The COVID-19 pandemic has led to mandatory mask-wearing. Many mask-wearers have complained of “maskne” which refers to acne caused by wearing their masks for too long. What are the possible causes of this? Is it due to the material of the mask or accumulated sweat? In this article, I shall share my dermatological expertise on maskne, including common skin conditions that arise from a face mask and maskne treatment.
Maskne is a variant of acne mechanica or occlusion acne, which previously prior to the COVID-19, was most commonly seen in athletes who wear headgear (helmets, face guards), amongst medical staff (surgical mask, N95 mask in infectious disease settings), motorcyclists and construction workers who wear helmets. It is a disorder arising from the occlusion of hair follicles, directly related to mechanical stress (pressure, occlusion, friction) and microbiome dysbiosis (from the imbalance with heat, pH, moisture from biofluids including sweat). Both of these are affected by increased duration of mask-wear.
Besides mask acne, what other types of skin diseases can arise from prolonged mask wearing?
Several other skin diseases can be associated with prolonged mask-wearing, due to increased heat and moisture, and may also mimic symptoms of maskne. For example, eczema, rosacea and heat rash may manifest as red bumps and red patches which one may perceive as skin irritation. In my private dermatology practice, we do not do epidemiological studies regarding the number of cases, which should be assessed on a national level. Suffice to say, there has certainly been a very significant increase across the board in incidence of skin diseases associated with mask-wearing.
For those who wear their masks for prolonged periods of time, is there a possibility that the bacteria trapped inside the mask could cause skin infection or irritation?
Mask wearing creates an occlusive microenvironment and this changes the normal microbiome of healthy skin. 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.
What are some of the severe forms of skin disease that could result from prolonged mask wearing?
There are other conditions apart from maskne that can arise from prolonged mask wearing. Individuals with preexisting conditions such as acne vulgaris, perioral dermatitis, eczema of the face and rosacea, may have their conditions aggravated and suffer serious flare ups. This is due to disruptions of the barrier function and microbiome of the skin as a result of prolonged mask wearing which impacts the skin microenvironment and involves also mechanical factors, such as textile-skin friction.
For example, the unique microenvironment created by a face mask causes exposure of the skin to biofluids such as the nasal and respiratory droplets which can alter the pH and microbiome of the skin. With this, individuals who are already prone to greasy skin and acne may find that their acne gets infected more seriously, leading to painful cysts and pustules. In another case, when one is speaking with the mask on, saliva inevitably gets onto the mask.
Saliva itself contains various digestive enzymes. Constant exposure to saliva may cause a form of facial eczema or dermatitis in individuals. In addition, constant contact with mask material also known as textile-skin friction, leads to frictional dermatitis, a form of eczema. It causes redness and results in post inflammatory hyperpigmentation.
For individuals with sensitive skin, what kind of mask material should they opt for, in order for better breathability?
Firstly, individuals with sensitive skin are actually atopic individuals with eczema. It is important to understand that these individuals perceive friction, as well as changes in skin temperatures and other sensations much more acutely. The ideal fabric mask is not just in the material but also in the design, as I have proposed in my white paper on maskne, the Diagnostic and Management Considerations of Maskne in the Era COVID-19, published in the Journal of American Academy of Dermatology1.
The ideal fabric mask design for maskne treatment should encompass details which have been published in the paper. This is a design that minimizes textile-skin friction, omits elastic ear straps which cause additional pressure over the back of the ears, and also allows adequate coverage with the use of a UPF protective biofunctional textile.
In terms of material, we know that natural fibres such as cotton has long been the material of choice for individuals with sensitive skin.
In my white paper, I covered a few key points about the material of face masks affecting the skin. Firstly, natural fibres like bamboo, cotton and silk can wick moisture away, keeping skin dry. However, they retain fluids and become heavy. This is known as increased fluid saturation. This makes mask wear more uncomfortable. It can also create a sticky feeling. Natural fibres also disintegrate easily with wear, making it ineffective as a face covering to prevent fluid spread. On the other hand, synthetic materials that have been treated with biofunctional properties, examples are dri-fit, or what we incorporate in our biofunctional textiles can cool skin rapidly by enhanced evaporation. They are also water-resistant, minimising spread of contagious droplets.
The OSMIUM BLUE™ anti-aging fabric mask with nanoparticle technology is incorporated with CUIONS™ nanoparticles, which are rigorously lab tested for the active release of copper metallic ions clinically effective for anti-ageing by promoting collagen production and reducing skin pigmentation.
What are some of the additional skincare features that can be incorporated into a face mask?
In my paper on the ideal face mask design, I discussed the novel incorporation of ultra-violet protective factor, UPF into the mask material. This solves the problem of wearing sunscreen under the face mask which can increase comedogenicity -i.e. acne formation. To reduce heat retention and flare-ups of heat-related skin conditions such as miliaria rubra and facial hyperhidrosis, choose light or reflective colours.
The ZINCOOL™ zinc nanoparticle impregnated fabric is self-cleaning with whiter than white technology, and incorporates superior skin cooling, creating a highly breathable skin microenvironment, with super evaporation coefficient. It has anti-inflammatory, bactericidal and sebum control functions to treat maskne, and offers benefits for individuals who have facial eczema or are acne prone
In addition, these biofunctional textiles with metallic nanoparticles like copper and zinc have additional anti-oxidant and anti-ageing benefits. The CUIONS technology for biofunctional face masks by Dr. TWL Biomaterials includes copper oxide polyesters associated with reduced face wrinkles. While a lot of masks tout anti-bacterial benefits, these metallic ion textiles with copper, zinc and silver kill bacteria and are considered “bactericidal”. This reduces antibiotic resistance in acne treatment1 as well.
What are your recommendations for maskne treatment?
When it comes to maskne treatment, I would suggest to avoid conventional acne spot creams with synthetic active ingredients such as retinoids, benzoyl peroxide, sulfur, 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.
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 for maskne treatment. 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. Special consideration for skincare as makskne treatment should include anti-bacterial gentle cleansers, moisturisers formulated as Prescription Emollient Devices (PEDs) that help maintain a healthy skin barrier/microbiome.
References:
Teo WL. Diagnostic and Management Considerations for ‘Maskne’ in the Era of COVID-19 [published online ahead of print, 2020 Oct 1]. J Am Acad Dermatol. 2020;S0190-9622(20)32664-5. doi:10.1016/j.jaad.2020.09.063
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 Pimple Cream
When it comes to maskne skincare, avoid acne spot creams with synthetic active ingredients such as retinoids, benzoxyl peroxide, 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 pimple 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.
