The Truth About Acne In Vietnam

If you break down the occurrence of acne by race, from least to most, South Asians have the least acne, with 23% being affected. White people come in second with a 24% occurence. North, central, and eastern Asians have a 30% rate of acne, while Hispanics clock in at 32%. Black/ African Americans come in at 37%. The highest rate is in Southeast Asia, with a whopping 50% of the population being afflicted, and of all Southeast Asians, the Vietnamese have the worst skin in the world.

The truth is, they don't have acne. They have MADISH - Metabolizing Aquired Dioxin Induced Skin Hamartomas. It looks just like acne, but it is very different. It used to be called chloracne, but that term is now considered a misnomer, as chlorine has nothing to do with MADISH. During the Vietnam War (1961-1971), the US dropped 19 million gallons of chemical substances on South Vietnam to defoliate the jungles. That included Agent Orange, which contained 400kg, or 882 lbs of Dioxin. Dioxin poisoning now affects 5 million Vietnamese, but tens of thousands have died, and today's victims still have the diseases and birth defects. The dioxin didn't stay where it was dropped. Monsoons and typhoons, with flooding and wind, have spread ground zero poisoning throughout the south and into areas in the north. The true time span of dioxin is known to last at least 100 years. Beyond that, they just don't know.

The Science

Dioxin enters the body in several ways. Exposure to ground that has been poisoned or food grown there, water, where it clings to the bottom of ponds, rivers, and streams, through inhalation of dirt particles, and during conception and gestation. Fathers have the toxin in their sperm cells, and mothers have it in their eggs. If the parents or grandparents have been exposed, it is harbored in these gametes. During gestation, the mother passes even more toxins to the embryo/fetus. Cows and other plant-eating animals pass the toxins on to consumers, as the plants pick up toxins from the soil. Water is very toxic. Imagine, if you will, a Vietnamese grandfather who can no longer work the farm, decides to go fishing. In the pond or lake, there are tiny snails that eat algae. Algae pick up dioxin from the sediment at the pond bottom. At the end of the day, the snail has picked up 5 units of dioxin (an arbitrary amount). Each snail is then eaten by a guppy-sized fish. The small fish eats 10 snails and now has 50 units. Ten small fish are eaten by medium-sized fish, which have accumulated 500 units. The grandfather catches a big catfish, which has eaten 5 medium-sized fish, giving him 2,500 units of dioxin. He joyously brings the fish home to feed his family, not knowing he is poisoning them. MADISH is the expression of all of this pollution in the skin.

The contaminant enters the pores, wreaking mayhem. There is a protein in your cells that acts as a sensor for toxins. It's called AhR, and dioxin binds to it. The pollutant enters your cells, and it can alter your genes. You inherit AhR from your parents, and there are many variations of this gene. Some people are highly responsive to genetic alterations, while others are less so. Highly responsive people trigger massive inflammatory reactions, even with low exposure to dioxin. While the exposure is environmental, your DNA determines the threshold at which your skin reacts.

Why Antibiotics And Medicine Don't Help

There are only 169 dermatologists in Vietnam, located in Hanoi and Ho Chi Minh City, meaning there is one dermatologist for every 90,000 people. Approximately 72% of the people live in rural areas where access is limited. Even in the cities, private dermatologists have to be paid up front for services that are prohibitively expensive. Public doctors still have to be paid 40% of fees up front, and they have no access to advanced skin care technology. They can only perform manual extraction of the cysts and removal of the cyst walls.

Salicylic acid, retinol, and other surface treatments don't work because the pores are reprogrammed to produce cysts. Antibiotics do not work because cysts formed by MADISH form a biofilm that acts as a physical shield, preventing antibiotic access to the bacteria. Repeated use of antibiotics in MADISH causes "superbugs" to form that are antibiotic- resistant.

The Vietnamese Solution

The answer the Vietnamese have come up with is extraction spas. Although they offer full-service skin care, extraction is the most popular service.

