You have the best available weapon against acne already working on the skin now that your acne control regimen is started. Armed with new knowledge about acne and what affects it, there are still some extra things that can be done to ensure that the regimen will work. Ensure that your skin is receiving the fullest possible benefit from the medication and that the body is in good general health and not under undue stress. All this boosts the success of an acne control program. Next, we offer eight "extras" that can help a regimen be more effective.

HOW TO PUSH THE EFFECTIVENESS OF YOUR PROGRAM
If several weeks into your regimen there isn’t sufficient flaking and peeling of the skin, there are five ways to push the action of the products to ensure the skin is receiving its full force. These pushing techniques are aimed at acne sufferers with unusually oily or tough skin.

1. Wash your face just before applying the therapeutic products.
Products will be more potent if it doesn’t have to fight its way through an oily film. Always wash thoroughly just before applying the tonic. The Normalizing Tonic Forté can be used to make sure the oily film is totally stripped off of the face before applying vitamin A lotions.

2. Apply your lotions more frequently. Dr. Fulton says, "Don’t forget the ice."
If you have journeyed through all the exposure levels by applying the lotions twice daily and then wearing them around the clock and you still are not peeling enough, you can push your regimen even further. These products provide their maximum action in the first three to four hours of wearing time. So when your schedule permits, wash the skin every three hours and reapply a new layer of products.

Keep doing this throughout the day. One warning: Do not wake up in the middle of the night to re-apply medication. That would be counterproductive. Sleep is far too precious to disturb those hours.

3. Don’t forget the ice treatment.
The ice cubes in the freezer may be the second best therapeutic tool available.

First, to avoid freezing your hands, wear plastic gloves or wrap the bottom of the cube in a napkin or washcloth. Instead of using ice cubes, create your own ice applicator by freezing water in a Styrofoam cup. Fill it all the way to the top. The ice expands as it freezes, creating a raised domed effect. As it is used, peel down the Styrofoam to expose more of the top.

Now take the ice cubes (or ice cup "dome") and rub it for two or three minutes over the areas where the medication will be applied. The cold slightly "damages" the top layers of the skin and increases the product’s penetration. Ice also creates an anti-inflammatory effect so it helps reduce inflammatory

papules, nodules, and cysts. If there is a new nodule or cyst developing, apply the ice directly on top of the sore spot for several minutes. The next day there should be less redness and swelling. Repeat this daily until the lesion subsides. Many of my patients forget about the ice treatment, probably because ice is too cheap. If ice costs one dollar per cube, you would certainly remember to use it.

4. Add sulfur to benzoyl peroxide lotion.
The old standby peeling agent, sulfur, by itself is of questionable value in acne treatment. But I’ve found that when sulfur is mixed together with benzoyl peroxide, the benzoyl peroxide becomes twice as effective. First, sulfur increases the stability of benzoyl peroxide (that is, it helps benzoyl peroxide retain its strength in the formulation). Second, it produces a synergistic effect with benzoyl peroxide when applied to the skin, boosting the peeling action. I have often added sulfur to various formulations for my patients. You can do it yourself. CAUTION: Do not improvise or attempt the following formulation mixing unless you follow these directions carefully.

Directions: You can buy flowers of sulfur or precipitated sulfur in many drugstores. The sulfur is sold in powdered form. Empty out the benzoyl peroxide lotion into a bowl. Add enough powdered sulfur to equal an approximate 10 percent concentration; that is a ½ teaspoon for a one-ounce tube of lotion or one heaping teaspoon of sulfur for a two-ounce tube. Grind the sulfur into the lotion with the back of a spoon until the mixture is smooth. Store the lotion in the refrigerator in a wide-mouthed jar. Use this sulfur-boosted lotion for evening and overnight applications or any other time that you are able. It leaves a noticeable light yellow film on your skin so you may wish to keep a tube of regular benzoyl peroxide lotion for daytime use (it’s less visible on the skin when it dries).

5. Try the plastic wrap trick for stubborn acne on the back or chest.
If, after trying the toughest regimen and adding all the above tricks, your back is still not peeling (and therefore not clearing up), here’s the answer of last resort. More than a decade ago, dermatologists discovered that topical medications could be made ten times more effective by applying a thin plastic wrap on top of the formulation. This technique is especially useful in the treatment of psoriasis. Lately, we have applied the same principle to acne.

