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Dr. Tarbox: Hello and welcome to "Skincast," the podcast for people who want to learn how to take the very best care of the skin they're in.

I'm Dr. Michelle Tarbox, a dermatologist and dermatopathologist at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hey Hello, everybody. This is Dr. Luke Johnson. I am a pediatric dermatologist and general dermatologist with the University of Utah in Salt Lake City.

Dr. Tarbox: So what are we going to talk about today, Luke?

Dr. Johnson: Hey Today, we're going to talk about alopecia areata. This is a condition that affects 1% to 3% of the population, so it's fairly common. So again, that means if you just grabbed 100 random people off the surface of the earth, 1 to 3 of them would have alopecia areata.

And alopecia areata shows up as bald spots. Usually they're little circles. Usually they're on the scalp, though people with alopecia areata can also lose hair elsewhere on their body.

Dr. Tarbox: And there are some celebrities that have it, right, Luke?

Dr. Johnson: Hey Yes. As you might guess, since 1% to 3% of people have it, there are some celebrities who have it. One of them recently brought the condition into public viewing, front and center, Jada Pinkett Smith. I don't pay too much attention to this stuff, but I was told that there was slapping of movie stars at the Oscars and it was a big deal. I've heard the term Slapgate, I think.

But apparently, Jada Pinkett Smith has the condition. So do Tyra Banks, Selma Blair, Christopher Reeve, and an actor named Matt Lucas. I'm a big nerd, so I know that Matt Lucas was in "Doctor Who," and I also saw him in "The Great British Baking Show" when I was walking past my wife while she was watching "The Great British Baking Show."

Dr. Tarbox: Yeah. And I think that Slapgate somewhat, as some people are calling it, emphasizes the emotional nature of hair loss. So hair loss can be a condition that has a significant psychological impact on the patient, and something, especially for female patients but also for male patients, that sometimes causes quite a lot of anxiety or potentially depression, sometimes avoiding social interaction because they don't want to have to explain.

Dr. Johnson: Hey Alopecia, by the way, is just the medical term for hair loss, and alopecia areata is this particular type of hair loss. There are lots of other reasons for people to lose their hair. Androgenetic alopecia, for example, is the medical term for just male-pattern hair loss or female-pattern hair loss.

But all hair loss is pretty crummy. People like their hair. I like my hair. I hope it doesn't fall out. But if you notice that you or your child have started to get circular bald spots, there's a pretty good chance it's alopecia areata because there's not a lot of other stuff that looks exactly like that.

Dr. Tarbox: And that last name of the condition, the areata part of alopecia areata, comes from a Latin term meaning area and referring to the vacantness of it, so an empty space. And so while other kinds of alopecia lead to generalized thinning sometimes, a completely hairless patch is less common, disregarding the kind of large central patch that might happen in advanced androgenetic alopecia. So a completely hairless patch anywhere on the scalp might be this condition.

Dr. Johnson: Hey It's an autoimmune disease. It's caused by the immune system attacking the hair follicles. Why does somebody's immune system decide to attack their hair follicles but somebody else's doesn't? We don't really know. Kind of like some other conditions we've discussed like vitiligo. We assume there's a genetic predisposition, so something about somebody's genes puts them at risk for it. And then something kind of triggers to make those genes become active, and then the immune system is off to the races.

Dr. Tarbox: And those triggers can be variable. The most common one that patients express is stress-related. Often, you'll see this condition arise maybe in a child whose family is moving or whose parents are going through a divorce. You may see it in young patients who are going through college entrance exams, but it can also just occur all by itself.

Dr. Johnson: Hey And whenever we talk about stress making things worse, I like to emphasize that it's not your fault that you're so stressed, and because you're not dealing with your stress appropriately, that's why your hair is falling out, because that's nonsense. Everybody has got stress and sometimes these genes just play tricks on us.

Good news is that there are treatments for it, if you want to treat it. Like we talked about with vitiligo, there are some people who could be really, really bothered by the appearance of their hair not being there. And then there are some people who just don't care and live their life kind of ignoring it. And there are some people who kind of like the way that it looks and wear it loud and proud.

So that's one reason I think it's kind of helpful to talk about these celebrities because some of them, like Matt Lucas, seem to wear it loud and proud and serve as advocates for patients who have the condition.

Dr. Tarbox: Yeah. But there are lots of treatments for it. So some of the things that we usually start with are topical steroids. These medications are relatively easy to use, relatively simple to obtain most of the time, and are relatively predictable in how they're going to behave on the skin.

Often, we'll either use a liquid solution or a gel. The scalp has got hair on it, so putting a cream on that ends up with kind of a lot of crusty cream mess on your hair and people tend not to like that.

In patients who have a more coiled hair structure, sometimes we'll use an ointment base because the moisturizing nature of that might help prevent hair breakage that an alcohol-based solution might exacerbate.

Dr. Johnson: Hey Good news is that whether we treat it or not, the odds are that the hair will recover. Unlike some other conditions that we've discussed, this one usually kind of just gets better on its own in the majority of cases. Probably at least two-thirds of cases, if we do nothing, in a year the hair will all be back to where it was before the condition began.

So this is what I tell patients and their parents. I say, "We do have some medicines that we can use that can probably help the hair come back faster, but if you're like most people with the condition, it's going to come back whether we do anything or not."

Of course, if you look up the condition on the internet, you'll find the dramatic situations where that was not the case, but in most people, it comes back on its own. So that's another reason why treatment might not be necessary.

Dr. Tarbox: But if you do have a condition that is getting worse or not improving, there are a lot of options. So we start with the topicals. If those are not working and the patient is amenable and capable of tolerating it, we sometimes will do intralesional-injected steroids, meaning we take a syringe that has the medicine inside it and we actually inject the medicine directly into the patch of hair loss. This is sterile medicine that's intended for injection, so this should only be done in a physician's office who has experience with the treatment, but it can be very effective.

Dr. Johnson: Hey If you've listened to other episodes of "Skincast," you probably have heard us talking about immunosuppressant medications. So these are fancy medicines that you take by mouth or even that you get injected, which turn down the immune system overall. They have names like methotrexate and cyclosporine and mycophenolate and azathioprine.

We can use them in dermatology when the immune system is rudely being overactive in particular parts of the skin. But as we have mentioned before, they have significant side effects, as you might guess, since they have such an effect on the entire body, so we prefer not to use them. That said, most people who take them don't really have any significant side effects and it can be really helpful to help stop hair loss in this condition.

Dr. Tarbox: Other things that can potentially be useful? There are some specialized treatments that are also used in physician offices, including platelet-rich plasma where blood is actually taken from the patient, centrifuged, and then the platelet-rich fraction of that is re-injected into the area of hair loss.

Red light therapy has also been beneficial for some patients. Not every red light device is equal. You actually do want something that has near-infrared wavelengths. So the most effective ones that are available over-the-counter to the lay populace is the Theradome, the Hairmax laser comb, and some versions of the iRestore. So those are different red-light-emitting devices that can be helpful for hair loss of all kinds and also for alopecia areata.

Counter-irritants is another thing that might be done in a physician's office where they may apply a little sensitizing agent to part of the skin and then use a lower concentration of that to elicit a very low-level contact dermatitis, which sort of switches the type of inflammation that's happening in that skin away from the kind that's attacking the hair follicles to the kind that makes a dermatitis. And so you sort of trade one problem that's a more problematic issue for a slightly less troublesome problem that's easier to treat.

And then there's a special kind of laser-like device that's called a laser but it's not really a laser. It's called the excimer laser. And it has a UV wavelength that can be used with the targeted hand piece to help treat patients who have these patches of hair loss.

What are some other medications that are coming up, Luke?

Dr. Johnson: Hey There are some new medications in therapeutic trials for this condition. There is a type of medicine called a JAK inhibitor, which shows a lot of promise even for people who've had alopecia for a long time.

So kind of like we discussed with vitiligo, the longer the hair loss is present, the harder it is to regrow the hair. But some patients who have had hair loss for even 10 years or more, again this particular type of hair loss, alopecia areata, have regrown their hair with these medicines. And they look pretty safe. So they're not FDA approved yet, but my guess is that they will be in the next one to two years.

Of course, some people who have more extensive hair loss, as you might guess, prefer to disguise or camouflage the areas of hair loss with hairpieces and extensions and things like that.

