Skin Diseases of Adolescence
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Adolescence represents a time of the greatest change humans experience during their lifetime--the dramatic shift from childhood to adulthood, with all the attendant reproductive capabilities. At one end of adolescence is an innocent child and at the other end a fully grown man or woman. This dramatic time of transformation effects doshic changes that, more often than not, lead to the skin diseases of adolescence, acne vulgaris and keratosis pilaris.
Puberty, the defining event of adolescence, consists of a number of phases of hormonal change that bring to an end the kapha time of life and usher in the pitta time. The first change, occurring about a year before puberty proper, is adrenarche, the maturation of the adrenal cortex, signalled by the appearance of pubic and axillary hair. Adrenarche involves production of the adrenal androgen dehydroepiandrosterone sulfate (DHEA-S). With DHEA-S to stimulate androgen production, gonadarche or maturation of the hypothalamic-pituitary-gonadal axis (HPG axis) occurs about one year later. The rapid changes of this time provoke vata while the onset of the pitta time of life with its attendant androgens can lead to a state of pitta provocation that endures until the body's physiology learns to adapt to its new, adult state.
Skin diseases of adolescence affect upward of 85% of all adolescents in varying degrees of severity. Acne vulgaris is a nearly universal skin disease afflicting 79% to 95% of the adolescent population in Westernized societies (1,2), while keratosis pilaris affects 50-80% of all adolescents. Appearance is extremely important to adolescents, who may suffer intensely due to even a benign or harmless skin condition. To make matters worse, severe acne may leave scars that are permanently disfiguring. Another pitta condition that soars during adolescence is suicidal depression, which may be exacerbated both by the disfigurement of a facial skin disorder as well as by some of the prescription medications given for these conditions (3).
Keratosis pilaris (KP), often described as chicken skin, is a genetic disorder of keratinization of hair follicles of the skin. This benign condition is extremely common, manifesting as small, rough bumps, usually with a hair in the middle. It occurs chiefly in the outer-upper arms and thighs as well as the face. KP is a rasa gati vata condition often described in association with other dry skin conditions such as ichthyosis vulgaris, (dry scaly skin) xerosis, (dry skin ) and, less commonly, with atopic dermatitis or eczema. A variant form, keratosis pilaris rubra, shows pitta involvement as the bumps are erythematous (red and inflamed). Although harmless in nature, KP can be distressing, especially when it occurs on the face. There is no biomedical treatment for this condition. There appears to be a hormonal component to this condition, since it is especially common during the hormonal changes of adolescence.
Acne vulgaris is a well known plague of adolescence, occurring in the areas of skin with the densest population of sebaceous follicles-- the face, upper chest and back. Acne can be classified into three categories: comedonal, inflammatory and nodulocystic. (4) Comedonal acne consists predominantly of open or closed comedones (blackheads and whiteheads) with little or no accompanying inflammation. Inflammatory acne is characterized by erythematous papules and pustule, although comedones may also be present. This form of acne represents a higher level of pitta provocation in rasa dhatu. Nodulocystic acne, with a kapha involvement, may consist of comedones and inflammatory lesions, as well as deeper nodules and cysts. It is important to note that open comedones or blackheads are not related to dirt. As a pitta teenager this author desperately used 'cleansers' on her skin to remove the offending blackheads, to no avail, feeling secret guilt about her 'dirty' skin, which was not dirty at all, but simply affected by abnormally keratinized desquamating cells.
A number of factors contribute to acne. There is a bacterial component related to the organism Propionibacterium acnes, which begins to colonize skin during the years prior to sexual maturity, growing chiefly on the oilier skin of on the face and upper chest. Snigdha is one of the gunas of pitta and P. acne thrives in the lipid-rich (oily/snigha) microenvironment of the hair follicle, producing inflammatory mediators that result in the papules, pustules, and ultimately, nodulocystic lesions of inflammatory, pitta acne. Thus some researchers consider that inflammatory acne is due to hypersensitivity to Propionibacterium acnes (5). This organism is sensitive to tetracycline, providing the rationale for the long courses of tetracycline given to youth with inflammatory acne.
Acne is also more common in adolescents with oilier skin (pitta or kapha skin types). There may well be a dietary component to acne, which is extremely prevalent in Westernized countries with a diet high in refined foods and processed sugars, for acne has been found to be almost non-existent in hunter-gatherer tribes following their indigenous diet (1). And the typical onset of acne in girls a year before menarche, i.e. at the time of adrenarche, points to an involvement of DHEA-S in acne. Elevated levels of DHEA-S have been implicated in adult onset acne, especially when associated with hirsutism (6).
In evaluating an adolescent with acne, it is crucial to take a holistic view. Teenagers do not respond well to being lectured or 'told' by older adults. Enlist yourself as an ally and take plenty of time to listen. Listening will also help you evaluate whether or not significant depression is present and, if so, to refer for psychological or psychiatric services for evaluation of suicide risk (3). In the case of teenage girls with severe acne, look for hirsutism (unwanted hair growth), excess weight or irregular menses. A constellation of several of these symptoms could indicate PCOS (polycystic ovarian syndrome).
