Acne: The Bane of Teenage Existence

Recognizing that teenage acne can cause both trauma to the skin and emotional trauma for those that suffer it, I would like to present a case of how TCM dermatology treatment can help significantly improve acne in a practical fashion. I am writing this for the teen (or parent) who has some anxiety about the condition of their skin, as well as for TCM practitioners seeking to gain more insight on how to successfully treat this condition.

Too Much Acid: Reviewing BHAs and AHAs: Pro's and Cons

Most teens start their acne treatment with OTC products. There is no shortage of acne products or regimens available on the market, and many begin with some sort of acid either as a spot treatment, peel, exfoliator or wash. Therefore, I will review the major acids here along with what I’ve learned from my patient’s usage of these products.

Maintaining a healthy skin barrier is of utmost importance for skin health and involves having an intact uppermost layer of the skin, the stratum corneum. This helps prevent infection, exposure to inflammatory allergens, and promotes even sebum distribution across the skin. Any activity that weakens the skin barrier should be avoided. This is why, in my opinion, based on observation of my patients and the mechanisms of action of the various acids, the overuse of these acids possibly disrupts the skin barrier and can lead to further acne.

Early on, I noticed a repeated trend when interviewing acne patients: many of them reported significant benefit when starting regular use of various acid-based products and peels, but then after some time they would report "I don't know what happened, my skin suddenly started to get worse". With so many similar conversations, it forced me to really reflect on it.

The patients I mention often arrive at my office having been on regimens that included a variety of alpha hydroxy acids (AHAs) and beta hydroxy acids (BHAs). Alpha hydroxy acids include glycolic, lactic, and mandelic acids. Beta hydroxy acids refer to salicylic acid and its weaker version, betaine salicylate. Before seeing me, patients often used these in a variety of daily washes and creams, weekly peels and applications, and monthly peels they might have received from an esthetician.

AHAs are water soluble and stay on the surface of the skin. They work by exfoliating the top layer of the skin and are considered stronger. While they can improve the smoothness of the skin via exfoliation, their strength can also lead to skin irritation and sun sensitivity. BHAs are oil soluble and therefore penetrate the pores. They are considered gentler than AHAs, but the ability to penetrate the pores, dislodge dead skin cells and reduce inflammation makes them very handy.

Despite AHAs offering a good cosmetic effect by exfoliating the top layer of skin, I question whether this weakens the skin barrier, based on the observed experience of worsening acne over time with regular use of these products. In terms of BHAs, as they are gentler, they are often recommended for daily usage. I question this frequency of usage as well based on the reports of my patients.

However, to only portray these products in a negative light would be misleading. They are popular due to having some effectiveness, and some have been shown to stimulate collagen production as well. I believe the issue is the overuse of these products, and feel these products are more helpful when used infrequently with a specific purpose. With that said, I do in certain cases recommend the sparing use of salicylic acid to patients, because it is also my job to be pragmatic. The infrequent usage of salicylic acid has little side effects and having a product to assist in unclogging pores before the benefits of TCM treatment have really taken hold can hasten some patient's recovery. Again, these products should be used sparingly and infrequently.

What TCM Brings to the Table for the Treatment of Acne

Acne is referred to as Fen Ci 粉刺 (White Thorn) or Fei Feng Fen Ci 肺風粉刺 (Lung Wind White Thorns) amongst other names in Traditional Chinese Medicine (TCM). Chinese Medicine has recognized acne and began development of treatment strategies at least 2000 years ago, as evidenced by its mention in the foundational Chinese Medical text the Huang Di Nei Jing 黃帝內經 (Yellow Emperor's Inner Canon). Since then, different theories about acne, its etiology, and treatment have been developed. As a modern person suffering with acne, or a practitioner seeking to expand your clinical knowledge, you now have the benefit of treatment approaches that have been refined for over 2 millennia. TCM can be a primary treatment option for acne and its remnant marks: hyperpigmentation and scarring.

Acne Case Study and TCM Treatment

I will review the case of J.K., a 16-year-old female, who sought help for 'cystic acne' with scarring.

J.K. History

At the onset of treatment, J.K. reported suffering with acne for 4 years with a gradual progression of symptoms throughout that time. She said the acne started with small bumps and pustules on her forehead and worked its way down to her cheeks and jawline. Once the acne was further down on her face, the patient reported that she started to develop more severe acne with cysts and nodules that would leave scars on her face and could take up to 2 months to resolve. She denied acne on her upper back and shoulders.

