Episodes

Acne (with Dr. Alexa Shipman)

Why are we so grossed out by acne? What is it that makes popping pimples so satisfying? And why doesn’t acne go away after adolescence?

Today’s guest is Dr. Alexa Shipman, a consultant dermatologist for the NHS in the United Kingdom.

Citations and further reading:

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Taboo Science is written and produced by Ashley Hamer. Theme music by Danny Lopatka of DLC Music.

TRANSCRIPT

Ashley: I am gonna say something that would terrify me if I heard it at 16. I’m 35 and I have a zit on my chin and 16 year old Ashley, I hate to tell you this, but it’s not even the only zit I’ve had this week. My entire life, I’ve believed that acne was a teenage problem. I mean, haven’t. I thought that once I turned 18 or 21 or 25, I’d stopped getting pimples and I’d just have this clear porcelain skin for decades, you know, until it was time to start worrying about wrinkles, which wouldn’t happen forever.

Right? Yeah. 16 year old Ashley, that wrinkle worrying time. That happens a lot earlier than you think, too. Sorry. But really it turns out that literally anyone at any age can break out with zits, even babies. Swear to God. It goes without saying that nobody wants acne. What would be nice is if we all knew how to prevent it.

But I read a lot of teen magazines back in the day that contained tons of tips about acne, and none of them ever seemed to work. Same with the special face washes and serums and detox masks you see in the drugstore. It turns out that a ton of the stuff I thought I knew about acne was just plain wrong.

And those myths aren’t just keeping us from having flawless skin. They’re making acne more taboo, and that’s hurting the many, many people who deal with it. Like one thing I learned. For most people, acne is curable as long as you can deal with a few side effects. I’m Ashley Hamer and this is Taboo Science.

The podcast that answers the questions you are not allowed to ask.

I don’t need to tell you that. Are stigmatized. Research presented in 2016 found that in a lineup of skin conditions that included cold sores, warts, eczema, psoriasis, and acne, only cold sores freaked people out more than zits did. 68% of the volunteers in that study said they’d find someone with acne unattractive, and around 40% said they’d feel uncomfortable touching them or even being seen in public with.

And that has an effect. A 2018 study that followed thousands of people in the UK after they developed acne, found that they had a 68% increased risk of depression in their first year with the condition. But why are we so put off by a blemished face? I mean, it’s easy to explain it away as something to do with health, right?

Like people who are perceived to be healthy are generally also perceived as attractive. So you’re considered less attractive if you have signs of poor health, or maybe it’s our fear of disease. Skin issues like rashes and warts and herpes blisters are all contagious. So it makes sense that they’d make us re.

Or maybe we take it as a sign of poor hygiene, like greasy hair or smelly clothes. The problem is that none of these things are true. Acne is a skin disorder, sure, but it’s not really a sign of poor health in general. Acne also isn’t contagious. You can make out with a breakout and you won’t be putting your kissing companion at risk.

Acne also isn’t caused by poor hygiene. Unfortunately, as many of us have learned, washing your face regularly isn’t enough to keep zits at bay. Of course, our lizard brains don’t know that. We see skin imperfections and our evolutionary drives go, boo boo, boo. Unhealthy, diseased, unclean, boo boo boo. It also doesn’t help that the faces we see on billboards and magazines are airbrushed to within an inch of their lives.

Okay, let’s back up and start with the basics. If acne isn’t caused by disease or too few showers, what does cause it?

Alexa Shipman: It is complicated.

Ashley: That’s Dr. Alexa Shipman.

Alexa Shipman: I’m a consultant dermatologist in the UK and I only do NHS work, so which means in the NHS we don’t do any cosmetics. It’s probably multifactorial.

There’s partly genetics to blame. So some families, everybody will have acne and have bad acne. It’s certainly hormonal driven, which is why as children we don’t usually get it. And it starts developing around puberty and, and it often improves over age. And it’s the male hormones, the androgens, which are responsible.

Um, so women with a higher androgen levels such as polycystic ovaries will have worse acne than women with, uh, normal estrogen and, um, androgen. Um, there’s a bacteria that plays a part we think, called cutie bacteria acnes. Um, and we think that sets off a local inflammatory response and then it causes the sort of fats in your oil glands if sebum, to break down into fatty acids, which triggers more inflammation, and it just becomes this cycle of sort of inflammation, skin thickening, blocking pause.

And your things like your antigens, et cetera, all alter that balance.

Ashley: So it’s not the sebum itself.

Alexa Shipman: Yes. Yeah. We need grease on our skin and as we get older, we produce less grease, which is why often acne improves and why older people often get quite itchy dry skin because they stop producing all their oil.

