All about rosacea and acne rosacea

Rosacea is a chronic skin condition that most notably causes flushing and redness on the face. Just like acne, it’s a highly misunderstood condition and it’s often misdiagnosed. True rosacea is actually very rare and in the decade or so that I have been practicing, I have probably had over a hundred people who thought they had rosacea because they were diagnosed or they self-diagnosed and only 3 of those people actually had rosacea. Symptoms of rosacea might flare up then calm down in cycles but rosacea flare ups tend to last weeks or months whereas acne flare ups tend to last years.  

ROSACEA IS OFTEN MISDIAGNOSED FOR THESE CONDITIONS

• Acne rosacea is often confused for a type of acne called inflamed acne

• Irritation from using skincare products that are too strong, irritating, or not appropriate for your skin type

• Irritation from using skincare products that are not nourishing or moisturizing enough 

• Redness from chronic picking or post-inflammatory hyperpigmentation (PIH) which are dark marks leftover from inflamed acne or picking

• Redness from having a genetic tendency to flush easily that is common in people with fair skin

SYMPTOMS

There are four subtypes of rosacea that I list below but there are some common symptoms that can occur with all of the subtypes:

• Redness and flushing on the face or body that looks like a sunburn

• Broken blood vessels on your face or eyes that look like spider veins

• Rough, raised, dry patches called plaques

• Sensitivity, burning, stinging

• Oils skin or enlarged pores

• Bumpy skin texture

ROSACEA TYPES

You might have one or a combination of these subtypes and your type of rosacea might also shift throughout your life:

• Subtype One: Erythematotelangiectatic Rosacea

  This is the most well known form of rosacea characterized by persistent redness, flushing, and enlarged blood vessels.

• Subtype Two: Papulopustular Rosacea
  This is rosacea that occurs with acne-like breakouts.  It can also show up as hardened patches called plaques and excessive oiliness.

• Subtype Three: Phymatous/Rhinophyma Rosacea
  This is a rare type of rosacea that causes thickening skin on the cheeks, chin, forehead, ears, or nose (Rhinophyma).

• Subtype Four: Ocular Rosacea
  This type of rosacea affects the eyes and can cause symptoms like pain, swelling, redness, and vision issues.

CAUSES

The cause of rosacea is unknown but, much like acne, it’s likely a multifactorial disease that is caused by the perfect storm of genes, internal factors, and external factors.  There are theories that it might be caused by a bacteria called Helicobacter Pylori, an overgrowth of demodex mites, or a protein called cathelicidin that might cause redness and swelling.  Similar to acne, there are many potential internal and external triggers that can initiate a flare up or exacerbate an existing flare up.  Everyone has different triggers so you might be triggered by one or a combination of any of these:

• Spicy foods

• Hot drinks

• Exercise

• Cosmetics and skincare products

• Certain drugs + medications

• Extreme weather (cold or hot)

• Sun exposure

• Wind exposure

• Stress

• Heat, humidity

• Alcohol

• Smoking

• Improper skincare routine (products that are too strong or not nourishing enough)

RISK FACTORS

Rosacea can affect anyone but these factors make it more likely:

• Fair skinned people with blond hair, blue eyes, and European descent

• Women are more like to develop rosacea than men

• Rosacea usually affects people between the ages of 30-50

• Family history of rosacea

• Smoking can increase the risk

DIAGNOSIS

There are no tests to diagnose rosacea but your Doctor will examine your skin and ask you questions to determine whether or not you have rosacea.  They might also test you to rule out lupus or allergies which both have similar symptoms. As I mentioned, many of our clients who have red, sensitive skin or a type of acne called inflamed acne come to us mistakenly thinking they have rosacea or acne rosacea because they have been wrongly diagnosed by a doctor or they have self diagnosed.  This isn’t a surprise since Doctors and Dermatologists tend to spend very little time actually touching and getting to know our skin, lifestyle, habits, and skincare routines. Most of the time, we find that they don’t actually have rosacea and their skin is just raw and red from not having a proper skincare routine or they have one of the four types of inflamed acne which are also characterized by redness, swelling, and soreness.

TREATMENT

Just like acne, there is no cure for rosacea and it’s a condition that needs to be managed long term using a multi-targeted approach.  Also, just like with acne, Dermatologists can be less than helpful and will likely spend 2 minutes barely looking at your skin before writing you one prescription after another.  In my experience, Dermatologists and Doctors rarely take the time to really understand our particular manifestation of a condition and to put the time into developing a comprehensive treatment plan that is customized based on our unique skin type, rosacea type, and lifestyle factors.  They will likely prescribe you a bunch of different topical and/or oral medications and they will just keep on prescribing until you land on one where the improvements you see outweigh the potential side effects. Some common treatments might include:

• Antibiotics like doxycycline, tetracycline, or minocycline may reduce swelling, inflammation, and the acne like bumps that occur with Papulopustular Rosacea.

• Isotretinoin is a very strong drug that may be prescribed under one of it’s brand names like Accutane, Absorica, Myorisan, Sotret, Zenatane, Amnesteem, or Claravis.  Potential side effects include vision and hearing problems, birth defects, liver or pancreas problems, increased pressure inside the skull, and joint pain.

