Dispelling common myths about the causes and treatment of acne can make all the difference in how acne patients view themselves and others who suffer from this all-too-common and distressing medical condition. Acne is the most common condition that dermatologists treat. While assessing which acne treatment is appropriate for a patient, it is valuable to consider the beliefs — the mythology if you will — of patients regarding acne. Popular discourse perpetuates these myths, and these myths echo in the examination room, sometimes drowning out the recommendations of the dermatologist and utilization of dermatological acne treatments. Knowing these myths helps dermatologists better understand some of the inner beliefs of such patients in order to help enhance their outer appearance. Dispelling these myths is a service to both patient and dermatologist alike.
MYTH 1 — ACNE IS A COSMETIC CONDITION
More than 50% of those suffering with acne problems report negative comments and other feedback from members of society, regardless of whether or not the acne resulted in scarring. De¬pression is more common in acne patients than in those without acne. Acne can be devastating and life-altering, resulting in clinical depression and low self-esteem. It should be noted that the degree of depression does not always correlate with the physician’s global assessment or clinical severity. Physicians would be wise not to assume an otherwise minor case of acne is not distressing to the patient. Studies show that patients and parents of patients underestimate the psychological impact of acne. Acne is a disease that requires medical treatment. Those who say it is only a cosmetic concern perpetuate a myth that is false and pernicious.
MYTH 2 — SWEATING HELPS CLEAR ACNE
Some patients believe that going to a steam room or using hot towels will improve their acne. There is no basis for this myth. In fact, some studies — including an Indian study in which patients said their acne was worse in the summer — have suggested that sweating makes acne worse, which the authors guess is due to increased temperature, marked humidity and sweating. In any case, let patients know they cannot sweat out their acne, and patients who do this should consider the lack of data for this course of action.
MYTH 3 — SEX AND MASTURBATION CAUSE ACNE
The theory that sex or masturbation cause acne is not based on scientific evidence. It seems likely that this theory, which may have originated as early as the 17th cen¬tury, was designed to dissuade young people from having premarital sex. Patients who believe this should be told that neither sex nor masturbation cause acne, nor is degree of acne proportionate to sexual activity. However, the debates between parents and their children over sex should not obscure the fact that acne is at least in part a disease of hormones and those in the process of undergoing sexual maturation. This provides an etiologic basis for understanding acne and a foundation for some acne treatments such as oral contraceptives/hormonal therapy.
MYTH 4 — ACNE IS CAUSED BY DIRT
Patients need to understand that acne is a complex disease of follicular units unrelated to dirt. The bacteria responsible for inflamed acne breakouts are Propionibacteria acnes (P. acnes). Blackheads are not due to dirt, but rather to pathology of follicles and buildup and alteration on sebum, ie, pilosebaceous ductal hypercornification. Patients should be taught that blackheads are open comedones that are due to the oxidation of sebum, and that scrubbing may inflame them. Open comedones can be removed by acne surgery and prevented with topical retinoids, but dirt plays no role in acne, which leads us to consider the fifth myth.
MYTH 5 — THE MORE YOU WASH YOUR FACE, THE LESS ACNE YOU’LL HAVE
If acne is not caused by dirt, it stands to reason that acne cannot be simply washed away. The makers of abrasive acne scrubs would have patients believe that a harsh wash is a treatment for acne, a concept that is not supported by studies. A study that compared an abrasive cleanser with the same cleansing agent without the abrasive granules for acne found the two treatments equal in effect. Of course, this is not to suggest to pa¬tients that washes cannot help acne, as those with ingredients such as benzoyl peroxide, salicyclic acid and sulfur compounds can help to abate acne, most specifically on the face. The key washing myths to debunk are (1) that plain soap and water improve acne; (2) that abrasive cleansers help acne; and (3) that constant washing — even using the right products — helps decrease acne. In fact, irritation from the interaction between harsh cleansers and topical retinoids may decrease compliance.
MYTH 6 — ACNE GOES AWAY ON ITS OWN AND DOES NOT NEED TO BE TREATED
Acne is a condition that can last for years. If left alone without even attempts at topical treatment, it can worsen and scar. Treatment — even with mild over-the-counter benzoyl peroxide — helps and should not be avoided simply because someday the acne will go away. Acne is treatable and early intervention, which can be mild and topical, matters.
