Article Summary

What is acne?
The cause of acne
Acne types and marks
Seeking treatment
At-home routine

If you’ve ever experienced acne, you’re probably familiar with the unsolicited advice that it can invite. All you have to do is click on the Instagram comments of anyone applying makeup on acne prone skin to see this in real time - from suggestions to “stop wearing makeup and wash your face more” or “drink more water and cut out sugar and dairy.”

But while acne may be one of the most common skin concerns worldwide, affecting over 8% of the entire population, we have a long way to go when it comes to correcting misinformation. This acne guide is intended as a resource of evidence-based acne education to anyone interested in learning more about acne. It is not intended to diagnose, treat, or offer medical advice.

What is Acne?

Acne is defined as an inflammatory skin disorder and while common, it’s still a skin disease that can require medical intervention. It affects people of all ages including adults, but about 85% of all adolescents will experience acne. In the medical field, acne vulgaris is the term for common acne but you’ll also see more severe forms like acne conglobata or acne fulminans.

Acne vulgaris targets what we call the pilosebaceous unit - the hair shaft, the hair follicle under the skin, and the sebaceous gland that is attached to the hair (which produces an oily substance called sebum). “Pores” are actually just the opening of the hair follicle and during acne, they become blocked with dead skin cells and sebum, allowing bacteria to grow. There are different types of acne lesions and they can range in severity.

It’s important to understand that if you’re someone who gets acne, it’s not because you didn’t wash your face enough or you don’t eat enough vegetables. It’s a complex skin disorder with a number of contributing factors that we will discuss. Just remember that you’re not alone in dealing with this and you can seek medical treatment if you’re feeling overwhelmed or not seeing results.

Examining the Cause

In the medical field, etiology is the cause of the disease while pathophysiology looks at the changes in the body that result from the disease.

Contributing Factors

The contributing factors to acne are well established and include inflammation, hormones, acne causing bacteria, abnormal shedding of dead skin cells, and excess oil production.

As discussed in our blog on purging, microcomedones are like the seeds of acne. It’s believed that those five acne contributors cause a harmless microcomedone to turn into an acne lesion.

Microcomedone Progression:

oil production is increased
dead skin cells do not shed normally and accumulate within the pore
The pilosebaceous unit is colonized by Cutibacterium acnes
Inflammation occurs

The pathophysiology (impact of the disease on the body) of acne is well defined. A combination of increased oiliness (often from hormones), general inflammation, and skin cells shedding abnormally and being too “sticky” all cause a pore blockage that becomes the perfect home for acne-causing bacteria.

But it’s the etiology (underlying cause) where things become less clear. We aren’t fully sure yet what causes these contributing factors in some people and not others… or what serves as the initial trigger for them. We’ll cover some of the most established theories before getting to the acne types.

Potential Causes

Hormones. The link between hormones and acne is well established but more research is needed to further elucidate their exact role. For women especially, high levels of hormones called androgens can make the skin more oily and may also be involved in something called follicular hyperkeratinization (dead skin cells get all stuck together and clog up the pore).

Insulin Resistance and Diet. The precise role of diet is unclear but the strongest evidence in this area points to high glycemic foods having the potential to influence both insulin and androgens, worsening acne severity. There has also been a potential link found between patients with acne and insulin resistance. We recommend avoiding online diet advice and consulting your provider or a dietician if you have any questions about your health or diet.

Oxidative Stress. Exposure to the sun and other environmental stressors generate oxidative stress in the skin. This can cause not only the inflammation associated with acne but some studies suggest that the oxidation of lipids within the hair follicle also contributes to the cause of acne.

Skin Microbiota. The acidic skin surface is composed of a diverse population of microorganisms, many of which actually help keep our skin healthy. We’ve known for a long time that overgrowth of Cutibacterium acnes is associated with acne but emerging research suggests that alterations in normal microbial counts in general as well as a higher pH level of the skin is associated with acne.

Acne Types

There are different types of acne lesions and they are used to categorize acne based on its severity. Grading acne is then used by providers to determine the best treatment course. It should also be noted that more severe acne is more likely to result in scarring or hyperpigmentation once it heals.

Acne Lesions

Comedones. This can include closed comedones (whiteheads) and open comedones (blackheads). Comedones are clogged pores that are not inflamed. They just look and feel like bumps on the skin. Closed comedones are skin-colored, while open comedones are black because the sebum inside has oxidized.

Papules (red bumps). These are a step up from comedones. The clogged pore has become inflamed and is pink, red, or purple. It doesn’t have a head, and can resemble a bug bite.

Pustules (filled with white or yellow pus). When your immune system responds more strongly to a comedone, it can send white blood cells to fight the acne bacteria. As those white blood cells die, they form pus that fills a pustule. Many pustules have a white head in the middle.

Nodules and Cysts. Like a pustule, but larger, more inflamed, and with a higher risk of scarring.

Post Acne Marks

Post inflammatory hyper-pigmentation (PIH). These dark brown or purple spots can be left behind after a breakout. As a form of hyper-pigmentation, they respond well to pigment inhibitors like arbutin.

Post inflammatory erythema (PIE). More common in lighter skin tones, these will respond better to azelaic acid and niacinamide as they target redness.

