Acne

Definition

Acne is a disease of the oil-producing glands and hair follicles of the skin. The most common areas in which acne occurs are the face, neck, chest, back, shoulders and upper arms. Acne can appear as small, pinpoint whiteheads and blackheads, termed closed and open comedones, respectively. Acne can also appear as red inflamed bumps and large, tender cysts under the skin. Scarring can also occur, especially with the most severe forms of acne. Acne also causes significant emotional distress and has been associated with depression and anxiety.

There are effective treatments available, and new, more effective products are constantly being introduced. Many people see a physician only when the disease becomes severe, but it is better to begin treatment as soon as the condition begins, to prevent scarring, worsening of the disease, and emotional distress. Effective treatment can help individuals with acne achieve clear, healthy skin with an excellent cosmetic result and improved overall well-being.

The American Academy of Dermatology has a system for classification of acne. It describes three levels of disease: mild, moderate and severe. Mild acne is defined by few to several papules and pustules (pimples), but no nodules. Moderate acne has several to many papules and pustules with few to several nodules. Severe acne is defined as the presence of numerous or extensive papules and pustules as well as many nodules and scarring.

Cleansing the skin with gentle products to remove excess oil and dead skin cells is effective and usually non-irritating. However, under the care of a licensed professional, a specific regimen with naturally-occurring alpha-hydroxy or beta-hydroxy acids can drastically improve acne by unclogging pores and gently exfoliating the skin. Some of the most popular naturally-occurring acids are glycolic acid found in sugar cane, and salicylic acid found in willow bark.

Causes

Four factors work together to cause acne. They are:

Overproduction of oil (sebum)
Abnormal shedding of dead skin cells which irritate and plug hair follicles
Bacteria (Propionibacterium acnes) and debris buildup
Inflammation caused by the body's immune response

Inflammation increases when the hair follicles open up, pouring out fats and bacteria into the surrounding skin. A plugged hair follicle may bulge above the surface of the skin to produce a whitehead. If the plug is open to the air the contents may darken, producing blackheads. A raised red spot with a white center is called a pimple. Blockage of the follicle and inflammation deep below the surface of the skin can cause lumps in the skin, called cysts. Factors that can make acne worse include:

Hormones, called androgens, increase in puberty in both males and females, causing the sebaceous glands to increase in size and make more sebum. Oral contraceptives and pregnancy can cause hormonal changes that trigger the production of more sebum.
Several medications are known to cause or worsen acne, corticosteroids, androgens and lithium (used to treat bipolar disorder).
Some foods can trigger acne including dairy products and high-carbohydrate foods, such as bread, bagels, and chips, which increase blood sugar.

It is a myth that greasy foods, chocolate, and dirty skin cause acne. In fact, scrubbing the skin too vigorously and using harsh chemicals and soaps can irritate skin and make acne worse. Cleansing the skin with gentle products to remove excess oil and dead skin cells is effective and usually non-irritating.

There are a number of risk factors which can trigger and aggravate acne, hormonal changes being the greatest, especially in:

Teenagers of both genders
Pregnancy
Two to seven days before menstruation
Certain medications, especially corticosteroids, androgens and lithium

Other risk factors include:

Recurrent direct contact with greasy or oily substances such as cosmetics
A family history of acne
Friction or recurrent pressure on the skin, such as cell phones and collars
Stress doesn't cause acne but can aggravate it

Signs And Symptoms

Acne appears on the parts of the body with the highest concentration of sebum-producing glands like the face, neck, chest, shoulders and upper arms. It can take several forms:

Noninflammatory lesions
Comedones - Whiteheads and blackheads occur when the openings of hair follicles become plugged with sebum and dead skin cells
Inflammatory lesions

Papules are small raised bumps from inflammation in the hair follicles; they may be flesh colored or red and tender.
Pustules are red spots with white pus at the center
Nodules are large, solid, painful, tender lumps beneath the surface of the skin, without opening to air; they are formed of the buildup of sebum and dead skin cells deep within hair follicles
Cysts are painful, tender lumps of pus beneath the skin's surface; these have the most potential for scarring

Prevention

Even after the skin responds to treatment and may clear entirely, medication is usually continued to prevent new breakouts. In some cases, a topical medication is used on vulnerable skin regions. Oral contraceptives or other treatments may be recommended by your doctor. Other acne-prevention tips include:

