Bill Klaproth (Host): This is the Healing Podcast brought to you by MarinHealth. I'm Bill Klaproth, and with me is Dr. Lucinda Kohn. She is a pediatric dermatologist at MarinHealth Dermatology, a UCSF Health Clinic. Dr. Kohn, thank you so much. We appreciate your time. So, can we start with this, can you explain to us first what is acne and what causes it?

Dr. Lucinda Kohn: Yeah. Hi, Bill. Thanks so much for having me on the podcast. I'm excited to be here today. That's a great question. What is acne? Acne always starts off as an oil gland. When the oil glands produce more oil in the teenage years, they can get bigger, and sometimes they get clogged up. When you have a simply clogged oil gland, that's called a comedone or a white head or a black head if it becomes open. And then, sometimes that clogged pore then becomes inflamed, either because of bacteria or because it gets so big that the inflammatory cells just come and make it into a pink bump and that's an inflammatory acne. So, acne, what causes it, it's a combination of increased oil production from the oil glands and hormones and a little bit of bacteria on the skin that can make it worse.

Host: It's the oil glands, always. The oil glands. So as our bodies change throughout our lives, you were talking about hormones and other factors, that really does impact oil gland production. Would that be right?

Dr. Lucinda Kohn: Yeah. Hormones are probably the thing that impacts oil gland production the most. Sometimes diet plays a role too. Sometimes the diet can affect the hormones. And sometimes if you eat more oily foods, like even, for example, like, a lot of nuts, that can also increase your oil gland production as well.

Host: Wow, that's interesting. So, what are the different types of acne and then how do they differ?

Dr. Lucinda Kohn: So, I like to divide them into two big categories. So, there's the comedonal acne, which is the non-inflamed oil glands that are clogged up. So, you start out with a whitehead, which is usually sometimes pinpoint in size, can be up to a millimeter in size or the little tiny skin-colored bumps that you see on usually, you know, the forehead, the T zone, so around the nose and the chin. And then, sometimes when they open up, when that pore opens up, the oil in that pore oxidizes from the oxygen that's in the air and it turns black and so it becomes a blackhead. But the blackheads and the whiteheads are both comedones, just closed comedones and open comedones.

And then, the other category is inflammatory acne. So, those are the large pink bumps that we can get. And sometimes they are just pink bumps, sometimes they have a little bit of pus in them and then we call that a pustule. And then, they can be really big and deep too. So usually, those are called the nodules or the cysts. And in that category are the ones that leave scars behind, so acne scars as well.

Host: Not that either of them are good, but the ones that are deep like you just mentioned and can leave a scar, I mean, those are the ones really that are more problematic. Would that be right?

Dr. Lucinda Kohn: Yeah, I agree with that, just because the scars are more long lasting, they can create a lot of self-confidence issues with appearance.

Host: Yes. As a kid who had acne, I can definitely relate. So, what are some of the most effective over-the-counter treatments?

Dr. Lucinda Kohn: It depends on the type of acne you have. So for your comedones, you want products that will get rid of dead skin on top of that oil gland that's clogging it up. So, salicylic acid and glycolic acid products are really good at declogging pores. They come in washes, spot treatments. The leave-on spot treatments are a little bit more irritating to the skin because it is an acid that you're keeping on the skin versus a wash that you would put on temporarily and wash off.

Another really good over-the-counter product for comedonal acne is adapalene, that's the active ingredient, 0.1% gel. It used to be a prescription, kind of like Retin-A substance. It was our gentlest one. And then maybe seven years ago, the FDA made it over-the-counter. And so, one of the brand name medications that makes it is called Differin. So, Differin gel is adapalene 0.1% gel, and they sell it everywhere in the drugstores and online.

Other treatments that are good for more inflammatory acne are benzoyl peroxide. Benzoyl peroxide kills bacteria and it declogs pores, so it comes as spot treatments and washes. And also, sulfur is another great ingredient to use for acne. Sulfur is naturally antimicrobial and anti-inflammatory. There are sulfur spot treatments that you leave on overnight, and they actually do a really good job of quickly shrinking the pink painful bumps down. And then, there's also a bunch of washes that have sulfur in them as well. And that would also help get rid of the redness in the skin

Host: So, is the goal of most of these to wash away or scrub away that dead skin blocking the pores? And then, part two then is actually, is it minimizing the oil production?