WARNING: Use only in places where you need to boost the treatment like on the back and chest where the skin’s thickness makes benzoyl peroxide penetration difficult. Your face is much too sensitive for this technique.

Directions: Apply a generous layer of benzoyl peroxide to the back or chest early in the evening. Let it dry completely. Apply a layer of plastic wrap up and down the back or chest and over the shoulders (you’ll need someone’s help for this). Tape it temporarily into place at the shoulders. Then slip on a tight T-shirt to help hold the plastic layer in place. Or wrap an Ace cloth bandage (the kind athletes use to bind up an ankle or knee) around the torso to hold the plastic wrap in place.

CAUTION: Do not get benzoyl peroxide under the armpits or on the sides of the chest because those areas are more sensitive to it. If the skin becomes overly irritated and dry from this trick, give it a rest for two or three nights. Then try the plastic wrap technique again with a less liberal application of benzoyl peroxide onto the center of the back or chest.

AUTHORIZED PICKING
Finally, what you’ve been waiting for: permission to engage in "picking" or extraction as it is called in the doctor’s office. Picking is a double-edged sword. If

you pick a new, developing lesion, you may drive it deeper and cause greater inflammation and potentially deeper scarring. On the other hand, if a lesion is a mature pustule, proper extraction will speed healing, stop tissue digestion and reduce scarring. It’s all a matter of doing it right.

First rule: Don’t even think about extracting until your regimen has been followed for at least three weeks. First give the products a chance to "open up" the skin and loosen impactions.

Second rule: Recognize which lesions can be extracted and which ones cannot. A blackhead can be extracted rather easily because the pore opening is already dilated and the impaction has moved up to the surface. A whitehead can also be successfully extracted if it is reasonably close to the surface and you are able to dilate the pore opening with a sterile needle. Leave an inflamed papule alone. After several days when you notice a yellowish center developing in the papule, pus has moved up to the surface bringing the impaction with it. Then, it is ripe for extraction.

On the other hand, an immature nodule, which is a deep, undefined red bump, cannot be extracted by an amateur. Often it cannot be done by an expert either. Any attempt to do so will only make it worse. This is also true for most cysts. Leave them alone! Instead, employ ice applications to reduce the inflammation. However, there is one kind of cyst that can be extracted: the "ripe" cyst which features a soft, pus-filled pocket near the surface. This may benefit from extraction especially if it has an obvious center to serve as a draining point but one must be able to recognize the center. That spot will be softer and purplish or, at some point, a pore opening may become visible; then you can open the lesion with a sterile needle. However, if the cyst is a hard lump or is very deep or very sore, leave it alone or leave it to a professional therapist in a doctor’s office. CAUTION:

Don’t allow a physician to cut it open with a scalpel. That practice is too likely to leave a permanent scar. Let the lesion mature until the draining point becomes obvious then a sterile needle will open it to allow drainage.

Third rule: Use the proper equipment. Forget all of the commercial drugstore metal comedo extractors sold for this purpose. Of the various instruments, I recommend only one, the Schaumberg extractor*. Even this instrument is useful only for non-inflamed blackheads or whiteheads. The best instrument, again, is the cheapest. You need a sharp, sterile needle. In the clinic, we use a 20-gauge syringe needle which would be equivalent to a large sewing needle. The second tool is even easier to find. This tool is the soft, padded ends of your fingers wrapped in tissue to further "pad" them and provide a clean contact surface. If you have long fingernails, trim them or forget about extracting. Fingernails can damage the skin badly.

Now here’s the step-by-step procedure:
1. Sterilize the needle either with boiling water or by soaking it in alcohol for ten minutes. Also scrub your hands with soap and a hand brush. Pretend you are a surgeon and scrub for a full three minutes.
Figure 23. If a pustule is mature, dilate the opening of the pore with a sterile needle. Wrap your fingers in tissue and gently apply pressure (see further directions in text). Successful technique will yield the impacted material without tissue damage.

2. Find the pore opening or center of the pustule. It’s easier for our clinic therapists because they can look at the patient’s skin through a magnifying glass. You can find it with the naked eye if you look carefully.