MYTH 7 — TANNING CLEARS ACNE
While some light therapies and lasers help treat acne and tanning can mask it, ultraviolet radiation dries out the skin and induces premature skin aging and can worsen acne. Some think that porphryins associated with P. acnes can be targeted with light therapy. This may be the case, but make the point to your patients that any benefit to acne from tanning is outweighed by its role in the induction of premature aging and the promotion of skin cancer.
MYTH 8 — POPPING ACNE PAPULES AND PUSTULES (PIMPLES) MAKES IT BETTER
Acne is a follicular disease and picking at acne papules breaks the follicular unit spilling inflammatory media¬tors into the surrounding tissue, resulting in scarring. Patients should be encouraged not to pick at their faces. While discussing treatment at length is beyond the scope of this article, it should be noted that spot treatment of lesions with topical agents and injections of low-dose intralesional corticosteriods are far more optimal interventions than having patients pop their pimples. In fact, there is a distinct type of acne caused by picking that is well known to dermatologists as acne excoriee de jeune fille (translated as “picked pimples,” although it literally means “the picked at acne of the young woman”). The myth of pimple popping as a treatment must be debunked again and again because of the urge patients have to address acne in this inappropriate fashion. However, comedones can be extracted by a well-trained health professional with some benefit, and in fact is recommended by Dr. Danby in his Helpful Handouts column on acne in the May issue of Skin & Aging.1
MYTH 9 — PATIENTS WITH ACNE CANNOT USE COSMETICS
While it’s true that some types of cosmetics can make acne worse, those that are nonacnegenic or noncomedogenic generally do not worsen acne. Dermatologists can help patients decide if, whether, and when to use facial cosmetics. There are some concealers that contain benzoyl peroxide, resorcinol or salicylic acid, and there are also tinted acne treatment products. Patients who believe foundation may be contributing to their acne, can be encouraged to wear mineral-based makeup. So, let them know it’s a myth that they must leave their acne lesions uncamouflaged; they simply need to know what is most appropriate for them.
MYTH 10 — IF A LITTLE ACNE MEDICATION IS GOOD, A LOT IS EVEN BETTER
Topical acne medica¬tions should be used in the minimal amount, as they work on medial pathways, not by the law of mass action. Patients need to know that topical acne medications are not masks, they are medicine, and too much medication may cause overdrying of skin, leading to irritation and more blemishes, which will lead patients to stop to using medications altogether. So, make sure they understand that more is not better for topical treatment, that they should not use acne medications like sunscreen. Remind them that only a pea-sized amount of a retinoid is needed to cover a face.
MYTH 11 — ACNE MEDICATIONS WORK IMMEDIATELY
By the time some patients develop the motivation to make the appointment and arrive at the of¬fice, they want immediate results. In one study, 66% of patients believed that acne would improve immediately after the first treatment. They need to know medications may take up to 12 weeks to make a significant difference, and that acne can relapse as well. The average acne patient is used to a strep throat getting better with a few days of antibiotic treatment, whereas we know as clinicians that even the strongest medication like oral isotretinoin or minocycline can take months to significantly clear acne. But whatever patients may think, results will not be immediate. So, this might be the time to finally use all that pharmaceutical representative paraphernalia collecting in your drawers and show patients that most acne studies reach their highest efficacy at 12 weeks, which is how long they may have to wait for clearer skin.
MYTH 12 — OTC TREATMENTS ARE EQUIVALENT TO PRESCRIPTION MEDICATIONS
Proactiv is the number-one selling acne medication in the United States, but it is not the most effective. Benzoyl peroxide (BPO) is an excellent topical acne treatment, but it is not more effective than isotretinoin. In fact, stud¬ies of combination drugs utilizing BPO and clindamycin or adapalene all show superiority over BPO alone. Evidence-based clinical studies back prescription medica¬tions. Clearly, patients vote for Proactiv, but this dynamic is driven by hype, promotion, and, of course, the fact that BPO is an effective treatment for acne.