Dr. Lucinda Kohn: It's not to minimize the oil production. But yeah, most of the acne treatments are to help the skin turn over a little bit faster so the oil glands don't get as clogged up.

Host: The oil is still going to be there, but it's just allowing it to get out and then washing it away with the scrubs and the treatments so it doesn't create the red pimples, et cetera.

Dr. Lucinda Kohn: Exactly. And then, some of the other treatments kill the bacteria on the skin too, which also helps prevent the comedones from becoming inflamed over time.

Host: So as a person that suffered acne, I certainly can relate to all of this. So when should someone consider seeing a dermatologist and what treatments might they offer that differ from over-the-counter options?

Dr. Lucinda Kohn: I think people who are having acne that's scarring, or if the acne is really affecting self-esteem and mood. Those are great reasons to see a dermatologist and also just on a basic level, if the acne is not responding to the over-the-counter treatments that you're trying, another reason that you might need to level up to the prescription things. Pediatricians can also help. So oftentimes, patients will start with pediatricians. And then, if they fail the first line topical treatments, then they see a dermatologist.

And as for your second part of that question, what treatments might I offer, there's a whole range of treatments for acne, which is great. So in my mind, I divide them into topical treatments and oral treatments. So topically, we have retinoids. Retinoids are creams that help the skin turn over faster. So like I said, the over-the-counter counterpart to that is the Differin 1% gel, adapelene 1% gel that's brand name Differin. We also do prescription topical antibiotics and we often combine them with the benzoyl peroxide washes that are over-the-counter, or there's also prescription combos of antibiotic plus the benzoyl peroxide in combination and the gel that we'll use as well.

And then, if those topical treatments don't work, then we're looking at oral treatments. So, we still use antibiotics to treat acne. Antibiotics to treat acne has been around for decades, and we still do it. It's a temporary fix. So usually, the acne is better when people are on the antibiotics. But then when they come off, the acne comes right back.

And then, another treatment that we offer is Accutane, which has also been around since the late '60s. It's really a good pill medication for acne, considered our only disease-modifying drug for acne, meaning that in many cases it can be curative after a six-month course. So, it's a great option for most people, although it comes with a lot of side effects and things that we have to monitor when you're on it.

And then lastly, for the girls, we sometimes will offer hormonal options, so oral contraceptives as well as another hormone medication called spironolactone. And these help counteract the androgen or testosterone-like hormones that can make the acne worse.

Host: So, that's specifically for women, because they have different hormones, right? So, that's why it's designed for them.

Dr. Lucinda Kohn: Yes, exactly. And transgender people can use it as well, but mostly women.

Host: Yeah, I did Accutane. And it really helped me a lot. It really cleared it up. But then, at night, I would put this cream on my face, I would just rub it in all over, and it really dried my skin. I would do that every night before I went to bed and that kind of maintained it and really kept everything under control. So, I haven't been on it in so long, but that's kind of what I did. I saw a dermatologist and went through the getting of the blackheads out and I did all that stuff. And finally, it was like, "Okay, next step." I did the Accutane and that really took care of it for me.

Dr. Lucinda Kohn: I mean it's a great medication. A lot of people have been on it and are on it currently. You probably did tretinoin, which is one of our retinoid creams that we love to use for acne. It dries out your skin though.

Host: That's what it did, it totally dried my skin up. So, I did Accutane, showing my age here in the late '80s. So, my teen years, if you will. But it worked. So, I was very happy for it. And then, like I said, I was kind of like on a maintenance program. So, I mean, I still at my age today still get pimples now and then some white heads. It's like, "What is this?" But it's certainly manageable. It's not a big deal now. But back then, it was really bothering me a lot. I used to get these-- they were almost like swollen, like the glands would get so blocked. It would almost like pump up, like bump. It was not good. But Accutane really, really helped me out. Can you talk to us about lifestyle modifications? Because people are also interested in those things as well that can help prevent or reduce acne outbreaks.

Dr. Lucinda Kohn: That's actually some of the more interesting research and data on acne. So, like you mentioned, you're still getting acne now as an adult, even after Accutane, and we do see that's common now, in a way that it wasn't in the 1950s and '60s. And it's due to our diet.

