A dermatologist talks: Treating acne and pores in humid Singapore
Clear skin, clear day
I've already written about skin fundamentals such as treating pigmentation and anti-ageing options, but one of the most common concerns here are acne and oily skin. My patients often say, "My pores are big and my skin is greasy, how do I shrink them and get flawless skin?" First, there is a medical term for such a condition. It is known as hyperseborrhea, and it refers to the excessive production of sebum. Sebum is the body's own moisturiser, produced in the sebaceous glands in skin. The composition of sebum is a mixture of fats that help to prevent excessive water loss from the skin to the environment, preventing dry skin. In a healthy person, this is regulated and does not cause problems. When excessive oil production occurs, hyperseborrhea occurs and often presents as excessive shine and a greasy sensation on one's face, which can be socially embarrassing, as well as having a tendency to break out in acne.
Oily skin is not the same as acne, although almost all acne patients have a tendency to oily skin. In order for acne bumps to form, one must first have a genetic tendency to produce inflammation, oil production (driven by hormones) as well as an excess of skin bacteria known as Propionibacterium acnes. The link between oily skin and acne is this — without oil, acne bumps do not form. However, it is possible to have oily skin without acne.
Treatment of seborrhea depends on severity. Acne itself is considered a medical condition which is controlled with prescription medications, ranging from topical retinoids and oral antibiotics to isotretinoin. Acne should be treated at any age, primarily because of its potential to scar as well as its link to depression and anxiety.
TREATING OILY SKIN
If you simply struggle with excess oil production and a shiny complexion, try over-the-counter cosmeceuticals designed to regulate skin health. For oily skin that's prone to breakouts, an over-the-counter antibacterial gentle cleanser is recommended. I stay away from chemical cleansers like triclosan, and have formulated a medical grade honey cleanser which has natural antibacterial properties. The oil control is achieved by the gentle foaming action of honey as an emulsifier, substituting the bulk of chemical lathering agents such as laureth sulfates.
The key to a good oily skin cleanser is that it should have an effective lathering action to remove oil dirt and grime, but at the same time, should respect the skin barrier by not stripping the skin completely dry. Chemical sulfates tend to damage the skin barrier after repeated use, and it is a total myth to treat oily skin with 'deep cleansers'. Oily skin often reacts by producing even more oil when it is stripped of its natural moisture barrier, a condition known as reactive seborrhea. In addition, such deep cleansers often contain small concentrations of salicylic acid or lactic acid, which when used daily, often cause facial dermatitis and eczema. This pharmaceutically compounded, 1% hyaluronic acid serum, is also used to regulate skin moisture without the oil you would find in a moisturising cream.
If your seborrhea is particularly stubborn and you are determined to rid yourself of it, plan a visit to an accredited dermatologist who can recommend you a targeted regimen consisting of in-office chemical peels, lasers to shrink oil glands permanently and oral medications, if required, to control oil production.
If you don't have pimples but struggle with enlarged pores, read on. Looking closely in the mirror, you would realise that facial skin is covered with tiny hair follicles (some people having more than others) and at the base of this is a gland known as the sebaceous gland. Overactivity of the sebaceous gland can lead to prominence of each of these pores, which makes skin look uneven and rough. This is driven primarily by the androgen hormones, which both men and women start to produce at puberty. The amount of testosterone in men is higher than women, which explains why women tend to have softer and smoother skin. Another cause of enlarged pores is the condition acne rosacea, which looks a lot like teenage acne except that it has much more background redness, and sufferers complain of readily flushed and red complexions when outdoors, exposed to heat, spicy foods and even when experiencing intense emotions.
Rosacea itself is due to excess dilatation of blood vessels, causing redness of skin. It is a medical condition which is much more severe than acne because one does not simply 'grow out of' rosacea — it is a long term skin condition which leads to skin thickening, first presenting as enlarged pores. A severe complication of rosacea is rhinophyma, whereby the nose is disfigured due to uncontrolled rosacea over many years. This can certainly be prevented with appropriate prescription oral medications and lasers, so do visit your dermatologist if you suspect you have this condition.
ACNE TYPES AND TREATMENT
Pimples and acne are synonomous. The terms blackheads and whiteheads are commonly used by laypersons to describe acne bumps on their face and it's helpful to define them here.
Blackheads tend to appear like bits of black dirt stuck in 'pores' and are more precisely named as open comedones. The cause of this is the same as all types of acne — a combination of genetics, inflammation, oil production driven by hormones as well as bacteria. Blackheads cluster around oily areas like the forehead, nose and chin. There is really no 'black dirt' in there — its appearance is caused by the buildup of keratin and oil around the follicle, which is oxidised by air and turns blackish.
Whiteheads — otherwise known as closed comedones are also described by some as 'hidden' pimples which appear stuck under the skin's surface. The accurate term for this is closed comedone, which are seen as tiny bumps on the skin surface. Closed comedones is due to the underlying inflammation that produce these tiny 'seeds', which slowly rise to the skin's surface. Certain types of makeup or skincare cause comedones, so it is important to look for the label 'non-comedogenic' on your makeup and for dermatologically-tested labels on your skincare. Also, if you are wearing certain types of headgear or face masks, you can develop a type of acne known as occlusion acne, over the specific areas of contact and pressure.
Closed comedones should not be ignored because they develop into more severe forms of acne like papules, cystic acne and gram-negative folliculitis. Never try to prick and extract the closed bumps or let any facial aunty do that because it will introduce bacteria. I personally treat closed comedones using a specialised machine with a vacuum handpiece that gently extracts blackheads and whiteheads without pain or scarring, at the same time infusing a customised blend of fruit-based acids that exfoliate the skin.
Cystic acne is harder painful bumps which may feel 'boggy', produce pus and leave a bad scar. This is the most severe type of acne that warrants dermatologist care as it leads to scarring and can be secondarily infected leading to cysts and abscesses (collections of pus under the skin). Never pick your pimples or squeeze your whiteheads or blackheads as the bacteria on your fingers will cause infection. The way to remove whiteheads and blackheads is with prescription creams containing tretinoin, and with chemical peels and microdermabrasion. Oral medication will be necessary for acne, and a medication known as isotretinoin, may be prescribed to help to shrink your oil glands, which has to be taken under close medical supervision.
In closing, I feel it is important to debunk the myths in common home beauty remedies for acne. Firstly, do not use scrubs with rough beady material as these only irritate the skin further besides being totally ineffective at removing whiteheads, blackheads and definitely can worsen cystic acne. In terms of skincare, even oily skin types do need moisture. However, do not use oil-based moisturisers if you have any form of acne, opt for emulsions (oil in water) which are more comfortable in a humid climate like Singapore, and help to restore the skin's protective barrier. Lastly, persistent acne is not normal and should be treated by an accredited dermatologist to avoid infections and scarring.
Dr. Teo Wan Lin is a leading dermatologist in Singapore and also the Medical Director of TWL Specialist Skin & Laser Centre