MYTH 13 — ISOTRETINOIN SHOULD NOT BE USED FOR THE TREATMENT OF ACNE
Isotretinoin is the only agent that has been shown to induce long-term remission, and it has curative potential for acne. The idea that it should not be available does not serve patients. Isotretinoin is not for every patient, but it has been used by 10 million patients in the United States with often amazing effect. iPledge and the litigation against Roche over the link of isotretinoin and inflammatory bowel disease aside, the concept that isotretinoin should not be used for acne may not fit the definition of a myth, but is due to misguided beliefs, in the opinion
MYTH 14 — ACNE IS A DISEASE OF TEENAGERS
Acne certainly affects teenagers, but it affects other age groups as well. Some people develop acne for the first time in their 20s or 30s, and they are often shocked because the mythos of acne is that it is a disease that disappears before college. In the business districts of Manhattan, most patients treated for acne vulgaris are women between the ages of 20 and 45. Young white collar professionals are often distraught about still getting acne and feel they are not taken seriously at work when they are breaking out. They should be reassured that acne can be a disease of those aged 20 to 45 and that effective acne treatments do exist.
MYTH 15 — DIET DOES NOT CAUSE ACNE
People in some indigenous societies do not experience acne at all. Whether it is genetics or diet — or both or something else — is unclear. Some studies show acne is linked to milk, which leads to postprandial insulin and basal insulin-like growth factor-I (IGF-I) plasma levels. Increased insulin/IGF-I signaling activates the phosphoinositide-3 kinase/Akt pathway, thereby reducing the nuclear content of the transcription factor FoxO1, the key nutrigenomic regulator of acne target genes. Nuclear FoxO1 deficiency has been linked to all major factors of acne pathogenesis, ie, androgen receptor transactivation, comedogenesis, increased sebaceous lipogenesis, and follicular inflammation. The final evidence is not in, but it seems that acne and diet are linked in ways that we did not suspect two decades ago. Make sure your patients have access to information on theories on the usefulness of dairy-free and/or low glycemic load diets. (Note: See Helpful Handouts online to print out Dr. Danby’s handout on acne, with information and resources related to the role of diet an in acne. https://skinandaging.com/content/acne.)
CONCLUSIONS
People’s assumptions about acne, much like their assumptions about other complex matters, often are the result of misun¬derstandings and require clarification. It is therefore left to the experts, who often disagree with one another, to dispel myths related to acne in order to enhance our patients’ health. The myths that are particularly important to address are those related to the psychological cost of acne, avoiding isotretinoin, and the role of milk in acne. Knowing these myths tunes us in to the acne zeitgeist, so when we step into the treatment room we are ready to listen, educate and act. Reference Danby FW, Margesson L. Helpful handouts: Acne. Skin & Aging. 2011:5:22-24.
Dispelling common myths about the causes and treatment of acne can make all the difference in how acne patients view themselves and others who suffer from this all-too-common and distressing medical condition. Acne is the most common condition that dermatologists treat. While assessing which acne treatment is appropriate for a patient, it is valuable to consider the beliefs — the mythology if you will — of patients regarding acne. Popular discourse perpetuates these myths, and these myths echo in the examination room, sometimes drowning out the recommendations of the dermatologist and utilization of dermatological acne treatments. Knowing these myths helps dermatologists better understand some of the inner beliefs of such patients in order to help enhance their outer appearance. Dispelling these myths is a service to both patient and dermatologist alike.
MYTH 1 — ACNE IS A COSMETIC CONDITION
More than 50% of those suffering with acne problems report negative comments and other feedback from members of society, regardless of whether or not the acne resulted in scarring. De¬pression is more common in acne patients than in those without acne. Acne can be devastating and life-altering, resulting in clinical depression and low self-esteem. It should be noted that the degree of depression does not always correlate with the physician’s global assessment or clinical severity. Physicians would be wise not to assume an otherwise minor case of acne is not distressing to the patient. Studies show that patients and parents of patients underestimate the psychological impact of acne. Acne is a disease that requires medical treatment. Those who say it is only a cosmetic concern perpetuate a myth that is false and pernicious.