The Hydrocolloid Blemish Vanish Patches conform comfortably to your skin and increase the absorption of the Blemish Spot Cream for faster healing. It also provides a barrier to prevent irritation from the face mask and secondary skin infection.
What are hydrocolloid patches?
In the ideal maskne skincare routine, hydrocolloid acne patches are a maskne product that 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 a maskne product 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 Hyaluronic Acid (In-House Formula) is an intensely concentrated serum containing laboratory-grade pure hyaluronic acid serum, freshly compounded for total skin hydration.
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.
Sunscreen/UV-Protection
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[10]. 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[11].
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.
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.
Dr. Teo Wan Lin is an accredited dermatologist and an expert on cosmeceutical skincare research and development. She is the author of “Skincare Bible – Dermatologist’s Tips for Cosmeceutical Skincare” which was published July 2019 by Barnes & Noble, Baker & Taylor and Apple Books and available in bookstores islandwide from January 2020. She heads up Dr.TWL Dermaceuticals, a specialist cosmeceutical skincare line with evidence-based active ingredients for anti-ageing and skin health. Its subsidiaries, the Pi-Cosmeceutical Custom Makeup Lab and the Conscious Mask Bar are part of the Conscious Concept Pharmacy launched in December 2019, featuring environmentally sustainable makeup and skincare materials. In this article, she shares about hormonal acne.
1. What is hormonal acne?
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 Miel Honey™ Cleanser is made of a blend of nature-derived emulsifiers. It thoroughly cleanses the skin with botanical emulsifiers leaving a clean yet moisturised feel. It contains Arnica Montana Extract which stabilizes skin and reduces flaking. It is also a natural anti-bacterial and anti-fungal active ingredient.
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.
The Mineral Booster contains Polyglutamic Acid holds 4-5 times more moisture than Hyaluronic acid. It is an effective moisturiser for oily, acne-prone skin as it is lightweight while directly hydrating the skin. It prevents reactive seborrhea.
Dr.TWL Vita C GOLD™ Serum is a neutral stabilized form of Vitamin C which is suitable for individuals with sensitive skin. The potent anti-oxidants reduce activity of acne bacteria and improve scarring.
“How do we avoid acne breakouts?” As dermatologists in Singapore, this is the commonest question we get asked. Certainly not a surprise, considering over 90% of the world population is affected by acne at one point or another in their life. Yes, acne is not a problem unique only to Singapore, which has a constantly hot and humid climate that some may try attribute their less-than-ideal complexion to.
Whilst the climate could play a role in proliferation of the P. acnes bacterium responsible for acne breakouts, the underlying cause of it is actually multi-factorial and intertwined with one’s genetics. Given the pervasiveness of acne, there are naturally burning questions surrounding what we can do to get rid of pimples that have popped up and how do we prevent them from reoccurring, which we discuss below.
Pimples that have come to the surface have two possible outcomes. One outcome would be the pimples going away, so the pus and all the debris get extruded out within two to three days. The pimple flattens out and leaves a mark and eventually it fades. The other possible outcome, which is undesirable, would be having the pimple grow bigger and bigger. This becomes cystic acne and may feel as being very deep under the skin. The pimple may also become part of broader acne breakouts, with multiple cysts and may even be painful. It is therefore a no brainer that we want to prevent the second outcome.
The crux here is to understand that having just 1 or 2 pimples a month is classified as physiological acne. This can actually be very well managed with over the counter topical acne creams. However, if you have anything more than five pimples a month, there is a need for prescription medications. Be it in the form of creams or oral medications, because otherwise, you will likely end up in an inefficient cycle, find that the problem keeps recurring and never goes away.
If you have anything more than 5 pimples in a month, it means that under your skin, you have at least 20 pimples gradually rising to the surface. These embedded pimples take turns to come out. That is why some people struggle with having acne which never seems to go away. The pimples do not appear overnight, contrary to popular belief. Micro-comedones, which are little bumps under your skin, rise to the surface of skin through the process of inflammation. These could take 1 to 2 weeks to appear. In the interim, over the counter (OTC) acne medications may be useful in resolving some bumps, especially where there are fewer bumps.
There are plenty of OTC active ingredients we know traditionally for treating acne. These include benzoyl peroxide, salicylic acid, and some people use sulphur based solutions. However, in my opinion, these only work for very mild acne. I personally do not prescribe any of these in my practice anymore, because they cause irritation and very often the side effects outweigh the benefits. Furthermore, you can get a lot of sensitivity, redness, burning and stinging sensations.
If you have more than 5 pimples a month or experience acne breakouts, you have at least moderate to severe acne. This warrants a visit to your dermatologist for comprehensive management of your acne condition. The following are some tips which I would dispense to those having mild acne breakouts, and also applicable as adjuncts during acne treatment and maintenance thereafter.
1. Use anti-inflammatory creams on acne breakouts
In place of the traditional acne treatment ingredients, I am now proposing anti-inflammatory pimple creams that are composed of bioactive viable botanical ingredients. One such cream is the Blemish Spot Cream, which I have formulated using an algae extract and amino acids. This is instead of the traditional harsh chemical ingredients which work by drying out the skin.
With studies in more recent years, we understand more about acne being an inflammatory condition, which is genetically determined. Accordingly, we work towards reducing inflammations. Therefore, certain amino acids like serine and methionine, that help to repair wounds and reduce inflammations, would be effective. If you think of your pimple as an injury to the skin, which it really is, you want the skin to heal faster. By the same principles, the raw materials supporting wound healing, i.e. amino acids, have the effect helping the pimple to resolve.
In addition, lipid extracts from the algae chlorella vulgaris is also a critical anti-inflammatory constituent. A 2015 study showed that these extracts have tremendous efficacy in inhibiting human inflammatory mediators, with nearly 80% inhibition in some permutations, thereby reducing the pathogencity of P. acnes in causing acne breakouts.
Another key ingredient in the Blemish Spot Cream cream tackles oil production. Oil production significantly worsens acne, causing it to become more inflamed. The abundance of oil also becomes a perfect breeding ground for bacteria, to even cause secondary bacterial infections. In this light, we use extracts from the Argania spinosa tree, colloquially known as argan oil, to reduce oil gland activity. Apart from regulating oil production, sterolins (a form of plant fats) in argan oil also has a potent anti-inflammatory effect from dampening overactive antibody immune responses.
