Understanding Acne Basics

What Is Acne?

There’s a reason it’s called “common acne” — nearly everyone suffers from a pimple outbreak at some point in life.

 

It starts when greasy secretions from the skin’s sebaceous glands (oil glands) plug the tiny openings for hair follicles (plugged pores). If the openings are large, the clogs take the form of blackheads: small, flat spots with dark centers. If the openings stay small, the clogs take the form of whiteheads: small, flesh-colored bumps. Both types of plugged pores can develop into swollen, tender inflammations or pimples or deeper lumps or nodules. Nodules associated with severe cases of acne (cystic acne) are firm swellings below the skin’s surface that become inflamed, tender, and sometimes infected.

 

Although acne remains largely a curse of adolescence, about 20% of all cases occur in adults. Acne commonly starts during puberty between the ages of 10 and 13 and tends to be worse in people with oily skin. Teenage acne usually lasts for five to 10 years, normally going away during the early 20s. It occurs in both sexes, although teenage boys tend to have the most severe cases. Women are more likely than men to have mild to moderate forms into their 30s and beyond.

 

Acne lesions are most common on the face, but they can also occur on the neck, chest, back, shoulders, and upper arms.

 

Contrary to popular belief, acne isn’t caused by a harmful diet, poor hygiene, or an uncontrolled sex drive. The simple truth is that heredity and hormones are behind most forms of acne. Swearing off chocolate or scrubbing your face 10 times a day won’t change your predisposition to this unsightly, sometimes painful, and often embarrassing skin problem.

What Causes Acne?

The cause of acne is not fully understood. Though stress can aggravate acne, it clearly does not cause it.

Hormones. Common acne in teenagers starts with an increase in hormone production. During puberty, both boys and girls produce high levels of androgens, the male sex hormones that include testosterone. Testosterone signals the body to make more sebum, the oil produced in the skin’s oil glands.

Bacteria. Excess sebum clogs the openings to hair follicles — especially those on the face, neck, chest, and back. Bacteria grow in these clogged follicles. This makes blackheads or whiteheads, also known as ”comedones,” form on the skin’s surface. Sometimes, this clogging causes the follicle wall to break under the pressure of this buildup. When this happens, sebum leaks into nearby tissues and forms a pustule or a papule — this is called inflammatory acne. Larger, tender pustules are called nodules.

Depending on the type of pill, oral contraceptives may trigger acne in some women but suppress it in others. Some injectable contraceptives and intrauterine birth control devices (IUD) may also cause acne. Steroids taken by some bodybuilders and other athletes can also lead to severe outbreaks.

Acne has many subtypes. Acne neonatorum and acne infantum occasionally affect newborns and infants, usually boys. A pimply rash appears on the face and usually clears within weeks with no lasting effect. However, acne infantum may last longer, be more severe, and cause scarring.

People who escaped their teen years almost pimple-free may develop persistent adult-onset acne as they get older. Despite the normal increase in androgen levels during puberty, some doctors believe that flare-ups of acne have less to do with androgen levels than with how a person’s skin responds to an increase in sebum production or to the bacteria that causes acne. The bacteria Propionibacterium acnes occurs naturally in healthy hair follicles. If too many of them accumulate in plugged follicles, they may secrete enzymes that break down sebum and cause inflammation. Some people are simply more sensitive than others to this reaction. Sebum levels that might cause a pimple or two in one person may result in widespread outbreaks — or even acute cystic acne — in another person.

What Are the Symptoms of Acne?

The symptoms of acne are:

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Call Your Doctor About Acne If:

What Are the Treatments for Acne?

The occasional pimple can be concealed. If used at all, over-the-counter cover-up creams and cosmetics should be water-based. Even if outbreaks of acne cannot be eliminated, conventional treatment can provide relief.


The best treatments inhibit sebum production, limit bacterial growth, encourage shedding of skin cells to unclog pores, or a newer treatment that blocks male hormones in the skin. Because many therapies can have side effects, any patient with acne should proceed with caution when trying a new treatment. People with any type of acne that lowers their self-esteem or makes them unhappy, those with acne that is leaving scars or people with severe, persistent cases of acne, need the care of a dermatologist.