MYTH 2 — SWEATING HELPS CLEAR ACNE
Some patients believe that going to a steam room or using hot towels will improve their acne. There is no basis for this myth. In fact, some studies — including an Indian study in which patients said their acne was worse in the summer — have suggested that sweating makes acne worse, which the authors guess is due to increased temperature, marked humidity and sweating. In any case, let patients know they cannot sweat out their acne, and patients who do this should consider the lack of data for this course of action.
MYTH 3 — SEX AND MASTURBATION CAUSE ACNE
The theory that sex or masturbation cause acne is not based on scientific evidence. It seems likely that this theory, which may have originated as early as the 17th cen¬tury, was designed to dissuade young people from having premarital sex. Patients who believe this should be told that neither sex nor masturbation cause acne, nor is degree of acne proportionate to sexual activity. However, the debates between parents and their children over sex should not obscure the fact that acne is at least in part a disease of hormones and those in the process of undergoing sexual maturation. This provides an etiologic basis for understanding acne and a foundation for some acne treatments such as oral contraceptives/hormonal therapy.
MYTH 4 — ACNE IS CAUSED BY DIRT
Patients need to understand that acne is a complex disease of follicular units unrelated to dirt. The bacteria responsible for inflamed acne breakouts are Propionibacteria acnes (P. acnes). Blackheads are not due to dirt, but rather to pathology of follicles and buildup and alteration on sebum, ie, pilosebaceous ductal hypercornification. Patients should be taught that blackheads are open comedones that are due to the oxidation of sebum, and that scrubbing may inflame them. Open comedones can be removed by acne surgery and prevented with topical retinoids, but dirt plays no role in acne, which leads us to consider the fifth myth.
MYTH 5 — THE MORE YOU WASH YOUR FACE, THE LESS ACNE YOU’LL HAVE
If acne is not caused by dirt, it stands to reason that acne cannot be simply washed away. The makers of abrasive acne scrubs would have patients believe that a harsh wash is a treatment for acne, a concept that is not supported by studies. A study that compared an abrasive cleanser with the same cleansing agent without the abrasive granules for acne found the two treatments equal in effect. Of course, this is not to suggest to pa¬tients that washes cannot help acne, as those with ingredients such as benzoyl peroxide, salicyclic acid and sulfur compounds can help to abate acne, most specifically on the face. The key washing myths to debunk are (1) that plain soap and water improve acne; (2) that abrasive cleansers help acne; and (3) that constant washing — even using the right products — helps decrease acne. In fact, irritation from the interaction between harsh cleansers and topical retinoids may decrease compliance.
MYTH 6 — ACNE GOES AWAY ON ITS OWN AND DOES NOT NEED TO BE TREATED
Acne is a condition that can last for years. If left alone without even attempts at topical treatment, it can worsen and scar. Treatment — even with mild over-the-counter benzoyl peroxide — helps and should not be avoided simply because someday the acne will go away. Acne is treatable and early intervention, which can be mild and topical, matters.
MYTH 7 — TANNING CLEARS ACNE
While some light therapies and lasers help treat acne and tanning can mask it, ultraviolet radiation dries out the skin and induces premature skin aging and can worsen acne. Some think that porphryins associated with P. acnes can be targeted with light therapy. This may be the case, but make the point to your patients that any benefit to acne from tanning is outweighed by its role in the induction of premature aging and the promotion of skin cancer.
MYTH 8 — POPPING ACNE PAPULES AND PUSTULES (PIMPLES) MAKES IT BETTER
Acne is a follicular disease and picking at acne papules breaks the follicular unit spilling inflammatory media¬tors into the surrounding tissue, resulting in scarring. Patients should be encouraged not to pick at their faces. While discussing treatment at length is beyond the scope of this article, it should be noted that spot treatment of lesions with topical agents and injections of low-dose intralesional corticosteriods are far more optimal interventions than having patients pop their pimples. In fact, there is a distinct type of acne caused by picking that is well known to dermatologists as acne excoriee de jeune fille (translated as “picked pimples,” although it literally means “the picked at acne of the young woman”). The myth of pimple popping as a treatment must be debunked again and again because of the urge patients have to address acne in this inappropriate fashion. However, comedones can be extracted by a well-trained health professional with some benefit, and in fact is recommended by Dr. Danby in his Helpful Handouts column on acne in the May issue of Skin & Aging.1
MYTH 9 — PATIENTS WITH ACNE CANNOT USE COSMETICS
While it’s true that some types of cosmetics can make acne worse, those that are nonacnegenic or noncomedogenic generally do not worsen acne. Dermatologists can help patients decide if, whether, and when to use facial cosmetics. There are some concealers that contain benzoyl peroxide, resorcinol or salicylic acid, and there are also tinted acne treatment products. Patients who believe foundation may be contributing to their acne, can be encouraged to wear mineral-based makeup. So, let them know it’s a myth that they must leave their acne lesions uncamouflaged; they simply need to know what is most appropriate for them.
