Acne is one of the most common skin conditions around the globe. Acne (acne vulgaris) occurs when oil, bacteria, dirt and dead skin cells clog up the tiny pores in the skin. The result is what’s commonly referred to as blemishes, whiteheads, blackheads, pimples or zits.
If the skin is repeatedly affected by continuous clogging, you may have acne. This condition can be reasonably mild (just a few spots) or more severe (many spots covering the face, neck, chest and back which can be small or bigger, more solid and inflamed lumps or cysts that can be painful).
Acne is a common condition among teenagers when hormonal changes in the body are rife. Many experience bouts of acne which then subsides as hormonal levels stabilise following the teenage years. Some women can have acne as an adult (even those who did not have the skin condition in their teens), often in the days leading up to their menstrual periods, during or after pregnancy too.
When severe, an acne condition can be quite distressing for a person. How you feel about your condition is not necessarily only related to how bad or severe it is, many males and females are bothered or embarrassed about it even when in mild form. Others, even if severe, will not be upset about it at all.
Acne typically affects the face and for this reason, the condition can impact a person’s self-esteem. Over time, severe acne can also lead to scarring which can cause further emotional distress.
The important thing to remember about acne, is that although it can be persistent, the condition is not life-threatening. It can be painful and distressing, but for many it can be treated or adequately managed. Treatments can effectively reduce the number of blemishes and your chances of physical scarring.
Symptoms of acne
The condition typically affects the face, neck, back, chest and shoulder areas of the body, but can occur almost anywhere in the skin. Acne is typically characterised as persistent, recurring red spots or swelling on the skin, or just beneath the surface of the skin.
Swelling becomes inflamed and is often filled with pus (a thick opaque liquid that is yellowish or greenish in colour, produced in infected tissue. Pus consists of dead white blood cells and bacteria with tissue debris and serum).
Blemishes can form as whiteheads (tiny white bumps or plugged pores) or comedones (blackheads/dark spots with open pores at the centre). Blackheads open at the surface of the skin and are black in appearance due to the effect of oxygen in the air. Whiteheads remain closed just beneath the surface of the skin.
Blemishes can also be more inflamed (papules, pustules, nodules, cysts and large lumps) and are more likely to cause scarring on the surface of the skin. Physical scarring can be long-term if not treated and managed properly.
- Papules: These are typically small, raised inflamed bumps caused by infected hair follicles.
- Pustules: These are small red blemishes (pimples) that contain pus at their tips.
- Nodules: These are solid, often very painful (or tender) lumps just under the surface of the skin. These can be quite large in size.
- Cysts (cystic lesions) and large lumps: These are large and often painful lumps beneath the surface of the skin that contain pus.
For most, hormone changes in the body during puberty (teenage years) can result in the skin becoming oilier. Oil production and dead skin cells, as well as bacteria and dirt, clog the skin’s pores leading to swelling, redness (inflammation) and pus.
Hair follicles become plugged mostly in areas of the skin that have the most oil production (sebaceous glands). These areas typically include the face, neck, back, chest and shoulders. Hair follicles are connected to these oil glands. The glands secrete an oily substance called sebum to lubricate the skin and hair follicles. This normally travels along the hair shaft and through the opening of the hair follicles onto the surface of the skin.
When an excess amount of sebum and dead skin cells is produced, it can build-up in the hair follicles and form a soft plug. This creates an ideal environment for bacteria to thrive, leading to an infection that causes inflammation.
The soft plug (pore) causes the follicle wall to ‘bulge’, producing a blemish (a whitehead). A plug (pore) may open at the surface of the skin and darken, causing a blackhead (the pore is congested with bacteria and oil and turns dark brown or black when exposed to air). Spots that are red and raised, with a white centre, develop when the blocked hair follicles become inflamed (infected). The blockage can cause inflammation deep inside the hair follicle and produce cyst-like lumps beneath the surface of the skin.
Acne can run in families. If one or both parents have or have had acne, chances are that you will experience this skin condition too.
Factors that can worsen acne
An existing bout of acne can be triggered or aggravated by any of the following:
- Hormones: During puberty androgen hormones in the body (in both boys and girls) cause sebaceous glands to enlarge and produce more sebum. Women tend to experience fluctuations in hormones throughout their lives. Those with low amounts of androgens circulating in the blood can also contribute to worsening acne breakouts. Hormonal changes during pregnancy can lead to acne breakouts, as well as those brought on with the use of some oral contraceptives (birth control pills – although some brands may also help to clear the skin). Any hormonal changes affecting sebum production in the body can result in mild or severe acne breakouts.
