I was a typical German teenager with tight Wrangler jeans, folklore tunics, and patchouli incense sticks, listening to Led Zeppelin’s ‘Stairway to Heaven’ all day long. Unfortunately, skin problems dampened my fantasy that I’d become one of Robert Plant’s groupies. At 56, I am still a sucker for Led Zep – and I still have breakouts. My acne is mild and does not nag me as much as it did when Clearasil was the prevalent remedy in late-1970s Germany. I remember how dry and itchy my skin was from treatment – an experience I can do without, now that I am in my 50s and worried about wrinkles.
Caption: Photo by Gerda Friedel (2020)
Clueless for years, I washed my face with soap (any soap!) and randomly bought antiaging serums or aloe vera gel. Some months ago, this regimen didn’t work anymore. My skin was irritated and pimples grew on my neck, chin and jaw line. I realized it was about time to leave my Clearasil trauma behind and do something. I had an instinct that acne at my age was not one-dimensional, but I was not completely prepared for the complexity of the topic.
How aesthetic medicine can help
Johannes Lang, M.D., is a specialist for aesthetic medicine. He owns a private practice in a historic building in the center of my hometown Erlangen.
Dr. Lang treated hyperpigmentation on my hands and spider veins on my legs. One September afternoon, I went to see him for a checkup. He welcomed me in his spacious office; I could not see his smile because for coronavirus regulations he was wearing a face mask like I did.
Caption: Dr. Johannes Lang, photo by Gerda Friedel, 2020
Opening up about my bothersome breakouts, I learned from him, for the first time, what acne is – that it starts in the sebaceous (oil) gland, and how crucial inflammation and hormones are in that process. For tackling mature acne skin, his clear answer was ‘ Photobiologic Therapy’ (PBT), a low-level laser therapy. “ We can treat the inflammatory reaction plus anti-aging side by side,” he said.
Red-light low-level lasers with extreme accurate wave lengths could boost the energy level in the skin cell and improve its overall performance, he told me. Blue light would reduce inflammation and kill the harmful acne bacteria in the gland without skin damage. Since acne bacteria release a color substance in the sebaceous gland in which the blue wave lengths are absorbed, a heat effect is caused.
“It’s like boiling the acne bacteria in its own soup,” Dr. Lang said.
Since I had time and the laser was available, I tried PBT right away. Lying on a stretcher, the laser device came down on my face like an octopus held by a spider arm. Because I had to wear eye protection, I only got a glimpse of a myriad glowing red-light bulbs starting to act on my skin. After a while, I noticed blue laser light, and a pulsating light toward the end of the treatment.
Afterward I was sleepy and relaxed with no instant visible changes on my skin. A 16-minute session is 50 euros and Dr. Lang said two treatments should suffice to see results. He pointed out that I might need to take sessions again when hormonal imbalances or stress triggered my acne.
Photobiologic Therapy (PBT) at Dr. Lang’s private practice in Erlangen, photo by Gerda Friedel, 2020
Acne essentials: Facts and current research
On their website, the American Academy of Dermatology describes acne as “ the most common skin condition in the United States, affecting up to 50 million Americans annually.“
Medical science says acne vulgaris is a chronic inflammatory disorder of the sebaceous gland that causes lesions in the form of open and closed comedones, papules, pustules, nodules, skin scarring and post-inflammatory hyperpigmentation.
Regardless of age or gender, the course of acne is: An overproduction of oil, skin pores becoming clogged by “sticky” skin cells called follicular keratinization, a biofilm and colonies of bacteria known as Cutibacterium acnes (C. acnes) followed by chronic inflammation of the sebaceous gland.
Acne mostly occurs in puberty – and it is highly genetic. I remember my brother having acne, which ceased in his twenties, he told me. Unlike him, the only time I was pimple-free was during pregnancy, but then I resembled a manatee instead.
Hormones are another important trigger for acne. In Dermato-Endocrinology, Australian researchers wrote that acne is “typically affecting areas with a high density of hormonally-responsive sebaceous glands such as the face, neck, chest, upper back, and upper arms.”
