What is acne vulgaris (pimples)
Acne vulgaris (hereafter referred to as acne) is a chronic inflammatory skin disease that occurs in the sebaceous glands of hair follicles. Since there is a process to recognize the disease, the process of recognizing the disease has given it many different names. The most common aliases include acne, acne vulgaris, and acne. In Chinese medicine, acne is referred to as lung wind and wine pimples, while in Hong Kong and Taiwan, acne is also referred to as pimples. Because beauty salons of all kinds do not know much about this disease, they use many different names, causing confusion in the minds of many people. Why do some people say I have acne instead of pimples?
How people with acne vulgaris feel
The truth is that people with acne vulgaris generally hate acne so much that they let acne patients talk about what it’s like to live with this nasty acne.
“I don’t look in the mirror, it makes me less confident and ruins my mood. When I needed to comb my hair I would look at a reflective wall, as long as it showed the outline of my face. For years I hadn’t looked at myself with my eyes, like a vampire, afraid of mirrors and unable to face myself. It was painful not to be able to look in the mirror, but there was nothing I could do about it. That’s what acne causes, it’s acne scarring.”
“If I had a little more self-esteem, I think I might go out more, I might go to more parties, maybe give more straightforward speeches in class without fear, and maybe not feel so uncomfortable when I walk up to the podium to speak to my classmates.” This is an outgoing and cheerful person who has become introverted due to acne and understands how different things would be if he didn’t have acne.
“Without acne control on my face I really feel very humiliated, I often have to keep my head down, I’m ashamed to face others, I’m 25 years old and having to do this makes me feel very depressed.”
Just a few words expressing his low, uncontrollable, shy, embarrassed and frustrated feelings. The fact is that with the many effective treatments available today, there is no reason for patients to suffer from such psychological torment any longer.
“Acne is always associated with being dirty, and I hate that because that’s not how things work. It’s something I inherited from my mother, who used to tell me she had exactly what I have now, and that it would go away naturally. Inheriting this from my mother makes me almost crazy. My father had great skin in his younger years so he didn’t understand why he had acne, which made me feel even more upset…. I get so frustrated when people look at me and notice that I have bad skin, and I really, really hate that.” Stories about acne have from time to time been a source of conflict for families. Teenagers always tend to be rebellious about everything, and do they need a false knowledge about acne to exacerbate their differences with their parents? One viewpoint that may make family problems worse is that severe acne is untreatable and it is better to leave it on the face. Yet this viewpoint is indeed wrong.
“No matter how hard I tried to control myself and look good, I couldn’t look like I was happy with the acne that was always there in those places, and that disturbed me greatly. There is never a day when I stop worrying about these things, should I spend so much energy on this? I could be doing something other than spending 5-10 minutes a day looking in the mirror to clean my face or tossing my face for acne.” This patient was so aware of her facial acne that she was almost neurotic about picking it out. It is clear that she is stuck with acne because almost all of her efforts to make herself look better have failed because of it.
Clinical symptoms of acne
1. Age distribution: Most acne occurs around the age of adolescence (16 to 18 years old), but there are also cases with earlier onset (e.g., around age 10) and later onset (e.g., after age 40).
2. Clinical manifestations: Acne has two main types of lesions: non-inflammatory lesions and inflammatory lesions. Non-inflammatory lesions are acne. Depending on whether the acne has an opening, there are two types of acne: blackhead acne (open acne) and whitehead acne (closed acne). Inflammatory lesions have various manifestations: papules, pustules, nodules, and cysts.
3. Prevalent sites: lesions are most likely to be found on the cheeks, forehead and nasolabial folds, followed by the chest, back and shoulders.
Pathogenesis of acne
The pathogenesis of acne is not completely understood, but the following four pathogenetic components are recognized
1. Hyperkeratosis of the follicular funnel.
Under normal circumstances, only non-adherent keratinized cells and monolayers of cells are shed into the lumen of the follicular funnel. In contrast, at the beginning of acne formation, the terminal stage of cellular keratinization becomes impaired, the adhesion between keratin-forming cells increases, the keratinized cells in the funnel do not disintegrate and fall off, and the rate of cell turnover is accelerated, resulting in faster keratinization of the follicular funnel and the formation of microcomedones. There are a number of hypotheses about the finer causes of keratinization abnormalities, but the in-depth causes are not well understood.