Ashley: And what are things that we do to ce. Acne because I know there are a lot of myths out there about it. Right?

Alexa Shipman: A lot. And a lot of them have been disproved. For example, chocolate doesn’t cause acne. Certainly being overweight does. And that’s partly because it shifts your hormone balance. If you are overweight and obese, then you produce more male hormones and so your acne worsens.

So there’s no particular dietary, uh, requirement apart from of course being on normal healthy weight for you, which is slightly different for different ethnic. So the BMI charts are for white, Caucasian. If you are south or East Asian, you have to be thinner. You allowed to be heavier if Caribbean cause your bones and muscles are heavier.

So the chart has to taken a pinch of, essentially, you’ve got to be a healthy weight for you.

Ashley: Humans have been dealing with acne for a long, long time.

Alexa Shipman: Well, I mean, as far as we’ve got written medical records, there’s, there’s talk about boils and spots. I mean, the term acne wasn’t used until about 1840, so before that, there’s lots of different terminology for it, but it’s, it lits all the medical literature from us as long as we’ve been doing it.

Ancient Egyptians, the use of papyrus, all sorts of things.

Ashley: The terms that were used are actually pretty fascinating. Aristotle and Hippocrates wrote about acne using the Latin virus and the Greek ion. The singular of which refers to the first growth of a beard. So clearly this issue was associated with teenagers, and as Dr. Shipman mentioned, acne makes an even earlier appearance in the abers papyrus, the Egyptian medical tone. That’s one of the world’s oldest known medical works. It’s authors called Acne Aku, which really sounds like acne and maybe why we call it that.

Alexa Shipman: Yeah, and they’ve all got different ways of treating it.

Some are using sort of fruits and vegetables, other animal things like honey, for example. And Honey’s very widely used. Still lives in medicine cause it’s so very useful. And there’s a very large part, a dark part of medicine where we only concentrated on the four hums for sort of several centuries and did no further research where the cure for everything was bleeding or purgatives, et cetera.

So there’s a large period where we were just, Bleeding people for acne and praying. Of course, herbal poultices and then the Victorians in particular are very into special diets and blaming sex and masturbation for everything. And you know, even throughout the sort of early part of the 20th century, there was very much a fixation on diet and cls and environment, et cetera.

And it wasn’t until later on in the 20th century we finally moved on to some, some more effective medication.

Ashley: Are there still, do you. Kind of echoes of, of all of that. I mean, everything you’ve said, it’s like, I feel like I’ve seen those things in beauty magazines like today.

Alexa Shipman: Oh yes. Oh yes, absolutely. I suppose the top is, I mean, I come from the NHS world. Healthcare is free, so you know, there’s no barrier for people to seek medical help.

But I imagine if you have to pay for it, you’d probably want to start with something that you might want to do yourself, lifestyle or diet changes. And that’s very reasonable. Cause certainly having a normal weight will help. But the trouble is everybody. Pins, their hope that a special dietary exclusion will clear their skin.

Where, of course, it’s never going to happen because it’s, it’s partly due to your hormone profile and your genetics. You’re never going to cure that with diet. There’s also, you know, a billion dollar industry based around dietary supplementation, vitamins, health classes and all that sort of thing. So you know, you’re never going to be able to sort of counteract the power.

They have to influence people’s faults. So it is difficult to counteract that. And, and sometimes we don’t push too much because also, you know, medicines don’t suit everybody. So you can’t promise to cure everybody with modern medicine cuz we’re still not at the sort of Star Trek generation where you can just wave something that somebody and go, I know the cure for you.

So there’s always a little bit of, we do rely on people’s own enthusiasm and wish to get better, but we just want to sort of temper it in the right direction.

Ashley: Now, when I set out to make this episode, I believe. Well, I believed a lot of things that didn’t end up being true, but one big one, acne is acne. I mean, yeah, there are different types of pimples, like they’re deeper or shallower or bigger or smaller or whatever, but I believed that they were all the same thing.

Nope. Turns out that there are many different ways for your skin to ruin picture day.

First you’ve got acne vulgaris.

Alexa Shipman: So acne vulgaris is your commonest one. Vulgar means common. So any medical term of vulgaris means it’s the commonest form of a particular disease. So acne vulgaris is your commonest form of acne or teenage pimples.

Ashley: There’s also acne inversa.

Alexa Shipman: Acne inversa is acne all spots and boils, let’s say in your genitals, in your armpits under your bust.

