The following is an excerpt from the Glow Journal podcast. To listen to the full interview, subscribe now on iTunes or Spotify
In this instalment of our Ask An Expert series with our friends at Candela Medical, we’re taking YOUR questions to Dr Firas Al-Niaimi. One of the most prolific and well-published dermatologists in the UK, if not the world, Dr Firas has written and contributed to over 160 publications, has delivered lectures in over 50 countries and is on the editorial board of multiple dermatology journals. A globally respected opinion leader, Dr Firas was who I felt was the ideal doctor to answer YOUR questions on acne, acne scarring, post-inflammatory hyper pigmentation and pore size.
Away from our regular brand founder conversations, I am frequently asked so many highly specific questions about the skin. Given that I am an educated consumer and by no means an expert, it would be extremely unethical for me to even attempt to address your skin concerns- which is why I have long insisted on taking those questions to a medical doctor. That’s why I truly love producing this Ask An Expert series with Candela. Although the series itself is sponsored, doctors legally and ethically have to remain completely objective in interviews like this. For this reason, this series is the single most authentic way for me to integrate branded content into the podcast because it’s giving you, the listeners, completely unbiased expert answers to your most specific skin questions.
GLOW JOURNAL: We’re covering quite a few topics today and a lot of the questions I’ve been sent are quite specific, so I thought we might start with a broad one. What is acne?
DR FIRAS AL-NIAIMI: Acne is a common inflammatory condition. It’s a condition affecting the grease glands in the skin, which we the sebaceous glands. The clinical presentation will be excessive oiliness of the skin, blackheads, whiteheads and red pimples that, essentially, are all related to the grease grands. The sebaceous glands in our skin are overly active and produce a lot of oil. As a result, you get a lot of inflammation. So that is, in very simple terms, what acne is.
When we talk about acne scarring, there seems to be two categories of common concerns- we’ve got pitted acne scars or the dark, pigmented spots that tend to linger after a pimple has gone, commonly referred to as scars but they are actually post-inflammatory hyperpigmentation. Perhaps we’ll start with the former. What are those pitted scars and what causes them?
The pitted scars are essentially the sequela of inflammatory acne. Once the acne is over, and sometimes in severe case whilst they’re still ongoing active acne, you can see pitted scars.
In general, we tend to see the pitted scars once the acne phase is over. In simple terms, this is just the destruction of the collagen, the matrix of the skin, there’s just been damage to the makeup of the skin as a result of the inflammation that is caused by acne.
I give the analogy that inflammation is something like a civil war within the skin and, as a result, you get the destruction and the damage to the matrix, to the build up of the skin- predominantly the collagen. And that’s why you get the pitted scars. It’s basically the damage done as a result of the inflammatory process.
A number of listeners have asked if topical skincare can help with those pitted acne scars, or if laser is essential.
That is a good question because there are some reports and some studies published that topical treatments can prevent you getting from them, the pitted scars, but not active treatments of the pitted scars. One ingredient, which is retinoic acid, that is widely internationally known as tretinoin, that has been shown to increase collagen. So in some mild cases, some very mild cases of pitted scars, there might be an improvement and the patient might see an improvement.
But I agree- the best and most effective treatment for pitted scars will be with lasers, but there is a place for creams in terms of prevention and possibly as a synergism with the lasers.
And what is the best laser treatment for those pitted scars?
That depends largely on the severity of the pitted scars and the background skin color of the patient. In lighter skin type patients and in severe cases of pitted scars, the fractional technology but more with the fractional ablative one, like the CO2 (the carbon dioxide) will be the best treatment option, because it gives better and faster results.
In patients who are very dark, that [laser] could lead to one of those complications which is post-inflammatory hyperpigmentation, which we’re going to be talking about. In those cases, the fractional, non ablative [lasers] like the Nordlys device from Candela, which has a specific wavelength called the 1550 nanometers, [is recommended].
I’ll keep it simple. For the lighter skin types and the more severe cases, the fractional ablative laser, such as the CO2, and for the darker skin types and milder cases, the fractional non ablative will be better.
