ENLARGED PORES THE INTEGRATIVE AND HOLISTIC APPROACH FROM DIET AND SKIN CARE TO LIFESTYLE AND LASER

Victor Gabriel Clatici, MD, takes an in-depth look at this common skin concern and explains why a holistic approach is the best form of treatment

ABSTRACT

Physiologically speaking, pores are defined as apertures from the surface of a tegument (animal, vegetal) that ensure the input or output of gases or fluids.

Dermatologists often face challenging questions from their patients or customers about the presence of large or enlarged skin pores and the practical possibilities to alleviate such undesired aspects. Although not a medical concern, enlarged pores are a cosmetic concern for a large number of individuals. This obsession has even led dermatologists to coin the term ‘porexia’ for those with neurosis about their pores.

Many endogenous and exogenous factors are known to cause enlarged pilosebaceous pores. Sex, genetic predisposition, ageing, chronic ultraviolet light exposure, comedogenic xenobiotics, acne, and seborrhoea. In female patients, additional hormonal factors, such

PEOPLE OFTEN DESIRE TO MAINTAIN a youthful and healthy appearance indefinitely. However, our fears of death, rejection or abandonment, and failure can sometimes hinder us. The fear of rejection is often linked to our appearance, while the fear of failure is often tied to our competence.

The skin has multiple functions, including defence against mechanical, physical, and chemical aggressions, microorganisms, and solar radiation. It also regulates temperature, acts as a barrier to prevent loss of water and electrolytes, serves as a reservoir for stem cells, provides immunologic function, and functions as a sensory organ that can detect pressure, temperature, and touch.

The health of our skin affects our self-esteem, mental state, and the way we interact with others. Essentially, our skin health plays a vital role in determining our quality of life1. The condition of our skin plays a vital role in our overall well-being and how we are perceived in terms of health and beauty2 as menstrual cycles, affect the pore size. Pore size was significantly increased during the ovulation phase. because good-looking skin with an even tone, clarity, and radiance is a sign of health, well-being, and fertility. Therefore, taking care of our skin and maintaining its appearance is essential.

Because various factors cause enlarged facial pores, it might be helpful to identify the underlying causes to select the appropriate treatment. Enlarged facial pores are challenging to treat due to the multifactorial nature of their pathogenesis. They are primarily treated by addressing associative factors, such as increased sebum production and cutaneous ageing.

Treatments for enlarged facial pores primarily aim to decrease sebum production, rejuvenate skin, remove hair, and/or decrease follicular size.

In this paper, I review the current treatment modalities for enlarged or dense facial pores, including diet and sun protection, topical retinoids, chemical peels, oral antiandrogens, and lasers and energy-based devices (EBDs).

The level of attractiveness of a person’s face is a significant social characteristic. It is often regarded as a factor that helps determine social and intellectual abilities, including selecting a partner and earning potential4,5. The face is crucial for human social communication, as it provides the primary source of information for social perception. Even slight imperfections can significantly affect mental health and quality of life6,7. Research has shown that the texture and colour of female facial skin can impact how people judge their age, health, and attractiveness8,9. This is true even when taking into account the influence of facial shape.

KEYWORDS

Pores, Skin quality, skin texture, laser therapy, Energy-based devices, EBDs

Desmond Morris3, a Zoologist, made an interesting statement about our skin. He said that having flawless skin is something that is desired universally. This is

Having a ‘camera-ready’ face is crucial for social media10, and making a good first impression is crucial, as research shows that you only have 100 milliseconds to do so and you won’t get a second chance11. The colour and texture of a person’s facial skin significantly impacts their perceived attractiveness, according to studies12,13. As a result, these factors are considered when evaluating facial attractiveness14,15

Pores: definition and impact

The word ‘pore’ comes from the Greek word ‘poros,’ which means ‘a passage or way’16. The adjective ‘porous’ is commonly used to describe surfaces with small spaces or interstices. In simple terms, pores are openings in the skin or surface of an animal or plant that allow gases or fluids to enter or exit17

‘Skin pores’ refer to the openings of the pilosebaceous follicles that are visible topographic features on the skin surface. They can become more visible and enlarged under specific circumstances.