Ashley: 

This variety shows up in that area because it involves inflammation of your apocrine sweat glands, which are located around your genitals and armpits. They’re the ones that are to blame for your smelliest areas being smelly. Next is acne excoriee, which gets its name from the French word for scraped or abraded.

Alexa Shipman: sometimes called acne jeune fille for young girls, cuz it’s the pick, pick picking.

So you see girls with lots of scabs over their face just because they’re picking and squeezing rather than really, they’re acne.

Ashley: There’s also nodulocystic acne.

Alexa Shipman: we call them nodulocystic because they’re essentially, they’re a big cyst under the skin. As that oily gland has got completely blocked, it’s time to produce oil.

It just gets bigger and bigger under the skin, and the more nodules cystic your acne, the more scarring and the more stronger treatments you require

Ashley: And there are a whole bunch more.

Alexa Shipman: And there’s acne rosacea, which is your sort of rosy, red flushed face that of older ladies tend to get. And gentlemen too, acne mallorca, which is a sun stimulation, acne.

So quite a lot of acnes, and

Ashley: while most of them are harmless from a health standpoint anyway, there are rare forms that can be pretty scary.

Alexa Shipman: So acne fulminans is a, the really terrible end of acne where you start getting liver arrangements could bleed to death. Free cysts can just die from acne fulminans, but that’s enormously rare.

Um, we don’t see that very often, particularly in the modern age of medicines where we can control people’s acne. But you know, we used to lose particularly young men to acne very occasionally and the sort of acne versus the sort of hidradenitis suppurativa pathway. It can be awful. Deep sinuses and tracts eroding food to the sort of rectum and vagina, et cetera, enormously damaging, but those are much sort of severe, uh, rarer ends of the spectrum compared to your normal acne.

Normally, it doesn’t cause harm unless either you got the novel cystics, which scar or your picking, and that’s the, the picking will give you scars. As

Ashley: far as picking like what kind of harm do we do to ourselves from acne? I mean, are there, are there ways that we make it worse by trying to make it better?

Alexa Shipman: I suppose so, yes. Individually and even as a medical profession, we’ve had some real disasters with acne treatment. Uh, you know, in the sort of fifties, sixties, we used to. And even before, we used to do x-rays and then we used to do radioactive paint, so we then gave people terrible scars from those treatments and then multiple skin cancers afterwards.

So I’ve got lots of, you know, 80, 90 year olds who had radiation and radioactivity paint, who I’ve now got to chop various bits of their skin as a consequence. But, It is more difficult to get such abrasive treatment. Certainly historically you could buy all sorts of terrible things and the regulation in healthcare has helped prevent a lot of that.

But certainly you’ve got to be slightly careful pursuing sort of laser and pills until you’ve really controlled your underlying acne as you’re sort of essentially just sort of paying money for a, a chronic disease that actually needs sorting out.

Ashley: Alright, but enough of the pleasantries. What I wanna know is why was my 16 year old self so very wrong?

One of the big wonders I’ve always had is, you know, when I was a teenager I was always looking forward to being an adult and not having. Pimples anymore, and uh, that has not happened yet. No. So what’s up with that?

Alexa Shipman: So, I mean, it certainly improves because we have a big flare of hormones as we go for puberty.

So that’s why the teenagers are spottiest. But as long as we are producing sex steroids, i e, as long as it’s women wear before the menopause, and men for longer, as long as we’ve got those sex steroids, we’re going to have Scott’s. And there was a very good American study, actually, but nicely demonstrated.

But you have terrible acne as a teenager. You’re gonna have terrible acne in your forties and fifties too. Whereas those on the milder spectrum, it will continue to improve as you.

Ashley: Good news, kids, your acne will improve with age, somewhat. You know, unless it’s really, really bad. In which case it will still be really bad when you’re a grownup.

While we’re at it, some of your bullies in school will go on to be rich and successful while you struggle to find a job that uses your college degree. Welcome to life. It’s full of disappointments.

Okay, so it’s very clear that almost everyone everywhere will get a pimple at some point in their lives. So how should you deal with it?

Alexa Shipman: Well, I mean, it’s very difficult to tell people not to pick because of course that’s what everybody likes to do. So I don’t think there is any real defined medical way.

Our main job is to try and stop you getting. So if you have to pick your pimple, you have to pick your pimple, but I would suggest in the least damaging way possible. So no digging around with needles and squeezing until it’s completely scabby. You know, gentle as possible.

Ashley: Squeeze too hard, and you may force the pimple’s contents back down into your skin.

