rosacea treatment. It can alleviate psychosocial distress. Patients suffer significant embarrassment from episodes of facial redness. This perpetuates a cycle that makes the chronic condition more stressful.
Rosacea Skincare Tip #5 A daily skincare ritual can help with your skin and also boost your mood
Stress is a major trigger factor for rosacea. Some scientific ways to reduce psychological stress include cognitive reframing and mindfulness activities. Adopting a daily skincare ritual is beneficial mentally and physically for rosacea treatment. We have discussed the essential steps in a skincare regimen for sensitive, reactive skin. This maintains a healthy skin barrier, restores the skin microbiome and provides anti-oxidants to help protect. However, the additional value of a daily skincare ritual is that it improves psychological well being.
Self-care is a concept that allows the mind to re-charge together with the body. As a rosacea skincare tip, having a bed-time ritual for example, is healthy for sleep hygiene. Starting your work day with a ritual, can make you more productive. I created the 360 Conscious Mask Bar as a complete self-care concept with anti-inflammatory benefits for rosacea, sensitive/reactive skin patients. Cold therapy/ cryotherapy can be relaxing and soothing both physically and psychologically.
Conscious Beauty by Dr.TWL Dermaceuticals stars model-actress Sara Malakul Lane, international burlesque performer Sukki Singapora and dermatologist at TWL Specialist Skin & Laser Centre Dr. Teo Wan Lin. Feminine beauty as a modern tale told by the girls themselves, through the lens of fashion model-turned photographer Sabrina Sikora. E-book version only.100% of proceeds received from CONSCIOUS BEAUTY will go to charitable causes supported by Dr.TWL Dermaceuticals – Action for AIDS Singapore and the United Nations World Food Programme. Available on Amazon Kindle, and the Dr. TWL Dermaceuticals website.
“Your healing journey towards beauty, begins with your consciousness of the inner world,” Dr. Teo Wan Lin
Dr. Teo Wan Lin is an accredited dermatologist practising at TWL Specialist Skin & Laser Centre. An expert in dermocosmetics for skin diseases, the skin microbiome and biofunctional textiles, her work has been published in top dermatology journals. Her additional research interest is in the brain-skin connection which emphasises psychological wellbeing in sufferers of chronic skin disorders. In her journey of helping dermatology patients for over a decade in practice, she strongly believes that true beauty has to begin from the inside rather than from the external.
There has been a lot of skincare advice thrown around the internet- but not all of it is good. In fact, some of these “advice” may be harmful to your skin. It’s time to clear the air and put these skincare myths to rest, so that you can start making informed decisions when it comes to your skin.
Skincare Myth #1: Skin problems like pigmentation, acne and sensitive skin can be treated with skincare products and facials
Almost every brand is boasting a special cleanser or cream that can treat these problems over the counter, be it in the form of lightening cleansers or anti-acne cleansers or anti-redness creams. The truth is, healthy skin can be maintained with cosmeceutical skincare recommended by dermatologists, but when you have any one of these issues, they are actually true medical conditions of the skin.
My advice is, if you have any of these symptoms, stop self-medicating and applying a bunch of anti-redness or “sensitive skin” products. See a dermatologist as soon as you can because all of the above can be promptly treated with proper medications. This will probably save you a lot of pain, money and regret in the medium to long term.
I have seen so many patients who have spent thousands of dollars on online supplements, fad diets, facials at spas or aesthetic centres, did not get better and actually had a true dermatological condition, such as perioral dermatitis (which looks like acne, for example, but occurs in adults) and rosacea which can be effectively treated by a dermatologist with the correct medications.
Skincare Myth #2: Scrub and use a clay mask.
Dermatologists do not agree with a lot of what beauty companies/aesthetics providers are telling the public. Dermatologists have seen way too many complications because of an incomplete understanding of the actual science of how skin behaves. Scrubbing with harsh beady grains of sand would work if your skin was made of wood, if you imagine using it like a sandpaper. In reality, you do not brighten or “exfoliate’’ your skin with that; rather, you are causing damage and irritation to your skin, that’s maybe even the cause of your sensitive skin and red face problems.
Clay masks are also totally unnecessary, even for oily and acne-prone skin types because it’s actually the salicylic acid content in these masks that causes your acne to get better, but not without really dehydrating your skin after that and causing facial eczema in the long term. Yes it is possible to have oily acne prone skin and facial eczema at the same time.
Dermatologists do not prescribe clay masks for any skin problem because there are much more effective options for treatment of oily skin and acne. What counts in a skin treatment product is the active ingredient in these masks and products, so again, so, do thorough brand research, check the ingredient list of your next bottle or just go with what your dermatologist would recommend.
TheSilkpeel Home Medi-facial Kit is a home chemical peel equivalent. The effects of the SilkPeel Home Facial Peel System are that of microdermabrasion which has a similar effect to microscopic skin exfoliation.
“Glass skin, a poreless appearance of the skin, popularised by K-beauty isn’t a myth. Cosmeceuticals such as polyglutamic acid, which is a large molecule, sits on the surface of the skin while functioning as a humectant 5x more effective than hyaluronic acid. The SilkPeel system utiliizes polyglutamic acid based solutions with potent antioxidants delivered via vacuum microdermabrasion that helps to achieve a translucent appearance of the skin, reducing the appearance of pores,” accredited dermatologist, Dr. Teo Wan Lin.
Skincare Myth #3: Lower SPF coverage is fine, since SPF represents the duration of sun protection, not the quality.
I read this in a beauty magazine about an aesthetic doctor’s sunscreen product and honestly this is the sort of stuff that would make a dermatologist cringe, because it is dangerous to spread this sort of belief and sun protection isn’t just about beauty but also skin cancers. It is very enticing given our humid climate when such brands promise that their sun protection mist offers lightweight cover without leaving a white stain.
Skin cancer can be avoided with good sun protection. In fact, you should never go without a good sunscreen because the harmful sun rays is also the number one cause of ageing. However, beware of the dangers of misleading labels on sunscreens. You should go for a sunscreen recommended by your dermatologist that is at least SPF 30.
A sunscreen should effectively block both UVB and UVA rays, which is possible with an agent that has an SPF of 30 or greater. It is also important that your sunscreen is labeled with the term “broad spectrum”, which means it protects your skin against UVA rays. There are differences between 15, 30, and 50. SPF is measured in the laboratories whereby the amounts applied at 2g/cm2 and this never happens in real life.
And on top of that, most of us don’t apply sunscreen properly. SPF (sun protection factor) is derived by taking the time it takes you to burn with sunscreen on and dividing it by the time taken for you to burn without sunscreen on. SPF specifically protects against ultraviolet B (UVB) rays that cause sunburn. I would recommend a minimum of SPF 30 for an everyday sunscreen and SPF 50 when outdoors for extended periods of time.
The SunProtector is SPF 50/PA+++ and is exquisitely formulated for humid climates. It is a broad-spectrum sunscreen that also regenerates and soothes sensitive skin. Designed with unique pigments blended to be almost invisible under make-up.
The following is a transcript from Dr. Teo Wan Lin’s podcast, Dermatologist Talks: Science of Beauty on fillers and vaccines. Subscribe to her podcast on a journey to discover the science of beauty. We’ll cover the science behind active ingredients and get deep into the cosmetic formulations. Stay on trend with the latest on botanical actives, technology and be part of our FUTURE OF BEAUTY.
