By Fiorella Valdesolo  |  December 01, 2011

 Because we’re desperate. “The conventional acne treatment for teenagers is to dry them out and get rid of the oil,” says New York dermatologist Dennis Gross, MD. Although we have less sebum as we age, the oil we do have turns into a pore-clogging glue. “With adult acne, it’s a problem with the oil chemistry. As hormones change, oil does too­—becoming more viscous. And as it flows through the gland and out through the pore, it gets stuck.” Sometimes, products designed to strip away oil just exacerbate acne by increasing inflammation. “Plus, when skin is dry, dead cells flake off, further blocking pores that already have a problem, leading to more acne.”

 Rather than blasting skin topically, many derms are tinkering with the hormonal precursors that lead to breakouts. During the teen acne years (between the ages of 12 and 18), the hormone Insulin-like Growth Factor 1 (IGF-1) peaks; it “decreases as people reach their twenties and may account for the decline in acne in many people,” says NYC dermatologist Kavita Mariwalla, MD. “But at the same time there are plenty of other hormonal irregularities that cause adult acne.” For example, progesterone spikes each month when we ovulate. “Progesterone, more than estrogen, resembles testosterone, and that’s the one that seems to be more villainous when it comes to stimulating and driving the sebaceous glands,” says dermatologist David E. Bank, MD, of Mount Kisco, New York.

 The hormonal cascade released when we’re stressed is another acne agitator. “Your adrenal glands that sit right above your kidneys secrete cortisol and trigger your fight-or-flight response,” says New Jersey–based Jeanine Downie, MD. “When you’re stressed, your adrenal glands are secreting more cortisol, which can pack on pounds around the waist and lead to more significant amounts of hormonal acne.” So stress leads to acne, which, in turn, leads to even more stress—it’s a vicious cycle.

 While facialists have bashed dairy for decades, clinical studies have only recently established a link between milk consumption and acne. “Milk contains testosterone precursors, which cause increased sebum production,” says New York dermatologist Francesca Fusco, MD. “What’s fascinating is that one study found that of all milk, skim milk has the strongest correlation with acne. We’re not sure why, but some hypothesize that skim milk has less estrogen than whole milk.”

 And switching to organic milk won’t remove your exposure: “All milk naturally contains androgens and IGF-1,” Mariwalla says. “There’s no such thing as hormone-free milk. Plus, milk contains sugar, a lactose, so it stimulates insulin.”

 Another recent study suggests that following a low glycemic index diet—that means one with less refined sugars, carbohydrates, and sugar-containing foods—may result in fewer acne outbreaks. “As the glycemic index goes up, it affects insulin production and all the hormones,” Fusco says. “They are all in a delicate balance—your female hormones are in balance with your thyroid hormones, which are in balance with your insulin. When you have more in one area, it’s like a domino effect on the others.” Since the dietary acne provoker may vary for every person, New York dermatologist Ellen Marmur, MD, recommends keeping a food diary outlining what you eat in the days before a breakout to determine what your triggers are. “Then you start a very slow reentry, introducing one new item, like dairy, every six weeks to see what happens on the skin,” says Marmur, who believes that it takes just 48 hours for what you eat to show up on your face. “So you can look back two days ago and figure out what you were eating,” she says. “It may not be the same foods for you as it is for me. Personally, when I eat chocolate, I’ll break out 48 hours later.”

 Historically, the premier hormonal mediator has always been the birth control pill, which works by replacing the hormones your ovaries are producing with synthetic varieties that won’t stimulate those pesky sebaceous glands as much. But this doesn’t have to be your first line of defense. Marmur points out that while the Pill may clear up acne, it can also provoke another unsightly reaction: melasma, a noticeable discoloration of the skin that she says is on par with acne in her practice as a top complexion complaint. If you do opt for the Pill, figure out an exit strategy first. “Birth control pills can be very effective. But eight or nine times out of ten, when you stop them you are right back where you started,” says Bank, who’s a big fan of the controversial Accutane, the prescription-only vitamin A–derived pill, because it continues to work after you stop using it. “Accutane is still, hands-down, our most effective, lasting antipimple medication,” he says. “My Accutane-treated patients are among the happiest and most grateful patients.” Although an Accutane prescription comes with significant FDA regulation (because of possible birth defects, patients have to agree to use two forms of birth control and undergo regular pregnancy tests during treatment and for one month after), most of the derms we interviewed believe it to be worth the trouble. Downie calls Accutane “the be-all end-all for really bad cystic acne,” and Mariwalla says it is “phenomenal”: “After you stop the medication, many people have a durable response for many, many years.”

 Gold-standard topical acne fighters such as retinoids, benzoyl peroxide, and salicylic acid remain the solutions most frequently name-checked by our dermatologists; what’s new are the streamlined formulas, delivery systems, and accompanying ingredients. “Old medications are being revived by novel combinations,” says North Carolina dermatologist Zoe Draelos, MD. She cites prescriptions like Ziana, a blend of the antibiotic clindamycin and the retinoid tretinoin, and Epiduo, which contains another retinoid, adapalene, plus benzoyl peroxide.