2. Androgens and sebaceous gland hyperfunction
The growth and differentiation of the sebaceous glands are regulated by androgens by a complex and not yet fully understood mechanism. Weaker circulating androgens are converted to highly active testosterone and dihydrotestosterone in the skin, a process that depends on specific enzymatic substances, such as 5α-reductase, in the hair follicles and sebaceous glands. The first step in the action of androgens on the sebaceous glands is to bind to the androgen receptor, which produces a series of programmed changes: DNA replication and protein synthesis, and ultimately the regulation of sebaceous gland function.
Androgens are essential to the development of acne, but acne is not caused by a simple increase in androgens. In fact, acne patients have few endocrine abnormalities because most patients have normal serum levels of various androgens and androgen-binding protein levels, which are not higher than those of the general population. So where does the cause lie? It is possible that this is due to increased activity of 5α-reductase in the sebaceous glands and/or increased affinity for androgen receptors.
3. The role of microorganisms in the sebaceous unit of the hair follicle
There are at least three types of microorganisms living in the sebaceous units of hair follicles, namely: Staphylococcus, yeast and Propionibacterium. The one more closely related to the development of acne is Propionibacterium. There are generally three types of Propionibacterium in the hair follicle: Propionibacterium acnes (P. acne), Propionibacterium ovalis (P. avidum), and Propionibacterium granulosum (P. granulosum). However, only P. acne can be isolated 100% of the time and is always the dominant growth. The most closely related to acne is also P. acne, which obtains the glycerol fraction of triglycerides in sebum as an essential energy substance for its growth by means of extracellular cutase, while leaving the de-esterified fatty acid fraction (i.e., free fatty acids) in the sebum, so that the amount of free fatty acids and the number of bacteria are sometimes proportional.
However, there are also many unknown and contradictory relationships between P. acne and the pathogenesis of this disease.
4. Inflammation and the host’s immune response
All inflammatory acne almost always develops from fine acne, however, even acne that does not appear clinically inflammatory can find signs of inflammation when viewed at the pathological level. Inflammation in acne differs from ordinary infectious inflammation in at least the following clinical aspects: (1) inflammation tends to be more chronic and prolonged; (2) inflammation often ends in scarring; and (3) inflammation varies greatly between individuals, and even within the same individual, the degree of inflammation varies significantly from follicle to follicle. These characteristics of acne inflammation make acne itself highly variable in terms of responsiveness to treatment.
However, although the above four pathogenic links are widely recognized, it is important to know that none of the above four links is sufficient to cause the disease. The fact that all individuals in adolescence have the basis for acne (high P. acne, some degree of follicular obstruction, and high seborrhea), but most do not develop acne, and that the data on fat concentration in sebum and P. acne in acne patients compared to the normal population overlap considerably, despite the fact that the acne group is somewhat higher than the non-acne group, suggests that these factors all participate individually in the pathogenesis, but are not the underlying factors.
Finally, it should be emphasized that many current advertisements and propaganda always simplify the pathogenesis of acne for their respective commercial interests, sometimes even attributing it to a single cause to convince patients to buy the drugs they promote, which is unreasonable.
Triggering factors of acne
There are many factors that can aggravate acne or trigger the development of the disease, usually for the following reasons: (1) long-term exposure to oils, asphalt, etc.; (2) exposure to certain chemical substances, such as chlorine and bromine; (3) use of certain drugs, such as androgens, sebum hormones, lithium, azathioprine, rifampin, etc.; (4) all factors that can increase skin inflammation, such as alcohol and pepper. But there are also many factors that are exaggerated or even misunderstood, the main one of which is food. Oily things and sugary foods generally have little effect on the disease. Cosmetics were once thought to be a cause of clogged pores and acne onset, but there is a lack of strong evidence. Many TCM practitioners believe that digestion and acne are very closely related, such as constipation, which may cause acne, but this seems to be unconvincing. However, it is certain that various diseases may be aggravated when the organism is strained, including acne, so many acne patients often complain that staying up late will aggravate acne. Therefore, acne patients are advised to avoid exertion and stay up as little as possible.
Classification of acne
Acne vulgaris
Very common and relatively mild acne, it is the type that is dominated by pimples. Pimples may be blackheaded pimples, whiteheaded pimples, or both. The number of pimples can be very small or so numerous that the face is densely covered.
