Acne is one of THE most frustrating problems practitioners, patients and parents have to cope with. The patients are psychologically impacted by their and other’s response to the ongoing pustules and scars. The parents are psychologically impacted by their children’s suffering and financially impacted by the cost of attempting to find the cure. Practitioners committed to attempting to deliver a cure are rarely rewarded in attaining their goal therefore either don’t treat acne patients or dislike treating them as a result of negative reinforcement. Additionally, patients are unhappy with having acne, unhappy with dry, flaking skin which inevitably results, at least on occasion from practitioners’ ardent attempts to clear the acne, and chronically unhappy with their perception of our abilities as practitioners, because we can’t make acne disappear immediately and magically. I, who daily, desperately seek to solve the acne scourge, am more desperate to find the magic wand. I share my acne etiology and treatment knowledge and insights, in hopes that one of you will send me the still missing magic wand.
Acne is a multi-billion dollar a year medical problem. There are many treatment modalities yet few, in my experience treat all the precipitating causes. Its etiology is multi-factorial which is why my approach is “wholistic,” i.e. you have to be aware of and treat all the contributing and exacerbating factors in order to most likely be successful. Skin pathology is overall the end manifestation of internal organ pathology-both of which increase inflammation, the cause of all disease and aging. The organs of the body are an orchestra and all the instruments must function harmoniously otherwise every organ is more challenged in its level of functioning. The “wholistic” treatment approach attempts, as much as possible, to re-establish homeostasis of physiological functioning in all organs contributing to pathology. Medically, this will keep inflammation and disease more in check. Our goal is always cure, not just treating symptoms. So what causes acne, and can we cure it?
The primary cause of all acne, teen and adult is androgens- DHEA from the adrenal cortex, testosterone from the gonads, and their metabolites. The enzyme, 5 alpha reductase, metabolizes DHEA, testosterone and cortisol in the peripheral tissues to their also active metabolites, 5 alpha DHT and Androsterone. DHEA stimulates the cells lining the hair follicle to energetically proliferate, follicular hyperkeratosis. Testosterone and 5 alpha DHT do the same to the sebocytes, which cause enlarged sebaceous glands and copious amounts of oil production. Androsterone energetically stimulates hair production. There are a genetically predetermined number of androgen receptors and their sensitivity is genetically predetermined by the amount of 5 alpha reductase enzyme present. Virtually always in acne patients there is a normal level of androgens but an increased number and sensitivity of androgen receptors in the pilosebaceous units, which are most numerous in the face, neck, back and chest. This results in thicker skin due to epidermal DNA synthesis thus epidermal hyperplasia, more oil production due to sebaceous hyperplasia, more, and more robust hair with the hair follicle lumen narrowed due to hyperkeratinization. Bacteria, viruses and fungus come in contact with our skin 24/7 and feast on oil, the hair wicks the microbes down into the narrowed, thickened follicle resulting in comedones to cystic acne. Inflammation, which is present chronically from pollution, sun, diet, stress, chemical and electromagnetic exposure everyday, personifies exponentially.
Why are there 2 times as many females as males with adult acne? Birth control chemicals. Birth control chemicals are synthetic progestins, which chemical structure the body reads as androgenic, and synthetic estrogens, which are also often read chemically as androgenic and increase sex hormone binding globulin (SHBG), which lowers free and active testosterone and DHEA, until the birth control is discontinued. Then the brakes are off and the body races to return androgen levels to normal plus androgens are becoming free and active from previously being bound to the increased SHBG. The androgen sensitive patient becomes a mass of recalcitrant to treatment acne, beginning about 6 months after discontinuing birth control and continuing for a period of time exceeding what is the normal 12-18 months, to re-establish hormone homeostasis- if the adrenals, thyroid, liver, pituitary, hypothalamus and sex organs are functioning ideally, rare in today’s toxic and stressful environment. Chemical birth control methods contain and deliver higher amounts of synthetic hormones than synthetic hormone replacement medications. Some studies show that once patients have been exposed to synthetic progestin and estrogen birth control chemicals, the amount of sex hormone binding globulin is increased in perpetuity, therefore the body upregulates androgen production over time, further challenging the androgen hypersensitive acne patient.
