I'm an adult! Why do I have acne? | CBC's The Dose

0:01Hey, it's Shoshana. Today I'm sharing another podcast you may like called The Dose from CBC podcasts. Every Thursday, Dr. Brian Goldman cuts through the confusion to deliver credible health news you can use. They ask questions like, are certain blood types really in more danger? Should we be anxious about ibuprofen? And will warmer weather really bring some respite? In today's episode, Dr. Brian Goldman explores a subject that can be touchy for a lot of people, acne, particularly adult acne. And while it's a skin condition usually associated with teens, it can develop at any stage of life. He speaks with Dr.

0:37Keri Purdy, the head of dermatology at Dalhousie University, as she explains some of the risk factors for acne and how to treat it. Here's The Dose with more.

0:53Hi, I'm Dr. Brian Goldman. Welcome to The Dose. Acne is a skin condition that most of us know pretty well. It affects almost everyone at some point in their lives. Mild for some, severe for others. Most of us can remember getting breakouts during puberty, during adolescence, teenage years, but it's a condition that also shows up rather frequently in adults. So this week we are asking, I'm an adult. Why do I have acne? Hi, Carrie. Welcome to The Dose. Hi, Brian. Thanks for having me. When adults with acne come to see you, how often do they reference their teenage years? Almost every single time.

1:34Some people will say, I never had acne as a teen. Why is this happening now? And other people say, I thought I got rid of my acne during my teen years, or I've always had acne since I was a teen. So you almost always hear about it in one way or another. You obviously have great empathy for them and clinical knowledge, which is why we've come to you before we begin. Can you give us a hi, my name is, tell us what you do and where you do it? just ad lib. Hi, my name is Keri Purdy. I'm a full-time academic dermatologist in Halifax, Nova Scotia. Let's start with the basics. When we're talking about acne, tell us about the full range of things that fall under the umbrella of acne.

2:12Acne can be certainly a bit of a challenge. I like to think about why people get acne, and we can certainly talk about that after, and then what type of acne they have and how severe it is. But thinking of spectrum, you know, So acne can affect babies. It tends not to affect young children. But then as soon as you get into that peripuberty time, you can see acne basically from then on. Many people lose acne as they become older adults or for women when they go through menopause. But there are other medications, and particularly in the cancer realm now, that cause acne or make acne worse. So we do tend to see it right through generations.

2:50And we're talking about a spectrum of manifestations, pimples, whiteheads, blackheads. What's the full range of that? Yeah, so there's about three types of acne. And so what you might consider to be blackheads or whiteheads, I would call comedones, open and closed comedones. So comedonal acne, there are people that get the pimples and the pustules. So what people would classically refer to as zits or pimples, that's what we call popular acne. and then deeper lesions can be more cystic or nodulocystic, and they can result in scarring. Many people have a combination of all of those types of acne.

3:28Do we know why people get one type and not another? We don't really know the specifics of that. There's probably some thought about genetic tendencies. Some people just have a little bit more active inflammatory acne. There are people that have certain conditions, for example, inflammatory bowel disease. So Crohn's or ulcerative colitis, those patients often get deeper, more significant acne. So there's probably something there. Specifics, not quite clear yet. Isn't that interesting? We're talking about an age-old disease and one that certainly has been, you know, that wasn't suddenly detected in the year 2015.

4:05You know, we've known about it forever. Many, many years. And we don't know. And there are still so many unanswered questions. Okay. You started to talk about the causes, but I want to go deeper on that. What are the known and suspected causes of acne? There's sort of four main reasons that people get acne. So when I talk to patients, I'll often draw them a little picture of a hair follicle and I'll say, this is why you get acne. So one of the things is that the sebaceous glands, which are oil producing glands, they make more oil. They seem to be enlarged in people that have acne. The other thing that can happen is there's inflammation.

4:36And so if you look down around the base of the hair follicle, there's white cells, there's inflammation. Everybody has a bacteria on their skin called P. acnes, and that probably plays a pathophysiologic role. And finally, your skin is essentially made in the hair follicle. And so what happens in people with acne is some of those areas get a bit messed up, if you will. And so it creates a little plug, which is the early beginnings of a comedone. Now, we used to always think that was the first thing that happened in acne, but there's emerging evidence to suggest that the inflammation might come first.

5:09So you get inflammation first and then a bacterial infection? Well, everybody has this bacteria. It's what we call a commensal or it's always on our skin. What role that plays in the inflammatory part of acne is not entirely clear. But if you do look at people that have acne compared with people that don't, they seem to have a higher burden of P acnes on their skin. So now let's move to risk factors for acne. There's a number of things that can increase the risk of acne. We know that there's a genetic component. We know that there's a hormonal influence. Things that are very occlusive to your skin can make acne worse.