• Topical treatments like Brimonidine 

THE AES SOLUTION

Many of our clients with acne rosacea (subtype 2: Papulopustular Rosacea) have seen significant improvements with our prescription-free program using a combination of personalized product plans made up of balancing and nourishing skincare products and lifestyle coaching.  Since most people who come to our clinic thinking they have rosacea actually just have irritated skin, inflamed acne,or PIH, we take a 3-step approach to determining whether or not they actually have rosacea:

1. The first step whether we are working with a client who has rosacea or acne is to rehabilitate any sensitivity and dryness using our skincare products made up of balancing, nourishing ingredients.  This helps rule out sensitivity and irritation. If a client is local and able to come to our clinic, we will customize a product plan for them during the Initial Consultation but we also teach our long distance clients how to customize their own product plan based on where there skin is at on any given day through our Virtual Program and our e-course The 8 Steps To Clear Skin. 

2. Once someone is on an appropriate product plan, the second step is to clear their acne with our prescription-free program which helps rule out regular acne vs. rosacea acne. 

3. Once the acne is cleared, we target the PIH using specialized chemical peels and products which rules out the possibility that the “rosacea” is actually pigmentation.

If there is still remaining redness or other rosacea symptoms after all of these steps, then it can be deduced that rosacea is actually present.   If you are curious to learn more, you can get in touch with any questions through our website or Instagram @aes_acneclinic.

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Should you take antibiotics for acne? A complete guide

Antibiotics are a common treatment option prescribed by Doctors for acne and it was one of the first (of many) unsuccessful treatments my own Dermatologist prescribed me years ago.  The multiple topical and oral antibiotics I was prescribed improved my acne slightly but they certainly didn’t clear me up completely. I am sure there are people who see good results for their acne with antibiotics (I hope there are anyway!) but the most common feedback I hear from many of my own acne clients 20 years later mirrors my own personal experience: slight improvements, no significant long term results.  I am sure there are also plenty of people who take antibiotics without ever having to deal with a side effect and severe side effects are uncommon but, unfortunately, I wasn’t one of those lucky ones and it was partially due to the fact that my Dermatologist kept me on it way longer than I should have been. My experience with prescription medication drove me to develop a program that is prescription free, sustainable, and that aims to clear acne completely rather than just improve its symptoms but the AES method is certainly not the easy route and everyone has to choose the acne solution that feels right for them.  If antibiotics feel like they might be the right option for you or if you are just curious to learn more about it from the perspective of someone who has had acne and who has successfully coached hundreds of people to clear skin, read on.

HOW THEY WORK

Antibiotics kill bacteria which is supposed to reduce symptoms of inflammation like redness, swelling, and pus but inflammation can be managed just as well (if not better) with benzoyl peroxide and icing which are both important parts of our acne program.  The worst side effect of icing is that it can be too cold but that is nothing compared to the potential side effects of antibiotics.  And the worst side effect of benzoyl peroxide is that some people report it stains their pillowcases and clothes (I have personally never had this issue in 20 years of using it) but it should only be used at night anyways so this can be easily remedied by using white pillowcases.

POTENTIAL SIDE EFFECTS

• Yeast infections

• Bacterial resistance to antibiotics

• Clostridium difficile (C. diff) infection

• Oral thrush

• Gastrointestinal issues (stomach pain, nausea, diarrhea)

• Headaches

• Photosensitivity

• Dizziness

TOPICAL ANTIBIOTICS

Because there is such a high risk of antimicrobial resistance, topical medications are often combined with benzoyl peroxide to reduce the risk of developing resistant bacteria.  Common topical antibiotics you might be prescribed are:

• Clindamycin such as Cleocin and Clinda Derm

• Erythromycin such as E-Mycin

• Benzaclin, Duac, Acanya and Onexton (clindamycin + benzoyl peroxide)

• Benzamycin (erythromycin + benzoyl peroxide)

• Ziana (clindamycin + tretinoin)

ORAL ANTIBIOTICS

• Tetracycline is a class of antibiotics that are commonly prescribed for acne.   It should be taken on an empty stomach and it should not be taken by pregnant women because it can affect a baby’s bone growth and can also cause their teeth to become stained. It can also cause teeth staining in young children so it’s not recommended for children under 9 years old and it’s sometimes advised to hold off until as late as 12 years old. 

• Doxycycline belongs to the class of Tetracycline that should be taken with food .  Brand names include Doxy, Ocudox, Doryx, Vibramycin, Oracea, Acticlate, Monodox, Atridox, Morgidox, Vibra-Tabs, and Alodox.

• Minocycline also belongs to the class of Tetracycline.  Brand names include Mino-tabs and Minomycin.

• Erythromycin Ilotycin, Ery-Ped, Ery-tab, Staticin, Erythra-Derm, Akne-mycin, Pce, Eryc, Ery, Eryped, T-Stat, Erygel, and E.E.S.

• Azithromycin. Brand names include Zithromax Z-Pak, AzaSite, Zithromax TRI-PAK, and Zmax.

• Clindamycin is an oral antibiotic but it also comes as a topical solution.  Brand names include Clindagel, Cleocin-T, Evoclin, Clinda-Derm, Clindets, and C/T/S.

• Trimethoprim/Sulfamethoxazole (TMP/SMX) is a combination antibiotic that should not be taken while pregnant or breastfeeding.  Brand names include Bactrim, Bactrim DS, Sulfatrim, and Septra I.V.