Dr. Tarbox: And most of the time with the camouflaging agents, those are going to be something that you clip into the hair or put on top of the hair. There are camouflage powders such as XFusion or Viviscal fibers or something called Toppik. Those work well for most types of alopecia.

If you have a completely hairless patch, though, they won't work because the way they work is to attach themselves through an electrostatic charge to hair shafts. And if you don't have any hair shafts in that area, there's nothing for that kind of sprinkle powder to attach to. So it might have to be more of a scalp applied dye or a hairpiece.

Dr. Johnson: Hey But look at all the medications that are available. So if you or somebody you know has alopecia areata, and you want to treat it, then you should probably see a doctor, perhaps a dermatologist, because there are lots of treatments we can use.

Dr. Tarbox: Is there anything else that people who have alopecia areata need to worry about, Luke?

Dr. Johnson: Hey Well, like with other autoimmune diseases, if you've got one, then there's a chance you might have another. Most people who have alopecia areata do not have other immune diseases. But if they do, the most common one is thyroid. So perhaps your doctor would want to check a little bit of lab work, especially if you have other symptoms of thyroid disease.

And like other autoimmune diseases, we can't change your genes yet. I guess CRISPR-Cas9 might be coming. But for now, if your hair does come back, which again is the norm, it might come out again. So a common story is little 6-year-old kid develops alopecia areata during a move, hair comes back just fine, and then that same kid becomes a college student and again loses patches of hair while studying for finals. It might happen.

Dr. Tarbox: One thing I want to emphasize is that sudden patchy hair loss is pretty much never normal. So it should probably be seen by a physician, because there are also other conditions that may cause patches of hair loss on the scalp.

There's something called alopecia neoplastica, which is actually a condition where some kind of cancer actually metastasizes to the skin of the scalp because of the specialized structure of some of the veins in that part of our body. And you can end up with a lumpy patch of alopecia. If you have a patch of hair loss that's got lumps underneath it, you need to see a doctor quickly because that could be something called alopecia neoplastica.

There are also certain infectious conditions that can cause patchy hair loss, including tinea capitis, which is basically ringworm on the scalp. So a fungal infection on the scalp can cause hair loss and should be treated with medical attention.

And then hopefully not too commonly, but syphilis can also cause some patchy hair loss on the scalp and is a condition you would definitely want to see a physician for if you had concern that might be something you had.

Dr. Johnson: Hey And I mentioned that most patients with alopecia areata, the hair just recovers on its own. Sadly, that is not the case for everybody. So perhaps a third or a bit less of patients will progress. So these are the patients you're likely to see if you Google alopecia areata image search. And there are individuals who then lose all the hair on their scalp, or even all the hair on their head including eyelashes and eyebrows, or even all of the hair on their body as well.

And when it's that extensive, it gets special names. So alopecia totalis is the name if you lose all the hair on your head and alopecia universalis if you lose all your body hair.

Again, some people are not bothered by it. It's not a medically dangerous condition. Some people choose to just go on "Great British Baking Show" as a host. But if you do notice that your hair or your child's hair is progressing to that degree and you want to do something about it, you want to see a doctor sooner rather than later so we can implement some of these therapies.

Dr. Tarbox: Well, I hope everybody has gotten to learn a whole lot about alopecia areata today. If you're really interested in alopecia areata, and you want to dive deeper, you might want to listen to our other podcast.

Dr. Johnson: Hey We talk about all kinds of stuff on this other podcast, including alopecia areata and a lot of different dermatologic diseases and treatments and things. It's called "Dermasphere." We say it is the podcast by dermatologists for dermatologists and for the dermatologically curious. So if you are a dermatology nerd, like we are, then you can come hang out with us there on Apple Podcasts or wherever you get your podcasts.

Dr. Tarbox: And of course, we also want to give our special thanks to our institutions.

Dr. Johnson: Hey Yes, thanks to the University of Utah for supporting the podcast and thanks to Texas Tech for lending us Michelle. You can find our "Skincast" archives on Apple Podcasts or wherever you are finding your podcasts. And you can find the next episode of "Skincast" hopefully in two weeks. We'll see you then.

Dr. Tarbox: Hello and happy holidays from Skincast. We’re taking a little break to refresh ourselves over the holidays, but don’t worry we’ll be back soon with more information on how to take the very best care of the skin you’re in.

Dr. Johnson: We are working on some brand new episodes — hopefully with some fun guests — so we will see you then!

Dr. Tarbox: Hello and welcome to "Skincast." This is the podcast that helps you understand how to best take care of the skin you're in. You wear your skin your entire life. It is the most expensive garment you will ever wear so you want to take great care of it.

My name is Michelle Tarbox, and I am a dermatologist and a dermatopathologist. I'm an associate professor at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas, and I love helping people take better care of their skin. And joining me is my co-host...

Dr. Johnson: Hey, this is Dr. Luke Johnson. I'm a pediatric dermatologist and general dermatologist with the University of Utah.

Dr. Tarbox: So today we're going to go over acne basics. Acne is a common skin condition that affects most people at some point in their lifetime, and utilizing a few simple techniques you could really help minimize the impact of this condition on your skin.

Dr. Johnson: So acne is super annoying. I had pretty bad acne when I was a young lad. I still get the occasional pimple even though I'm 40. Really seems unfair. But when I, you know, became a dermatologist, we learned about what causes acne. And actually, I remember being a teenager sitting in my dermatologist's office and looking with fascination at the posters on the wall about the causes of acne.

So, in dermatology, we consider acne a disease of the hair follicle unit. So one of the first things that happens is that the hair follicle gets kind of blocked up with sticky skin cells. And the hair follicles are often connected to oil glands, and the oil glands produce oil. The special term for this kind of oil is sebum. And so since the sebum can't get out of the hair follicle because the hair follicle is blocked up, the hair follicle gets all kind of filled up with this sebum.

Dr. Tarbox: And one of the interesting . . .

Dr. Johnson: Who likes to eat sebum? Bacteria like to eat sebum. So bacteria come to eat it, and then that creates an inflammatory reaction from your immune system and that sort of really gets the whole ball rolling down the hill.

Dr. Tarbox: That's actually one of the things I like to think through as kind of fascinating that these bacteria, which are called Propionibacterium acnes — they're named after the condition that they cause — are almost like little farmers of the oil that they eat. So they actually make our skin cells more sticky to each other so it plugs up the hair follicle more, and that actually makes a little reservoir of oil that these bacteria can use as a food source.

Dr. Johnson: And you might wonder why this tends to get worse around adolescence. And hormones play a big role as you might guess. A lot of the hormones make your oil glands crank out more oil and they make your skin a bit stickier so it makes the whole thing worse.

Dr. Tarbox: Whenever you have that backup of oil, it can actually break open the edges of the hair follicle and then that skin oil and possibly those bacteria and the dead skin cells get into the part of our skin that's not supposed to have foreign bodies in it. So if you've ever had a splinter and it got inflamed and red and irritated, you know how much our skin doesn't like things that don't belong there. And that oil is just as inflammatory.

Dr. Johnson: I think it's helpful to understand why acne shows up because then we can understand how the treatments work. So the treatments for acne affect some of those factors that cause the acne to begin with. And our best treatments are those that can affect more than one of those factors at the same time.

Dr. Tarbox: Here on "Skincast" we are not sponsored, but we are going to mention specific trade products because it makes it easier for patients to find them and I think that it's a little bit less complicated than people scouring an ingredient list looking for a specific and very technical chemical name.

Dr. Johnson: Yes, we have no commercial interests. This is just stuff we found that is good for our patients. And if you've got some acne, then there is some over-the-counter stuff that's fairly helpful. One of my favorites is a medicine called benzoyl peroxide. Not hydrogen peroxide. That's something else. This is benzoyl peroxide. It's in a lot of over-the-counter acne treatment products. So if you stroll down the acne treatment section in your local grocery store, you'll find benzoyl peroxide in various concentrations. Usually it's something like 4% to 10% that's present in cleansers, in spot treatment pads, in creams, and in various other formulations.

