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The Dose Transcript for October 10, 2024

Host: Dr. Brian Goldman

BRIAN GOLDMAN: Hi, 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, Kerri. Welcome to the Dose.

DR. KERRI PURDY: Hi, Brian. Thanks for having me.

BRIAN GOLDMAN: When adults with acne come to see you, how often do they reference their teenage years?

DR. KERRI PURDY: Almost every single time. Some 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.

BRIAN GOLDMAN: 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.

DR. KERRI PURDY: Hi, my name is Kerri Purdy. I'm a full-time academic dermatologist in Halifax, Nova Scotia.

BRIAN GOLDMAN: 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.

DR. KERRI PURDY: Acne 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, acne can affect babies. It tends not to affect young children. But then as soon as you get into that peri-puberty 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 in, particularly in the cancer realm now that cause acne or make acne worse. So, we do tend to see it right through generations.

BRIAN GOLDMAN: And we're talking about a spectrum of manifestations: pimples, whiteheads, blackheads. What's the full range of that?

DR. KERRI PURDY: 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 comedians. So, comedonal acne. There are people that get the pimples and the pustules. So what people classically refer to as zits or pimples, that's what we call papular acne. And then deeper lesions can be more cystic or nodulocystic cystic, and they can result in scarring. Many people have a combination of all of those types of acne.

BRIAN GOLDMAN: Do we know why people get one type and not another?

DR. KERRI PURDY: 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.

BRIAN GOLDMAN: 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, in the year 2015. You know, we've known about it forever.

DR. KERRI PURDY: Many, many years.

BRIAN GOLDMAN: 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?

DR. KERRI PURDY: There are 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. And 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 comodone. 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.

BRIAN GOLDMAN: So you get inflammation first and then a bacterial infection?

DR. KERRI PURDY: 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.

BRIAN GOLDMAN: So now let's move to risk factors for acne.

DR. KERRI PURDY: 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. So, 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.

BRIAN GOLDMAN: Seriously?

DR. KERRI PURDY: 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 about 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. Those things can make it worse.

BRIAN GOLDMAN: What about foods? I've been hearing and reading about dairy and high carbohydrate diets being risk factors.

DR. KERRI PURDY: 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, and 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.

BRIAN GOLDMAN: You know, I would say that diet is one of several common myths out there. Fast food, unclean pillowcases, poor facial hygiene. [KERRI: Mm-hmm.] Do any of these play a role?

DR. KERRI PURDY: Lots of people come in and they say, can you tell my, you know, son to stop eating pizza and chocolate? And I say, 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. But 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. You know, like I said, sometimes if you're wearing, you know, sweaty clothes for long periods of time, that can worsen things a little bit. But certainly not the cause.

BRIAN GOLDMAN: Here's something that may not be a myth. Is it fair to say that you shouldn't be picking at your acne?

DR. KERRI PURDY: Absolutely, people 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.

BRIAN GOLDMAN: 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?

DR. KERRI PURDY: 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.

BRIAN GOLDMAN: There's the name of a condition that was popularized during the time of President Bill Clinton, and that is rosacea. How does that relate to the whole acne story in adults?

DR. KERRI PURDY: 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. And 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.

BRIAN GOLDMAN: 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.

DR. KERRI PURDY: Absolutely.

BRIAN GOLDMAN: 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?

DR. KERRI PURDY: 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.

BRIAN GOLDMAN: What are the most common prescription medications that might trigger acne?

DR. KERRI PURDY: 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.

BRIAN GOLDMAN: And I would imagine that anabolic steroids would be as well.

DR. KERRI PURDY: Absolutely.

BRIAN GOLDMAN: What steps can people take on their own to prevent acne and make it less severe?

DR. KERRI PURDY: I think it's a challenge. So, people avoiding things that are going to make acne worse. 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, you know, 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.

[laughter]

BRIAN GOLDMAN: That would, that would be very helpful, wouldn't it? If you can, if you're spending time teaching patients how not to be stressed, then I want to be one of your patients.

DR. KERRI PURDY: Yeah, I haven't quite got that down yet, so I'll have to let you know if I ever do. You 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.

BRIAN GOLDMAN: And 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?

DR. KERRI PURDY: 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 Avène. 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.

BRIAN GOLDMAN: So far I haven't heard shea butter body wash.

DR. KERRI PURDY: 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.

BRIAN GOLDMAN: Okay. So now, let's get to the work of physicians, particularly dermatologists. How do you treat it? What's first line treatment?

DR. KERRI PURDY: 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. The 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, etc. And so usually having a vitamin A topical is part of all treatment regimens, unless people are pregnant. And then other than that, there are topical antibiotics, there are topical things like azelaic acid, topical dapsone, topical clascoterone. And so there's a variety of different things that people can use from a cream perspective. That's first line.

BRIAN GOLDMAN: How effective are they?

DR. KERRI PURDY: 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 a 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. I 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.

BRIAN GOLDMAN: At some point, some of your patients are going to be receiving medication. So what medications are commonly prescribed?

DR. KERRI PURDY: 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. We 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.

BRIAN GOLDMAN: So let's talk specifically about isotretinoin. How effective is it?

DR. KERRI PURDY: It's very effective. So in terms of, you know, efficacy, the way we quote it for patients is to say, if you complete a full course, the chance that your acne is gone in the long term is about 75%. Sometimes a bit higher, sometimes it does come back. But 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.

BRIAN GOLDMAN: 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?

DR. KERRI PURDY: 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 happened in dermatology is the bad rap that isotretinoin gets. By 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. And if not, it just might not be the right fit for that person.

BRIAN GOLDMAN: And what about that risk of suicide and depression?

DR. KERRI PURDY: 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's 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. And 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.

BRIAN GOLDMAN: From what you've mentioned, social media is a potent source of misinformation about isotretinoin.

DR. KERRI PURDY: 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. And 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.

BRIAN GOLDMAN: Is there anything more specific about treating adults with acne that might be different from treating adolescents?

DR. KERRI PURDY: 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. But 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.

BRIAN GOLDMAN: Is there anything coming down in the years to come that might offer some hope for eliminating this scourge from our society called acne?

DR. KERRI PURDY: 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. It'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.

BRIAN GOLDMAN: Well, Dr. Kerri 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.

DR. KERRI PURDY: Thanks so much for having me.

BRIAN GOLDMAN: Dr. Kerri Purdy is an associate professor and division director of dermatology at Dalhousie University. Here's your 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. These 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. It tends to run in families. Diets high in cows' 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. Topical 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 health-care providers say these are generally well known and manageable. If you have topics you'd like discussed or questions answered, our email address is thedose@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 Sameer Chhabra. Our 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 health-care provider. I'm Dr. Brian Goldman. Until your next dose.

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I'm an adult! Why do I have acne? - Transcript

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