29 DEC 2020: Hi guys, this is Dr. Teo Wan Lin, and welcome to this week’s dermatology flash briefing. The Moderna COVID-19 vaccine apparently causes swelling and inflammation in patients with cosmetic facial fillers. The FDA advisory committee reviewing the new Moderna vaccine, has come out to state this very specific side effect that has involved several trial participants who have had cosmetic facial fillers. I want to just quickly share with you guys today what exactly this is about, how it occurs, and if that’s something we ought to be worried about.
What exactly are dermal fillers?
Dermal fillers are used primarily for facial augmentation. The filling agents are meant to restore fullness in one’s appearance that could be lost over time with age as a result of subcutaneous fat atrophy, or a side effect of certain medications such as retroviral medications. The ideal facial filler should have the following properties: first of all, it should have physiologic compatibility with your body – meaning that it readily incorporates itself with your tissues. It should be free of complications or side effects, and ideally, it doesn’t degrade with time. But this is, of course, untrue for the commonest type of facial filler which is used in most cosmetic practices – that would be hyaluronic acid based and they should be relatively easy to administer. You also have alternatives such as those that are collagen based, or hydroxylapatite based – for example, Sculptra is from poly l lactic acid.
What are the side effects of facial fillers?
In terms of the known side effects from using these facial fillers as injectables, some of the common complications that occur would be tenderness, bleeding, bruising. When lumps and nodules occur, this can be because of inappropriate injection techniques, or accumulation of the filler in a more superficial location than expected.
So what’s the deal with the fillers and vaccines?
Now what’s happening with the Moderna vaccine and this painful facial swelling that occurs where facial fillers have been previously injected, its best thought of as an allergic reaction, or basically an immunological reaction. The key thing here is the process of injecting a vaccine, essentially causes the immune system to be stimulated. That in turn results in the body recognizing that the facial filler in that case, is not a part of the body tissues, and the body starts to mount an immunological reaction against it. Based on the cases that were reported to the FDA, the profile of these patients essentially had swelling and inflammation in the area that was administered the filler. A couple of the patients had the cheek filler 6 months prior to the vaccine, and one patient had lip filler done just 2 days after the vaccine. In all of these scenarios, the patients were treated with oral steroids, anti-histamines, and was observed that their reaction resolved.
What exactly is an allergic reaction?
Typically it is considered a medical event due to an immune system respond to a perceived allergen. It is not likely that these individuals would have developed this response had they not been given the vaccine. The reason is because facial fillers are medically engineered to be biocompatible, but in the case where you’ve had a vaccine, your immune system will start to detect that these substances that were injected, are actually not part of your body tissues.
What are your thoughts, as a dermatologist?
As a dermatologist, I have some opinions with regards to the observation of these adverse events. First of all, we do expect that massive rollout of vaccinations against the COVID19 virus is expected to be happening internationally, and I feel that it is a very important part in ensuring that we get some level of control and immunity in a very severe pandemic like COVID 19. In terms of immunological reactions that are occurring in response to facial fillers in this case, we note that the attendings have actually treated these patients with oral steroids.
We know that oral steroids suppress your immune system, and in fact, make you more vulnerable to the virus. Personally, I have not given oral steroids as far as possible to many of my patients in the last few months. For patients who otherwise would have benefitted from steroid therapy for chronic inflammatory disorders such as severe eczema, I have certainly been a lot more cautious in terms of exploring other therapies before using oral steroids. The reason is because it’s been known to worsen the prognosis in the event you do get COVID, and also, because it reduces your body’s natural immune system response – you’re going to be more susceptible to catching COVID.
The answer is not an easy one. Facial fillers are used in millions of people internationally, and it is not as if it is the first time we are hearing of an adverse reaction. Another known complication from facial filler injections that is relevant in the context of the modern vaccine would be non-allergic inflammatory responses- we call these granulomatous reactions. These don’t occur so quickly, and we right now have no long term data as to what the vaccination would do in terms of individuals who are going to have fillers or have had fillers, and who are going to receive the vaccine.
What are granulomatous reactions?
These granulomatous reactions are usually non-painful lumps, and it is all a part of inflammation that is caused by the immune system being stimulated. In fact, in 2017, there was a case report about a granulomatous reaction to a dermal filler that was hyaluronic acid based in the Journal of Cosmetic and Laser Therapy. A granulomatous reaction is a delayed onset inflammatory nodule that is usually painless, that occurs much later than the so-called allergic reaction in individuals who have painful swellings, such as those who have received the Moderna vaccine and found that the site of the facial filler injection previously became painful. The key thing here is that in order for us to diagnose a granulomatous reaction, it’s going to take a longitudinal study for as long as 5 years before we can determine if it was truly a problem in individuals who received the vaccine, and also had the facial filler injected.
In 2015, in the Journal of Dermatologic Surgery, there was a series whereby the author conducted a retrospective chart review of patients who were treated with HA fillers, within a 5 year period, to evaluate for delayed onset nodules. The conclusion was that although they are pretty uncommon, it is important to be aware of this side effect, and to have a management protocol in place. In their conclusion, the authors also said that from the patients responses and from the literature, that these nodules are immune-mediated in nature.
What I’m trying to say is that because we are currently in an unprecedented public health situation internationally, where we have a raging pandemic that’s deadly, we may have to reconsider the risk that we might be taking with aesthetic treatments. Now, I do perform facial filler and botox injections, but the truth is, vaccinations are going to be a priority for most people and most countries in order for us to get the pandemic under control. I feel that the public should realize that we are also not going to be 100% certain how these facial fillers will further on be affected by these vaccines -for example, the development of granulomatous reactions. The truth is, if you already had a facial filler, I certainly don’t think that should deter you from getting a vaccines because these are established complications. If you do have it then, visit an accredited dermatologist who will be able to diagnose it accurately and will be able to treat it.
A word of caution here, not all painful filler related swellings are due to an immunologic response to the vaccine, depending on the characteristics observed during clinical examination, your dermatologist will also evaluate you for other differential diagnoses which may also include atypical infections. These are usually a result of poor aseptic technique, which introduces environmental bacteria into the deeper tissues.
Overall, my two cents is that if you are thinking of getting a facial filler, as a dermatologist, I feel that you certainly can wait. The reason is really because the cost of human life in this pandemic, simply outweighs any other considerations that one may have.
The human facial structure is a composite of skin (the epidermis and dermis) the subcutaneous fat, the SMAS layer, the muscle and ageing affects all these structures dynamically, fillers only address one part of the ageing equation – restoration of volume. In terms of restoring facial structure and facial sagging – which can be corrected with other technologies such as: radiofrequency, High Intensity Focused Ultrasound, which do not involve injection of other substances into your body tissues. A board-certified dermatologist or plastic surgeon will be able to advise you on these options.
The CollagenUp Facial Wand is a FDA approved device that includes cleansing + treatment + toning + radiofrequency + red photon + blue photon + EMS functions for the ultimate home-based skin rejuvenation system.
