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Many people believe that acne is predominately a teenage problem. However, as we grow older, we realize that many of us face the pain and inconvenience of acne throughout our entire lives. Dr. Kassouf discusses the causes of acne and what options are available to you in the pursuit of clearer skin.

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How To Deal With Acne with Amy Kassouf, MD

Podcast Transcript

Speaker 1: There's so much health advice out there, lots of different voices and opinions, but who can you trust? Trust the experts, the world's brightest medical minds, our very own Cleveland Clinic experts.

Speaker 1: We ask them tough, intimate health questions so you get the answers you need. This is the Health Essentials Podcast, brought to you by Cleveland Clinic and Cleveland Clinic Children's.

Speaker 1: This podcast is for informational purposes only and is not intended to replace the advice of your own physician.

John Horton: Welcome and thank you for joining us for this episode of the Health Essentials Podcast. My name is John Horton and I'm your host. Today, we're talking about acne with Dr. Amy Kassouf, a dermatologist here at Cleveland Clinic. Now, as a teenager, you probably thought you'd outgrow your acne, that adulthood would finally mean perfect skin. As we get older, though, we realize that no matter our age, zits happen. So skin related concerns like acne just don't magically disappear for many, many people. So what can you do about it? Well, that's what Dr. Kassouf is here to talk to with us about. She's going to talk about the causes of acne and what options are available to you in your pursuit of clear skin. Dr. Kassouf, thanks so much for being with us here today.

Amy Kassouf: Thank you for having me.

John Horton: Great. Let's start by having you tell us a little bit about yourself and what you do here at Cleveland Clinic.

Amy Kassouf: I'm a board certified dermatologist. I see patients of all ages. I have a bit of a laser specialty, cosmetic specialty, but a lot of medical dermatology as well.

John Horton: Well, let's dive in here with just kind of a basic kind of intro question. What is acne? And are there different kinds?

Amy Kassouf: So acne is an infection or inflammation of the hair follicle unit. So what we think of as our pores always have some kind of hair. Sometimes, the hairs are so small we don't see them. Sometimes, they're big and large. But all of those pores can have inflammation for different reasons and different distributions. And so that's what basically acne is. It can be one lesion, it could be whole areas of lesions.

John Horton: OK, all right. Well, we're going to dive more into it here as we talk. So let's start with, I guess, two words that people are very familiar with: blackheads and whiteheads. Now, are those considered acne?

Amy Kassouf: So that's comedonal acne. So comedones come as open comedones, which are what we consider a blackhead. The open comedones are where the air can actually get to the sebum and the dead skin cells in the pores, and that actually oxidizes and turns black. The whiteheads are actually where the pore is still sealed, and the dead skin cells and the sebum don't see the air, and so they stay white because they're naturally white.

John Horton: OK, all right. Well, that makes sense. There's a lot going on there in your skin, I guess, as this is happening, a lot of forces. Another term, now this I looked up, sebaceous filaments, which, I mean, it sounds like it should be some sort of fancy overpriced light bulb, but it's a skin condition or a skin issue.

Amy Kassouf: So technically, I had to look it up because it's not a term that we use as dermatologists or physicians, but it is out there, and basically everybody's squeezed a whitehead, right, and as you squeeze it, that little string of cheesy waxy material comes out like a filament, even though it's not actually fibrous. That's what everybody is calling a sebaceous filament.

John Horton: OK, yeah. And people do squeeze at them. We probably shouldn't. But is that different than acne? I mean, what the sebaceous filament is?

Amy Kassouf: So pores clean themselves. They're lined with skin and they have dead skin cells that turn over and they have the oil glands that empty into the pore. And the way that they clean themselves is the oil washes out those dead skin cells, and that's in that sebaceous product, sebaceous filament, whatever you call it. So it's a natural process. Everybody has it.

John Horton: It's amazing all this stuff is going on. I mean, you don't really think about your skin all that much, but yet all these things are working at once. Getting back to acne, what are some of the causes of acne? What brings it out?

