Acne is the most common skin condition, and according to AAD (American Academy of Dermatology), affects up to 50 million (yes, million) Americans annually. Although acne is so common, there is no cure for it, which can lead to a long term search for the most effective lifestyle changes and treatments. For this all about, I decided to delve in to acne and condense the information I found into an easy to follow post.
First of all, what is acne?
Sebum (a waxy, oily substance that your skin naturally produces to lubricate the skin) and dead skin cells clog your hair follicles (pores), which cause Propionibacterium Acnes (AKA: P-acne bacteria) to get trapped in the pores, leading to inflammation (acne vulgaris).
Types of acne:
Blackheads: The result of clogged pores and are known as open comedones. Often mistaken for dirt, blackheads are actually the result of the open head of the comedone being oxidized and turning a dark color.
Whiteheads: Essentially the same thing as a blackhead, except it is a closed comedone, resulting in a whitish “head” on the surface of the skin. Blackheads and whiteheads are considered non-inflammatory acne be
Papules: Raised red bumps that can be painful to the touch. Papules are considered inflammatory acne.
Pustules: Similar to papules, but are pus-filled. Pustules are considered inflammatory acne.
Cysts and nodules: The most severe form of acne, cysts and nodules are much deeper in the skin than other forms of acne and are usually contributed to hormonal and/or adult acne. This type of acne is also more likely to scar, including pitted scars, which are difficult to treat. Cysts and nodules are large red, sometimes pus-filled bumps and can be very swollen and painful, and often require professional treatment. This is considered inflammatory acne.
Fungal acne: Fungal acne has become quite the popular term lately, but it’s not really acne at all, rather it is known by dermatologists as malassezia folliculitis (or pityrosporum folliculitis), and is an infection caused by an overproduction of malassezia yeast that lives on the skin. Although it is not acne, it is very commonly mistaken for a regular breakout, which can lead to incorrect self diagnosis and treatment. The most common treatment is antifungal cream or an anti dandruff shampoo.
Sebaceous Filaments: Another case of mistaken identity, sebaceous filaments look a lot like blackheads, but are very different. While blackheads are the result of clogged pores, sebaceous filaments are a natural part of the skin, and the function is to be a channel for oil to travel through the hair follicle to the surface of the skin. Sebaceous filaments are more flat and lighter in color than blackheads and are more noticeable on those with oily skin. You can’t get rid of sebaceous filaments permanently, but you can use products containing BHA to reduce oil production and prevent clogged pores.
Causes of acne: Acne can be caused by deeply rooted internal issues, related to hormones, gut health, allergies, inflammatory response, medication side-effects, and stress. It can also be caused by external factors like climate, bacteria, damaged skin barrier, reaction to cosmetics, and improper skin care routine. For most people, it is a combination of factors, and some issues can feed another, e.g., gut issues can be connected to food allergies.
Common acne ingredients and what they do:
Acne patches: Small skin protecting adhesives (like acne bandaids), used to keep bacteria and dirt out of the pimple, and hydration in. There are different types of acne patches, hydrocolloid patches are meant to absorb fluid and be a protective layer to promote skin healing, some have microneedles that penetrate and deliver acne ingredients deeper in the skin, and some are thinner, medicated patches. Acne patches are best for the occasional breakout or pesky pimples.
Salicylic acid: The most widely used BHA (beta hydroxy acid), salicylic acid works within the skin to unclog pores by dissolving oil and exfoliating the skin, and is also anti inflammatory. Salicylic acid is best for whiteheads, blackheads, and mild acne.
Benzoyl peroxide: Antibacterial, decreases oil production, mildly exfoliating, and unlike antibiotics, does not cause antibiotic resistance, so bacteria does not become immune to the benzoyl peroxide over time. It is a good ingredient for mild to moderate inflammatory acne. Benzoyl peroxide can cause dryness and flakiness, and can also stain clothes and pillowcases.
