Read an Excerpt

Unblemished

Atria

Chapter One

"My little nephew, who's only two, turned to me and said, 'Auntie, can I connect the dots on your face?' He didn't know what he was saying, but I was totally humiliated. I used to wake up crying because I'd feel a new lump on my face every morning."

Amanda, age thirty-one

No matter what your skin color or type, whether you're eight, eighteen, thirty-eight, or sixty-eight, you can get acne. You may have one pimple or a hundred, but the process is the same. Acne vulgaris is the most common and often the most debilitating skin disease that exists. Over 90 percent of all people on earth suffer from it at one point or another. So even if you didn't get it as a teenager, chances are extremely high that you'll experience it later in life. It's a rare human indeed who manages to get through life without a single zit!

Before we explore acne in detail, let's learn a little bit about the organ it affects: the skin.

all about skin

Even when it is covered with acne, your skin is still a marvelous organ. It reflects who you are and how you feel, and it keeps you safe. Ithas an almost magical ability to repair itself, and we certainly almost always take it for granted. (Except, of course, when plagued by acne.) Constantly replenishing itself, the skin covers a whopping twenty square feet and constitutes 15 percent of our total body weight. In the three layers of one square inch of skin you'll find:

19 yards of blood vessels

65 hairs

78 yards of nerves

100 sebaceous glands

650 sweat glands

1,300 nerve endings

20,000 sensory cells

129,040 pores

9,500,000 cells

Epidermis - Top Layer

The first living layer of the skin is the epidermis. This microscopically thin layer is seven to ten cells thick and in a young adult completely renews itself every twenty-eight days. Nearly 95 percent of the epidermis is composed of new cells called keratinocytes. The remaining 5 percent is made up of the cells that produce melanin, the substance that gives skin its color, and the all-important Langerhan cells, which work with the immune system to help fight infections.

As keratinocyte cells age, they flatten out and eventually lose their nucleus, becoming horn cells. These horn cells create the stratum corneum, the outermost layer of skin. Even though the stratum corneum consists of dead, overlapping horn cells, like shingles on a roof, it serves a vital function as our first line of immunological defense between the outside world and our bodies. The renewal rate of the epidermis diminishes with age. As a result, the stratum corneum becomes thicker and the pores pack up with dead skin cells, which makes them look larger.

Dermis - Middle Layer

Most of the skin's volume is found here. The dermis is composed of collagen and elastin fibers; nerve endings that sense temperature and pressure; blood vessels supplying nutrients to keep everything replenished and renewed; sweat glands, which function to cool you down, and erector pili muscles, which contract, causing you to shiver and making your hairs "stand up" (these functions keep you at a stable 98.6 degrees Fahrenheit); hair follicles; and those pesky oil glands, which produce the sebum that keeps skin soft, pliable, and waterproof. However pesky they are, you can't live without those oil glands (although when your acne is bad, you certainly wish you could!).

Subcutaneous - Bottom Layer

Here lie lots of fat cells. These fat cells are good fat cells. Without them, you'd lack insulation and protection for your fragile organs. Also rooted in these fat cells are most of your hair follicles. The hair follicle and the attached sebaceous, or oil, gland share the space known as the pilosebaceous gland (pilo means hair and sebaceous refers to the sebaceous, or oil, gland). The pore is the passageway from the base of the hair follicle to the surface of the skin. Sebum, an oily substance composed of free fatty acids, cholesterol, triglycerides, and wax, is released from the sebaceous, or oil, gland into the pore and travels to the skin's surface to keep it pliable and protected. Without sebum, your skin would look as dry as dust.

what kind of skin do you have?

From a dermatologist's viewpoint, contrary to all those surveys published in women's magazines, just about everybody has combination skin. Human bodies are constructed with the greatest density of oil glands in the T-zone - the nose, cheeks, chin, and forehead - so that even if you have dry spots, you will most likely also have oily spots.

The texture, pore size, and oiliness/dryness of your skin is in large part determined by your genes and regulated by your hormones. There's nothing you can do about your body's natural inclination to be dry or oily. You can, however, do something about how the environment in which you live affects your skin. For example, it's easy enough to humidify (or dehumidify) the air inside your home.

Equally important is the fact that your skin changes as your body ages. You can have oily skin as a teenager and dry skin as an adult. Be aware that as these changes take place, your skin care needs change, too. We often see women still using the same products after age thirty, which may not be the optimal treatment plan for their skin.

What if your skin is mostly dry?