Amy Kassouf: Well, so most people associate acne with puberty. So the onset of hormones actually stimulates the sebaceous glands, the oil glands, to start producing more oil. And as those follicles start to mature, they start to produce more oil. They can get a little gummed up or a little sticky. And then they start to back up and then you can get some inflammation. So the hormones can also change your skin pores. So the kinds of things that live in your pores, the bacteria and things like that, start to change and that can cause some inflammation. So acne is very multifactorial, but it's usually starts around puberty with all those hormones.

John Horton: We've all had that. Usually right before a dance, if I remember right back. Yeah. What are some other factors? I mean, could genetics play a role in how much you develop acne?

Amy Kassouf: Genetics play a huge role. So when I see the parents come in with their children, I look at their skin and say, "Oh, there's some acne scarring there. We could be in for a more inflammatory degree of issue here." So yes, there's a big gene issue. Sometimes, it skips a generation, so sometimes, the parents come in and say, "Hey, I never had a problem with this, but such and such uncle or cousin or whatever had this problem and now my child's experiencing it." So it's definitely out there.

John Horton: OK, all right. Could you also just get it from, I mean, we do so much stuff. You're out and about and you're doing things, just kind of bacteria and dirt getting on your face, touching, rubbing your face, wearing makeup? Could all that also bring about some bouts of acne?

Amy Kassouf: You can plug up your pores with lots of thick makeup, and that's a slippery slope because if you get a little acne, you want to cover it up and then you put a thicker makeup on, you're going to get more acne and then all of a sudden it gets out of control. You can work in a fast food restaurant in an environment that's very greasy and end up with more grease on your skin, more backup if you're not washing it off properly and things like that, and that can aggravate it. Medicines can aggravate it. I have big issues with certain hormones that people take, and we can talk a little bit more about that at length, too. But, yeah, there's a whole lot of influences externally and internally on acne.

John Horton: Wow, OK. Yeah, so a lot going on. So I've heard there's a term called acne face mapping, which it sounds really interesting, but as I understand it, it's kind of the process of figuring out where you're prone to breaking out on your face. And if you can understand that, is this something you can kind of figure out the underlying cause of what the acne is?

Amy Kassouf: So there's clues. There's definitely clues by where the acne is developing. So if I walk into a room and somebody has very strong acne on their jawline, their upper neck, their chin, I know that that's a big hormonal influence. If it's basic T-zone acne, that's kind of the generic run of the mill acne. Cheeks are often caused by something else. There may be a different influence, hair products or something else that we have to look into. So there's definitely zone issues with acne.

John Horton: All right. What's the T zone?

Amy Kassouf: So the T-zone is basically your forehead across the top and down your nose in the center. And that's so common because those are bigger pores and bigger sebaceous glands. So that's just a physical thing where most people get their acne or at least start with.

John Horton: All right. It sounds really cool, when you say it like that, but you just don't want your zits there. It's the worst spot. What does it mean if you're getting acne in other places? I know they call “bacne,” or, I mean, there's always those really aggravating ones you get on your butt. What's bringing those out?

Amy Kassouf: So I would say a lot of people who have more truncal acne, which includes the butt and the back and other places, too, the center of the chest, that's often genetic. It's often a more inflammatory kind of acne. It goes a little bit deeper, it's a little harder to treat. Occasionally, if it's just the “buttne” that some people talk about, that can be friction. We're all wearing these exercise shorts and yoga pants and all that, and sometimes, those little hairs get a little friction on them and they get a little sweaty and then they don't like that and they get inflamed.

John Horton: It happens. Skin does not like getting all sweaty and that it creates some … there's some conditions there that are not ideal, I guess. Let's kind of change course a little bit and talk about treatment of acne. I understand the most severe form of acne is cystic acne. What kind of options do you have if you have that?

