Everything You Wanted To Know About Acne

There are many forms of acne as well as causes. Acne may appear on your face, forehead, chest, shoulders, and upper back. Although acne cannot be cured, it CAN be controlled with treatment.

What are the types of acne?

There are several types of acne, including:

• Fungal acne (pityrosporum folliculitis): Fungal acne occurs when yeast builds up in your hair follicles. These can be itchy and inflamed. Can be caused by humidity, antibiotics, skincare products with oil, inflammation, and being immune-compromised.

• Cystic acne: Cystic acne causes deep, pus-filled pimples and nodules. Cystic acne occurs when bacteria, dead skin cells, and sebum (the substance that makes your face feel oily) get trapped beneath the skin's surface and become infected. This leads to a large, swollen cyst (bump) that can hurt just to touch. Cystic acne can cause scars.

• Hormonal acne: Hormonal acne affects adults who have an overproduction of sebum that clogs their pores. Hormonal acne develops when hormonal changes increase (mainly Androgens) the amount of oil your skin produces. This oil interacts with bacteria on the pores of your skin where hair grows (hair follicles) and results in acne.

• Nodular acne: Nodular acne is a severe form of acne that causes pimples on the surface of your skin, and tender, nodular lumps under your skin. It happens when your skin's pores become blocked, trapping dead skin cells, hair and sebum (an oil your body makes to keep skin moist).

All of these forms of acne can affect your self-esteem, and both cystic and nodular acne can lead to permanent skin damage in the form of scarring. It’s best to seek help from a healthcare provider early so they can determine the best treatment option(s) for you.

 What are the symptoms of acne?

Symptoms of acne on your skin include:

• Pimples (pustules): Pus-filled bumps (papules).

• Papules: Small, discolored bumps, often red to purple or darker than your natural skin tone.

• Blackheads: Plugged pores with a black top.

• Whiteheads: Plugged pores with a white top.

• Nodules: Large lumps under your skin that are painful.

• Cysts: Painful fluid-filled (pus) lumps under your skin.

Acne can be mild and cause a few occasional pimples or it can be moderate and cause inflammatory papules. Severe acne causes nodules and cysts.

What causes acne?

Clogged hair follicles or pores cause acne. Your hair follicles are small tubes that hold a strand of your hair. There are several glands that empty into your hair follicles. When too much material is inside your hair follicle, a clog occurs. Your pores can clog with:

• Sebum: An oily substance that provides a protective barrier for your skin.

• Bacteria: Small amounts of bacteria naturally live on your skin. If you have too much bacteria, it can clog your pores.

• Dead skin cells: Your skin cells shed often to make room for more cells to grow. When your skin releases dead skin cells, they can get stuck in your hair follicles.

When your pores clog, substances plug up your hair follicle, creating a pimple. This triggers inflammation, which you feel as pain and swelling. You can also see inflammation through skin discoloration like redness around a pimple.

What are some triggers of acne?

Certain things in your environment contribute to acne or they can make an acne breakout worse, including:

• Wearing tight-fitting 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 and creams, or working in an area where you routinely come in contact with grease, such as working at a restaurant with frying oil.

• Stress, which increases the hormone cortisol. High cortisol levels prompt the skin's sebaceous glands to produce more sebum (oil).

• A side effect of a medication.

• Picking at your acne. If you push some of the contents inside the pimple deeper into the skin, which often happens, you increase inflammation. This can lead to more-noticeable acne. Some people develop acne scars and pain. When you pop pimples yourself, you also run the risk of getting an infection from the bacteria on your hands.

Foods that cause acne:

Some studies link particular foods, diets and chemicals to acne, like:

• Skim milk.

• Whey protein.

• Diets high in sugar.

• Energy drinks

• Eggs

• Laundry detergent

• Spirulina / Chorella

• Certain ingredients in skincare products

While high-sugar diets may lead to acne outbreaks, chocolate isn’t directly linked to acne.

To reduce your risk of acne, choose to eat a balanced, nutritious diet with plenty of fresh fruits and vegetables, especially those rich in vitamin C and beta-carotene, which helps reduce inflammation.