- Medications: Corticosteroids, androgens or lithium ingredients in certain medications can worsen acne.
- Diet: Certain dietary factors have been indicated in studies to trigger acne. Dairy products and carbohydrate-rich foods (breads, bagels, chips) can play a role.
- Stress: Increased levels of stress can worsen acne breakouts.
Myths about acne
Many tests and studies have been done to either prove or disprove worsening effect or causes of acne. Some that appear to be baseless or have very little to do with scientifically causing or worsening acne breakouts include:
- Greasy foods: The actual consumption of greasy foods has shown to have little to no effect on acne. If you work in a greasy area (for instance a kitchen) oils can stick to the surface of the skin and block hair follicles, leading to irritation and inflammation which can cause or worsen acne.
- Dirty skin: Dirt isn’t a cause of acne but can get trapped in the pores of the skin. Scrubbing the skin too harshly with soaps and other chemicals can irritate the skin just as much as dirt and bacteria, worsening acne. It does help to gently remove oil, dead skin cells and other substances that lead to acne breakouts.
- Cosmetics: Non-comedogenic (oil-free) make-up doesn’t necessarily worsen acne by clogging pores. Make-up should always be removed regularly. Non-oily cosmetics have not been proven to interfere with the effectiveness of an acne medication either.
Treatment Procedures – Remedies and Relief
When should you see a dermatologist?
Acne as a skin condition can be either mild and occasional or severe and persistent. In either instance, you may feel unhappy, embarrassed or uncomfortable.
It is advisable to consult a primary care doctor or skin specialist (dermatologist) if:
- Your acne affects your self-esteem and makes you unhappy or uncomfortable
- You have noted scarring on the skin as a result of your acne breakouts
- You notice the appearance of dark patches (or pigmentation) on the skin
- You have severe acne breakouts
- Your acne breakouts don’t appear to respond to over-the-counter remedies and topical ointments
A primary care doctor (general practitioner or GP) can prescribe some medications to help reduce breakouts or clear acne.
If breakouts are persistent or more severe it is best to seek medical treatment from a dermatologist who specialises in conditions that affect the skin. He or she will advise medical treatment that is best for your condition. This will include topical lotions and cleansing products, as well as prescribed medication.
Some popular non-prescription acne lotions, cleansers and other skin products can cause an adverse reaction to those more prone to sensitivity. General skin sensitivity (redness, itchiness or irritation) in the area a product has been applied shouldn’t be confused with a ‘reaction.’
Sometimes a non-prescription product can cause any of the following and should be seen to by a medical professional as soon as possible:
- Feeling faint
- Difficulties with breathing
- Tightness of the throat
- Swelling of the eyes, face, lips or tongue
Diagnosis and tests
Early detections and treatment of acne does significantly reduce the risk of long-term physical scarring, as well as lasting damage to a person’s self-esteem.
Your dermatologist or GP will make their assessment by examining your skin to identify the types of lesions and their level of severity during the consultation. From there, if necessary your GP will refer you to a dermatologist for specialist analysis. If you are already consulting with a skin specialist, he or she will examine, diagnose and determine the best course of treatment for you.
Your doctor will also discuss your medical history with you. Information that is key includes conditions that have been diagnosed by a medical professional and any prescription or over-the-counter medications, products or supplements you are currently using.
Any major stresses or recent life changes should also be mentioned. Women will be asked about their menstrual cycles to determine if hormonal fluctuations are playing a role in acne breakouts.
You may also have questions about your condition and the treatment options available to you. Questions that are beneficial for you to ask your specialist include:
- What treatment approach do you think is best for me?
- If the first course of treatment isn’t successful, what will you likely recommend we do next?
- Will there be any side effects I can expect with treatment?
- How soon after beginning treatment will my acne begin to clear?
- How often will you need to see me to evaluate the progress of my treatment?
- Is it safe to stop my medications if I don’t feel they are helping?
- Are there any self-care steps I can do to help alleviate my symptoms?
- Would you recommend any changes to my diet or any over-the-counter products (soaps, lotions, sunscreens and cosmetics) I am using on my skin?
Your specialist will likely also ask you a number of questions, some of which may require in-depth explanations. These may include:
- When did you first develop this skin condition?
- Is there anything you have noticed that appears to trigger an acne breakout? (stress or a menstrual cycle)
- Are you currently taking any medications or supplements? (prescription or over-the-counter)
- For girls and women: Are you using any oral contraceptives? Do you have regular menstrual periods? Are you pregnant? Do you plan to fall pregnant soon?