A listener has asked about treating acne scars that are upwards of 15 years old. Would you approach those differently to a fresher scar?
Not so much, really. The duration of the scars, in my experience, doesn’t necessarily relate much to the response. Of course, if the scars are relatively fresh, sometimes they are a bit easier to treat. Then there might be a place for the topical [skincare] to also contribute a little bit. But for those old scars, the improvements that one can can get from the topical [treatments] are probably going to be very, very low, if negligible, but they can still expect good results with the lasers. So the duration of acne scars, in my experience, is less of an issue.
Another listener has asked specifically about keloid acne scarring and the treatment options that are available, as she says she has tried Derma rolling but has found that the results with that have just been temporary.
It’s important to actually to classify the type of the acne scar, because I think classifying the exact type of scar means that you’re going to tailor the treatments as there are different types of scars.
Keloid and hypertrophic scars are different to pitted scars because, in pitted scars, that’s destruction and loss of collagen in the skin matrix- this is why the skin is pitted. The opposite happens with hypertrophic and keloid scars, because there is excessive or too much buildup of the collagen, so what you want to do is you want to break down that college.
Steroid injections are simple, straightforward, and can be very effective. And for those red hypertrophic or keloid scars, we can reduce the redness by using a vascular laser, like the Pulsed Dye laser. We can also combine that with the fractional ablative CO2 laser, with the steroid injections.
We might move on to post-inflammatory hyperpigmentation because that was something I was asked a lot about. Firstly, what is it? And secondly, why do so many of us suffer from it?
Post-inflammatory hyperpigmentation, if we literally just translate the Latin, “post” is after, “inflammatory” is the process of inflammation which, as I said, is like a civil war on the skin, “hyper” meaning excessive, and “pigmentation” meaning darkening. So post-inflammatory hyperpigmentation is basically increased, abnormal pigmentation- abnormal as in not the usual background skin colour for the patient, following an inflammatory process.
So that could be acne, for example, which is a common inflammatory condition. As a result of the inflammation, we get this hyperpigmentation and, because it was after an inflammation, we call that post-inflammatory hyperpigmentation.
What it is is essentially increased activity of the melanocytes, which are the pigment cells that we have in the skin. As a result of the inflammation, they have been turned on, they produce more melanin, which is the pigment, and some of that leaks into the deeper parts of the skin. As it dissolves, we just see that as increased pigmentation. So it’s all the result of the inflammation causing stimulation of the melanocytes to produce pigments.
The reason why we get it… there are two key reasons. One of them is it’s much more common in darker skin type patients, so patients who have skin types 3 and 4. Those would be, for example, those from Middle Eastern, Mediterranean backgrounds, Southeast Asians, the Indian subcontinent. The darker the skin, the higher the risk.
The other risk, and the reason why you have it a lot in Australia, is because you have a lot of sun. One of the key, important measures in treating and preventing post-inflammatory hyperpigmentation is adequate sun protection. When we have inflammation in the skin, these pigment cells, the melanocytes, they’re very active and their activity is sustained by ultraviolet light. This is why it’s absolutely important that we always advise on meticulous sun protection and the use of sunscreens. Now, sometimes even with all the good faith, in a country like Australia where you have strong sunshine, that could be a contributing factor.
I received a lot of questions from listeners about at home treatments and topical skincare. What ingredients should those looking to fade post-inflammatory hyperpigmentation be looking for?
I think the first thing to say is which ingredient to avoid- and that would be hydroquinone.
Hydroquinone is a bleaching agent that sometimes is illegally available online or in certain stores. The prolonged use of hydroquinone can cause somelong lasting problems in the skin. The first thing I would like to warn is not to use hydroquinone without medical prescription and without medical supervision. I think that’s the important thing, because we see that a lot here [in London] because, for example, in certain African shops and African stores, high concentration of hydroquinone can be purchased illegally. Without medical supervision, this can have disastrous effects on the skin. So that’s the first thing I’d like to say in terms of the ingredients.
