Medically termed as “Post Inflammatory Hyperpigmentation” or PIH, these are dark brown to blue to black pigmentation that are left behind as a sequelae of the acne.
PIH can cause more concerns for individuals with acne than the acne itself but the good news is that, PIH are lesser evils of all pigmentation issues that occurs in our skin, they are preventable and completely treatable for many.
So why do PIH occurs ?
Skin type (i.e darker skin type), along with UV radiation and ongoing inflammation from the acne all work together to cause PIH
How can one minimise the risk of development of dark spots or PIH?
Though PIH/dark spots from acne can fade with time, we do see many individuals whose PIH last longer than expected.
Why is my PIH not fading?
Do over the counter products work for PIH post acne?
To some extent, YES, they do!
OTC products that addresses pigmentation along with treatment for acne and sun protection can definitely help fade acne scars as long as they are superficial epidermal PIH. Deep/Dermal PIH or mixed type of PIH would respond better to prescription medications +/- in office procedures such as chemical peels, LASERS etc
I’ve written post on this a while ago, and not much data was available then regarding truncal acne.
So here’s an update on another common issue : Truncal acne.
Truncal acne refers to the acne involving the back and or chest. Around 50% of patients with facial acne also suffer from truncal acne while ~ 3% suffer from just truncal acne without any acne on their face.
How is it different from facial acne?
Truncal acne has been neglected in comparison to facial acne. Not much studies are available on this entity and treatment options are limited as well. Creams or gel that are available for face may not be enough or prove to be too costly for application over large surface areas such as the back or the chest.
Triggers for truncal acne
Triggers are external factors that could cause development of acne in genetically predisposed individuals.
Whey protein supplements have been reported to cause acne eruption in body builders
How is body acne treated?
In general, treatment of truncal acne follows the same principles as for facial acne.
The only difference is that one needs to be mindful for the choice of products for truncal acne. A small 15g cream or gel may prove to be too costly as it may not be enough to treat large surface areas such as the back and chest.
Lotion or foam formulation may be a better and more convenient choice for the back/chest.
Few are available as over the counter (OTC), while medications such as antibiotics, retinoids or steroids require prescription and supervision by a dermatologist
When in doubt of the diagnosis and how to use these products
If you have a personal history of developing hypertrophic or keloidal scars (thick, large scars), early treatment will help prevent such scar formation
Severe extensive involvement may require a course on antibiotics or isotretinoin
Managing post truncal acne scars either atrophic, hypertrophic or pigmented scars may require in office procedures such as chemical peels or LASERS, etc
Do you often get your breakouts just before one event? Have you ever used Pimple patches? What is these patches made of? Do they even work? Can they work for all types of pimples?
What are pimple patches?
These patches are hydrocolloid dressings which were traditionally used for treating acute or chronic wounds. They’ve also been used for the management of post surgical wounds.
Hydrocolloid are hydrophilic (water loving) substance composed of gelatin, pectin, carboxy-methylcellulose. As these substances are attracted to water, they are they can absorb water, and pus from the wounds and then forms a gel which provides a moist environment for the wound.
How do hydrocolloid help in wound healing?
How do hydrocolloid dressings work for acne?
Which type of acne are they best used for?
Single or limited acne
Perfect as an SOS solution for those pimple that always pop up before an event.
Acne which is inflamed (red, painful, with or without pus)
Pimple patches are not ideal for severe, cystic acne.
How to use pimple patches?
Wash face clean before application
Apply the patches over the acne on dry, clean skin
The patches can be left overnight or longer (12-48hrs)
Dispose used patches. Do not reuse them
Skip using face serums, moisturisers oven the active acne before applying the patches
The patches are transparent so they be used during the day.
These patches do not replace the regular acne medications such as benzoyl peroxide, adapalene etc. They serve as rescue treatment for those once in a while acne breakouts.
Are there any concerns regarding these patches?
Well as great as they seem in theory as the emergency acne rescue option, there have not been much research done for their use in acne. I would love to see more studies comparing these to spot application with benzoyl peroxide or salicylic acid.
Some individuals may even be allergic to either the adhesives used in these patches or other ingredients.
So in conclusion:
If spot application of benzoyl peroxide works for you, continue it. There is no need to buy spend extra money on these patches. But if your skin gets too irritated or dry with actives such as benzoyl peroxide or salicylic acid, or you’re the type that just can’t control picking on your acne, then these patches could be a great option for you.
Pimple patches available in the Indian market
Pimple patches are available as either pre cut patches or as single sheets for a customisable size. One can make heat shapes or star shapes or whichever fun shapes out of these sheets.