Papulopustular type.
The most common type of acne is papulopustular acne, which often has both acne and pustules or papules, meaning that this acne will usually have both non-inflammatory and moderately inflammatory lesions. The severity of acne is mainly determined by the ratio of pimples to papules and pustules. The more papules and pustules there are, the more severe the acne.
Nodular acne
Nodular acne is much more severe than papulopustular acne. This type of acne is characterized by the appearance of nodular skin lesions that are not only disfiguring, but may also be painful to some degree. As mentioned earlier, nodular cystic acne is very prone to permanent scarring.
Agglomerative Acne
Finally, there is a very severe form of inflammatory acne, the type known as comedogenic acne. In addition to inflammation, this type of acne may also have bacterial infection. This type of acne mainly occurs on the back, buttocks and chest. This type of acne is sometimes very difficult to treat and often requires surgical treatment.
Acne caused by cosmetics
Certain ingredients in some cosmetics can clog pores and cause acne. Such products include makeup products, cosmetic bases, night creams and moisturizers, and they may be responsible for the development of acne. You should use products that do not cause or cause less acne. Cosmetic acne is often not very serious and does not lead to scarring, however, it can persist without fading, sometimes for decades. Making the problem worse, some young women will use more makeup to cover and disguise the rash on their face, with counterproductive results, in addition to being prone to acne in their younger years themselves.
Medication for acne
All current drug treatments are theoretically carried out by intervening in the above four components
Inhibition of sebaceous gland hyperfunction: (1) Anti-androgen drug therapy. In theory this idea has at least the following three treatment options: estrogens, progesterone and anti-androgen drugs. Estrogen and progesterone treatment is unsatisfactory, and the more successful drugs used in the clinic are Daine-35 (1#/d) and Androstadil (100mg/d). The former has good effect, the latter has unsatisfactory effect. (2) Inhibition of sebaceous gland function. The most effective drug still seems to be 13-cis-retinoic acid, also known as Tylenol or Tevis (0.5~1.0mg/kg/d).
Anti-keratinization abnormalities of follicular sebaceous ducts: There are many drugs belonging to this category, most of which are topical. Among them, 13-cis-retinoic acid can be used both orally and topically. Other therapeutic drugs are: 0.025-0.1% all-trans-retinoic acid (trade name Vetamin, or Dewey cream), 20% azelaic acid, 2.5-10% benzoyl peroxide (trade name Bensa), 2-5% salicylic acid, etc. However, among the many anti-keratosis abnormalities, only retinoids (such as Ansulis, Daphne, and Dewey cream) really normalize epidermal keratinization.
Inhibition of microbial growth: These drugs are numerous and among the most used today, and are often used as first treatment drugs. Treatment is usually empirical and customary, and the choice of the drug of choice varies greatly from doctor to doctor, as it is very difficult to compare the various antibiotics.
The drugs usually used are: tetracyclines, macrolides, sulfonamides, quinolones; others are chlortetracycline, benzoyl peroxide and azelaic acid. The biggest problem of antibiotic treatment is the problem of drug-resistant bacteria, it seems that almost all antibiotics can cause varying degrees of resistance, but there are three exceptions, which are benzoyl peroxide, azelaic acid and zinc acetate, they rarely cause resistance, and their compound preparations show better therapeutic effect, such as 3% erythromycin and 5% benzoyl peroxide pay prescription (trade name: Bimaxen The best efficacy of the topical drug is still one of them, but unfortunately this drug has been withdrawn from the market in China.
Inhibition of inflammation: Theoretically, all drugs that inhibit inflammation should be effective for acne. In fact, oral low-dose corticosteroids are effective for severe acne and are often used in combination. The therapeutic effects of various antibiotics currently appear to stem from their anti-inflammatory activity. Although oral zinc preparations have some anti-inflammatory effect and were once popular for the treatment of acne, the results were not very satisfactory, but they can be considered as a companion drug.
The most important issue for systemic treatment is the duration of treatment. Generally speaking, antibiotic treatment takes 3-6 months, vincristine treatment takes about 4 months, and sex hormone treatment usually takes 1 year or longer.
The most important issue of topical drugs is the correct use of various drugs. In terms of treatment principle, it is necessary to apply topical drugs comprehensively, not just locally on the affected area.