MYTH 10 — IF A LITTLE ACNE MEDICATION IS GOOD, A LOT IS EVEN BETTER
Topical acne medica¬tions should be used in the minimal amount, as they work on medial pathways, not by the law of mass action. Patients need to know that topical acne medications are not masks, they are medicine, and too much medication may cause overdrying of skin, leading to irritation and more blemishes, which will lead patients to stop to using medications altogether. So, make sure they understand that more is not better for topical treatment, that they should not use acne medications like sunscreen. Remind them that only a pea-sized amount of a retinoid is needed to cover a face.
MYTH 11 — ACNE MEDICATIONS WORK IMMEDIATELY
By the time some patients develop the motivation to make the appointment and arrive at the of¬fice, they want immediate results. In one study, 66% of patients believed that acne would improve immediately after the first treatment. They need to know medications may take up to 12 weeks to make a significant difference, and that acne can relapse as well. The average acne patient is used to a strep throat getting better with a few days of antibiotic treatment, whereas we know as clinicians that even the strongest medication like oral isotretinoin or minocycline can take months to significantly clear acne. But whatever patients may think, results will not be immediate. So, this might be the time to finally use all that pharmaceutical representative paraphernalia collecting in your drawers and show patients that most acne studies reach their highest efficacy at 12 weeks, which is how long they may have to wait for clearer skin.
MYTH 12 — OTC TREATMENTS ARE EQUIVALENT TO PRESCRIPTION MEDICATIONS
Proactiv is the number-one selling acne medication in the United States, but it is not the most effective. Benzoyl peroxide (BPO) is an excellent topical acne treatment, but it is not more effective than isotretinoin. In fact, stud¬ies of combination drugs utilizing BPO and clindamycin or adapalene all show superiority over BPO alone. Evidence-based clinical studies back prescription medica¬tions. Clearly, patients vote for Proactiv, but this dynamic is driven by hype, promotion, and, of course, the fact that BPO is an effective treatment for acne.
MYTH 13 — ISOTRETINOIN SHOULD NOT BE USED FOR THE TREATMENT OF ACNE
Isotretinoin is the only agent that has been shown to induce long-term remission, and it has curative potential for acne. The idea that it should not be available does not serve patients. Isotretinoin is not for every patient, but it has been used by 10 million patients in the United States with often amazing effect. iPledge and the litigation against Roche over the link of isotretinoin and inflammatory bowel disease aside, the concept that isotretinoin should not be used for acne may not fit the definition of a myth, but is due to misguided beliefs, in the opinion
MYTH 14 — ACNE IS A DISEASE OF TEENAGERS
Acne certainly affects teenagers, but it affects other age groups as well. Some people develop acne for the first time in their 20s or 30s, and they are often shocked because the mythos of acne is that it is a disease that disappears before college. In the business districts of Manhattan, most patients treated for acne vulgaris are women between the ages of 20 and 45. Young white collar professionals are often distraught about still getting acne and feel they are not taken seriously at work when they are breaking out. They should be reassured that acne can be a disease of those aged 20 to 45 and that effective acne treatments do exist.