Ugh, that just makes the pimple more inflamed and it can even lead to permanent scarring. But following that advice can be so hard sometimes. And if it’s so bad for us, why does it feel so satisfying? Well, like with many human quirks, there’s no single explanation. Some experts say pimple popping is a way to feel a sense of control over an otherwise uncontrollable skin problem.

Others say it’s a deep-seated fascination with what lies beneath our skin. The stuff we don’t normally see popping out into view literally, or it may be even deeper than. It might harken back to our ancestors’ needs to clear their skin of insects and parasites that could make them sick. If you run your hand over your skin and feel a speed bump along the way, chances are it’s not supposed to be there and you need to get rid of it.

Just in this case, our urge to get rid of it can do more harm than good. The best advice, of course, is to prevent zits before they ever. And one of the very best treatments for that Dr. Shipman says, is isotretinoin, also known as Accutane or Roaccutane, depending on where you live.

Alexa Shipman: And there’s a drug called Isotretinoin or roaccutane or Accutane you might call it.

Which is an amazing drug. I mean, it’s one of our few drugs that really can almost cure almost everybody. Um, so it’s enormously effective. The disadvantages, it has lots and lots of side effects, um, and regulations and rules about prescribing. But as far as effectiveness, it is enormously effective. And there’s only been one or two people who I’ve struggled with over my career.

Ashley: Yeah. Let’s talk side effects. Cause that’s the one that causes his birth defects, right?

Alexa Shipman: That’s right. So essentially you don’t get pregnant whilst you’re on it. And for about a month afterwards, it’s the drug is based on vitamin A, which is a fat soluble vitamin, which means that when you take it, it gets absorbed into your fat.

So when you stop taking it, it takes about a month to leach back out of your fat. So for as long as you’re on it and for a month afterwards, you don’t get pregnant. That’s the rule. Um, and after that, then you won’t get a damaged baby. But during it, it’s very high chances of having a damaged baby.

Ashley:  what kind of, uh, safeguards do they have?

Do women have to do pregnancy tests all the time when they’re on it or anything like that?

Alexa Shipman: Yes. So it depends. Um, certainly in the UK we have two forms of consent forms. So you either sign to say that you are not sexually active, not at risk of getting pregnant, and therefore you don’t need to have the pregnancy test.

But anyone at risk of getting pregnant, i e basically anyone who’s sexually active, who’s still got a boom, needs to sign the, uh, consent form. Um, and they come for monthly pregnancy tests and they just get four weeks of R to time.

Ashley: In the United States, it’s more intense. Here we have the Eye Pledge Program, which is an effort to prevent any fetal exposure to the drug.

Everyone prescribed isotretinoin must register for the program, and people with uteruses are required to have two negative pregnancy tests before starting the prescription. Every month After that, they must have a negative pregnancy test. That they’ve been using two forms of birth control. It’s a lot.

And even beyond the birth defects, the run-of-the-mill side effects can be pretty nasty. In an article for the Atlantic writer, Emily Goldberg recalled how dry and flaky her skin and lips became when she was on the drug. The dryness was so bad sometimes that she’d suffer from nosebleeds, but for her it was worth it years.

She still has clear skin. Is Accutane something you have to take for your whole life or, or just for a little while and then it works forever? Yes.

Alexa Shipman: It’s, it’s so good. You just generally need to do it six months and that’s it for life. Wow. Yeah. That’s incredible. It is incredible . It is incredible. There’s a lot of bad press about it.

I think when it first came out, people were so excited. It was used with gay abandon and we had a lot of ladies pregnant, which is why the Travat effects became so well known, and there became concerns about people’s mental health or whether it was affecting people’s mood and causing depression and suicide.

And that remains a question up to modern day. Generally, most of us in dermatology are the impressions that it probably doesn’t affect the mood, but it, it is difficult because the vast majority of people, we treated teenagers and that’s the time when mental health issues appear and it’s. The highest rates of suicides are intuit teenagers and, and self-harm attempts.

And it’s where mental illness starts manifesting. Um, the Scandinavians are the best country for these sorts of research cause everybody’s on a database in Scandinavia. So they’ve demonstrated that there’s no difference between the suicide rates of teenagers who are on RTA versus those who aren’t. You know, and that’s an entire country population study.

So we use that sort of data to try and reassure people that a lot of the bad press is not. But if you search the internet, you’ll find a lot of bad press about RTA and, and it doesn’t fit what we see in clinical practice. You know, we treat thousands of, of young people a year without any problems.

Ashley: Isotretinoin is definitely the most powerful tool we’ve got in the fight against acne. But if your acne isn’t all that severe, there are milder tools at your disposal. Like instead of taking isotretinoin in pill form, you can use it as a face cream, what’s called a topical retinoid.