In general, it can be quite difficult to get compliance with adolescent clients because impulse control is typically undeveloped in this age group and peer pressure is significant. However, because of the importance of appearance to teens and young adults, we have seen some instances of self-motivated young people taking on an Ayurvedic programme. First, address diet to the greatest extent possible. The more fast foods, high fat or fried items and refined sugars in the diet, the worse will be the acne;(7,8) yet social pressures lead teenagers in the direction of hamburgers, pizza and sodas. Appeal to the young client's sense of 'trophyism' by portraying Ayurvedic eating as something special--a trophy. Some of our young patients have not only learnt to prepare dal and kitcheri, they have also proudly shared their skills with friends and created their own subculture within high school, becoming informal diet mentors.
In terms of treatment, looking first at KP, this ailment has no known treatment in Western medicine, yet as a vata condition it may be improved by regular application of sesame oil or vata or pitta massage oil (as indicated according to prakruti.) General measures to manage vata and use of vata pacifying herbs such as Ashwagandha may prove beneficial, while KP rubra will also require pitta soothing measures and herbs such as Shatavari.
Where acne is concerned, in addition to general measures to control pitta, more vigorous specific is required since treatment of acne can result in scarring. Rich in polyphenols and flavonoids, sesame oil can be used both topically and externally for sebum control, helping to minimize outbreaks of acne. (9) For facial application, sesame oil can be emulsified with rosewater to prevent clogging of large pores. The astringent taste is especially useful in management of acne, since it will tend to break up the keratinized desquamated cells giving rise to whiteheads and blackheads. One adolescent boy who was plagued with acne instituted a daily regime of Triphala tea face rinses and found that he could control his acne effectively with the help of this home remedy. Triphala is also scraping enough to be of benefit even in the cystic stage of acne.
For control of P. acnes it is valuable to use antibacterial herbs such as neem, Manjista and turmeric, which not only have antibacterial action, they also "show anti-inflammatory activity by suppressing the capacity of P. acnes-induced ROS and pro-inflammatory cytokines, the two important inflammatory mediators in acne pathogenesis."(10). In the earlier stages of acne, external use of herbs may suffice, such as washing the face with neem soap. In inflammatory acne, as well as continuing such external uses; neem, Manjista and turmeric should also be used internally. A rakta shodhan formula such as Blood Cleanse, which contains Manjista, neem and turmeric as well as Guduchi and burdock, is ideal to use in this situation and shouls be easy for compliance since it is in tablet form. Triphala tea of Triphala tablets (for easier compliance) can be added to the regime to help clear ama from the system.
Thus by enlisting compliance and utilizing appropriate polyphenol-rich oils, astringent and tannin-rich herbs and antibacterial herbs, acne control may be obtained without the use of medications which may have significant side effects.
Loren Cordain, PhD; Staffan Lindeberg, MD,PhD; Magdalena Hurtado, PhD; Kim Hill, PhD; S. Boyd Eaton, MD; Jennie Brand-Miller, PhD Acne Vulgaris A Disease of Western Civilization Arch Dermatol. 2002;138:1584-1590
Krowchuk DP, Lucky AW Managing adolescent acne. Adolesc Med. 2001 Jun;12(2):vii, 355-74 Affects 17 million in USA including 85% of adolescents
Peter R. Hull Acne, Depression, and Suicide Dermatologic Clinics Volume 23, Issue 4, October 2005, Pages 665-674 Psychocutaneous Disease
BETTY ANNE JOHNSON, M.D., PH.D., and JULIA R. NUNLEY, M.D Use of Systemic Agents in the Treatment of Acne Vulgaris American Family Physician Oct 2000
Webster GF. Inflammatory acne represents hypersensitivity to Propionibacterium acnes. Dermatology. 1998;196(1):80-1.
Seirafi, Hassan MD; Farnaghi, Farshad MD; Vasheghani-Farahani, Amir MD; et al, Assessment of androgens in women with adult-onset acne. International Journal of Dermatology. 46(11):1188-1191, November 2007.
Smith RN, Mann NJ, Braue A, Makelainen H, Varigos GA: A low-glycemic-load diet improves symptoms in acne vulgaris patients: a randomized controlled trial. Am J Clin Nutr 2007, 86:107-15Logan AC:
Dietary fat, fiber, and acne vulgaris. J Am Acad Dermatol 2007, 57(6):1092-3
Clinical and instrumental study of the efficacy of a new sebum control cream. Journal of Cosmetic Dermatology. 6(2):113-118, June 2007.Dobrev, Hristo MD, PhD
Inhibition of Propionibacterium acnes-induced mediators of inflammation by Indian herbs.Jain A, Basal E. Phytomedicine. 2003 Jan;10(1):34-8
Alakananda Ma M.B., B.S. (Lond.) is an Ayurvedic Doctor (NAMA) and graduate of a top London medical school. She is co-founder of Alandi Ayurveda Clinic and Alandi Ayurveda Gurukula in Boulder Colorado, as well as a spiritual mother, teacher, flower essence maker and storyteller. Alakananda is a well known and highly respected practitioner in the Ayurveda community both nationally and internationally.
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