I have outlined the science of the “how and why” of acne. In the spring issue, I will delineate the myriad of treatment strategies to attempt to cure acne -“wholistically” vs. traditionally – what works – utilizing all the pieces of the body’s puzzle! Food for thought and a puzzle for you to solve for the HAPPY HOLIDAYS!
The “wholistic” treatment approach is to look at the forest, not just the tree, attempting to cure the cause of the problem not just treat the symptoms, diagnosing the challenges and re-establishing homeostatic physiological functioning in all organs contributing to pathology. “Wholistic” implies taking care that the treatment of existing pathology is not causative of new or delayed pathology. “Wholistic” is choosing the treatment modalities individualized to best fit each unique patient’s physiology, needs and goals. “Traditional” historically was “wholistic”, understanding that allopathic medicine practiced by MD’s is the newest of all forms of healing is the key word. Healing, the multi-factorial dilemma of acne is best achieved by the medical practitioner being armed with an overview of all the diagnostic and treatment tools in the “traditional” and “wholistic” solution boxes.
In Part I, I delineated the primary cause of acne in patients to be a genetically predetermined, increased number and sensitivity of androgen receptors and amount of the enzyme 5-alpha reductase, which metabolizes the normal amount of androgens acne patients generally have (DHEA from the adrenal cortex, testosterone from the gonads and their active metabolites) and cortisol, in the pilosebaceous units, most numerous in the face, neck, back and chest. These genetics cause the resulting symptoms of thicker skin, more oil production, enlarged sebaceous glands, more robust hair and hyperkeratinization causing narrowed pore lumens. These symptoms with the combination of, skin and body inflammation caused by pollution, stress, internal and external chemicals, electromagnetic exposure, sun, food and food allergies which further weaken the skin’s protective acid mantle and immune system and increase androgen production. All the bacteria, viruses and fungus to which our skin are continually exposed, which feast on the oil and sebum and become trapped in the narrowed pore lumen, result in the varying clinical manifestations of acne. Increasingly, fungus is shown to be the predominant acne pathogen, shedding light on why antibiotics have lacked success in treating acne. Furthermore, many birth control pills increase sex hormone binding globulin, now shown potentially to be in perpetuity, which causes the body to upregulate androgen production, precipitating or exacerbating acne in patients with or without genetically increased androgen receptors and sensitivity, and further imbalancing all hormone ratios which result in concomitant menstrual symptoms of progesterone deficiency - PMS, heavy flow with cramping, breast tenderness and enlargement and contributing to infertility, all caused by negative feedback on hormone production from the upregulation of androgen production. Accutane works because it essentially shuts down cell production in every organ of the body.
You understand now why just treating the external skin is not going to cure the problem. So what is the path to most treatment success and least toxicity (do no harm)?
Clearly you see that the saying “Rome was not built in a day” is applicable here when communicating to patients why there is no magic wand, one treatment, medication or technology to cure the symptoms immediately. This is why treating acne has become a more than 2 billion dollar per year industry and why the “wholistic” approach is physiologically correct.
We cannot cure the genetically predetermined hypersensitivity and overabundance of androgen receptors and 5 alpha reductase. We can however, down regulate 5-alpha reductase activity by taking whole ground flax meal or flax oil, preferably organic, and/or evening primrose and black currant seed oils and bio-identical progesterone cream which does the same, decreases androgen production and treats PMS and menstrual symptoms. Spironolactone is a weak anti-androgen, which in men is a greater problem over time.
Managing stress, which increases DHEA, cortisol, epinephrine and norepi production, greatly decreases immune functioning and increases inflammation in the body. This is the cause of disease and aging and these increases are also physically precipitated by lack of sleep and the type of foods we eat.
Foods which exacerbate acne are: those which increase blood and tissue acidity, contain and increase hormone dysregulation such as cow’s milk dairy and red meats; refined carbohydrates and simple sugars which depress the immune system, thyroid, feed fungus and microbes; wheat, white rice (except wild rice) and any gluten containing foods,MANY of which people are allergic to causing chronic constipation and acne, foods fried in any oil except extra virgin olive oil or green tea oil, MSG and processed foods with synthetic oils and no nutritional value. The more green foods and fresh fruit the better, because of the digestive enzymes, fiber and the tissue alkalinization, which combats inflammation. Many acne patients suffer from chronic constipation, also generally caused by food allergies to primarily cow’s milk, wheat and gluten foods.