Advances in our understanding of textile cosmeceuticals in the form of polysaccharides,polymers and nanoparticle materials can create an optimal skin microenvironment that stimulates collagen production, improving the hydration of the stratum corneum that creates plumpness and firmness of the skin.
In conclusion, if you’ve had a facial filler before, don’t let that deter you from getting the vaccine, as the cost of human life is much greater and this is a known filler complication (definitely enhanced by the vaccine) but the benefits will outweigh the risks. If you ARE thinking of getting fillers done, my personal opinion is that you may wish to consider alternatives, given the current context of our pandemic.
The tendency of the fabric mask to alleviate or trigger the dermatological disease
Acne, perioral dermatitis, seborrheic dermatitis, eczema, and rosacea are some of the common skin conditions that will be worsened by the wearing of a face mask. The reason is due to the occlusive microenvironment increasing the growth of bacteria and yeast, as well as the friction causing skin discomfort which can trigger off inflammation in individuals with pre-existing dermatological conditions. All fabrics will reduce the ventilation around the area of the skin covered by the mask, and this will increase heat and moisture, factors that promote microorganism growth. When it comes to maskne prevention, these are important factors to consider.
How functional textiles can help balance the “germs” required in maintaining skin health
What is the skin microbiome?
The term microbiome refers to the balance of germs-bacteria, viruses, fungi, mites, that work with our body to keep it healthy. These germs have to be present for our immune system to work and self-regulate. It is formed at birth, changes as one age, varying in terms of each location i.e. the germs on our scalp are vastly different from that in our oral cavity, our nose, and the rest of the skin. Various dermatological conditions have now been shown to be linked to microbiome dysbiosis, which relates to an imbalance in the skin flora.
Acne patients, for example, are colonized with propionibacterium acnes, and the latest research shows the link between a new type of bacteria known as C.acnes, on the skin of sufferers. Seborrheic dermatitis, a flaky condition that can affect the eyebrows, the nasolabial folds, around the nose area, and the scalp, is linked to an overgrowth of a yeast organism known as Malassezia furfur, which favors oily, moist and humid environments. Eczema is linked to staphylococcus aureus colonization, which drives a superantigen effect that causes inflammation in eczema patients.
Functional biotextiles in dermatology, such as those impregnated with silver, zinc, or copper ions, have been proven to have biocidal effects i.e. inhibiting or killing off microorganisms upon skin contact. These have been used to treat fungal and bacterial infections, as well as an adjunct therapy in the treatment of eczema. Such textiles hold potential for the treatment of maskne, and help in maskne prevention because of its effects on the microbiome and may reduce the risk of antibiotic resistance in individuals being treated for maskne.
The CUIONS™ Copper Silk Face Mask has been laboratory tested to kill Staphylococcus Aureus, a common bacteria that can cause secondary skin infections in acne and worsening of facial eczema. Bacterial/Fungal infections can cause maskne, making the mask ideal for maskne prevention. The surface is also water/splash resistant with adjustable ear loops.
The copper nanoparticle mask is clinically proven to be more hygienic than the standard fabric mask. It has anti-odor properties with the copper ions killing bacteria/fungi/microbes that come into contact with the mask. This is particularly suited for comfortable wear against your skin over prolonged periods. Copper impregnation is also backed by clinical studies to have active skincare properties such as anti-wrinkle and anti-ageing, due to stimulation of collagen growth through contact with copper ions actively released on contact with skin. Data from randomised controlled trials demonstrate statistically significant reduction in facial wrinkles after 2 weeks of exposure to copper infused textile.
How the material of fabric masks affect the skin – poor ventilation as a contributing factor
Many would have heard the term “breathable” fabrics being used when discussing the material of face masks and it is appropriate for me to delve further on this topic here for maskne prevention.
Our skin maintains a healthy microenvironment via self-regulation through transepidermal water loss, ceramide skin barrier, and natural moisturizing factors. Most of us are born with healthy skin barriers and the topmost layer also known as stratum corneum where most of the action happens. The health of the stratum corneum is crucial because we are able to produce sufficient amounts of lipids and natural moisturizing factors at the surface of our skin. Our stratum corneum adjusts according to our environment.
Transepidermal water loss increases in dry temperate climates and reduces in humid climates like Singapore. However, there is always a problem that arises when you have a dysregulation of the skin microenvironment. Poor ventilation is a very simplistic way to think about it in terms of what’s going on at the skin barrier but it reduces the evaporation of fluids from the surface of your skin. The fluids refer to your saliva, your nasal secretions, sweat which otherwise will not get in contact with skin. All that creates a new environment that does not allow your skin to breathe. The key concept here is that it is important to maintain a healthy skin microenvironment
Maintaining a healthy skin microenvironment for maskne prevention
Firstly, counteract the negative environment that the facial covering is creating — essentially the increased moisture and heat retention. How do we do that? The type of material matters. We know that there are breathable fabrics and there are non-breathable fabrics. Breathable fabrics would typically be made up of natural plant-derived origins such as silk, cotton, linen. However, these do not wear well and are less durable. They can have the added function of wicking moisture away from your skin which results in increased breathability, but also can retain the moisture within the fabric itself due to low evaporation rates and result in increased discomfort from the weight and stickiness of the fabric.
Synthetic fabrics – polyester, polyurethane derivatives are commonly used as part of surgical masks as well as N95 masks. The reason is that the tight weave of these synthetic fabrics can effectively prevent the transmission of respiratory particles and droplets. However, these are not kind to the skin at all. In fact, polyester creates an even “stuffier” environment and this can increase your chance of getting acne mechanica also known as occlusion acne, and does not help with maskne prevention.
That’s when the concept of breathability becomes important in maskne precention. What exactly is this breathability about? It is the material’s ability to wick moisture away from your skin and to keep it dry. You are constantly breathing in and out and this moisture will accumulate regardless especially when you talk while the fabric is in direct contact with your skin. Our saliva also contains enzymes. In individuals who have prolonged contact with this saliva on their skin, some may develop eczema or dermatitis in addition to mask acne bumps.
The Lyosilk Mask is synthesised to be anti-microbial due to its quick drying and moisture wicking properties. It provides a cooling, sweat-wicking, breathable layer against skin to prevent skin irritation due to prolonged surgical mask wear.
The benefit of natural materials is that it is breathable. Though these are not waterproof, the density of these fibers is often much less than synthetic ones hence reducing the protection to the environment. This reduces the efficacy of the product. Natural fibers would include silk, cotton, linen. In my practice, we have been recommending individuals who have to wear a surgical mask in restaurants and medical settings to use a mask slip.
An example would be the Lyosilk mask slip to use with the surgical mask (derived from 100% plant cellulose fibers). It is very smooth and soft on the skin while wicking away moisture, which leads to increased breathability on your skin. This, however, would mean there is an added layer to the surgical mask, which would increase the heat retentive properties of the mask. For usage in non-healthcare (lower-risk) settings, a reusable fabric mask made of a treated synthetic fabric with increased evaporation coefficient, cooling properties would be ideal for maximum comfort without compromising on the effectiveness of controlling the environmental spread of respiratory droplets.
It is important to maintain a healthy barrier between your skin and the mask to minimize the chance of skin irritation. In this chapter on maskne skincare, we will touch on the fundamentals of the skin microbiome – the balance of good and bad bacteria and yeasts on one’s skin, and the importance of skin care to maintain the microbiome balance.