Everything you see on the face of a client, from the tiniest pinpoint blackhead to the Mount Everest of "whiteheads", is a cyst. They all have sacs. The pore is programmed to produce large numbers of skin cells and sebum-free sacs. The lack of sebum makes the skin dry. These clients have no mechanism to soften or protect the skin. Any moisture on the skin is from a pre-session steaming and facial. These spas are all over social media, showing exactly what they do, and they have 10's of thousands of viewers. You can see the sacs of blackheads all the time. Cystic acne does not have sacs. It is called cystic acne because it is cyst-like. The average Vietnamese person earns $200-$399 USD, and the spas cost $28 for a one- hour session. Most clients book two sessions per month. So it is 29% of the lowest monthly income. Each individual can require from a few to as many as 14 sessions. There are illegal mobile extraction sites, located in alleys or on street corners, completely unregulated, unlike the heavily monitored licensed spas.

The Youngest Ages 12-45

Hamartomas(large whiteheads) can begin anytime after birth; they do not need puberty to have a response to dioxin poisoning. The youngest clients at spas seem to be around 12 years old. It is extremely painful. The cysts formed are deep, and the pressure they exert causes capillaries to burst, filling the cyst with blood. The pus in infections is either straw yellow or green, unlike cystic acne, in which the pus is light yellow or white. When the extractor squeezes a scabbed, nearly healed hamartoma, you will see that underneath is a new hamartoma ready to burst through the skin.

These are the hardest videos to watch, not because of the blood, but because of the skin trauma. You can easily see where scars will form and continue to scar. Dioxin-induced cysts stay active for a lifetime. This is not a temporary breakout but a permanent anatomical change. If you watch videos without background music, you will hear grunts, groans, and the sucking of air through teeth. It is heartwrenching.

There exists an "acne" stigma in Vietnam that causes depression, feelings of shame, and embarrassment, leading to societal withdrawal. Many Vietnamese perceive the skin eruptions to show poor hygiene, poor eating habits, and that it is contagious. People are excluded from the job market because of their disfigurement. It can even affect a student's recognition in academia, with affected students getting lower grades and fewer academic awards. In fact, they are treated similarly to lepers during Biblical times. As this is a third-world communist country, most people are unaware of the nature of MADISH.

As Above, So Below

The individuals in this age group also experience hamartomas in their armpits and the entire anogenital area. This includes the tops of the inner thighs, the penis, scrotum, perineum (area between scrotum and anus), the anus, and the lower buttocks. As you can imagine, this is excruciatingly painful, often leading to unemployment, the destruction of sexual relationships, and severe depression. There are specialized men-only spas to handle these lesions. They do not advertise and have no signage at the locations. The spas are found using private Facebook communities or Zalo (Vietnam's most popular instant messaging app). These groups have titles like "Men's Health" or "Skin Treatment Secrets." They share photos and specific spa locations. Every discussion is in code. The spas provide male extractors and when a man enters the spa, they are shown to a soundproofed private room. That tells you just how painful the extraction process is. When skin touches skin, there is a much stronger possibility of bacterial infection. Clothes rubbing against skin cause extreme irritation and can make hamartomas explode. These clients are red, raw, and rife with bacteria.

Ages 45-70

After the hamartomas are done ravaging the face, a client is left so badly scarred that some look like burn victims. They will have icepick scars, which are small and deep, boxcar scars, which are rectangular and large, or atrophic scars, which are commonly called "craters." These are irregular, circle-shaped scars. Clients can also have rolling scars. These cause an irregular, undulating, or "wavy" texture across a patch of skin. They occur when fibrous bands of tissue anchor the skin's surface to the deeper subcutaneous tissue, pulling it downward unevenly. To add insult to injury, they are heavily peppered with blackheads that can exist at the bottom of a scar or around it. These are very hard to remove. Some people will continue to have full hamartomas for life. The ones who scar are the lucky ones.