Dr. Tarbox: Benzoyl peroxide can be a great help when you're dealing with acne. One thing you do have to be thoughtful about is that it has peroxide in it. So if you've ever bleached your hair or thought about bleaching your hair, you might know that peroxide can lighten things. And it's true that if you have a benzoyl peroxide product on and it gets on a bed sheet or a towel or clothing, it can lighten or bleach the clothing. If you have fine light brown hair, it can also lighten your hair color around the hairline.

Dr. Johnson: Yeah. So this is one reason why I like it as a wash or a cleanser. I figure most people are washing their face anyway. Might as well put some medicine in there so you don't have an extra step to do. I say wash your face in the morning with this stuff because then they're not immediately putting their face on a pillowcase and discoloring their pillowcase. You do want to use white towels though or you'll have some messed up looking towels. That's the main downside with this benzoyl peroxide stuff.

It can also be a little bit irritating to the skin. In general, the lower percentage, the less irritating it is. So how sensitive is your skin? If it's not that sensitive, just buy whatever's cheapest, like I do, the generic brand. But if it's a little bit sensitive, there's a couple brands out there that are especially gentle. There's one called AcneFree. All one word. You might have to get it online. It's 2.5%. And then CeraVe makes a good one called Acne Foaming Cream Cleanser. It's 4% benzoyl peroxide. Also, very gentle.

Dr. Tarbox: I really like that CeraVe product, and I think that patients can do really well with benzoyl peroxide. Some people can't tolerate it, and, in that setting you can potentially use a milder wash made from something called salicylic acid, which is actually a relative of aspirin.

Dr. Johnson: Yeah, I do prefer benzoyl peroxide, but salicylic acid doesn't have this bleaching property and is usually present again in the same sorts of products that benzoyl peroxide is found in. Usually it's 2%. And if the benzoyl peroxide is just too irritating or you hate that half of your clothes are discolored, then salicylic acid is a decent option.

Dr. Tarbox: If you are aspirin sensitive, you would not want to use salicylic acid, and if you're pregnant, you would not want to use salicylic acid as it is a derivative of an aspirin-like chemical.

There's another wash that I really like for patients who have very sensitive skin that can't tolerate benzoyl peroxide or salicylic acid. This is a product from Cetaphil that actually has zinc sulfate in it, and it's an oil control acne wash.

Dr. Johnson: So there's our cleansers. Something else that's really nice that's over-the-counter is a medicine called adapalene. The brand name is Differin, D-I-F-F-E-R-I-N. Differin the brand makes several products now I think. So you want the one that's called Adapalene, is the medicine.

Until about five years ago, this was a prescription product that cost about $220, and now it's an over-the-counter product that costs $12. So a rare example of medication costs moving in the right direction. It comes as a gel, and you put a little blob of it on your finger. I usually recommend that people do it at night. And then you get that blob on your finger and you kind of dot it all over your face and then you rub it in everywhere.

So neither of these approaches is a spot treatment. Both of them go over your whole face because they help prevent acne from showing up as well as treat acne that's currently there.

Dr. Tarbox: If you're looking for adapalene over the counter, there are a couple different brand names. Differin is the original brand name, but you also can buy it as a La Roche-Posay product. That's a French company that retails products across to pharmacies in the United States. And the name of that line is Effaclar.

Dr. Johnson: I did not know that. It can also be a little bit irritating. Usually not too bad. But I usually tell people if it dries you out, just give your skin a break for a day or two, let your skin recover and then come back to it. Most people's skin will kind of get used to it. If you find that you're using it every night and it's not irritating you at all, well, you could probably step it up to a prescription strength version of the same thing.

Also, this is a retinoid. So there are components called retinol that are in a lot of over-the-counter sort of anti-aging products. And they also work. They're pretty similar to adapalene. They tend to be a little bit higher priced though. But the reason that they are in these anti-aging products is because adapalene and retinol and all these things are good not only for acne but also for scarring, for wrinkles, for dyspigmentation, so pigmentary changes in your skin. Basically, anybody who's not pregnant or breastfeeding should probably be putting one of these things on their skin.

Dr. Tarbox: Yeah, I love my topical retinoid. I don't leave home without it. Speaking of irritation, sometimes people, when they have bad acne or acne that they're frustrated with, will really kind of go after it with everything and the kitchen sink and they can end up really stripping their skin and making it too irritated and dry, which can actually make the acne worse.

Dr. Johnson: Yeah. So just as important as knowing what to do, things like benzoyl peroxide and adapalene, are knowing what not to do. So your poor little skin doesn't need astringents, it doesn't need scrubs, and it doesn't need things that are just too expensive. So sometimes I have patients who come in and they bring their Ziploc bag full of products that they've been using and I love it when people bring them, but it kind of breaks my heart that they've been spending 20 or 30 bucks on a benzoyl peroxide cleanser because you can buy one of those for 4 or 5 bucks.

So things don't have to be expensive, in fancy bottles, and advertised on television for them to work well. You just want to look for these ingredients — benzoyl peroxide, adapalene, retinol, things like that.

Dr. Tarbox: Sometimes patients will also over exfoliate. There are products that are coming off of the market because they have microplastics in them with those little beads that sometimes were included in products for exfoliation. And there are also products that have ground up walnut shells and things like that, which are pretty abrasive to the skin and can do more harm than good. If you want to gently exfoliate, a gentle facial brush that you keep clean and use with minimal pressure is a great alternative.

Dr. Johnson: So those are pretty good things that you can do over the counter. But what if you've done those or your teenage kid has done those and they've still got acne? Well, it might be time to go to a dermatologist. Another reason to go is even if you haven't tried those things, if somebody's acne is moderate or worse and all of those over-the-counter things just aren't going to be good enough, come to one of us. There's really good acne medicines these days. Really the only downside for our acne medicines is that they take a little while to work. So I am sorry if you are getting married next week. There might not be a whole lot that we can do. So come early. It usually takes our medicines about three months to really kick in, but after that, modern medicine does a pretty good job of treating acne.

Dr. Tarbox: Yeah, I always remind patients if your acne is leaving footprints, if it's scarring, you want to seek professional help because scarring is permanent and while we can do a lot of things to help improve those sort of scars that are formed over the years, like chemical peels and microneedling, it's better to prevent than to treat those scars.

Dr. Johnson: I would like to have a little myth-busting section of our podcast here because I think there's a lot of myths out there around acne. One of the main things that gets bandied about is diet. So there's been a fair amount of research into diet and acne, and I will admit that, before I read some of this research, I just didn't think diet mattered at all. Now I think that diet matters... just a little bit.

So the research says that if you have a high glycemic diet — so that's a diet where you eat a lot of like sugar and fat and carbs and things — that can make your acne a little worse. And for some reason, skim milk specifically has been associated with acne. Again, I think the effect is pretty mild. So if you have a high glycemic diet and you drink a bunch of skim milk, instead of having five pimples a month, you might get seven. So it's not really going to make or break things, but there is some data out there. So if you want to listen to your grandma and not eat that bag of Doritos, it might help your face a little.

Dr. Tarbox: Yeah, the skim milk connection is really fascinating, because when you have skim milk, it's had the fat taken out of it so more of that product is protein. And our hormones are proteins. Animals that aren't raised organically sometimes have extra hormones added to make them big and strong and overproduce milk, and those can affect some patients. If you are sensitive to that, going for the organic alternative or going for a vegan alternative may help you.

What about cleaning the skin, Luke?

Dr. Johnson: Well, I don't think cleanliness is as important as a lot of, well, to be honest, mothers and grandmothers seem to tell their children and grandchildren. Obviously, you should do something, but blackheads, for example, are not black because there's dirt in there. That's the sebum, remember the oil, and it just gets oxidized when it's exposed to the air and it turns black. So it's not dirt in the skin. And you don't need to be overly vigorous, as we've discussed, with these scrubs and things. So I think washing your face once a day with something gentle, especially with something with some acne medicine in it, like we've discussed before, is probably all you need to do. But having acne does not mean you are an unclean person.

Dr. Tarbox: That is such a good thing to tell people because sometimes there is a stereotype that goes along with bad acne especially. If I have an active young person that's a student athlete, I do like for them to cleanse their skin after exercising, and the product I really like for this is something called Simple Face Wipes because they're little pre-moistened towelettes in a little convenient packet that can go right in the gym bag and the patient can just wipe their face down after exercising or sweating and it helps to decrease that kind of post-exercise gunk that sort of stops up the hair follicles.