Some pimple patches also contains active anti acne ingredients such as salicylic acid, tea tree or cantella asiatica which helps in calming and soothing the skin.
These are available at either amazon or on flipkart
Azaelic acid is one of the most underrated active skin care ingredient which is found naturally in our skin, and is helpful in the treatment acne,rosacea and as part for your skin care routine for a blemish free skin.
Azaelic acid (AA) is a dicarboxylic acid that is naturally found in wheat, rye and barley. Azaelic acid is also produced by a yeast that lives in our skin called Malassezia furfur. This explains why over colonisation by this yeast results in pale patches in the skin which is medically termed as Pityriasis versicolor. Owing to this acid’s potential to cause reduce pigmentation, azaelic acid has been widely used to treat hyperpigmentation.
AA is found in grains such as wheat, rye,barley
M. furfur as seen by an electron miscorscope
How does it work?
Azaelic acid has been shown to have a bacteriostatic (inhibits the growth of microbacteria) and bactericidal (kills the microbacteria) action against micro organisms in our skin particularly Priopionibacterium sp (bacteria responsible for acne).
Azaelic acid also displays anti keratinising effect i.e it inhibits the proliferation of keratinocytes (cells of our skin) which would otherwise build up and clog our pores thus leading to formation of comedone (white or black head)- precursors for acne. If you recall from my previous posts, retinoids (vitamin A derivative) also has this action. AA does not however reduce sebum production (oil secretion) in your skin unlike oral isotretinoin (vitamin A derivative used in the treatment of acne).
Azaelic acid demonstrated cytotoxic effect (toxic to cell) towards active melanocytes (pigment producing cells of our skin), which means it does not affect the inactive melanocytes in the normal skin, thus it particularly targets just the abnormally pigmented area. It also inhibits the action of the enzyme tyrosinase, which is required for melanin (skin pigment) synthesis. Therefore it is effective as a skin lightening agents and is used to treat pigmentation disorders.
Azaelic acid (AA) has been found to act as a scavenger of reactive oxygen species (ROS) therefore reduces inflammation and redness of the skin.
Dermatological conditions in which Azaelic acid is proven to be beneficial
Acne:
Azaelic acid in the strength of 20% have been shown to be effective in the treatment of mild to moderate acne. Studies have shown that twice daily application of 20% AA cream is effective than a vehicle (cream without any active ingredient) in the management of acne. Significant results were only well appreciated after 12 weeks i.e 3 months of continuous use. A study has also shown that 20% AA is as effective as 0.05% tretinoin (retinoid) in the treatment of comedonal acne.
Another study comparing the effectiveness of 15% AA with 5% benzoyl peroxide and 1% clindamycin gel (other active ingredients for the treatment of acne) showed equal efficacy of AA at the end of 4 months.
All these studies as well as reports from dermatologists have noted that the average time of achieving improvement with AA for acne was ~73 days equivalent to over 2 months of continuous use.
Azaelic acid is a great option for acne prone skin especially if someone is not tolerating other active ingredients used for acne such as adapalene, tretinoin or benzoyl peroxide.
Rosacea:
AA is FDA approved in the US for the management of rosacea (particularly papupopustular rosacea). Rosacea is a condition which can present like acne with multiple red bumps with red inflamed cheeks. Patients with rosacea have extremely sensitive skin and the redness can be triggered by various stimuli such as hot drinks, smoking etc.
A case of rosacea- red inflamed skin with papules (red bumps) and dilated blood vessels
15-20% AA used topically twice a day was shown to be effective for reducing the number of papules and pustules and to a little extent the redness in patients with rosacea. These improvement were achieved over a 15 week course of treatment.
Pigmentation:
Azaelic acid either alone or in combination with various other active ingredients is used to fight pigmentation. A study on the effectiveness of topical 20% AA in patients with FST IV -VI i.e brown or Indian skin type to black African type, concluded that twice daily application of AA lighten the pigmentation after 24 weeks (6 months) and also improved the smoothness and texture of the skin (which is great if you’re trying to even out your skin tone and skin texture)
Combination of 20% AA and 0.05% tretinoin is also available for the treatment of melasma. The study to support this combination compared AA as monotheray vs the combination therapy. Patient showed faster improvement in the form of decrease pigmentation and decrease in the size of the pigmented area in the combination group than AA monotherapy. However at the end of the study, i.e 6 months both treatment form achieved similar overall results.
How to use azaelic acid ?
Studies on azaelic acid either use 15% or 20% AA applied to the entire face twice a day. The side effects are mild stinging sensation or itching for the initial few days which subsides with subsequent continuous use.