The last point to note is that the same drug has different trade names because of different manufacturers, so if the businessman carries out certain publicity and advertising, sometimes it will give patients a misunderstanding. For example, the same benzoyl peroxide has many different trade names due to different manufacturers: Acme, Acne King, Acylic, Bene, Bansai, etc.
Other acne treatments
This is one of the most effective acne treatments available, but it can only be used as an adjunctive treatment. It is necessary to use medication at the same time as this treatment in order to stop the growth and development of acne. .
Intranodal corticosteroid injections in nodules/cysts: This helps with the rapid resolution of inflammation and is a very effective treatment for larger nodules and cysts.
Cyst excision and drainage: For very large cysts, excision and drainage is an effective way to avoid future lesion mechanization and scar formation.
Photorejuvenation (IPL): This treatment is a pulsed intense light (IPL) treatment that can help with the fading of red marks in the later stages of inflammatory acne and also has a beneficial effect on reducing the size of large skin pores.
Scar grinding: It is an effective treatment for atrophic scars and is very effective in improving depressed facial scars and is the only treatment available. There are two methods of scar grinding, one is the traditional skin grinding treatment, which has a tendency to be gradually eliminated by laser grinding because of the high bleeding during the treatment and the depth of grinding is not easy to control. The other grinding method is laser grinding, which is a treatment method that uses pulsed high-energy CO2 laser to grind the skin without bleeding, with high precision and good results, so it is gradually replacing traditional grinding as the main treatment method.
Red and blue light: the effect is better and long-lasting, and now it can also be combined with 5-aminoketovaleric acid for photodynamic therapy. There will be a topic on this therapy at a later date.
How to treat the marks and scars left by acne?
There are two types of marks left by acne, one is a red mark and the other is a pigmented spot. Both types of marks can fade on their own with time, so they can be left untreated. If you feel that the fading time is too long or too slow, affecting your daily life and aesthetics, you can undergo photorejuvenation treatment to help this pesky mark fade as soon as possible. Because red marks are actually caused by dilated blood vessels, and pigmented spots are caused by abnormal pigmentation, photorejuvenation can have a more pronounced treatment and promotion effect on these two skin problems.
There are also two types of scars left by acne, one is depressed scars and the other is hyperplastic scars. One is the traditional grinding treatment, which is generally no longer used in hospitals with conditions due to more bleeding and slower recovery, and the other is laser grinding, which does not bleed after treatment and has a relatively faster recovery and better treatment effect, so it is now used more often. At present, high-energy pulsed CO2 laser and pulsed erbium laser are commonly used for laser grinding. Hyperplastic scars are generally treated by local injection of corticosteroids and/or combined with surgical excision and radiation therapy. However, the results are often not very satisfactory.
Common misconceptions
Acne itself is a very common skin condition, so common that there are many stories and anecdotes circulating among the public, and with the encouragement and “guidance” of some “cosmetologists”, some misconceptions have become enduring and “popular”. In addition, these misconceptions are passed down in the family, with parents often telling these stories to their next generation, who in turn tell their next generation. Friendships also bring these misconceptions to life. TCM is an empirical clinical discipline, and some herbalists often tell their patients unproven and unaccepted opinions, which to a certain extent also confuse them. What’s more, these misconceptions are often used by some businessmen to integrate into their advertisements, making it impossible for patients to get out of the various misconceptions. Under the guidance of these misconceptions, patients actually go to experience “acne” under the strong psychological implication of the misconceptions, and as a result, patients are convinced of these misconceptions, which greatly affects treatment. Common misconceptions include the following
1. Acne can fade on its own and does not require treatment
Acne does have a certain degree of self-limitation, as shown by the fact that the disease has a certain age of onset and natural course. The high-risk period for most people is adolescence, after which it gradually remits and fades on its own. However, treatment is still needed because: 1) Acne often leads to the formation of facial scars, which vary in performance, either depressed or hyperplastic, and are difficult to treat and will exist for life, greatly affecting beauty and aesthetics. Early, timely and regular treatment can not only significantly shorten the course of the disease, but also prevent the formation of scars. 2) The onset of acne is not necessarily at the age of puberty, but rather after the age of 30 in many cases, and the course of the disease lasts for a very long time in many cases, such as after the age of 40, and in a few cases, even at the age of 50, the disease does not resolve itself. A regular full course of treatment can usually eliminate acne in six months to a year.