3. Determine the slant of the pore. Pore openings don’t go straight down, they actually go on a slant. You can determine that slant by checking the tiny hairs in that area; the direction in which they lie is also the direction of the slant of the surrounding pores.

4. Gently push the needle (at a slant parallel to the hairs) into the natural pore opening about 1/16th of an inch. Don’t be afraid; it doesn’t really hurt. Move the needle slightly from side to side to assure a complete pore opening.

5. Now wrap your fingers in tissue and gently push down and in. If successful, the comedo will pop right out. If you obtain only blood or serum (clear liquid), you have either missed the natural pore opening or the lesion is simply too deep to be extracted successfully. CAUTION: Don’t force it at this point. Instead, apply the ice treatment. The lesion may spontaneously resolve itself or may become easier to extract in a few days. Be sensible. It is when you feel you must get it out "at all costs", that you begin to damage your skin. Know when to leave well enough alone.

6. If you don’t feel that you have completely extracted the lesion, wait for five to ten minutes and then try again. The swelling leads to better tissue firmness and a gentle push, after the waiting, may yield the impaction.

Rule of thumb: If you attempt to extract four or five lesions and are unsuccessful with all of them, quit. Your skin simply isn’t ready for the procedure yet. Speed up your treatment program and allow it time to loosen the impactions. Postpone any further extraction attempts for a week or two. After the lesions "open up," extraction is easy. If you have been successful, the material extracted from the pore will be composed first of some whitish pus (the white blood cells which massed during the inflammation) and at the very end there will be a slightly harder, tiny round blob (almost like a little seed). That is the culprit in this whole affair. If you have extracted this impaction, then the lesion will quickly resolve. If, on the other hand, you only forced out a stream of pus but left the hard little impaction inside, the whole process of inflammation in that pore may repeat itself. So learn to choose the lesions carefully.

CAUTION: Proceed with extracting only if you have carefully read these directions and feel confident about following them. It’s better not to do it at all than to do it badly. If you have chosen a buddy or relative as an acne therapist and they wish to perform the task, make sure they first read these directions. If you do not trust either your own or your friend’s skills but wish to reap the benefits of extraction during your regimen, find a local nurse or cosmetician who is skilled in acne extraction or is willing to learn. (I periodically hold special training classes for cosmeticians who wish to become acne therapists. I am personally pleased with the results of this program. I fully expect that one day excellent acne therapy will be available from specially certified cosmeticians and estheticians in communities across the country. In Germany and other European countries, such specially trained cosmeticians work hand-in-hand with dermatologists to provide well-rounded acne treatment. The result is better care for acne patients.)

TAKE ZINC TABLETS
I rely very little on internal medication. The key to acne treatment is topical. Although, I have found one exception. Zinc tablets help reduce inflammation of lesions in many severe acne patients. Therefore, I routinely suggest at least 100 mg of zinc per day for

Grade III and IV acne patients. This is a nonprescription item that you can easily add to your regimen if you wish. The Scandinavians were the first to advocate zinc. We repeated their research and after three of four weeks of zinc treatment, many of our test subjects began to notice a decrease in inflammation. There was less redness, swelling, and angry festering appearance to lesions. The size of nodules and cysts decreased but the number of blackheads and whiteheads remained the same. Zinc is not, in itself, a solution to acne. But anything that reduces inflammation also reduces scarring and can lend a helping hand to your regimen. Zinc doesn’t work in everyone. To see if it helps, begin taking at least 100 mg of zinc per day for thirty to sixty days. If you notice an improvement, continue zinc supplements for six months. If you do not see any benefit, discontinue it.

BEGIN A LOW-STRESS DIET
Many Americans have notoriously unhealthy dietary habits which unknown to them place cumulative stress on their bodies. They wake up in the morning and rush off to work or school without eating breakfast. They stimulate their sluggish morning bodies with doses of caffeine via numerous cups of coffee and continue stimulating their bodies with caffeine all day through coffee, tea, colas, and other soft drinks. Additionally, they elevate blood sugar levels with candy and snacks. Lunch is often on the run and composed of fast food rich in fats, starches, and salt. At the end of the day, Americans usually consume their heaviest meal at which time they stuff themselves. As they let down during the evening, they raid the refrigerator often reaching for sugary snacks to give them a stimulating shot as they feel more tired. One more late-night snack before bedtime assures that their blood sugar elevation will last all night. Then with too few hours of sleep ensuing, the cycle starts again. This eating pattern is about as destructive as any could be. If you see yourself following the above description, you need to develop new eating habits, not only to boost the effectiveness of your acne control program but also to prevent going down a sure path to stress damage as serious as heart disease or cancer.