First cleanse your face using a gentle cleanser
Let your face dry for like 30 mins and then apply a small amount of AA to your entire face.
If you are new to active ingredients for your skin care, I suggest starting with a low strength such as 10% AA twice a day to a clean face which can then be increased to 15% or even to a maximum of 20% AA.
This can then be layer with a moisturiser on top.
Do not forget your sunscreen in the morning after the above routine.
AA can be used as spot treatment for the inflamed acne or rosacea as well in addition to the twice daily application.
What to expect with Azaelic acid?
AA is a good option to treat mild to moderate acne and rosacea and its safe during pregnancy and can be used safely in nursing mothers as well.
For those of you who are planning pregnancy, or are pregnant, AA is a great option to use especially for someone who was using a retinoid (which is contraindicated in pregnancy) and needs some other active ingredient for their skin care.
Azaelic acid will definitely test your patience. Acne and rosacea usually show improvement in 2-6 months while it can take upto 6 months to achieve significant results with AA for pigmentation disorders such as Melasma.
Azaelic acid available in the market
AA is available as 10%,15% and 20% cream and gel particularly used for the treatment of acne and rosacea.
Finacea 15% is available as a foam and is particularly useful for rosacea who cannot tolerate other ingredients present in the cream base.
AA is also available as a combination of 20% AA + 0.05% tretinoin cream and as a combination with trenexamic acid in a serum form.
As part of the series for active ingredients for pigmentation and as a continuation to my blog post on “vitamins and skin”, let’s dive in the details of another vitamin, that is – Vitamin A, also known as Retinoid.
Retinoid was a term first used to describe the active form of vitamin A. It comes in two forms: trans retinoic acid (tretinoin) and cis retinoic acid (isotretinoin), depending on the molecule groups orientation. The prefixes “cis” and “trans” are Latin for: “this side of” and “the other side of”.
Today retinoid is used as an umbrella term to encompass all derivatives of viatmin A such as retinoic acid, retinol, retinal esters, retinaldehyde.
Vitamin A and its derivative
The order of activity of a topical retinoid
The order of activity of a topical retinoid is as follows:
In others words retinoic acid is highly effective while retinol esters are least reactive. The irritant potential however is reverse, retinol esters causes the minimum irritation while retinoic acid causes maximum irritation.
How Vitamin A works on the skin?
Vitamin A derivative found in our skin are retinol and retinyl esters. These are then converted to retinoic acid, the biologically active form, by certain enzymes. Retinoic acid binds to receptors present inside the nucleus (center) of our skin cells to mediate various biological effects.
It regulates the cell turnover: As the cells in our skin divide and move from the basal layer to the uppermost layer as dead cells (the stratum corneum) and are shed off, there are various changes that can take place, such as changes in the shape and composition of the cells. This entire process is call “keratinisation” or in simple words “cell turn over” which takes approximately 28-30 days. Retinoids help regulates and makes sure this process is occurring normally. This is particularly useful for acne, where the follicular keratinisation (the cell lining inside of a hair follicle) is abnormal. Check out my previous blog post on to see how acne develops: “How to deal with truncal acne?”.
fig. Layers of the epidermis (superficial most layer of skin)
It also affects the growth and differentiation of cells: it increases the activity of cells responsible for production of collagen, and causes an increase in the thickness of the epidermis.
Retinoids also increase production of extracellular matrix and prevent its degradation by UV rays. Extracellular matrix are carbohydrate molecules present in the dermis which act as a cushion in which blood vessels, collagen and elastin are embedded and is responsible for the suppleness of our skin.
Anti-inflammatory: Thus helps prevent the development of inflammatory (red, painful) acne.
Reduction in pigmentation: Retinoid inhibits tyrosinase – an enzyme required for melanin production (pigment responsible for our skin colour) and due to the increase cell turnover it reduces the transfer of melanin to the keratinocytes.
The expected results with retnoid
The overall clinical effects of topical retinoid are:
It prevents formation of comedones (white heads, black heads), reduces the number of breakouts. Retinoids are the topical medication for choice for non inflammatory comedonal acne.
Helps reduce fine lines, and can reverse changes seen with chronic unprotected sun exposure (photoaging).
Retinoids can help improve the appearance of pores, and provides a smooth texture with a youthful appearance to the skin.
Retinoid in the form of retinoic acid (tretinoin) is used in combination with hydroquinone (depigmenting agent) and mild steroid called “triple combination” to decrease pigmentation and evens out skin tone. This combination has been the standard first line treatment by dermatologists for pigmentary disorders such as melasma, post inflammatory pigmentation (dark spots following conditions such as acne, or various forms of dermatitis). Another combination using 10% retinol + 7% lactic acid has shown to be equally effective to reduce pigmentation.