5:45So oil, oil-based products. I sometimes say, you know, if you're working at McDonald's over the fryer, that kind of thing can make acne worse. Seriously? Yeah, yeah. That can make acne worse. But you really have to be over it for quite some time, not just a quick one. The other things that can make acne worse, there are a number of medications I mentioned earlier, but a number of different immunotherapy medications or new chemotherapies can cause acne or make it worse. And then we know sometimes people get increased acne in places like their chest and back if they're very sweaty and they're wearing sweaty clothes.

6:18Those things can make it worse. What about foods? I've been hearing and reading about dairy and high carbohydrate diets being risk factors. There's never really been any convincing evidence to suggest that diet plays a role. And I do like to tell people, you know, this isn't something as simple as, you know, what you're eating or what you're doing. This is genetic and hormonal. So to the point of the dairy piece, we do know that high amounts of dairy consumption are felt to be pro-inflammatory. But what that actually means for acne is a little bit more challenging. And if you drill down into the data that's available, most of them are, you know, these retrospective large data analysis sets.

7:00and it's hard to make a lot from those. Sometimes people will tell me, gosh, when I cut out X, Y, or Z, my acne got worse. And I'll say, okay, great, go ahead. But from a population perspective, there's really not any evidence to support that we would recommend that to everybody. You know, I would say that diet is one of several common myths out there. Fast food, unclean pillowcases, poor facial hygiene. Do any of these play a role? Lots of people come in and they say, can you tell my son to stop eating pizza and chocolate. It's not related to that. So not that diet piece. Poor hygiene, you know, certainly having poor hygiene in and of itself is not going to give you bad acne.

7:40But if you have acne, having your hygiene as good as possible and using bland products that will help to maintain your skin barrier, that's really important. The way I think about skin is it's that layer between you and the world, essentially. And so if you can keep it as happy as possible, that's going to help to some extent. Other things too, like I said, sometimes if you're wearing sweaty clothes for long periods of time, that can worsen things a little bit, but certainly not the cause. Here's something that may not be a myth. Is it fair to say that you shouldn't be picking at your acne? Absolutely.

8:17People should not be picking at their acne. That will often add to scarring tendency. And so it also hurts. So I try to tell people, I will give you less to pick at. Please try to leave it alone. Easier said than done sometimes. We've dealt with, call it Acne 101. Let's move into the topic du jour. So first of all, just how many adults live with acne? I mean, if you think about acne across the board, probably 20 % of people have it at some level. So we're looking at, you know, millions of Canadians, not quite as common in the older years, but still relatively common. There's the name of a condition that was popularized during the time of President Bill Clinton, and that is rosacea.

8:58How does that relate to the whole acne story in adults? Yeah, so some people used to use the term acne rosacea. They're two separate entities, really. This is sometimes where, if it's unclear, dermatologists can be helpful because rosacea is essentially those inflammatory papules and pustules, but you do not see the blackheads and whiteheads, and you do not see the deeper nodulocystic lesions and scarring. There's a different type of process that can happen with rosacea where you get thickening of the skin and scarring, but it's different. And the background about why people get rosacea is inflammation in addition to abnormal blood vessels in your face, essentially.

9:38And so they're different from a pathophysiologic or cause standpoint. So there's a lot of crossover occasionally in adults that have what looks more like rosacea or acne. And so what we spend time in dermatology doing is getting that history, looking for comedones, looking for scarring, and then trying to determine really where a person falls along rosacea versus acne spectrum. For those people who are listening to our conversation who are politicos and are wondering why the heck I mentioned President Bill Clinton, well, he had rosacea. And there were lots and lots of articles written about rosacea because the President of the United States had rosacea at the time.

10:18Absolutely. From what you're saying, it's a similar disease across the age spectrum, but what are some of the more specific causes of acne in adults? So a lot of times adult-related acne has more of an underlying hormonal aspect, I guess, if you will, especially for women. Many times while they're still having their menstrual cycle or in that perimenopausal period tends to flare and settle. And so we know that there's a hormonal component. As we get older, our hormones naturally shift. And then the other thing that will give us a lot of more adult-onset acne is medications, whereby we can see acne flaring because of the medications that they're taking.

10:55What are the most common prescription medications that might trigger acne? Usually, they're not something that people are just going to happen upon. The medications that tend to flare up acne are ones that people are on for different types of cancers, and they're usually called immunotherapies. And so although they target the cancer cells, they also target other things, and the skin is a common target for that. So we will often see acne. Prednisone or steroids, systemic steroids or otherwise, are also a big cause of acne. And I would imagine that anabolic steroids would be as well. Absolutely.