Ages 70-100

Why would men this old bother to have blackheads excised? It may well be that their familial responsibilities are over, and they now have a few dollars to spend fixing a problem that has haunted their entire lives. Maybe they remember a time when they were free of this affliction, and don't want to die with something they weren't born with.

Blackheads in the elderly tend to accumulate around the eyes, down the sides of the face, on the nose, and on the tops of the cheeks. They can be quite large and very old. Some of them have been there since childhood. They may be thick enough to actually change the superficial skin color to a ghastly, ghoul-like gray because the black part reaches below the skin line. When they are extracted, you can see the skin return to its actual skin tone.

Some elderly men are literally covered in epidermoid, steatocystomas, and chalazia. One 93-year-old man had cysts so heavy that they pulled his lower eyelid down so low that he continually had eye infections. One thing the spas do not do correctly is cyst removal. They rarely empty the cyst of material, and they almost never remove the sacs in which the cysts are contained. If you don't remove the sac, the cyst will come back in the exact same spot. Even if they did attempt removal, this is best done by a doctor who can remove the sac in its entirety. At the spas, they can only puncture the growth, making it hard to get the sac. Doctors can make an incision that allows a complete removal.

Client Breakdown

If you were to watch a randomly selected group of 100 videos, you would find that about 55% of the clients are young males under 45. About 15% would be men in late middle age and early old age clients. Another 15% would be elderly, and 15% would be female. Of the women clients, about half are elderly women getting their millia removed. They have them all over the face, not just around the eyes. The other half would be young women under 45. This might be because women don't have complete coverage of cysts and blackheads as men do, or they might just not like being on camera.

What Is Being Done To Help Victims?

There are places called Peace villages where the extremely disfigured can live without stares and comments. They do get medical care, although it is minimal. The occurrence of MADISH is actually going higher, with 50% of university students and 79% of adolescents reporting this affliction. It is difficult to get residency in Peace villages. Clients need medical proof of MADISH, which can be difficult because only 2 labs worldwide do dioxin level tests, and they cost about $1,500.

USAID has been discontinued by the current US government, so there is no help there. Facing the World is a UK-based charity that sends specialized surgical teams to Vietnam to treat facial disfigurements. They focus on complex cases that local doctors cannot treat. Medical Missions Foundation provides dermatological care for various conditions, including MADISH. VAV (Vietnam Association for Victims of Agent Orange/Dioxin) operates the Peace Villages. The Vietnam Red Cross finances mobile clinics, and they offer palliative care for the heavily disfigured who can't get to urban centers.

None of these reflects a United States involvement. We need to step up and help. We could offer to forgive a year of medical school loans in exchange for one year of service in a rural village to excise cysts and treat scarring. We could reinstitute USAID as well. Why focus on MADISH when people are suffering from birth defects, cancer, and a host of disorders? MADISH sufferers suffer from cirrhosis of the liver alongside MADISH, and have cancer complications as well. But this is something we can fix. It seems so unfair that innocent people are affected by something we did as a nation. Know that the US government was fully aware of all of the repercussions of using dioxin as a defoliant, and they knew it for 7 decades. They used it regardless. Doctors trained to use electrocautery and laser therapy to treat scarring should be available at no cost. Forgive a loan, give doctors decent housing, and middle-class salaries in Vietnam, and some will take that offer. Train any doctor in the dermatological skills they need, and train the Vietnamese doctors as well. Educate the various communities in the specific aspects MADISH includes, and track liver function every 4 months. That is what we can do, but we don't, and it is our responsibility. We did this, and we could fix this. Keep an eye out for bills in Congress that apply to Vietnamese health care and urge your congresspeople and senators to vote for them. It is money better spent than money for wars. (If you would like to see a sampling of Vietnamese MADISH or compare it to other countries, this site covers Vietnamese and clients from around the world in small snippets that are enough to give you the gist of excising both acne and MADISH.)