Therefore, retinoids in various forms are used for the management of acne and as an anti ageing ingredient.
Commercially available retinoids
1. Retinoic acid
The biologically active retinoid, retinoic acid is available as tretinion. It comes in three strengths : 0.025%, 0.05% and 0.1% formulated in a cream base. There is also a microsphere gel base in the strength 0.04% and 0.1%.
Adapalene is a synthetic retinoid similar to all trans retinoic acid tretinoin. It is available as a 0.1% gel, cream or solution and as a 0.3% gel for the treatment of acne. Adapalene (Differein) can be bought at the pharmacy without a prescription. It is now available as a combination with benzoyl peroxide (Deriva BPO gel, Epiduo gel) or with clindamycin (ClearApgel, Deriva CMS gel) as well.
3. Retinaldehyde
Retinaldehyde is the immediate precursor of the active form of Vitamin A-retinoic acid. Retinaldehyde in 0.05% and 0.1% concentration used twice daily for 12 weeks have been shown to be effective in treating photodamaged skin (rough, dry skin with fine or coarse wrinkling) and pigmentation. After application, retinaldehyde needs to be converted in the skin to retinoic acid by certain enzymes. This prevents the over saturation of our skin with retinoic acid and thus is better tolerated with fewer side effects. However the expected results can be slower than with retinoic acid.
3. Retinols
Many over the counter anti ageing, and pigmentation cream contain various concetration of retinols (0.3%, 0.5%, 0.1%) as the active ingredient. As you can see from the above image on vitamin A & its derivative, retinol needs to be converted to retinaldehyde which is in turn converted to retinoic acid. Retinol is 20 times less potent than retinoic acid (tretinoin) but the bears the advantage of less side effects. But retinol is highly unstable and gets degraded easily to inactive forms therefore the choice of the vehicle is of utmost importance for this ingredient. This neutrogena does not mention the concentration of retinol but from what I found online, its probably a lower concentration of 0.025%, which is great if you’re just starting with a retiniod.
Side effects of topical retinoids and how to combat it
Over saturation of our skin with retinoic acid can irritate our skin. Therefore the side effects are mostly seen with topical retinoic acid such as tretinoin. For this reason and because retinoic acid has biological effect when applied on the skin, it is considered a drug and requires a doctor’s prescription. Such regulations are not followed in India, and one can buy almost anything over the counter here, but I strongly discourage using retinoic acid as part of your skin care regimen without a prior dermatological evaluation or without supervision from your prescribing doctor.
During the first few weeks of topical application of a retinoid, redness, flaking of the skin, acne flare, photosensitivity are expected. This can be minimised by starting with the lowest concentration of retinoid, or by limiting the amount and the frequency of application.
It is advised to start with either twice in a week application, or alternate days application once at night for the entire face and never in the morning. The frequency and strength can be increase according to our skin’s tolerance to the product. Moisturisers and sunscreens are a must while using a retinoid.
Retinaldehyde and retinols have fewer chances of causing this irritation and are the best bet if one wants to start using a retinoid in their skin care and for someone with sensitive skin.
Retinoic acid such as tretinoin being more irritant should be avoided for someone with dry, sensitive skin or someone with skin conditions such as Rosacea.
Retinoids should not be used during pregnancy.
Interested in a vegan option?
Retinol, retinaldeyde and retinoic acid are animal derived forms of vitamin A while beta carotene is derived from plant and fruits. Beta carotene can be converted to retinal esters and retinaldehyde in our body which are then converted to the active form retinoic acid.
However a carrot can only provide a maximum of 6 mg of beta carotene. So if you want to duplicate the results of this study, you’ll need at least 6 large carrots a day.
Since long term study on the effect of vitamin A supplementation on our body as a whole has not been carried out, the potentials dangers that may result from toxicity of vitamin A has not been ruled out yet. Till we know more about the the benefits and risks of oral intake of vitamin A (beta carotene supplements), its best to avoid oral supplementation and stick to what we know, which is topical sunscreens and topical retinoids to fight signs of ageing and pigmentation.
It is important to note that, scientific research on the role of an active ingredient for pigmentation or ageing are performed over weeks with a minimum of 12 weeks before any conclusion can be drawn from the studies.
Therefore, always use a product for at least 12 weeks before you decide to conclude that the product is not working and move on to the next best thing.