The bad dietary habits we just described have the effect of artificially elevating hormone levels. Remember, increased hormone levels can aggravate your acne. Therefore, a diet which reduces hormone levels could lend a helping hand in your fight against acne. By itself, a better diet won’t stop your acne but it can help your regimen work better. Less stress and better general health also means faster healing. Even if it didn’t do one thing for your acne, changing bad eating habits could save your life some years down the road.

Here’s what I suggest:

1. Read The Pritikin Program for Diet and Exercise39 which suggests that we return to a "primitive" diet of whole grains and cereals, fresh fruits and vegetables, fish and poultry. Then begin following the book’s suggestions as I have summarized below.

2. Stay away from "white" substances such as refined sugar and refined bleached flour. Ingestion of these foods results in a surge in blood sugar which places unnatural stress on the body.

3. Start the day with a hearty old-fashioned breakfast. An ideal choice would be a large bowl of cooked cereal such as rolled oats (not the minute kind which are too refined) topped with a green banana. Eat a large portion.

4. Midmorning, have a substantial snack of cut-up carrots, celery, cauliflower, apples, cottage cheese or a cold piece of chicken. At noon, eat large portions of steamed vegetables, fish, or poultry. Finish with fresh fruit. Repeat a similar meal in the evening. (If you need it, a mid-afternoon snack could include cut-up fresh vegetables or fruit. Keep your refrigerator full of such healthful snack items.) No snacking is allowed after your evening meal. That way, the bulk of the calories will be ingested in the early part of the day which is just opposite of the unhealthy eating pattern described at the beginning of this section.

5. Avoid stimulants such as cigarettes, coffee or other caffeinated beverages, or alcohol. These artificial stimulants can radically alter the body’s metabolism causing a wide fluctuation in blood sugar levels resulting in stress. They can suddenly cause you to feel hungry and eat more than you need which just adds more stress. (One of my patients actually added sugar to her morning, afternoon, and evening cola. She went through severe withdrawal when the sugar and caffeine were stopped but it was important to the health of her body and her skin to correct her overstimulated and stressed state). If you like the tradition of a hot social drink during the day, choose from the wide array of spicy, fruity, decaffeinated teas now available. Chinese green tea is the best as it also contains anti-inflammatories.

6. If you can’t discipline yourself to follow the above eating schedules, follow some of the suggestions by starting with the easiest ones such as shunning caffeine and sugary snacks and munching on raw vegetables whenever you feel like snacking. One by one, replace each bad habit with a new and healthier one. It’s important to help your children learn good eating habits right from the start. There is compelling evidence that high-fat, high-calorie, and high-stimulant diets contribute to an earlier onset of puberty in this country. Dr. E. William Rosenberg, professor of dermatology at the University of Tennessee, postulates that earlier puberty brought

That could help explain the puzzling studies showing that Eskimo children develop acne when they switch to Western diets. Other similar evidence shows that young Japanese people whose elders experienced no acne during their teens develop acne when they abandon traditional Japanese foods in favor of Americanized diets. If such a diet-linked early puberty were connected to acne, we would all do well to encourage different eating habits in our children who are inheriting our acne tendency and will be more prone to the various factors that can aggravate acne. Clearly, these speculations about dietary factors do not point to a particular food as causing pimples the next day but, rather implicate long-established eating habits developed over many years. You may not be able to undo your bad habits in time to substantially affect your own acne but, you could do the next generation a big favor by not passing on your unhealthy eating patterns. It’s something to think about. on by elevated hormone levels due to unhealthy diets could have something to do with acne. Perhaps the too-high, too-early hormone levels prompt the flow of sebum before the pores are anatomically well developed enough to handle it.40

START A SENSIBLE EXERCISE PROGRAM
Hand-in-hand with better eating habits is a good exercise program. If on the acne history form you answered question J-6 which asks you to rate your amount of daily exercise by circling "too little," it is time to correct the problem. How could exercise boost your acne treatment program? Stress aggravates acne and exercise is one of the greatest stress reducers around. Develop an exercise habit

whether it is jogging, swimming, or any other physical activity you enjoy and can do every day. The resulting better health and happier outlook will show up in your skin. Again, exercise doesn’t amount to acne treatment in itself. Your pimples won’t disappear because of jogging or swimming but exercise represents a simple, enjoyable treatment booster and a way to build a better, healthier body. Get moving.