• Trimethoprim

• Cephalexin

BACTERIA DOES NOT CAUSE ACNE

If I could go back in time to that moment my Doctor prescribed me antibiotics, I would tell myself what I know now: Bacteria doesn’t cause acne!  Propionibacterium acnes (P. acnes) was actually misnamed when scientists and Doctors mistakenly thought that acne was caused by this bacteria. We now know that acne is not caused by this bacteria or any bacteria, it’s caused by Retention Hyperkeratosis.  We also know now that EVERYONE has P. acnes living in their skin and those of us with acne don’t even have more of it than people with clear skin. It’s just that this bacteria is anaerobic which means that it can’t exist in an environment where there is oxygen.  People without acne have a constant flow of oxygen circulating in their follicles because they are clear of congestion. Those of us with RH have congestion due to the back up on dead skin cells, oil, and comedogenic products so oxygen isn’t able to reach inside of the follicle and bacteria gets the perfect environment to thrive in.  P. acnes also feeds off of oil but it only eats a portion of the oil and then it basically poops the rest in the follicle causing irritation and leading to inflammation. But, again, inflammation is just a symptom of the bacteria overgrowth and the overgrowth of bacteria is just a symptom of the RH so both bacteria and inflammation stop being a problem once the underlying RH is dealt with.

BACTERIA IS MOSTLY GOOD AND ESSENTIAL TO LIFE

Even if bacteria did cause acne, killing all of the bacteria with antibiotics is something that should only be done when absolutely necessary.  Bacteria has a bad reputation as something dirty and dangerous that needs to be sanitized but most of the bacteria in our bodies are good and they are an essential part of the human microbiome.  They live all over and within our bodies throughout our entire lives and they aid in crucial processes like fighting disease, growth, digestion, and regulating mood and although some species can cause infection or disease, they usually only do when the natural microbiome is disturbed. 

ANTIBIOTICS CREATE SUPER BACTERIA

In recent decades, antibiotics have been so frequently prescribed and people have been kept on them for such long periods of time that there has been increased rates of antimicrobial resistant “super bacteria”.  Because antibiotics throw off the balance of good and bad bacteria, the bacteria that survive adapt and morph into stronger strains that are resistant to antibiotics. It’s almost like antibiotics have acted as vaccines for bacteria and bacteria have become more and more immune to them.  The bacteria that cause tuberculosis, malaria, and gonorrhea, for example, now have several antibiotic resistant strains and propionibacterium acnes is now becoming more resistant as well. 

TO GET COMPLETELY CLEAR LONG TERM, YOU HAVE TO DO THIS

It amazes me that 20 years after  antibiotics are still such a commonly prescribed treatment for acne because I have yet to meet one person who actually got completely clear long term from it.  Antibiotics can be helpful in reducing some of the inflammatory symptoms of acne which might make your acne look less noticeable. But the results are not usually sustainable after you get off of antibiotics which you have to do at some point for your health.  And improvements, if any, are often unimpressive because acne is a multifactorial disease that is caused by so much more than bacteria. At the root of acne is a genetic disease called Retention Hyperkeratosis and there are many potential triggers and symptoms that play a role in exacerbating RH so to get completely clear long term usually requires a whole-istic approach that deals with not just symptoms like bacteria but the underlying cause, the dozens of triggers, and each of its symptoms which is what our acne fighting program does.

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Fungal acne does not exist but here is how to treat Malassezia Folliculitis

Fungal acne is the new buzz term in the beauty world and everyone and their Moms think they have fungal acne right now.  But fungal acne doesn’t even exist! Literally, it’s not a thing y’all. So if you jumped on the fungal acne bandwagon and are now convinced that your acne is caused by fungus, read on.

ACNE CANNOT BE CAUSED BY FUNGUS

Just the very term ‘fungal acne’ is a contradiction in terms because acne is defined as a chronic condition caused by a genetic dysfunction called Retention Hyperkeratosis (RH).  RH is a disease that causes an overproduction of skin cells to get backed up in the follicle which then creates little acne “seeds” called microcomedones. These seeds then grow like a flower due to a number of internal and external factors like diet, products, and bacteria called triggers.  If the seed becomes big enough to rupture the follicle wall, inflammation sets in but inflammation is just a symptom of acne, not the cause of it. So acne is a formation of lesions formed primarily by dead skin cells, not fungus.  

WHAT EXACTLY IS ‘FUNGAL ACNE’ THEN?

What is inaccurately referred to as ‘fungal acne’ is actually a condition called pityrosporum folliculitis or malassezia folliculitis (MF).  MF and acne both occur in the hair follicles but unlike acne which is caused primarily by an overgrowth of dead skin cells, malassezia folliculitis is caused by an overgrowth of yeast called malassezia.  We actually all have yeast and bacteria all over our skin and inside of our bodies and they serve important functions but MF develops when this particular fungus (yes, it is a fungus) proliferates for a number of potential reasons.  Antibiotic usage can kill all of the “good bacteria” in our bodies and cause a yeast imbalance. And similar to acne mechanica, prolonged heat and moisture caused by occlusive clothing like tight, sweaty exercise clothes can also cause yeast overgrowth. 

WHY DO THEY CALL IT FUNGAL ACNE IF IT’S NOT ACTUALLY ACNE?

Two words: ignorance and confusion.  Even the most highly paid beauty bloggers and influencers are so freakin’ ignorant about acne that they just refer to any type of bumps on the skin as acne. It’s also easy to confuse the two because there are 7 different types of acne and one type of acne, non-inflamed acne, looks similar to MF because they both look like small bumps under the skin.  This is a tricky type of acne that most people don’t identify as acne because it’s not big or red. A lot of people don’t even refer to it as acne, they refer to it as “texture” and I have even had some clients who have been mistakenly told by their Dermatologist that it’s an allergic reaction! If the skin doctors have trouble discerning the different types of bumps on our skin then it’s no wonder there is so much garbage information out there.