Nonprescription Treatment for Acne

Soap and water. Gentle cleansing of the face with soap and water no more than two times a day can help with acne. However, this does not clear up acne that is already present. Aggressive scrubbing can injure the skin and cause other skin problems.

Cleansers. There are many cleansers and soaps advertised for treating acne. They often contain benzoyl peroxide, glycolic acid, salicylic acid, or sulfur.

Benzoyl peroxide. For mild acne, you may try, or your doctor may recommend, treatment with a nonprescription drug that contains benzoyl peroxide. It’s believed that this compound works by destroying the bacteria associated with acne. It usually takes at least four weeks to work and it must be used continuously to keep acne at bay. Like many over-the-counter and prescription products, it does not affect sebum production or the way the skin follicle cells are shed, and when you stop using it, the acne comes back. It is available in many forms: creams, lotions, washes, foams, cleansing pads and gels. Benzoyl peroxide can cause dry skin and can bleach fabrics, so take care when applying it. Consider wearing an old T-shirt to bed if you are applying it to your back or chest overnight.

Salicylic acid. On the skin, salicylic acid helps to correct the abnormal shedding of cells. For milder acne, salicylic acid helps unclog pores to resolve and prevent lesions. It does not have any effect on sebum production and does not kill bacteria. It must be used continuously, just like benzoyl peroxide, because its effects stop when you stop using it — pores clog up again and the acne returns. Salicylic acid is available in many acne products, including lotions, creams, and pads.

Sulfur. In combination with other substances such as alcohol, sodium sulfacetamide (a prescription medication) and salicylic acid, sulfur is a component of many over-the-counter acne medications. It usually isn’t used by itself because of its unpleasant odor and temporary skin discoloration. Sulfur helps to prevent pores from being clogged and inhibits growth of bacteria. but it has only a marginal benefit in most cases.

Topical retinol gel or creams. Retinol works to keep pimples from being able to form. It affects the growth of cells, causing increased cell turnover to unblock pores. Your acne may appear to get worse before it gets better because it will work on the pimples that have already started forming beneath your skin. It must be used continuously and may take 8-12 weeks to get results. Retinoids used to be available in only a prescription strength. Differin Gel is the only topical retinoid approved as an over-the-counter treatment for acne.

Alcohol and acetone. Alcohol is a mild anti-bacterial agent, and acetone can remove oils from the surface of the skin. These substances are combined in some over-the-counter acne drugs. These agents dry out the skin, have little or no effect on acne, and are generally not recommended by dermatologists.

Herbal, organic, and “natural” medications. There are many herbal, organic, and natural products marketed to treat or prevent acne. The effectiveness of these agents isn’t proven and they are unlikely to have much benefit.
Note: When pus-filled pimples are ready to break, apply a hot towel for a few minutes to encourage the natural bursting process. Inflamed pimples should be opened only by a nurse or doctor using surgical instruments and following antiseptic practices. Squeezing pimples yourself may lead to further inflammation and perhaps permanent scars.

Prescription Treatments for Acne

Antibiotics. Antibiotics may be used on top of the skin (topical) or taken orally (systemic). Antibiotics work by clearing the skin of acne-causing bacteria and reducing inflammation. There are several topical products available in creams, gels, solutions, pads, foams, and lotions. Topical antibiotics are limited in their ability to penetrate the skin and clear more deep-seated acne, whereas systemic antibiotics circulate throughout the body and into sebaceous glands. However, systemic antibiotics often cause more side effects than topicals, but they can be used for more severe kinds of acne. Usually, topical antibiotics aren’t recommended alone as an acne treatment, as they can increase the risk for antibiotic resistance in skin bacteria. However, using benzoyl peroxide with a topical antibiotic may reduce the chances of developing antibiotic resistance.

Topical clindamycin (Cleocin T, Clinda-Derm) and erythromycin (Akne-Mycin, ATS, Erycette, Erygel, Ilotycin) are antibiotics that are also anti-inflammatory drugs and are effective against a number of bacteria. They should always be combined with benzoyl peroxide or a topical retinoid and applied directly to the skin. Oral erythromycin is also available, but you may become resistant to its effects, limiting its usefulness.