Hormones and acne

Acne is largely a hormonal condition that’s driven by androgen hormones (testosterone). This typically becomes active during teenage and young adult years. You might also notice acne forming around the time of your period as a result of hormone activity. Sensitivity to this hormone — combined with surface bacteria on your skin and substances released from your body’s glands — can result in acne.

How is acne diagnosed?

A healthcare provider can diagnose acne during a skin exam. During this exam, the provider will closely look at your skin to learn more about your symptoms. In addition, they may also ask about risk factors for acne, like:

• Are you feeling stressed?

• Do you have a family history of acne?

• If a woman or person AFAB, do you notice breakouts during your menstrual cycle?

• What medications do you currently take?

Your healthcare provider won’t need to run any diagnostic tests for acne, but they may offer tests to diagnose any underlying conditions if you have sudden, severe acne outbreaks, especially if you’re an adult.

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.

How is acne treated?

There are several ways to treat acne. Each type of treatment varies based on your age, the type of acne you have and the severity. A healthcare provider might recommend taking oral medications, using topical medications or using medicated therapies to treat your skin. The goal of acne treatment is to stop new pimples from forming and to heal the existing blemishes on your skin.

Topical acne medications

Your healthcare provider may recommend using a topical acne medication to treat your skin. You can rub these medications directly onto your skin as you would a lotion or a moisturizer. These could include products that contain one of the following ingredients:

• Benzoyl peroxide: This is available as an over-the-counter product (such as Clearasil®, Stridex® and 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.

• Salicylic acid: This 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: This 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): Retinol, such as Retin-A®, Tazorac® and Differin®, which is available without a prescription, breaks up blackheads and whiteheads and helps prevent clogged pores, the first signs of acne. Most people are candidates for retinoid therapy. These medications aren’t spot treatments and must be used on the entire area of skin affected by acne to prevent the formation of new pimples. You often need to use these for several months before noticing positive results.

• Antibiotics: Topical antibiotics like clindamycin and erythromycin control surface bacteria that aggravate and cause acne. Antibiotics are more effective when combined with benzoyl peroxide.

• Dapsone: Dapsone (Aczone®) is a topical gel, which also has antibacterial properties. It treats inflamed acne.

Oral acne medications

Oral acne medications are pills that you take by mouth to clear your acne. Types of oral acne medications could include:

• Antibiotics: Antibiotics treat acne caused by bacteria. Common antibiotics for acne include tetracycline, minocycline and doxycycline. These are best for moderate to severe acne.

• Isotretinoin (Amnesteem®, Claravis® and Sotret®): Isotretinoin is an oral retinoid. Isotretinoin shrinks the size of oil glands, which contributes to acne formation.

• Contraceptives: The use of certain contraceptives can sometimes help women and people AFAB who have acne. The U.S. Food and Drug Administration (FDA) approved several types of birth control pills for treating acne. Some brand names include Estrostep®, Beyaz®, Ortho Tri-Cyclen® and Yaz®. These pills contain a combination of estrogen (the primary AFAB sex hormone) and progesterone (a natural form of steroid that helps regulate menstruation).

• Hormone therapy: Hormone therapy is helpful for some people with acne, especially if you experience acne flare-ups during menstruation or irregular periods caused by excess androgen (a hormone). Hormone therapy consists of low-dose estrogen and progesterone (birth control pills) or a medication called spironolactone that blocks the effect of certain hormones at the level of your hair follicles and oil glands.

Additional acne therapies

If topical or oral medications don’t work well for your acne or if you have scars from your acne, a healthcare provider may recommend different types of acne therapies to clear your skin, including:

• Steroids: Steroids can treat severe acne with injections into large nodules to reduce inflammation.

• Lasers: Lasers and light therapy treat acne scars. A laser delivers heat to the scarred collagen under your skin. This relies on your body’s wound-healing response to create new, healthy collagen, which encourages growth of new skin to replace it.

• Chemical peels: This treatment uses special chemicals to remove the top layer of old skin. After removal of the top layer of skin, new skin grows in smoother and can lessen acne scars.

How do antibiotics treat acne?

Antibiotics are medications that target bacteria. Some used to treat acne also can decrease inflammation. Bacteria can clog your pores and cause acne. Antibiotics are responsible for:

• Blocking bacteria from entering your body.

• Destroying bacteria.

• Preventing bacteria from multiplying.