Botanical-based anti-inflammatory creams have in fact increasingly taken the place of prescription antibiotic ointments in our practice. You may have heard of clindamycin, clindoxyl and erythromycin gels which are topical antibiotics that kill surface bacteria. The antibiotic gels, however, have demonstrated limited success in suppressing acne inflammation. Furthermore, I think it is important to highlight that these lose efficacy after a maximum of 3 months. This is because the body gradually develops resistance against topical antibiotics and should be closely managed by your dermatologist.
A more sustainable second category of prescription medication would be retinoid creams. Retinoids belong to the vitamin A group of topicals. Different trade names exist, although by and large the mechanism of action is similar. Essentially, retinoids such as tretinoin work by treating the microcomedones under the surface of the skin.
They accelerate the rate of cellular turnover of the skin, thereby bringing up to the surface microcomedonic bumps in the first one to two months of treatment. This is before they start to suppressing the growth of such microcomedones. However, these are not without side effects, such as redness and irritation which may occur during the course of treatment and needs to be monitored by your dermatologist.
For those with mild acne, the potent anti-inflammatory properties of the Blemish Spot Cream will be handy in resolving acne breakouts. This is especially when the pimples are not yet fully inflamed and in clinical practice for such cases, has demonstrated particularly quick spot resolution of comedones. For those undergoing acne treatments or maintenance post treatment, the Blemish Spot Cream may also be used for prevention of acne breakouts around acne-prone areas.
2. Use an anti-bacterial cleanser
I think for acne it is very important that you use an anti-bacterial cleanser. For the ladies, double cleansing works in this method – oil soluble pigments such as those from makeup, especially eyeliner, mascara, eye shadows pigments, need to be dissolved in either a micellar formulation or a oil based emulsion. The oil-in-water emulsion forms a milky formula which is what I usually recommend to my patients because this is much gentler on skin.
The second stage of cleansing is where acne-prone skin would benefit from if done correctly. An anti-bacterial face wash in the past to us meant using a chemical such as triclosan. Triclosan, while effective in preventing acne breakouts, has had some controversy in its use. Although not definite yet, it has some reported effects on the human hormonal system and that is why I have also stopped prescribing that. Instead, we use a medical grade honey cleanser which helps to emulsify the grim, dirt, and it forms a foam which is not based off a very strong lathering agent like the laureth sulphates.
We are using the natural emulsifying lathering properties of honey and the same would go with a product such as soya. The great things about these natural emulsifiers is that they form a layer of what we call a humectant after you wash it off. This is so that while your skin feels clean after a wash, it is not dehydrated. The humectant layer in fact stays on the rest of the day and helps to form a healthy skin barrier between your skin and the environment to help prevent the onset of acne breakouts.
3. Healthy diets go a long way to prevent acne breakouts
The other aspect that should not be neglected would be your diet. I find that if you have problem skin and we start you on treatment, almost everybody will get well as long as they comply with treatment. However, the rate of recovery as well as the sustainability of the positive effects of treatment is significantly better in the group where they are conscientious with their diet.
We now know that diets high in trans fat, i.e. deep fried foods, dairy products, sugary foods, are pro-inflammatory which means that it can exacerbate your underlying acne conditions to cause acne breakouts. I tell my patients to stay away from that and also take an anti-oxidant rich diet. It is very hard to imagine that we are not what we eat. The same goes for skin, an organ that needs to be respected along with whatever nutrition that goes to your skin, which occurs via 2 ways.
Firstly, nutrition to the skin is topically applied and to me that is the most significant such as in the form of antioxidant cosmeceuticals. The second means, by consumption, is for the healthy functioning of all your tissues. This is for it to fight the daily assaults of free radical formation from environmental pollution, uv exposure, biological ageing. It is critical that have your supply of anti-oxidants in diet and all these do not have to be found in supplements which may be controversial, in terms of the amounts that have to be ingested in a sustainable manner.
We should perhaps instead look towards a healthy natural anti-oxidant rich diet. Do include lots of blueberries and even olive oil. Olive oil in our diet has been proven both by cardiologists as well as within the dermatology research community to have positive anti-ageing effects on the heart as well as on the skin. These factors do add up eventually for healthy skin that is free of acne breakouts.
Acne in teenagers and adults is a troubling condition, affecting one’s self-esteem and confidence levels. In my clinical practice as a dermatologist, acne vulgaris, colloquially known also as pimples, forms at least 50% of the daily load of patients I see. There are many aspects to be addressed within the dermatology consultation.
This varies from the cause of pimples, to questions about effective acne treatments, DIY formulas, over the counter acne creams and prescription medications. I have sought to share as many of these treatment pearls in the following article as comprehensively as possible, and hope it can help shed some light on the best acne treatments available.
Dr. Teo Wan Lin is an accredited dermatologist and an expert on cosmeceutical skincare research and development. She is the author of “Skincare Bible – Dermatologist’s Tips for Cosmeceutical Skincare” which was published July 2019 by leading bookstores Barnes & Noble, Baker & Taylor and Apple Books and available in bookstores islandwide from January 2020. She is the founder of Dr.TWL Dermaceuticals, a specialist cosmeceutical skincare line with evidence-based active ingredients for anti-ageing and skin health. Dr. TWL Pharmacy is the only full fledged online specialist dermatologist compounding pharmacy in Singapore and is jointly headed by a trained pharmaceutical engineer for strict quality controls.
Why do pimples form and what exactly is happening to your skin when a pimple forms
Pimples is the colloquial term for Acne Vulgaris. This refers to an inflammatory condition of the skin that presents with blackheads and whiteheads, otherwise known as closed comedones and open comedones respectively, inflamed papules as well as acne cysts. The cause of Acne Vulgaris is multifactorial.
First of all, it is determined by one’s genetics. Individuals with a family history of acne tend to have a higher chance of developing acne. This is brought on by the onset of puberty which leads to the secretion of the male hormone, testosterone. Testosterone, in turn triggers oil production in both men and women. That being said, sebum, the oily substance secreted by your sebaceous glands, is essential for the entire process of acne formation.
The third thing that occurs due to one’s genetics, is the process of inflammation itself which leads to comedone formation. All pimples whether whiteheads or blackheads arise first as microcomedones under the surface of the skin.
When they reach the surface of the skin, they become visible. The process that drives this is a mix of genetics, the presence of sebum as well as some form of dysregulation of the process of follicular keratinisation i.e. the way your skin retains dead skin cells around your skin pores.
Aside from genetics, there is also the involvement of a bacterium known as Propionibacterium acnes – a heavy commencer in individuals who suffer from acne. Finally, a lot of acne flare-ups can be due to the secondary bacterial infection of existing acne bumps known as gram-negative folliculitis. This tends to present with pus-filled papules and tend to have a yellowish tip.