Dr. Johnson: When we think about acne, we're often thinking about teenagers, but acne can show up in other people too. It can show up in adults, especially women, in which case it's often hormonal and we do have hormonal treatments. So there is hope out there if you are such a woman. Come in and see us. We can do stuff. And then I can see it in fairly young kids too. So, from hormonal standpoint, puberty supposedly begins around age eight. And, you know, having a couple of little kids of my own, that's rather terrifying. But I have seen acne show up in, you know, eight years, nine years. Usually, it's pretty mild, but I have had some significant acne in kids as young as about 10.

Dr. Tarbox: There's another special form of acne that can happen in young women called acne excoriée, and it actually has a French name. It's acne excoriée des jeunes filles ,which means 'the picked-on acne of the young woman'. And this is usually occurring in young women who are a little bit stressed out, often successful, intelligent, driven young ladies that sort of express a little low-level anxiety by picking at the acne lesions often sub, kind of, consciously. So bringing that to your attention, if you are a person that picks at the skin lesions, is a good idea and you should remember that the little scars and the marks that are left behind after manipulating or picking at an acne lesion are going to last longer and scar worse than the acne lesion itself.

Dr. Johnson: Don't pick at your acne. There. You heard it from some dermatologists.

There are some other sort of special forms of acne. Most of the time, when we see acne, it's standard acne or what's called acne vulgaris. But there's a form of acne called acne mechanica. So if you're wearing something like a mask, for example, on a part of your skin, then that can further occlude those little hair follicles and make acne a lot more likely. So maskne is a form of this acne mechanica stuff. People who wear a lot of sporting equipment, you know, goalie masks and things or fencing masks, I've seen it or surgical caps. I've seen that in surgeons because it occludes their forehead and they get acne there. I see it in military recruits who have to wear backpacks a lot. They get it on their back. That kind of thing.

Dr. Tarbox: You can also get acne from products that are put on other parts of your body. So if you use heavily oil-based products on your scalp, over the course of the day the heat from your body will melt those products and it just sub-clinically trickles down from the hairline to the eyebrows and patients can have a flare of acne on that forehead region because of their hair care products.

Dr. Johnson: Apparently, according to the textbooks, acne is also worse if it's really hot or humid. I live in Utah, where it's really hot, especially today, but it's not humid. But it has its own special name — tropical acne. So if you are a military recruit in some tropical place, I hope your back does okay.

Dr. Tarbox: There's certain medications that can also cause acne. Steroids, either steroid hormones, like the male and female type hormones, or steroids such as glucocorticoids or prednisone can cause acne to worsen as can other kinds of medications that are sometimes used to treat seizure disorders.

Dr. Johnson: But if you are taking one of those medicines and you get acne, we can help. So, you know, if you need to take testosterone or you need to take other hormone replacement therapies and things, then it makes sense to come see one of us if the acne is giving you trouble.

Dr. Tarbox: And especially if it's an anti-seizure medication. Those are not medicines you want to mess around with. So, you know, you would continue to take those based upon the recommendation of the doctor that takes care of you for those and then seek the expert advice from a dermatologist.

Dr. Johnson: I hope that you guys found this helpful. And we want to thank our institutions. Thanks to the University of Utah and to Texas Tech. And if you are a real dermatology nerd, you might be interested to know that Michelle and I co-host another podcast, which is really targeted at people practicing dermatology, but hey, maybe you'll find it interesting as well. It's called "Dermasphere," D-E-R-M-A-S-P-H-E-R-E.

Dr. Tarbox: Hello, and welcome to "Skincast," the podcast that teaches you how to take the very best care of the skin you're in. I'm Dr. Michelle Tarbox. I'm a dermatologist and dermatopathologist at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: Hey, everybody. My name is Dr. Luke Johnson. I'm a pediatric dermatologist and a general dermatologist with the University of Utah.

Dr. Tarbox: So today, we thought we would take on a multi-part episode about how to improve the appearance of your skin, and what you can do at home for that, and what you can do in the office for that.

Dr. Johnson: This is called "Cosmetics." There are a lot of people in the world who are very interested in cosmetics, and many of them are dermatologists, because we take care of the skin, take care of skin disease, and we can also improve its cosmetic appearance.

Michelle does a lot more cosmetics in her practice than I do. Full disclosure, I really don't do any. But if you live in Salt Lake City and you are interested in some cosmetic stuff, I certainly know some basics, but the University of Utah has a great cosmetics division. Michelle, however, will probably be doing most of the talking for this episode.

Dr. Tarbox: So we have a broad array of things that can be done at home, habits that you can start to implement, and procedures that can be performed that can help improve the appearance and health of the skin. One of the most important things is to have a good basic skincare regimen. So where do you usually start with that, Luke?

Dr. Johnson: Well, if you guys want to know exactly what Michelle and I do for our personal skincare routines, we have a whole episode about it. That's Episode 6.

Well, what I do, which I'll just give you guys in a nutshell here, is make sure I wash my face in the morning. And then I put on sunscreen, generally a moisturizer with sunscreen. So there are a lot of products out there referred to as daily facial moisturizers, which are moisturizers for your face that also tend to have sunscreen in them. Those are nice because they're formulated for the face. They won't clog up your pores and give you acne, and they usually have SPF at least 30.

And there's evidence that even just visible light, so the light wave just striking our skin from you having lights on in your home or at your place of work, can cause some aging appearance of the skin. So I always put on sunscreen, whether I'm going to go outside or not.

Dr. Tarbox: I think that's a really good habit to have, and you never really know how you're going to run into the sun in your day-to-day activities. So we are recording this episode in the middle of December, and in the wintertime, there are even more considerations for good skincare health.

So I like to tell patients to avoid foaming agents in the wintertime. One of the most common ones that's in over-the-counter products is called sodium lauryl sulfate. So if you look for sulfate-free cleansers or gentle cleansers, that's often going to be a good place to start.

My very favorite cleanser for the skin is the CeraVe Hydrating Cleanser. Here on "Skincast," we're not sponsored by anything. We don't have any relationships with any of these companies that make these products. These are just ones that we found that are helpful for our patients.

So the CeraVe Hydrating Cleanser and the Neutrogena Ultra Gentle Daily Foaming Facial Cleanser are the two that I like.

Dr. Johnson: And the reason that winter tends to be tough on the skin is because the world is drier. It's dry because usually just outside, there's less humidity, but even more importantly, it's cold in our houses, and we don't like that, so we turn on our heaters and the heaters are also quite drying. They kind of take the moisture out of the air as well.

So you may have noticed that your skin tends to be drier in the winter, that your eczema, if you have some, tends to flare in the winter. That's very common. And these ingredients like sodium lauryl sulfate that tend to make a cleanser foam, because people like things that are foamy, they associate that with cleanliness, can be extra irritating to skin that might be already a little bit more irritable in the winter.

How do you feel about sodium laureth sulfate?

Dr. Tarbox: It's very similar in terms of its foaming capabilities and ability to sort of strip the barrier from the skin, the moisture that's natural really there. So, if you can stick with a product that doesn't foam and cleanse your skin very gently, your skin will thank you.

Dr. Johnson: And by the way, the party line among dermatologists for just a general soap is white Dove bar soap. Just tends to be a good low-cost option for use in the shower, for example.

Dr. Tarbox: Especially the unfragranced one.

When it comes to sunscreens, you want to look for a good broad-spectrum sunscreen. If you have sensitive skin, sticking to a mineral-based sunscreen is best. The ones that I personally prefer include the Cetaphil Sheer Mineral Sunscreen, which is a broad-spectrum. The CeraVe Hydrating Sunscreen, which contains niacinamide, which is a skin-healthy ingredient. And we'll talk about some of those in our next episode. The EltaMD UV Clear Facial Sunscreen, which is SPF 46 and is very gentle for rosacea or acne-prone skin.

If you want to use a CC cream, I like the Supergoop! CC cream that has a 100% mineral base and has an SPF of 50.

And then if you want to actually get really aggressive with your anti-aging, there's a product I like that's called Eryfotona Actinica. So two words. Actinica is the second word. And this is a mineral sunscreen that actually has something in it called DNA Repairsomes. These are enzymes that are made to help repair existing sun damage. So I really like those sunscreen products.