In a 2017-medical review about ‘Emerging Issues in Adult Female Acne’, U.S. scientists said that acne is “ increasingly seen in adult women.” The authors pointed out that more women had acne than men, and it “ may persist beyond menopause.”
Menopause comes with a decline in the female reproductive hormones estrogen and progesterone. Around age 51, women reach menopause when a permanent lack of menstruation is confirmed after 12 consecutive months. Like in my case, mild and persistent acne on to adulthood in the lower third of the face (because that’s where the male hormone testosterone acts most) is the prevalent form of female adult acne.
When it’s all about hormones
Stress and hormones are two sides of one coin – with chronic stress as a top acne trigger. Constant stress can stimulate excess oil production, hormonal fluctuations and impairs skin healing. Also, research says, women with acne are often stressed by their persisting acne, which can lead to low self-esteem, frustration and even depression.
Wanting to learn more about my hormonal status, I took a saliva and blood test for a comprehensive female hormonal profile. On December 12, 2020, I discussed the results with Dr. Berndt Rieger in an online consultation. Dr. Rieger is internist, book author and a specialist for hormones and thyroid disorders like Hashimoto’s thyroiditis.
With his holistic approach, I have trusted Dr. Rieger’s expertise since I was diagnosed with Hashimoto three years ago. Hashimoto Thyroiditis is an autoimmune disorder leading to a gradual destruction of thyroid tissue and so-called hypothyroidism. Dr. Rieger told me that because of the hormonal changes due to menopause (like excessive testosterone or lack of female hormones) and my underactive thyroid, my acne could have worsened.
A classical hormone therapy as well as oral acne medication has never been an option for me, because I cannot tolerate the side-effects in many pharmaceuticals. I trusted Dr. Rieger and agreed to test red clover to stabilize my hormonal status. Aside from that, Dr. Rieger strongly advised me to supplement vitamin D to raise my vitamin D levels in the blood to fight inflammation, boost my immune system and stress tolerance.
Am I stressed? Hell, yes!
I am a freelance English teacher, mother of two teenagers and a Harvard grad student – my stress level has doubled in the current coronavirus situation with the whole family in their home office and me having become the unintentional chef of the kitchen.
What the German stay-at-home guidelines effective since early November also implied was that beauty salons were closed. Therefore, I started looking for so-called ‘cosmeceuticals’, which are over-the-counter alternatives to topical medication from a dermatologist or acne treatment by a cosmetician.
Cosmeceuticals for acne and aging skin
That’s how I came across Dermalogica, a U.S. skincare brand located in California and specialized in acne cosmetics for adult skin. Dermalogica skin care is certified cruelty-free, with neither artificial colors and fragrances, nor microplastics, their website says.
The products contain what cosmeceuticals for acne and aging skin preferably have: Retinol, salicylic acid and nicotinamide. Healing adult acne is special because of collagen breakdown from aging, the skin is weaker than that of teenagers.
Retinol, for example unclogs pores, exfoliates the skin, and reduces fine lines and wrinkles by building up collagen and increasing the rate in which skin cells divide.
Salicylic acid can seek out oil and clear away dead skin cells.
Nicotinamide is anti-inflammatory and helps fade post-inflammatory hyperpigmentation.
On their German website, I liked Dermalogica’s personal customer approach saying that Carla Zraika would readily answer questions followed by her mobile number and email address. I called and left a message. Mrs. Zraika instantly got back to me and when I presented my plans about testing their products for a feature, she agreed to send me free test kits for my skin needs and arranged an interview with Vera Nordqvist, education manager at Dermalogica German headquarters in Duesseldorf.