I have observed that I always get acne in the same spot
While I do hear this coming from my patients quite often, i.e. “I always get this one pimple now and then on my cheek, chin, forehead…”, there is no scientific answer to this. From my personal experience, this could be due to one of the following. Firstly, if you tend to pick at your pimples, there is a condition known as acné excoriée. The entire name of this condition in french is acné excoriée des jeunes filles meaning acne excoriée of young girls.
There is an element of this compulsive picking of acne and this is the main reason why I find my patients having acne at the same spot. They constantly pick at it so even when it is healing, it does not get the chance to heal and picking introduces secondary bacterial infection.
The second reason why is because you are suffering from some form of acne that is related to occlusion. Some people wear helmets or face masks. If acne develops around that area, it is a type of acne known as occlusion acne. It could also be due to the application of comedogenic, hair waxes etc.
The third thing, if you are talking specifically about acne on the chin, you have to consider perhaps it is not acne at all. There is a condition known as perioral dermatitis. Perioral dermatitis looks very similar to acne and if you are seeing a non-specialist, it is very easy to be confused. This is because the bumps look very similar to acne, except that it is a mixture of eczema and inflammation, acne bumps, or it could even be acne rosacea.
All about Acne Creams
When you apply a pimple-clearing product to your pimple, what happens to the spot? What are some of the ingredients that you’d want to look out for in a pimple product, and what should you avoid? Are pimple drying lotions ok for the skin and how do they work?
If you find yourself searching online for answers to these questions, you are not alone. These are some frequently asked questions by sufferers of acne and I shall seek to clarify them here. There are a few categories of pimple-clearing creams. The first being the good old-fashioned creams that simply dry out the skin and reduce sebum production.
Pimple Drying Medications
This category would include topicals that contain the following active ingredients: benzoyl peroxide, salicylic acid, calamine lotion, sulfur-containing lotions. In some mild cases these creams may lead to an improvement in acne itself.
Pimple Creams Containing Antibiotics
The second category of acne treatment creams would be those containing antibiotics. The commonest antibiotic-acne gels would be those which contain clindamycin or erythromycin as an active ingredient.
These work on the premise that a lot of cystic acne is caused by secondary bacterial inflammation. As with all topically applied antibiotics especially in a chronic skin condition like acne which is not primarily due to skin infection, there is a huge problem with using topical antibiotics.
Topical antibiotics work well in a short-term simply because the skin has never been exposed to it. But very quickly the body learns to identify the antibiotic and develops resistance.
This is particularly concerning because the resistance doesn’t just take place in the skin level. Exposure of the topical antibiotics on the skin level leads to resistance systemically as well. For example, it could lead to antibiotic resistance when one is older.
The main thing about antibiotics is that it is a mere short-term fix and does not work after some time. There are other combinations of antibiotic gels, such as clindamycin combined with benzoyl peroxide which is the active ingredient present in the OXY pimple cream. The benzoyl peroxide component has been proven to reduce the emergence of bacterial resistance.
Prevention Creams – Retinoids for Acne Treatment of Whiteheads and Blackheads
The third category of pimple creams which I consider more preventive rather than treatment sort of cream is the retinoid category. These are the vitamin A derivative creams. We have heard of creams like tretinoin and adapalene which may have differing trade names. Both these creams are Vitamin A derivatives and they work via preventing microcomedone formation.
However, when you apply these creams, you should not apply it to inflamed active pimples as this can worsen the inflammation process. Rather they should be used in conjunction with active acne treatments prescribed by a dermatologist which is proportionate to the severity of your acne as preventive treatment. When you start applying a retinoid cream for example, you only get to see the result 2-3 weeks later.
A Dermatologist’s Recommendation of the Ideal Pimple Cream – New Generation Anti-Inflammatory, Anti-Sebum Pimple Creams
The fourth category of acne treatment creams is actually what I actively advocate now and which we have formulated in a highly effective Blemish Spot Cream under Dr.TWL Dermaceuticals. It is targeted at reducing inflammation itself. I am very convinced that botanicals have a prominent role to play in cosmeceuticals.
Cosmeceuticals are no longer just confined to the realm of having anti-ageing properties but are also adjuncts for the treatment of many medical skin conditions. I have used botanicals extracts successfully in the treatment of rosacea for example.
For acne, I incorporate an algae extract from chlorella vulgaris which actively reduces the oil gland activity. This is combined with amino acids such as methionine and serine that help to heal the skin when you apply it. The main thing is that when you try to dry up an active pimple, very often you get more inflammation as you are burning the skin around it.
What you need to do is to try to get the pimple to heal as quickly as possible. This is so that you minimise the risk of scarring. At the same time, this also treats the underlying problem of acne pimples which keep forming.
Are there different pimple creams best suited for the different types of acne (eg blackheads whiteheads, red swollen pimples)?
For tretinoin and adapalene which are the two main available form of vitamin A creams, these should not be used for red, painful, swollen acne treatment. They are best suited for comedonal acne which would be your blackheads and your whiteheads. For drying pimple creams, like benzoyl peroxide, salicylic acid, calamine lotion, I don’t recommend applying these to areas that have broken skin.
If you apply these to broken skin, the irritation and drying potential is just going to be multiplied. Potentially, you are going to end up with something that looks like a chemical burn. That is something much redder with a lot of peeling flaking and bad scarring.
Instead, I would recommend using an anti-inflammatory product with botanical-based extract that doesn’t contain anything irritating like salicylic acid. For example, the one we use is based on an algae. There is no issue applying this over areas with broken skin, although it also really depends on the formulation itself.
In addition, for a correctly labelled and medicated acne cream, i.e. not just a cosmetic product, there would be very clear indications of use available.
Does my skin ever get used to pimple-clearing products – is that why my pimple never seems to heal?
If you are using a medication like clindamycin and erythromycin, then yes because you develop real bacterial resistance which stops the medication from working. If you are using something which is drying such as the first category I spoke about earlier, or something anti-inflammatory, there is no evidence that your skin can actually develop a form of resistance to that. It is simply that the severity of acne has progressed or in the first place it wasn’t sufficient acne treatment.
Adult Acne Treatment
For patients with mild acne, they will have approximately 3-5 pimples every month and they tend to be of the teenager age group. Once you are past your teenage years, from the age of 21 onwards, it is a different ballgame of what dermatologists term as adult acne. If you still suffer from acne then, meaning having an average of more than 5 pimples every month after the age of 18, it is at the minimum, a case of moderate acne.