Maskne skincare recommendations for mask-wearing
The wearing of an occlusive face mask has implications for the absorption of skincare applied. A moist and humid environment increases the absorption of any topical applied to the skin, which in the case of acne treatments, can increase the irritation potential of the active ingredient(s)
When mixed with sweat, certain active ingredients may also be biochemically altered and cause dermatitis (eczema). Sunscreens commonly cause irritation in individuals with eczema, and wearing a chemical sunscreen (as opposed to a physical sunscreen) under occlusion and sweat will increase the chance of developing sensitivity to the sunscreen.
Choice of Cleanser
A gentle emulsifying cleanser is important for thorough cleansing. For individuals who wear makeup, double cleansing is recommended to remove residual sweat, grime, oil, and make-up build-up. For non-acne prone individuals who wish to prevent maskne, it may be time to get started on a gentle cleanser with antibacterial properties.
My personal maskne skincare recommendation is the cleanser from my cosmeceutical line formulated with medical-grade honey. Medical grade purified honey functions as a broad-spectrum antimicrobial with natural emulsifying properties.
Medical grade honey is used in the Miel Honey Cleanser which has natural emulsifying, antibacterial, anti-fungal properties for gentle and effective cleansing in eczema-prone individuals. Natural honey is also a humectant, trapping a layer of moisture for protection after cleansing.
Choice of Acne Cream
When it comes to maskne skincare, avoid acne spot creams with synthetic active ingredients such as retinoids, benzoxyl peroxide, aulfur, salicylic acid as these will cause increased skin irritation (irritant contact dermatitis) when applied under the occlusion of a face mask. Individuals who apply retinoids for night acne treatment may find that wearing a mask in the day increases the risk of retinoid dermatitis, a form of eczema that leads to redness and flaking on the skin.
There are many different formulations of acne creams. The ones that we are familiar with would be benzoyl peroxide, salicylic acid and even sulphur or tea tree oil base formulas. These have largely fallen out of favor in dermatologists in the last 2 years primarily because of irritation potential.
Benzoyl peroxide is also known to bleach fabrics and may alter the structural integrity of the face mask, rendering it less effective for control of droplet spread. Anti-inflammatory acne spot creams are recommended. Acne formulations with botanical actives such as Chlorella Vulgaris work by regulating sebum production, whilst natural moisturizing factors like amino acids fight inflammation and have additional moisturizing properties to protect the skin barrier.
The Blemish Spot Cream is formulated with an algae extract, Chlorella Vulgaris, that reduces the activity of oil glands and has anti-inflammatory properties. Natural Moisturising Factors (NMF) in the form of amino acids help to reduce scarring and promote wound healing of the pimple.
In the ideal maskne skincare routine, hydrocolloid acne patches can be helpful because of the following reasons: 1. Prevents touching or picking which can lead to infection and scarring 2. Creates a moist microenvironment for faster and better healing 3. Increases absorption of active ingredients in pimple cream (non-irritating anti-inflammatory formulas recommended; avoid those with salicylic acid or retinols if you have sensitive skin) 4. Absorbs fluid to aid in quick resolution of acne papule/cyst
Hydrocolloid patches can sometimes contain active ingredients i.e. salicylic acid and benzoyl peroxide, hyaluronic acid and niacinamide, although it can certainly be used on its own with benefits as above. Overall, it helps acne papules heal faster by reducing inflammation.
Use of powder formulations to control excess oil and moisture
Mineral zinc oxide has anti-microbial and oil regulating properties. I currently recommend a loose powder formula for my acne-prone patients, as part of treatment for their oily skin. The benefits of using a zinc oxide powder formula for individuals suffering from maskne are as follows: control of bacteria as zinc oxide is antimicrobial, control of sebum regulation and absorption of excess moisture in those who suffer from hyperhidrosis (excess sweating). In addition, zinc oxide is an inert ingredient which means it is not affected by changes in pH or sweat.
For dry skin: Use protective emollient creams that contain barrier repairing ceramides and humectants such as polyglutamic acid, hyaluronic acid and natural moisturizing factors like amino acids. Avoid urea or lactate based humectants as this will likely cause skin irritation when mixed with sweat on the skin. Avoid occlusives such as white soft paraffin as this may increase the incidence of acne mechanica
The Multi-CERAM Cream is a new generation “Smart Moisturiser” formulated as a Prescription Emollient Device. It is formulated with an optimal skin lipid mixture, containing a mixture of plant-derived phytoceramides and synthetic ceramide. Antioxidants that fight skin inflammation are incorporated for optimal treatment of eczema.
For combination/oily skin: Use serums and emulsions/lotions rather than cream formulas. Cosmeceutical formulations containing plant anti-oxidants like Portulaca Oleracea, Centella Asiatica, Brassica Oleracea are anti-inflammatory and can be helpful in maintaining healthy skin function.
The Radiancé Fluide™ Hydrating Emulsion contains amino acids, oligopeptides and niacinamide for regeneration and skin brightening, specially formulated for a lightweight feel to impart a radiant glow.
The Elixir-V™ Total Recovery Serum is an intensely nourishing concentrate of deep hydrating, lifting and tightening peptides for the perfect V-face look.
Predominant outdoor mask wear in warm, humid climates
A maskne skincare tip would be to use serum or lotion vehicles instead of cream formulas. Choose humectants and emollients instead of occlusives (petroleum jelly, mineral oil-based liquid paraffin). This applies to both dry and combination/oily skin. The occlusive effect of the face mask in combination with a humid climate can lead to worsening of facial eczema and trigger occlusion acne
The Mineral Booster™ is power-packed with amino acids for repair, potent plant root extracts for UV-protection and polyglutamic acid for superior moisture retention.
When it comes to sunscreen as part of the ideal maskne skincare routine, the following issues are of concern here:
1. The oil solvent in sunscreen formulations can be comedogenic and can trigger off flare-ups of conditions such as perioral dermatitis. 2. The chemical sunscreen components (azobenzenes, cinnamates) can cause irritant contact dermatitis, which can be worsened by the occlusive effect of a face mask as well as by sweat accumulation on the skin. 3.The waterproof formula is necessary due to moisture and sweat build up under the face mask and will require frequent reapplication. 4. Reapplication of sunscreen under the face mask throughout the day may not be practical.
When one develops irritation after applying sunscreen, it is often due to chemical sunscreen components mixing with sweat. Some individuals feel stinging whenever they wear sunscreen, and it is usually not because they are allergic to sunscreen itself but it’s simply because the chemical block components can be altered via exposure to UV-light and when mixed with sweat (ammonia content).
The Sun Protector is exquisitely formulated for humid climates. It is a broad-spectrum sunscreen that also regenerates and soothes sensitive skin.
The relevance of UV-protection is not to be undermined. For normally healthy individuals, it is an important step to the prevention of photo-aging and skin cancers. For photosensitive individuals i.e. on acne treatment (retinoids/oral tetracycline), rosacea, lupus, post-laser, it is a key part of dermatological treatment. Sunscreen requirements should include broad-spectrum protection minimum SPF 30+, although the standard in dermatology practices are SPF 50+. Physical sunscreens are preferred over chemical sunscreens due to the inert formula of physical blockers, being less likely to trigger dermatitis.