How about you, Luke?

Dr. Johnson: Well, you said if you want a CC cream, what's a CC cream?

Dr. Tarbox: Ah, so CC creams and BB creams are very similar. CC creams take things a little step farther and they have a color correction in them. So color-correcting creams have a little tint to them, which can be helpful for blocking those visible wavelengths of light. And then they also tend to have skin-healthy ingredients and sunscreens in them.

So color correcting creams, I think, is what the CC part stands for. It's similar to the BB cream. Those are just something you can use on a daily basis to help improve your skin quality and protect it from the sun.

Dr. Johnson: So, if CC stands for color correcting, what does BB stand for?

Dr. Tarbox: I think it's like beauty basic. I don't actually know what that stands for.

Dr. Johnson: I didn't know any of this stuff. See, that's what I get for being a pediatric dermatologist. But I do know that the tinted sunscreens are better at blocking out visible light, and visible light can also play a role in making dark spots on your skin even darker. So especially if you're a woman, a tinted sunscreen with an iron oxide component can be helpful.

And as you would hear in my skincare routine episode, I use a La Roche-Posay Toleriane product as a daily facial moisturizer with sunscreen in it.

Dr. Tarbox: I do like that product too.

Dr. Johnson: I found it reasonably priced and it feels good when you put it on and claims to have sunscreen.

Dr. Tarbox: And it is very gentle. So CC is for color correcting. BB is for beauty balm. Both of them have some coverage and hydration. The CC creams are usually a little bit more lightweight with fuller coverage and have anti-aging ingredients, things like the little ribosomes and things like that. So that's kind of cool.

I also think that most people can benefit from a retinoid. What do you do for your retinoid, Luke?

Dr. Johnson: So a retinoid is a vitamin A derivative, and our cells have little receptors within them that can bind to these vitamin A derivatives. And that makes our genes turn on and turn off. The overall net effect is that it's good for the skin. They're good for wrinkles. They're good for dark spots. They're good for acne. They're good for what ails you.

There are some people who think they can even help prevent skin cancer. Sometimes I have patients say, "Well, is it safe for me to just use this forever?" And I say, "Why yes, it's beneficial to use it forever. I've been using one for the last 25 years and look how handsome I am."

Dr. Tarbox: There are some myths about retinoids. Some people think that retinoids thin the skin. This is probably because some people, when they first start using a retinoid, have some skin peeling. And so people can perceive that and assume that their skin is thinning, but actually, retinoids are stimulating collagen production, which thickens the skin. The peeling is just one of the responses of the skin cells having increased cellular turnover.

Dr. Johnson: There are a lot of these different retinoid products and a lot of them will make you dry and flaky when you start, but most people's skin will get used to them. So I often recommend that you start just every other day or just go every night until you start seeing yourself get a little peely, and then stop and give yourself a break for a day or two. But then come back to them because your skin will probably get used to them.

Those that are available over the counter, there's a product called Adapalene. The brand name is Differin. And that's basically just a pure retinoid. You can certainly use that one.

And then there are a lot of products, especially those that claim to be anti-aging, that have retinol or retinoic acid in them. And that can also be effective, though it can be hard to tell which product is actually stronger than another.

Dr. Tarbox: Yeah, they will often have a percentage on them, but the way that the skin absorbs the ingredients can vary based off of the formulations of the different products. So you may have to experiment a little bit to find the one that really agrees with your skin the best.

A couple of good, easy-to-find, over-the-counter products that aren't too terribly expensive include the Neutrogena Rapid Wrinkle Repair Retinol Pro, which is a 0.5% retinol over-the-counter. That's put together very well and works very nicely for some patients.

Another one that's a reasonably priced option is Paula's Choice 1% Retinol Treatment. These are something that I can have patients use on a really regular basis, and it helps with a lot of skin issues. So retinol is generally useful for most patients.

What are other things we can do to make sure the skin looks its best?

Dr. Johnson: Well, before we move on from retinols, if you are using a retinol product over the counter and it's not drying your skin out, you might be ready for a prescription strength. So dermatologists and other doctors can prescribe you stuff called tretinoin or even tazarotene. That's stronger versions of all of that stuff. And I think the strongest version that your skin can tolerate will give you the best results.

Dr. Tarbox: That's a really good point, Luke. Well, in the time of the pandemic, we also have to think about an extra dimension of skincare, and that's caring for the things we put on our skin, which can include, in this day and age, the masks that we might wear every day. So what are some good tips for patients who are having to wear masks?

Dr. Johnson: You can use a disposable mask where you just throw it out afterward and you say, "Take that, Mother Nature." That's what I do. If you're using a fabric mask, you want to wash it. Try not to re-wear it more than one day in a row.

Dr. Tarbox: Yeah. And then anything that touches your face, you want to think about its cleanliness as well. So if you're using brushes to apply makeup, you want to think about how often you're cleansing those.

Anything that is heavily immersed in a liquid-based makeup, like a foundation makeup brush, needs to be washed at least once weekly and then allowed to dry in an upright position or laying off the side of the counter depending on the type of the brush.

Eyeliner brushes that go kind of close to the eyelid margin also should be washed once a week. Eyeshadow and powder brushes should be washed about twice monthly.

And the way that you cleanse these can be done with a gentle soap or brush cleanser, or if you use facial cleansing wipes, which some patients really like. And I tend to sometimes use those as well, especially when I'm traveling or if I'm doing a lot of theater stuff. Those are very helpful to cleanse your makeup brushes as well. You can actually kind of gently swipe the makeup brush on the facial cleansing wipe until the residue of the makeup comes off.

Dr. Johnson: That's not what I do for my makeup routine, because I don't wear makeup. But after our episode, again, about our personal skincare routines, you recommended something called micellar water to clean the skin. So my wife immediately went out and bought the brand that you recommended, which is Simple, and now she uses it every evening to wash her face off and she keeps telling me I should use it too.

Dr. Tarbox: It's a great product. It's very gentle. It's not fragranced. It helps to encapsulate the oil droplets that can be on the skin that can make makeup hard to remove or can make skin oil hard to remove. And it's a very nice, gentle way to cleanse your skin. You can also use that micellar water to cleanse the makeup brushes.

Dr. Johnson: This was the first part in our cosmetic series that we thought we'd cover stuff everybody should be doing. In the next episode, we'll talk about things you can do for specific concerns.

Michelle, anything else you want to hit here that everybody should maybe be doing?

Dr. Tarbox: Well, when you really think about it, skin is a fabric you live your whole life in, so you want to care for it gently. A lot of us tend to be a little aggressive with our skincare sometimes. I know it's frustrating when you have a blemish and you just want it to go away, but as much as you can, try not to pick or squeeze at the skin. Anything that creates any kind of redness or bleeding can potentially cause scarring. And if it's not done in a safe and controlled manner, like would be done in an office procedure, then it can leave a scar that's undesirable.

So remember, you live your whole life in your skin. Be gentle to it and take good care of it.

Dr. Johnson: I'm also suspicious of products that seem especially harsh, like astringents and exfoliators. I think most people, if they're doing this other stuff . . . A retinoid, for example, is like an exfoliator, but a much more slow and gentle and medically proven way to do it. So I generally think people shouldn't be using products like astringents, and exfoliators, and cleansers with little beads in them.

Dr. Tarbox: And the microbeads are actually being phased out of production because of environmental damage that they do. But other exfoliating cleansers, like the one that contains the walnut shells, which are basically just randomly ground up bits of walnut shell, that's a very unregulated kind of angular particle that you're rubbing aggressively against your skin, which could scratch up the skin and cause irritation. So generally, that product is not something dermatologists like.

Dr. Johnson: Well, that's what we've got for these cosmetic basics tips, friends. Thanks for listening. Thanks, of course, to our institutions. Thanks to the University of Utah for supporting the podcast and thanks to Texas Tech for lending us Michelle.

And if you are a super dermatology nerd, you might be interested in our other podcast. Michelle, you want to tell them about "Dermasphere"?

Dr. Tarbox: So "Dermasphere" is a podcast that's engineered more for dermatologists and people who are dermatologically interested. A lot of people listen to it, including medical students, residents, and industry partners. This is a longer podcast with more scientifically-based discussions about different issues that affect the skin. And it's a lot of fun, takes about an hour each time, but if you're a real dermatology nerd, you might love it.

