Acne is a very common skin condition that causes pimples mostly on the face, forehead, chest, shoulders and upper back. There are a variety of causes including genetics, fluctuating hormone levels, stress, high humidity and using oily or greasy personal care products. Acne commonly affects teenagers but can occur at any age.
Typical teenager with facial acne.
What is acne?
Acne is a common skin condition where the pores of your skin become blocked by hair, sebum (an oily substance), bacteria and dead skin cells. Those blockages produce blackheads, whiteheads, nodules and other types of pimples. If you have acne, know you’re not alone. It’s the most common skin condition that people experience. It’s estimated that 80% of people ages 11 to 30 will have at least a mild form of acne, and most people are affected by it at some point in their lives.
Who does acne affect?
Though it mainly affects teenagers and young adults undergoing hormonal changes, many people continue struggling with acne into their 20s, 30s and beyond. Some even develop acne for the first time as adults.
Where does acne most commonly occur?
The most common spots where you might have acne are your face, forehead, chest, shoulders and upper back. Oil glands are all over your body, but those are the places where there are the most. The best way to treat acne depends on how severe it is. Acne can be mild (a few occasional pimples) moderate (inflammatory papules) or severe (nodules and cysts).
What are the different types of acne?
Acne can take several forms. They include:
- Blackheads: Open bumps on the skin that fill with excess oil and dead skin. They look as if dirt has deposited in the bump, but the dark spots are actually caused by an irregular light reflection off the clogged follicle.
- Whiteheads: Bumps that remain closed by oil and dead skin.
- Papules: Small red or pink bumps that become inflamed.
- Pustules: Pimples containing pus. They look like whiteheads surrounded by red rings. They can cause scarring if picked or scratched.
- Fungal acne (pityrosporum folliculitis): This type occurs when an excess of yeast develops in the hair follicles. They can become itchy and inflamed.
- Nodules: Solid pimples that are deep in your skin. They are large and painful.
- Cysts: Pus-filled pimples. These can cause scars.
All of these forms of acne can affect your self-esteem. It’s best to seek help from your healthcare provider early so they can help determine the best treatment option(s) for you.
SYMPTOMS AND CAUSES
What causes acne?
Acne is largely a hormonal condition that’s driven by androgen hormones, which typically become active during the teenage and young adult years. Sensitivity to these hormones — combined with surface bacteria on the skin and fatty acids within oil glands — can result in acne.
Certain things can cause acne and/or make it worse:
- Fluctuating hormone levels around the time of a woman’s period.
- Picking at acne sores.
- Clothing and headgear, like hats and sports helmets.
- Air pollution and certain weather conditions, especially high humidity.
- Using oily or greasy personal care products (like heavy lotions, creams or hair pomades and waxes) or working in an area where you routinely come in contact with grease (such as working at a restaurant where there are greasy food surfaces and frying oil).
- Stress, which increases the hormone cortisol, can also cause acne to flare.
- Some medications.
Does chocolate cause acne?
Some studies have linked particular foods and diets to acne. Skim milk, whey protein and diets high in sugar may contribute to acne flares. Chocolate has not been directly linked to acne.
Why do so many teenagers get acne?
One of the causes of acne is a surge in hormones called androgens (specifically testosterone), which both women and men produce. Those hormones tend to be at their peak during the teen years.
Do certain foods cause acne?
For the most part, hormonal changes in the body drive acne. There is some evidence that skim milk, whey protein and diets high in sugar may cause acne breakouts, although this remains controversial.
Eating a balanced, nutritious diet with plenty of fresh fruits and vegetables, especially those rich with vitamin C and beta carotene, helps reduce inflammation. There is also some evidence that eating fish can help.
Can acne cause scars?
Acne does sometimes result in scarring. It happens when the acne penetrates the skin and damages the deeper layers. Inflammation makes the acne pores swell and breakdown occurs in the wall of the pore. Scarring can, of course, be a source of anxiety, which is normal. But before it can be treated, your healthcare provider will determine what type of acne caused the scars.
There are several available treatment options. Chemical peels, dermabrasion, laser resurfacing, microneedling and surgery can all be used to treat acne scars.
DIAGNOSIS AND TESTS
How is acne diagnosed?
Your healthcare provider can diagnose acne during a skin exam. They may also ask if you’re undergoing significant stress or if you have a family history of acne, all of which are risk factors. Teenage girls and women may also be asked about their menstrual cycles, as breakouts are sometimes related. Sudden, severe acne outbreaks in older people can sometimes signal another underlying disease that requires medical attention.
How severe can acne get?
Dermatologists rank acne by severity:
- Grade 1 (mild): mostly whiteheads and blackheads, with a few papules and pustules.
- Grade 2 (moderate, or pustular acne): multiple papules and pustules, mostly on your face.
- Grade 3 (moderately severe, or nodulocystic acne): numerous papules and pustules, along with occasionally inflamed nodules. Your back and chest may also be affected.
- Grade 4 (severe nodulocystic acne): numerous large, painful and inflamed pustules and nodules.
MANAGEMENT AND TREATMENT
How is acne treated?
Your healthcare provider may suggest some non-prescription medications for your condition. Depending on the condition’s severity, your age, the type of acne you have and how effective the over-the-counter remedies have been, you may need stronger prescription medications.