MYTH 15 — DIET DOES NOT CAUSE ACNE
People in some indigenous societies do not experience acne at all. Whether it is genetics or diet — or both or something else — is unclear. Some studies show acne is linked to milk, which leads to postprandial insulin and basal insulin-like growth factor-I (IGF-I) plasma levels. Increased insulin/IGF-I signaling activates the phosphoinositide-3 kinase/Akt pathway, thereby reducing the nuclear content of the transcription factor FoxO1, the key nutrigenomic regulator of acne target genes. Nuclear FoxO1 deficiency has been linked to all major factors of acne pathogenesis, ie, androgen receptor transactivation, comedogenesis, increased sebaceous lipogenesis, and follicular inflammation. The final evidence is not in, but it seems that acne and diet are linked in ways that we did not suspect two decades ago. Make sure your patients have access to information on theories on the usefulness of dairy-free and/or low glycemic load diets. (Note: See Helpful Handouts online to print out Dr. Danby’s handout on acne, with information and resources related to the role of diet an in acne. https://skinandaging.com/content/acne.)
CONCLUSIONS
People’s assumptions about acne, much like their assumptions about other complex matters, often are the result of misun¬derstandings and require clarification. It is therefore left to the experts, who often disagree with one another, to dispel myths related to acne in order to enhance our patients’ health. The myths that are particularly important to address are those related to the psychological cost of acne, avoiding isotretinoin, and the role of milk in acne. Knowing these myths tunes us in to the acne zeitgeist, so when we step into the treatment room we are ready to listen, educate and act. Reference Danby FW, Margesson L. Helpful handouts: Acne. Skin & Aging. 2011:5:22-24.
Dispelling common myths about the causes and treatment of acne can make all the difference in how acne patients view themselves and others who suffer from this all-too-common and distressing medical condition. Acne is the most common condition that dermatologists treat. While assessing which acne treatment is appropriate for a patient, it is valuable to consider the beliefs — the mythology if you will — of patients regarding acne. Popular discourse perpetuates these myths, and these myths echo in the examination room, sometimes drowning out the recommendations of the dermatologist and utilization of dermatological acne treatments. Knowing these myths helps dermatologists better understand some of the inner beliefs of such patients in order to help enhance their outer appearance. Dispelling these myths is a service to both patient and dermatologist alike.
MYTH 1 — ACNE IS A COSMETIC CONDITION
More than 50% of those suffering with acne problems report negative comments and other feedback from members of society, regardless of whether or not the acne resulted in scarring. De¬pression is more common in acne patients than in those without acne. Acne can be devastating and life-altering, resulting in clinical depression and low self-esteem. It should be noted that the degree of depression does not always correlate with the physician’s global assessment or clinical severity. Physicians would be wise not to assume an otherwise minor case of acne is not distressing to the patient. Studies show that patients and parents of patients underestimate the psychological impact of acne. Acne is a disease that requires medical treatment. Those who say it is only a cosmetic concern perpetuate a myth that is false and pernicious.
MYTH 2 — SWEATING HELPS CLEAR ACNE
Some patients believe that going to a steam room or using hot towels will improve their acne. There is no basis for this myth. In fact, some studies — including an Indian study in which patients said their acne was worse in the summer — have suggested that sweating makes acne worse, which the authors guess is due to increased temperature, marked humidity and sweating. In any case, let patients know they cannot sweat out their acne, and patients who do this should consider the lack of data for this course of action.
MYTH 3 — SEX AND MASTURBATION CAUSE ACNE
The theory that sex or masturbation cause acne is not based on scientific evidence. It seems likely that this theory, which may have originated as early as the 17th cen¬tury, was designed to dissuade young people from having premarital sex. Patients who believe this should be told that neither sex nor masturbation cause acne, nor is degree of acne proportionate to sexual activity. However, the debates between parents and their children over sex should not obscure the fact that acne is at least in part a disease of hormones and those in the process of undergoing sexual maturation. This provides an etiologic basis for understanding acne and a foundation for some acne treatments such as oral contraceptives/hormonal therapy.
MYTH 4 — ACNE IS CAUSED BY DIRT
Patients need to understand that acne is a complex disease of follicular units unrelated to dirt. The bacteria responsible for inflamed acne breakouts are Propionibacteria acnes (P. acnes). Blackheads are not due to dirt, but rather to pathology of follicles and buildup and alteration on sebum, ie, pilosebaceous ductal hypercornification. Patients should be taught that blackheads are open comedones that are due to the oxidation of sebum, and that scrubbing may inflame them. Open comedones can be removed by acne surgery and prevented with topical retinoids, but dirt plays no role in acne, which leads us to consider the fifth myth.