You can still have dry skin even when it's covered with acne. If you look at the surface layer of the dead cells in the epidermis (the stratum corneum), they're superhydrated in high-humidity environments and desiccated in dry ones. Drinking gallons of water won't necessarily plump up your skin in Arizona - you'll just be spending much more time in the bathroom. And as you age, circulation naturally slows down, hormones dwindle, oil production diminishes, and the surface dead cell layer thickens and fissures, allowing water loss from the skin. The result is that your skin won't be as moist as it was when you were younger. Some medications also dry out skin, most notably Accutane.

Using humectant agents (moisturizers) can help relieve dry skin. So can humidifiers. Air conditioners and forced-air heating systems tend to zap the moisture out of the air, so be judicious with their use.

What if your skin is mostly oily?

"My skin's too oily - make it stop!" We hear that all the time from our patients. Unfortunately, there's no little faucet we can turn off or on to decrease or increase oil flow. Oil production constantly changes. For instance, one month your skin might be oily the week before your period; the next month it might not. And, you may have oily skin and terrible acne or oily skin and no acne. Oily skin is not a life sentence for acne or even necessarily a symptom of acne.

Living in a hot, humid climate will stimulate oil gland production. Exercise, stress, and androgenic (masculinizing) hormones, such as testosterone or DHEA-S, will also increase oil flow.

Oily skin generally needs no moisturizers except on the eyelids. Oil absorbers; loose, oil-free powders; and medicated, clay-based masks will help absorb excess oil. However, frequent facial washing (in excess of two to three times a day) may eventually result in increased oil production, because when the surface of the skin is excessively stripped of lubrication, the oil glands' response to perceived dryness is to produce additional oil.

Why Is Dryness/Oiliness So Important?

Knowing that the layer of dead cells (the stratum corneum) in the epidermis is crucial to healthy skin, we became interested in trying to stabilize, protect, and repair the barrier function it provides. Any assault to this top layer increases the skin's susceptibility to infection and environmental irritants. This can produce a range of skin conditions, from impetigo to herpes eczema to contact allergic dermatitis.

One enduring myth about acne is that the best form of treatment is to strip all the oil off your skin. Drying the skin's surface with ingredients like rubbing alcohol leaves the skin parched and irritated, with greater susceptibility to infection while failing to treat the acne process. Perhaps you've even tried to clean your skin with harsh scrub soaps that contain apricot or walnut pits, which can tear your defenseless cells. You look raw and red. Your skin peels. It itches. It doesn't heal properly, and your acne doesn't go away. As a result, your acne may take longer to heal and leave scars behind.

In chapter 5, you'll see how an acne treatment program can be gentle yet effective, maintaining a healthy balance of dryness and oiliness in the epidermis.

Do You Really Have Sensitive Skin?

Many of our patients tell us that they have sensitive skin. In truth, the vast majority of people do not have sensitive skin even though they think they do. The clinical definition of sensitive skin is skin that has a noticeable reaction with product application. It turns red, itches, tingles, or burns. Or all four.

There are two causes of sensitive skin: environmental and genetic. Environmental factors causing sensitive skin are usually product-derived. Most people tend to use more than one product on their face, and in each of the products there are often ten to twenty different ingredients. The more products you layer on, the more ingredients you are exposed to, and the more likely you are to create a sensitive skin response. When you strip your skin of its barrier function, irritated skin often follows.

Then there is the genetic factor. Twenty percent of babies develop eczema, also called atopic dermatitis, within the first six months of life. Atopic dermatitis is often accompanied by allergies, asthma, and hay fever. By the time children are twelve, most outgrow atopic dermatitis. However, because the skin of people with atopic dermatitis may remain somewhat immunologically compromised, the risk of developing skin sensitivity is greater. Patients with a history of atopic dermatitis in childhood are especially prone to eyelid dermatitis, hand eczema, and keratosis pilaris (tiny red bumps on the back of arms) as teenagers or adults. These patients may also be intolerant of some topical acne preparations.

Many people with rosacea, another genetic condition, have sensitive, reactive skin. For more information on skin sensitivity, see chapter 13.

what is acne?

Acne is complicated. Many factors are involved in its creation. It is, however, most influenced by genetics and hormones. These hormones, known as androgens, stimulate a four-step process in the skin.

Step 1 Abnormal keratinization in the pore leading to a plug (clogged pores)

Step 2 Overproduction of oil (sebum)

Step 3 Overgrowth of p. acnes bacteria

Step 4 Inflammation (swelling) as a reaction to the bacteria and its by-products

The bump that appears on your face is actually the final step in a process that began two weeks before. Even though that painful bump on your face looks bad and feels worse, the real damage is happening underneath the skin. The secret to controlling acne is to get down deep in the pore - to stop the acne process before bumps are visible on the skin's surface.