Azelaic acid (my current favorite!): Antimicrobial, anti-inflammatory, mildly exfoliating, reduces hyperpigmentation, improves skin texture, and is also used as a treatment for rosacea. It is available in both OTC and prescription strengths. There have been great results in studies using azelaic acid to treat various skin conditions, however, the majority of studies were using prescription percentages. OTC azelaic acid is still a promising ingredient and I have personally seen positive results.
Niacinamide (vitamin b-3): Minimizes appearance of pores, anti-inflammatory, decreases oil production, evens skin tone, and there is some evidence that it can repair the skin barrier. Niacinamide is another ingredient used in the treatment of rosacea and is best for mild to moderate acne. Some people are sensitive to niacnamide and get skin irritation when used in high concentrations. Niacinamide is a common ingredient used in skincare, from cleansers to sunscreen, so keep that in mind when looking for new products.
Retinoic acid (tretinoin cream, brand name: Retin-a): Retinoids are an umbrella term for various vitamin A derivative ingredients. Over the counter retinols go through a process to be converted to vitamin A on the skin to be converted to retinoic acid. Retin-a is retinoic acid and does not need to go through a process, and is much stronger than OTC products. Retin-a is only available by prescription (although in some countries it is available OTC). Retin-a encourages skin shedding, promotes cellular turnover, increases collagen production, reduces fine lines and wrinkles, improves skin texture, and evens skin tone. Retinoic acid is a very effective and powerful ingredient and should be used with caution, under the supervision of a dermatologist. Retin-a is used to treat moderate to severe cystic and nodular acne.
Adapalene (differin gel): A type of retinoid, adapalene exfoliates the skin and supports cellular turnover, reduces inflammation, improves skin texture and tone, and helps prevent new acne from occuring. Adapalene used to be available by prescription only, but is now available over the counter (Differin gel). Differin gel is best for mild to moderate acne. With any retinoid, you can experience redness, flakiness, and stinging. These side-effects are normal when first starting a retinoid, and usually occur within the first few weeks of use and subside after four weeks (according to the Differin website), although everyone’s skin is different, so it is important to talk to a dermatologist before continuing use, if irritation persists.
Sulfur: Reduces oil production, mildly exfoliating, antibacterial, and antiinflammatory.
Sulfur can cause skin dryness and is known to have a “rotten egg” smell. It is best for mild to moderate acne and true oily skin types.
Antibiotics (can be topical and/or oral): Oral antibiotics kill acne causing bacteria. Topical antibiotics are often used in conjunction with benzoyl peroxide to treat acne, since the two ingredients are both antibacterial, in different ways (antibiotics work in the short term and benzoyl peroxide continues working overtime).
Isotretinoin (accutane): An oral vitamin A derivative used as a treatment for severe acne. Accutane is only available by prescription from a dermatologist and requires rigorous tests and checkups during the course of treatment. Taking accutane can be a life altering thing for many people, but is often considered a last resort treatment option. It can have various side-effects, which will be discussed with your dermatologist before and throughout treatment.
Steroid injections: Administered by a board certified dermatologist to quickly decrease inflammation in cystic and nodular acne. This treatment can offer fast results, but if done improperly, can leave an indentation in the skin.
Clays (bentonite, kaolin, and green clay are among the most common): Contain beneficial minerals, absorb excess oil, unclog pores, and help bring pimples to the surface. Clay masks work for a lot of people, but can be stripping and irritating, so be sure to follow the instructions and use a moisturizer.
Tea tree oil: Antibacterial and skin calming. Tea tree oil can be irritating and should not be used on the skin undiluted or in high concentrations.
Mixing active ingredients:
Using too many acne treatments at once can cause skin irritation and lead to a damaged skin barrier. Make sure to discuss with your dermatologist or esthetician which activities you should and should not be using at the same time or in the same routine. Also, when adding new active ingredients, your skin can go through a purging period, which is basically when your skin gets worse before it gets better. Here are some resources to learn more about skin purging vs reactions.