11:29What steps can people take on their own to prevent acne and make it less severe? I think it's a challenge. So people avoiding things that are going to make acne worse. So So for example, those thick, heavy makeups, oil-based products. If you go to the drugstore and you look for a product and it says oil-free or non-comedogenic, those are things that are safer to use if you have acne. So avoiding those things, avoiding sitting around in sweaty clothing, for example, rinsing off, that's very helpful. I know that stress is a big cause of acne. So if you could just simply not be stressed, that would be great.

12:05That would be very helpful, wouldn't it? If you're spending time teaching patients how not to be stressed, then I want to be one of your patients. Yeah, I haven't quite got that down yet. So I'll have to let you know if I ever do. I know that's tongue in cheek, but, you know, stress certainly does make it worse. We know that when people use good, bland products on their skin as well to kind of keep that barrier intact. So with people that have acne, I'm often recommending that they use bland, fragrance-free, oil-free cleansers and using moisturizer cream and not wearing heavy makeups or using heavy oil-based creams or heavy sunscreens.

12:41And you want them to pay attention to cleaning whatever is, whatever products they do use off their face. So what kind of skin cleansing do you recommend? I like bland, fragrance-free skin cleansers. And so you could certainly spend a fortune, but you don't have to. I like Cetaphil. I like CeraVe. I like Spectroderm. I like anything by La Roche-Posay or Avene. There are lots of options that goes across a price spectrum. Really what you're looking for is just something that can cleanse. And cleansers don't have to foam either, right? So there's a lot of really nice oil-free cleansers that don't get all foamy, but they do a very good job at cleaning.

13:18So far, I haven't heard Shea Butter Body Wash. No, Shea Butter tends to be a little bit thicker. So for people that have very dry skin, they may prefer something like that. But typically speaking, those heavy oil-based butters could make acne a little bit worse. Okay, so now let's get to the work of physicians, particularly dermatologists. How do you treat it? What's first-line treatment? First thing is, you know, I always say the exam answer. You assess the patient and determine how severe it is. But really, that does matter. So let's just say that somebody is on the relatively mild acne spectrum.

13:50The first line of treatment are topical therapies or creams. There's a bunch of different topical therapies that are available, but most people will be given something that has a vitamin A or a retinol. Retinoid, retinol, vitamin A, all interchangeable. There's a variety of different products available. They come in a lot of different vehicles, which means what they're in. So is it more of a gel? Is it more of a cream? Is it more of a lotion? and you can really tailor that treatment for a person if their skin's more oily or more dry or more sensitive, et cetera. And so usually having a vitamin A topical is part of all treatment regimens unless people are pregnant.

14:31And then other than that, there are topical antibiotics, there are topical things like azelaic acid, topical dapsone, topical clascotorone. And so there's a variety of different things that people can use from a cream perspective. That's first line. How effective are they? If people have mild acne and they are diligent about use, they can be very effective. The one thing I do always tell people is they can irritate at the beginning. So I spend a little time describing how to minimize that. And the second piece is they don't work overnight. So people have a tendency to use something two, three times, go, bah, that didn't work and toss it in the trash.

15:07I really try to encourage people to use these for 8 to 12 weeks to see the effect and then to maintain that effect. So once they start seeing improvement, people are pretty good about using it, but you really need to get them into that improvement period, which is not immediate. At some point, some of your patients are going to be receiving medications. So what medications are commonly prescribed? Oral antibiotics are often used, so tetracycline-based antibiotics, not because of the infection component and not because of that P-acnes, but because these particular medications are quite good at decreasing inflammation.

15:40We also will use oral contraceptive or anti-androgen medication sometimes for women. So spironolactone is something you might have heard of for blood pressure, but we use it for acne as well. And then isotretinoin, or what most people probably know of as Accutane, although Accutane's a brand and there's four possible brands that people could be given. So let's talk specifically about isotretinoin. How effective is it? It's very effective. So in terms of efficacy, the way we quote it for patients is to say, if you complete a full course, the chance that your acne has gone in the long term is about 75%, sometimes a bit higher, sometimes it does come back.

16:21But there's no limit to the number of times you can take that medication if needed. And each time you take a course, you get that 75 % long-term improvement. There were lots of concerns early on about the risk of isotretinoin, less so these days, but there is still a risk. So how do you help patients navigate the risk? Absolutely. I think one of the best things that's happened in dermatology is the development of isotretinoin to be able to prevent scarring acne in people and really change their lives. But on the flip side of it, I think one of the worst things that happens in dermatology is the bad rap that isotretinoin gets.