Amy Kassouf: So classically severe cystic acne is the kind that leaves scarring, and we really want to jump on that before you get something that you have to live with forever. The classic medicine for that, we'll start with antibiotics. We'll start with topicals to try to get it under control, but a lot of times, people end up with Accutane® or isotretinoin. And there's a lot of generics for isotretinoin, but it's actually a vitamin A derivative that can actually permanently get rid of cystic acne.

John Horton: Oh, wow. Now, you said you have to jump on that right away. So I take it if you have cystic acne, I mean, you know, it's not one of those things that just jumps out one day. Is it, just it builds?

Amy Kassouf: They're deep, they hurt, they're multiple usually. Anybody can have one cyst on your chin or your butt or wherever, and that's not cystic acne, but when you're starting to get multiple of them, then you know, and you have a family history and you've been kind of warned by your parents or your parents' siblings that that could happen, then you want to get after it because if it gets repeatedly inflamed in the same spot, you can get scarring. And we don't want people to have scarring.

John Horton: All right. And I assume that's the sort of thing where you're better off, you should go and see somebody on that, as opposed to just trying to fight that with some over the counter products and just letting it go like that.

Amy Kassouf: You're welcome to try, but I'd make the appointment at the same time.

John Horton: OK, all right. Now let's talk about the treatment options if you have less severe acne. I think what a lot of people have, you just have the occasional unfortunate zit that kind of pops up or it just kind of happens. What kind of options do you have for that? How should you approach it?

Amy Kassouf: So there's lots of stuff over the counter, and a lot of the systems that have come out are just putting together all of over the counter medicines into a routine that can help. Sometimes, all you need is a good washing routine. We have teenagers who aren't really on a regular schedule yet, and so they're not routinely washing in the morning, washing at night, washing after they exercise, and things like that. So sometimes, just getting into a good routine will help clear up a lot of the acne.

Amy Kassouf: Men tend to get more severe acne in the teenage years, especially right before a growth spurt. So they'll get a hormonal surge, they'll get an acne surge, and the next thing you know, they're two inches taller or they're filled out or they're something like that.

Amy Kassouf: Women tend to get it more with their menstrual cycle, so they tend to get the monthly flare that comes before their menstrual cycle. And that can happen before you even start your cycle. So you can start to see a little flare once a month, and then, all of a sudden, you can time it, and you'll know that the cycle is going to start.

John Horton: Does your skin type play a role? I mean, obviously we're all walking around, we all have different — there's light skin, dark skin — I mean variations of everything — does that play a role in how prone you might be to getting zits or pimples?

Amy Kassouf: I think your sensitivity level — like people with a little drier, more eczema prone skin, people with keratosis pilaris, which are the little red bumps on the backs of the arms and lower face — tend to be a little less acne prone. And people who have more oily skin, more sebaceous skin, tend to be a little more acne prone.

John Horton: OK, all right. Going back to acne, the face mapping. You said that kind of tells you where it's forming or how it's happening and how you treat it. Do you use that then, the mapping, to come up with a treatment plan?

Amy Kassouf: So I don't physically map people. That's kind of more a good way to explain it to a lay population. But I do sort of recognize these zones and I do use that to figure out what's going to work for them. So if I'm seeing a young woman with lots of jawline and chin acne, I know that we're probably going to have to work on those hormones just a little bit. They may not yet have settled into a pattern or there's different ways to intervene hormonally to help the acne, whether it's a birth control pill or some other medicines. They even have topical medicines now that help with some of the hormonal components of the acne. If I see a young man with acne in those areas, I could actually make them happy because I'll say, "Oh, you're going to have a growth spurt pretty soon," which is good, but then, they still want to address the acne. And with men, we don't address the hormones because they need them. So we tend to address the inflammation more with antibiotics and things like that.

John Horton: Do you treat, especially on the face … are there different treatments depending if it's in the T-zone that you had mentioned, the cheeks, scalp? There are different approaches for each area?