So, there's been a lot of different small studies published worldwide. There's been good ones in China and Korea, even Europe on acne and the diet. And uniformly, all the studies have shown that anything that increases your glycemic index. So, it essentially causes a spike in your blood sugar, will cause your acne to get worse. And the basic science behind that is that, when you have a spike in your blood sugar, your body produces insulin to help your body absorb the sugar. And in that production of insulin, it causes your body to be also more sensitive to the androgen hormones like testosterone. And there's another one called DHEAS. And those hormones then increase sebum production by the oil glands and then cause the acne to get worse. So, it's sort of an indirect pathway that happens. But essentially, the proof is there that anything that spikes your blood sugar is going to make your acne worse.

Host: So, anything oversugary, in general, that would spike blood sugar?

Dr. Lucinda Kohn: It's carbs. So, simple carbs. I've had, you know, patients on Accutane-- and I see this in clinic all the time-- I have them on the Accutane. They're near the end of their course. They're mostly clear. And then, they come in and they say, "Oh, I had breakout last week." And I ask, "Oh, do you know why it happened?" And inevitably, the answer is something like, "I had a bag of chips the night before and then I broke out" or "I had finals. I wasn't moving around as much. I was snacking a lot and then I'm breaking out." And the breakouts on Accutaine are just like one or two pimples. It's not a lot, but it's enough to know that it's the correlation between spiking your blood sugar up by usually eating some carbs and maybe being a little bit more sedentary. Because we also know that if you used your muscles after you have a meal, the muscles will preferentially use up the sugar, and you'd have less of a glucose spike in your blood.

Host: That's so funny. My dermatologist told me, "Stay away from the chips, okay? What, are you eating potato chips? Stop it." So, how funny that you say that. So, what would you recommend for an effective skin care routine for acne-prone skin, including, like, what ingredients you would look for and which ones would you avoid?

Dr. Lucinda Kohn: It's a tough question, because it depends on your skin type and the type of acne you have. But if you're someone who has just a few little acnes and they're mostly the comedonal kind, I would recommend starting out with the over-the-counter Adapalene gel. And maybe add in an acid wash. So, either a salicylic acid wash or a glycolic acid wash. And that will help get rid of the small bumps. If you're someone who has the larger pink bumps, but you're only getting one or two of them a time, I would check out the sulfur spot treatments. They usually come as a paste, and you just kind of dab it on your acne, let it sit overnight. And then, in the morning, it'll be a lot smaller. But if you have more than that, then that would be the time to either see your pediatrician or a dermatologist for more prescription options.

Host: Hearing you answer that, making me think, well, what about girls, women, who are putting makeup on? Does that exacerbate acne with the makeup they're putting on their skin and is that a thing?

Dr. Lucinda Kohn: It can. So, anything that occludes the skin can make the acne worse, and it's not just makeup. We see this a lot in sports with helmets and shoulder pads. Those tend to make the acne worse. So, anything that's sitting on your skin. I also see it with, like, guys who wear baseball caps or girls who wear the silk bonnets overnight to help protect their curly hair, those can also make the acne worse.

But essentially, for makeup, I usually just recommend that they wash their sponges and their brushes at least once a week. There are makeups now made that are non-comedogenic, which means non-pore-clogging. And so, those are the products that I have my acne patients gravitate towards.

Host: And it sounds like the skincare routine that you talked about certainly would help with that.

Dr. Lucinda Kohn: Yes. It just increases the skin turnover and keeps the dead skin minimized on the skin.

Host: So obviously, on TV, you hear a lot and see a lot of acne remedies and prescriptions and things. Are there certain ones that we should avoid for sure? Or in your opinion, what we should avoid?

Dr. Lucinda Kohn: A lot of the products out there do work. Some of them can be irritating. I personally don't like the benzoyl peroxide products, because I often get messages from my patients saying that their face turned red, and they're not sure why. I think it's about also not using scrubs. I guess I don't like scrubs. The things with the beads in them or like physical scrubbers, I think that actually ends up harming the skin more than it helping.

Host: Okay. That's good advice for sure. Before we wrap up, we did touch on acne scars before, and that really does bother people. Your appearance, like you said, it can affect your confidence. It's the way you go out in the world, because you're always worried about your acne, and "Oh, my God, my face looks terrible." "Oh, my gosh." I mean, it really can have an effect on your self-esteem, and certainly people that have the acne scars now, I mean, that's a really bad byproduct that of this. So, are there ways to prevent scarring during an acne outbreak and what treatments are available to reduce scarring?

Dr. Lucinda Kohn: Yeah. So, preventing scarring during an acne outbreak is just treating the acne and being pretty aggressive with your treatment. You don't want the acnes to get super inflamed. You want to keep them as small as possible, as much as you can help to not pick when they're super inflamed, meaning pink and deep. That's the best thing that you could do.

