Acne, also known as pimples, or the proverbial zits, takes many forms and usually plagues teens and young adults, but can also affect people of all ages. There are effective treatments, but for some, acne can be persistent. Where one goes away others can pop-up creating embarrassment at times. Depending on its severity, the emotional stress and scarring left behind, can be socially stigmatizing. Questions that persist, do factors like hygiene, greasy foods or even cosmetics contribute to the problem are often brushed aside for one key question… how do I treat them?
Guests:
Jonathan Fialkow, M.D., Chief of Cardiology at Baptist Hospital and Chief Population Health Officer at Baptist Health.
Judith Crowell, M.D., Dermatologist with over 30 years of experience and a member of the Baptist Health Quality Network.
Acne, also known as pimples, or the proverbial zits, takes many forms and usually plagues teens and young adults, but can also affect people of all ages. There are effective treatments, but for some, acne can be persistent. Where one goes away others can pop-up creating embarrassment at times. Depending on its severity, the emotional stress and scarring left behind, can be socially stigmatizing. Questions that persist, do factors like hygiene, greasy foods or even cosmetics contribute to the problem are often brushed aside for one key question… how do I treat them?
Guests:
Jonathan Fialkow, M.D., Chief of Cardiology at Baptist Hospital and Chief Population Health Officer at Baptist Health.
Judith Crowell, M.D., Dermatologist with over 30 years of experience and a member of the Baptist Health Quality Network.
Speaker 1:
At Baptist Health South Florida, it's our mission to care for you when you're injured or sick, and help you stay healthy and fit. Welcome to the Baptist Health Talk podcast, where our respected experts bring you timely, practical health and wellness information to improve your family's quality of life.
Dr. Jonathan Fialkow:
Welcome Baptist Health Talk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Baptist Health's Miami Cardiac and Vascular Institute, where I'm also chief of Cardiology at Baptist Hospital and Chief Population Health Officer at Baptist Health. Today's podcast is about acne. Acne, which is known as pimples or the proverbial zits, can take many forms and usually plagues teens and young adults, but actually can affect people of all ages. There are effective treatments, but for some acne can be persistent where one goes away, others can pop up creating embarrassments at times. And depending on its severity, the emotional stress and scarring left behind can be socially stigmatizing. Questions that persist, like do factors like hygiene or greasy foods or cosmetics contribute to the problem, are often brushed aside for the one key question, which is how do I treat them? Joining me today to update us on the latest in acne treatment is Dr. Judith Crowell. Dr. Crowell is a dermatologist with over 30 years experience and part of the Baptist Health family. Welcome to the podcast, Judy.
Dr. Judith Crowell:
Thank you for inviting me, Jonathan, and I'm ready to get started.
Dr. Jonathan Fialkow:
All right. So I think when we deal with these kind of general topics in the podcast, it's always good to start out with a definition. While I think most people who have survived teenage years would know what acne is from a general medical standpoint, how would you define acne in its basic elements?
Dr. Judith Crowell:
Well, most people just think of it as the teenage acne that we get, but actually you can have infants who have an infantile acne, neonatal acne. You can have adult onset, which is mostly hormonal. There are some very fulminate forms that are very serious and extraordinarily scarring, plus can be associated with other underlying diseases. So acne is just not one disease. But the one that we mostly think of is one where you get flesh colored bumps, open and closed comedones, blackheads and pustules and nodules and cysts, and they can be very painful. And so, it's not just one form and people can get different presentations of this disease.
Dr. Jonathan Fialkow:
That's fascinating. Again, something that you would think is so ubiquitous is obviously more complex, like most things with medicine than you might otherwise think. And again, we think of acne in the face and in the back. Are there more predominant parts of the body where you see acne?
Dr. Judith Crowell:
No. Mostly it's going to be in the face, the chest, the back, because that's where you have the predominance of the sebaceous glands, which are primary to having this disorder. There are other associated things that you can have like hidradenitis suppurativa, which is these inflamed nodules that people can get under their breast, under their arms, in their groin, and it can be associated with forms of acne.
Dr. Jonathan Fialkow:
Is acne generally considered benign? I mean, as you go through these more complex components in acne, again, we generally think acne it's, as we said, hormonal. Though it could be more and it's embarrassing, but it goes away. Are there ever medical conditions related to acne that one would need to be concerned about?