There are a number of ingredients that can help with lightening of the skin, such as kojic acid, soy, arbutin, niacinamide, thiamidol, vitamin C, and even the retinols can help too. These are some of the common ingredients. We call them cosmeceuticals, so they are non-prescriptive, they can be purchased from chemists or from beauty stores and they can, in some cases, be effective in hyperpigmentation, with a high safety margin. It’s also important to use sunblock of course, and sun protection that protects against the UVA and UVB.
I’ve had another listener ask “Is prescription retinol more effective for reducing acne pigmentation than acids?” I’m assuming she means AHAs and BHAs.
So retinols, as such, are non-prescriptive. The only variance, the only prescriptive one is the retinoic acid, which is tretinoin, and yes, that is strong.
In general, that also depends on the concentration. Prescriptive retinoic acids come in three different strengths- a low concentration, a medium and a high concentration. The side effects, such as dryness and peeling, will also depend on the concentration.
But yes, if you are using the high concentration peescriptive retinol, in general and in my experience, it tends to be more effective than the lower concentrations and AHAs and BHAs that are available in the market.
You mentioned vitamin C earlier. I had a few listeners who have asked how long it should take for vitamin C to make a difference to post-inflammatory hyperpigmentation and would the concentration of the product affect how long it should take?
This is a very good point, and I actually have a particular interest in vitamin C and have published on it. Vitamin C, as such, is more important when it’s combined with a sunscreen in terms of a synergistic protection against sunlight. So when someone has pigmentation, such as post-inflammatory hyperpigmentation, the vitamin C is usually used alongside sunscreen to improve, strengthen, and enhance the sun protection. When you combine vitamin C plus sun blocks, you get much better sun protection.
Vitamin C on its own has some relativity weak lightening activity. If you are just using the vitamin C for pigmentation, it may take six to eight weeks before you’ll notice a reduction in the pigmentation. It is not as strong as the soy, arbutin or kojic acid in terms of the lightening effect.
And definitely the concentration in important, because for vitamin C to be really active and to give results, it should be at a concentration of around 10 to 15%.
Another listener says that she has tried vitamin C, but she’s noticed no difference to her acne scars after several months. Would a clinical treatment be the next best step for her?
Yes. Vitamin C, as I said, is not a treatment for acne scars, certainly it’s not the treatment for pitted scars. If what she’s meaning is the meaning the post-inflammatory hyperpigmentation or the brown marks, then the vitamin C is still useful alongside the sunblock, at least in preventing them from getting worse. But yes, the next stage will be more active treatments such as chemical peels or lasers.
And what are the best laser treatments available for fighting post inflammatory hyperpigmentation?
The best treatments available will be with the new, pigment specific lasers- the picosecond lasers from Candela, called the PicoWay.
That’s what I get! That laser is my favourite thing in the whole world. Would you treat pigmentation on the body differently to the face? I had one listener write in asking specifically about hyperpigmentation on her knees and on her elbows.
Hyperpigmentation on the knees and elbows can just be purely increased pigmentation, but it can also be some form of thickening of the skin and some longterm friction that can lead to skin changes and darkening of the skin. In that case, patients generally require more treatments compared to the face, and it may not necessarily respond as well- just like any other pigmentation, let’s say if it’s on the back or on the chest.
Specifically on the elbows and knees, it can also be a thickened skin and some effects of friction. As a result, it’s not just pure pigmentation but, in general, yes, we use the same device. We use the same machine, the PicoWay, except when it’s off the face it requires more treatments and the response tends to be a bit slower.
So the other way to look at it is that treatments on the face tend to be somewhat easier. The response is seen faster compared to the body. So that’s the other way of looking at it.
A topic I was asked a lot about was pore size, I suppose due to the link between blocked pores and acne prone skin. Firstly, is it at all possible to actually shrink the pores?
The term “open pores,” in a way is a misnomer, because pores by definition are open. When we get closed pores, we get the clogged pores and the black heads and the white heads. So by definition, the pores are always open.