Fabrics with ultraviolet-protective function (UPF
One part of maskne skincare, is the type of face mask chosen. All fabrics confer some level of protection from ultraviolet light, although for a garment to qualify as ultraviolet protective, there are key requirements, based on the current European guidelines. The design of the garment has to cover a maximal body surface area. Following which, the UPF-rating of the material itself depends on scientific measurements such as fiber chemistry, porosity, concentration, fluorescent whitening agents, UV-absorbers, and other finishing chemicals. While natural fibres such as cotton, silk and linen are breathable, they often confer very minimal to no UV protection. All approved UV-protective garments are synthetic in nature.
Currently, I recommend UV-protective fabrics for fabric masks, as a practical solution for sun protection during the pandemic. UPF 50+ qualifies for excellent protection according to the Skin Cancer Foundation Seal of Recommendation guidelines. A UPF 50 fabric blocks 98 percent of the sun’s rays and allows two percent (1/50th) to penetrate, thus reducing your exposure risk to UVA and UVB radiation, which causes photoaging, pigmentation and skin cancers.
Implications for individuals with skin pigmentation concerns
Given that it is highly recommended to wear a face mask during the COVID pandemic, it may be a turning point in dermatological care for the treatment of pigmentary disorders. Dermatologists are always looking at the topic of sun protection with great interest because firstly, it is the biggest contributor, other than our own genetics, to skin cancer. Secondly, it is the most significant external factor affecting aging, pigmentation disorders such as melasma and solar lentigines (sun spots). Sun protection advice for individuals suffering from facial pigmentation has been traditionally centered on the use of broad-brimmed hats, broad-spectrum sunscreens with minimum SPF 30.
With current recommendations to wear face masks, it is timely to revisit the topic of UV-protective clothing. In countries where there is a culture of sunbathing, there are higher rates of skin cancer, especially in individuals who are of a lighter skin phototype/have light-colored eyes i.e. blue or green eyes. The benefits of UV protective clothing is as such – offers gold standard protection with UPF 50+, not affected by factors such as reapplication (of sunscreen) or water-resistance. Fabrics are conferred with ultra-violet protection properties by way of specific material treatments, and are also required to meet the basic requirements of maximal skin coverage.
Have you been experiencing more breakouts during the COVID-19 pandemic? In this interview transcription, Dr. Teo Wan Lin talks about Maskne skincare, common skin issues, and self-care tips in the COVID-19 era.
Dr. Teo Wan Lin, a #HerWorldTribe member and a key opinion leader in the field of cosmeceuticals (including the realm of maskne skincare), was invited as a guest dermatologist for Clinique’s #EvenBetterTomorrow campaign on HerWorld Singapore’s IG Live.
Covered in this transcription of the interview are some of the questions asked about common and maskne skincare problems women have during this pandemic, also featuring a Q&A session with the Instagram live participants, and Dr. Teo’s vision for an even better tomorrow. Topics includ common skin concerns women have during this Covid-19 period, pigmentation and acne skin concerns especially in tropical Singapore, how to treat them, and her plans for an even better tomorrow. She also shares some best tips for scalp hygiene and hair care in warm and humid Singapore.
I just wanted to ask you a few questions about maskne skincare, I think we all have some burning questions you can help us answer. Just like plenty of women have faced during this pandemic, I’ve experienced more breakouts on my chin, and my scalp seems a little oilier, can you tell me why?
That’s a great question that I’m sure lots of people have too. First of all, breaking out over the mouth area covered by the face mask is something that we’ve observed in more and more people over the last couple of months. I’m sure all of us have heard of ‘Maskne’ and even ‘Maskne Skincare’. I just wanted to share a little bit of a scientific, medical perspective on this issue amidst all the beauty buzzwords and information overload.
It’s not a brand new condition, it’s actually a variant of a well established form or acne called acne mechanica. Acne mechanica is due to local factors such as friction, pressure, as well as the microenvironment of the skin being affected by humidity and increase in skin temperature. All these will influence little subtleties in the skin such as pH, and the microbiome balance – which refers to the bacteria and organisms that live on your skin. So it is not a surprise to us that this new lifestyle intervention of wearing a face mask – which is mandatory in many countries – has led to an increase in acne mechanica.
Now, for the second question about the cause of scalp oiliness. It is very common in tropical countries like Singapore for young adults who do produce a bit more oil, to develop a more greasy scalp because of the condition Seborrheic Dermatitis. As you know, once we hit puberty, because of the influence of hormones, our body starts producing oil. This oil, together with ambience factors of increased heat and temperature in an outdoor environment, can breed the overgrowth of a certain type of yeast known as malassezia.
Malassezia can cause Seborrheic Dermatitis, which is what you just described: oily scalp, a bit of scalp discomfort, and sometimes people even develop dandruff. Seborrheic dermatitis is also worsened by stress, as acne is, so it is not surprising that in 2020, where so many things have changed for all of us, that we see an increase in these concerns.
Can it be fixed?
Absolutely. As a dermatologist, the important thing I always highlight to my patients is that we have to first understand the disease process, then we can suggest therapies that directly address it. Once you have the correct diagnosis, there are specific medical treatments we can recommend that are effective for these conditions.
Great, I also want to find out a little more about your business during this period. How was Circuit Breaker for you personally and professionally?
Well I think it was probably a lot better for us than alot of others. The reason is because I had already implemented teledermatology at the end of last year for my overseas patients, as it was something that we felt was a real need for international patients who couldn’t get their medication or get their regular consultations at a specialist hospital.
We’ve been doing that for medical dermatology specifically, so the transition for us was not so abrupt, except that we had many more patients that qualified for teledermatology from February onwards. As you know, Circuit Breaker started in April, so we already had 6-7 weeks of prep before we decided to convert 95% of all our patients to teledermatology.
Let me share a little bit about teledermatology with you, because it could sound a little bit foreign. It’s not something that’s brand new. Telemedicine is an established field within medicine, and dermatology, being a visual specialty, is very suited for virtual consultation. It is still considered a legal consult, so the way we design the protocols do abide by medical legal standards. We require the clarity of the photos to be of a certain standard, and my nurse is in fact a lot busier, because they have to do a lot of video explanations.
The unfortunate thing of course, is the loss of the human touch and interaction, but we do try to make up for it in terms of the time we spend, and also through the fact that my practice has always been based on educating the patient about disease processes and empowering them to be able to handle their skin and scalp conditions. So at the end of the day, it’s been difficult for a lot of people, but it’s something that we’ve all grown used to.
You had the foresight to launch teledermatology last year, even before COVID happened. How have your recent experiences mold the way you view life and work?
I would say that the most important lesson that all of us should take home from COVID is humility. I think for too long, we have all been very self-centered as a modern society. We’ve forgotten that we are part of a very large ecosystem, which is nature itself. For me, I’ve always been very into botanicals and nature. My personal hobby is gardening, and I have been growing edibles for the past 5-8 years.
So the humbling experience that all of us have gone through because of COVID – where there was some uncertainty even about food supply, the mad rush at the grocery stores etc, has helped to mold a perspective that as humans we’re not alone in this world. We have to bear in mind that whatever actions we make, especially when it’s impacting the environment, the animals or even their habitats, there will be some sort of consequence that we have to suffer. I think this is the most humbling lesson.