HOW DO I KNOW IF IT’S FUNGUS OR ACNE?

A fungal infection like MF can look so similar to non-inflamed acne that it can be hard to tell the difference.  The only way to know for sure if you have MF is to have it checked and examined under a microscope by a Doctor but here are some hints:

1. Does it itch? 

   Acne does not typically itch and MF does.  The only time you will have itchy acne is if you have an inflamed acne lesion but that kind of itching is typically mild and doesn’t last a long time.  And if it is inflamed acne, it will be swollen, red, and maybe full of pus so it will look very different from the small uniform bumps that characterize MF. 

2. Pattern

   MF bumps tend to appear in clusters and are uniform in size whereas acne tends to be randomly distributed and appears in varying sizes.

3. Is there a head or a core?

   All types of acne start with a little “seed” called a microcomedone that is made up of mostly dead skin cells so all of the 7 types of acne have a grain-like seed inside of or on the surface of the skin.

FOREHEAD BUMPS ARE USUALLY CAUSED BY THIS

Lots of bloggers and influencers who talk about fungal acne claim that it usually appears on the forehead.  But MF is actually more common on the body than it is on the face. It’s more likely that your forehead bumps are caused by Retention Hyperkeratosis and triggered by comedogenic hair products.  I say triggered because acne, regardless of what type or where it is located, is always caused by RH. If you are genetically prone to acne and are using a shampoo, conditioner, or hair styling product that contains one of these pore-clogging ingredients or you have recently gone to the hair stylist or gotten your hair blown out and they used a comedogenic product in your hair, you are likely breaking out from that. We have a whole Pinterest board with acne-friendly hair product recommendations that you can check out but make sure to double check the ingredients of every product (even if I suggested it!) before purchasing since products get reformulated all the time.

HOW IS FUNGAL ACNE TREATED?

Only your Doctor can diagnose and propose a treatment for your MF but it’s usually treated with one or a combination of these:

1. Lifestyle adjustments

   Avoiding saunas, sun exposure, and steaming
   Wearing loose fitting clothes
   Changing sweaty workout clothes right away
   Showering immediately after exercising

2. Anti-fungal shampoo or body wash

   You might be prescribed a shampoo that contains selenium sulfide, pyrithione zinc, or ketoconazole like Selsun Blue or Nizoral.

3. Oral anti-fungal medication

4. Prescription topical creams

HOW TO GET RID OF ACNE ONCE AND FOR ALL

Hopefully you have a better idea after reading this whether or not you actually have “fungal acne”. If you are one of the few who actually has MF, you should get in touch with your Physician so they can advise you on next steps. If you are just of the many people who have been mistakenly thinking that you have fungal acne but you actually just have stubborn acne, our acne programs offer a prescription free method for getting clear in a way that offers sustainable, long term results.

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How to tell if your extractions for acne are done properly

Extractions are the process of manually removing debris from the skin.  If you have ever picked or popped your own pimples, you were basically performing an extraction.  Depending on the state that you live in, you might receive extractions from an Esthetician or a Dermatologist and if extractions are performed properly, they can significantly accelerate the clearing process.  If they are not done properly, they can slow down the clearing process and also contribute to scarring, infection and pigmentation so it’s crucial to find someone who can do them the right way.  If you cannot find someone to do them properly, receiving bad extractions is actually worse than not receiving them at all. Read on for the important things to pay attention to.

ARE THE RIGHT TYPES OF ACNE BEING EXTRACTED?

There are 7 types of acne and not all of them are appropriate to extract.  Papules, cysts, and nodules should never be extracted because there is such a high level of inflammation blocking the actual acne “seed” that the level of trauma that would need to be inflicted on the skin in order to thoroughly clear out the follicle is very likely to cause scarring.  The three types of non-inflamed lesions (microcomedones, blackheads, and whiteheads) can all be extracted safely and one type of inflamed lesion, pustules, can usually be extracted because the comedone is essentially sitting on top of the inflammation which is why you see a head.  If your Esthetician or Dermatologist is extracting everything on your face without being methodical about which types are appropriate, you should find someone else.

ARE THEY THOROUGHLY EXTRACTING THE ENTIRE FOLLICLE?

One of the most common extraction mistakes people and even professionals like Estheticians and Dermatologists make is that they leave debris in the follicle which can then lead to further infection and inflammation (which can then create scarring and severe pigmentation).  It can be hard to tell right away if the entire follicle has been emptied because even if the extractions are done correctly, you will likely have scabbing that forms and creates a slight bump over extracted areas. But it should be relatively flat still immediately after the extractions and once the spot heals, it should be completely flat and you should not feel or see any big or small bumps left in it.

HOW MUCH DAMAGE IS BEING DONE TO THE SKIN?

Extractions are traumatic for the skin regardless of whether or not they are done properly so there are some negative side effects that I list below that you should be prepared for regardless of who is performing them.  The question you should be asking is how much damage is being inflicted on the skin, how long is it lasting, and whether or not the pros outweigh the cons.  As I mention below, most of the side effects should last a few days to two weeks.  These normal side effects are basically the price of manually pulling acne out of the skin but there are some side effects that are not normal.  Scarring is not normal so if you have actual scars after extractions, your extractions were not done properly and you should find someone else.  Just be careful to not confuse scars with dark marks because dark marks are a normal side effect of any trauma to the skin and they are temporary.