Amy Kassouf: Sometimes, the approach depends on the actual lesions. Do we just have little comedones? If I just have little comedones like we talked about — the blackheads, the whiteheads, things like that — we look to medicines that kind of help those skin cells come out of the pores and turn over. So benzoyl peroxide is a good medicine for that, and it's over the counter. Some of the retinoids — so they're creams based on vitamin A — make those dead skin cells less sticky so they can come out of the pores and turn over. So there's actually now — we didn't have over the counter versions of that — but adapalene has come out as an over-the-counter medicine that can do that function. So we start with those with the little lesions. When you start to get more redness, more pustules, more inflammation underneath, then we start to think more about topical and oral antibiotics. And then once we get into the cystic lesions, the nodules, the things that are more likely to scar, then we either get more aggressive antibiotics, hormonal interventions, or the Accutane®, the isotretinoin.

John Horton: OK, all right. What about … we had mentioned when you get acne on other parts of your body, what do you do if you're getting it on your shoulders or back or, I mean, other areas like that? What kind of treatment options do you usually look for?

Amy Kassouf: So what I find generally is it's hard to reach all those places on a regular basis. Hard to apply twice a day. The skin's a little thicker. It doesn't penetrate as well. I tend to use washes because you can do that in the shower. You can get a back scrubber and do that with a wash. But I also use a lot more oral medicines. The skin's a little thicker … if you get a little help from the inside out, then you can get the acne under control better.

John Horton: That makes a lot of sense. So it is tough to reach, if you can't see it, it's a little tough to put some ointment on.

Amy Kassouf: And you don't always have somebody who wants to help you with that, yeah.

John Horton: All right, so what about, now, we've all had that really unfortunate pimple that you get and you just cannot resist the urge to pick at it. Should you be hands off? I mean, should you just do everything you can to try to stay away?

Amy Kassouf: The problem is, sometimes, you do it and you drain that pimple and it does heal up a little faster. Most of the time, you do it, and if it ruptures underneath, it gets worse.

John Horton: It gets angry.

Amy Kassouf: Exactly. So you're better off sort of letting it run its course. We do have sort of emergency pimple treatments we have for people who are getting married, going to prom, big events like that, make it go away in a day or two. But, yeah, it's better to let them be.

John Horton: So you can get those, those sort of blemishes, if you want to get rid of them in a hurry, are there products you can get over the counter, you can go to the store and emergency stuff? Or is that you need to go in?

Amy Kassouf: Well, so there's pimple patches and things like that that have a modest effect. So you can try some of the things over the counter and there's some effect from them. If it's a really big one and you have a really big event, then you're better off coming in.

John Horton: Get the good stuff.

Amy Kassouf: Yep, absolutely.

John Horton: All right. So we've talked about treatment and how everything kind of forms. Let's talk about prevention a little bit because the best way … you'd rather not treat it, just not have it. A lot of people wonder about vitamins or supplements to try to keep acne at bay. I mean, do those work mean? Is there anything to it?

Amy Kassouf: That's a really good question. And the studies are fairly mixed. In general, we also used to figure out, well, what can we blame for our acne? Everybody wanted to blame the chocolate or the soda pops or that kind of thing. And it turns out that when you look at all these studies together, probably the one thing to avoid is a diet that's high in simple sugars.

John Horton: Like candy and things like that. I mean, you're talking like the really sweet stuff.

Amy Kassouf: Well that, and actually, it turns out that dairy has a little bit of lactose in there, and that lactose is actually stimulatory for some of the acne as well. So if you lower your dairy intake, if you watch your simple sugars, that can be preventive.

John Horton: Now, are there things that you can take that might help? I mean, I think I've seen vitamin A or zinc, stuff like that. Is that just, kind of, maybe it does, or is there any proof that it might help?

Amy Kassouf: So vitamin A is a really interesting story. So a lot of our topicals, like retin-A, are vitamin A derivatives, adapalenes, in that family. Tazorac® is in that family. So a lot of those molecules do make the dead skin cells less sticky. They help it come out. People did take high doses of vitamin A for a while and it helped their acne. It turns out that's very toxic. It's toxic to your liver. It's a vitamin that can build up. And so they developed Accutane® or isotretinoin to be a vitamin A type molecule that's actually less toxic than taking large doses of vitamin A. So we do use that, but it's not something that you do at home on your own.