- Is your acne affecting your self-esteem and level of confidence in your everyday life?
- Do you have any relatives with acne problems?
- What type of soaps, lotions, sunscreens, cosmetics or hair products do you use?
- Have you tried any other methods of treatment or taken other self-care steps to treat your acne? Has anything been effective or appeared to worsen your symptoms?
In most instances, testing may not be necessary to diagnose acne. If it is suspected that acne may be a symptom of another medical problem, specific tests may be requested. Some women have higher than normal amounts of testosterone in the body which can lead to breakouts.
Treatments and medications
To treat any case of acne, your dermatologist will first determine if you have a mild to moderate or severe type of condition. He or she will work with you to try and get your breakouts under control, avoid any scarring or other damage to your skin, and help reduce the appearance of any developed scars.
In some instances combination treatment may be assessed as the best route for you. This typically involves topical lotions or gels you can apply to the skin (blemishes only or entire area affected), and oral medications. Combination treatment will often offer you the best results, as well as help you avoid developing drug-resistant bacteria.
- Mild acne: Treatment typically involves gentle cleaning using a mild soap (Dove or Cetaphil) and warm water, and applying salicylic acid and benzoyl peroxide products to the skin. If these topical measures do not work, a prescription for stronger lotions, gels or creams may be given Your dermatologist may also along prescribe an antibiotic lotion that helps to unclog your pores.
- Moderate to severe acne: Your dermatologist may recommend stronger medicine or a combination of treatments. Blemishes which affect deeper layers of the skin (cysts and nodules) are more likely to leave scars. You may be prescribed oral antibiotics to promote the healing process (from the inside). Depending on the severity of your acne, you may be given a benzoyl peroxide to apply on the skin, as well as prescription antibiotic creams, gels or lotions, prescription retinoids and azelaic acid. Your doctor may need to drain large pimples and cysts for you. He or she will also prescribe oral antibiotics and oral retinoids (isotretinoin).
Medications work to help reduce oil production, speed up skin cell turnover, fight any bacterial infection and reduce inflammation. You may see improvement within 4 to 8 weeks of medication treatment. It is possible for your breakouts to get worse before showing any improvement while taking some medications. Your dermatologist will warn you about this. For some it can take many months or even years before your skin clears up completely.
Expectant moms will not be prescribed any oral medications for acne during their pregnancy.
- Topical medications: These work best when applied to clean and dried skin about 15 minutes after washing. Improvement to the skin can be seen within a few weeks. Redness (inflammation), dryness and even peeling can occur at the beginning of treatment but should improve with continuous use. A gradually increased dosage and other care instructions may be recommended by your dermatologist in order to minimise these side effects. Common topical prescriptions include retinoids (derived from vitamin A and include tretinoin, adapalene and tazarotene), antibiotics, and dapsone (Aczone) gel.
- Oral medications: Antibiotics reduce bacteria and help fight inflammation. Popular choices include tetracyclines (such as minocycline and doxycycline). Antibiotics may be tapered off as symptoms begin to improve or as soon as it becomes clear that the medication is not working. Tapering is necessary to prevent antibiotic resistance. Antibiotics may lead to side effects such as an upset stomach (ask your doctor about a probiotic that can be used to alleviate this) or dizziness. The skin’s sun sensitivity may also increase. Reduced bone growth in children born to women who took tetracyclines while pregnant has been noted as well, so it is important to discuss all medications you take or are thinking of taking with your doctor before and during pregnancy. Combined oral contraceptives (oestrogen and progestin) are often useful for treating acne in women and adolescent girls. Common side effects of these medications are headaches, nausea, weight gain, breast tenderness and breakthrough bleeding (spotting). A potentially serious complication is a slightly increased risk of blood clots. Anti-androgen agents may be considered for women and adolescent girls who have not seen any improvement using antibiotics. These work by blocking the effect of androgen hormones on the sebaceous glands. Side effects can include breast tenderness, retention of potassium and painful menstrual periods. Isotretinoin is generally recommended for those with the most severe cases of acne. It is a powerful drug and is very effective when taken orally. Potential side effects can be rather serious (especially for women of reproductive age) and will need to be monitored by your dermatologist very carefully. These can include ulcerative colitis, and increased risk of depression, severe birth defects and even suicide.
- Light-based therapies have been tried with some degree of success. Light therapy targets bacteria that causes acne inflammation and can be done in a doctor’s office. Blue-light therapy can be done at home with a hand-held device. Some can experience pain, temporary redness (inflammation) and sensitivity to light as possible side effects.