Adding on, food sustainability, for one, is something I have also been working on. My new project that we have been researching over the last 8 months or so, is born out of my interest in sustainable vertical gardens, and is a solar-powered home vertical hydroponic system, so look forward to that in the future. But at the end of the day, I feel that the biggest take home from this entire 2020 COVID experience is that we have to understand we’re part of a larger ecosystem and we’re not just manipulating the other species, so we can’t take these things for granted.
I absolutely agree. Besides what we have addressed about common skin concerns, what are some of the must-have ingredients in our maskne skincare, and also that will help to take care of, brighten, and even out skin tone?
That’s a great question. Before I answer that, I want to set the background right for the scientific approach of aging. You have to understand that the skin is an organ, just like your lungs, your liver. The great thing about topical application with serums, creams, emulsions is that it’s able to access the skin directly.
So as long as you’re able to address the process of cell senescence, which is responsible for the process of aging, you can expect some sort of efficacy of the product. In terms of addressing age related or environmental related consequences, such as what you mentioned – lack of radiance, uneven skin tone, irregular pores – these are what we label as the negative signs of skin aging.
Now on a more specific note, I want to talk about the importance of the use of botanicals. On the topic of plants, the amazing thing is that Earth has provided us with all these little miracles in the life of a plant. In dermatology, we are familiar with the concept of antioxidants – that can be categorized into compounds such as polyphenols – which I want to break down for our listeners today.
If you understand how skin dullness is caused by free radical damage, then you’d understand how antioxidants combat free radical damage. Polyphenols present in extract in Green Tea Camellia Sinensis, Resveratrol extracted from grapes; these have potent free radical scavenging properties, which is exactly what will target the cell mechanisms responsible for deterioration in your skin’s appearance.
Another category of ingredients I’m sure you’ve heard of is Vitamin C, which is an established antioxidant. In conditions like Maskne, Vitamin C plays a role in improving the condition of your skin via two ways. The first is in controlling the acne itself. The very fact that it is an antioxidant molecule means that it makes it slightly more difficult for the bacteria responsible for acne to cause inflammation. Secondly, we know that Vitamin C reduces scarring because it lightens the amount of pigmentation through melanin inhibition.
To summarize, the two important functions a good ingredient should have when it is formulated in maskne skincare and skincare in general is: cell protective effects and photoprotection (protection from environmental and sun damage). Botanical extracts have this amazing property of fulfilling both antioxidant, cytoprotective and photoprotective effects on skin.
What are the effective ingredients in the Even Better Clinical serum that you would say embody some of what you mentioned earlier, that we should be looking out for?
Before I answer your question, here’s a tip on how to read the ingredients on your product, be it maskne skincare or any skincare in general. It is an FDA and HSA requirement that all skincare products sold have a full ingredient list. The top-most ingredient is what is present in the highest percentage, going in descending order to the bottom. This is how you can roughly figure out how much of each ingredient is present in your product.
After examining the Even Better Clinical Serum, I’ve noted that the great thing about the formulation is the combination of botanical extracts that this product has demonstrated. The presence of not just Camellia Sinensis polyphenols, as we discussed earlier, but in combination with other nature-derived extracts, is what is great about this formulation. For example, this product contains rice bran extract, which is a potent anthocyanin, meaning it works directly on the cell mechanisms to reverse environment-related aging processes. When used regularly, it will help to improve radiance of the skin, as well as skin quality.
Another thing I wanted to highlight is that just because it is a serum meant for skin lightening, it doesn’t mean that it completely ignores the concept of the skin barrier. A good antioxidant serum will have moisture stabilizing properties.
In this case, the Even Better Clinical Serum contains Sodium Hyaluronic, Squalane and Glycerin – which are all important humectants that help to trap moisture under the skin. In order for us to have healthy, radiant skin, we have to address both the antioxidant properties of a cosmeceutical product, as well as the barrier restorative properties. This is so that you don’t just have radiant skin, but healthy skin that is resilient against environmental stressors.
That’s good to know, because often we buy our skincare and products in general but we don’t know exactly what to look out for.
Yes, and it’s difficult for anyone to navigate, simply because of the abundance of information on the internet, especially with the amount of advertising that’s going on. At the end of the day, I think we should be moving towards the direction of promoting skin health because it helps the self-esteem of every individual, rather than pointing out the negative effects of aging, or trying to attain something that is not part of skin health.
As a practice, I think it’s important for us to center on the individual as a whole; and as a dermatologist, I play the important role of explaining the process of skin health and treatment goals in this very confusing world of beauty.
Speaking of that, can you explainmore on how “dermatologist-tested” products differ from other products or maskne skincare in the market? Is it really suitable for people with sensitive skin, or is it suitable for everybody?
Firstly, I want to highlight that this term “dermatologist-tested” isn’t regulated, so you’ll probably find that the majority of products sold in supermarkets, pharmacies, malls have this label on it. Since this term isn’t regulated, it’s important to understand the brand history and the brand ethos before you trust it. If it’s been “dermatologically-tested” it doesn’t necessarily mean it’s been developed in conjunction with a dermatologist in a clinical setting, nor does it mean they worked with a dermatologist to assess the efficacy or allergenicity of the product.
Clinique is one of the exceptions to this, as they have worked with dermatologists to develop their products. The brand is also well-known for keeping their product formulations allergy-free, so in my opinion is much more valuable than a “dermatologist-tested” label. There has been lots of information and different labels thrown around callously in the beauty world, and I think it’s educational for us to share this with our viewers.
Are sun spots and discoloration relevant concerns now that people are wearing less makeup, or tend to wear less sun protection and products with SPF while at home?
While this may seem like a simple yes or no question, it’s not so straightforward. I’ve seen both men and women who come into my practice and are bothered by these visible imperfections on the skin. While it may not be so severe to me, it is very obvious to them, so it really is a reflection of how they themselves have suffered with this perceived imperfection over a period of time.
Answering your question, I didn’t find that there were less people bothered by it throughout this period, but there’s always been individuals who may not have very severe pigmentation that are more bothered by it, and certain individuals who might not care about it at all.
Going into the science behind pigmentation, we know that we’re born with a natural skin phototype, and it’s not healthy for us to be chasing after this ideal of lightening our skin or changing our skin tone. But the presence of increased pigmentation over specific areas, such as sunspots as you mentioned, is a diagnosis known as solar lentigo that is related to age, sun-damage and genetics. Specific treatments for solar lentigo would include using topical ingredients that inhibit melanin synthesis, and enhance the cell synergistic effects of your skin’s chemical mediators that help to remove the pigmentation.
For deeper pigmentation conditions like Melasma, it’s not related to staying at home or being outdoors. Instead, Melasma is a chronic, long-standing process which takes several years to develop. Hormonal imbalances can also influence the development of Melasma.
I just wanted to address some of the questions we have from the Instagram live participants, are there any superfoods that you would recommend that are beneficial for our skin or as part of maskne skincare?