John Horton: Well, it's something you want to be careful, and I know we talk about this a lot. I mean, I think people just assume if you take vitamin A, it's going to be good for you. But with any of these, if you start messing around too much, there could be side effects and you want to be careful.

Amy Kassouf: Yeah, it's totally counterintuitive. You would think that the natural form would be less toxic than the medicine and it's the opposite.

John Horton: OK, all right. What about just some natural ways? I mean, we talked vitamin supplements, but just things that you can do as part of a normal healthy routine that might help keep your skin clear?

Amy Kassouf: Sure. I like foaming cleansers. I like things with a little surfactant that helps get the pollutants off, get the oils off, help with that turnover a little bit, just to keep everything nice and clean. So that's probably my No. 1 thing that I like people to do is just use a foaming cleanser. Some people think they're too sensitive and they like the lotion cleansers, but you can find a foaming cleanser that's still good for sensitive skin and can help that acne.

John Horton: And I think, just, I mean, regular — I hate to say just a “regular” throw wash, wash cloth, soap, scrub your face, should take care of a lot of problems.

Amy Kassouf: There's a lot of devices out there that twirl and help you exfoliate. You can overdo it. A little bit is good. A lot is not better. So you don't want to scrub your face to the point where the tops of the pores swell and everything backs up. A little gentle exfoliation is good, even the extra devices are OK to some degree, but I wouldn't overdo them.

John Horton: Right. I've heard, too — is there something where if you apply makeup all the time, you should be cleaning your makeup brushes? If you just reuse them over and over and over again, I think you probably get crud on them and then that's getting on your skin and causing problems.

Amy Kassouf: You get those oils on there, you can get some of those bacteria on there from your skin that like your oils and so, yeah, you should wash them. And a lot of the good brushes you can wash in shampoo.

John Horton: Oh, wow, OK. What about just some lifestyle changes that you could do if you're having breakouts? Is there, I don't know, you limit fast food or chocolate or what kind of things could you look to do?

Amy Kassouf: So we talked about the low glycemic index diet. That's the word I forgot before. So diets generally a little bit lower in simple sugars, somewhat lower in dairy, that's a really good thing. Diets high in antioxidants — so antioxidants are very helpful for your skin to help it heal. So brightly colored fruits and vegetables. Blueberries are awesome, and things like that will actually help your skin be able to recover faster and not break out so much, decreases inflammation in general in your system.

John Horton: Yeah, it always amazes me how much if you just eat right, it solves so many problems that we have. Is there anything that we haven't talked about today that you think would be important for our listeners to know about acne and skin care?

Amy Kassouf: The one thing that I find that generally doesn't get out there enough is that especially for … well, solely for women … a lot of birth control options that have just progesterone, some of the IUDs, some of the implants, things like that, can actually stimulate acne a lot. And there are cases where all I have to do is stop that medication. So you do have to look at your medications, you do have to look at other things that you're doing differently to see, "Maybe this might be participating in the cause of my acne."

John Horton: Well, and it sounds like then that's probably something you do. If somebody comes in, you try to dissect kind of what, "Have you had any changes lately? You taking new medication? On a new diet?" and that can sometimes give you a clue.

Amy Kassouf: Yeah. And sometimes it's as simple as just stopping that, which is really nice when that happens.

John Horton: If only it was always that easy.

Amy Kassouf: It's not always that easy, but it's always nice, yeah.

John Horton: Oh, Dr. Kassouf, thank you very much for joining us today. I appreciate you lending us to your time and your expertise.

Amy Kassouf: Awesome. Nice to be here.

John Horton: If you'd like to schedule an appointment with a Cleveland Clinic dermatologist, please visit or you can call 216.444.5725. Thank you for joining us today. Bye-bye.

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