Patients or customers frequently ask dermatologists, cosmeticians, and aestheticians about the appearance of large or enlarged skin pores and how to reduce them. It can be a complex issue to address, but practical options are available17. Patients who have been affected by these pores have been complaining about a cosmetic issue commonly referred to as the ‘orange peel skin’ effect and are seeking treatment18. While not harmful, they can cause concerns about appearance and may be seen as indicators of ageing skin by many17

Enlarged or dilated pores refer to the visible features on the skin’s surface that correspond to larger openings of pilosebaceous follicles19. Different studies have varying definitions of enlarged pores. According to Kim et al.20 , visible skin pores range from 0.1 to 0.6 mm2, while enlarged skin pores are between 0.3 and 0.6 mm2

What do these changes in the patient’s topography mean? Will it affect their texture, general appearance, and makeup results, or will it have any psychological effects?

Several factors, including proportionate contours, consistent skin tone, and a smooth skin surface, influence the appearance of the face. Scars can make the skin look rough, but enlarged or dilated pores can make the skin surface appear uneven21. Enlarged facial pores are a major aesthetic concern for many women, and they have been identified in the literature as a potential consequence of photo-ageing18

According to new research22 conducted among over 2,000 adults in February 2014 by Harris Poll on behalf of L’Oreal Paris, found that:

■ Nearly half of women (45%) wish they could change the size of their pores

■ Almost one in three women (28%) are more concerned about their pore size than wrinkles. This obsession has even led dermatologists to coin the term ‘porexia’ for those with neurosis about their pores.

On the other hand, a growing number of young adults visit the dermatology clinic to address enlarged pores, which are not necessarily linked to other signs of ageing skin18

Individuals with enlarged skin pores often experience low self-esteem, hindering their ability to interact socially and decreasing their overall quality of life. Additionally, attempts to conceal the pores using cosmetic products can be ineffective due to the uneven texture of the skin and product buildup in the pore openings23

Enlarged pores: causes and risk factors

Enlarged facial pores are a dynamic and multifactorial condition. Several non-modifiable risk factors for its development have been identified. One of the most important aspects to discuss and to communicate with our patients is the dynamic nature of the pores, which is determined by the dynamic nature of the factors involved.

Various internal and external factors can cause enlarged pilosebaceous pores. These factors may include gender, genetic traits, ageing, prolonged exposure to ultraviolet light, comedogenic substances, acne, and seborrhea24. Seborrhea, loss of skin elasticity and tension, and hair follicle size are most clinically relevant to the pathogenesis of enlarged pores. In addition, chronic recurrent acne, sex hormones, and skin care regimen can affect pore size25 During the ovulation phase of the female menstrual cycle, there is a significant increase in sebum output and pore size. This is most likely due to increased progesterone affecting the activity of sebaceous glands24, 25

Facial pore development is mainly associated with increased sebum production and reduced skin elasticity. Studies have found that there is a negative correlation between skin elasticity, tensile strength, and facial pore size and density when measured visually and mechanically20. Other authors confirm that the enlarged pore counts correlate with wrinkle severity and found the correlation varies depending on the location on the body26

The skin surface around noticeable pores underwent structural changes that included both concave and convex structures, with inner skin structures also changing27. I want to highlight the importance of structural changes and their impact on the surface and depth of the skin. These changes are caused by factors involved in the development of dilated pores.

According to some authors, there is a connection between the appearance of a pore and the characteristic feature at the epidermal-dermal junction. In crosssectioned images of large pores, it is often noticed that the epidermal-dermal junction around the pore’s opening is strongly undulated28

There was a significant correlation between the serum level of IGF-1 and the total pore area, as well as with the severity of impairment of epidermal architecture around facial pores and sebum output levels21

It’s worth noting that our skin can look different depending on the season. For instance, pores may appear more prominent during the summer months compared to winter29. It’s also important to remember the effect that lifestyle can have on our skin. Even just one night of sleep deprivation can make our pores look worse and decrease skin hydration, elasticity, brightness, and translucency30

Several internal and external factors can contribute to the enlargement of pores. These factors include prolonged exposure to the sun, hormones, sebum production, being male, age, and genetic predisposition. When the skin’s structural components around the pores, like collagen and elastin, are damaged, the pore

Enlarged pores: principles of therapy

Our patients require a programme that includes clear and established events. These events should trigger multiple synergistic processes, which will be carried out according to a set schedule. Our actions should be systematised and based on an individualised plan. The purpose of a programme is to alleviate decision fatigue by knowing what tasks need to be done, why they are essential, how to do them correctly, and when they need to be completed. The goal of the programme is to save time, money, and energy.