Dr. Judith Crowell:
Absolutely, because there is acne conglobata, which is a very inflammatory form of it, and it can be associated with all sorts of underlying issues like psoriatic arthritis. It itself can be an autoimmune disease.
Dr. Jonathan Fialkow:
And here I thought we're just going to do a simple podcast about just basic pimples, but no, this is great information. I always love learning from the podcast that I host. So going further, you mentioned what causes acne a little bit at a high level, which is hormones. Can you get a little detailed to what actually causes that little inflammatory component in the skin?
Dr. Judith Crowell:
Yes, absolutely. And, it's multifactorial, number one, because there are some forms of acne that seem to be more genetic. So if it runs in the family, there's a good chance you're going to get it. And it has to do with the way that the layer of dead cells form around the hair follicle and the hair follicles have the little sebaceous gland that empty it into them. And what first seems to happen is you get these sticky dead cells that are at the opening to the pore. Sometimes if they're close to the surface you'll see them and it looks like blackheads. It's not dirt, it's dead cells with all their melanin in it that are giving it its color.
And what happens is that as that plug forms, you get a sebaceous gland that really is primeval. It knows how to do one thing, and that is to produce sebaceous material and it pumps out its oils, it's nowhere for it to go. So what happens is that it forms this little pocket filled with this sebaceous material. And bacteria then starts breaking down this material into free fatty acids, which our body doesn't like. And it sets up a whole inflammatory process that occurs. And of course hormones can play a role in it. The bacteria plays a role in it. The fact whether you have a buildup of these dead cells play a role. And so you can have all forms of acne, just blackheads. You can have ones that just look flesh colored bumps, and they're really black heads, they're just deeper into the skin so you're not seeing the dead cells build up. And then of course, once bacteria form, then you can get the inflammatory papules, pustules and nodules that we also [inaudible 00:06:27]-
Dr. Jonathan Fialkow:
So again, a lot of stuff going on in our body, very complex mechanisms to produce that pimple.
Dr. Judith Crowell:
That's right.
Dr. Jonathan Fialkow:
Scorn of our population.
Dr. Judith Crowell:
It's not just this easy thing that happens. Yes.
Dr. Jonathan Fialkow:
Yeah. So let's go through some more lifestyle and other types of questions that people may have. Start with some basics. Is acne at all genetic? Does it run in families? If a family, if a parent had significant acne as a teen, would that make another teen more likely? Are there other conditions? So is there a genetic or a family history?
Dr. Judith Crowell:
There's definitely a genetic link. But, having said that, 85% of individuals from 12 to 24 are going to have some form of acne in their lifetime.
Dr. Jonathan Fialkow:
So it's fairly prevalent.
Dr. Judith Crowell:
So it's pretty high.
Dr. Jonathan Fialkow:
So whether you have a family history or not, it doesn't affect whether you're going to get it or not, it's still have to deal with it.
Dr. Judith Crowell:
Yeah.
Dr. Jonathan Fialkow:
What about stress? We always talk about stress contributing to acne. Is there any truth to that? And if so, is there a known mechanism?
Dr. Judith Crowell:
Absolutely there is truth to that. And it seems that when we are stressed, we secrete something called substance P into the skin, which is very irritating and it can trigger all sorts of things. If you're acne prone, it can help trigger acne. If you're eczema prone or psoriasis prone, it can help trigger that. So stress plays a very large part.
Dr. Jonathan Fialkow:
So it is a contributor.
Dr. Judith Crowell:
Yeah.
Dr. Jonathan Fialkow:
And then of course, it's good that teenage years are just nice and relaxed and there's no social pressure.
Dr. Judith Crowell:
Right. Right. And raging hormones have nothing to do with it either.
Dr. Jonathan Fialkow:
Right. Right. So going back and making the jokes, because that's what we see. You did mention it can happen at any age. It can happen in children, infants, but the predominant kind of acne we see, is it in that teenage year group or are there-
Dr. Judith Crowell:
Absolutely.
Dr. Jonathan Fialkow:
... patterns that you see elsewhere? Yeah.
Dr. Judith Crowell:
It really happens as our hormones are starting to rage, and generally it's about at age 12. Now we're seeing some precocious puberty now where you're seeing younger people starting to develop acne lesions even as early as seven.
Dr. Jonathan Fialkow:
There's a term, adult acne. Is that just, again, by age, it's just again, the same process, but it's just staying in a younger age or what is adult acne?