J.K. stated her acne was significantly worse during the school year and improved over summer break. In terms of acne triggers, she also stated that stress and anxiety were the worst, and that she had significant bouts of both; particularly due to schoolwork and extracurricular activities. During the school year, J.K. reportedly slept only 4 to 7 hours per night, ate irregularly and often skipped meals.

Other Pertinent Health History:

J.K. ate a vegetarian diet. Respective to her menstrual cycle, J.K. reported that her menses had started approximately 4 years prior and that her overall cycle was 34 days, with an occasional early cycle after two weeks. J.K. stated that she had not observed any correlation between acne breakouts and the stages of her menstrual cycle, and reported regular bowel movements without issue.

Understanding Acne Through Visual Examination

Please familiarize yourself with photos A through L. In these photos you'll find almost every type of acne lesion and see J.K.'s progress through treatment. To put the visual into context, I will summarize the various acne lesions and why they occur using J.K.'s photos as a reference.

What is Acne?

Acne refers to chronic disease of the pilosebaceous unit. Pilo refers to hair and sebaceous to the sebum gland associated with each hair follicle. The 'pores' that most people refer to in acne, or generally in skin care, are the openings of the pilosebaceous unit, even when the hair is so small or thin that it is not visible. Acne typically presents on the face, neck, upper back and chest, the shoulders, and even on the mid to lower back. There is a wide spectrum of lesions, which correlates with how deep into the pilosebaceous unit the disease process has extended.

The first step in the development of acne is the production of excessive sebum. Sebum is an oily substance that lubricates the hair and skin. The primary factor of excess sebum production is hormonal changes, primarily the increase of androgens during puberty. Androgens, such as testosterone and metabolites of testosterone such as dihydrotestosterone (DHT), have been shown to increase the size of sebaceous glands on the face and other areas associated with acne, but not on others such as the legs (Gollnick, 2015). Many individuals prone to more severe acne have increased numbers of lobules in their sebaceous glands (Gollnick, 2015). The lobule is the part of the sebaceous glands that contain sebocytes, which are the sebum producing cells in the gland.

In some females, hormonal fluctuations associated with a normal menstrual cycle can also play a role in acne development. While androgens are the key culprit in excess sebum production in both males and females, estrogen and progesterone fluctuations can also contribute to acne in females. Estrogen typically reduces sebum production and therefore balances the effect of testosterone and other androgens on pubescent females' sebaceous glands. However, estrogen declines in parts of the menstrual cycle allowing an increase in sebum production by androgens. In some individuals, progesterone can also lead to increased sebum production, and acne can result from normal cyclical increases in progesterone but does not lead to acne in all people. It is no surprise that J.K.'s acne started at the onset of puberty and around the arrival of her menses, as the same hormonal drivers of puberty were increasing the size of her sebum glands.

The development of microcomedones and comedones are the next steps in the development of acne. Microcomedones occur when dead keratinocytes (keratin producing cells in the skin) plug the pore and mix with the excess sebum that is being produced. Microcomedones are not visible to the naked eye or even with magnification. We know they occur, but we don't see them. As the microcomedones continue to develop in size they become larger and visible and are then called comedones.

Comedones are the primary acne lesions and exist in two forms: open comedones (black heads) and closed comedones (white heads). Closed comedones present as small bumps on the skin that consist of clogged pores where the sebum protrudes but is covered by a thin top layer of skin. This protruding sebum has a whitish appearance, oftentimes even in people of color, but not always. Closed comedones are also present with all skin types. With black heads, the sebum in the clogged pore often becomes oxidized, changing the color to black, regardless of skin color. Photo A clearly shows numerous black heads on the right cheek of J.K. In Photo D, you can see both types of comedones present on the forehead.

The next step is the bacterial colonization of the blocked pore by Propionibacterium acnes (P. acnes) - bacteria which normally lives on the skin. The bacteria feeds on the trapped sebum and releases many pro-inflammatory compounds. Due to the bacterial colonization, white blood cells are sent to the pilosebaceous unit. Cytokines are also released in the area. Both of these developments lead to swelling and redness around the comedones.

The now closed and inflamed comedones if red (not always visible depending on skin color) are called papules. The plugged and inflamed hair follicle can then erupt as sebum has nowhere to flow. Pus will develop because of further immune responses; this is called a pustule. Again, many mistake pustules for 'white heads'. Photo A shows a cluster of pustules. In Photos C and J one can see varying degrees of inflammation and redness around papules.