Dr. Johnson: There are also a lot more puns, for better or worse. We'll see you next time.

Dr. Tarbox: Hello and welcome to "Skincast." This is the podcast that helps you understand how to best take care of the skin you're in. You wear your skin your entire life. It is the most expensive garment you will ever wear so you want to take great care of it.

My name is Michelle Tarbox, and I am a dermatologist and a dermatopathologist. I'm an associate professor at Texas Tech University Health Sciences Center in beautiful sunny Lubbock, Texas, and I love helping people take better care of their skin. And joining me is my co-host...

Dr. Johnson: Hey, this is Dr. Luke Johnson. I'm a pediatric dermatologist and general dermatologist with the University of Utah.

Dr. Tarbox: So today we're going to go over acne basics. Acne is a common skin condition that affects most people at some point in their lifetime, and utilizing a few simple techniques you could really help minimize the impact of this condition on your skin.

Dr. Johnson: So acne is super annoying. I had pretty bad acne when I was a young lad. I still get the occasional pimple even though I'm 40. Really seems unfair. But when I, you know, became a dermatologist, we learned about what causes acne. And actually, I remember being a teenager sitting in my dermatologist's office and looking with fascination at the posters on the wall about the causes of acne.

So, in dermatology, we consider acne a disease of the hair follicle unit. So one of the first things that happens is that the hair follicle gets kind of blocked up with sticky skin cells. And the hair follicles are often connected to oil glands, and the oil glands produce oil. The special term for this kind of oil is sebum. And so since the sebum can't get out of the hair follicle because the hair follicle is blocked up, the hair follicle gets all kind of filled up with this sebum.

Dr. Tarbox: And one of the interesting . . .

Dr. Johnson: Who likes to eat sebum? Bacteria like to eat sebum. So bacteria come to eat it, and then that creates an inflammatory reaction from your immune system and that sort of really gets the whole ball rolling down the hill.

Dr. Tarbox: That's actually one of the things I like to think through as kind of fascinating that these bacteria, which are called Propionibacterium acnes — they're named after the condition that they cause — are almost like little farmers of the oil that they eat. So they actually make our skin cells more sticky to each other so it plugs up the hair follicle more, and that actually makes a little reservoir of oil that these bacteria can use as a food source.

Dr. Johnson: And you might wonder why this tends to get worse around adolescence. And hormones play a big role as you might guess. A lot of the hormones make your oil glands crank out more oil and they make your skin a bit stickier so it makes the whole thing worse.

Dr. Tarbox: Whenever you have that backup of oil, it can actually break open the edges of the hair follicle and then that skin oil and possibly those bacteria and the dead skin cells get into the part of our skin that's not supposed to have foreign bodies in it. So if you've ever had a splinter and it got inflamed and red and irritated, you know how much our skin doesn't like things that don't belong there. And that oil is just as inflammatory.

Dr. Johnson: I think it's helpful to understand why acne shows up because then we can understand how the treatments work. So the treatments for acne affect some of those factors that cause the acne to begin with. And our best treatments are those that can affect more than one of those factors at the same time.

Dr. Tarbox: Here on "Skincast" we are not sponsored, but we are going to mention specific trade products because it makes it easier for patients to find them and I think that it's a little bit less complicated than people scouring an ingredient list looking for a specific and very technical chemical name.

Dr. Johnson: Yes, we have no commercial interests. This is just stuff we found that is good for our patients. And if you've got some acne, then there is some over-the-counter stuff that's fairly helpful. One of my favorites is a medicine called benzoyl peroxide. Not hydrogen peroxide. That's something else. This is benzoyl peroxide. It's in a lot of over-the-counter acne treatment products. So if you stroll down the acne treatment section in your local grocery store, you'll find benzoyl peroxide in various concentrations. Usually it's something like 4% to 10% that's present in cleansers, in spot treatment pads, in creams, and in various other formulations.

Dr. Tarbox: Benzoyl peroxide can be a great help when you're dealing with acne. One thing you do have to be thoughtful about is that it has peroxide in it. So if you've ever bleached your hair or thought about bleaching your hair, you might know that peroxide can lighten things. And it's true that if you have a benzoyl peroxide product on and it gets on a bed sheet or a towel or clothing, it can lighten or bleach the clothing. If you have fine light brown hair, it can also lighten your hair color around the hairline.

Dr. Johnson: Yeah. So this is one reason why I like it as a wash or a cleanser. I figure most people are washing their face anyway. Might as well put some medicine in there so you don't have an extra step to do. I say wash your face in the morning with this stuff because then they're not immediately putting their face on a pillowcase and discoloring their pillowcase. You do want to use white towels though or you'll have some messed up looking towels. That's the main downside with this benzoyl peroxide stuff.

It can also be a little bit irritating to the skin. In general, the lower percentage, the less irritating it is. So how sensitive is your skin? If it's not that sensitive, just buy whatever's cheapest, like I do, the generic brand. But if it's a little bit sensitive, there's a couple brands out there that are especially gentle. There's one called AcneFree. All one word. You might have to get it online. It's 2.5%. And then CeraVe makes a good one called Acne Foaming Cream Cleanser. It's 4% benzoyl peroxide. Also, very gentle.

Dr. Tarbox: I really like that CeraVe product, and I think that patients can do really well with benzoyl peroxide. Some people can't tolerate it, and, in that setting you can potentially use a milder wash made from something called salicylic acid, which is actually a relative of aspirin.

Dr. Johnson: Yeah, I do prefer benzoyl peroxide, but salicylic acid doesn't have this bleaching property and is usually present again in the same sorts of products that benzoyl peroxide is found in. Usually it's 2%. And if the benzoyl peroxide is just too irritating or you hate that half of your clothes are discolored, then salicylic acid is a decent option.

Dr. Tarbox: If you are aspirin sensitive, you would not want to use salicylic acid, and if you're pregnant, you would not want to use salicylic acid as it is a derivative of an aspirin-like chemical.

There's another wash that I really like for patients who have very sensitive skin that can't tolerate benzoyl peroxide or salicylic acid. This is a product from Cetaphil that actually has zinc sulfate in it, and it's an oil control acne wash.

Dr. Johnson: So there's our cleansers. Something else that's really nice that's over-the-counter is a medicine called adapalene. The brand name is Differin, D-I-F-F-E-R-I-N. Differin the brand makes several products now I think. So you want the one that's called Adapalene, is the medicine.

Until about five years ago, this was a prescription product that cost about $220, and now it's an over-the-counter product that costs $12. So a rare example of medication costs moving in the right direction. It comes as a gel, and you put a little blob of it on your finger. I usually recommend that people do it at night. And then you get that blob on your finger and you kind of dot it all over your face and then you rub it in everywhere.

So neither of these approaches is a spot treatment. Both of them go over your whole face because they help prevent acne from showing up as well as treat acne that's currently there.

Dr. Tarbox: If you're looking for adapalene over the counter, there are a couple different brand names. Differin is the original brand name, but you also can buy it as a La Roche-Posay product. That's a French company that retails products across to pharmacies in the United States. And the name of that line is Effaclar.

Dr. Johnson: I did not know that. It can also be a little bit irritating. Usually not too bad. But I usually tell people if it dries you out, just give your skin a break for a day or two, let your skin recover and then come back to it. Most people's skin will kind of get used to it. If you find that you're using it every night and it's not irritating you at all, well, you could probably step it up to a prescription strength version of the same thing.

Also, this is a retinoid. So there are components called retinol that are in a lot of over-the-counter sort of anti-aging products. And they also work. They're pretty similar to adapalene. They tend to be a little bit higher priced though. But the reason that they are in these anti-aging products is because adapalene and retinol and all these things are good not only for acne but also for scarring, for wrinkles, for dyspigmentation, so pigmentary changes in your skin. Basically, anybody who's not pregnant or breastfeeding should probably be putting one of these things on their skin.

Dr. Tarbox: Yeah, I love my topical retinoid. I don't leave home without it. Speaking of irritation, sometimes people, when they have bad acne or acne that they're frustrated with, will really kind of go after it with everything and the kitchen sink and they can end up really stripping their skin and making it too irritated and dry, which can actually make the acne worse.

