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 impaction's.
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.
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