Dr. Judith Crowell:
Adult acne is different because whereas the teenage acne can affect both males and females pretty equally, the adult acne is really more a woman's problem and it really has more to do with their hormonal responses. And so you can have women who once a month a week before their period, they start to get these painful nodules and usually it's a different location. So women who get it, adult acne is more on the lower face and the upper neck, whereas in the teenagers, they're more in the T-zone. So it's a different acne all together.
Dr. Jonathan Fialkow:
So before we get to I guess, the germ of the podcast, which is what people can do about it and certainly what's the role of a dermatologist. Two other quick questions I just had, first was, are there diets or dietary components that have been shown to be relevant to acne? Certain kinds of macronutrients and foods or anything that seems to be associated with an increased prevalence in acne?
Dr. Judith Crowell:
This is still pretty controversial. There has been some evidence that maybe skim milk can be a set up for acne, especially in men. I don't know that this is proven, disproven. It's something that if I know somebody is breaking out and they have a high diet on this particular type of dairy, I will try to discourage them from it, to try. We always thought that chocolate did it and then chocolate was no, chocolate didn't do it. And then it was nuts. So none of this is really [inaudible 00:10:40]. The biggest problem is that we eat a lot of finger food in America, and the potato chips and the oils and the french fries. If you don't wash your hands after you eat and you're bringing all of that stuff to the face, that can help set it off.
Dr. Jonathan Fialkow:
And I remember with the COVID experience, we touch our faces, was it 20 times an hour or 30 times an hour? Just constantly transmitting those oils. That's interesting. And then the other question before we get to again, what people can do about it is, what about makeup? It was something we brought to attention in our introductory comments, but it's something again I see. And I remember seeing my daughter was young, which she's fortunately past that age. Does any association with makeup or the kind of makeups? Or do you recommend to young girls, young women, to avoid certain makeup components because of acne?
Dr. Judith Crowell:
For sure. If you're acne prone, we will tell you to look for noncomedogenic products or oil free products. And they're available on the market and they're readily marked so you can find them easily.
Dr. Jonathan Fialkow:
And then I guess presumptuously because of that as well, which I guess we'll get to is washing your face, keeping clean would be beneficial?
Dr. Judith Crowell:
However, you over washing your face is not good either. So we're recommended to really, if you're going to wash your face once or twice a day, that's it.
Dr. Jonathan Fialkow:
And what's the reason that you're taking out natural oils?
Dr. Judith Crowell:
Yes, and natural protection.
Dr. Jonathan Fialkow:
So let's get to the good stuff. First place, when would you think a person should see a dermatologist because of their acne? And the second part of that question is, as a dermatologist what do you recommend for people or how do you address someone when they come to you with what they perceive as bad acne?
Dr. Judith Crowell:
So obviously when it bothers them is a good time for them to seek medical care, especially if they've tried a lot of the over-the-counter things and it's not working. And it's interesting because what will bother one person, won't bother another. And there are people that I have seen out and about who have severe scarring acne and I wonder why they're not seeking healthcare because there is so much that we can do to prevent scarring and prevent the [inaudible 00:13:06] sequela that bad acne can leave someone with. And it's not just scars on the face, but there's emotional scarring. And that's an important point, Jonathan, because what happens is that I can have one person who comes in and they have a spot and they are so focused on the spot that it is interfering with their ability to want to walk out the door. And then you can have individuals that have severe acne and don't care.
Dr. Jonathan Fialkow:
Yeah, I was going to actually ask you about that after the answer, but you brought that up. Which is, in your role, and I presume have to customize the approach towards the patient expectation and what their needs are. And some of that might be emotional support or I'm sure you're a little bit of a psychologist in some of how you deal with these patients as well.
Dr. Judith Crowell:
Right. I actually have told more than one patient that they have to stop being their own worst enemy, that other people are looking for ways to tear them down and that they have to start focusing on what is wonderful about themselves. Stop looking at the one pimple and realize that they're not seeing that they're looking at your beautiful eyes, they're looking at your great smile, whatever it is. And it is, it's trying to refocus somebody's attention, especially since there are forms of body dysmorphism that's more than anorexia. And so, it's a lot of what I do is psychological.
