Congratulations on making it through to the next stage - what I call the Tidy-up phase!
So something that causes almost as much distress as the breakouts themselves is post-inflammatory hyperpigmentation - or PIH. It literally means the marks left behind after the inflammation has settled. Depending on your natural skin-tone, these might be red through to dark brown. The more intensely and persistently inflamed your blemishes, the more these marks tend to hang around. They’re distinguishable from scars (which actually create an indentation on the surface of the skin) as they’re flat. The good news is these marks can be improved by good topical choices.
Let’s talk about those choices…
How to treat: Actives that multi-task
Night-time remains reserved for your retinoid. The goal here is to max out the strength in order to do most of the ‘heavy lifting’ at night, in terms of prevention + repair. So keep escalating until you find the level that maintains control and is the strongest your skin will tolerate.
For daytime, we can look at Actives that help with both acne treatment and improving skin-tone, if additional preventor effort is needed in the daytime - azelaic acid and niacinamide are two favourites. New natural Bakuchiol also shows promise as it posesses both anti-inflammatory properties and improves skin-tone.
Note that at this stage, you should have less use for anti-inflammatories - so rather than using them all over your acne zones, you can use them in a more targeted way as an on-the- spot treatment. The idea is that your all-over treatments AM and PM are preventing the vast majority of blemishes, so you end up with far fewer breakthrough, inflamed spots.
On prescription I like the combination of AHAs and hydroquinone (I like the Obagi Nuderm system) but bear in mind this does mean that your AM routine will do little to alter the course of your acne, so you’ll be relying on your nighttime step to maintain control. There’s nothing more disheartening than trying to treat the PIH, only for the acne to recur so the timimg of this is important, and shouldn’t be attempted too early.
Lets talk about acne scarring
There are several different types of scars that manifest as ‘dips” in the skin - rolling scars, box scars and ice-pick scars. They are usually most visible in cross lighting or downlighting. Whilst around ⅓ are thought to get better over 3 yrs (and prescription retinoids probably help this process along), ice-pick scarring and box scars aren’t likely to improve left to their own devices . And it should be noted that high risk areas for scarring include the jawline and temples, so adult female acne with it’s tender, stubborn nodules in the U of the face needs to be taken in hand to avoid this unwanted outcome. If scarring is present, I’d recommend heading straight to see a doctor for help with a prescription-based routine as this is a medical matter that requires urgent attention to switch the acne off. Then a considered approach on how best to manage the scarring can be planned - please research this properly as acne scarring management is complex and there are many different technique as a one-size fits all approach doesn’t work. Do treat the PIH in the meantime with the above approach, as this will also help things start to look better.
Sun protection isn’t for skipping
This is crucial, whatever the season, as PIH marks will get darker when exposed to UV light. So find a weightless, non-clogging broad spectrum option that works with your make-up so you’re never tempted to skip because you actually like using.
Lighter base, lighter heart
I think choosing new make-up might just be the best part of reaching this phase - more sheer, dewy finish cosmetics are suddenly a possibility. Feeling strong enough to go down this route can take a nudge - but I wholeheartedly encourage you to reframe how you see yourself in this way when you’ve done the hard work and are seeing results.
For lots of patients I treat, the hardest challenge is changing the way you see yourself. So often an acne sufferer becomes defined by their skin; they feel that’s all people see. And with control of their skin comes a renewed sense of self. I spend a lot of time talking to patients about enjoying the fruits of their hard work…because its just so easy for us to move onto something else that needs ‘fixing’. No!! Success must be luxuriated in as the major achievement that it is.
I really hope that my Acne Solved series has given you hope, and a practical framework to structure a sound routine - I’ve really enjoyed reading your comments on this series and hearing your experiences so please do continue to use the hashtag #thedrsamsystem so we can all share in this journey towards Great Skin Days!
Dr Sam xo