NORMAL SIDE EFFECTS OF EXTRACTIONS

With the exception of PIH which can last months, most of these side effects should last up to a week but it can take up to two weeks if your body has a really slow healing response.  If they last more than two weeks, whoever performed them isn’t skilled enough to extract in a way that causes the minimum amount of trauma necessary so you should find someone else.  Here are the most common side effects:

Scabbing
Redness
Soreness
Bleeding
Oozing
Dryness + flaking
Post inflammatory hyperpigmentation (PIH) which is darkening of the skin

WHY EXTRACT THEN?  THE PROS SHOULD OUTWEIGH THE CONS

Even though these side effects are not pleasant, the benefit of manually clearing the follicles should far outweigh the temporary side effects because properly extracting acne can significantly speed up the clearing process. If your skin is not manually cleared of acne, it can take years for those lesions to work their way out of the skin which is significantly longer than the week or two most of these side effects usually last.  Dark marks leftover in the spots that were extracted (PIH) are the side effect that usually takes the longest but it should take just a few months since whoever is performing the extractions should be approaching your acne using a multitargeted approach that works to clear AND even out your skin tone simultaneously anyways.  Plus, acne takes at least 3-4 months to clear in the best case scenario so a few dark marks shouldn’t make that much of a difference in the grand scheme of things.

EXTRACTIONS ARE NOT ENOUGH FOR ACNE

Extractions clear the skin temporarily but if you are not on a program that helps you eliminate all of the various triggers that clog up the follicles, it is just a matter of time before your follicles become congested again.  The only way to clear acne in a long term and sustainable way is to use a multi targeted approach that not only works on clearing acne that has already formed on the surface of the skin but that works on preventing new acne seeds from being planted in the skin.  So extractions should be one part of a comprehensive program like our acne program that targets acne from multiple angles.  Check out our 8 Steps To Clear Skin E-course and our in-person and virtual acne programs to learn more.

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A list of great Bay Area therapists and clinics if you struggle with acne

I wrote a post about How To Find A Good Therapist If You Struggle With Acne where I talk about what type of therapist to look for and the process I go through for finding someone good.  But I also wanted to list some of my favorite Bay Area therapists as well as some referrals for local Bay Area therapists:

hybrid THERAPISTS

Colette Mercier (in-person Sebastopol + online)
Eugenia Guidi (in-person Marin/Sonoma + online)
Laura Bulchis (in-person San Rafael + online)
Gavrila Abramson (in-person Soquel + online)
Yatra Pesantez (in-person Oakland + online)
Eitan Saenger (in-person Oakland + online)

online only THERAPISTS

Kristin Fialko
Normandy Daniels
Antony Thier
Joshua Cross

SLIDING SCALE CLINICS

These clinics have multiple counselors all over the Bay Area that work on a sliding scale.  Many of them are advanced level students but do not let that deter you! Some of my favorite therapists were interns and trainees and some of the worst therapists I have seen were department chairs with decades of experience. So I have learned that experience has nothing to do with how good a therapist is and at the end of the day, you are seeking a person with a warm heart and not a professional with a long resume.  Some of these clinics have therapist profiles so you can choose a few that resonate with you and give them a call directly. Others do not have profiles so you need to call the clinic to do an intake and they match you with someone. I recommend requesting to be matched with at least 3-5 people so that you can get a sense of who feels right and if nobody feels right, call back and ask to be matched with a few others!

SAN FRANCISCO CLINICS

The Center for Somatic Psychotherapy
Integral Counseling Center at Pierce Street
Church Street Integral Counseling Center
Golden Gate Integral Counseling Center
Center For Mindful Psychotherapy
Marina Counseling Center
New Perspectives Center For Counseling
Grateful Heart Holistic Therapy Center
Holos Institute
SF Marriage Center (the therapists here see individuals and not just couples)

EAST BAY CLINICs

Center For Mindful Psychotherapy
Grateful Heart Holistic Therapy Center
Axis Mundi Center
Holos Institute
Heart in Balance Counseling Center
SF Marriage Center
Blue Oak Therapy Center
Earth Circles Counseling Center

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How to avoid breakouts after waxing or threading

To stay hairy or risk breaking out?  This is just one of the many dilemmas that those of us with acne have to grapple with in our daily lives and like any other type of breakout, it’s not as simple as it seems.  Acne is a multifactorial disease so even a breakout that surfaces after waxing or threading isn’t actually caused by waxing or threading: these are just some of many potential triggers that can ignite an underlying genetic condition called Retention Hyperkeratosis.  Read on to learn more.

WHY DO I BREAKOUT AFTER WAXING OR THREADING?

There are typically four potential triggers that spark breakouts after a hair removal procedure: 

1. There is a comedogenic product that is being applied to your skin before or after the procedure that is clogging your pores and planting new acne seeds in the skin.

2. The irritation from the wax itself or the hair being pulled out of the follicle is causing existing acne under the surface of the skin to become inflamed. 

3. The friction caused by the hair being ripped out of the skin is irritating your follicles and causing something called “acne mechanica” which is a form of acne caused by pressure and friction on the skin.

4. The bumps on your skin might actually be a rash (e.g. contact dermatitis or folliculitis) caused by irritation from the wax or bacteria rather than acne.

TIPS FOR REDUCING HAIR REMOVAL BREAKOUTS

• The single most important tip I give my clients about preventing hair removal acne is to make sure that whoever is performing the hair removal does not apply any potentially pore-clogging products on their skin before or after.  As we discuss in our e-course, it only takes one ingredient in one product to touch your face one time for one second to break you out which means that you need to literally check the ingredient lists on any toners, creams, powders, solutions, sun protectants etc. that they want to put on your skin.  The best thing to do is to bring your own acne-friendly products because even if you check their products, there is still a risk that they contain undisclosed pore-clogging ingredients.  