Step 1: Clogged Pores

Normally, skin cells are in a continuous, gradual state of renewal. As the old cells die, they mix with your skin's natural oil and are sloughed off, making room for fresh, new skin every thirty days.

But sloughing doesn't always happen as it should. Sometimes the dead skin cells don't shed evenly or cell turnover slows down (as it does when we age, for example). When this happens, skin cells become "sticky." These sticky cells combined with oil clog your pores. A plug called a comedo (comedones is the plural) is formed inside the hair follicle. It's like a cork in a bottle. The corklike plug traps oil and bacteria in the follicle.

Step 2: Overproduction of Oil (sebum)

Hormones, known as androgens, stimulate oil production in the sebaceous glands, which are attached to your hair follicles. Normally, the oil (sebum) flows freely to the surface of your skin. But if your hormones tell your sebaceous glands to get moving, they'll churn out sticky oil, which results in potentially clogged pores and a wonderful environment for bacteria to grow.

Step 3: Bacterial Attack

Once your pores are clogged, an anaerobic bacteria naturally growing on your skin called Propionibacterium acnes (p. acnes for short) proliferates and starts feeding on the trapped oil. It likes the oxygen-free atmosphere deep in the pore. The overgrowth of p. acnes digests the entrapped sebum, breaking down the oil molecules into smaller particles. When a tiny bit of these broken-down oil molecules leaks outside the follicle, your body is going to respond.

Step 4: Inflammation

The body's response to the bacterial invaders and the oil by-products is a swarming army of red and white blood cells sent to contain the infection, attempting to wall off the follicle. The end result? Intense swelling and inflammation experienced as pimples, bumps, pain, and suffering. Otherwise known as acne.

Different Kinds of Comedones

Though all acne starts the same way, the lesions may look different on your skin.

Whiteheads

If the plug stays below the surface of the skin, it's called a closed comedo, or a whitehead. The white debris is composed of trapped sebum and dead white blood cells.

Blackheads

If the plug enlarges and widens the pore, it's called an open comedo, or a blackhead. Blackheads are not caused by trapped dirt, even though that's what they look like, and you can't wash them away. The black spots are from a buildup of melanin, the dark pigment in your skin, and oxidized oil.

Different Kinds of Pimples

(For more photographic examples, go to unblemished.com.) Acne can be noninflammatory or inflammatory. Noninflammatory acne consists of blackheads and whiteheads. Inflammatory acne occurs from an immune response to the bacteria and plug. The degree of inflammation determines the different kinds of pimples, the severity of acne, and ultimately the potential to scar. The different kinds of pimples are:

Papules

Papules are small, pink, domed bumps. They are tender to the touch.

Pustules

Pustules are small, round, pus-filled lesions. They are swollen and appear red at the base, with a yellowish or whitish center.

Nodules and Cysts

Nodules and cysts are large, deep, and painful bumps filled initially with blood, then with pus. Nodules can linger under the skin's surface for weeks or even months and hurt so badly you aren't even tempted to squeeze them. Persistent nodules can harden into deep cysts. Both nodules and cysts may leave deep scars.

Different Grades of Acne

(For more photographic examples, go to unblemished.com.) Most people think of acne as juicy, red, nasty bumps. Yet blackheads, whiteheads, papules, pustules, nodules, and cysts are all part of the acne spectrum. Dermatologists have a grading system that helps determine the correct course of action. The number one priority of a dermatologist is to prevent permanent scarring, so moderate-to-severe category is managed most aggressively.

A dermatologist's second priority is to clear your acne so you look and feel better about yourself. In mild cases, permanent scars are not a worry, so there is more leeway in trying different topical products.

Due to fluctuations in hormones and other factors, the grading of your acne can change as you age - over months, years, or even your lifetime. For example, a thirteen-year-old boy might have mild acne. If left untreated, by the time he's sixteen, his acne may become severe. Our grading system gives an instant checklist for appropriate treatment.

what causes acne?

Acne is not your fault. Acne is not caused by the food you eat or how often you wash your face. It's caused by a complex combination of factors on two sides of the equation.

The first side is genetic, and it is totally beyond your control. Those with a family history of moderate-to-severe acne are at greatest risk, and the onset is often in the early teen years. You can no more change your genetic destiny than you can permanently change the color of your eyes. The other side of the equation is what we call cofactors or promoters, which can exacerbate preexisting acne. We will explore both the genetic factors and cofactors that cause acne.

(Continues...)

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Excerpted from Unblemished by Katie Rodan Kathy Fields Copyright © 2004 by Rodan & Fields Inc.. Excerpted by permission.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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