Textural issues - What is going on with my skin and how can I fix it? (Photos)

Question

I attached a few photos in different lighting for reference. I have some textural issues and I can't figure out where to start. I'm currently cleansing twice a day, using topical Vitamin C and tretinoin 0.05% every other day. I've been doing this for the past year with no results. Could this possibly be fungal acne? I'm just looking to guided in the right direction.

Carl Truesdale, MD · Answer

Thank you for your photos. Based on your photo, the horizontal lines across the forehead are consistent with dynamic rhytids, meaning they are caused primarily by repeated movement of the frontalis muscle over time (forehead muscle). Each time the brow is raised, the muscle contracts and the skin folds, and over the years this repeated motion causes the lines to become more etched even at rest. Botox works by temporarily relaxing the frontalis muscle, which reduces this repetitive movement so the skin is no longer being constantly creased, allowing the lines to soften and in some cases improve significantly over time. Because Botox is not permanent, it typically lasts about 3–4 months, and maintenance treatments are needed to sustain the effect.
For the skin texture component, both chemical peels and laser resurfacing can be helpful, but they work in different ways. A chemical peel uses a controlled chemical solution to exfoliate the outer layers of skin, improving fine lines, pigmentation, and overall surface texture with a more superficial to moderate depth effect depending on the strength of the peel. Laser resurfacing, such as CO2 or an Ultraclear laser, uses targeted light energy to create controlled micro-injuries in the skin, which stimulates deeper collagen remodeling and tends to produce more significant tightening and texture and pigmentation improvement. In general, chemical peels are better for mild to moderate surface irregularities and pigmentation, while laser resurfacing provides more powerful skin tightening and wrinkle reduction. Both options can complement Botox well by addressing both the muscle-driven and skin-quality components of aging.

Anna Chacon, MD, FAAD · Answer

This is where I’d push back a bit—if tretinoin hasn’t helped after a year, something else is going on.

Possibilities:

Not fungal acne (overdiagnosed online)
More likely:
clogged pores (comedonal acne)
barrier irritation
sebaceous filaments

Next steps:

Simplify routine
Consider:
salicylic acid
professional extractions
light chemical peels

Stefan Weiss, MD · Answer

Persistent texture despite topicals may benefit from in-office treatment. A CO2 laser can resurface the skin, improve tone and texture, and address stubborn irregularities effectively.

Viva Eve Dermatology - New York · Answer

Hi there!
This is a great question. Vitamin C and tretinoin are great ingredients to use in your skincare routine; Vitamin C helps with overall tone, while the tretinoin increases cellular turnover to decrease oiliness and some texture. From these photos, it seems as though your skin is an oilier skin type, but I would not call this fungal acne just from the photos alone. That being said, you may benefit from some additions into your skincare routine with other ingredients that aid in cellular turnover, as well as some skin treatments such as a series of chemical peels or a few treatments of a resurfacing laser. 
As always, an in-depth, in-person consultation is required to properly and safely assess your anatomy and select the correct treatment for you. 
Sincerely,Eleni SgantzosCosmetic Dermatology PA-C

Textural issues - What is going on with my skin and how can I fix it? (Photos)

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