The least acneic potential birth control pill is Ortho Tri Cyclen Lo whose chemical form of synthetic estrogen and progesterone do not mimic as androgens and minimally increase sex hormone binding globulin. I inform the GYN or FP on this.
Supplements which are proven beneficial include: probiotics-the more and varied the organisms the better-these treat fungus and pathologic organism overgrowth and ameliorate constipation and the inflammatory impact of food allergies on the gut and body along with organic whole leaf aloe, minerals including Zinc, Selenium and Chromium (antibacterial, stabilizes blood sugar and insulin), B vitamins (anti-inflammatory and facilitate hormone metabolism), MSM (organic sulfur), fish oils (omega 3 and vitamin A), vitamin E (decreases sebum peroxidation and inflammation), beta carotene in yellow/orange foods, liver and toxin cleansing and antioxidant alpha lipoic acid (the more and varied antioxidants internally and externally the better).
Drinking lots of water is always recommended for skin and body hydration and detoxification.
Many of the makeup, sun blocks and skin products, especially moisturizers contain pore clogging, oil inducing and thickening ingredients.
Correct skin care ingredients, re-establishing the acid and lipid protective external mantle and decreasing inflammation are of the utmost importance. Cleanliness is next to godliness, but avoid ingredients which exacerbate inflammation such as lauryl sulfates and sarcosinates, synthetic propylene glycol, PEGs, Ureas, triclosan and those that mimic hormones including triethanolamine, all parabens and acrylates. Do not over-cleanse, stimulate or exfoliate which enhances oil production, destroys the protective acid mantle, thins by irritating and potentially exacerbates infection. Ingredients in skin products, their correct chemical form thus ability to penetrate into the skin and skin cells and concentration are the essence of therapeutic potential and success, providing the skin cells what they need, want and are lacking. Ingredients which decrease oil such as D-cholic acid, stone root, saw palmetto, pregnenolone, retinols or oids, that reduce inflammation such as L-ascorbic acid (and do not quickly oxidize), salicylic, varied and many antioxidants, antibiotics and fungals such as topical organic sulfur, tea tree oil, lavender, niacinamide, topical minerals, benzoyl peroxide (which is inflammatory, negatively impacts the protective mantle, drying and aging, therefore I avoid), hyperoxygenate and chemically exfoliate such as l-lactic acid and enzymes (no receptor in the body for glycolic, so it is inflammatory therefore I avoid and microdermabrasion crystals can become foreign bodies in acne lesions and mechanical exfoliation of inflamed skin can be harsh and inflammatory).
Technology utilized, subsequent to addressing the physiological dysregulation internally and externally include: Candela Smoothbeam laser which diminishes sebaceous gland size and function, blue light which kills P. acne bacteria but not fungus and Levulinic acid which enhances the effect by destroying sebaceous glands and epidermal cells concomitantly and radio frequency whose heat shrinks sebaceous glands and stimulates the skin to remodel and regenerate and enhances skin immune functioning.
Despite all these options and explanations, acne remains at large because there are exceptions to all of the above such as patients without oily or thick skin or facial hair who have never been on birth control pills and are vegetarians. Individualize, be a detective, don’t forget food allergies, sugar and carbohydrate intake, thyroid dysfunction, stress and fungus as possible culprits. Keep searching for the magic wand and send it to me!
Julia Tatum Hunter, M.D., the founder of Skin Fitness Plus located in Beverly Hills, CA creates healthy bodies and healthy, beautiful skin in a “wholistic”, anatomically and physiologically correct method, addressing the skin from the inside and out. She combines an individually prescribed plan of essential “what does your body need, want and not want” supplementation, nutrition, exercise, and bio-identical hormones, with therapeutic, anti-inflammatory, non-toxic products, peels, laser and tightening procedures. Dr. Hunter works with men, women and teens, providing pragmatic, doable solutions to treat acne, aging, skin diseases and promote skin restoration and prevention. She is a noted speaker on ingredients in foods, skin, supplements and nutritional products and the imperative of treating all the pieces of the body’s puzzle. Dr. Hunter developed the scientifically correct, yet simple formula for science vs. commerce and how to live life and be young at any age. She can be reached by calling 310-247-8744 or via email at info@skinfitness.com
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