Acne scars. Unlike PIE or PIH, true acne scars will be either raised or indented and often have a white appearance once healed. You’ll want to see a professional to address them.

Acne Treatment

The treatment of acne is focused on addressing the contributing factors we discussed above. Generally, the more contributors that a treatment can address, the more effective it will be for acne. Seeing a dermatologist is very important in getting a good treatment outcome because they will carefully assess the presentation and severity of your acne prior to selecting the right treatment regimen.

Monotherapy (a single medication or therapy) usually isn't as effective as it’s very difficult for one medication to unclog the pores, target bacteria, reduce inflammation, and also address hormones.

Combination therapy (two or more medications) has been shown to be more effective in acne research and is also now recommended in the American Academy of Dermatology’s clinical guidelines for acne treatment. This is usually what you can expect when you see a dermatologist for acne treatment.

OTC Acne Meds

Note: while many people with mild to moderate acne have success with over-the-counter (OTC) acne meds, we cannot specifically advise in the treatment of a skin disorder. If breakouts persist or are more severe, you should seek medical treatment.

Retinoids. Stimulate cell turnover and normalize the shedding of dead skin cells while also compacting the skin barrier so your medication can penetrate better.

Salicylic Acid. Anti inflammatory, comedolytic, and keratolytic agent that can exfoliate the pore lining and skin surface.

Benzoyl Peroxide. Comedolytic and keratolytic while also being antibacterial.

Azelaic Acid. A mild exfoliant with anti-inflammatory properties that can also address both red and dark spots.

Seeing a Professional

More severe acne not only has a higher risk of hyper-pigmentation and scarring but also isn’t as responsive to OTC acne meds. Many consumers try popular ingredients like salicylic acid and niacinamide only to be disappointed because they’re often inadequate for hormonal or cystic acne. If you haven’t had any success in addressing acne on your own or if it’s more severe, seeking a professional is always your best bet.

Dermatologist: a type of medical doctor that specializes in skin, hair, and nails. They can diagnose skin disorders and prescribe treatment in the form of medications or in office interventions.

Esthetician: a beauty professional licensed by the state that focuses primarily on skin. While they cannot treat or diagnose, they can offer in-office treatments as well as help with your skincare routine.

Emily Hilburn is a licensed esthetician, Face Reality certified acne expert, and owner of Pinnacle Modern Skincare in Los Angeles, California. “The number one service I recommend to clients for the treatment of acne and acne scarring is chemical peels,” she says. “Chemical peeling agents like TCA (trichloroacetic acid) as well as more mild peels like salicylic and mandelic can be a very effective tool to unclog pores, reduce pigmentation, and smooth texture.”

“I also utilize red light therapy in-office as a supportive tool in the treatment of acne along with chemical peels and a consistent homecare regimen,” Emily continues. “Red light therapy has evidence to support its usefulness in decreasing inflammation, reducing acne-causing bacteria, as well as encouraging collagen production.”

When we asked Emily about whether to see a dermatologist or an esthetician, she had this to say: “It’s common for me to work with clients who are also under the care of a dermatologist. It can be helpful to refer clients to a dermatologist when prescription medication may be warranted for acne that does not respond to in office treatments and over the counter regimens. I also rely on the referral to a dermatologist for diagnosis confirmation of acneiform eruptions (acne imposters).”

Estheticians and dermatologists have different roles but can work well together to address your concerns so don’t feel like you need to pick one. And a good esthetician will know when to consult with a dermatologist when it comes to skin disorders that require medical intervention.

The At-Home Routine

It’s easy to forget about skin health in the pursuit of clear skin. It’s hard not to feel like your skin is misbehaving when it’s breaking out and most of us have fallen into the trap of trying to whip our skin into shape with harsh cleansers and astringent toners. But even if we’re dealing with acne, our skin is still an important protection against our environment and working hard. It’s so important to still care for our skin and be kind to it.

Acne meds need to be used consistently to work and that can be hard if your skin is dry and irritated. But more importantly, acne really does a number on your skin - from the inflammation, disruption in the surface acidity, and the alterations in the skin barrier. Acne prone skin is the most deserving of TLC but can be neglected.

Like with any other skin type or concern, you’ll want to make sure you have your skincare routine fundamentals. This will generally include a cleanser, sunscreen, and moisturizer. Here’s some ingredients you can look for to further help support skin health.

Skin Savers for Acne Prone Skin

Ceramides, Cholesterol, and Fatty Acids. Acne prone skin has been shown to be deficient in linoleic acid as well as other components of the skin barrier like ceramides. Looking for these ingredients in your skincare can help support barrier health and keep your skin happy.

Gentle, low pH Cleansers. As discussed, acne prone skin has been shown to have a higher pH level than we’d like so using a nice mild cleanser that is under pH 5.5 can protect skin surface acidity as well as minimize further irritation and barrier disruption.

Anti-Inflammatory Agents. Niacinamide in particular is a great one as this multi-tasker will help support the skin barrier too but it’s also an anti-inflammatory and some people find it helps with oiliness.

Wound Healing Ingredients. Plant extracts like centella asiatica as well as growth factors like EGF can help repair the skin faster and can hopefully help reduce the risk of dark spots.

References

Mastering Acne: Your Go-To Resource for Evidence-Based Education on Clearing Skin