And then in terms of treatments available to reduce scarring, a lot of those treatments are not over-the-counter treatments. So, chemical peels can help with the scarring, so can lasers. But usually, I start off with a retinoid cream. So, some of the retinoid creams, they can once again turn over the skin a little bit faster, but they also boost collagen production. So, if you use them for long enough, they will slowly smooth out the skin, especially if your scarring is very minimal. For the bigger, deeper scars, I think it's more about the lasers and the peels.

And then, people should know that the pink spots that linger after acne, those are scars, but they self-resolve. So, if it's the color that's bothering you, just know that it goes away with time. But if it's more the texture, then there are other things we can do, like the retinoids or the lasers and the peels.

Host: Well, that's good to know. And of course, trying to take care of it earlier rather than later is probably a good thing too. Would that be right?

Dr. Lucinda Kohn: Exactly. So, staying on top of your acne is good. Most dermatologists won't treat the scars until the acne is under control, because otherwise it's, you know, a losing battle. With every new acne is a potential scar, so...

Host: That's right. I'm very lucky. I have very minimal scar. I mean, you wouldn't even be able to tell, because it was pretty bad. I mean, I did Accutane, but I stayed on it. I went to a dermatologist, I went through the minimally invasive stuff. And then, it was to a point, it's like, "Your next step is Accutane." And I'm like, "Let's do it." And it really stopped it and helped me out. So, as a person that did Accutane, I would recommend it highly. And I think I don't have scarring is, because I attacked it early and really aggressively went after it and took care of it.

Dr. Lucinda Kohn: I think that's right. So, your Accutane, it sounds like it didn't clear you for life, but it did get your acne under great control. So, you know, you just have a blemish here and there.

Host: That's right. Absolutely. And more so when I was in my 30s, it was a little-- I would put the cream on. So as I got into my 40s, I didn't anymore. I'm like, "I don't need this anymore." And I haven't used the cream in a long, long time now. But I did, and that was good maintenance for me. But now and then, yeah, it still happens now and then. It's all right. It makes me feel like a teenager. Makes me feel young again. So, maybe it's not all bad.

Dr. Lucinda Kohn: Right. Anything to do to stay young, right?

Host: Just stay young. "Hey, got a pimple, everybody. This is great. I'm a teenager again." No, I'm kidding. And thank you to what you do, because the dermatologist really helped me out. Because like I said, it affects your self-esteem, your confidence. So, it was really big for me to go see a dermatologist and have them help me through the whole process. So, I'm very thankful for it and for the medicine. So, it really helped me out a lot. If you saw pictures of me as a 19-year-old kid, you'd be like, "Jesus, look at this kid." It was bad. I look at those pictures now and I'm like, "Oh my, Lord." But the medications and the dermatologist that I saw really got me through it.

Dr. Lucinda Kohn: That's great that you responded so nicely. Everyone responds on Accutane, but sometimes it takes a while before you get to that result.

Host: For sure. I'm sure you have stories, too. It's got to make you feel good as a physician when you see somebody come in and you can tell, it affects the way you carry yourself because of it, because of your face, you're so self-conscious of the way you look. So, I'm sure you feel better when you're able to help somebody through that and really help them get their acne under control and get rid of it.

Dr. Lucinda Kohn: Yeah, I do. And inevitably somewhere along that Accutane course, there's a smile that appears on my patients and I love seeing that smile.

Host: Oh, it's big. I got to tell you, when it starts to come, I mean, it was red and I really had these big block of really-- almost like I was swollen. It was so big at times. I'm sure you've seen that. And when it starts to calm down and go away, you're like, "Oh man, I feel like a person again." I know it sounds, it may sound silly to anybody listening, but you're so self-conscious of it all the time. It really affects you. But this has really been great. It's been great talking to you about this. And hopefully, whoever is listening to this will draw some inspiration from this and have a guideline of what to do for themselves as well. So Dr. Kohn, thank you so much for your time today. This has really been great.

Dr. Lucinda Kohn: Yeah. It was my pleasure, Bill. Thank you for having me on your podcast.

Host: You bet. Absolutely. And once again, that is Dr. Lucinda Kohn. And to learn more, just visit mymarinhealth.org, that's mymarinhealth.org. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. This is The Healing Podcast brought to you by MarinHealth. Thanks for listening.