This is part 2 in my series about female adult-onset acne. Part 1 can be found here.
I’m a hypochondriac who hates going to the doctor. Joint pain? Osteoarthritis. Unexplained rashes? Autoimmune disease. Lower back pain? Slipped disc. But whenever someone would suggest I go to the doctor, I’d back down. “No, no. You know what? It’s not that bad.” But at some point, I’d realize that the joint pain was keeping me from exercising and the unexplained rashes were keeping me up at night scratching and the lower back pain was keeping me from going on walks. And then, acutely aware that my quality of life had gone down, I’d begrudgingly schedule a doctor’s appointment. The joint pain turned out to be chondromalacia femoropatellar syndrome, a misalignment of the kneecap over the knee joint; the rashes were an allergy to a medication; and the lower back pain was sciatica. In each of these cases, as much as I hadn’t wanted to see a doctor, medical intervention turned out to be the right thing so I could strengthen my joints, stop taking that medicine, and do physical therapy for my back.
In the case of my acne, I didn’t need to complain outwardly about inward symptoms. The blemishes on my face couldn’t be hidden under layers of makeup and were only growing worse, despite my many attempts to find the perfect skincare routine to clear it up. One evening, I stood in high heels in front of the bathroom mirror, face inflamed to the point that lightly touching it stung. My boyfriend leaned against the bathroom doorframe, watching as I patted and dabbed and winced, trying to rush so we could make our reservation,
“Nothing’s working,” I whined, turning this way and that to examine my reflection. “I don’t know what’s happening.” For years after my teenage acne had subsided, nothing, barely anything. Now this? I sighed in desperation.
“Why don’t you see a dermatologist, then?” he asked.
I was ready to spout out my litany of excuses. “Oh well, it’s not that bad” or “It’s probably nothing.” or “They’ll tell me it’s no big deal.” But I paused and thought of the embarrassment and shame I’d experienced: the meetings at work where I wanted nothing more than to slink under the table, the outings with friends I wanted to cancel, knowing that everyone would wonder why I was so dirty and couldn’t keep my skin clean enough to keep the acne at bay. My usual regimen of salicylic acid and oil controlling lotion had proven grossly ineffective. It was time. “Okay. I’ll go.”
The diagnosis turned out to be fairly simple: female adult-onset acne, not the terrifying skin condition I’d feared. Female adult-onset acne is increasingly common, although doctors aren’t entirely sure why. One of the most common causes is, like many conditions that mess with women’s lives, hormones. Androgen is a hormone that occurs in both men and women, but levels of the hormone are naturally lower in women. Androgen instructs skin glands to produce sebum, the main cause of acne. This excess oil, the root cause of all acne, appetizes bacteria that live on the face. These bacteria start eating away at the oil. The bacteria can cause infection, which leads to--you guessed it--inflammation.
There are two main reasons androgen causes acne in women: sensitivity and excess. Some women may have “normal” levels of androgen but are simply “sensitive” to it, and any amount of androgen can cause excess production of sebum. Other women have excess levels of androgen, like women with polycystic ovary syndrome.
The reason why the acne was so stubbornly staying put on my cheeks, rather than the t-zone of my teenage years, was terrifyingly easy to explain: that’s where I’d have grown a beard if I were a man.
But why all of a sudden did I, like many women with adult-onset acne, have this flare up, seemingly out of nowhere? In my case, my birth control pill had prevented androgens from getting too active. From age sixteen on, I’d taken birth control pills, and the version I take, Yasmin, contains spironolactone, an androgen antagonist that works against androgens, keeping those levels at bay. But the previous year I’d switched to Nuvaring, which does not contain spironolactone. Androgen, left unchecked by the pill, had gotten too active and upset the balance I needed to keep my skin clear.
The dermatologist, her wide blue eyes almost bulging from her delicate face, walked me through my new skincare regimen by writing it down on a prescription pad.
Cyclobenzaprine/benzoyl peroxide gel (something I’d used in my teenage years, back when having acne actually made sense) in the morning to combat the bacteria, which I knew would dry out my skin like no tomorrow and possibly stain my clothes if I wasn’t careful;
Aczone, a relatively new (and expensive) topical antibacterial to be applied morning and night (“You’re going to love this,” she promised, “It doesn’t dry out your skin at all”);
and a retinol cream with vitamin A to promote cell turnover.
She warned me against any products with oils, saying she didn’t get why beauty companies kept promoting oil moisturizers. She also told me to throw out all my salicylic acid products since they’d only dry out my skin more and paradoxically promote more oil production, and she recommended only lotions that were non-comedogenic, hypoallergenic, and fragrance-free. I’d been totally wrong to try every skincare product in Sephora in an attempt to get this shit under control.
She warned in a quiet, almost raspy voice that it’d take at least two to three months to start seeing improvement and that in some women, the acne worsened before it got better. No overnight miracle cures, no quick-fixes. Just following her instructions and hoping for the best, praying that I wouldn’t need spironolactone medication to get me back on track--and if it did work that I wouldn’t be left with any scars.
The pain persisted for the first few weeks, and each morning when I woke up and looked in the mirror, I’d emit a little sigh of frustration. It’s not better yet. I hate going out in public. Why can’t I just be better already? I stuck to gentle cleansers and bland moisturizers, ignoring the beauty product emails in my inbox. Slow and steady wins the race. Slow and steady.
In a fit of panic, I scheduled my annual exam with my gynecologist and said, “I want to go back on the pill.” Forget the inconvenience of taking a pill every day. This was war.
I visited my parents in Texas for my twenty-fifth birthday, soaking up the sun while escaping the tail end of New York winter (but wearing a wide-brimmed hat, as instructed, to prevent skin damage and lessen the possibility of scarring). It’d been only a few weeks after the dermatologist, and the number of whiteheads and red spots hadn’t lessened. My brother and sister-in-law came over for some cake, and my sister-in-law, who is a professional photographer, took some pictures. I blushed from all the attention and from hearing the lens shutter and click. Looking at the photos after, I cringed. Even in the dim light, the redness peppered my cheeks, which were now beginning to burn. I asked her not to post any of them online. “It’s okay, I can photoshop those out,” she promised me.
It’d take more than photoshop to make me feel any less ugly. Soon, I promised myself. Just keep doing this, and it’ll be better soon enough.