A healthcare provider will recommend antibiotics if you have acne caused by bacteria or if you have an infection. Antibiotics get rid of an infection if bacteria gets into a popped pimple, which can swell and become painful. This medication isn’t a cure for acne and you shouldn’t take it long-term to treat acne.

How can I make my acne go away at home?

If you have acne, you can start an at-home skin care routine to help your acne go away by:

• Washing your skin at least once daily with warm (not hot) water and a gentle cleanser. Cleansers are over-the-counter skin care products that help clean your skin.

• Washing your skin after you exercise or sweat.

• Avoid using skin care products with alcohol, astringents, toners and exfoliants, which can irritate your skin.

• Removing your makeup at the end of the day or before you go to bed.

• Choosing an oil-free moisturizer to apply on your skin after cleansing.

• Avoid popping, picking or squeezing your acne. Let your skin heal naturally to prevent scars from forming on your skin.

If your at-home skin care routine isn’t effective at treating acne, visit a healthcare provider.

Is acne treatment safe for people who are pregnant?

Many topical and oral acne treatments are NOT safe to take during pregnancy. If you’re pregnant or planning on becoming pregnant, it’s important to discuss acne treatments with your healthcare provider and notify them if you become pregnant.

How long does it take for acne to go away?

On average, it can take between one to two weeks for acne pimples to clear up on their own. With medicated treatment and a good skin care routine, you can speed up your body’s healing time to make acne go away faster. For severe acne, it can take several weeks for your acne to go away, even with treatment.

Can acne cause scars?

Yes, sometimes acne can cause scarring. This happens when the acne penetrates the top layer of your skin and damages deeper skin layers. Inflammation makes your acne pores swell and the pore walls start to breakdown, which causes skin damage. Scarring can be a source of anxiety, which is normal. Before treatment, your healthcare provider will determine what type of acne caused your scars. There are several treatment options available for acne scars.

How does acne affect my mental health?

Acne can cause disruptions in your mental health because it affects your appearance and self-esteem. Often, acne development is out of your control if hormones cause it. This can create stress, which can influence future breakouts. Acne can be challenging for teenagers and young adults. If your acne causes you to feel anxious or it prevents you from participating in social activities with your friends and family, talk to a healthcare provider or a mental health professional.

Topical medications

The most common topical prescription medications for acne are:

• Retinoids and retinoid-like drugs. Drugs that contain retinoic acids or tretinoin are often useful for moderate acne. These come as creams, gels and lotions. Examples include tretinoin (Avita, Retin-A, others), adapalene (Differin) and tazarotene (Tazorac, Avage, others). You apply this medication in the evening, beginning with three times a week, then daily as your skin becomes used to it. It prevents plugging of hair follicles. Do not apply tretinoin at the same time as benzoyl peroxide.
  Topical retinoids increase your skin's sun sensitivity. They can also cause dry skin and redness, especially in people with brown or Black skin. Adapalene may be tolerated best.

• Antibiotics. These work by killing excess skin bacteria and reducing redness and inflammation. For the first few months of treatment, you may use both a retinoid and an antibiotic, with the antibiotic applied in the morning and the retinoid in the evening. The antibiotics are often combined with benzoyl peroxide to reduce the likelihood of developing antibiotic resistance. Examples include clindamycin with benzoyl peroxide (Benzaclin, Duac, others) and erythromycin with benzoyl peroxide (Benzamycin). Topical antibiotics alone aren't recommended.

• Azelaic acid and salicylic acid. Azelaic acid is a naturally occurring acid produced by a yeast. It has antibacterial properties. A 20% azelaic acid cream or gel seems to be as effective as many conventional acne treatments when used twice a day. Prescription azelaic acid (Azelex, Finacea) is an option during pregnancy and while breast-feeding. It can also be used to manage discoloration that occurs with some types of acne. Side effects include skin redness and minor skin irritation.
  Salicylic acid may help prevent plugged hair follicles and is available as both wash-off and leave-on products. Studies showing its effectiveness are limited. Side effects include skin discoloration and minor skin irritation.

• Dapsone. Dapsone (Aczone) 5% gel twice daily is recommended for inflammatory acne, especially in women with acne. Side effects include redness and dryness.