• Make sure the area is cleaned before and after with a gentle but effective acne-friendly toner.  You definitely don’t want to use an active toner that contains any exfoliating ingredients because this can increase irritation and even potentially cause a burn from the wax. You also want to make sure the toner doesn’t contain any comedogenic ingredients.  If you are on our program or using our product kit then spray a little bit of Clarifying Toner onto a clean cotton pad and gently swipe over the area immediately before and after the procedure. 

• If you have access to ice, gently swiping a clean ice cube directly on the area for 2-5 minutes after toning can help reduce the irritation caused by having the hair pulled out of the follicle.  Unfortunately, having hair ripped out of your skin is going to be irritating for the follicles regardless but this can help minimize the irritation.

• Do not touch your face before or after.  After a hair removal procedure, your follicles are open so it’s important that you don’t touch them and potentially get bacteria or other debris inside of your open pores.

WHAT POST-CARE INSTRUCTIONS SHOULD I FOLLOW?

As I mentioned above, you should bring an acne friendly toner that doesn’t contain any active ingredients like our Clarifying Toner so you can clean your skin before and after.   You should also bring a soothing gel or moisturizer like our Aqua Gel to apply after you tone to help soothe any potential irritation. And then you finish with a broad spectrum SPF of at least 30 to apply after the gel/moisturizer dries.  You should apply these products with gloves so bring your own or ask whoever is performing the procedure (or you can just ask them to apply these things for you with a fresh pair of gloves). Avoid applying makeup for the rest of the day and if you were waxed, avoid using any active products for the rest of the day as this can burn and further irritate your skin.  If your skin is still tender, irritated or sensitive the next day, avoid any active products until your skin has calmed down.

HOW TO TRULY GET RID OF HAIR REMOVAL BREAKOUTS

The tips I listed above might help mitigate potential breakouts from waxing or threading but, as I mentioned above, the underlying cause of any type of acne regardless of what triggers it is a genetic condition called Retention Hyperkeratosis. So the only way to truly clear the skin from the inside out in a long term and sustainable way is to target both the triggers and the underlying cause using a multi-phase and multi-targeted approach which is what the AES method does.  To learn the roadmap for doing clearing acne for good using a prescription free method, check out our e-course The 8 Steps To Clear Skin.

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The best and worst oils if you have acne

Oils are a very tricky topic when it comes to acne.  I have already written about how Oil Cleansing Is Actually Terrible For Acne and although I recommend avoiding oils as a general rule, not all oils are equal and there are some oils that are more acne friendly than others if used in the right amount, the right way, in the right place.  In my e-course, The 8 Steps To Clear Skin, I have a section about oils in Step 3 where I discuss the best practices for making sure you are using oils in the safest way (such as avoiding it directly on your face) but here is are a few shortlists for you.

The worst oils for acne:

Argan Oil
Avocado Oil
Coconut Oil
Soybean Oil
Evening Primrose Oil
Grapeseed Oil
Hydrogenated Vegetable Oil
Linseed Oil
Mineral Oil
Mink Oil
Peanut Oil
Rosehip Oil
Sesame Oil
Shark Liver Oil
Sulfated Castor Oil
Sulfated Jojoba Oil
Wheat Germ Oil
*Cocoa Butter, Coconut Butter and Shea Butter are not technically oils but they are similar and highly comedogenic so avoid these too

The best oils for acne:

These are some of the less comedogenic oils for acne but that does not mean they are acne safe (nothing is ever acne safe, there are only ingredients that are friendlier than others).  As I discuss in my e-course, the amount you apply, how you apply it, and where you apply it (e.g not on your face) all matters:

Jojoba Oil
Kukui Nut Oil
Macadamia Nut Seed Oil
Safflower Seed Oil
Squalene Oil
Sunflower Seed Oil

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Birth Control For Acne: What You Should Know Beforehand

In my previous post about the Best and Worst Birth Controls For Acne, I mention that even if you follow the guidelines for choosing a birth control that is “safer” for acne, hormones affect everyone differently so there actually isn’t a way to know if a birth control will make your acne better, worse, or make no difference at all.  Prescription medication isn’t usually that effective for getting or staying clear and it certainly isn’t necessary but if you are considering taking birth control to control your acne, there are some other things you should know beforehand.

BIRTH CONTROL SIDE EFFECTS

As with most prescription medications, there are many potential side effects with birth control: headaches, depression, changes in sex drive, weight gain, mood changes, nausea, breast tenderness, vaginal dryness, pelvic pain, chest pain, heart attack, blood clots, stroke.  For me, the scariest thing about birth control isn’t actually the potential side effects: it is the fact that we are the first generation of women who have been prescribed birth control for such prolonged periods of time so the effects of long term birth control use are still unknown.  I have a 30 year old friend who has been on birth control for 15 years (which is normal nowadays). She was having severe cramps and when she got checked out, they found bumps on her ovaries that they thought might be cancer. Luckily, they were clusters of cysts that weren’t cancerous but her Gynecologist told her that she is seeing more and more women around that age developing cysts from long-term birth control use.  This is just one small example that shows that our bodies are essentially being used as experiments which is fine if the risks don’t concern you and/or the benefits outweigh the potential side effects but to manage a condition like acne does not require this level of risk.