PIH (post inflammatory hyperpigmentation): A brown or purple mark (pigment, caused by the overproduction of melanin) left as a result of inflammation (acne, skin picking, scratches, sun exposure, and other skin conditions and injuries). PIH is most common in darker skin tones. Common treatments include AHA/BHAs, retinol, vitamin C, niacinamide, peels, and lasers. It is also important to wear sunscreen to prevent causing or worsening PIH.
PIE (post inflammatory erythema): A pink or red mark left as a result of inflammation (acne, skin picking, scratches, sun exposure, and other skin conditions and injuries). While PIH is more related to melanin, PIE is vascular and happens closer to the skin’s surface. The best treatment for PIE is time for your skin to heal, but other common treatments include keeping the skin hydrated with ceramides and humectants, niacinamide, azelaic acid, green tea, using gentle skin care products, avoid popping or picking pimples, vascular lasers, silicone sheets, and of course sunscreen. A common way to tell the difference between PIH and PIE is to press down on your skin where the marks are, and if it disappears (like if you had a sunburn), it is most likely PIE.
Keloid (hypertrophic scar): Raised bumps caused by an overproduction of collagen, in response to wound healing. Common treatments include steroid injections, laser treatments, and surgical remover. Keloids have a tendency to grow back, even after being removed.
Atrophic (or pitted) scarring: Indentations left in the skin as a result of poor tissue regeneration. There are different types of atrophic scars (icepick, boxcar, and rolling). Read more in depth about different types of atrophic scars here.
Common treatments for pitted scarring include fraxel laser, microneedling, chemical peels, and filler injections.
Microneedling (or dermarolling): Small needles are rolled or pressed into the skin to create micro punctures. The benefits include increased collagen production, improved skin texture, and minimized appearance of pores. There are at home microneedling kits, but improperly using one can damage the skin and cause infection, so it’s best to leave it to the professionals.
Fraxel laser: A microscopic laser that penetrates deep into the skin (much deeper than microneedling) and promotes collagen production. Fraxel laser works to resurface the skin, improve skin texture, decrease hyperpigmentation, and decrease fine lines and wrinkles. Fraxel has a bit more downtime than microneedling (although it’s still considered non-invasive) and can yield great results. A potential downside is the high price.
Chemical peels: A chemical solution is put onto the skin to even tone, improve skin texture, reduce hyperpigmentation, and improve fine lines and wrinkles. Even though there are at home options, chemical peels should only be done by a licensed dermatologist or esthetician. Trying an at home product could result in chemical burns, damaged skin barrier, and lead to worse scarring. There are different types of chemical peels, and some go deeper into the skin than others, so it is best to talk to a professional, to discuss which is best for you.
Filler: Administered by a dermatologist or medical esthetician. Filler, usually hyaluronic acid based, is injected into the scars to fill in the indentation and create a more even surface.
Silicone scar pads: Silicone sheets that are stuck onto the skin, usually for long periods of time, to improve the appearance of raised acne scars. It isn’t known exactly how silicone scar sheets work, but they do protect the skin, increase hydration, and can help relieve itchiness.
Acne isn’t just on your face, it can be anywhere on your body, from your scalp to your butt (yep). Body acne can be hard to treat because you’re less likely to apply skincare on hard to reach areas of the skin. Common OTC treatments for body acne include benzoyl peroxide wash and spray treatment products. It’s good to use a gentle body wash and change clothes after sweating to prevent further irritating the skin. It can also be helpful to look into the hair products and laundry detergent you are using, as some ingredients (and fragrance) can cause or worsen acne.
Acne and Dairy:
There are conflicting studies on why dairy might cause or worsen acne. Some people swear that cutting out dairy seemed to completely clear their skin, while others don’t notice a significant difference. However, when you think of dairy, ice cream, sugary yogurt, milkshakes, and other processed food probably come to mind. Processed foods can wreak havoc on metabolic, gut, and hormone health, so it makes sense that it worsens acne as well. It’s best to eat and drink high quality, grass fed dairy, whenever possible. If you are concerned you might have an intolerance to dairy or other foods, talk to your doctor to figure out what is causing it.