Wash acne-prone areas no more than twice a day to remove excess sebum and dead skin cells. Use a gentle cleanser and oil-free, water-based skin care products.
Use an over-the-counter acne cream or gel to help dry excess oil, with products containing benzoyl peroxide or salicylic acid.
Avoid heavy or greasy cosmetics; powders, rather than creams, are less irritating.
Remove makeup before bed, to avoid clogging tiny openings of hair follicles. Discard old makeup and clean cosmetic brushes and applicators regularly.
Wear loose-fitting clothing to avoid trapping heat and moisture in areas of friction against the skin.
Shower after exercising and strenuous work, when oil and sweat may trap dirt and bacteria on the skin.
Wash with a gentle cleanser in the morning, and then double-cleanse in the evening. A double cleanse consists of a non-active gentle cleanser first to remove makeup, excess oil, and dirt build-up from the day. This is then followed by an active cleanser containing active ingredients such as salicylic acid to allow for a deeper clean.
Follow with a treatment cream or gel, such as benzoyl peroxide to oxygenate the skin and treat and prevent further breakouts.
Use a humectant, such as hyaluronic acid or glycerin to draw moisture back into the skin to prevent aging as well as prevent irritation from the acne treatments.
Follow with an oil-free moisturizer (occlusive), to lock in that moisture and prevent trans-epidermal water loss.
Look for non-comedogenic makeup to prevent further clogging of pores.
Don’t squeeze or pick at acne, it will only cause the further spread of bacteria. Instead, use a cold roller to reduce inflammation and make an appointment with a local skincare professional.
Always use sunscreen when treating skin conditions like acne as ingredients in treatments may cause sun-sensitivity.

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Treatment

Acne treatments work by a variety of actions including: reducing oil protection, speeding up skin cell turnover, reducing bacterial infection and inflammation, or a combination of actions. It may take four to eight weeks before you begin to see improvement regardless of the mechanism of action. The acne may get worse during the wait for treatment to take effect. Prescription medications may be recommended. Some are topical (applied to the skin surface) or taken by mouth. At times they are used together. Oral medications should not be used during pregnancy. Types of treatment include:

Over-the-counter topical treatments: These dry up excess oil, kill bacteria and remove dead skin cells. Over-the-counter products are usually mild and contain benzoyl peroxide, salicylic acid, or sulfur. Mild side-effects include skin irritation, dryness and flaking. Side effects may be short-term.
Prescription topical treatments: Tretinoin, adapalene and tazarotene are examples of products derived from vitamin A. They cause skin cells to speed up production while shedding the old. There are also topical antibiotics which work by killing excess skin bacteria. A combination of medications may be necessary.
Antibiotics: For moderate to severe acne, a short-term oral antibiotic may be prescribed, to reduce the number of bacteria in and on the skin. Many oral antibiotics are no longer effective against acne because the bacteria has become resistant. Oral antibiotics also cause side effects which can be very unpleasant, possibly even dangerous, including nausea, dizziness, and skin discoloration. They can cause sun-intolerance and may interfere with the effectiveness of oral contraceptives.
Isotretinoin: This powerful medication is usually reserved for severe cystic acne with its potential for scarring. It causes birth defects if taken during pregnancy. Women of child-bearing age must agree to enter a monitoring agreement that they will not try to become pregnant while using it and will have routine pregnancy tests to continue the medication. It has very uncomfortable side effects such as dry lips and mouth, nose and skin. It can increase cholesterol levels and effect liver function. Isotretinoin is extremely effective for the right candidate but must be monitored by a board-certified dermatologist.
Oral contraceptives: These include combinations of estrogen and progesterone which may improve acne in women. They cause other side effects, however, such as headaches, nausea, depression and breast tenderness. The most severe complications are an increased risk of heart disease, high blood pressure, and blood clots, usually in the legs.
Laser and light therapy: This method reaches the deeper layers of the skin without harming the surface. It may work by suppressing oil production. It also targets the particular bacteria that cause acne and may reduce inflammation. It may improve the texture of the skin and reduce the chance of scarring. It may be uncomfortable however and mimic severe sunburn.
Cosmetic procedures: Chemical peels and microdermabrasion can lessen the appearance of discoloration and scarring, reduce fine lines and sun damage. Short-term, there can be severe redness, scaling, blistering and long-term discoloration of the skin. Seeing a licensed skincare professional regularly for facials and chemical peels can drastically reduce acne as well as prevent scarring. They can also recommend a personalized home-care regimen to ensure you are carrying on those results at home. More advanced treatments such as microdermabrasion, and even micro needling can be performed as well to unclog pores and prevent acne scarring in more severe cases. Short-term effects are redness, flaking or peeling, and temporary hyperpigmentation which will fade within a few days to a week.