- A chemical peel involves repeated applications of a chemical solution (salicylic acid) and is most effective when used in combination with other treatments (except oral retinoids as this can significantly irritate the skin). Some scaling, blistering, severe redness and even long-term discolouration of the skin can sometimes occur.
- You can also undergo an extraction of whiteheads and blackheads. Your dermatologist will use special tools to gently remove these blemishes that haven’t cleared up with topical medications. Some scarring can occur using this method.
- Nodular and cystic lesions can also be treated with a steroid injection. A steroid drug is injected directly into a nodular or cystic lesion. This can help to improve the appearance of the lesion or cyst (reduce swelling) without the need for extraction. It can however, cause thinning of the skin, lightening of the skin and the appearance of small blood vessels on the treated area.
Treating acne scars
Treatments which can help to reduce the appearance of scars include:
- Soft tissue fillers: Fillers such as collagen or fat is injected under the skin and into indented scars to fill out and stretch the skin, making them less noticeable. Results are temporary and can include side effects such as swelling, redness or bruising. Periodic injections may be needed. Downtime: None
- Chemical peels: A high-potency acid is applied to the surface of the skin to remove the top layers and reduce deeper scars. Downtime: The length of recovery depends on the depth of the chemical peel. Light peels have no downtime although slight redness may appear for a day or two, medium depth peels take anything from five to 10 days to heal and deep peels will usually take one to two weeks to heal.
- Dermabrasion: This involves sanding (planing) of the surface layer of the skin with a rotating brush. Scars caused by acne are blended in to the surrounding skin. This procedure is usually most effective for severe scarring. Dermabrasion does have significant downtime, with swelling taking a few days to a week to subside. Sensitivity and a light pink appearance may continue for up to several weeks.
- Laser resurfacing: A laser is used to improve the appearance of the skin through a resurfacing procedure. The length of recovery after a laser resurfacing procedure will depend on the type of laser used, the area treated and the individual’s capacity for healing but you can expect anything from a five to 14-day recovery period with CO2 laser resurfacing.
- Light therapy: Lasers, pulsed light sources and radiofrequency devices will be used to treat scars without injuring the epidermis. The treatment involves heating the dermis to encourage new skin to form. Acne scars will be reduced after several treatments and become less noticeable. There is generally no downtime after a light therapy session.
- Skin surgery: Punch excision is a minor procedure where your doctor will cut out individual acne scars and repair the hole (scar site) with stitches or a skin graft. Downtime will vary based on the individual, the area treated and amount of surgery needed and usually takes a week to 10 days.
There is plenty you can do to help control acne breakouts with some self-care techniques:
- Use a gentle cleanser or mild soap with warm water on problem areas twice a day. Facial scrubs, astringents and masks can irritate the skin, as can excessive washing, shaving or scrubbing.
- Avoid oily or greasy cosmetics, moisturisers, sunscreens, concealers or hairstyling products. Use water-based or noncomedogenic products instead.
- Avoid picking or squeezing blemishes as this causes further infection or scarring.
- Be mindful of what touches your skin. Try and avoid resting your face on your hands or other objects that may carry bacteria. It is also a good idea to try and keep your hair clean and off your face. Tight clothing and hats can sometimes be problematic if you are prone to sweating. Sweat and oils can cause breakouts.
It is important to remember that most treatments for acne take time, with improvements only noticeable between 6 and 8 weeks. Some treatments may cause acne to worsen before any signs of improvement.
What is the outlook for someone with acne?
For most, treatment for acne is successful. Improvements can be seen between 6 to 8 weeks. Flare-ups and breakouts are still common and may require additional or long-term treatment. Prompt treatment of acne can successfully reduce scarring or prevent it altogether. Isotretinoin is a treatment favoured by dermatologists as it provides the best results in the long-term.
Can acne be prevented?
It is a difficult condition to prevent, but you can take precautions to prevent breakouts, even after treatment.
- Wash acne-prone skin twice a day to remove excess oil and dead skin cells. Use gentle cleansers and oil-free, water-based skin care products and cosmetics.
- Use over-the-counter acne creams or gels to help dry excess oil. Products containing benzoyl peroxide or salicylic acid as active ingredients work best.
- Remove all make-up before going to bed every day to avoid clogging up your pores. It’s also a good idea to throw out old or expired make-up and regularly clean cosmetic brushes and applicators with soapy water.
- Wear loose-fitting clothing to avoid trapping heat and moisture that irritates the skin.
- Shower after participating in strenuous activity.
- Avoid touching or picking at blemishes to prevent further infection.
- Maintain a healthy and nutritious diet and take steps to reduce stress levels wherever possible.