Moderate severity acne means that while you don’t have severe scarring or cystic acne, it is still very persistent and would need to be treated medically by an accredited dermatologist. In my clinical experience, moderate acne does not respond well to topicals only regimens. Topicals are only useful as an adjunct in the treatment of moderate acne.
On the other hand, using appropriate cleansers and pimple-clearing gels works well and is sufficient for mild acne. It may be a selection bias by default, given that attendances at a dermatologist practice would be moderate cases.
This is because the mild cases perhaps get treated at the GP level before they do get to us. Moderate cases of adult acne would need more treatment than just topicals. According to international dermatology guidelines, there are two options for the treatment of adult cystic acne.
Oral Acne Treatments
Firstly, the oral pathway for which I must emphasise that there are many oral medications that are safe and effective that have been widely prescribed by dermatologists internationally for decades. Examples of commonly prescribed medications include low dose oral antibiotics like doxycycline, erythromycin. These function primarily as anti-inflammatory medications to prevent comedone formation.
Minocycline is less frequently used these few years as it has been linked to a few rare cases of hypersensitivity syndrome, on top of potentially causing blue-grey skin discolouration.
Erythromycin in particular is safe for pregnant and lactating individuals. Oral contraceptive pills such as Diane-35 and Estelle-35 contains estrogen as well as cyproterone, which blocks androgen (testosterone activity). Androgens are male hormones that trigger off oil production, exacerbating adult hormonal acne.
Women with a history of irregular menstrual periods with cystic acne may have undiagnosed polycystic ovarian syndrome (PCOS). Such individuals will benefit from joint management of a dermatologist and a gynaecologist. Treatment of PCOS is with hormonal therapy, which will benefit adult acne treatment as well as preventing infertility.
Non-Oral Acne Treatments and Physical Therapies
Secondly, we have the non-oral pathway for acne treatment which involves physical therapies that have to be administered in a clinic setting. For example the usage of LED wavelengths, blue-light, two times a week for one month.
Blue light is therapeutic for treating acne that is especially worsened by the bacteria Propionebacterium Acnes. This has been proven to be effective in a regimen of twice weekly 30 minutes duration for a one month regimen.
Chemical Peels and Lasers for Acne Treatment – Can they be used independently?
Use of chemical peels and specific lasers like the carbon laser helps to shrink the oil glands of someone with active acne, especially in individuals that may not want to go on oral medications.
I always recommend those with persistent moderate acne to go for a short course of a safe antibiotic such as erythromycin or doxycycline in conjunction with any of these physical therapies. This is the most cost-effective option that targets inflammation that goes on in acne rather than blindly treating it from the surface.
For severe acne, you may suffer from deep painful cysts which often involve pus and bleeding and there will be a lot of scarring. The treatment for this is very straightforward, our first line is always this medication called isotretinoin.
The medication is also known as accutane or oratane which are brand names of the forms of isotretinoin available. Isotretinoin is an extremely effective oral medication which works essentially by shrinking your oil glands.
Without oil, your skin simply doesn’t produce acne. However, isotretinoin use does come with drawbacks like increased sun sensitivity, dryness of the lips and eyes. One also has to monitor your liver function and cholesterol levels whilst on isotretinoin.
A lot of patients in my practice have asked me to gauge the number of days to determine if an acne product works and my answer is simply this.
The Wound Healing Process of a Pimple’s Life Cycle
When a pimple forms it is best viewed as an injury caused by inflammation to the skin. You may go by the principles of wound-healing, especially when it only involves the top two layers of the skin (the epidermis and dermis).
Within the first 2-3 days of a cyst, there should be signs of pus draining. Should there be blood coming out of it, soon one should observe the redness and swelling resolving as well.
Acne That Does Not Heal
Acne may progressively accumulate and get larger instead of reducing in size. For example, the acne may get more painful, accumulate more pus and blood that doesn’t seem to be draining. When this occurs, one has to consider that there is an underlying cyst forming.
What is An Acne Cyst?
The formation of an acne cyst involves the collection of haemoserous material – blood, sebum, dead skin, keratin and debris. These substances subsequently get “cordoned off” by the body with a wall around it. This is part of the immune system’s response to inflammation. Acne cysts do not respond well to any topical treatment.
Proper Treatment of An Acne Cyst
Acne treatment of cysts involves a combination of the following. Firstly, an injection known as an intralesional steroid injection helps to reduce inflammation locally. It is injected right into the centre of the nodule and within 3 days, swelling will reduce the underlying swelling.
It is very important for the injection to be administered. This is because untreated acne cysts can lead to more severe problems like facial abscesses with drainage of pus.
Furthermore, it can spread to other parts of your face which is rare but has been documented. Concurrently, large painful acne cysts should be treated with an oral antibiotic such as amoxicillin, sufficient to treat the secondary bacterial infection that causes this reaction.
In the light of the Covid lockdown, our clinic is open to TeleDermatology services for acne treatment. This includes complimentary doorstep courier of prescription, contactless delivery within 3 working days. Same day delivery can also be arranged.
If you suffer from mild to moderate acne, you may try these over the counter cosmeceuticals proven for acne treatment.
Dr. Teo Wan Lin is an accredited dermatologist and an expert on cosmeceutical skincare research and development. She is the author of “Skincare Bible – Dermatologist’s Tips for Cosmeceutical Skincare” which was published July 2019 by leading bookstores Barnes & Noble, Baker & Taylor and Apple Books and available in bookstores islandwide from January 2020. She heads up Dr.TWL Dermaceuticals, a specialist cosmeceutical skincare line with evidence-based active ingredients for anti-ageing and skin health. Its subsidiaries, the Pi- Cosmeceutical Custom Makeup Lab and the Conscious Mask Bar are part of the Conscious Concept Pharmacy launched in December featuring environmentally sustainable makeup and skincare materials. In this series “Dermatologist Talks” she shares her top tips on common skincare topics. In this article, she focuses on a growing trend – Teledermatology.
What is teledermatology?
Telemedicine is the practice of using telecommunication technologies to transfer medical information. Information can be shared through audio, visual and data communication. Teledermatology is a subset of telemedicine involving the dermatology specialty, that incorporates healthcare management such as during consultation, diagnoses, treatment and education via an encrypted digital platform.
What are some examples of teledermatology practices?