Alexa Shipman:  And that’s amazingly good.

Plus it is also anti-aging, anti wrinkle, anti blemish. It’s what’s in all the extensive anti-aging creams. So it’s, it’s quite a good one to get into the habit of using to control your acne cause you’ll also end up looking beautiful forever. Retinoids basically shrink your oily glands. So when you’re taking it by mouth, you become super, super, super dry with nose bleeds and you’re greasing your lips and things like that.

And you probably juggle to wear contact lenses and you almost look like you got eczema. Whereas the cream, you’re just getting the local effects. So your skin may get a little bit red to start with, but you often then get used to it so it settles down. But it’s basically sort of stripping all the oil out your skin.

So you are a lot less greasy and the oily glands start shrinking, so they start getting blocked. So you lose all those little pimples and blackhead.

Ashley: How is that in an anti-aging cream then? I feel like that would be the opposite of what you want.

Alexa Shipman:  because it also stimulates collagen formation, so it seems to prevent some of that wrinkle formation.

Retinoids have a quite a large number of effects, which we don’t truly understand. We also use the retinoid drugs for psoriasis, uh, for hand eczema, for cutaneous lymphoma, so we’re not just using retinoids for acne. They have a, a myriad of amazing skin effects, but are not very well understood.

Ashley: And in the future, teenagers might have even better treatments at their disposal. I can only imagine. Dr. Shipman told me about how researchers are trying to see if they can repurpose a blood pressure medication for acne treatment.

Alexa Shipman: We’ve got a very interesting trial going on matter drug called spi. So because the acne women are partly driven by the male hormones, um, there’s always a lot of pressure for women to go on the pill, for example, to control their acne.

And there are certain pills with, with antigen properties. Meaning they settle down the sort of male hormone aspect, but they’re associated with slightly higher risks as pills go. So our family doctors, our general practitioners are generally not quite so happy about prescribing them long term. So a drug corone, which is a diuretic, meaning it’s a blood pressure tablet, but we.

Have lots of 80 and 90 year olds on, which has a similar antigen genetic property. So we’ve got a trial going on at the moment in the UK to try and get it licensed as an acne treatment. So we’re treating anybody over 18 with the mildest of acnes only acne, but we would consider needs treating to see if it works.

Because if it does, that’ll be very exciting because it, it will help a lot of those people with sort of a chronic sort of milder to moderate acne who really don’t want to risk the side effects of rta, who don’t want be on long-term antibiotics because I think that’s all of a concern of ours. We’ve got to be careful with our antibiotics stewardship, but we’re not just handing it out willy-nilly to people for years on end.

So I think it’ll be a wonderful, if that works, cause we’ll have a good, nice, safe option for sort of long-term acne control. All those people that would’ve had acne for 20 years, it’ll be a nice, safe drug for them to be on and cheek cheap as it’s been around for a long time.

Ashley: acne comes with a heightened risk of depression anyway, even before you start treatment.

So just imagine if you could give someone the magic bullet that would make their acne go. I had to think that dermatologists like Dr. Shipman were changing lives left and right and she might be, but because she’s so successful, she kinda has no way of knowing.

Alexa Shipman: They’re generally delighted, but it is the nhs, so we don’t follow off anyone who doesn’t need it.

so, so generally they get discharged as soon as we’ve treated them, but the vast majority of them never come back to us, which we see as a good. You know, I particularly like treating the younger teenagers when they’re still at home with their parents who can keep an eye on them, check them all right, get them through the course, you know, before they’re getting married, having sexual relationships and babies and you know, essentially to me, I think, you know, you’ve got them better before they ever go off to university or, or college or what have you, or work, and nobody ever needs to know they ever had spots so they can just sort of start life again as a brand new person without worrying about the psychological and sort of embarrassment of having lots of posts on your.

Ashley: Starting over again as a brand new person with clear skin. Oof. Sounds life changing to me.

Thanks for listening. Taboo Science is written and produced by me, Ashley Hamer. The theme was by Danny Latka of DLC Music. Big thanks to Alexa Shipman for taking the time to talk to me. Oh, and hey, did you see that Taboo Science made an end of year list? Yeah. This show was named one of the 68 best podcasts of 2020 by Discover Pods.

Amazing. I hope it’s even better in 2021. If you’re listening soon after this publishes, I hope you have a very happy holiday. If you’re listening in the future, let me know how 2021 turns. I don’t know why I have to change my plans. Anyway, that’s all for now. See you in two weeks. When we talk about vaginas.

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