I feel that skin health is a manifestation of our general health. We all know the old saying ‘we are what we eat’ – our diet plays an important role in the health of our skin. From a scientific point of view, there have been many studies related to effects of a high saturated fat diet, high sugar diet, consumption of dairy products, as well as chocolate that can worsen the symptoms of acne.
But for skin health specifically, it is true that when we are consuming a healthy diet, consisting of superfoods like those in the category of Brassica Oleracea such as kale, broccoli, cauliflower, it has the ability to inhibit growth of cancerous cells. From day one, our bodies are constantly fighting off the proliferation of these cancerous cells. When we go past the age of 25, about the time when our skin shows signs of aging, we are also trying to address the question of cell senescence, or the cell aging pathway.
Beetroot, for example, is one of my favorite foods, and also one of the superfoods favored by athletes. It’s been proven to increase your body’s ability to take up oxygen, and increase your stamina and performance too. So I have been trying to incorporate Beetroot creatively in all my meals, and also have moved to a predominantly plant-based diet from the start of COVID.
Building on that, as a medical doctor, it was very scary to see COVID’s spread, because we’ve never seen any microorganism or any infectious disease of this nature. It’s potentially life threatening and fatal, but at the same time, spreads asymptomatically in otherwise healthy individuals. The origin of this virus, from the data, is from the animal kingdom.
It’s not normal in any sense for these viruses to cross over to us in such a way and cause a pandemic. This clearly has to do with the fact that we are encroaching into another species’ habitat and farming them in ways that are unethical, that is causing all these mutant pandemic strains to arise. So as a personal decision, I decided to stop eating animals, so that it’s much less likely for us to get another pandemic.
Furthermore, it is increasingly being recognised by science that it is possible for us to have a complete, holistic diet from a plant-based diet. However, I do still eat a lot of fish, which is full of what we call ‘good unsaturated fats’ that can help with skin health, and the process of anti-aging, as well as brain health. But I do think that it is important for us to appreciate that our diet is very significant in not only nutrition, and will affect our skin as well.
Two last skincare questions, from comments from viewers during the LIVE session…
“How different is the skin on our body with skin on our face?”
“I have chronic arm acne, would you recommend using the same products as what I use on my face?”
If you have acne-like lesions on your body, it does not always mean that it is acne. But let me get into the difference between the skin on your face and your body. The key thing here is the production of oil. The face is what we call a seborrheic area. Our palms and soles, for example, are completely devoid of oil glands.
Depending on genetics, certain individuals may have more oil production on the centre of the chest, as well as the back, which can be a manifestation of acne. But when you have acne-like lesions on the upper arm, it’s not so typical for it to be true Acne Vulgaris, which is what we’ve been talking about so far.
Acne Vulgaris is influenced by genetics, hormone production, increase in oil production, as well as bacteria. Acne-like lesions on your arm, however, can be characteristics of a condition known as Keratosis pilaris (KP), which is actually a form of eczema. Individuals with KP may have some pigmentation, and have tiny bumps, which can also be inflamed because of infection, making it look like acne. But the distribution in this case is in non-seborrheic or less-seborrheic areas, like on the upper arms or thighs.
It’s also relevant for us to touch on other mimics of acne. Many people who suffer from acne on the chest or the back may have a concurrent condition known as Pityrosporum folliculitis – or as you’ve probably heard, fungal acne. As a dermatologist practicing in the tropics like Singapore, a lot of individuals with chest and back acne, actually have concurring Pityrosporum folliculitis.
Pityrosporum folliculitis is caused by a yeast, a fungal organism that overgrows in hot, humid climates and areas that produce more oil. Treatment for this condition has to address the yeast overgrowth, typically with an antifungal shampoo and cream, in conjunction with anti-inflammatory acne treatment if there is acne as well.
You’ve clearly kept yourself very busy this year despite Covid. While you’ve talked about transitioning to a plant-based diet, can you tell us more about what you have done to ensure an #EvenBetter you?
I love the perspective of this campaign, because self-improvement is essentially my life ethos. Those who know me, know that I’m always keen to learn new things, and like to adopt holistic integrated measures for health in general. I have always been an avid athlete, and love sports in general. Aside from that, I think it’s important for every individual to understand that our life really depends on the decisions we take. We can talk about our mental, physical, and emotional health, but you should understand that they are never independent of each other.
With this, when you address your physical health, in this case, the health of our skin, you mustn’t neglect the emotional and psychological effects too. It’s very difficult for many to grasp the fact that we’re no longer able to socialize as freely as we did before. But I think it’s been a very good healing process for all of us. The way I view COVID is that we’ve all been traumatized by this major catastrophe, so the initial reaction is shock and confusion, then you start to grieve, and then, finally, accept.
The long term life lessons that I would like to share is that essentially, you have to look within yourself for your sense of identity, and that includes being very comfortable and assured in your life goals, and not be easily swayed by the things that are happening around us. If you are able to find an inner sense of identity, it will help you to cope with things around you.
That’s always been my way of dealing with various stresses I come across in life, because it’s not possible to live in a world that’s trouble free – even on the best days, there are hiccups. It’s not that you’re waiting for everything to go awry from the way you’ve planned it, rather, it’s the assurance that you are equipped to handle things that arrive unexpectedly on your lap.
Dr. Teo, one of Singapore’s prominent dermatologists and medical director at TWL Specialist Skin & Laser Centre, is also a pioneer dermatologist in the field of biofunctional textiles. She leads the research and development at Dr.TWL Biomaterials, that focuses on ecologically sustainable, cutting edge technology for new generation biofunctional textiles in skin applications i.e. textile cosmeceuticals. The Biomaterials group launched the Anti-Ageing, Anti-Maskne, or Mask Acne, Copper Nanoparticle Reusable Fabric Mask with UPF 50+ in July 2020 – a biofunctional textile that releases active copper ions for reducing facial wrinkles and kills skin-disease causing bacteria on contact.
Research Paper on Mask Acne
In October 2020, Dr. Teo’s original research letter “Diagnostic and Management Considerations of Maskne in the Era of COVID-19” was published by the Journal of the American Academy of Dermatology, ranked the top* dermatology journal internationally. The journal is the official scientific publication of the American Academy of Dermatology, which is the most influential and most representative of all dermatologic associations internationally, having a membership of more than 20,500 physicians worldwide. The article has also been indexed by leading scientific publisher, Elsevier’s COVID-19 resource centre as highly relevant medical information pertaining to the pandemic.
In the research letter, Dr. Teo characterizes the diagnostic criteria for maskne – including a distinct O-zone facial pattern of Mask Acne (Figure 1) and discusses the ideal face mask design to minimise textile- skin friction (Figure 2), the concept of biofunctional textiles including zinc/copper oxide fabric infusion for antimicrobial benefits to treat and prevent skin disease. The paper also discusses the potential for biofunctional textiles with additional medical/ cosmeceutical benefits to incentivize mask wearing, as well as Dr. Teo’s recommendation for UPF 50+ protection fabric masks to replace sunscreen wear for the lower half of the face.
For more details regarding the Mask Acne publications, attached here is a link to the high resolution press gallery. Dr. Teo’s article pre-proof is available via an online link from ScienceDirect here. Interested journalists are invited to request for a complimentary press copy of the Kindle e-book. For the latest on anti-pandemic personal protective equipment from Dr.TWL Biomaterials, including the UVC Germicidal Lamp for Room Disinfection/Purification, please click here.
