Transcript | Ep. 105: How to Face Adult Acne

Cristen: I love popping zits. Like when the compulsion starts, like, I will just zone right in. And I was just yeah. I was just wondering if you're a popper.

Ali: Yeah. Totally team popper. I get these tiny pimples on my chest from, like, sweating usually. And so I go to town there, especially in the winter, because I can just put on a big sweater and nobody's the wiser with my little sort of bubble wrap adjacent situation. And so, yeah, I'm a big, big popper fan.

Cristen: OK, thank you. I feel seen.

Ali: Yeah, totally.

[Theme music]

Cristen: Caroline, I learned a new term early in quar, and it wasn't social distancing.

Caroline: Oh, really?

Cristen: I learned, from firsthand experience, was a little hot mess called perioral dermatitis.

Caroline: Peri-who ha what now

Cristen: It’s a face rash that’s often mistaken for acne, and it suuuuucked. I already get hormonal acne around my jawline, and this spring, I was like, OK I’m gonna step up my skincare game and emerge from lockdown looking like a Neutrogena commercial — Clean, Clear and Under Control.

Caroline: Oh yeah, I think a lot of folks had a similar idea early in quarantine.

Cristen: Well I was trying out all these exfoliants, oils, lotions n potions … annnnnd my face revolted. The whole lower half of my face broke out….

Caroline: Oh no

Cristen: Oh yes. I finally saw a dermatologist and she was like, stop using everything but face wash and moisturizer. You gotta take an antibiotic for the perioral dermatitis. THEN we can work on the hormonal acne. But what really struck me was just how much that breakout took over my whole brain. I avoided looking at myself in the mirror...on Zoom...

Caroline: Oh I get it. Cristen, I started breaking out in middle school, and it just … never stopped. I’m 36 years old. But my hormonal adult acne has been getting way worse this past year. And like we were talking about last episode with my forehead wrinkles and debating Botox, I’m trying to be ~ feminist zen ~ about it. But I spend way more time than I’d like getting mad at my skin. Do you know how much I have spent on zit creams and masks?!

Cristen: Well Caroline, we are sold SO. MUCH. SHIT. to allegedly fix our skin, but how do we fix what it does to our heads? And that question inspired us to ask Unladylike listeners about how and whether quote unquote “bad skin” occupies their mental space.

Caroline: Long story short - IT DOES!

Gen: I was casually dating somebody at the time. And I remember them telling me, you know, I don't feel anything when I touch your face. Don't worry about it. But it didn't, it didn't really matter what they said. I could see it. I could feel it. It was as if my skin was crawling all the time.

Cristen: Today's first guest is an Unladylike listener named Gen Lindsay. Her acne story immediately jumped out to us. She’s lived with acne since middle school and just recently began working to unlearn the lies we’re led to believe about bad skin -- that it makes us unattractive, unworthy and even unloveable.

Caroline: Then, we’re getting a mental health consult with Dr. Jen MacGregor, a dermatologist practicing in New York City and a leading specialist in transgender skin care. She’s going to offer us her professional perspective on the deeper ways our skin affects us.

Cristen: Then finally, reporter Ali Francis will share her self-love journey of coming to terms with her all-of-a-sudden adult acne.

Ali: Don't get me wrong, I don't like to wake up and see, like three period pimples on my face. I don't rejoice at that, but I'm much more compassionate and I'm much more able to look at the big picture and understand that this is not my doing and it's most likely circumstantial. And to sort of like take in that context as a first instinct rather than that first instinct just being self-blame.

Cristen: So today, we want to find out: Why does breaking out make us feel like breaking down?

[Stinger]

Caroline: Gen Lindsay's breakouts started as a classic case of preteen acne.

Cristen: By the time she got to high school, Gen was super self-conscious about the acne on her face, as well as the acne folks couldn't see.

Gen: I had the you know, the displeasure that, you know, a lot of people have of having back-ne and acne on my chest as well. And I just remember back then, especially the word back-ne was just said with so much shame associated with it. And I remember hearing that and thinking to myself, you know, well crap I have that. So therefore you know, I should be ashamed of it and I should hide it and I don’t want people to see that I have this.