Evidence is not strong in support of using zinc, sulfur, nicotinamide, resorcinol, sulfacetamide sodium or aluminum chloride in topical treatments for acne.

Oral medications

• Antibiotics. For moderate to severe acne, you may need oral antibiotics to reduce bacteria. Usually the first choice for treating acne is a tetracycline (minocycline, doxycycline) or a macrolide (erythromycin, azithromycin). A macrolide might be an option for people who can't take tetracyclines, including pregnant women and children under 8 years old.
  Oral antibiotics should be used for the shortest time possible to prevent antibiotic resistance. And they should be combined with other drugs, such as benzoyl peroxide, to reduce the risk of developing antibiotic resistance.
  Severe side effects from the use of antibiotics to treat acne are uncommon. These drugs do increase your skin's sun sensitivity.

• Combined oral contraceptives. Four combined oral contraceptives are approved by the FDA for acne therapy in women who also wish to use them for contraception. They are products that combine progestin and estrogen (Ortho Tri-Cyclen 21, Yaz, others). You may not see the benefit of this treatment for a few months, so using other acne medications with it for the first few weeks may help.
  Common side effects of combined oral contraceptives are weight gain, breast tenderness and nausea. These drugs are also associated with increased risk of cardiovascular problems, breast cancer and cervical cancer.

• Anti-androgen agents. The drug spironolactone (Aldactone) may be considered for women and adolescent girls if oral antibiotics aren't helping. It works by blocking the effect of androgen hormones on the oil-producing glands. Possible side effects include breast tenderness and painful periods.

• Isotretinoin. Isotretinoin (Amnesteem, Claravis, others) is a derivative of vitamin A. It may be prescribed for people whose moderate or severe acne hasn't responded to other treatments.
  Potential side effects of oral isotretinoin include inflammatory bowel disease, depression and severe birth defects. All people receiving isotretinoin must participate in an FDA-approved risk management program. And they'll need to see their doctors regularly to monitor for side effects.

**From Cleveland Clinic: last reviewed on 01/04/2023

Skin care tips when using acne products:

Acne products are just one step in your skin care routine. When using acne products:

• Wash acne-prone skin twice daily. Twice a day, use your hands to wash your face with a mild cleanser (Cetaphil, Vani-cream, others) and warm water. Be gentle. Too much washing and scrubbing can worsen acne. Avoid facial scrubs, astringents and masks. They tend to irritate the skin, which can worsen acne and the side effects of your medicated acne product.

• Use just the right amount. Use a thin layer of the product — just enough to cover the face. Apply it just after cleansing the skin. Some cloths and towelettes come with benzoyl peroxide and other active ingredients in them, so you don't need to apply more product with these active ingredients after cleansing.

• Use nonoily, water-based facial products. Choose nonoily (noncomedogenic) products for your facial moisturizers, acne concealers and cosmetics. They help avoid clogged pores and ease dry, peeling skin.

• Avoid irritants. Oily or greasy skin care products, sunscreen and hair products can worsen acne. Choose products labeled water-based or noncomedogenic, which means they are less likely to clog pores and cause acne. Silicone- or glycerin-based hair products formulated as moisturizing liquids might be a good replacement for heavy, oil-based ones. If you don't want to give up a favorite hair oil, try applying it to just the middle of your scalp and hair ends. This helps avoid acne on your forehead and temples.

• Don't pick or squeeze blemishes. Doing so increases your risk of infection or scarring.

• Watch what touches your face. Keep your hair clean and off your face. Protect your acne-prone skin from contact with phones, helmets, caps, tight collars, straps, backpacks and other items that might transfer sweat or oil to your skin.

• Protect your skin from the sun. The sun worsens dark spots (post-inflammatory hyperpigmentation - PIH) that can linger after acne has cleared. And some acne medications make you more likely to sunburn. Check with your health care provider to see if your medication is one of these. If it is, stay out of the sun as much as possible. Regularly use a nonoily moisturizer that includes sunscreen.

• Shower after strenuous activities. Oil and sweat on your skin can lead to breakouts.

If your acne doesn't improve after 2 to 3 months of trying a skin care routine with your chosen acne products, consider seeing your health care provider or a skin specialist (dermatologist) for a prescription lotion or medication.