Other oral antiinflammatory antibiotics often used are doxycycline, minocycline, and tetracycline, all of which are quite effective in many cases of acne.

Antibiotics do not address the other causative factors in acne and may take several weeks or months to clear it up. Antibiotics are often used in combination with other drugs that “unclog” follicles. Many oral antibiotics for acne should not be used during pregnancy.

Retinoids or vitamin A derivatives. These drugs are available as topical or oral drugs. Topical retinoids clear up moderate-to-severe acne by affecting the way the skin grows and sheds. They can be used in combination with other acne products, such as benzoyl peroxide and oral antibiotics. Topical retinoids don’t have the severe side effects of oral retinoids; however, they aren’t recommended for pregnant or nursing women. Side effects of topical retinoids include redness, dryness, and itchy skin.

For severe cystic acne, isotretinoin (Absorica, Accutane, Amnesteem, Claravis, Sotret, Zenatane) is the most effective therapy. This drug is the only drug that intervenes in all of three of the causes of acne. It can often even clear severe acne that hasn’t responded to other treatments. However, the product can have side effects. It can cause severe birth defects and must NEVER be taken by a woman who is pregnant or who is not using contraception. In addition, it shouldn’t be taken by a woman who is nursing. Some studies suggest its use has been associated with an increased risk of depression, suicide, and inflammatory bowel disease. Talk to your doctor about the potential risks of this drug.

Other side effects are dry skin and lips, muscle and joint pain, headache, elevated triglyceride levels (a type of cholesterol), elevated liver enzymes, decreased night vision, and, rarely, temporary hair shedding. For most people taking these drugs, side effects are tolerable and not a reason to discontinue therapy before the acne clears up.

Azelaic acid. Another topical is azelaic acid, which comes in a gel, cream or foam and has antibacterial and anti-inflammatory properties. It is more commonly used for another type of condition called rosacea, but it may help mild acne.

Dapsone. Dapsone is a topical gel that is antibacterial and anti-inflammatory.

Oral contraceptives. Birth control pills contain female hormones that work by counteracting the effect of male hormones (such as testosterone) on acne. Their use is limited to female patients. The maximum benefit of oral contraceptives on acne occurs in three to four months. Side effects include nausea, spotting, breast tenderness, and blood clots

Spironolactone (Aldactone). Spironolactone is an oral drug that can block the action of the body’s hormones on the skin’s oil glands. This medication is not FDA-approved for acne, but is especially helpful for women who have acne that worsens around the time of menstruation and menopause.

Clascoterone (Winlevi) is a newly approved topical treatment for moderate to severe acne which is considered an alternative to spironolactone. It targets the hormones that cause acne. Just how it works is not quite understood but it has been found to reduce acne in both males and females over the age of 12.
Another common drug your doctor may try is triamcinolone, a type of corticosteroid solution that is injected directly into acne nodules.

Warning About Acne Treatments

Patients taking acne drugs should be alert to possible side effects and interactions with other drugs and herbal remedies.
The topical retinoids and benzoyl peroxide can leave skin reddened, dry, and sensitive to sunlight.
Oral antibiotics may cause sensitivity to sunlight and stomach upset.
Benzoyl peroxide may inhibit the effects of some topical retinoids, so never apply them at the same time of day.
Taking oral antibiotics for more than a few weeks may leave women susceptible to yeast infections.
Some over-the-counter acne products can cause rare but serious allergic reactions or severe irritation. Seek emergency medical attention if you have symptoms such as throat tightness, difficulty breathing, feeling faint, or swelling of the face or tongue. Also stop using the product if you develop hives or itching. Symptoms can appear anywhere from minutes to a day or longer after use.

Acne Scar Treatments

Some adults carry scars from acne. Some relatively aggressive surgical procedures can improve scars. Procedures include dermabrasion, several types of lasers, and chemical peeling. These procedures remove the scarred surface and expose unblemished skin layers. Dermatologists may also use the following:

Dermatologists may use more superficial peels such as glycolic or salicylic acid help to loosen whiteheads and blackheads and decrease pimples.
Microdermabrasion has little effect on acne itself, but is effective in combination with lasers. Before considering any treatment it is important to discuss the procedures, necessary precautions, and likely results with a doctor.