Caroline: Her backne even messed with a timeless teen tradition: watching romantic movies.

Gen: I'm sure most people remember the movie A Walk to Remember Mandy Moore, Shane West. And there's that scene where they're on that cute little date. And Shane West is going to put a tattoo on her, a little temporary tattoo.

CLIP: Walk to Remember

Gen: And Mandy just like gently lowers her shirt so the back of her shoulder is exposed. And he puts the tattoo on her. And it's just a really nice moment. And I could never watch that moment without feeling like crap because I would think to myself. God, how awful would that be if a guy that I really liked. I don't know why he would ask to put a tattoo on my shoulder. If he did. Gen [00:21:53] If I happened to be in that exact situation, how awful would it be for them to see my acne and, you know, how would I get out of that situation and what would they think of me? You know, those thoughts always went through my head and I felt, you know, that's sort of where my feelings of, you know, "will somebody ever be able to like me" started. And I know that's so extra and that's so dramatic but it sort of colored how I perceived my ability to be intimate and to accept physical touch.

Caroline: What was it about touch that that brought up so much anxiety for you?

Gen: I had it in my head and I still do. You know, when we're talking about these unattainable beauty standards and whatnot, I thought that my skin should be smooth and that just the the negative association with acne as a whole, I assumed that if anybody touched me and felt the acne, that they would be grossed out. And that made me not want to put myself in those situations in the first place just in case. Right.

Caroline: It’s because of that anxiety that Gen says she actively avoid having sex until she was 22.

Gen: For the longest time I did not want to try. And the few times that I got a little hot and heavy with somebody, I'm pretty sure my shirt stayed on for the longest time and. That was really embarrassing for me, and I try not to be embarrassed about it, there is, you know, no shame in when you decide to have sex and everybody has their own reasons. But it just highlights the fact that I was being so hard on myself with acne and it shouldn't have mattered, but it did.

Caroline: So then were your fears confirmed or not, once you actually started getting more sexually active?

Gen: Honestly, I really didn't have anything to worry about. To be fair, you know, my back-ne improved on, my acne improved at different times, it would get worse. It would get better. It would get worse. It would get better. And I was probably more inclined to try having sex when it was better. But I do remember, you know, going on a date with somebody who ended up being my boyfriend later and using powder on my chest to cover up the redness and the bumps and whatnot. But did he care? No. Should it? I mean, I shouldn't be validating myself based on whether or not a dude cares about my skin anyways. But I don't think I've ever had somebody say, you know, I do not want to have sex with you because you have back-ne gross, go away.

Cristen: Gen’s teenaged acne followed her into adulthood. Then in her late 20s, she developed a more severe form called cystic acne. So, Gen went to the dermatologist.

Gen: I was with him for an hour, probably going over, you know, this is my history, this is how it's affecting me. Nothing has worked. I've tried so many different things. And now, you know, I'm at a point where I don't have any other ideas. And he said to me something along the lines of “you need to adjust your expectations for one.” And I could sort of understand that to a point. But then he went on to say that this, the cystic acne, that it was the new me.

Cristen: Oh oh.

Caroline: Like, what did he mean about “adjust your expectations”?

Gen: Basically that I should just get used to having it. Right. Get used to the fact that you have chronic dandruff, get used to the fact that you're itchy all the time, get used to the fact that you have acne.

Cristen: OK, C, I hate that derm. But he did suspect that something hormonal might be up, and recommended Gen talk to a gynecologist about getting on birth control.

Caroline: Within a month of starting the NuvaRing, Gen’s cystic acne had cleared up, but her chest and back acne stuck around.

Cristen: As Gen has started being more open about her skin problems though, she’s noticed a deeper difference.