 “BenzEFoam short-contact cleanser is a great new vehicle for benzoyl peroxide,” Bank says. “It’s a mousse formulation that you leave on the skin for a couple of minutes and then wash off, so you don’t have to keep it on all night, which can be drying.” Though there has been some trepidation about benzoyl peroxide because of its ability to spike free radicals, no studies, according to Mariwalla, have shown that they are wrinkle-causing. “Actually, in the case of benzoyl peroxide, we have one of the few times when free radicals can help you,” Mariwalla says. “In the skin, the peroxide part dissociates and kills the bacteria that’s causing the acne, stopping the inflammatory process.”

 Although, as Marmur notes, it takes only two days for a pimple to crop up, you need to give any topical preventive measure 42 days to kick in. “The lifespan of a pimple is about six weeks, so that’s the magic number for how long you should give a product before you give up,” she says. “The biggest mistake people make, besides picking at a pimple, is giving up on products too early. It’s like driving a car—you don’t want to make any rapid changes.”

 As far as picking goes, it’s hard to resist the lure of the magnifying mirror, that evil contraption that turns every pore into a crater. But while it may appear that your clogged pores number in the thousands, many of those little dots, particularly on the nose, are entirely normal hair follicles. Resist the urge to squeeze; leave extractions to the professionals. “If you have a well-trained medical aesthetician working under the auspice of a derm, they can use acne extractors or microneedles to actually get in there for the more difficult whiteheads,” says Neil Sadick, MD, who shares his Park Avenue office space in New York with facialist Luzinete Ripardo, famed for her incredibly thorough (“almost OCD,” says one fan) pore cleanses. (And for emergency spot reduction, the best cure is a shot of cortisone from the doc.)

But the most major advancement may come thanks to gene research, such as that done at P&G’s Miami Valley laboratory in Ohio. A team of researchers led by Rosemarie Osborne, PhD, recently developed an innovative combination of a topical antimicrobial (sodium dehydroacetate) and vitamin B (niacinamide) that was shown, in double-blind independent clinical studies, to reduce sebum production significantly (both can be found in the new Olay Pro-X Clear line). What next? “The biggest genomics breakthrough relative to acne is understanding why some of us get acne and others don’t,” Osborne says. “This type of research will lead to more customized solutions for acne-prone skin in the near future.” For longtime acne sufferers, that sounds akin to a quantum leap—one that just may help ensure that we never have to turn to toothpaste as a skin care treatment again.

Popular Off-Label Options

Advil: “An [oral] ibuprofen can help with red, inflamed pimples but not whiteheads or blackheads,” Fusco says.

Aspirin: “It’s a salicylate,” Mariwalla says, “so you can make a little paste of it and apply to a pimple.”

Benadryl: According to Fusco, “Benadryl can be beneficial for only one subset of acne: acne rosacea.”  

Hibiclens: This antibacterial all-purpose cleanser is “good for folliculitis­—infection of the follicles that looks like acne,” Mariwalla says. “But it’s too drying for the face.”  

Monistat: “For people who have little tiny pimples that are often a form of yeast, not typical bacterial acne, Monistat is actually good,” Marmur says. “No matter what, it won’t hurt you—it will just function as a moisturizer.” 

Pepto-Bismol: “The main active ingredient in Pepto is bismuth subsalicylate,” Mariwalla says. “While some people think that the benzoic acid, an inactive ingredient, will make red marks fade away, the results are iffy.”

Top Blemish Blasters

 An AHA-glycolic complex in La Roche-Posay Effaclar Serum tightens pores; Sampar Pure Perfection Prodigal Pen rolls on eight pimple-fighting essential oils; Olay Pro-X Clear Sulfur Mask absorbs oil; banish blemishes around the clock with the a.m./p.m. formulas in Kate Somerville 24 Hour Pimple Punisher; blue LED therapy plus gentle vibration makes Tända Clear+ (an at-home light device) a non-irritating acne solution; (Malin + Goetz) Acne Treatment zaps zits with 10 percent sulfur; lycopene found in Yes to Tomatoes Acne Roller Ball Spot Stick controls oil production. 

Thank you for the email inquiry. I would be very happy to see you in consultation for acne scarring. I treat a lot of acne scarring on all types of skin. It is possible, if you have a dark complexion, that the CO2 may not work for you, however, the Fraxel laser may be a great option. We can discuss it in consultation. I do very comprehensive consultations and spend time talking about ALL options for whatever your condition or concern is. I feel that, from a laser standpoint, Pacific Dermatology and Cosmetic Center has all of the very best lasers for acne scarring. There are many other lasers out there, but many of them are not as good as the real Fraxel Restore and the Total FX Lumenis Fractional CO2 laser. We can also consider other options if they are right for you (such as fillers, surgical excision, scar subcision and face lift (not done here, but I have great recommendations for fabulous plastic surgeons in Seattle)

 As far as cost, we charge 80$ for the cosmetic consultation. Again, I will personally spend 30 minutes with you discussing the options and writing out a plan to take home with you. We will give you brochures and personally written information on the different options – it’s a great starting point to know what is best for you.

Thanks again for the email, and I look forward to seeing you.

Dr. Jennifer Reichel of Pacific Dermatology & Cosmetic Center in Seattle