Birth control is not usually a sustainable option

If you take birth control to manage your acne, chances are that you will want to get pregnant at some point.  At that point, you will have to get off of birth control and if that has been the way you have been controlling your acne, there is a good chance it will reappear once you get off.  I have had so many clients come to me because they are terrified to get off of birth control because they are scared about what effect it will have on their skin even though they are desperate to get pregnant.  It is so sad to have to worry about your skin when getting pregnant and having a baby comes with so many of its own challenges. Even if you don’t ever want to get pregnant, consider whether or not you want to be on medication forever to manage your acne and, if not, I recommend finding a solution for managing your acne that is sustainable throughout all of the stages and phases of your life.  

Birth control only targets one piece of the acne puzzle

In my e-course, The 8 Steps To Clear Skin, I talk about how one of the reasons most acne solutions fail is that they only target one or two aspects of the acne puzzle and birth control is no exception.  Birth control targets hormones but acne is a multifactorial disease that requires a multitargeted approach to get truly clear long term so only targeting hormones ignores the other dozens of potential acne triggers out there. The most common thing I hear from my clients who have been using birth control is that their skin might have improved when they started taking birth control but it didn’t get completely clear.  Or maybe it got completely clear but it was temporary. A truly effective approach to managing acne will not just improve your symptoms but will clear acne from the inside out and it will yield sustainable, permanent results rather than be a temporary fix.

Birth control does not deal with the root of the issue

Even if the birth control you choose helps manage your oil producing hormones, the root of acne is a genetic condition called Retention Hyperkeratosis and oil is just one of many factors that make up the acne puzzle.  Acne is a really tricky disease (yes, it is a dis-ease) to manage because there is an underlying cause and lots of potential internal and external triggers that can ignite or exacerbate it and all of them have to be managed at the same time to be effective.  When choosing an acne program, product, method, or professional, make sure that they are targeting each piece of the acne puzzle at the same time. If the solution you are choosing claims to target oil or bacteria or inflammation, that is a good sign it’s probably not going to work.

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The best type of exfoliation for acne

Exfoliation is the process of ungluing dead skin cells that are stuck together.  And if you have taken our e-course The 8 Steps To Clear Skin, you know that acne is caused by a genetic disease called Retention Hyperkeratosis.  When we are born with RH, our follicles are basically missing the mechanism that properly washes out our follicles so dead skin cells get glued together and lodged in our skin.  Since exfoliation is the process of ungluing congestion in our skin, it is basically a way of artificially replacing a mechanism that those of us with acne just don’t have naturally.  When most people think of exfoliation though, they usually think of a scrub or an exfoliating brush.  But there are two kinds of exfoliation, mechanical exfoliation and chemical exfoliation, and one of these is not just useless for acne but it can actually be harmful.  

CHEMICAL VS MECHANICAL EXFOLIATION

Also known as physical exfoliation, mechanical exfoliation is the process of using a tool or a physical product to manually break up skin cells.  A chemical exfoliant is a product that includes chemical ingredients that dissolve dead skin cells.  If you are like many others, you might have already made a judgement that chemical exfoliation must be worse than mechanical exfoliation because chemicals get a bad rap but you would be wrong.  There are lots of chemicals that are safe and effective and a high quality chemical exfoliant is much more useful for the clearing process than a mechanical exfoliant and it can cause less harm too.  Sure, there are plenty of chemicals that are harmful but don’t overgeneralize and group naturally derived chemicals like glycolic acid together with a dangerous chemical like cyanide.  After all, YOU are made of chemicals, plants are made of chemicals, babies and puppies are made of chemicals, everything is made of chemicals!  Even “natural” ingredients and products are made of chemicals and since acne has to be managed both from the inside out through diet, lifestyle, etc. AND the outside in through effective skincare products, chemicals play a crucial role in the clearing process.  

MECHANICAL EXFOLIATION IS USELESS AND POTENTIALLY HARMFUL FOR ACNE

Mechanical exfoliants are basically useless for acne because they only dissolve skin cells on the surface of the skin.  That would be great if acne was a surface skin problem but it’s not and neither are wrinkles or discoloration which is why mechanical exfoliation are basically useless for those things too.  Acne is a problem that ENDS on the surface but it STARTS deep down inside of the follicle which is why I tell my clients that I don’t really care about the acne that is already visible because by the time acne reaches the surface of the skin, it’s already at its last stage of life.  So you can scrub your skin until it’s raw but it’s not going to do a darn thing in the long run.  If you are lucky, you might see results for a few days or maybe a few weeks but whatever acne is underneath the surface will eventually move up.  In order to manage acne in a long term and sustainable way, you have to target acne where it starts rather than where it ends which is what chemical exfoliation has the potential to do.  

Also, mechanical exfoliation works through abrasion which can cause microtears in the skin which can lead to inflammation, irritation, and even infection.  This is especially dangerous if you have an inflamed acne type because inflamed acne is caused by tears in the follicle wall.  And finally, most forms of mechanical exfoliation are just plain gross because they remain wet and can breed bacteria and mold.  

TYPES OF CHEMICAL EXFOLIATION

Alpha hydroxy acids
AHAs or alpha hydroxy acids are a class of naturally derived acids that are typically derived from plant and food sources.  AHAs are used in both the food and beauty industries.  In cosmetics, they can be found in many different skincare products and chemical peels and are used for a number of things including wrinkles, acne, and discoloration.  There are lots of different types of chemical exfoliants including glycolic acid which is derived from sugar and lactic acid which is derived from milk. We primarily utilize mandelic acid in our serums because it’s the only AHA that offers three benefits: it doesn’t just exfoliate but it can help with inflammation and pigmentation as well.