MYTH 5 — THE MORE YOU WASH YOUR FACE, THE LESS ACNE YOU’LL HAVE
If acne is not caused by dirt, it stands to reason that acne cannot be simply washed away. The makers of abrasive acne scrubs would have patients believe that a harsh wash is a treatment for acne, a concept that is not supported by studies. A study that compared an abrasive cleanser with the same cleansing agent without the abrasive granules for acne found the two treatments equal in effect. Of course, this is not to suggest to pa¬tients that washes cannot help acne, as those with ingredients such as benzoyl peroxide, salicyclic acid and sulfur compounds can help to abate acne, most specifically on the face. The key washing myths to debunk are (1) that plain soap and water improve acne; (2) that abrasive cleansers help acne; and (3) that constant washing — even using the right products — helps decrease acne. In fact, irritation from the interaction between harsh cleansers and topical retinoids may decrease compliance.
MYTH 6 — ACNE GOES AWAY ON ITS OWN AND DOES NOT NEED TO BE TREATED
Acne is a condition that can last for years. If left alone without even attempts at topical treatment, it can worsen and scar. Treatment — even with mild over-the-counter benzoyl peroxide — helps and should not be avoided simply because someday the acne will go away. Acne is treatable and early intervention, which can be mild and topical, matters.
MYTH 7 — TANNING CLEARS ACNE
While some light therapies and lasers help treat acne and tanning can mask it, ultraviolet radiation dries out the skin and induces premature skin aging and can worsen acne. Some think that porphryins associated with P. acnes can be targeted with light therapy. This may be the case, but make the point to your patients that any benefit to acne from tanning is outweighed by its role in the induction of premature aging and the promotion of skin cancer.
MYTH 8 — POPPING ACNE PAPULES AND PUSTULES (PIMPLES) MAKES IT BETTER
Acne is a follicular disease and picking at acne papules breaks the follicular unit spilling inflammatory media¬tors into the surrounding tissue, resulting in scarring. Patients should be encouraged not to pick at their faces. While discussing treatment at length is beyond the scope of this article, it should be noted that spot treatment of lesions with topical agents and injections of low-dose intralesional corticosteriods are far more optimal interventions than having patients pop their pimples. In fact, there is a distinct type of acne caused by picking that is well known to dermatologists as acne excoriee de jeune fille (translated as “picked pimples,” although it literally means “the picked at acne of the young woman”). The myth of pimple popping as a treatment must be debunked again and again because of the urge patients have to address acne in this inappropriate fashion. However, comedones can be extracted by a well-trained health professional with some benefit, and in fact is recommended by Dr. Danby in his Helpful Handouts column on acne in the May issue of Skin & Aging.1
MYTH 9 — PATIENTS WITH ACNE CANNOT USE COSMETICS
While it’s true that some types of cosmetics can make acne worse, those that are nonacnegenic or noncomedogenic generally do not worsen acne. Dermatologists can help patients decide if, whether, and when to use facial cosmetics. There are some concealers that contain benzoyl peroxide, resorcinol or salicylic acid, and there are also tinted acne treatment products. Patients who believe foundation may be contributing to their acne, can be encouraged to wear mineral-based makeup. So, let them know it’s a myth that they must leave their acne lesions uncamouflaged; they simply need to know what is most appropriate for them.
MYTH 10 — IF A LITTLE ACNE MEDICATION IS GOOD, A LOT IS EVEN BETTER
Topical acne medica¬tions should be used in the minimal amount, as they work on medial pathways, not by the law of mass action. Patients need to know that topical acne medications are not masks, they are medicine, and too much medication may cause overdrying of skin, leading to irritation and more blemishes, which will lead patients to stop to using medications altogether. So, make sure they understand that more is not better for topical treatment, that they should not use acne medications like sunscreen. Remind them that only a pea-sized amount of a retinoid is needed to cover a face.