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Lifestyle And Home Remedies

Wash problem areas with a gentle cleanser. Masks, astringents and facial scrubs are not recommended because they irritate the skin and make acne worse.
Try over-the-counter lotions to remove excess oil and promote peeling. Look for lotions which have benzyl peroxide or salicylic acid as the active agent.
Avoid irritants such as oily or greasy cosmetics, sunscreens, hair products and some acne concealers. Some people must avoid sunlight. Some products increase sun-sensitivity. Use sunscreen that doesn't clog your pores.
Keep hair clean and off your face. Try to avoid letting hands or objects touch or rest on your face. Avoid tight clothing. Promptly remove dirt, sweat and oil.

Alternative Medicine

Some studies suggest that the following supplements may help treat acne:

Tea tree oil: Gels containing five percent tea tree oil may be as effective as lotions containing five percent benzoyl peroxide, although it may take longer to work. It can cause a skin reaction known as contact dermatitis. There's also some concern that topical products can cause breast development in young boys.
Alpha hydroxy acids: These are found in foods such as citrus fruits, sugar cane, apples and grapes. They help remove dead skin cells and unclog pores when applied topically. They may improve the appearance of acne scars. Adverse reactions to the acids include redness and irritation.
Beta Hydroxy Acids: Found in willow bark and in aloe.
Vitamin B5 supplements: Pantothenic acid supplements have also been shown to reduce acne lesions safely and effectively.
Zinc supplements: These play a role in wound healing and reduce inflammation. Taking it with food may reduce side effects, including a bad taste in your mouth and nausea.
Nicotinamide: A natural B vitamin, nicotinamide supplements can be useful in the treatment of inflammatory acne.

Acne Scar Treatment

Scarring, especially with severe cystic acne, can destroy self confidence and quality of life. There are some procedures which can decrease the visibility of scars:

Soft tissue fillers. Collagen or fat from the patient's body can be injected into areas in which scarring has caused uneven texture. It fills out or stretches the skin, making scars less visible. The results are temporary and usually periodic and repeat treatments are necessary to maintain the scar-diminishing effect.
Chemical peels. A strong acid is applied to the skin to remove the surface layer and minimize deeper scars.
Dermabrasion. This method removes the top layer of skin with a rapidly rotating wire brush. It's usually reserved for the most severe scarring. Surface scars may be entirely removed and deeper scars may be less noticeable. It can cause pigment changes, especially on darker skin.
Microdermabrasion. This is a newer treatment in which tiny crystals are blown into the skin to polish the surface. A vacuum tube then removes the crystals from the skin. No new damage is created and skin irritation is minimal. It's less effective than dermabrasion and scars may still be visible, even after several treatments.
Laser, light sources and radiofrequency procedures. Laser therapy removes the surface layer of skin (epidermis) and heats the deeper skin (dermis). New skin heals the wounds. Less intense lasers (nonablative), pulsed light and radiofrequency devises don't damage the epidermis, but heat the dermis, causing new skin formation. They have a shorter recovery time but results are subtle, even after numerous treatments.
Skin surgery. Plugs of scar tissue (punch excision) are removed from individual scars. Sutures (stitches) or a skin graft are used to close the defects left at punch sites.
Micro needling or collagen induction therapy. Micro needling or collagen induction therapy is a new treatment in which the skin is repeatedly punctured with sterilized micro needles. It has shown drastic improvement in the appearance of acne scarring by increasing collagen production within the skin. Side effects include redness, sunburn sensation, and possible peeling for up to one to two weeks. Results are best shown with a series of treatments over the course of six months.

Your Questions Answered About Acne

Can acne be cured? Ensuring a good home skincare regimen is followed prescribed by a local licensed skincare professional can also make a huge difference in the manageability of acne. Acne tends to reoccur. All but the most extreme acne can be well-controlled, but it is very difficult to cure acne. One of the most effective treatments for acne, both topical and oral, are antibiotics effective against the bacteria (Propionibacterium acnes) that has a role in causing acne. Unfortunately, the bacteria have developed resistance to the most commonly used antibiotics. They may improve acne, even with the resistance, but many don't have the same potent effect they had when introduced in the 1960s. There are newer antibiotics, but they can be so expensive that many people can't afford them, especially for on-going treatment, and insurance plans may reject paying, taking the position that treatment is cosmetic. Newer drugs may also develop resistance. Acne associated with various stages of life, such as pregnancy or premenstrual acne, can improve when hormonal balance is restored.