The Zincool fabric face mask, infused with zinc nanoparticles for preventing maskne will be launched November 2020. The zinc face mask has similar anti-microbial benefits to treat and prevent maskne, UPF 50+ protection for skin, and has additional oil-control benefits for acne-prone individuals (especially in tropical climates) and incorporates superior skin cooling and sweat wicking textile technology.
*2019 impact factor rankings published by the Journal Citation Reports (JCR) Web of Science Group.
In August 2020, Dr. Teo Wan Lin, author of Skincare Bible – Dermatologist’s Tips on Cosmeceutical Skincare, was invited as a guest dermatologist for Clozette’sInstagram live session on the topic of maskne. A prominent researcher in the area of cosmeceutical skincare, Dr. Teo answered questions about acne care, hydrocolloid patches, maskne, and imparted useful tips for skincare routines. Read on to find out more about what Dr. Teo shared with editor Becks Ko and beauty KOL Khaw Xin Lin.
When it comes to choosing skin care products to tackle maskne, should we choose natural ingredients or “chemical” ingredients?
Dr. Teo emphasized that one should focus on whether the ingredient itself is evidence-based. “Some examples of naturally-derived ingredients that are beneficial come in the form of potent plant-based antioxidants, while chemical ingredients that are beneficial include salicylic acid, benzoyl peroxide, retinol, and retinoids. While these are synthetic structures, they have also been proven in our studies to have specific benefits for the skin.”
Botanical ingredients are anti-inflammatory
Dr. Teo highlighted a few specific botanical ingredients that can address inflammation. “Centella Asiatica (CICA), also known as the Indian pennywort, has been well-established to be a potent antioxidant. Centella Asiatica reduces inflammation and promotes good healing of scars. Ingredients like those derived from avocado oil are rich in polyphenols and fatty acids. Oleic acid – can also help in inflammation as well as the healing of acne scars. Salicylic acid which was first derived from the bark of willow trees, is a chemical compound that can have good effects in terms of reducing oiliness of skin.”
What is the ideal cleanser?
On the topic of cleansers, Dr. Teo pointed out that the ideal cleanser is one that can effectively remove the oil, dirt, and grime, while at the same time, functions as a humectant. This means that it preserves a layer of moisture on the surface of your skin to minimize water loss to the environment — a phenomenon known as transepidermal water loss. “In individuals who have skin conditions such as acne, eczema, there is an imbalance in this bacterial count, and cleansing then particularly becomes an important part of the skincare routine. If the cleanser is too harsh on the skin, you’re going to aggravate these conditions because it dries the skin barrier out.
On the other hand, it has to effectively remove all these particles that are a breeding ground for bacteria.” She further elaborates, “If you find that your cleanser is making you feel that your skin is squeaky clean and a little bit tight after rinsing it off, this is a sign that it is far too drying and it may not even address your concern of having greasy skin. Such a phenomenon will actually lead to excess oil production as a compensatory response.”
Sulfate-based vs amino acid surfactants
“The science behind a cleanser is really that of surfactants, which are basically the key ingredients involved in the cleansing work.” In traditional sulfate-based cleansing surfactant systems, there is a very high pH environment. Over time, it increases the abrasiveness and dehydration of the skin’s barrier. All of which increase the skin’s susceptibility to infections and dryness.
How to use an acne spot cream?
If you are wondering what skincare routine one should adopt for acne-prone skin, Dr. Teo underlined the steps to take. “First, cleanse with a good cleanser that doesn’t dehydrate the skin. Now, the second part, moisturizing. If you suffer from acne or maskne, it’s good to have on hand an acne spot cream that works for you. If you tend to be acne-prone over the entire chin or the cheek area, on regular days, I would apply a thin layer of the acne cream over the entire acne-prone part of your face.
And when you have a pimple, depending on the recommended dosage of the product, to apply it at the earliest sign of the pimple developing. Finally, use sunscreen. Whenever you heal from a pimple, post-inflammation hyperpigmentation (PIH) is a concern, and wearing sunscreen can help to inhibit excess melanin production caused by inflammation, reducing scarring.”
Should people with acne-prone or oily skin type skip moisturizers? What type of moisturizers to use for oily skin?
On the importance of moisturizing, Dr. Teo brought attention to how skipping moisturizers even if you have oily skin is a myth. “The reason is that even when your skin is greasy, it may lack the lipid barrier that protects your skin from the environment. This is a common phenomenon in individuals who find that they have both oily and dehydrated skin.
If you have oily skin and you decide to skip a moisturizer and use a very harsh, astringent cleanser and toner, you may actually have you have a paradoxical phenomenon called reactive seborrhea. That’s when overproduction of oil occurs because the oil glands attempt to compensate. This is definitely not ideal when you are trying to control oily skin.” If you tend to have oily skin, avoid heavy cream formulas and opt for serums and emulsions in the daytime, especially in a humid climate like Singapore.
A dermatologist’s approach to treating acne or maskne – separating myths from facts
Preventing acne from reappearing on the same spot
“If you have acne that keeps appearing over a certain spot, you could actually have something a little deeper known as an acne cyst.” An acne cyst is essentially a collection of pus, dead skin material that is segregated by a cyst wall. While it may reduce when it’s less inflamed, the cyst wall persists.
If you’re having a recurrent, painful, deep acne bump that lasts for anything longer than 2 weeks, then the suspicion of having an acne cyst is more likely. On another note, Dr. Teo elaborates, “if you tend to get acne over a certain area such as your chin or your cheeks, then using the right products can help prevent the formation of microcomedones, to prevent appearance of acne.”
Letting our acne “breathe”
“This is quite a paradox because, on one hand, we know that occlusion acne can occur with comedogenic substances and more recently, maskne, which is acne mechanica due to occlusion of the face mask on skin. On the other hand, a moist environment is optimal for the healing of inflammation.”
“If you do not have inflamed acne, then it is important for your skin to have some breathability in terms of moisture-wicking because this breeds bacteria and can cause flare-ups in acne. However, if you do have inflamed acne, then using the right acne care product can help the acne to heal faster. The effects of such products can be enhanced by creating a moist, wound-healing environment such as using a hydrocolloid acne patch.
Should we pop our acne?
“Popping a pimple is always a bad idea because it can get more inflamed and you may introduce more bacteria. If you notice your acne is coming to a head and there’s pus at the surface, after a warm shower, you can use a damp cotton pad to gently compress the area and the pus should come out naturally. However, if you’re not able to do so, definitely don’t proceed to squeeze it.”
Best fabric to prevent maskne?
On the point of choosing the best fabric to prevent maskne, Dr. Teo suggested opting for functional textiles. “None of the natural materials are waterproof. However, if you’re talking about skincare, typically natural fibers tend to allow more breathability in layman’s terms.
What I am recommending my patients right now is the concept of functional textiles. So the usage of synthetic fibers, in this case, would be ideal because it’s waterproof, but it has to be treated so that it’s skin-friendly. There are several physical factors that can alter the breathability of synthetic textiles, such as incorporating certain metallic ions like silver, copper, and zinc which can confer antibacterial properties that can reduce the occurrence of maskne.”
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.