Dr Edwin Ishoo believes that most of we are told about
Acne is wrong and that it has been over simplified by
simple minds for even simpler minds. After extensive
studies, Dr. Ishoo has come to the following conclusions:
1. “Acne Vulgaris” is not a simple disease with a simple
cause. It is similar to “Irritable Skin Syndrome” or
“Acne Spectrum Disorder” with a range of signs,
symptoms and etiologies along the spectrum.
2. Acne is as much a “genetic “disease as is Irritable
Bowel Syndrome or Autism Spectrum Disorder. There
may be some multigenetic contributions such as variation in metabolism of certain vitamins and fatty acids, inflammatory reactions, hormone production or end-organ sensitivity but it is primarily of an infection and an environmental etiology.
3. There is a much stronger influence of diet over various causes of acne than anything else. This is not unlike most other pathologies. As human beings we are just a bag of chemicals and all our functions are regulated by hormones, enzymes and co-enzymes or vitamins. All these chemicals are made from our diet especially cholesterol which is the basic building block of all steroids in our body. We also know that the ratio of Omega 6 to Omega 3 fatty acids in our diet is directly correlated with acne formation. Acne Vulgaris is almost exclusively a disease related to the western diet. How can any so-called “acne specialists” continue to repeat the disinformation regarding the lack of connection between acne and diet? yet another contribution of Dr. Fulton and his cult of mindless parrots at the Face Reality Acne Clinic.
4. We do not yet understand the pathophysiology and formation of Acne. Whitehead and Blackhead comedones are not necessarily progenitors of nodulocystic Acne. I do not believe there is a direct link. Some studies show less than 20% of the nodulocystis acne derive from comedones.
5. ALL Acne is inflammatory. In fact, all organic life is in constant state of inflammation. That is the natural state of human existence and we are designed on every level to react to our environment, especially the anatomic surfaces that come in direct contact with the environment such as GI, pulmonary and mucodermal surfaces. We not only have a complex humoral immune response, but we also have cellular inflammatory response specific to the skin such as Langerhans cells. At any time we are modulating our inflammatory response along a wide spectrum. There is now plenty of evidence in the literature that inflammation is present at any level of comedone or acne formation and preceeds pore impaction. The so called whiteheads and Blackheads have subclinical inflammation and the pustules have clinical inflammation where it can be appreciated by simple inspection or palpation.
6. The bacteriology of Acne vulgaris is complicated. P. Acne is not the only bacteria involved. In fact, I believe that there is evidence that P. Acnes, being a comensal, aerotolerant anaerobic bacteria, is present on all humans and may be protective against “Acne” or clinical infection by production of Propionic Acid and nitric oxide. It is a specific virulent strain of P. Acnes that becomes infectious and causes acute clinical inflammation not only of skin but other organs and anatomic sites. So, regular symbiotic P. Acnes strains are protective, not infectious. The specific virulent strain is not only infectious, but CONTAGIOUS. Yes, you heard me right, based on reviewing hundreds of studies and my personal experience with hundreds of patients over 17 years, I conclude that Acne is an infectious and contagious disease (this is not a myth).
7. P. Acnes virulent strain is spread from person to person. and from one area to another. This is why its not a good idea to share make up with someone who has acute, clinically inflamed acne. Also, human beings are not born colonized by any bacteria in GI or on the skin. We as humans, cannot exist without our bacterial partners which allow us to interact with out environment. This relationship is so important that cell mitochondria is theorized to be a bacteria so essential to our cellular function that was incorporated into our cells millions of years ago but it has maintained its separate bacteria DNA. We become secondarily colonized by bacteria from the people around us, like our parents. Thats why certain diseases run in families but are not genetic. We also know that strains of bacteria that are antibiotic resistant have appeared on family members that have never been treated with that antibiotic. Also, staph and strep can also cause Acne-like eruptions and those are known to be contagious.