The use of certain contraceptives can sometimes help a woman’s acne go away. The Food and Drug Administration has approved three types of birth control pills for treating acne. All four contain a combination of estrogen (the primary female sex hormone) and progesterone (a natural form of steroid that helps regulate menstruation).
Various medications and therapies have proven to be effective. They target the underlying factors that contribute to acne. You might require at least one or multiple, depending on the severity of your condition.
Medications applied topically:
- Benzoyl peroxide is available as an over-the-counter product (such as Clearasil®, Stridex®, PanOxyl®) as a leave-on gel or wash. It targets surface bacteria, which often aggravates acne. Lower concentrations and wash formulations are less irritating to your skin. Irritation (dryness) is a common side effect.
- Salicylic acid is available over-the-counter for acne, as a cleanser or lotion. It helps remove the top layer of damaged skin. Salicylic acid dissolves dead skin cells to prevent your hair follicles from clogging.
- Azelaic acid is a natural acid found in various grains such as barley, wheat and rye. It kills microorganisms on the skin and reduces swelling.
- Retinoids (vitamin A derivatives) such as Retin-A®, Tazorac®, and Differin® (which is now available without a prescription) break up blackheads and whiteheads and help to prevent clogged pores, the first signs of acne. Most patients are candidates for retinoid therapy. These medications are not spot treatments and must be used on the entire area of skin affected by acne to prevent the formation of new pimples. The most common side effect is irritation, which usually improves with moisturization and time on the medication.
- Antibiotics (topical types include clindamycin and erythromycin) control surface bacteria that aggravate and often encourage the swelling of acne. Antibiotics are more effective when combined with benzoyl peroxide.
- Dapzone (Aczone®) is a topical gel, which also has antibacterial properties, can be used for inflamed acne. It’s applied to the skin twice a day.
Medications taken orally (by mouth):
- Antibiotics, especially tetracycline antibiotics such as minocycline and doxycycline, are commonly used to treat moderate to severe acne.
- Oral contraceptives can help with breakouts associated with menstrual cycles. Three classes of medications have been approved by the FDA for acne patients. Some brand names include Estrostep®, Beyaz®, Ortho Tri-Cyclen® and Yaz ®.
- Isotretinoin (Amnesteem®, Claravis®, Sotret®), an oral retinoid, is an especially effective drug used only for the most severe cases of acne. Isotretinoin shrinks the size of oil glands, which contributes to acne formation. The most common side effect is dryness, but can also cause birth defects. Some evidence suggests a possible increased risk of ulcerative colitis and depression. Because of these risks, anyone using the drug must take part in a Food and Drug Administration-approved risk management program known as iPledge.
Depending on your condition, your healthcare provider might suggest one of these specialized therapies, possibly combined with medication.
- Steroids. Rarely, steroids can be used to treat severe acne or injected into large nodules to reduce inflammation.
- Lasers. Currently, lasers are primarily used to treat acne scars. A laser delivers heat to the scarred collagen under the skin, this relies on the body’s wound healing response to create new, healthy collagen. This encourages the growth of new skin to replace it. There are different types of laser resurfacing—ablative and non-ablative. Your dermatologist will determine which type is best for your skin type and nature of acne scars.
- Chemical Peels. This treatment uses special chemicals to remove the top layer of old skin. Typically whenever the top layer is removed, the new skin that grows in is smoother and can lessen acne scars.
Do I need to see a specialist?
Your acne can be managed by your general healthcare provider. However, when acne does not improve or is severe you should see a board certified dermatologist.
What should I do while waiting to see a dermatologist?
Continue washing your face at least daily with lukewarm water and a mild facial cleanser that you can buy over the counter. Products containing benzoyl peroxide and salicylic acid are effective. You can also now purchase the topical retinoid, Differin®, over the counter and use as directed.
Can acne be prevented?
Preventing acne is difficult if not impossible during normal hormonal changes. But some things can help:
- Wash your face daily with warm water and a mild facial cleanser.
- Routinely use moisturizer.
- You don’t have to stop using makeup, but try to use “non-comedogenic” products and remove makeup at the end of each day.
- Keep your hands away from your face.
OUTLOOK / PROGNOSIS
What can I expect if I’ve been diagnosed with acne?
Acne often goes away in early adulthood, though some people will continue to experience acne throughout adulthood. Your healthcare provider or board certified dermatologist can help manage this difficult condition.
Are there any special concerns for women of childbearing age with acne?
Many topical and oral acne treatments are contraindicated during pregnancy. If you’re a woman in your childbearing years, it’s important to discuss acne treatments with your healthcare provider and alert them if you become pregnant. Isotretinoin is known to cause severe birth defects and therefore, two methods of birth control are required while on this medication.
Hormone therapy is helpful for some women with acne, especially for those that flare-up with menstruation or those with signs and symptoms (irregular periods) of excess androgen (male hormone). Hormone therapy consists of low-dose estrogen and progesterone (birth control pills) or a medication called spironolactone that blocks the effect of male hormones at the level of the hair follicles and oil glands.
When should I see my healthcare provider about my acne?
See your healthcare provider as soon as you notice the pimples so that you can start treatment immediately, before scarring occurs.
What questions should I ask my healthcare provider about acne?
- What type of acne do I have?
- How severe is my acne?
- Do I need to see a dermatologist?
- Do I need a referral?
- What over-the-counter medications do you recommend?
- What prescription medications do you recommend?
Acne is the most common of all skin conditions and can have a profound psychosocial impact.
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