Teledermatology can be practiced in the following ways: Store and forward (SAF) and real time or interactive teledermatology. A simple example of SAF could be sending an email inquiry with an attached digital image of a lesion to receive advice on how to treat the skin condition. For real time teledermatology, it includes a live video conference between the medical provider and the patient. TWL Specialist Skin & Laser Centre developed a stringent teledermatology protocol incorporating both store and forward as well as real time interactive technology via an encrypted platform.
How is it relevant for me?
Teledermatology has many benefits. First, it is a convenient practice as it does not require both parties to be present at the same location. Some skin conditions require follow up appointments up to two times per week. This can takes up a lot of time. As such, teledermatology can be used to drive down the time and costs required in such follow-up visits.
Teledermatology can also be used to help patients receive a second opinion on their diagnosis to improve accuracy. In the unusual healthcare situation such as that of the COVID-19 Virus currently, the availability of remote consultations will greatly assist in public healthcare needs. Teledermatology enables you to consult with a dermatologist right in the comfort of your home.
Twl Specialist Skin & Laser Centre offers accredited Teledermatology services, via virtual interactive real time technology with our dermatologist. Available as of 1st February 2020, all consultations are also integrated with online pharmacy dispensary services. Delivery to doorstep fulfilment of prescriptions available for local and international patients.
What should I expect from a teledermatology appointment?
1. Book an appointment via our online booking system or call 63550522. Key in a valid email address and phone number which will be the main form of correspondence. You will receive a confirmation of the appointment within 1 working day.
2. A Payment Link will be sent, to be completed for First Consultation/Subsequent Consultation Fees before commencement of consultation.
3. A Post-Payment Secure Process will be communicated to you via email for the subsequent steps which will involve the following:
Filling up of 3 single page forms, submission of required images at least 2 hours before scheduled consultation time with our dermatologist*, a fully encrypted video call saved on our secure patient data base will be conducted.
Subsequent fulfilment of prescription is done by our in-house pharmacy with full courier services to your home.
When it comes to acne, most of us tend to think of facial acne – the most visible form of acne vulgaris. Back and chest acne, or truncal acne, is often overlooked even though more than half of people with facial acne can also have truncal acne. Further, acne on any part of the body can impact one’s self-esteem, body image or self-confidence.
What causes truncal acne?
Truncal acne develops in a similar way to facial acne. Major causes of acne include excess sebum secretion, abnormal desquamation (shedding) of skin cells, the presence of the bacteria Propionibacterium acnes (P.acnes), and inflammation. These elements can be found as much on the back and chest as on the face.
Genetics is also a crucial component. Your genetic disposition can influence the formation of comedones or the way your body responds to the P. acnes on your skin.
Acne forms when abnormal desquamation of epithelial cells causes sebum and keratin to accumulate and block hair follicles. This creates comedones – either open blackheads or closed whiteheads.
An increased production of sebum also creates an ideal environment for P.acnes to thrive, especially during puberty when oil glands are excited by hormones called androgens. The activated oil glands produce inflammatory factors, such as cytokines, that increase the skin’s inflammatory response.
Your back, shoulders and chest are also more prone to acne mechanica, meaning acne caused by the pressure, occlusion, friction or heat of clothing or physical activity. Sports equipment, such as shoulder pads and tight straps, can further exacerbate acne. Sweaty clothing traps sweat, oils and substances that support the growth of P. acnes. As a result, be sure to change out of sweaty clothing after a workout or seek shade when the sun is at its strongest.
How can I treat truncal acne?
First-line therapy for truncal acne should always be a combination of a topical and antimicrobial treatment to reduce the risk of bacteria resistance. Treatment lengths should also be kept as short as possible – to a three to four month course – and cautiously managed by an accredited dermatologist.
Topical treatments
Benzoyl peroxide: Decreases inflammation and abnormal desquamation. It also contains anti-microbial properties that kill bacteria, but can bleach clothing and bedding. As such, it may be less desirable for treatment of truncal acne
Antibiotics e.g. erythromycin, clindamycin: Reduce the proliferation of P.acnes but are not recommended to be used as the only form of treatment due to the risk that bacteria will grow resistant to the effects of medication.
Azelaic acid: A newer form of treatment that has three pharmacological effects: anti-inflammatory, antimicrobial, and stabilizing on abnormal desquamation. Above all, azelaic acid also fades post-acne marks by inhibiting the release of tyrosinanse, an enzyme that controls the production of melanin.
While skin on the body can withstand acne medication that may be too irritating on facial skin, they can be harder to apply on the back. Also, skin on the body is thicker than the face and may respond more slowly to treatment.
Oral antibiotics
Antibiotics work to limit the proliferation of P.acnes, which makes them useful in treating moderate to severe acne.
Hormonal therapies
Oral contraceptives work to reduce androgen levels, which in turn decreases sebum production. Oral contraceptives are effective against inflammatory acne in females. Patients who do not mind being on contraceptives can consider this treatment.
Oral isotretinoin
Isotretinoin is a form of oral retinoid that is effective against severe. It helps to decrease sebum production, bacterial proliferation, inflammation and abnormal rate of skin cells shedding.
However, isotretinoin can have severe side effects. It can disturb the development of a fetus and cause birth defects if the mother is taking it at the time of conception or during pregnancy. Other potential side effects include mood changes, liver damage, or fluctuations in lipid levels. As a result, this medication should be cautiously managed by a dermatologist.
Cleansing
Proper cleansing should also follow alongside other treatment therapies. Dr. TWL’s Miel Honey™ Cleanser is a dermatologist-formulated cleanser ideal for acne-prone skin and uses medical grade honey as an anti-bacterial and anti-inflammatory agent. A gentle cleanser that lathers up from botanical emulsifiers, the foam produced is generous and refreshing on the skin.
Cosmeceuticals
Truncal acne patients can also consider cosmeceuticals as part of their treatment. Cosmeceuticals are cosmetic products that contain active ingredients that deliver medical benefits to the skin. Vitamin C, in particular, works as an antioxidant that helps clear the skin of inflammation. Another botanical to consider is Arnica Montana flower extract, which is especially beneficial for acne-prone skin as it stabilises inflammation and reduces skin flaking.
Meet with Dr Teo Wan Lin, an accredited dermatologist at TWL Specialist Skin & Laser Centre, for a thorough consultation to determine the most suitable treatment for your skin.
To book an appointment with Dr Teo, call us at +65 6355 0522, or email [email protected]. Alternatively, you may fill up our contact form here.
Any acne google search will reveal links between acne breakouts and a variety of factors including cosmetics, spicy food, sunlight, chocolate, and even sweat. However, one less tangible factor that is often included but rarely explained is stress.