But in terms of treatment, it's very different depending on what walks in the door. I'm obviously going to treat somebody who has just blackheads differently than somebody who has inflammatory acne with cyst and pustules and nodules. And so it has to be tailor made. And I also have to recognize that the patient has to be invested in taking care of themselves. I get kids who are dragged in by a parent that the acne bothers the parent more than it bothers the kid. And so I will do this sort of negotiation, "How about if I can give you one thing that you do once a day that will help your acne and make your mom happy?" And usually we can get to some sort of an agreement that they could do that, you have to make it easy.
Dr. Jonathan Fialkow:
Yeah, yeah. Ultimately you want the person with the acne to get better. So whatever mechanism and whatever buy-in you get has to be customized, as we said. So clearly if someone has acne and it bothers them, obviously seeing a professional will help, not just, they can go and buy a cream that everyone buys. That might be something specific to their kind of acne or what's causing it, which you would work with. But again, is it pills, is it the creams, is it just hygiene or some combination of all of them that you wind up with more commonly?
Dr. Judith Crowell:
Well, for most individuals, we have some phenomenal new drugs out there that are topical that for most individuals I try to steer away from the oral antibiotics, unless it really is severe and inflammatory. And then I will start them on a short course of antibiotics to try to calm things down because most topicals will take from six to three months to kick in and actually control it. So there are individuals that are going to need to be on antibiotics to see whether we can slowly wean them off the antibiotic and let the topicals continue to take control.
There's also some very good evidence that there's some nutrients that may be missing in people's diet. So there are several prescription medications that are actually combination of vitamins that are anti-inflammatory. That I have found that I can keep individuals completely off the oral antibiotics and use these type of vitamin enriched, usually enriched with things like nicotinamide and zinc, are part of those ingredients that are really very effective.
Dr. Jonathan Fialkow:
So again, best under the auspices and direction of a professional dermatologist for those type of conditions. So here's my last question, I promise, because again, this is actually very fascinating information. Differences in the presentation of acne and/or treatments and/or long term effects, i.e. scarring based on the darkness of one's skin, are there racial differences or anything having to do with that?
Dr. Judith Crowell:
Absolutely. Unfortunately, if you are skin of color, you are more able to put down pigment. And so more often, even as the acne clears up, you will be left with what we call post-inflammatory hyperpigmentation. But that tends to fade over time. And there are things that we can do to help that. Lighter skin, they may not have pigmentation issues, but they may be left with redness, what we call hyperemia, red marks where the inflammatory lesions were. And that too can take a while. Now of course the worst ones are when you get severe nodular acne and that can lead to pitted scars and really severe scarring on the face. So that sort of sequela can lead to longer term psychological effects.
But you know what, we have some great treatments now. I mean in my early years there were very little available for us. I mean there are so many drugs and some of the old ones that have come back. The isotretinoin, which was Accutane that was taken off the market and now is back on the market. When you look at a drug and you can say that a drug can cure 80% of the individuals who take it for the first course, that's unheard of. And if people take that drug a second time because it didn't go away, we increase the percentage to a 90% cure rate. I mean, most drugs don't have that type of effectiveness, and it's really pretty amazing. And so there are going to be certain individuals that really need to go on the isotretinoin.
Dr. Jonathan Fialkow:
And again, going back and just iterating that point again, get the professional help. Not a stigma, it's a medical condition. Seek assessment and help early if it's something bothering you. Lots of opportunities and lots of weapons available and whether it be lifestyle, hygiene, proper creams, et cetera, and even medical therapies to make the acne controlled. And most importantly gets in certain conditions to avoid scarring for those that might be at risk for scarring. Great information. Before I wrap up, anything to add or anything you want to emphasize in the conversation?
Dr. Judith Crowell:
I think the most important thing is that don't hesitate to get help because early intervention can really prevent scarring and the sequela that follows with acne. And even if it starts very mild, it could progress and it's easier to treat it when it's not fulminant.
Dr. Jonathan Fialkow:
And to that end as well, don't panic. Doesn't require going to an emergency room when you see it.
Dr. Judith Crowell:
Right.
Dr. Jonathan Fialkow:
Well, this is great, Dr. Judith Crowell, dermatologist in the Baptist system. Again, great information. Really appreciate your response and your passion in helping people with this very common condition. And to our listeners, if you have any comments or suggestions for our future topic, please email us at baptisthealthtalk@baptisthealth.net, that's baptisthealthtalk@baptisthealth.net. We'd love to hear from you. And thanks for listening.
Speaker 1:
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