When we say “open pores,” we are actually referring more to dilated pores where they’re more visibly seen and they’re wider and dilated. It is possible to tighten them- to shrink them or tighten them so that they become visibly less wide. This is not very easy, because it’s a physiological behaviour of the skin to have the pores open. But treatments such as the fractional hand piece of the PicoWay and the fractional technology, and controlling the oil production like using the prescription retionic acid plus series of microneedling or fractional lasers can help tighten the pores. But the patient may need longterm maintenance treatment for this.
Another listener has asked “Do pores get bigger as you age?” I assume by bigger, she’s meaning more dilated and more visible.
It is possible, although it is not necessarily an ageing process as such. There are many people in their sixties or seventies who don’t necessarily have dilated pores.
The risk of dilated pores is high with excessive sun exposure and limited protection, and with longterm oily skin. What happens is that, if you are prone to acne and oily skin, chances are that when you’re in your forties or fifties, the pores are wider and more dilated than when you were in your twenties. It is not so much just the pure chronologic ageing, but it’s more related to the duration of the oiliness.
I had a few men submit questions, all around why men’s pores can often look so much larger than women’s. Why is that?
That’s a good question. That is because, if we just get back to the very first question on what is acne, the entire unit around the grease gland is called the pilosebaceous unit which is essentially the hair follicle shaft attached to a grease gland and coming out the pore, so that’s the surface. So that unit and sebaceous glands are under the influence of a number of hormones, notably the male hormones, the androgens. This is one of the main reasons why teenagers, when their hormones are spiking, get acne. Men tend to have more androgens, more male hormones, than females, and as a result these grease glands and the pores are wider because of the increased activity that is related to the male hormone. Also, the skin of the man is thicker and therefore some of these changes are more noticeable.
Well, leads me to my next question. Should male skin be treated differently to female skin with regard to minimising the appearance of the pores?
What I find in clinical practice, from my experience, is that yes, male skin with dilated pores tends to require more treatments and with higher settings. It would still be the same technology, which will be the fractional technology, be it the fractional Pico or the fractional ablative or non ablative, but men with dilated pores require more treatment sessions at a higher intensity.
One listener has asked “Do pore strips actually do anything?” A loaded question!
Well, I think they strip off the most superficial layer of the epidermis, which is called the structural corneum. They strip it of something, which is the dead skin cells on the surface, hence they might just temporarily give the impression that the skin is a bit more luminous and clear. In terms of a long term solution, I think their benefit is very limited.
While we’re on pore strips, let’s talk blackheads. I had a lot of listeners wondering if there is a longterm solution or a way to prevent blackheads, as whenever they seem to get rid of theirs, they eventually pop back up.
Again, that is a physiological process in some individuals, and it still indicates some form of activity at the pore and the duct of the pilosebaceous unit.
So the way to prevent them is to continue longterm exfoliation, so a facial wash with salicylic acids or glycolic acids will be needed. It may not necessarily need to be every day because some patients, if they use it every day, the skin can get dry. But at least two or three times a week using a facial wash with a salicylic or glycolic acid is one thing to do. The other thing to do is to use either the AHA or BHA creams or use a retinol.
Generally speaking, if I have patients who complain of ongoing blackheads, my regimen will be to give them a facial wash with an acid, to start them on a retinol, and then of course there are some other treatments that they can do occasionally such as some facials or microdermabrasion to just keep the pores healthy. That can help too.
What about white heads? Is there a longterm solution, or even a preventative, for them?
We approached them in a similar fashion, whether they are white heads or black heads, because the colour is just related to the oxidation of the melanin in the blocked pore. So whiteheads and blackheads we approach in a similar fashion.
An overwhelming number of the questions I received were about acne on the body. Is your approach to the treatment of acne on the body different to facial acne?
Yes, to an extent. Acne on the body, in general, requires what we will call “systemic treatments”, which means we tend to treat with tablets and treat from within, because acne on the body tends to respond less well to the topical creams compared to the face.
In general with acne on the body, the vast majority of patients, especially those with moderate to severe activity, will end up on tablets to treat their acne.
One listener asks “Why do I get acne on my neck and my chest, but not on my face?”