Stress is truly a significant factor in acne. While it is unlikely to cause acne alone, it can trigger flares and aggravate the condition by causing excessive oil production and delaying the wound recovery time of acne.
Stress induces excessive oil production
During periods of high emotional pressure, the hypothalamic-pituitary-adrenal (HPA) axis is activated and produces hormones. The HPA axis is the interaction between our body’s central nervous system (brain) and the endocrine system (hormonal-related).
The HPA releases androgens and corticotropin-releasing hormones (CRHs) in response to stress. CRHs bind to the receptors on our oil glands and accelerate lipid synthesis. CRHs also activates the testosterone in our body, which further enhances lipid production.
When the body experiences tension, neuropeptides are also released. Neuropeptides are small proteins found in the brain that are engaged in the functions of signalling and communication. Neuropeptides can also influence hormones. In particular, a neuropeptide called Substance P can stimulate the growth in the number and size of oil glands, which contributes to acne.
Stress delays wound recovery
Individuals with high levels of perceived psychological pressure have shown significantly delayed recovery rates of the skin barrier. In other words, stress slows down the body’s ability to heal wounds, which can be a factor in slowing the repair of acne injuries.
It also triggers the increased level of the hormones glucocorticoids and catecholamines, which can adversely influence the healing process.
Glucocorticoids reduce the number of cytokines at the site of injury. Cytokines are essential in the early stage of wound healing as they protect against infection and prepare the injured site for repair by sending signals for phagocytes. Phagocytes kill and digest unwanted microorganisms. The later stages of wound repair are thus delayed with lower level of cytokines, meaning more time is required for acne to heal.
Further, catecholamines regulate a range of immune functions such as cell proliferation, production of cytokines (essential in wound-healing process) and antibodies. Elevated catecholamine levels during times of stress can inhibit the production of cytokines or suppress the body’s natural immune response to attacks.
Stress promotes habits that aggravate acne
The pressures of daily life may encourage individuals to pick at or scratch their skin. Such habits cause further inflammation, scarring and hyperpigmentation.
Stressed individuals are also more likely to have unhealthy habits, such as poor sleep patterns, imbalanced nutrition, and excessive consumption of alcohol. Stressed-out individuals can, at times, overeat in the face of chronic anxiety or increase their intake of calorie-rich food to calm the nerves. Comfort foods such as ice cream or cake can help to tone down the body’s anxiety responses but trigger acne or inflammation.
Finally, stress can cause people to neglect good self-care, including maintaining a usual skincare routine.
How to lessen the impact stress has on your skin?
Physical exercise can alleviate stress and regulate the production of stress-related hormones. Patients suffering from acne may be tempted to steer from exercise due to the discomfort from sweat, but exercising can provide important benefits to your skin. Just shower immediately after exercising and use a gentle moisturizer to keep your skin hydrated.
Experiment with other stress-reduction techniques as well such as meditation, yoga or reading a good book. If a stressful event is around the corner, be sure to get sufficient sleep and consume proper meals to eliminate other potential triggers that can aggravate your acne.
In addition to managing your stress-levels, consider visiting a dermatologist. Acne is treatable with the help of an accredited dermatologist, so it is worthwhile to seek professional advice.
Meet with Dr. Teo Wan Lin, an accredited dermatologist at TWL Specialist Skin & Laser Centre, for a thorough consultation to determine the most suitable treatment for your skin.
To book an appointment with Dr. Teo, call us at +65 6355 0522, or email [email protected]. Alternatively, you may fill up our contact form here.
Spa facials are now commonplace, offered everywhere from shopping malls to neighbourhood estates. While these may help you unwind, conventional spa facials may not be able to deliver effective results to your skin, and they may even cause more harm than good.
This is because facials at conventional spas or beauty salons are unsupervised by a doctor and may cause irritation and skin sensitivity. Often they include forceful extraction of pimples, blackheads and whiteheads that not only inflame the skin and cause pain but also increase the chances of secondary infections and deep scarring. Some of our patients have even contracted viral warts from contaminated instruments used for pimple extraction.
Enter the Medifacial. Short for medical facial, it is a procedure performed at a licensed medical establishment with non-invasive dermatological procedures. It causes neither pain or scarring, and uses pharmaceutical grade solutions and serums. A form of microdermabrasion very gently exfoliates dead skin cells, and a specialized vacuum handpiece extracts blackheads and whiteheads. The procedure both removes impurities and intensely hydrates with potent serums, including antioxidants and hydroxy acids, that soothe and rejuvenate the skin.
Medifacials can be tailored to the address a patient’s individual skin concerns including:
Microdermabrasion is a safe and painless resurfacing procedure that results in decreased levels of melanin and increased collagen density. Not to be confused with dermabrasion, it targets the epidermis – the outer skin layer – instead of the dermis which is the deeper skin layer.
In conventional dermabrasion, a handpiece sprays inert crystals onto the face – such as aluminium oxide, magnesium oxide or sodium chloride or other abrasive substances – and vacuums them off.
In a medifacial, the microdermabrasion process uses a specialized vacuum handpiece embedded with an abrasion tip that is designed to rotate and gently exfoliate the skin while concurrently applying a soothing solution. The vacuum pressure and speed is adjusted to each patient’s sensitivity and tolerance to maintain as comfortable a procedure as possible.
The mechanism of abrasion and suction gently exfoliates the outer skin layers to remove dead skin cells. With a superficial depth of skin removal, microdermabrasion helps improve the conditions of skin surface such as scarring or photodamaged skin.
By producing controlled superficial trauma, the procedure also promotes facial rejuvenation. Repetitive injury to the epidermis can cause gradual improvement as it stimulates collagen production and fibroblast proliferation. (Fibroblast are cells found in connective tissues that produce collagen and other fibres.) This allows new collagen deposition in the dermis layer.
Mild erythema (redness) may occur at the end of a microdermabrasion treatment but will subside within hours. Microdermabrasion should not be confused with dermabrasion.
Facial Extraction
If you have self-extracted comedones at home, you will likely be aware of the excessive scarring and breakouts that often follow. It is likely that the right pressure or angle is not applied during home extractions, disrupting the integrity of follicles and causing inflammation. Not using medically sterilised equipment can also lead to infections, exacerbating the condition.
In a dermatologist’s office, extraction is safely and easily performed and rarely leaves residual scarring. An accredited dermatologist can first assess between comedones that are suitable for extraction versus those that are not. After prepping the skin with alcohol, a tiny prick incision is made with a surgical blade to lightly pierce the epidermis. Light or medium pressure is applied directly on top of the comedo until all of the contents are removed. The treatment may cause minor discomfort but also help achieve an almost instant improvement in skin appearance.