While pustules are usually smaller surface lesions on the epidermis, in some the acne progresses to larger lesions that go down into the dermis; those lesions being nodules and cysts. If a plugged follicle ruptures all the way down at the dermis, a nodule can develop. Nodules are larger, deeper, round and hard lesions that are often painful. The nodule does not have pus but is filled with sebum, bacteria, and inflammatory cells such as neutrophils, macrophages, and lymphocytes. Nodules can be hard and painful, and the longer that a nodule is present the more likely it is to develop scar tissue. While nodules can leave scarring due to inflammation in the dermis, this is less likely and severe compared to cysts. A nodule can be seen in Photo K, slightly discreet due to its location in the nasolabial fold. It was hard and J.K reported some discomfort from it.

Acne cysts occur when the plugged follicle of the pilosebaceous unit ruptures deeply like a nodule, but the immune system responds by creating a walled area around the rupture that fills with pus. Cysts are soft due to being filled with pus and are more inflammatory than nodules as pus itself is highly inflammatory. Acne cysts contain many inflammatory components that in turn lead to the release of other inflammatory components, which can lead to further tissue damage and greater probability of scarring. The neutrophils in pus release enzymes such as elastase and collagenase that further break down the skin surrounding the cyst and worsen scarring. In response, the body produces more collagen, but it is not distributed evenly, thus also contributing to scarring.

If more severe acne persists with continued production of nodules and cysts, fistulas can develop. Due to repeated development and rupture of cysts and nodules in the same area, remnant space from the inside of the healed nodules and cysts becomes irregular, creating inflamed tunnels underneath the skin between newly formed cysts and/or nodules.

The Healing Process

In my experience it's important to understand the natural healing process of acne, as it can be mistaken for further decline. As it heals, inflamed tissue from acne will often develop post-inflammatory hyperpigmentation. This leads to an overproduction of melanin in the inflamed area and as the skin heals, the previously inflamed area will be left darker than the surrounding areas. This hyperpigmentation will often resolve on its own and is a separate process from scarring, although the two can co-exist. Hyperpigmentation can also linger without treatment.

Photo E shows hyperpigmentation on the left cheek, whereas Photo F shows a reduction of that hyperpigmentation after Chinese Herbal Medicine treatment for 9.5 months. Scarring occurs when there has been damage to the dermis. The dermis is the second layer of skin underneath the outermost epidermis. Nodules and cysts affect the dermis and often lead to scarring. Scarring occurs in 3 broad types: atrophic, hypertrophic, and keloid scarring.

Atrophic scars are the most common type of acne scars. Atrophic scars in general refer to a loss of skin thickness. 'Ice pick' scars, 'boxcar' scars, and 'rolling' scars are the 3 types of atrophic scars seen in acne. Atrophic scarring can be seen in Photo I. In Photos L and M notice how microneedling reduced the scarring. Also notice how with the reduced hyperpigmentation in Photos L and M how the remaining scarring is less accentuated. Treating hyperpigmentation will reduce the visual severity of scarring.

Treating Teenage Acne with Chinese Medicine

One of the specific issues of teenage acne is that the primary driver of the acne, increased androgens, will continue for some time. In addition, the increased androgens are only pathological for the pilosebaceous unit. So, a treatment plan is needed that considers the tendency for increased sebum production will be ongoing, even if the acne has started to clear. Success can be achieved with even severe cystic acne and relapses can be avoided with commitment to the treatment plan.

When a patient like J.K. comes into my office, I look at every acne lesion, develop an overall diagnosis, and create an herbal formula that addresses the predominant TCM pattern while also considering the different specific types of acne lesions present.

On J.K.'s first visit, Photos A through E, what stood out was the scarring and hyperpigmentation she suffered. Other notable lesions were numerous and large blackheads, numerous pustules, closed comedones on the forehead, and the presence of oil was everywhere on the skin.

In my conversation with J.K. and her mother, I made it clear that while hyperpigmentation would be addressed, the first goal would be to stop or reduce the active acne and to prevent those lesions from causing more hyperpigmentation and scarring. The game plan was to significantly reduce acne activity and then to focus on the remaining hyperpigmentation. Regarding scarring, I conveyed that the scarring would not seem as visible once the hyperpigmentation was resolved. J.K. was also advised that while the herbs would significantly reduce hyperpigmentation, it would be difficult to fill in the scars using herbal medicine. However, I did offer microneedling down the road to directly address the scarring.

Understanding the acne healing process described earlier is important. Many patients with active acne lesions that have been resolved, but that are left with some hyperpigmentation often feel they are worse off. I recall one patient in particular who was quite distressed even though all her cysts had resolved quickly. It seemed that she had a stronger dislike of hyperpigmentation than the acne itself. Even though it’s impossible to put out a raging fire without there being smoke - the most important thing is to first put out the fire. In J.K.’s case, I believed it would likely take 6 months to get the acne under control and that a longer treatment and maintenance period would likely be needed.