Dr. Johnson: Yeah. So just as important as knowing what to do, things like benzoyl peroxide and adapalene, are knowing what not to do. So your poor little skin doesn't need astringents, it doesn't need scrubs, and it doesn't need things that are just too expensive. So sometimes I have patients who come in and they bring their Ziploc bag full of products that they've been using and I love it when people bring them, but it kind of breaks my heart that they've been spending 20 or 30 bucks on a benzoyl peroxide cleanser because you can buy one of those for 4 or 5 bucks.

So things don't have to be expensive, in fancy bottles, and advertised on television for them to work well. You just want to look for these ingredients — benzoyl peroxide, adapalene, retinol, things like that.

Dr. Tarbox: Sometimes patients will also over exfoliate. There are products that are coming off of the market because they have microplastics in them with those little beads that sometimes were included in products for exfoliation. And there are also products that have ground up walnut shells and things like that, which are pretty abrasive to the skin and can do more harm than good. If you want to gently exfoliate, a gentle facial brush that you keep clean and use with minimal pressure is a great alternative.

Dr. Johnson: So those are pretty good things that you can do over the counter. But what if you've done those or your teenage kid has done those and they've still got acne? Well, it might be time to go to a dermatologist. Another reason to go is even if you haven't tried those things, if somebody's acne is moderate or worse and all of those over-the-counter things just aren't going to be good enough, come to one of us. There's really good acne medicines these days. Really the only downside for our acne medicines is that they take a little while to work. So I am sorry if you are getting married next week. There might not be a whole lot that we can do. So come early. It usually takes our medicines about three months to really kick in, but after that, modern medicine does a pretty good job of treating acne.

Dr. Tarbox: Yeah, I always remind patients if your acne is leaving footprints, if it's scarring, you want to seek professional help because scarring is permanent and while we can do a lot of things to help improve those sort of scars that are formed over the years, like chemical peels and microneedling, it's better to prevent than to treat those scars.

Dr. Johnson: I would like to have a little myth-busting section of our podcast here because I think there's a lot of myths out there around acne. One of the main things that gets bandied about is diet. So there's been a fair amount of research into diet and acne, and I will admit that, before I read some of this research, I just didn't think diet mattered at all. Now I think that diet matters... just a little bit.

So the research says that if you have a high glycemic diet — so that's a diet where you eat a lot of like sugar and fat and carbs and things — that can make your acne a little worse. And for some reason, skim milk specifically has been associated with acne. Again, I think the effect is pretty mild. So if you have a high glycemic diet and you drink a bunch of skim milk, instead of having five pimples a month, you might get seven. So it's not really going to make or break things, but there is some data out there. So if you want to listen to your grandma and not eat that bag of Doritos, it might help your face a little.

Dr. Tarbox: Yeah, the skim milk connection is really fascinating, because when you have skim milk, it's had the fat taken out of it so more of that product is protein. And our hormones are proteins. Animals that aren't raised organically sometimes have extra hormones added to make them big and strong and overproduce milk, and those can affect some patients. If you are sensitive to that, going for the organic alternative or going for a vegan alternative may help you.

What about cleaning the skin, Luke?

Dr. Johnson: Well, I don't think cleanliness is as important as a lot of, well, to be honest, mothers and grandmothers seem to tell their children and grandchildren. Obviously, you should do something, but blackheads, for example, are not black because there's dirt in there. That's the sebum, remember the oil, and it just gets oxidized when it's exposed to the air and it turns black. So it's not dirt in the skin. And you don't need to be overly vigorous, as we've discussed, with these scrubs and things. So I think washing your face once a day with something gentle, especially with something with some acne medicine in it, like we've discussed before, is probably all you need to do. But having acne does not mean you are an unclean person.

Dr. Tarbox: That is such a good thing to tell people because sometimes there is a stereotype that goes along with bad acne especially. If I have an active young person that's a student athlete, I do like for them to cleanse their skin after exercising, and the product I really like for this is something called Simple Face Wipes because they're little pre-moistened towelettes in a little convenient packet that can go right in the gym bag and the patient can just wipe their face down after exercising or sweating and it helps to decrease that kind of post-exercise gunk that sort of stops up the hair follicles.

Dr. Johnson: When we think about acne, we're often thinking about teenagers, but acne can show up in other people too. It can show up in adults, especially women, in which case it's often hormonal and we do have hormonal treatments. So there is hope out there if you are such a woman. Come in and see us. We can do stuff. And then I can see it in fairly young kids too. So, from hormonal standpoint, puberty supposedly begins around age eight. And, you know, having a couple of little kids of my own, that's rather terrifying. But I have seen acne show up in, you know, eight years, nine years. Usually, it's pretty mild, but I have had some significant acne in kids as young as about 10.

Dr. Tarbox: There's another special form of acne that can happen in young women called acne excoriée, and it actually has a French name. It's acne excoriée des jeunes filles ,which means 'the picked-on acne of the young woman'. And this is usually occurring in young women who are a little bit stressed out, often successful, intelligent, driven young ladies that sort of express a little low-level anxiety by picking at the acne lesions often sub, kind of, consciously. So bringing that to your attention, if you are a person that picks at the skin lesions, is a good idea and you should remember that the little scars and the marks that are left behind after manipulating or picking at an acne lesion are going to last longer and scar worse than the acne lesion itself.

Dr. Johnson: Don't pick at your acne. There. You heard it from some dermatologists.

There are some other sort of special forms of acne. Most of the time, when we see acne, it's standard acne or what's called acne vulgaris. But there's a form of acne called acne mechanica. So if you're wearing something like a mask, for example, on a part of your skin, then that can further occlude those little hair follicles and make acne a lot more likely. So maskne is a form of this acne mechanica stuff. People who wear a lot of sporting equipment, you know, goalie masks and things or fencing masks, I've seen it or surgical caps. I've seen that in surgeons because it occludes their forehead and they get acne there. I see it in military recruits who have to wear backpacks a lot. They get it on their back. That kind of thing.

Dr. Tarbox: You can also get acne from products that are put on other parts of your body. So if you use heavily oil-based products on your scalp, over the course of the day the heat from your body will melt those products and it just sub-clinically trickles down from the hairline to the eyebrows and patients can have a flare of acne on that forehead region because of their hair care products.

Dr. Johnson: Apparently, according to the textbooks, acne is also worse if it's really hot or humid. I live in Utah, where it's really hot, especially today, but it's not humid. But it has its own special name — tropical acne. So if you are a military recruit in some tropical place, I hope your back does okay.

Dr. Tarbox: There's certain medications that can also cause acne. Steroids, either steroid hormones, like the male and female type hormones, or steroids such as glucocorticoids or prednisone can cause acne to worsen as can other kinds of medications that are sometimes used to treat seizure disorders.

Dr. Johnson: But if you are taking one of those medicines and you get acne, we can help. So, you know, if you need to take testosterone or you need to take other hormone replacement therapies and things, then it makes sense to come see one of us if the acne is giving you trouble.

Dr. Tarbox: And especially if it's an anti-seizure medication. Those are not medicines you want to mess around with. So, you know, you would continue to take those based upon the recommendation of the doctor that takes care of you for those and then seek the expert advice from a dermatologist.

Dr. Johnson: I hope that you guys found this helpful. And we want to thank our institutions. Thanks to the University of Utah and to Texas Tech. And if you are a real dermatology nerd, you might be interested to know that Michelle and I co-host another podcast, which is really targeted at people practicing dermatology, but hey, maybe you'll find it interesting as well. It's called "Dermasphere," D-E-R-M-A-S-P-H-E-R-E.

Dr. Tarbox: Welcome to Skincast. This is the podcast to help you take the very best care of the skin you're in. This is Dr. Michelle Tarbox, and I'm a dermatologist at Texas Tech University Health Sciences Center in beautiful, sunny Lubbock, Texas. And joining me is . . .

Dr. Johnson: My name is Dr. Luke Johnson, and I am a dermatologist at the University of Utah.

Dr. Tarbox: Luke and I are both dermatologists. Luke, what is a dermatologist?

Dr. Johnson: A dermatologist is a physician. So we went to school for a long, long time. And then even after all of that school, we then did this training called a residency where we learned about skin from a medical standpoint. And now we're dermatologists, so we are doctors who specialize in the skin. I am a pediatric dermatologist as well, so I'm specially trained to take care of kids with skin issues, though I also see adults.