16:59By and large, most people that take it get a bit of dry lips, okay? And I tell everybody that they're going to get dry lips. There's a lot of controversy around some of the side effects that may come with isotretinoin, but I do spend time discussing it with patients. And much of what they're worried about are things that they might have seen on social media that when you really get into it, aren't particularly true concerns. Yes, we need to monitor blood work. Yes, we absolutely do not want women to become pregnant while on the medication. And they are going to get dry lips and sun sensitive. But beyond that, it's pretty well for most people to tolerate.

17:34And if not, it just might not be the right fit for that person. And what about that risk of suicide and depression? Yeah. So this is a hot topic that comes up every few years. If you look at, there's a large retrospective. So they look at people and, you know, going backwards, millions of people that had taken isotretinoin and that hadn't. And there's actually a lower risk of mental health conditions in the treated group. Now, causation is a little bit tricky. And many people that start taking isotretinoin for the first time are in the high risk period when, you know, suicidality and mental health conditions will first appear.

18:10And so there's never been anything that has convinced me that it's related. Occasionally, people will say, I really don't feel myself on this medication. In that case, we decrease or stop it. Everybody's different, but from a population level, again, really nothing to suggest that it is related. From what you've mentioned, social media is a potent source of misinformation about isotretinoin? I mean, I think about acne in general. You know, people think they have to do 12-step skincare routines, and that's just not factual. They think that X, Y, or Z is going to cure them. If they cut this out of their diet, they're going to get better.

18:44And then lots of bad stuff about isotretinoin. So yeah, it's a real problem. And I don't think it is only in dermatology, but we certainly are hit hard with misinformation on social media and dermatology. Is there anything more specific about treating adults with acne that might be different from treating adolescents? I do find in my own practice that many times adults can get away with a lower dose of certain medications like isotretinoin and maybe for a shorter period of time. But by and large, the principles are the same. Again, sometimes this is where medications like spironolactone are more effective in adult women compared with a teenager who I wouldn't give spironolactone to necessarily.

19:27But I do think the principles are the same. And ideally, if people have significant acne in their adult years, we should be treating it as well. Is there anything coming down in the years to come that might offer some hope for eliminating this scourge from our society called acne? My optimistic side would say probably. My pessimistic side will say I'm not totally sure. Research and innovation in dermatology has never been higher and looking at different targets with minimizing side effects and risk, I think absolutely down the road there will be something that we can hopefully use early and safely to prevent people from having scarring.

20:05It's so much easier to prevent scarring than it is to treat it. So I will remain hopeful that that's an option down the road. Well, Dr. Carrie Purdy, you have been a tremendous source of knowledge on acne and adult acne and teenage acne. And I want to thank you for coming on The Dose to talk about an important subject. Thank you. Thanks so much for having me. Dr. Carrie Purdy is an Associate Professor and Division Director of Dermatology at Dalhousie University. Here's a dose of smart advice. Acne occurs when pores and hair follicles become clogged by dead skin cells, resulting in the buildup of material made by oil glands.

20:46These pores and follicles also get inflamed. The blocked pores and follicles can also get infected with a bacterium that leads to redness, swelling, and pus discharge. Acne causes pimples, whiteheads, blackheads, and pustules. The most severe form, called nodulocystic acne, causes firm and often painful lumps under the skin. Adult acne, or post-adolescent acne, is defined as occurring after age 25. It is the same condition affecting teenagers, though some people only get acne for the first time as grown-ups. A substantial percentage of men and women have adult acne, but women make up three-quarters of those with the condition.

21:26It tends to run in families. Diets high in cow's milk or carbs may increase the risk. Emotional stress can make acne more severe. Cosmetics and other skin products that clog hair follicles and pores worsen the condition. Acne is also triggered by hormonal conditions that lead to a relative abundance of androgens or male hormones. Thus, women may get acne when they experience drops in estrogen levels. Polycystic ovary syndrome, or PCOS, is a disease in which androgen levels are higher. Steroid medications also increase the risk. For most people, the condition is manageable. Using a mild skin cleanser twice a day helps remove layers of old oil and skin products.

22:10Topical retinoid creams unclog pores and exfoliate the skin. They also reduce inflammation and help the skin heal faster. Topical anti-inflammatories are also helpful. These medicated creams and lotions generally take two to three months to show results, so be patient. If certain foods make your acne worse, try eliminating them. Oral medications are used for moderate to severe acne. They include antibiotics, oral contraceptives, and spironolactone, which reduces the effects of male hormones. oral isotretinoin is prescribed for severe nodular acne and for patients with milder acne that hasn't responded to other treatments isotretinoin has potential risks and side effects but healthcare providers say these are generally well known and manageable if you have topics you'd like discussed or questions answered our email address is the dose at cbc.ca if you like this episode please give us a rating and review wherever you get your podcasts this edition of The Dose was produced by Samir Chhabra.

23:12Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your healthcare provider. I'm Dr. Brian Goldman. Until your next dose.