Can acne be reversed? Active acne can be treated but underlying inflammation and precipitating factors must be controlled to avoid new acne lesions.

How do I stop my acne from progressing further? Please refer to the prevention section of this article for tips to stop acne before it starts. The most common cause of acne worsening, even while under treatment, is not using medications exactly as prescribed. Success with an acne treatment regimen requires commitment and working closely with a board certified dermatologist.

Is acne contagious? Acne is not contagious. Though there are bacteria found in acne lesions, these are not contagious and they are found on the skin of most humans.

Can acne kill you? There are very rare cases of acne associated with explosive, inflamed lesions, bone pain, fever, headaches, and other skin rashes. These syndromes are rare but can result in severe morbidity and even mortality if not recognized and treated.

If I use my once-daily antibiotic on my face, can I use it two or three times a day to get faster results? Medication should be used exactly as prescribed. Overtreatment can lead to skin irritation, inflammation, sensitivity to sun, allergic reactions, and can even make the problem more severe.

Is it true that if you take oral antibiotics that birth control pills aren't as effective to prevent pregnancy? While this has been commonly stated, studies have shown that most anitbiotics do not interfere with birth control. However, because antibiotics are themselves not safe for pregnancy, patients who take antibiotics should use two forms of birth control or remain abstinent while on therapy.

Does my antibiotic for acne protect me from sexually transmitted diseases? No!

What's the best way to remember to use my medication? Put your medication next to your toothbrush. You brush your teeth every day, and use your medication daily.

My acne gets really bad the week before my period starts. What can I do? Taking good care of your skin everyday of the month will help minimize the effects of your changing hormones the week before your period. Ask your doctor for a recommendation that's safe with your current medication. Using an over-the-counter product with benzoyl peroxide on the troubled spots may be helpful. Start using it a couple days before you expect your skin to become more troublesome. If the lesions persist, there are oral hormonal therapies available to treat this type of acne, which can be prescribed by a board-certified dermatologist.

Article Written By Sheila M. Krishna M.D., FAAD

Dr. Krishna is a board-certified dermatologist. She received her undergraduate degree at the Massachusetts Institute of Technology where she double majored in biology and foreign languages and graduated with Phi Beta Kappa honors. She is fluent in both English and Spanish. Dr. Krishna received her medical degree at the David Geffen School of Medicine at the University of California, Los Angeles, where she was a member of the Alpha Omega Alpha Medical Honor Society. She completed her dermatology residency at the Virginia Commonwealth University in Richmond, Virginia, and she served as Chief Resident in the Department of Dermatology. She completed an additional research year at UCLA with Dr. Lloyd Miller, where she gained expertise in research methods and protocol design and execution. Dr. Krishna is a Fellow of both the American Academy of Dermatology (AAD) and the American Society for Mohs Surgery (ASMS). Dr. Krishna practices in San Diego, California where she treats adults and children for skin conditions. Dr. Krishna was selected as a Top Doctor by her peers in San Diego in 2017. Website - https://www.sheilakrishnamd.com/

Article Reviewed By Natalia Kerr, Licensed Esthetician/Facial Specialist

Natalia Kerr is a licensed esthetician/facial specialist. She graduated from Orange Technical College in 2019 with her diploma in Facial Specialty. She is passionate about skincare and skin health, and has continued her education since graduation by attending various seminars, trainings, and trade shows. She struggled with acne for many years throughout her middle and high school years, and knows the damage to self-confidence that comes with it. This inspired her journey into the world of skincare, and she currently owns and practices at Skin by Natalia in Orlando, Florida. Website - https://skin-by-natalia.square.site/

More Information For The Public

References

Mayo Clinic: http//www.mayoclinic.com/health/acne/DS00169
American Academy of Family Physicians: Feldman, S. MD, PH.D., et al, Am Fam Physician. 2004 May 1;69(9):2123-2130.
National Institutes of Health: https://www.niams.nih.gov/health_info/acne/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4065280/
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5556180/