Gen: One thing that I have found in talking to people is that more people deal with acne or other body issues than you think. And it provided we provided me with so much comfort in knowing that I wasn't the only one and it helped me feel less shame. And I think that's an understandable thing, right? You feel shame, you isolate, you don't talk about it, you feel more shame, you repress like it just keeps going down. But when you breathe air into it. It doesn't feel as scary and shameful.

Caroline: Acne shame is. so. real. There’s actually a ton of research on just how much visible acne impacts our sense of self. For trans people, acne can intensify gender dysphoria. Cisgender women report far more acne embarrassment than cis men do. And regardless of gender, chronic, severe cases are linked to higher rates of depression and social isolation.

Cristen: That’s why we’re gonna take a quick break, then head to our Zoom appointment with a dermatologist who gets it.

Caroline: Don’t pop off!

[Stinger]

Caroline: We're back, and we're about to get an expert opinion on the emotional side of having "bad skin" with NY dermatologist Dr. Jennifer MacGregor. But first, let's take a hot second to lay out the acne landscape.

Cristen: Yeah. So first of all, it is super common — even in adulthood. According to the American Academy of Dermatology, half of cisgender women in their 20s and more than a quarter in their 40s experience adult acne.

Caroline: For folks like Unladylike listener Gen and me, our grown-up acne is what’s called persistent, meaning it started around puberty and … just never decided to leave. Then there’s adult-onset acne, which is exactly what it sounds like -- acne that appears for the first time usually in your 20s.

Cristen: But exactly WHY adult acne happens is hard to generalize. It depends on our individual brains and bodies. Things like medications, smoking, diet, stress — and yes, your COVID mask — can affect it.

Jennifer: Masks are just something that's making it worse. I always say there's an underlying skin condition and then there are all kinds of things that can make it worse. And the mask is just one of those things, along with stress and diet and smoking. It's all of these things that can make your underlying skin condition get worse or it can just be a trigger to bring it out again if you had it in control.

Caroline: OK, so you're telling me that already being predisposed to adult acne, wearing a mask and then drowning my sorrows in a bunch of Pinot Grigio, it's probably not the greatest for my skin.

Jennifer: Not the greatest thing for the skin. And then, of course, there's the high glycemic snacks that also go along with that scenario that are also another really common trigger for acne. So right now, we are seeing quite a lot of acne and rosacea flare ups as you can imagine.

Cristen: But pandemic or not, the most haunting culprit of all is hormones. Surging hormones are why acne is most common during puberty, and a common symptom of hormonal disorders like polycystic ovarian syndrome and endometriosis.

Caroline: Then, there are the hormonal tidal waves of pregnancy and menopause. Pregnancy is SUPER unpredictable — some folks will break out and others will get that glow.

Cristen: With menopause, estrogen production plummets, which means the relative amount of testosterone floating around increases. That hormonal shift sometimes triggers menopausal acne.

Caroline: Dr. MacGregor also works with a lot of transgender patients who are undergoing hormone therapy. But while estrogen often clears up acne, testosterone tends to spark breakouts, especially in the first six months.

Cristen: That’s why Dr. MacGregor takes a holistic approach to trans patients’ skincare. She’ll often work with the doctor who’s prescribing hormones to try to mitigate acne flare-ups and reduce the chances of severe scarring and pigmentation. Plus, living with a broken out face isn’t fun for ANYONE.

Jennifer: it's uncomfortable. You're breaking out. It's hard. It's a really tough thing to bet on when it's significant to really impact mood and quality of life significantly.

Caroline: Yeah, we we actually spoke with a podcast listener who has struggled with back and chest acne, and that to her was almost a more severe source of embarrassment than even acne on her face. Does that sort of jibe with what you hear from some of your patients?

Jennifer: It does, and it's also a little bit more challenging to treat. It’s a larger area if it's on the back, it's very hard to reach. So it's a little harder for people to use an effective skin regimen when they have hard to reach areas and the body can, believe it or not, can be even more sensitive in some cases to prescription acne topicals than the face.So it’s a little more challenging to treat.