Dr. Tarbox: And I'm a general dermatologist and a dermatopathologist with a special interest in cosmetic dermatology and skin of color and pigmented skin lesions.

Dr. Johnson: Yes. Thanks to the University of Utah and to Texas Tech University Health Sciences Center for supporting us.

Dr. Tarbox: We plan to release a podcast every two weeks to help people understand how to best take care of their skin, and to share that knowledge that we acquired over that long period of education to become a dermatologist.

Dr. Johnson: I like so many things about being a dermatologist. One of the best jobs in the world. So I like that I get to see kids and adults. I like that we take care of people with acute issues, meaning they have a problem right now and they need somebody to help. And we take care of people with chronic issues as well, like skin disease, like eczema that unfortunately we can't cure, but we can keep it under control. That allows me to see patients over and over again and develop relationships.

Dr. Tarbox: I think that is absolutely one of the strengths of the field, is that it's a very broad field and we have a lot of tools to help us maximize the impact we can have on the health and wellness of people in our specific organ system, which is the skin. We like to say it's one of the most important organs in the body.

Dr. Johnson: Well, of course, if you think there's something wrong with your skin, or hair, or nails, or mucous membranes, it might be a good idea to get in touch. One of the things dermatologists focus a lot on is skin cancer. So anything on your skin that is new or changing, it's probably a good idea to see one of us. A lot of times, it's not going to be a big deal, which is great, but the times when it is a big deal, you'll definitely be happy that you came in.

Dr. Tarbox: Another thing that can sometimes cause an important impetus for somebody to come see a dermatologist is any kind of rash on the skin, especially one that's not getting better, or any rash that's particularly painful or uncomfortable because some of those can be serious. So while fortunately most rashes most people will have in their lifetime are benign and self-limited, some of them can require more specific care, and dermatologists are expert in that type of care.

Dr. Johnson: And if you don't feel like coming into the clinic . . . we're recording this at what I sure hope is the tail end of the COVID pandemic. But one of the silver linings of the pandemic world is that it's opened up the gates to a lot more telemedicine. So dermatologists have been doing a lot of teledermatology, so kind of like a Skype or FaceTime call. So if you are unable to come in because you live three hours away, or you can't take time off of work, or you don't feel safe coming in because there's still this virus running around, a lot of us are doing teledermatology, so that might be an option for you.

Dr. Tarbox: I think that's so important to emphasize right now, and I think that one of the first steps that we can take in helping our listeners take better care of their skin is helping them understand what it actually does. A little Dermatology 101 if you will. So, Luke, what are some of the functions of the skin?

Dr. Johnson: I once heard a song by John Lithgow, "I like my skin because it keeps my insides in." Of course, that's part of it. It keeps other stuff in as well. It keeps water in most importantly, and a lot of times these functions aren't particularly obvious unless they're not working right. So if your skin is not keeping water in properly, then you might have eczema, which is called atopic dermatitis, for example. Then your skin can get pretty dry and inflamed.

Dr. Tarbox: Absolutely. Whenever you have an organ system that's functioning properly, the wonderful luxury of good health is that you don't have to notice it or pay attention to it. But my goodness, when it's not functioning properly, it's hard not to think about it. I think that one of the things that we can do as dermatologists is help to get that organ system back online and back to an area where we can enjoy the rest of the things life has to offer.

Dr. Johnson: The skin does a lot of other cool stuff, too. So in addition to keeping water and the rest of your insides in, it also keeps everything else out. So you can imagine if we didn't have skin, first of all, we'd look awfully strange, and also there would be a bunch of stuff from the outside world coming into contact with parts of the body that would not do well.

Dr. Tarbox: Absolutely. That protection role is very important, and also that immune role where our skin is actually our outer wall of defense against the entire world. It is sort of like the wall in "Game of Thrones," if you will. So you have to maintain the watch, and our skin does a beautiful job of that when it's healthy.

Dr. Johnson: It also helps regulate our temperature. So human beings are pretty amazing. We can live in most environments on earth, and our skin does a decent job of keeping our temperatures about the same.

Dr. Tarbox: So what things help us to get our skin in its best shape to do these important roles? And what things actually cause some problems?

Dr. Johnson: What great questions, Michelle. I think those are the questions that we're primarily going to be dealing with over the course of this podcast. Everybody wants their skin to work right. And again, you don't really notice your skin too much unless it's not working right, and we can certainly help. But people pay a lot of attention to their skin, and presumably to other people's skin as well. So there are a lot of things out there that people use to try to make their skin healthy and keep it healthy. We're going to be talking about some strategies over the course of things here.

Dr. Tarbox: Absolutely. My nemesis. Just kidding. The sun is very important, and here in beautiful, sunny Lubbock, Texas, it is a part of life. But we do have to think about the impact the sun can have on our skin's health.

Dr. Johnson: Yes, dermatologists have a bit of a love-hate relationship with the sun, though it's probably like 90% hate, and the main reason is that it's directly responsible for quite a lot of skin cancer.

Dr. Tarbox: Skin cancer is one of the things that we take care of as dermatologists that we would like the most to prevent for our patients, because sometimes it requires us to do surgery on a person's skin. And if we can keep people from having to go through skin cancer surgery, we sure would like to. What strategies can people use to protect their skin from the sun?

Dr. Johnson: Well, there's actually a lot. You're probably thinking I'm going to say sunscreen. And you're right, I'm going to say it. Sunscreen. So sunscreen is good. It's helpful. I think we're going to have another episode where we talk in more detail about sun protection.

Dr. Tarbox: And I think that a very important factor about sunscreen is that it's comfortable for you to use. You like the smell and feel of it. I'm looking forward to that sun protection episode. I think it's going to be very helpful for our listeners.

Dr. Johnson: Well, big old hats. So wide-brimmed hats can be good. A baseball cap, that's all right. I mean, it's probably better than all right, but we like the hats that go all the way around your head. Down in beautiful, sunny, Lubbock, Texas, hopefully you have people wearing cowboy hats. There's a reason that cowboys wear cowboy hats, and it's not just because they looked cool. It's because they help prevent the sun from beating down on them so much.

Dr. Tarbox: I love to see a cowboy hat, and I always compliment my patients on them because they have that beautiful wide brim. A baseball cap will protect the front part of your forehead and some of your nose. And as we like to say down here in Texas, it is mejor que nada, better than nothing, but a broad-brimmed hat does provide better protection. Staying in the shade can be good.

Dr. Johnson: My beautiful peepers I protect with sunglasses.

Dr. Tarbox: I think sunglasses are very important. Sometimes contacts have some UV protection as well.

Dr. Johnson: I was just thinking that. I don't know how much we want to get into this. I sometimes talk to my parents of kids with eczema about this. And again, because you see problems with the skin . . . when there's a problem, that's when you appreciate the functions of the skin. A lot of people can use whatever kind of soap wherever on the body and it's not a big deal. But especially if you have a tendency toward more irritable skin, I think that it helps to be conscious of which soap you're using and how you're using it.

Dr. Tarbox: I think that's a great way to instruct parents. I think one of the problems is we all learned how to do that self-care kind of from popular media in a way. And a lot of the popular media depictions of people showering or using soap is you get sudsy all over the body and it looks very fun and it's portrayed in especially those little commercials . . . I think of the Irish Spring commercial where the guy has got the lather all over his arms and all the way up his neck and onto his face.

Dr. Johnson: Well, I think moisturizing it is helpful. Sunscreen is helpful. Again, if your skin seems to be fine without any of this stuff, then that's great. But a good moisturizer, especially on the hands because they are the ones that get washed and get exposed to soap, can keep your hands healthy and not dry and cracked. Nobody wants dry, cracked hands.

Dr. Tarbox: Maintaining appropriate hydration, eating a good varied diet full of fruits and vegetables, multiple colors of things that grow up out of the earth, or things that walk around up on them, can also help improve our skin health and decrease the problems that we experience with our skin.

Dr. Johnson: Those of you who are particularly dermatology nerds might be interested in the fact that Michelle and I actually co-host another podcast. It's really directed at dermatologists and those who are dermatologically curious. It's called "Dermasphere." So if you've got an enthusiasm for both dermatology and podcasts, you might want to check it out. We'll see you guys next time.