Acne is often linked to teenage years, but for a lot of people acne shows up later in life. This is called adult onset acne, and it can be quite jarring to go from having seemingly clear skin most of your life, to dealing with breakouts. Adult acne is almost always linked to hormones, and because of this, it is important to talk to your doctor and/or see a dermatologist to determine the best course of treatment. Hormones can be negatively affected by poor gut and high stress, so it is important to work on these areas as well. To work on gut issues, you can start by swapping some overly processed foods for healthier, whole food options, and implementing pre and probiotic foods and supplements. *talk with your doctor to figure out which supplements are best for you
Dry skin with acne:
While acne is mostly associated with oily skin, it is possible to have a dry skin type and still struggle with acne. It is common for acneic skin to be dehydrated, and any skin type (including oily) can be dehydrated, so it’s important to know which your skin is, to use the correct skin care ingredients. Read about the difference between dehydrated and dry skin here. It can be tricky to treat acne while also making sure dry skin remains nourished. If heavy creams seem to make your acne worse, try layering skin care instead, i.e., using a hydrating serum, light moisturizer, then maybe an oil over top (like squalane), if you need a more occlusive product to hold the moisture in. Also, be sure to use gentle cleansers and acne products (like mild aha/bha)
How to pop a pimple:
While it’s technically best to not pick or pop your pimples at all, most people do it anyway, and it can be a hard habit to break. If you are going to pop, make sure your hands and face are clean, and only pop pimples that have come to a head, do not try to pick at pimples that are still underneath the skin, as this can cause more damage and inflammation. Also, do not push the pimple out with your nails or tool (unless you really know how to use it), instead wrap your fingers with tissue and gently push up and out. You can watch this video to learn more about how and when to properly extract pimples.
When to see a professional:
If you have persistent acne (or any skin issues) that isn’t responding to OTC treatments, or if you suspect you have hormonal/cystic acne, it is a good idea to see a dermatologist. It is their job to examine, diagnose, come up with an individualized treatment plan, and they can also provide prescription strength ingredients and medication, if needed. If you can’t find a dermatologist in your area, there are some popular, more affordable options like Curology and Dermatica. These companies are both online and provide consultations, then teams of dermatologists send you customized formulas.
Acne can be a traumatizing experience, both physically and mentally. It’s hard not to be self critical when the majority of pictures on social media and in mainstream media tend to create an unrealistic, idealized idea of what skin “should” look like. Although acne is an extremely common concern for many people, it can still feel like an isolating experience, and can have a negative impact on social experiences and even personal relationships. If you need to reach out to someone, here is a psychologist locator. You can type in your city, state, accepted insurances, and more to narrow down your search.
I used to search for and buy products that were made for acne. While the “good for acne” or “for oily skin” can be helpful guides if you don’t know a lot about skin care, you end up missing out on some great products. You might see a hydrating cleanser, meant for normal to dry skin, and think it’s not meant for someone with acne, but it is actually helpful to add in hydrating ingredients, as well as products marketed for sensitive or normal skin types, because they soothe and strengthen skin barrier, which in turn helps heal acne.
Goal of a skincare routine for acne:
A solid skincare routine should decrease acne causing bacteria, hydrate, support skin’s natural healing process, protect skin barrier, and be used in conjunction with other health and lifestyle changes to improve skin health.
Product Recommendations (my favorites = !)
Zapzyt Acne Treatment Gel (10% benzoyl peroxide) !
La Roche Posay Effaclar Duo Acne Spot Treatment (5.5% benzoyl peroxide)
Disclaimer: This post is not intended to diagnose, treat, or be a replacement for medical advice or treatment.
*this post contains affiliate links