8. The theory that the pore gets blocked and caused hypoxia deep in pore that triggers P. Acne which then causes inflammation does not hold water. The normal partial pressure of oxygen in healthy skin pores is HYPOXIC. The pores don’t get oxygen from the atmosphere. They get oxygen from the capillaries that feed the hair root. It doesn’t matter if the pores is mechanically blocked or not. We also know that we don’t need P. Acnes to have Acne formation. The literature is replete with studies showing lack of P. Acnes in many Acne lesions.
9. Its about skin pH. That’s what causes the change in chemistry and allows over population of the virulent strain of P. Acnes or other bacteria that then displace the protective bacteria. The commensal P. Acnes produces propionic acid which keeps the skin pH in the mid 4-5 range and controls fungus, viral as well as many other bacterial over growth. When alkaline soaps or cleaners are used without toners or astringents, the pH is raised and competing organisms can overgrow and displace the protective P. Acne and Staph causing disruption in skin’s ecosystem equilibrium and a shift in along the spectrum of baseline inflammation.
10. One potentially promising treatment approach is topical probiotics using bovine P. Acnes strain from cultures used to produce Swiss cheese. No more antibiotics, its time for probiotics and even bacteriophages designed to target specific strain of bacteria.
11. Benzoyl peroxide causes the same type of oxidative stress and cellular damage that sun light and UV light cause. If you keep applying it at increasing doses to continue burning and peeling the skin such as what face reality acne clinic recommends is ignorant and dangerous. I believe that incident of malignancy initiation by BPO is equal to repeat sun burns and its irresponsible. We constantly try to administer anti-oxidants to recover or improve the health of the skin so why apply such an oxidative stressor repeatedly to the skin in an increasing dose. If the oxidation of the P. Acnes with the free radical oxygen of Benzoyl Peroxide helps destroy the bacteria, I believe that the increase in atmospheric partial pressure of oxygen using a hyperbaric chamber with oxygen concentrator can be much more effective against the anaerobic bacteria without generating free radicals that damage DNA and in fact would provide significant boost in cellular oxygenation, not oxidation. Hyperbaric chambers are now affordable and portable for office and home use.
12. Sebum is not the only reason for Acne. It seems like dermatologist and estheticians have completely forgotten or never learned the anatomy of the pilocebaceous follicle. There are 2 types of sweat or sudoriferous glands: 1.Eccrine, most widely distributed; regulate body temperature by releasing a watery secretion from a pore separate from the hair follicle that evaporates from the surface of the skin, 2. Apocrine; secretion are stimulated by androgens similar to sebum and are secreted into the pilocebaceous duct deep in the pore similar to sebum and contains bits of cytoplasm from secreting cells; debris attracts bacteria from skin surface into the pore. This is how you get Acne on dry skin low or devoid of sebum, because sebum is not the only substrate of bacterial proliferation or skin irritation and increased inflammation.
13. Future of acne treatment involves nanotechnology to deliver micrograms of effective chemical such as Resveratrol or probiotics and anti-inflammatories deep into pores.
14. Accutane is an extremely dangerous chemotherapy drug that is more appropriate to treat pre-cancerous or early skin cancer lesions, not “Acne Vulgaris”. Yes, severe nodulocystic disase unresponsive to all other treatments.
15. Dermatologists have abdicated their role as Acne specialists to under trained and under educated estheticians due to apathy. This is dangerous as “cult” leaders of such dangerous organizations as Face Reality Acne Clinic have moved into that space and have begun diagnosing, treating and even formulating medications. That is dangerous and unacceptable. Estheticians should never diagnose and make treatment plans for acne or any other skin diseases.