Enlarged facial pores can be caused by various factors, but the three major contributors are increased sebum secretion, reduced skin elasticity around pores, and increased hair follicle volume, particularly with thick hair31

Our next step is identifying the specific factors contributing to each cause and determining actionable steps. To manage sebum secretion, we can modify diet and lifestyle, address hormonal imbalances (including hormonal drugs), use retinoids, and use energy-based devices and laser treatments. We should implement lifestyle measures, utilise laser therapy, and use appropriate skincare to maintain skin elasticity.

My personal point of view regarding treatment is it should be:

■ holistic and integrative

■ personalised and individualised

■ modulated and adapted

■ complete and complex

■ sequential and continuous.

If your patient is concerned about enlarged pores, there are several approaches they can take to address the issue. First, they can consider lifestyle factors such as diet, skincare routine, photoprotection, smoking habits, stress levels, and sleep patterns. Additionally, there are both local and general treatments available, as well as energy-based devices such as laser, IPL, and radiofrequency, which may be effective options to explore.

Although many therapies have been reported, currently, there is no universally approved or effective treatment for enlarged facial pores. Given the different possible causes for enlarged pores, therapeutic modalities should be individualised for each patient. In fact, it is possible that multiple factors orchestrally affect the pore structure of an individual. Therefore, multiple treatment modalities focusing on different modes of action may be applied for better and long-lasting outcomes20,25. Because of its multifactorial nature, treatment of enlarged facial pores has proved to be challenging as they tend to recur after discontinuation of treatment interventions25

For treatment and maintenance, laser technology is recommended. However, in analysing text and dynamic pore layout, it’s important to note that obtaining ‘definitive results’ is not possible due to the dynamic nature of pore sizes and the factors involved, as well as lifestyle and external conditions.

Other treatment options for enlarged facial pores include chemical peeling, topical retinoic acid, oral isotretinoin, antiandrogen therapy, botulinum toxin type-A injections, chemical peeling, lasers, radiofrequency, ultrasound devices, microdermabrasion, photorejuvenation, laser skin resurfacing, and fractional laser treatments, each yielding variable results25, 32–37

There are several benefits to using combined treatments for skin problems. These treatments are fastacting and minimise the risk of adverse reactions. Additionally, they provide therapy on multiple skin levels and address several issues simultaneously, such as enlarged pores, seborrhea, pigmentation spots, tonus, texture, and laxity. Essentially, combined treatments target multiple mechanisms involved in skin problems at the same time.

Enlarged pores: holistic approaches

To improve facial skin characteristics, such as pore size, and reduce the severity of impairment of epidermal architecture around facial pores, it is essential to develop strategies to lower levels of IGF-1. We must take action regarding the patient’s diet and make necessary adjustments to reduce sugar intake, high glycemic index foods, and milk.

Vitamin A derivatives, known as topical retinoids, are effective in treating the changes that occur in the skin due to ageing and sun exposure. Tretinoin, isotretinoin, and tazarotene are examples of these treatments that have been shown to improve skin rejuvenation in various ways, such as reducing facial pores, wrinkles, hyperpigmentation, skin sagging, and excessive oil production38

Chemical peels are utilised in skin rejuvenation and have been found to be effective in reducing enlarged facial pores. These peels temporarily break down and regenerate healthier cells at either the epidermal or dermal level, resulting in an improved skin matrix39

The most commonly used oral therapies to treat enlarged pores include antiandrogens, such as spironolactone, combined oral contraceptives, and cyproterone acetate. These medications modulate sebum production by targeting androgen receptors within the sebaceous glands40

Some authors have studied how seborrhea and excessive sebum production contribute to enlarged pores. A new study has found that injecting botulinum toxin type A (BoNT-A) directly into the skin can effectively reduce enlarged pores and seborrhea for up to four months. This was shown in a controlled, split-face study41 The underlying mode of action on the decrease in sebum level was hypothesised to be the neurologic modulation and vascular regulation of BoNT-A on sebaceous activity42, 43

Enlarged pores: energy-based devices

Let me point out that lasers (and other EBDs) are part of the puzzle but not the only one, and this approach needs support. Laser treatment must act on at least one of the primary mechanisms related to the sebaceous gland (if it does not act on the sebaceous gland — it must be complemented by a treatment on the sebaceous gland and hair follicle).