MYTH 11 — ACNE MEDICATIONS WORK IMMEDIATELY
By the time some patients develop the motivation to make the appointment and arrive at the of¬fice, they want immediate results. In one study, 66% of patients believed that acne would improve immediately after the first treatment. They need to know medications may take up to 12 weeks to make a significant difference, and that acne can relapse as well. The average acne patient is used to a strep throat getting better with a few days of antibiotic treatment, whereas we know as clinicians that even the strongest medication like oral isotretinoin or minocycline can take months to significantly clear acne. But whatever patients may think, results will not be immediate. So, this might be the time to finally use all that pharmaceutical representative paraphernalia collecting in your drawers and show patients that most acne studies reach their highest efficacy at 12 weeks, which is how long they may have to wait for clearer skin.
MYTH 12 — OTC TREATMENTS ARE EQUIVALENT TO PRESCRIPTION MEDICATIONS
Proactiv is the number-one selling acne medication in the United States, but it is not the most effective. Benzoyl peroxide (BPO) is an excellent topical acne treatment, but it is not more effective than isotretinoin. In fact, stud¬ies of combination drugs utilizing BPO and clindamycin or adapalene all show superiority over BPO alone. Evidence-based clinical studies back prescription medica¬tions. Clearly, patients vote for Proactiv, but this dynamic is driven by hype, promotion, and, of course, the fact that BPO is an effective treatment for acne.
MYTH 13 — ISOTRETINOIN SHOULD NOT BE USED FOR THE TREATMENT OF ACNE
Isotretinoin is the only agent that has been shown to induce long-term remission, and it has curative potential for acne. The idea that it should not be available does not serve patients. Isotretinoin is not for every patient, but it has been used by 10 million patients in the United States with often amazing effect. iPledge and the litigation against Roche over the link of isotretinoin and inflammatory bowel disease aside, the concept that isotretinoin should not be used for acne may not fit the definition of a myth, but is due to misguided beliefs, in the opinion
MYTH 14 — ACNE IS A DISEASE OF TEENAGERS
Acne certainly affects teenagers, but it affects other age groups as well. Some people develop acne for the first time in their 20s or 30s, and they are often shocked because the mythos of acne is that it is a disease that disappears before college. In the business districts of Manhattan, most patients treated for acne vulgaris are women between the ages of 20 and 45. Young white collar professionals are often distraught about still getting acne and feel they are not taken seriously at work when they are breaking out. They should be reassured that acne can be a disease of those aged 20 to 45 and that effective acne treatments do exist.
MYTH 15 — DIET DOES NOT CAUSE ACNE
People in some indigenous societies do not experience acne at all. Whether it is genetics or diet — or both or something else — is unclear. Some studies show acne is linked to milk, which leads to postprandial insulin and basal insulin-like growth factor-I (IGF-I) plasma levels. Increased insulin/IGF-I signaling activates the phosphoinositide-3 kinase/Akt pathway, thereby reducing the nuclear content of the transcription factor FoxO1, the key nutrigenomic regulator of acne target genes. Nuclear FoxO1 deficiency has been linked to all major factors of acne pathogenesis, ie, androgen receptor transactivation, comedogenesis, increased sebaceous lipogenesis, and follicular inflammation. The final evidence is not in, but it seems that acne and diet are linked in ways that we did not suspect two decades ago. Make sure your patients have access to information on theories on the usefulness of dairy-free and/or low glycemic load diets. (Note: See Helpful Handouts online to print out Dr. Danby’s handout on acne, with information and resources related to the role of diet an in acne. https://skinandaging.com/content/acne.)
CONCLUSIONS
People’s assumptions about acne, much like their assumptions about other complex matters, often are the result of misun¬derstandings and require clarification. It is therefore left to the experts, who often disagree with one another, to dispel myths related to acne in order to enhance our patients’ health. The myths that are particularly important to address are those related to the psychological cost of acne, avoiding isotretinoin, and the role of milk in acne. Knowing these myths tunes us in to the acne zeitgeist, so when we step into the treatment room we are ready to listen, educate and act. Reference Danby FW, Margesson L. Helpful handouts: Acne. Skin & Aging. 2011:5:22-24.