2. Acne cannot be cured and should wait until after marriage to subside on its own
This is a misconception very similar to the one above. In fact, acne is a skin disease that can be cured, and most people can not only be cured but also not recur, but must have a regular treatment and a long enough treatment course. Otherwise acne will recur and reoccur, giving you the illusion that it cannot be cured. Since acne in some people exhibits a more obvious self-limiting nature, with onset in adolescence and subsequent gradual improvement and remission as they age, but people usually marry naturally at this time, giving you the illusion that your acne will be cured after you get married. The improvement of acne has absolutely nothing to do with whether or not you have had sexual experiences. Don’t think that if you get married or if you have sexual intercourse, your acne will naturally improve.
3. Acne is caused by the use of unsuitable cosmetics
Perhaps some cosmetics in the past did cause acne to form, or could worsen the original acne condition. But cosmetic science has advanced to the point where this is very unlikely. In fact, most of the regular cosmetic manufacturers are now very aware of the effects of cosmetics on acne, and almost all of them have undergone some rigorous safety studies and are not known to cause acne. However, for some sensitive people, the possibility that cosmetics can cause acne to form or worsen acne is not completely ruled out. After all, acne-like hair diagnosis is relatively common among cosmetic adverse events, especially those with special therapeutic effects, and the incidence is higher.
4, cosmetics can cure my acne
Cosmetics themselves are used for the health and care of the skin. The biggest requirement of the state for cosmetics is that they must be safe for the skin, non-irritating, able to moisten and protect the skin. However, recently there have been some so-called cosmetics with special healing properties that do add low concentrations of drug ingredients to cosmetics that have a very limited therapeutic effect on acne, but of course these added drug ingredients are not new drug ingredients. The problem is that the concentrations of these drug ingredients are usually very low, below the therapeutic concentration of the drug, and therefore often insufficient to treat acne, and only have some suppressive effect on very mild acne. In addition, the state verification of such cosmetics is mainly to verify their safety and not to critically examine their efficacy, so usually the state also does not allow any cosmetic to make any commercial claims about their efficacy. Unfortunately, almost all cosmetic products advertise their miraculous “efficacy” and no one asks about this violation.
5. Acne is very easy to treat and can be treated in a few days with a refund.
This is the most common advertising phrase that appears in all kinds of commercial campaigns. With the development of dermatological science, acne treatment is now relatively easy and reliable, but it should be clear that even very effective treatment usually has to be maintained for several months to prevent recurrence. We do not rule out the possibility that the medication will work within a few days, but a short treatment of a few days is of little practical importance in the course of acne treatment. In fact, almost all effective medications have some effect within a few days. However, once this effect is cleverly designed and packaged with a certain scale of commercial promotion, the medication can become a miracle drug overnight and cause a short-lived sensation in the society.
6. Acne is caused by mites
After you read the previous pathogenesis, I believe you will no longer believe that mites can cause acne. This is perfectly normal, just like the presence of bacteria on our skin. However, sometimes follicles can cause a disease called follicular dermatitis, but there is a big difference between this disease and acne, so don’t get confused.
7. Acne is caused by endocrine disorders
This is one of the most widespread and representative misconceptions. Whenever you go to the hospital, almost all doctors will tell you that acne is caused by endocrine disorders, and there are all kinds of legends and stories about endocrine disorders circulating in the society. Although the occurrence of acne is closely related to endocrine disorders, it is true that acne is not caused by endocrine disorders. On the contrary, the levels of various sex hormones in the bodies of most acne patients are not different from those of normal people, and there is no endocrine disorder at all. Therefore, many people mistakenly believe that their endocrine disorder and therefore carry a heavy psychological burden, and thus constantly seek various ways to regulate endocrine treatment. Modern medicine has found that acne patients may have abnormalities in the sex hormone receptors in the skin, which is reflected in a higher than normal affinity for the receptors, and therefore overreact to the “normal” fluctuations in the body’s hormone levels, causing pathological changes in acne. Some female patients also experience an increase in acne before menstruation, which is also related to fluctuations in sex hormone levels in the body. However, this does not mean that there is an endocrine disorder. Only a very small number of acne patients may have an endocrine disorder, such as female patients who are too old for the onset of acne, and some patients whose acne worsens significantly before menstruation, etc. Their body’s sex hormone levels may be significantly higher than normal. There is a drug called Daine-35 that is very effective in treating female acne. Many people mistakenly believe that it is an endocrine regulator, but it is not. The reason why many doctors are answering your questions about the pathogenesis of acne being caused by endocrine disorders is because they know that it is very difficult and almost impossible to correct this social misconception about endocrine disorders, and when they are less willing to dwell on this issue with you, they will perfunctorily attribute the onset of acne to endocrine disorders.