16. Dr. James Fulton was reckless and irresponsible and in many ways fradulent in his approach to acne. He had a fundemental misunderstanding of acne as a genetic disease with no dietary contribution caused by retention hyperkeratosis. Wrong on every level. His poorly designed and fradulent agent orange studies on unsuspecting young soldiers in the Army or the infamous chocolate study on young prisoners in PA, the subject of a book named, Acres of Skin, chronicling the prison abuse not just in Nuremberg but in America, by Kligman and his protege, James Edwin Fulton. It is also well known that the Chocolate industry paid Kligman to report that chocolate does not worsen or cause Acne. We know that this was not truthful. The comedogenic studies of various substances using Rabbit Ear model has long been dispelled even by Dr. Kligman himself but still being propagated by the Face Reality Acne Clinic mindless cult. Also, you cannot call an establishment dealing with a medical condition a “clinic” if there is no medical doctor in charge. That is complete misrepresentation. Additionally, the idea that an extremely rare condition such as Retention Hyperkeratosis is the underlying cause of a skin condition such as Acne Vulgaris that affects 95% of the population is simply ignorant and lacks common sense let alone any scientific support.
Dr. James Fulton set acne science back by decades. He even plagiarized his so-called land mark book, Acne RX from a book he co-wrote with Elizabeth Black 15 years earlier, ” Dr. Fulton’s step-by-step program for clearing acne”. Ms. Black had written the majority of the book but when Fulton, who never had any of his own original thoughts and always either stole from Kligman, Plewig, Lee of Black as well as many others, republished the book, he changed absolutely nothing after 15 years except cutting out any and all reference to his co-author. That was pure fraud and plagiarism. He also took credit for “co-inventing Retin-A” when he was not even mention in Kligman’s patent application which was only for Retin-A use in acne treatment and not invention of Retin-A, which was made by Dr. Lee, one of my professors at U.C. Berkeley. Dr. Fulton went on to mutilate many unsuspecting patients with unapproved and experimental silicone injections for which he was sued by the federal government. Dr. Fulton was investigated by numerous medical baords and evetually had his medical license revoked in every state he held a license including CA, FL, TN, IL. This is all a matter of public record. When he formed Vivant, he merely took existing Gesner and TCA peels and created his so-called progressive peel the same way he previously used Benzoyl Peroxide. Neither the peel nor the progressive nature of its application were new or revolutionary. Unfortunately all his teachings from Retention Hyperkeratosis and genetics being the cause of comedones and not the diet or even comedogenic substances in topical applications or Idodine being comedogenic (halogens can cause acneic eruptions such as Chloracne but not Acne Vulgaris or comedones) were absolutely wrong and all adopted from Kligman, as Fulton lacked any intellectual capacity to deconstruct Acne on his own; however, he was best equipped to take financial advantage. He also complete misunderstood the role of stress and hormones and sebum in acne formation. He in fact states in his book that sebum has no role in normal function. That is simply ignorant even for a so called scientist in the tenth century, let alone the twentieth century. Kligman and Fulton not only set Acne science back by decades, but they set medical ethics back by centuries and just as we ethically refuse to acknowledge any contributions of the Nazi medical scientist. Fulton and Kligman’s experiments on soldiers and soldiers have been widely denounced as equivalent to “the barbarity and sadism of Auschwitz and Dachau”
Hornblum, Allen M. (1998). Acres of skin: human experiments at Holmesburg Prison: a story of abuse and exploitation in the name of medical science. Routledge. p. 38. ISBN 978-0-415-91990-6. Retrieved February 27, 2010.
17. Another reason why the pathophysiology that has been proposed for comedone formation lacks support is that Acne generally occurs in pores that do not contain thich or coarse hair but thin, villous hair or no hair at all. That contradicts the suggestion that a plug needs to form around a thick shaft of hair to block the pore as the inciting event for a comedone. Also, sebum production is a terminal event for the sebocytes which undergo apoptosis and release the fatty acids and esters. There is no continued production and build up. There is no support for that theory. There is no hydrolic pressure from the continued sebum build up that leads to the rupture of the follicle sac and formation of cyst. The over simplistic mechanism is the product of over simple minds and the parrots that keep repeating it as if it is fact. It is increasing inflammatory response that dissolve the sac wall and allow not just the fatty acids but the inflammatory products to extravasate into the interstitial space.