When we met online, Mrs. Nordqvist’s long brown hair was tied back in braids and I instantly noticed her flawless complexion. When I asked her to tell me something about herself and her job, she said that “ the major column at Dermalogica is staff education to increase recognition of our craft.” She gained a master title in cosmetics – the highest level of professional education in cosmetics in Germany – four years ago, she continued. Today, she is responsible for the company’s training concepts in Germany and Austria. Jokingly I asked her, if I was alone out there with my mature problem skin. She replied she considered adult acne an epidemic disease. “The demand for skin care for acne and antiaging is constantly growing,” she said.
My skin care routine
On Friday, November 20, I started my skin care routine with the ‘precleanse’ oil, a mild cleansing gel, a daily rice microfoliant, followed by ‘retinol clearing oil’ in the evening and an ‘AGE Bright Serum’ for the day, a moisturizer and eye serum. The first thing that struck me was that all products were extremely economical and that I overdosed in the beginning. Massaging my face with the clearing oil, I would take a deep breath and instantly feel carried away by the smell of lavender and rosemary into a wellness-spa daydream.
Soon my skin felt fantastic – clearer, brighter, smoother and not the least oily. Unfortunately, not for long. On Day Four, pimples were back and I was devastated looking in the mirror. I instantly emailed Mrs. Nordqvist. She reassured me that initial aggravation was positive – part of the transition phase – which meant enclosed sebum would come up and resolve. After a ‘sebum clearing masque’ and a gel for spots, my skin recovered within two days.
* * *
Lifestyle: What about my cappuccino?
With acne being multifactorial, a story about acne-prone aging skin would not be complete, if I skipped the fact that following lifestyle factors can trigger or worsen acne:
Smoking, UV exposure, alcohol or coffee, dairy, sugar and wheat, not enough sleep, touching the face, picking or squeezing breakouts, general hygiene like frequently washing hands and changing pillow covers.
Do I want to skip the cappuccino, the chocolate – the occasional cigarette?
Martin Auerswald is a health and nutrition coach with a master’s degree in biochemistry and molecular biotechnology. I asked him how he weighed in on lifestyle factors for acne when we talked online in December. He answered that, as with most chronic disorders, there are risk factors that could lead to a manifestation, but one exclusive trigger would not exist. I was eager to know if the small amount of milk I use for a cappuccino could cause my acne. He replied that for some people even that was too much.
“What about coffee? Are two cups a day too much?” I asked him.
” I personally feel that two cups are OK,” he answered,
“as long as it is something you enjoy and not for compensation of sleep, for example. ”
Life, it seems to me, is often about making choices and taking responsibility for them – also when it comes to the choices we make about health and our lifestyle, taking our mental and emotional needs into account.
* * *
On December 10, my skin worsened once more. After waking up, I noticed at least four flare-ups on my left jawline and two on my chin. I guess my stress level had peaked, I had also developed a thyroid inflammation. My throat hurt, my muscles ached and I was exhausted. Talking to Dr. Rieger, he advised me to relax whenever I could. I also remembered Dr. Lang saying that hormones could always kick in. On that day, I applied the sebum mask in addition to my normal routine. The next morning, pimples were smaller and the day after they were gone.
I had almost run out of samples and it was about time to figure out, if I wanted to stick to my skin care routine time- and money-wise. After New Year, I was going to try some more PBT sessions, and with Christmas around the corner, I knew what to put on my wish list.
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Chen, Y., & Lyga, J. (2014). Brain-skin connection: stress, inflammation and skin aging. Inflammation & allergy drug targets, 13(3), 177–190. https://doi.org/10.2174/1871528113666140522104422
Dreno, B., Bagatin, E., Blume-Peytavi, U., Rocha, M., & Gollnick, H. (2018b). Female type of adult acne: Physiological and psychological considerations and management. JDDG: Journal Der Deutschen Dermatologischen Gesellschaft, 16(10), 1185–1194. https://doi.org/10.1111/ddg.13664
Farage, M. A., Miller, K. W., Elsner, P., & Maibach, H. I. (2008). Intrinsic and extrinsic factors in skin ageing: a review. International Journal of Cosmetic Science, 30(2), 87–95. https://doi.org/10.1111/j.1468-2494.2007.00415.x
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