How Can I Prevent Acne?

Because of acne’s association with fluctuating hormone levels and possible genetic influences, many doctors believe there is no way to prevent it. The accepted wisdom is that neither good hygiene nor diet can prevent outbreaks. Treatments can control acne and minimize future breakouts. Sensible skin care is recommended, especially during adolescence. The basics include a daily bath or shower and washing the face and hands with unscented or mildly antibacterial soap.

Other tips for preventing future outbreaks include:

10 Tips for Preventing Acne

1. Keep your face clean. Whether or not you have acne, it’s important to wash your face twice daily to remove impurities, dead skin cells, and extra oil from your skin’s surface. Washing more often than twice daily is not necessarily better; it may do more harm than good. Use warm, not hot, water and a mild facial cleanser. Using a harsh soap (like deodorant body soap) can hurt already inflamed skin and cause more irritation.
Avoid scrubbing your skin harshly with a washcloth, an exfoliating glove, or loofah (a coarse-textured sponge). Gently wash it with a very soft cloth or your hands. Always rinse well, and then dry your face with a clean towel. (Toss the towel in the laundry hamper, as dirty towels spread bacteria.) Also, use the washcloth only once.

2. Moisturize. Many acne products contain ingredients that dry the skin, so always use a moisturizer that minimizes dryness and skin peeling. Look for “noncomedogenic” on the label, which means it should not cause acne. There are moisturizers made for oily, dry, or combination skin.

3. Try an over-the-counter acne product. These acne products don’t need a prescription. Most of them have ingredients such as benzoyl peroxide, salicylic acid, glycolic acid, or lactic acid, which curb bacteria and dry your skin. They may cause drying or peeling so start with a small amount at first. Then you can adjust how much you use and how often. Another option is a new OTC topical retinoid gel (Differin 0.1% gel). It works to actually keep the acne from forming. Use these products with caution if you have sensitive skin.

4. Use makeup sparingly. During a breakout, avoid wearing foundation, powder, or blush. If you do wear makeup, wash it off at the end of the day. If possible, choose oil-free cosmetics without added dyes and chemicals. Choose makeup that is labeled as “noncomedogenic,” meaning it should not cause acne. Read the ingredients list on the product label before buying.

5. Watch what you put on your hair. Avoid using fragrances, oils, pomades, or gels on your hair. If they get on your face, they can block your skin’s pores and irritate your skin. Use a gentle shampoo and conditioner. Oily hair can add to the oil on your face, so wash your hair often, especially if you’re breaking out. Got long hair? Keep it pulled away from your face.

6. Keep your hands off your face. Avoid touching your face or propping your cheek or chin on your hands. Not only can you spread bacteria, you can also irritate the already inflamed facial skin. Never pick or pop pimples with your fingers, as it can lead to infection and scarring.

7. Stay out of the sun. The sun’s ultraviolet rays can increase inflammation and redness, and can cause post-inflammatory hyperpigmentation (dark discoloration). Some acne medications may make your skin more sensitive to sunlight. Limit your time in the sun, especially between the hours of 10 a.m. and 4 p.m., and wear protective clothing, such as a long-sleeved shirt, pants, and a broad-brimmed hat. Whether you have pimples or not, always apply a broad-spectrum sunscreen with 6% zinc oxide or higher and SPF 30 or higher at least 20 minutes before sun exposure. Look for “noncomedogenic” on the sunscreen label to make new pimples less likely. Read the ingredients on the product label to know what you’re putting on your skin.

8. Feed your skin. Most experts agree that certain foods, like chocolate, don’t cause pimples. Still, it makes sense to avoid greasy food and junk food and add more fresh fruits, vegetables and whole grains to your diet. Dairy products and foods high in processed sugar may trigger acne. Avoid these.

9. Exercise daily. Regular exercise is good for your whole body, including your skin. When you exercise, avoid wearing clothing or using exercise equipment that rubs your skin and may cause irritation. Shower or bathe right after exercise.

10. Chill! Some studies link stress with the severity of pimples or acne. Ask yourself what’s making you feel stressed. Then look for solutions.
When in doubt, check with a dermatologist to see if you need more treatment to prevent or stop acne.

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