Cristen: This episode and exploration of adult acne was inspired by a terrible case of perioral dermatitis that came and visited my face early in quarantine, and it was it was the worst breakout I'd ever experienced. And I am grown woman, I'm 35, I'm a feminist, and yet I was I was freaking out about my face and I felt just cycling through just like embarrassment about my face with an embarrassment that I even cared, you know, all around. So. I'm just going to throw this question out to you, am I a bad feminist for fretting over my adult acne and poor skin care game?

Jennifer: It's funny, I see a lot of people with this internal dialogue, they battle skin issues or come in for some esthetic improvement. They think, oh, I don't wear makeup, I'm a feminist, I shouldn't care about this, but I have this new skin con - rash or I have a new acne outbreak or even I have lines on my face that are making me look angry all the time. And I don't need to look like I'm 20, but I would like just to not to look cranky or exhausted when I'm feeling good. So I see this all the time and I'm thankful for that as well. I think that's just a normal part of the human condition. We're all you know, struggling with what we think we should be behaving like and what's actually happening to us, but most people say, you know, if you could just clear up my skin or if you could just soften this one line that's making me look angry, I would be happy. And if we can fix it and it's not an ordeal or we can improve it, let's do it. So that's part of my job. And that's the most professionally rewarding part of my job is just to help people feel good and confident and like themselves again. I always say that if someone says, oh, I feel so much better, I just feel like myself again. And that's an absolute success, for me. So that periorificial dermatitis story is is is typical because it's difficult to treat that as you know now. And it can take a long time to clear. I hope you found something that works.

Cristen: I have. I have. And it did take time, but it was I mean, it was really the just the discomfort level to like, I felt like I was wearing my breakout, and it made me also feel just very out of control of my whatever was going on in my body. And I'm curious, like when you hear from patients, just that that feeling of being out of control and embarrassed, grappling with these feelings, do you as a dermatologist like have any go to advice for sort of managing that level of grappling with our skin.

Jennifer: I think now we're fortunate to be living in a time where people are really outspoken about more skin positive and body positive messages, because it's super important as someone who treats skin, hair and nails, I will tell you I can't treat everything and I can't make everything go away for people. So there's always an element of what can we make better and what do we just have to embrace as our own unique tiger stripes. And people who have vitiligo or alopecia or even just breakouts have to at some point embrace it and live with it and it doesn't - the two aren't mutually exclusive. That's that's the issue I'm seeing now, is that people feel like, well, because I have confidence and I accept myself as I am cellulite and stretch marks and all, or I accept my vitiligo, I shouldn't also try to treat anything. But I don't think they're mutually exclusive. So I think that’s that those things can go together as well. And that's really what I do all day treat skin, embrace it. And then we do the best that we can with what we've got.

Cristen: So as far as adult acne, if you could bust one myth about it, what would it be?

Jennifer: It would be that if something you did to cause it. That's the one thing people come in wracking their brains, driving themselves nuts because they're convinced that they did something or it's something they started using, which can be the case in periorificial dermatitis, sometimes stopping everything makes that one go away. But that's not that's not typical. It's typically you have an underlying skin condition and something's triggered it or made it worse. But it's not that you gave it to yourself. It's not something you did to cause it, it's just something that you're going to have to live with, embrace, control and make it the best you can and learn those things that make it worse. And that's true of most skin conditions, most skin conditions, you didn't give it to yourself. It's just. Something you have that makes you you.

Caroline: Hear that unladies? ADULT ACNE IS NOT OUR FAULT.

Cristen: We’re going to take a quick break so I can go repeat that to myself in the mirror.

Caroline: When we come back, we’re talking with reporter Ali Francis who un-learned her acne shame ...with help from bell hooks!

[Stinger]

Ali: I just thought I'd made it through. I didn't really have acne in high school, and so I thought I'd been one of the blessed people who'd kind of like, skipped that chapter of bodily dysfunction or bodily rebellion. And it turns out I hadn’t, so I think my reaction was like what the fuck.