18. Dirt or anything that can mechanically obstruct the pores can cause comedone formation and sebum filament impaction. Thats why good skin hygiene is important. So I dont understand why every mindless parrot with a website about acne declared the causation or aggrevation of acne by dirt a myth? thats just intellectually inconsistent and ignorant.
19. Chemicals, whether endogenous (hormones) or exogenous (drugs or irritants) affect the expression of Acne along the spectrum by modulating the constant, underlying inflammation. The manifestation of skin inflammation as “Acne” or ” Acneic eruption” may be syndromic in some circumstances as being a part of a set of signs and symptoms that appear together and characterize a disease or medical condition. However, when such a situation presents itself to untrained minds and eyes, the syndrome and the other possible related signs and symptoms will be missed or not connected in making a potentially life saving diagnosis. Acne, one of the most common skin disorders, is also a cardinal component of many systemic diseases or syndromes. Their association illustrates the nature of these diseases and is indicative of the pathogenesis of acne. Congenital adrenal hyperplasia (CAH) and seborrhoea-acne-hirsutism-androgenetic alopecia (SAHA) syndrome highlight the role of androgen steroids, while polycystic ovary (PCO) and hyperandrogenism-insulin resistance-acanthosis nigricans (HAIR-AN) syndromes indicate insulin resistance in acne. Apert syndrome with increased fibroblast growth factor receptor 2 (FGFR2) signalling results in follicular hyperkeratinization and sebaceous gland hypertrophy in acne. Synovitis-acne-pustulosis-hyperostosis-osteitis (SAPHO) and pyogenic arthritis-pyoderma gangrenosum-acne (PAPA) syndromes highlight the attributes of inflammation to acne formation. Ignorant evaluation of all Acne as common Acne or “Acne Vulgaris” but uninterested dermatologist, untrained paramedicals and even worse, the estheticians who are by and large uneducated but ignorant of their ignorance, presents a serious threat to public safety. Acne is a skin DISEASE with potentially serious medical, cosmetic and psychologic consequences and it is absolutely irresponsible for estheticians to be diagnosing, planning and then implementing their own treatment plan without direct involvement of a competent and engaged physician at all levels of management.
20. Some sun light exposure is therapeutic for acute acne as some wavelengths in the visible and invisible spectrum in the blue and ultraviolet range, respectively that excite a particular molecule within the bacteria called a porphyrinthe or porphyrine which then results in the death of the bacteria. This is also the basis of Light-based treatment of Acne and why many feel their Acne is at its best in the Summer months. So, I don’t understand why people are consistently being told to disregard their own experience and avoid all sun. Its only tanning or sun burn that should be avoided, not sun light.
21. Acne formation is not so much due to the level of circulating free androgen that stimulates sebum and apocrine sweat, as is the fluctuating sensitivity of these glands to hormones such as androgens, estrogens, Insulin and Insulin-like hormones. Hormonal treatment of acne is complicated. Progesterone can be androgenic or estrogenic. Androgens are made of cholesterol and then become precursor of estrogen. When excess estrogen and progesterone are introduced into the system, the consequences are much less predictable that most physicians claim. It is better to work with hormone blockers than hormones themselves. I believe there is more to gain from Spironolactone as an aldosterone antagonist in women and Finasteride as an 5alpha-reductase inhibitor in men than any other type of hormonal manipulation.
22. Improving the clinically inflamed lesions is much easier and more dramatic than the subclinically inflamed lesions which are also more difficult to clear. Do not be impressed with improving the inflamed lesions on the before and after pictures, most of them will spontaneously resolve and have nothing to do with the esthetician’s magic.
23. When I encounter an acutely inflamed nodulocystic lesion, I do not attempt to extract it. I may treat it with systemic oral antibiotics to calm it down for 7-10 days but I also find injection with a combination of corticosteroid such as Kenelog with Fluorouracil or 5-FU which not only subsides the inflammation but it also minimizes the resulting scarring and it produces a better cosmetic result than Kenelog injection alone.