Ongoing research has been conducted to explore the effectiveness of different types of laser devices and EBD procedures as potential solutions for enlarged facial pores44–53

Several lasers and EBDs work by inducing collagen remodelling, which is an effective way to improve the appearance of enlarged facial pores. Numerous devices have been documented in the literature to target the various pathophysiologic factors that cause the formation of large skin openings based on their unique mechanisms of action20, 24, 25, 54

The 1064 nm Nd:YAG laser has been widely used in cosmetic laser dermatology for the removal of unwanted hair, tattoos, and pigmented and vascular lesions and more recently in dermal remodelling for the treatment of wrinkles55, 56

In recent years, studies on laser treatments for facial pores have been gradually increasing due to good efficacy and few adverse reactions. The long-pulsed 1064-nm Nd:YAG laser (LPNY) has been widely used for facial rejuvenation. LPNY has been demonstrated in many studies to reduce facial wrinkles and improve skin elasticity57, 58. Researchers have utilised it successfully to treat enlarged pores50, 59, 60

The use of 1064 nm Nd:YAG lasers to treat enlarged pores has been studied extensively due to their ability to induce neocollagenesis44. Several trials have focused on optimising parameters, such as pulse duration and energy density, to achieve the best clinical results46, 48, 50, 60

A previous study conducted by Roh et al.,50 found that the use of Q-switched and quasi-long-pulsed 1064 nm Nd:YAG lasers resulted in a significant reduction in pore size and sebum output when compared to the untreated control. The authors suggested that the reduction in pore size could be attributed to the new dermal collagen deposition in the perifollicular area, while the direct effect of the laser was responsible for maintaining the reduced pore size and sebum level over a long period of time.

In contrast, the efficiency of using a carbon-suspended lotion was demonstrated in a separate study using a Q-switched laser with micropulse settings46

As previously discussed, enlarged pores are caused by various factors and can change over time. Laser treatment may not be able to fix all the causes of this condition20,25

A recent study was conducted to compare the effectiveness of two laser treatments for reducing facial wrinkles and enlarged pores. The picosecond 1064 nm Nd:YAG laser using a microlens array (MLA) and the quasi, long-pulsed 1064 nm Nd:YAG were both found to produce significant improvement in skin rejuvenation and pore reduction after five treatment sessions at 2-week intervals51

Using the concept of combining multiple approaches to address the different factors that influence enlarged

Key points

Having enlarged facial pores can be a major concern when it comes to aesthetics

Enlarged pores can be caused by a variety of factors, both internally and externally

The first step is a thorough consultation, with the evaluation of the lifestyle and the skincare process, as well as establishing the indications and contraindications for various types of EBD interventions pore appearance to achieve better outcomes, Cho et al.45 investigated the efficacy of combined laser modalities with the expected sebaceous injury effect of a 1450 nm diode laser, tightening effect of a Q-switched and quasi long-pulsed 1064 nm Nd:YAG, and the smoothening effect of a 10,600 nm carbon dioxide (CO2) laser. Four months after the final treatment, the condition of the patient’s pores were rated to have improved by 51–75%. However, the recovery time spent, the risk of adverse effects, and the cost of treatment must be taken into account with the benefit of using these multiple treatment modalities.

My personal point of view about treatment is Holistic and Integrative, Personalised and Individualised, Modulated and Adapted, Complete and Complex, Sequential and Continuous.

Other EBDs have been proposed as effective treatments, such as intense focused ultrasound (IFUS)49 , fractional radiofrequency devices47, and broadband light52

Theoretically, RF is another EBD that aims to manage several possible causes of enlarged pores47,61,62. The simultaneous thermal effect on s-urrounding tissues and/or the pilosebaceous unit due to tissue impedance to electrical currents aims to stimulate neocollagenesis for pore tightening and reduction of sebum secretion62, 63

A recent study using broadband light suggested its potential as an effective treatment for enlarged pores by improving skin laxity, epilation of facial hair, and decreasing sebum production52

Conclusions

Enlarged pores are difficult to treat, in part due to a lack of knowledge of the pathophysiology37, and many endogenous and exogenous factors are known to cause enlarged pilosebaceous pores24

In light of the changing world, we require a new approach. This entails developing first evaluation, medium-term, and long-term strategies and utilising combined therapies.

It’s essential to consider the experience of the end user, specifically the patient. This includes factors such as pain, the time needed for preparation, the intervention, and post-intervention, as well as downtime in social, professional, familial, and personal areas. This experience is ongoing throughout the year and all day long as patients balance their job with clinic visits. Additionally, we must consider the results of the service, whether they are instant, complex, or an ongoing process. Finally, we need to consider our service’s price and value.

There is no one-size-fits-all solution for skin care. Skin is a dynamic organ that requires a balance between effectiveness, safety, social downtime, and pain perception. Therefore, we need to approach skin care

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Declaration of interest

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