SLEEP EIGHT HOURS EVERY NIGHT
If you sleep less than eight hours per night, this lack of sleep could be contributing substantially to your acne. I discover over and over again that acne patients are not getting adequate sleep which corresponds to periods of flare-ups whether it’s staying up late studying for finals or partying all night. It has recently become popular to believe that people get too much sleep and that five hours is enough for the average person. For the duration of your acne control regimen, whether or not you believe the old-fashioned notion that you need eight hours a night, get eight hours of sleep anyway. Also, try to begin that good night’s sleep at an earlier hour. Go to bed at ten p.m. or eleven at the latest. Going to bed very late and then trying to make up for it by sleeping late the next morning doesn’t help. As I’ve emphasized earlier, the human animal seems designed to sleep when it becomes dark outdoors and rise along with the sun. Modern man has stretched that natural rhythm to a breaking point and bears the price for it in stress. Earlier bedtime hours and an earlier rising time appear to be healthier.41 Make better sleep patterns part of your regimen. I’m convinced it represents an important treatment booster. If you work at night and sleep during the day, it is very difficult to clear your skin. It is an unnatural rhythm. Switching your waking schedule to daytime hours for the sake of your skin is essential.

STRESS-REDUCTION TECHNIQUES
As we’ve already emphasized in Chapter 15, stress is the skin’s number one enemy. Eliminating unnecessary stress and diffusing unavoidable stress can enhance the success of your acne control program considerably. If you follow the three lifestyle-related treatment boosters we just described: a low-stress diet, a sensible exercise program, and adequate sleep you will be enlisting the three best stress management techniques around. A strong, healthy body gives you the edge in dealing with the inevitable stresses of life. There are several other things you can do to reduce and diffuse stress. If on the acne history form you noted that stress aggravates your acne, we asked you to identify the major sources of stress in your life. Look to see what stress sources you circled or penciled in. Those answers should give you a clue as to where to begin. If for instance, you circled "family life", ask yourself what specific ally in your family relationships is causing tension. Then begin planning ways to reduce those problems. The following tension-reduction suggestions are overlapping bits of practical wisdom most of which we’ve gleaned from self-help measures suggested by the National Association for Mental Health. Follow the ones that apply to your personal circumstances.

Talk it out. Don’t bottle up worries and problems. Find a level-headed trustworthy person to talk to about your problems. Another person can sometimes help you see your dilemmas in a new light and lend some fresh ideas on how to solve them. Plus, in the process, you inevitably discover that other people share similar worries and problems. Your problems are not as unique or as overwhelming as you might think. If your problems are seriously getting out of hand, choose a professional to talk to e.g. a psychologist, mental health therapist, or religious counselor. Often professional help is not as costly as you might imagine.

Try "creative flight" once in a while.
Sometimes the best way to confront a problem is to get away from it for a short time. Escape long enough to think and recover your balance. Then go back and deal with it when you are more composed. For example, if a co-worker bugs you, instead of "taking it" (which is a form of self-punishment) or "blowing up" (which actually makes the problem worse), take a walk even if it is just to the office water-cooler and back. Seek a brief change of scenery and then return. The key to this technique is in coming back and dealing with the conflict in a calm and sensible way. You also can practice creative escape when confronted with a task that suddenly seems to be too much for you. Instead of going around in circles, divert yourself from it for a bit. A movie, a book, a walk, or a ride can refresh and give you the perspective to go back and resume the task with greater efficiency and insight. It is the same principle as taking a vacation. Even a five-minute "vacation" away from a frustrating situation can give you the breather and resulting perspective to handle your problems and yourself better.

Take one thing at a time.
For persons under stress, even ordinary tasks seem insurmountable. Divide the task into steps according to priority and then proceed one step at a time.

Develop time and energy priorities.
Everyone has areas of competence and areas of lesser ability. Direct your energies to those areas of life where you function most effectively. Stay away from those life situations where you are ineffective and uncomfortable. This is not really a negative concept.