In a medifacial, the microdermasion and vacuum processes, together with specialized and hydrating solutions, “loosen” and extract blackheads, whiteheads, excess sebum, keratin and other impurities. The specialized medifacial handpiece creates a strong vacuum with precision control that targets comedones from enlarged pores and removes the associated waste from the epidermis. It avoids collateral damage to the surrounding tissue and is completely painless.
Infusion of potent serums
In a medifacial, topical infusion of various serums and solutions is carried out continuously using the specialized treatment handpiece. The serums contain a potent mix of sodium hyaluronate, antioxidants and hydroxy acids that are applied at different stages of treatment to achieve a variety of effects such as skin hydration, lightening of pigmentation and softening of the skin for exfoliation and extraction.
Antioxidants are substances that protect our body and skin from oxidative damage. With their highly protective and rejuvenating properties, they are a mainstay in skincare formulations and key ingredients in a medifacial treatment. Antioxidants used include vitamin E, vitamin C, and rosa damascena (or rose water) that have brightening effects to help skin achieve a radiant glow.
Larecea Extract™ is a dermatologist-formulated combination of bioactive antioxidants derived from brassica olereacea (cruciferous family plants) and potent regenerative amino acids. It is a trademarked ingredient in the Dr.TWL Dermaceuticals’ cosmeceutical line.
Hydroxy acids help remove the top layer (epidermis) of dead skin cells. They do this by dissolving the ‘cement’ between skin cells, revealing smoother and firmer skin. Hydroxy acids used in a medifacial treatment include salicylic acid and lactic acids. Lactic
So the next time you step out of a facial salon with unsatisfying results, do consider a medifacial instead. Conducted under the supervision of an accredited dermatologist, a medifacial clears up the skin and helps restore its brightness through microdermabrasion, extractions, and an infusion of potent nutrient serums that hydrate and rejuvenate. It also has zero downtime, and only requires liberal sunscreen application to protect against ultraviolet radiationafterwards.
Meet with Dr. Teo Wan Lin, an accredited dermatologist at TWL Specialist Skin & Laser Centre, for a thorough consultation to determine the most suitable treatment for your skin.
To book an appointment with Dr. Teo, call us at +65 6355 0522, or email [email protected] Alternatively, you may fill up our contact form here.
Suffering from acne? Also known asacne vulgaris, patients who suffer from this inflammatory disease typically develop it in adolescence.
Does my diet cause the acne?
The answer is not straightforward, because acne itself is multifactorial in origin, with genetics, inflammation, hormone related oil production in a complex interplay. However, a quick answer would be yes, diet does appear increasingly to influence the severity of acne and treatment outcome to a certain extent.
Acne vulgaris is often touted to be the epidemic disease of civilization, typically in first-world countries. Caused by an unhealthy diet fueled by modernization, it affects the sebaceous follicles of adolescents and adults. Today, a typical diet is characterized by high glycemic index foods, insulinotropic milk proteins and saturated fats.
Does a Western diet trigger acne?
To convince you, populations that are exposed to diets with low glycemic load and no milk/dairy consumption are acne-free, such as the Inuit, Ache hunters of Paraguay, rural areas of Brazil. Prevalence of acne increased as Okinawa islanders and the Chinese switch from traditional diets to Westernized food.
How do hyperglycemic carbohydrates cause acne?
High glycemic index foods are those that are extremely high in glucose. The glycemic index works by measuring the impact that your food has on your blood sugar level. High glycemic index foods cause your blood sugar to rise faster.
Eating lots of food like white bread and cereal can also cause the elevation of hormones, leading to increased sebum production. The high glycemic load changes the composition of sebum fatty acids, causing proinflammatory and comedogenic responses. A diet-induced change in sebum composition can trigger acne inflammation and drive the process of comedogenesis, also known as the formation of blackheads.
Can saturated fats lead to my acne problems?
The major culprit is a saturated fatty acid called palmitate, and it consists of 32% milk triglycerides. Palmitate triggers the abnormal proliferation of keratinocytes, a cell that produces keratin, resulting in micro-comedones. The continuous sebum accumulation, enlargement of follicle and build-up of keratin within the micro-comedones causes the formation of comedones.
Trans-fats, produced industrially that structurally resemble palmitate, are in the fast food that we eat. With the replacement of natural solid fats and liquid oils with hydrogenated fats in fast food, fried food and baked goods, it has led to unhealthy diets that contribute to acne. Such a diet contributes to inflammatory responses of our sebaceous glands and hair follicles.
Does milk cause acne too?
The link between milk consumption and acne is not a breakthrough, adolescent acne is closely associated with their diets being rich in milk, cheese, yogurt, cakes and low in fish, fruits and vegetables. Milk contributes to increased insulin levels which prevent that production of an important protein FoxO1. The deficiency of this protein has been linked to major factors of development of acne.
Milk intake can also influence comedogenesis as it contains androgens, a type of hormone, steroids and other components that can affect the sebaceous gland and hair follicle. Such molecules survive processing, and for instance, in cheese, fermentation leads to more testosterone being produced from the precursors in milk.
Milk facilitates the pathway of sebaceous lipogenesis and sebocyte proliferation. Excessive intake of milk protein also explains the onset and aggravation of acne.
How can I adjust my diet to be less acne-prone?
You may opt for a palaeolithic diet – no hyperglycemic carbohydrates, no milk and dairy products. Fish consumption has shown to have anti-acne effect, as the fatty acids from the fish can reduce inflammation.
Resveratrol, a compound found in the skin of grapes, has shown to inhibit the growth ofP.acnes, a bacteria that facilitates ace development in optimal environments.
Though multifaceted, dietary factors can worsen breakouts in acne-prone individuals. For a clearer skin, a good tipis to bear in mind what you consume, have a healthy balanced diet and lifestyle. However, if you have a persistent flare of acne for anything more than several months, medicated treatments such as oral antibiotics and topical retinoids may be necessary. So do visit a dermatologistearly to prevent complications such as secondary skin infections i.e. gram-negative folliculitis, orsevere acne scarring.
Meet with Dr. Teo Wan Lin, an accredited dermatologist at TWL Specialist Skin & Laser Centre, for a thorough consultation to determine the most suitable treatment for your skin.
To book an appointment with Dr. Teo, call us at +65 6355 0522, or email [email protected] Alternatively, you may fill up our contact form here.