8. Acne is caused by an uncontrolled diet
Another deep-rooted misconception is the effect of diet on acne. Some textbooks also emphasize the effect of food on acne, so many people are afraid to eat almost any food when treating acne, which is actually not necessary at all. Of course there was a lot of debate about the relationship between things and acne in the past, especially since Chinese and Western medicine have somewhat different views. However, modern medicine has proven that the following foods have little to no effect on acne: milk, chocolate, sweets, fatty foods (such as fried foods and meat), fish, etc. These foods are very safe to eat. Since acne is essentially an inflammation of the skin, eating these types of foods can also aggravate the condition of acne. However, we should know that even if such foods can aggravate acne, it does not mean that there is a causal relationship between the food and the onset of the disease, because Sichuanese people like to eat spicy foods, but they do not have a higher incidence of acne than people in other regions.
9. Acne is caused by constipation
This is a typical folk view, because TCM believes that acne is related to the lung wind, and the large intestine is related to the lung, so the onset of acne has some relationship with the large intestine. Sometimes Chinese medicine practitioners use some “laxative” drugs to relieve acne, which makes the story of constipation and acne even more popular and convincing. There is no denying that the onset of acne is related to the overall state of the body, which is in line with the laws of disease. In the case of the human body, almost all diseases are closely related to the overall state of the body. Acne is the same. When your body is in a poor state, such as when you are tired or stay up too late, acne will be significantly aggravated. Of course, when your body is not in good condition, some people may also have other problems, such as constipation, thus creating the illusion that there is a causal relationship between constipation and acne. In fact, acne and constipation may both be related to the overall state of the body, and both occur when the overall state of the body is not good, while there is no causal relationship between constipation and acne. Some herbs can relieve acne through laxatives (e.g., Niuhuang Detoxification Pills, etc.). In fact, these herbs by nature have powerful anti-inflammatory effects, and it is certainly not surprising that they are effective in treating acne. If we want to use this idea to treat acne, we should regulate the state of the body to achieve the purpose of treating acne, and there is no therapeutic efficacy in simply passing the pills.
10. Skin cleansing and hygiene problems are the cause of clogged pores, which eventually lead to acne
This is a viewpoint that is highly exaggerated, amplified and promoted by all kinds of skin cleanser sellers, as it facilitates the marketing of their products. Although clogged pores are an important part of the development of acne, it does not mean in any way that the clogged pores are due to any problems with skin cleansing. In fact acne sufferers take skin cleansing more seriously than anyone else, and they spend a great deal of effort cleaning their facial skin almost daily. Clogged pores in acne sufferers are mainly caused by something intrinsic to the skin itself, starting with abnormal keratinization of the pores, which eventually leads to clogging. Instead of cleaning the skin, excessive cleaning can sometimes aggravate the keratinization of the skin pores, which may further aggravate the clogging of the pores and worsen the condition. For example, the once popular scrubbing face wash, which is no longer mentioned, does sometimes irritate pores. Some advertisers try to play up the importance of deep skin pore cleansing, but of course this is just advertising. Deep pore cleansing cannot be done on the one hand and is unnecessary on the other. Of course, proper skin cleansing does have a certain auxiliary effect on acne treatment, but this effect is very limited. Many people buy a large number of various skin cleansing products (such as facial cleansers), hoping to use them as a substitute for medication to treat acne, which is actually ineffective and unnecessary, and is a treatment that puts the cart before the horse.
11. Acne is just a cosmetic skin problem, not a skin disease
Sometimes, we can even hear this kind of question from patients in the clinic: What can you doctors do about acne on my face that even beauty salons can’t do? This is a ludicrous question. There is no doubt that acne is a typical skin disease and a medical problem. In the strictest sense, cosmetics of all kinds do not have the efficacy to treat acne, and it is illegal to advertise the efficacy of various cosmetics on acne. In addition, acne exclusion treatment (mask) in beauty salons is also a violation, because skin care in beauty salons is not al