J.K.’s treatment plan started with a TCM diagnosis. Based on her reported stress, thin pulse, the violaceous nature of her lesions, and irregularities in her menstrual cycle I diagnosed her with Liver Qi Stagnation, Blood Heat with Stasis and Toxic Heat. Liver Qi Stagnation was diagnosed due to the patient’s reported 'stress'. Blood Heat is reflected in the increased activity of the acne on the skin as well as the early arrival of her menses at times. Toxic Heat presented as pustules and the deeper skin lesions like nodules that led to scarring. Regarding the reported biomedical diagnosis, I found J.K.’s acne to be less of 'cystic acne' and more of a papular acne or acne papulosa with some small cysts and nodules that led to shallow scarring.

To treat the Liver Qi Stagnation presenting as 'stress' I used Chai hu 柴胡. Chi shao 赤芍 and Dan shen 丹參 were used to address Blood Heat in order to decrease the acne activity on the skin. Both herbs, and in particular Dan shen, help reduce hyperpigmentation. Hu zhang 虎杖 was used to clear Blood Heat and Toxic Heat. Bai hua she she cao 白花蛇舌草 was used to address Toxic Heat. E zhu 莪術 was used to move the Qi and clear Blood Stasis, thereby addressing nodules and hyperpigmentation. Huang bai 黄柏 helped clear the pathological upward flare of ministerial fire, particularly with increased acne activity during stressful times. Tu fu ling 土茯苓 and Yi yi ren 薏苡仁 were used to reduce the amount of sebum on the face by draining dampness. Due to the very thin and weak pulse, Sheng di huang 生地黄 was used in small dosage with Dang gui wei 當歸尾 alongside the previously mentioned Dan shen to nourish Yin, Fluids, and Blood while clearing Blood Heat and moving Blood. Gan cao 甘草 was used to harmonize the formula. This herbal prescription was freely modified at each visit, depending on how the presentation changed and improved. During the first 2 months of treatment the patient’s acne activity reduced and the hyperpigmentation decreased slightly. See Photo G. Note the lack of pustules and the decreased hue of the hyperpigmentation. We were a month late with the next appointment due to the start of the Covid-19 pandemic. The patient took longer than expected to finish the herbs provided at her 2-month appointment, meaning she was missing doses and even whole days regularly. J.K. also reported that she started to eat more junk food and that her sleep cycle was dysregulated since she was not going to school. When we next met after 3.5 months, J.K. had flared up due to the factors listed above. See Photo H. The herbs were adjusted slightly, and a honeysuckle based TCM acne soap with a TCM topical acne cream containing Ji xue cao 積雪草 and bakuchiol was recommended. Note: Bakuchiol will be discussed following this case study.

While J.K. had made excellent progress at the start, it was not enough to stop the herbs or to be loose with lifestyle decisions which usually resulted in a flare-up of symptoms. Considering how much had changed in just a few weeks with the pandemic, missing a few days or weeks of herbs was not a big deal, and J.K really took it in stride and was ready to carry on. I recommended not eating junk food and going to sleep at a regular hour. J.K did seem to take these recommendations.

After the flare up at 3.5 months, J.K. got back on track with her herbal regimen and was seen every 3 to 4 weeks depending on her busy school schedule. The rate of new acne lesions reduced significantly once again at this point. Once this occurred, I decreased the number of herbs for Toxic Heat and Blood Heat but did not eliminate them completely. However, I added herbs that would better treat hyperpigmentation as well as constitutional imbalances. For instance, at different points I added Bai shao 白芍 and at others I added Ji xue teng 雞血藤. Both herbs nourish Blood, and both are known to reduce hyperpigmentation. Ji xue teng mainly moves the blood and opens the channels and similarly Dan shen was used throughout J.K.’s treatment as it moves and nourishes the blood to treat hyperpigmentation. Nine and half months into treatment, there was a marked decrease in new acne lesions and J.K. presented with significant progress in terms of hyperpigmentation. She still had open comedones. A few small pustules developed on occasion. This was an enormous improvement for her. See Photo I.

At this point, the dosage of herbs was decreased to less than half of what she originally started on as a maintenance dose. J.K.’s symptoms were not 100% improved, but after 9.5 months during very stressful times like the pandemic and applying to college, we were at a point where she could take a little break and only have herbs once per day.

