"All my girlfriends are on Spiro," a patient said to me recently. "ALL?" I asked, knowing she has a lot of friends. "Pretty much," she confirmed.
Spiro is short for spironolactone - an increasingly common pharmaceutical prescribed today for the treatment of post adolescent female acne. Officially classified as a diuretic, it is fast becoming known as an androgen blocker used specifically for hormonal acne that tends to show up along the jawline and chin, often with stubborn painful cysts.
There was a time when acne was known as mostly a teenage issue, but now post adolescent type acne is reportedly reaching epidemic proportions among women in their late 20's-30's. Last Spring Allure Magazine featured an extensive piece on acne as an epidemic, and included our TCM approach along with a thorough list of other current treatment methods. Formulator Marie Veronique is also inspired by this growing problem, as evident in her skincare collaboration with facialist Kristina Holey.
Medical solutions for this kind of acne are frustratingly few, and often include undesirable side effects as they are not all perfect solutions. Besides spironolactone other dermatological answers include birth control, isoretinoin, antibiotics, and if it just won't budge - accutane.
Though not as commonly sought out (yet) there is also the option of using TCM for acne as well as other dermatological disorders. The treatment of skin disease in Chinese medical history goes as far back to 200 BC. That's centuries of empirical knowledge and development of treatment strategies using plant medicine and other tools of TCM like acupuncture.
LOOKING THROUGH THE TCM LENS
Have you heard yet about the "new organ" that scientists have discovered "hiding in plain sight?" Well, the thing is Chinese medical doctors have recognized the interstitium as an organ for centuries. In fact, we call it the San Jiao, often translated as "Triple Burner" and it even has its own mapped out acupuncture meridian.
My point is that TCM has some very good ideas about how the human body functions and treating disease that are worth exploring. This applies not only to this "new" discovery but also to the treatment of skin. When you look at healing acne through the viewpoint of TCM, you will find an incredibly nuanced and sophisticated - but very very different way of understanding its pathology.
The western understanding of acne pathology is that it is primarily a hormonal disturbance that leads to the excess production of sebum. TCM sees it as coming from several different patterns of internal balance:
EXCESS HEAT IN THE SYSTEM
One TCM pathology primary in acne is something we refer to as excess internal heat. This is not in disagreement with the idea that it is hormonal - it's just looking at another, more macro part of the picture. Think of excess heat in the body like how a car gets overheated if you pump the gas with your breaks on. When we are under persistent stress it is like that for our bodies - one foot on the gas, one foot on the break. Needless to say, there doesn't seem to be a shortage of stress sources in our busy modern lives.
But to say that it's simply too much heat is too vague - we must identify where the heat is coming from. For acne, we can locate it to the lung organ system, the stomach system, the menstrual/blood system, or the presence of toxin in the body which generates a fierce fiery type of heat. To make it more complicated, in practice these patterns can also overlap.
How do we determine what system it is coming from? By very very closely examining the size, color, location and other characteristics of the pimples. We "read" the skin and then we match it up with what else is going on in your body. This is why when you see a TCM dermatology practitioner, you're going to play twenty x 10 questions when we ask you everything from the consistency of your poop to whether your menstrual bleeding is more the hue of bright cranberry or dark cherry? Our enquiring minds need to know.
STAGNATION IN THE SYSTEM
Another important factor in the formation of acne is stagnation, or when circulation becomes far too slow for optimal function. This is a common pathology recognized in TCM, and easy to visualize in the case of acne - which many understand as an issue of congestion. You will often hear someone with acne say, "my skin is so congested." And that's exactly it - there is congestion or stagnation in the skin, and this stems from even deeper stagnation affecting the blood and fluid system.
When stagnation affects the blood system we call it blood stagnation. Pimples will often have a dark red, even purplish color. They linger forever and often are painful. This pathology often shows up with problems like menstrual cramping or any kind of persistent, stubborn pain in the body. Acne will often be worse before your period.
If congestion occurs in the fluid system, we call it phlegm stagnation. In TCM phlegm is as you imagine: that sticky glob of goo that you cough out or blow out your nose with a sinus or respiratory infection. But it can also exist deeper in the body without such easy exits. Fluids under normal function should circulate well like a fresh moving brook. When it slows down, it becomes more and more dense until it is like a thick swampy situation or even straight up hard. Any form of cysts in the body whether facial, or deeper like ovarian (as in the case of PCOS) is often a phlegm stagnation issue (usually co-existing with blood stagnation).
HERBAL MEDICINE IS OUR TREATMENT MAINSTAY
To quell these vicious beasts of burden in the body, TCM relies on herbal therapy as primary medicine for healing acne. Of course, there are cases that can be resolved from switching up one's skincare routine or using acupuncture. As Trace Barhnill writes, treating acne is often like different levels of a video game, some get out of the game at switching up their topicals, others need to keep playing and go deeper. Chronic or stubborn cases usually require daily doses of customized herbal medicine to restore normal skin function.
An herbal formula for acne in my practice usually consists of 12-15 herbs. I try not to go beyond that for fear of diluting the action of the herbs. A well strategized precise formula always works better than throwing in everything and the kitchen sink. I believe this to be true for topical skincare formulations as well. For more on the logistics of herbal medicine see this article on TCM Dermatology.
Below is an example of a recent formula I wrote for a patient to illustrate how versatile and flexible our treatments can be. Please note: do not, I repeat do not, try to self-prescribe this formula. It was customized to a specific person who has other notable and concurrent disorders. Please always see a professional if you want to take herbs, or else you could end up spinning your wheels or even making the situation worse.
SAMPLE ACNE FORMULA:
(Clear toxic type heat)
BAI HUA SHE SHE CAO
YE JU HUA
(Soothe, regulate liver system to regulate menstruation, moods)
(Support digestion function)
CHAO ZHI KE
(Clear dampness and heat from the stomach system)
(Invigorate blood movement to soothe and regulate menstruation)
YI MU CAO
(Harmonizes all the herbs in the formula)
As you can see, different patterns of excess heat and stagnation overlap in one case. Once I settle on the pattern diagnosis, I match herbs that have the ability to correct on each. I have so many I can choose from too, which means I can select herbs that match this patient's personal characteristics best as well as those that are more helpful for acne. TCM, like haute couture, is very bespoke.
TIP OF THE ICEBERG
What I've covered is literally just the tip of the iceberg when looking through the TCM lens for acne. I believe there is a lot to be learned by our approach for the sake of all dermatology. But to manage your expectations, our medicine does take time. This is a long game medicine. On average I see results in 4-6 months depending on the severity and type of acne. But I have also seen it take less time, as well as up to a year or more. By the way, a year of treatment in Chinese medicine is not considered unreasonable to correct on dysfunction that has existed for many years (commonly since puberty began) or for acne that co-exists with other chronic disorders like IBS, migraines, PCOS, etc.
Healing skin takes time, that is the reality. Because our skin goal is to restore the function of the skin AND the underlying systems that feed into it, I encourage you to think of skin healing as a process that requires enough time and space for your body to release the old patterns and integrate the new. The upside for your willingness to play the long game is that your skin will be much more likely to remain healthy once our work is done. As Mazin Al-Khafaji, world renowned TCM dermatologist, says "once the skin is stable, it tends to stay stable."