Cristen: We’re back with reporter Ali Francis. We found Ali thanks to an article she wrote for Bon Appetit’s site Healthyish titled “Adult Acne Wrecked My Self Esteem. Here’s How I Dealt.”

Caroline: About five years ago, in her late 20s, Ali got adult-onset cystic acne. It made her feel super self-conscious, especially at work.

Ali: I remember sitting in meetings and feeling less excited to share my ideas because it would also mean, presumably the people around the table were looking at my face And so for me, yeah it was it was really it was kind of like this shameful secret almost where I just felt less inclined to socialize, certainly felt less less confident and less happy in the workplace. I felt like I was in a shell, like I felt like I was trying to hide myself.

Caroline: What did you assume that people at work were thinking?

Ali: Well, I don't know if I don't know if I made these connections cognitively or intuitively, but I think what I was feeling was, OK, if my skin looks like this and if society and my inner critic is telling me that I'm responsible for looking like that, then are my colleagues also thinking I'm irresponsible? Like are they taking my ideas seriously or do they think I'm sort of like a big teenager, like it was honestly sort of I I felt like I was taking perhaps I was taking myself less seriously. And so I assumed everybody else was too.

Caroline: Ali figured something hormonal must be going on, so she went straight to the gynecologist who put her on birth control. Her skin improved, but the acne didn't go away entirely.

Cristen: So you mentioned feeling like you had retreated into a shell, so. At what point did you start to break out of that?

Ali: Haha, breakout.

Cristen: I didn't mean to.

Ali: That was amazing. Yeah, I think. It's always I think it's a compounding of things, but I remember specifically reading All About Love, which is this incredible book by bell hooks, and I can't remember the exact quote, but it's something to the degree of,love and hatred can't coexist in any sense. And so I realized that I couldn't possibly come out of my shell and love myself and be my fuller self if I was so fixated and driving so much hatred towards my skin, like I was like hating my skin. And how can you hate your skin and love yourself at the same time? It doesn't work. And so I just remember this quote, just like shaking me and feeling like, wow, I am just trying to heal something with with hatred. And so I think it sort of started with this realization of the ways that have been treating myself and and then trickled on from there. So what does a more loving approach to skin care look like? ... Honestly, it's like simple things. I started hearing that voice in my head that's basically like, oh, this is so gross. And replacing it with like, you're fine, you're fine. And you're going to hang out with your friends like literally I would like to talk to myself. And yeah, then I think just trying to remind myself that I wasn't who I look, I wasn't what I looked like was a big part of it.

Caroline: Well what do you think about people who say, like in general, natural beauty is best, you’re prettier without makeup or feminists don’t need makeup …?

Ali: it's one thing to sit back and intellectually say, like, oh, your skin isn't perfect. Like you should love yourself beyond that and just not wear makeup and loud and proud about it. But when you actually are the person with that bad skin, that's so hard to do. When society absolutely rejects adult acne as even a thing like we're told that, you know, it's acceptable for a teenager to have acne, but it feels very unacceptable as like a woman in the world to have broken out skin.

Cristen: Yeah I feel like there is almost a moralizing of adult acne, specifically on women. I know for me, it is partly because of the messages I was raised with. My Mom seemed to interpret the condition of me and my sister’s skin as a sort of barometer of how well we’re living our lives. Do you feel like adult acne is moralized, and how does that connect with your confidence issues?

Ali: So I think people with adults with acne in particular, it's often assumed that you're not exercising perhaps or you're not washing your face enough or you're eating a really sugar heavy diet. And I think for a lot of people and for me in particular, at that point where I was suffering from acne, I was quote unquote doing all the things in the textbook right. I had I had nice skin products. I ate pretty healthily and I exercised four to five times a week. And none of that affected my skin. And I think a lot of other times you know factors can be anything from hormonal to stress or whatever that is based our skin is rebelling against. And that has absolutely nothing to do with you as an individual. And I think, like, this is just one extra way that we're ostracized from each other and isolated is by. Yeah. This kind of blame or this assumption that you failed and your skin is showing it.

Caroline: What has been the most surprising thing overall about your acne journey?