We met once a month for a few months more while J.K continued with her maintenance dosage. The herbal medicine had significantly improved J.K.'s complexion but there was still some mild hyperpigmentation with some atrophic scarring. The scarring led us to talk about microneedling which can offer great results following herbal therapy.

Chinese Medicine has a long history of using needles for both health and beautification. Microneedling is a modern twist on this. Microneedling is a minimally invasive procedure that involves creating tiny punctures in the skin to stimulate collagen production and improve the texture and appearance of acne scars. The benefits of microneedling for acne scarring include reduced scar depth, improved skin texture, and enhanced overall skin appearance due to the stimulation of natural healing processes and collagen formation.

We reduced the herbal dosage more by switching to a teapill form of Margarite Acne Pill. I don't believe pills would have been strong enough or specific enough at the onset of treatment but now at the end of treatment it was great for maintenance.

The patient completed 3 microneedling sessions, each at least one month apart, before she moved away. Notable improvements were seen with each session. Photos L and M compare J.K.'s photos from before treatment and up through her first 2 microneedling sessions. I typically would have liked to have completed 6 microneedling visits at a minimum. As you can see in the photos, there was significant and even remarkable improvement. In terms of age, while being a teen is a risk factor for acne, it also seems to allow for better and faster results from microneedling. If J.K. had stayed in town, we would have continued microneedling every 4+ weeks to fully reduce the scarring and to reduce the last lingering hyperpigmentation. Typically, I might have recommended microneedling earlier, once the active acne and inflammation had settled down. Due to the pandemic, I had taken a hiatus from microneedling at my office.

Bakuchiol

Earlier I mentioned a topical ointment with bakuchiol. The ointment is Ji Xue Cao Gao 積雪草膏 and it contains bakuchiol, which is a derivative compound from the Chinese and Indian herb Bu gu zhi 補骨脂. It is used topically for skin anti-aging and acne treatment. By adding this ointment to J.K.’s treatment, my intent was to balance sebum production and reduce hyperpigmentation. Bakuchiol on its own has been shown to provide benefits for acne, and I almost always use bakuchiol in creams with other herbs in the treatment of teenage acne.

While Bakuchiol has no direct relationship with retinol, it is usually described as a retinol alternative with less side effects. Retinol is a vitamin A derivative and considered the gold standard for its anti-aging properties and in the treatment of mild acne to help exfoliate, reduce hyperpigmentation, and inflammation of the skin. Retinol works by converting to retinoic acid in the skin which stimulates gene expression pathways associated with more youthful skin. However, it has many common side effects including dryness, peeling, skin irritation and increased sun sensitivity.

Bakuchiol has a different mechanism of action than retinol, but it stimulates similar gene expression pathways and has few to no side effects. Bakuchiol is helpful with acne by regulating sebum production, having an anti-inflammatory effect on the skin, improving cell turnover and the production of collagen. In a head-to-head comparison of retinol and bakuchiol, Dhaliwal (2019) found both products to have similar results via similar but different mechanisms. However, the bakuchiol participants reported significantly less of the aforementioned retinol side effects.

Conclusion

I suffered teenage acne growing up. At first it seemed like a nuisance, getting in the way of planned social events and the like. Initially the acne did not seem that out of the norm from what my friends and classmates had. Then I started to develop areas of cystic acne and scarring, which made the acne seem far more serious. Conventional treatments such as oral antibiotics, comedone extractions, and acid peels did not seem to help me. I suspect the prescription acid peels actually made the acne worse. Eventually my story turned out okay, but I would have loved to have known about TCM then and possibly spared myself a few years of concern. I hope this information helps you and your patients do exactly that.

References

• Al-Khafaji, M. (2017). Chinese Medicine Dermatology Diploma Course - Module 4. Seminar attended in October 2017 in San Jose, California.
• Dhaliwal, S., Rybak, I., Ellis, S.R., Notay, M., Trivedi, M., Burney, W., Vaughn, A.R., Nguyen, M., Reiter, P., Bosanac, S., Yan, H., Foolad, N. and Sivamani, R.K. (2019), Prospective, randomized, double-blind assessment of topical bakuchiol and retinol for facial photoageing. Br J Dermatol, 180: 289-296. https://doi.org/10.1111/bjd.16918
• Gollnick, H.P.M. (2015), From new findings in acne pathogenesis to new approaches in treatment. J Eur Acad Dermatol Venereol, 29: 1-7. https://doi.org/10.1111/jdv.13186
• Xu, Y. (2004). Dermatology in Traditional Chinese Medicine. Donica Publishing.