Acne, also known as acne vulgaris, is one of the commonest reason for a patient to visit a dermatologist. Truncal acne is when acne develops in the back or the chest. Most of the data and scientific studies available are concentrated facial acne, while less emphasis has been placed on truncal acne.
Most patients do not seek treatment specifically for their truncal acne. It is only when they’re asked for directly by their doctors or when undergoing a full clinical evaluation for their facial acne that they are raise their concern about their truncal acne as well.
How does acne develops?
It takes more to develop acne than just an oily skin.
Acne is a mutifactorial disease, caused by a complex interplay between genetics, hormones, micro organisms and inflammation.
The four main pathological process are: i) abnormal follicular keratinisation (anomaly in the process of how the cells of the skin differentiate into a layers of dead skin cells which are eventually shed off), (ii) increase sebum production (oily secretion produced by glands in the skin), (iii) Colonization by Propionibaceterium acnes (bacteria normally found on the surface of the skin but increase in number in acne vulgaris patients) and lastly, (iv) Inflammation (body’s natural response to the above three factors).
fig. How acne develops (simplified version). Red indicates the site of action of various acne medications
As I mentioned earlier, limited studies are available on management of truncal acne. From the studies that are available, the treatment modality is based on the severity of the acne.
Treating truncal acne can be challenging due to the large surface area of involvement. The topical medication such as face washes or creams may not be feasible for use on the back.
For this reason, different formulations such as foams, lotions or body washes are required for such large area. The problem with this type of formulation is that they are the least potent form of drug delivery system which deliver the least amount of active ingredient (benzoyl peroxide or salicylic acid etc).
Treatment of truncal acne follows the same principle as for facial acne. The treatment will vary among individuals and depending on the severity of the acne. Unfortunately, there is still no definite cure for this condition. One ray of hope is that truncal acne has lesser chances of scarring as compared to facial acne. The treatment options available are limited and for optimal results, consistency and long term maintenance is necessary for better control of the breakout and minimizing the chances of scarring.
A thorough evaluation by a dermatologist is necessary, for assessment of the severity, other relevant medical or drug history which may be the cause of the acne or to rule out any medical contraindication to a specific acne treatment.
There are many other conditions that can resemble truncal acne. Some of these conditions are acneiform eruption (acne caused by certain medications such as anabolic steroids, anti fungal drugs, or exposure to insectisides, mechanical trauma as seen in areas of contact with bra straps), gram negative folliculitis, and P.follicultis.
All red bumps on the back or chest is not acne.
Treatment options available for truncal acne
For mild truncal acne, a topical benzoyl peroxide wash available as 4%, 8% and 10% creamy wash once a day for at least 12 weeks. Washes are applied to the entire back and chest at the time of shower for a contact time of 20 seconds followed by rinsing with normal water. The method of application as stated in the article “Benzoyl Peroxide Cleansers for the Treatment of Acne Vulgaris: Status Report on Available Data”
Mild truncal acne
“20-10 approach” of gentle massage application to lightly moistened skin (a 20-second contact time) and gentle rinsing over an approximate 10-second period.
A longer contact time of more than 20 seconds may cause some irritation. Another drawback of benzoyl peroxide is that it can cause bleaching of the clothes that comes it contact with.
Benzoyl peroxide 4% (brevoxyl creamy wash) available in India
For moderate acne, addition of a topical antibiotic such as clindamycin available as foam cleansers can be beneficial. A systemic antibiotic may be required if response to the above topical medication is poor. Recently, topical dapsone (antibiotic) has also been shown to help improve truncal acne.
For severe acne, or truncal acne that fails to respond to the above mentioned treatment, systemic management with retinoid (isotretinoin) or hormonal therapy such as oral contraceptive pills are indicated. These treatment will require a thorough clinical assessment and certain baseline blood investigations prior to the initiation of therapy. Regular follow up will be necessary with such treatment.
Which soap to choose?
A recent study has shown that the pH of the skin at the back is higher compared to the pH of the skin on the face and chest. This alkaline pH at he back favors the growth and multiplication of Propionebacterium acnes in these areas which then contribute to the etiology of truncal acne. Avoiding soaps that can further increase this pH will be beneficial. Opt for a syndet (i.e. synthetic detergent) bar or body washes with neutral pH for example dove soaps are syndet bars which does not alter the skin’s pH.
It’s important to remember that similar to facial acne, truncal acne can be controlled with the occasional flare but with a consistent regimen the number of breakout can be reduced and scarring can be prevented. One gentle reminder which all of us are aware of yet fail to comply is to avoid picking on the acne.
Dr Naphisabet Wanniang 