It’s a way of pushing your best assets. Hand in hand with developing a sense of your most valuable personal qualities goes the sense of how best to spend your time. Don’t expend $10 worth of time and energy on a 10¢ problem. For the thousands of people who get caught up in the meaningless and frivolous details of life and miss the important things, this one simple principle can reduce a flood of inner conflict.

Learn to accept what you can’t change.
Many of the stresses of life are beyond your control. There’s no point in becoming upset about circumstances which you truly can’t change whether it’s the climate, income taxes, or a stranger’s behavior.

Give the other guy a break.
Sometimes we try to make loved ones suit our own ideals and fantasies. Sometimes we even demand perfection from strangers. This leads to endless frustration because it just can’t be done. Give the other guy a break whether it’s your spouse, parent, co-worker, or a stranger. Apply a less harsh "yardstick" to people around you and they’ll do the same for you. Competition is contagious but so is cooperation. When you stop making other people feel that you are a threat to them, they also will stop viewing you as a threat. If you envision life as a game in which you must trample on others to get to the top of the pile, you are headed for trouble. Examine your goals. It’s time to relax and figure out what really is important to you.

Balance work with play. Learn "creative loafing".
Schedule time for recreation and hobbies that you enjoy. Some active people feel guilty when they "sit around and do nothing." You need times of "doing nothing" to unwind and refuel. You can’t live in a state of constant stimulation and activity. Some of your creative loafing time should also include active play. Jogging, playing tennis, swimming, and other physical activity drains off the emotional and intellectual strain of your workday.

Learn some simple relaxation techniques.
Throughout the ages, cultures have developed traditional methods of relaxation and getting in touch with people’s inner selves. If you can’t make yourself relax, you need some organized techniques. Some people benefit from progressive muscle relaxation, deep-breathing techniques, yoga exercises, biofeedback, and transcendental meditation. Many religious people find inner strength and serenity through prayer and meditation. Classes in various anxiety-reducing techniques are available in many cities. Check with a local mental health chapter, psychologist, minister, rabbi or priest.42

HARNESS YOUR MIND’S HEALING POWER
We all possess powers of imagination, concentration and visualization that we never have tapped properly. Science is only beginning to unlock the mysteries of the remarkable powers that reside in the human brain. It well may be the next great frontier of medicine. Through knowledge and imagination, you can turn that force loose on your healing process. In a sense, this whole book is aimed in that direction. Increasing your understanding of acne is a way to turn your mind around and pour its power into your acne control program.

To examine the effects of relaxation, mental imagery, and biofeedback techniques on acne therapy, psychologist Dr. Barry Brown conducted a study of twenty-two Grade II acne patients of mine from the Hollywood Florida Acne Health Care Center. In addition to receiving the usual acne therapy, the test

group learned and practiced relaxation and imagery techniques. They visualized their benzoyl peroxide penetrating into the skin’s pores, killing the bacteria, opening and pushing up impactions. The progress of these patients was compared with a control group of similar patients who received our traditional acne therapy. During the period of the study, the first group’s actual acne lesion counts were reduced about 25 percent more rapidly than the group who received conventional therapy only.43 Since then, we’ve made cassette tapes to help interested patients utilize relaxation and visualization as a treatment tool to speed up clearing (see the last chapter of this book).

How can you harness and focus your brainpower on acne control? Using what you’ve learned in this book on an informal level, you can set aside some quiet time each day to focus on what is going wrong in your pores and what you wish to happen instead. You can concentrate on how your skin is opening up and responding to the benzoyl peroxide treatment. Be creative. Visualize the process and feel it happening. A few minutes of quiet time each day practicing this positive mental imagery can harness your brain’s latent powers to back up your acne treatment. One word before you get too carried away. Remember, this is not the treatment by itself. Biofeedback and mental imagery are backups or boosters to make the treatment work more effectively and to remove the obstacles your mind and body can sometimes throw up against proper treatment.

If you are successfully clearing, you can skip the next chapter. However, if you’ve faithfully stuck to the regimen for several weeks and are not satisfied with your improvement, you may be part of that 5 percent who have extreme difficulty. No one is a hopeless case. We have further suggestions. Turn the page and discover a few more tricks.