Ali: Well. I think this is going to sound really cheesy, and it is, but I think the thing that's most surprising to me is maybe my own resilience to the sense of how much maybe mental fortitude or whatever you want to call it, kind of comes from one of those murky places we can't really identify. But the ability to kind of conquer these awful feelings with with love, with dedicated self-love. And I don't mean self-care in the capitalist sense of the word, I mean genuine self-love, because it's not the same thing. And I think what surprised me is that a commitment to love had long lasting effects. It's not just like it helped me. You get over acne, it's helped with so many things in life, my just general mental health, my body image issues, my confidence and and sort of replaced all of that with an ability to feel a little bit more like I have this like base layer beneath whatever bullshit is going on that makes me feel like I'm going to be OK. You know, I feel sort of groundedness. And I really think that started developing in this time where I had to overcome like what felt like a bodily dysfunction or some kind of like thing to be shameful of with. Yeah. With dedicated efforts of self-love. And so I think that's really exciting to me and really inspiring because it's something I can just, like, take with me wherever I go. I feel like a deeper sense of comfort in who I am.

Caroline: Well Ali, is there anything that we didn't touch on about your story that you want unladylike listeners to know?

Ali: I I don't know if it's like something people need to know or not, but I do really think that like t can be really upsetting when people sort of don't validate your feelings in any sense. But in a sense particularly, I think it doesn't really matter if, like me, you just have these really heavy, mostly blind but painful and and consistent pimples like seven that just Houdini around your face, or you have constant acne everywhere. Like, I think that doesn't matter. It's not about severity. It's about how it makes you feel. And I think that. One of the biggest problems with society is that we have to see like that you're totally fucked before we're going to help you, and I hate that. And so I think the biggest thing is that I don't think people need to kind of, you know, struggle in silence, so to speak, about anything, and I think acne can be one of these things that we look for visual cues in, and it doesn't mean you don't know that somebody is not their back, is not covered with acne or their butt-ne is out of control and they can't even sit down, know like it's like you don't always see somebody struggling. So I think, like those people, I just I don't know. I just want them to know that they're not invalid for feeling bad, for having tough feelings just because someone on the outside isn't validating them.

Cristen: You can find more of Ali Francis’ writing online at alifrancis.me. And you should follow dermatologist, Dr. Jen MacGregor on insta @nyclaserdoc or find her at Union Square Laser Dermatology.

Caroline: You can find us on instagram, facebook and Twitter @unladylikemedia. You can also support Cristen and me by joining our Patreon; you’ll get weekly bonus episodes, listener advice and more fun at patreon.com/unladylikemedia.

Cristen: Nora Ritchie is the senior producer of Unladylike. Gianna Palmer is our story editor. Shruti Marathe transcribes our tape. Production help from Camila Salazar. Our music is by Flamingo Shadow, Amit May Cohen and Sarah Tudzin. Mixing is by Andi Kristins. Sound design and additional music is by Casey Holford and Andi Kristins. Executive producers are Peter Clowney, Daisy Rosario and Unladylike Media.

Caroline: This podcast was created by your hosts, Caroline Ervin

Cristen: And Cristen Conger of Unladylike Media.

Caroline: Next week …

Lindy West: What's better than rom and com, those are like the two best things. Like I'm a very like wimpy person, like I don't like I don't like to watch anything sad. real life is sad. I'm already sad all the time. you know, and I'm weak in that way. And I'm not good at, like, leaning into the feelings and just feeling them. I want to run from them. So that's that's the appeal to me. you know what you're getting you know, you're getting like hot people in a pickle and then they get out of it and then they kiss. That's all I need

Cristen: We’re talking rom coms and problematic faves with feminist firebrand Lindy West.

Caroline: You don’t want to miss this episode — or any episode this season!! Make sure you’re subscribed to Unladylike. Find us in stitcher, spotify, apple podcasts or wherever you listen to podcasts.

Cristen: And remember, got a problem?

Caroline: Get Unladylike.