I think the first first thing is to make the correct diagnosis and to make sure that that is indeed acne, not some of the other conditions that can look similar to acne which can affect predominantly the neck and the chest- like there are certain yeast infections that can give some spots, especially if one is wearing tight clothing or there’s friction and a lot of sweating, that can give an appearance of a rash, similar to the acne spots, but it might simply be related to the yeast. So I think that is one thing to bear in mind, that it may not necessarily be just acne. It might be something else.
The other reasons is that sometimes friction from clothing can cause a form of small acne-like spots. For example, people wearing tights denims can find it in the lower back and in the buttock area as well.
And then, lastly, it relates to the grease gland activity. In some males, the grease gland activity on the chest and upper back is much more pronounced compared to the face. So it is possible that one can get activity on the chest or the neck and the back but not on the face, but I would first make it sure that the correct diagnosis is being made.
Can laser be at all effective in the treatment of acne?
Yes. Again, that is something that I have a lot of experience in, have done some research on and published on.
There certainly is a place and a role for lasers in acne, although in my experience it’s always better to combine it with topical treatments like creams, because the effects are going to be better. But yes, in selected individuals, in some cases of acne, there definitely is a place for lasers.
A listener has asked if oral treatments like antibiotics and roaccutane, or things in that family, are the best way to manage hormonal acne.
They are certainly one way of managing hormonal acne. I think the best way of managing hormonal acne is, first of all, finding out whether the cause of the hormones can be corrected- if that is an underlying hormonal condition that can be treated with certain tablets, for example something certain contraceptions can either cause hormonal acne or can treat hormonal acne. Establishing the core first and see if that can be neutralised or eliminated- that would be the first way.
My preferred choice is either a contraceptive with anti-acne activity or accutane. Antibiotics, as such, are discouraged for pure hormonal acne for two reasons. Reason one being that if it’s hormonal acne, it tends to be something that lasts a long time, and we really want to limit the use of longterm antibiotics. The second reason is we try and not rely heavily on antibiotics for acne, because we now understand that they can have harmful effects on the guts and the microbiome which, again, is not necessarily very healthy for the individual. Unless the cause for the underlying hormone imbalance is not able to be neutralised or treated, accutane would be better than oral antibiotics in the management of hormonal acne.
Perhaps a nice all-encompassing note to end on- I had one listener ask “What is your number one piece of medical advice for dealing with breakouts?”
The number one medical advice would be to ensure that you are using the right skincare regimen that exfoliates the skin, that can benefit from reducing the inflammation, that you identify for yourself whether certain factors such as stress or diet, which is something we didn’t really touch upon, particularly excessive dairy products and excessive milk and high carbohydrates, that can sometimes also worsen acne and sustain it.
So my medical advice would be to make sure and check that your diet is not causing some of this, make sure that you are on the right facial wash and skincare regimen that can keep the skin healthy and exfoliated with a pores open, and potentially using something like a retinol for longterm maintenance.
Perhaps the only other thing I would mention again, since we’re covering acne, is the diet, which I think is something that is going to become more prominent and more important. If you look at the demographics of acne sufferers, the vast majority of them are young, they’re millennials, which means that they are also very tech savvy and they have access to online information. Therefore, I see that they’re much more aware of the healthy microbiome and the healthy gut and the gut-skin access. I’m understanding that the role that diets can play in some individuals is important.
The other important thing is the use of makeup.
Yes, that’s a big one!
Particularly in young women, where the advice is not to use occlusive, oil-rich makeup, which can potentially clog up the pores and cause these white heads and blackheads. The advice is to use non-comedogenic, oil free makeup, preferably mineral based.
One of the few joys of isolation is the way we’re all going a bit more bare faced.
And you know what? I have some patients who actually say their skin is getting better, and I think that’s because they’re using less occlusive makeup.
Certainly. I think everyone’s skin went a bit off kilter at the very beginning, because I suppose we were all so stressed. And now that it’s become a bit more routine, we’re all settling down a bit.
Yes, absolutely. So I always have a chat about not just the topical and the oral treatments, but I also like to talk about the skin care, makeup use and the diet, because I think that’s important to what we have been discussing.