Beta hydroxy acids
Salicylic acid is a BHA that is also naturally occurring in willow bark which is where aspirin is derived from as well.  The primary difference between an AHA and a BHA is that alpha hydroxy acids are water soluble and beta hydroxy acids are oil soluble.  We don’t bother using salicylic acid in any of our products because it doesn’t offer the triple benefits that mandelic acid offers and we haven’t found it to be as effective at exfoliating since there is a 2% concentration limit that is allowed in products.  It is also not recommended during pregnancy and we want our entire program to be sustainable for our clients through all of the stages and phases of their lives.

Enzymes
Enzymes are similar to AHAs because they also come from naturally derived sources like papaya and pineapple and they have similar exfoliating benefits but we don’t work much with them because they are too gentle to significantly impact the clearing process.

TYPES OF MECHANICAL EXFOLIATION

Scrubs
Exfoliating scrubs typically come in the form of cleansers that contain granules that are massaged into the skin to buff away dead skin.

Exfoliating brush
There are now tons of brushes on the market for exfoliation that might include a dry brush or loofah that is rubbed on the skin or a wet brush that may be electrical or non-electrical.

Exfoliating fabric
Any fabric that is abrasive enough to physically break up dead skin cells can be considered exfoliating.  This could include a towel, a loofah, a mitt or some other washcloth.

Pumice stone
Oh gosh, please don’t use a stone on your face.  Please.

HOW OFTEN SHOULD I EXFOLIATE?

If you have acne, you should generally be exfoliating everyday but it depends on many factors including how resilient your skin is (how sensitive, how dry, etc), how effective the exfoliant is, and how strong it is.  Our method is based on customizing product plans based on the condition of our clients’ skin on any given day so there really is no rule for how often you should use any type of skincare product because it should be adaptable and flexible given that our skin can change moment to moment.  Usually when acne sufferers start our program, their skin is extremely dry and sensitive due to over exfoliation or prescription medication usage so we start them off using our exfoliating serum every other day or even every third or fourth day.  Or we might have them not exfoliate at all for a few weeks and we have them just start on a product plan that is designed to nourish and balance their skin before we integrate any exfoliants.  When we work one on one with our clients at our San Francisco clinic or through our virtual program, we design product plans for them that are suited to their acne type, skin type, and any other conditions they are dealing with.

EXFOLIATION IS NOT GOING TO CLEAR YOUR ACNE

Acne is a multifactorial disease which means that it’s a complicated puzzle made of many different pieces including Retention Hyperkeratosis, diet, oil, bacteria, and comedogenic ingredients.  Since acne is caused by many different factors, you have to fight it in many different ways using a comprehensive and whole-istic approach. You can learn more about this multi targeted approach we have used to clear hundreds of acne sufferers in my e-course The 8 Steps To Clear Skin.

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If you have acne, changing your diet takes months to get clearer skin

When a client first starts our program and we review the 4 potential food triggers, it’s not uncommon for them to say, “I’ve already tried cutting out cheese or tofu and it didn’t work”.  One of the first things I ask is, “How long did you cut it out before judging whether or not it was working”, and, inevitably, they will say they tried for a few weeks at most.  Well, let me just tell you right now that it usually takes AT LEAST one month for the food we eat to manifest as visible acne on the surface of the skin but what we see in our clinic is that it typically takes 1-3 months on average.  As we discuss in our e-course, The 8 Steps To Clear Skin, different acne triggers have different delayed reaction times and ingestible triggers like food take the longest.  So next time you decide to test a potential dietary trigger, there are a few things you should keep in mind.

Food takes time to process

Just think about how long it would take for you to eat something to show up as visible weight on a scale.  It would probably take at least a few weeks and more likely some months. For example, you don’t eat a giant meal on Thanksgiving then see 5 extra pounds on the scale on Black Friday, do you?  No, of course not. You know logically that you probably won’t see the effects of what you ate during the holidays until January or even later and it’s the same concept when it comes to your skin.  It takes time for food to get broken down, take effect in the body, contribute to the formation of an acne seed (microcomedone) then for that seed to travel from the bottom of the follicle to the surface of the skin.

How long it takes depends on a number of factors

Exactly how long it takes for the effects of dietary triggers to show up as visible acne on the surface of the skin depends on a number of factors and varies person to person.  Just like different people would take different lengths of time to see visible weight gain depending on what they ate, how much they ate, their metabolism, body type, and how much physical activity they do, it takes different lengths of time for food to manifest as acne depending on what type of food and how much was consumed, someone’s acne type, their skin type, and how much exfoliation they are receiving through their product plan and peels.  

Exfoliation speeds up the process

Exfoliation helps speed up the purging of acne “seeds” called microcomedones in the skin so the more exfoliation you are using, the quicker congestion purges up through your follicles and out the surface of your skin.  If you eat dairy (or anything else) and it is a trigger for you, it can contribute to the formation of seeds inside of your skin but we can speed up the process of getting those seeds out by strengthening the level of exfoliation.  Stronger is not always better though when it comes to exfoliation and the type and level of exfoliation has to be appropriate for your skin. Your skin is like a muscle and you can condition it to be able to tolerate really strong products without getting dry or irritated and a good acne program will teach you how to slowly level up your product plan so active products are integrated slowly.

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