There’s nothing worse than waking up in the morning and finding a big, red pimple on your face. Most of us had when we were teenagers but some of us still suffer from acne breakouts well into our twenties and beyond.
Last year, I also started to have acne breakouts out of the blue after years of enjoying my smooth, acne free skin. I knew at the time that acne was caused by clogged pores so I thought I was doing the right thing when I washed my face every day, twice a day, with a heavy-duty exfoliating face wash. And to no one’s surprise, my acne problem didn’t get any better—in fact, it got worse! That’s when I decided to do my homework and actually learn about acne – the science behind what causes them and their treatments – through actual scientific research (and not what some girl says on Youtube).
So what causes acne and how should you treat it? Keep reading below to find out!
What is Acne?
To understand what causes acne, we must first understand how our skin works. Our skin has three parts to it: the uppermost layer, which is called the epidermis, the middle layer – where the sebaceous glands are located, called the dermis, and the bottom layer – where the hair follicle starts, called the subcutaneous tissue.
When our pores are unclogged and our sebaceous glands are producing the right amount of oil, all is well. However, problems start occurring when there is too much oil, a clogged pore, or a bacterial infection.
Contrary to what many people believe, a clogged pore is usually caused by a condition called hyperkeratinization, and not the result of poor hygiene or a “dirty” face. Normally, skin cells along the hair follicle detach at regular intervals and are then forced out by the growing hair. But when your skin makes too much keratin, which is largely influenced by genetics, these dead skin cells do not leave the follicle. The excess keratin and oil makes the dead skin cells adhere to each other, making it much more likely for a clog to form and cause acne.
In addition to clogged pores and excess oil, bacteria is the third member of the acne triad that we should know about. The bacteria that causes acne (Propionibacterium acnes) is an anaerobic organism that lives deep within the follicles of our skin and gets its energy by metabolizing the oil produced by the sebaceous glands. The bacteria itself is pretty harmless and does not cause a problem if our pores remain unclogged and lets any of the excess sebum that is produced to rise to the top of our skin. The trouble arises, however, when the sebum remains in a clog in the pore. It is in these cases where the bacteria rapidly multiples, triggers an inflammatory reaction, and the resulting red pimple.
The Different Types of Acne
There are five distinct types of acne, and can be separated into two distinct groups: inflammatory and non-inflammatory acne.
The two most common are whiteheads and blackheads, which are the non-inflammatory type of acne.
Whiteheads form when the pore is blocked near the top of the epidermis. The sludge of bacteria, sebum, white blood cells and dead skin cells remain trapped beneath the surface of the skin with only a microscopic opening, not big enough for the contents of the pore to be excreted out.
A blackhead, or an open comedo, is a wide opening on the skin with a blackened mass of skin debris covering the opening. They are filled with plugs of sebum and sloughed-off cells and have undergone a chemical reaction resulting in the oxidation of melanin. This gives the material in the follicle the typical black color.
When a pore becomes blocked and causes the wall of the pore to collapses and release the bacteria-ridden clog of skin cells and sebum into the dermis layer of the skin, it leads to other, more severe forms of acne lesions. Among these are papules, pustules, and cysts.
Papules are small bumps that appear on your skin and have a rough texture. These occur when the wall of a hair follicle break and cave in. The visible inflammation is due to white blood cells rushing in and trying to contain the bacterial sludge in the compromised pore.
Pustules are simply the medical term for pimples or zits. They are visible several days after papules have formed, when the white blood cells rise to the surface of the skin. Like cystic acne, pustules can be large and painful.
The most severe type of acne is when the inflammation reaches deep into the skin and an acne cyst forms. This happens when the bottom of the follicle breaks, and causes the follicle to completely collapse and spread the mixture of pus, bacteria and oil into surrounding tissue. Cysts are therefore very painful and people often see permanent scarring after this type of acne.
How To Treat Acne
Acne is caused by clogged pores, bacterial infection, and excess sebum production. Therefore, effective acne treatments work by speeding up the skin cell turnover (thereby reducing the chances of pore blockage), fighting bacterial infection, and reducing oil production.
For treating mild acne, like treating blackheads and whiteheads, we’re going to focus on the first two.
We need to first start off with a mild facial cleanser with glycolic or salicylic acid, like DHC’s Salicylic Acne Wash.
These are chemical exfoliants that remove dead skin cells from the skin and helps reduce the chances of future breakouts. It’s important to remember that acne-prone skin is typically not the result of poor hygiene or a dirty face. So avoid the urge to scrub your face too hard because that will likely cause more irritation in the skin, making the acne worse. When cleansing, be gentle and imagine you’re washing the soft skin of a baby’s face. Let these chemical exfoliants do their work and avoid scrubbing your face too harshly. Do this twice a day.
Next, we must deal with the bacteria. The gold standard is a topical cream containing benzoyl peroxide. I use Neutrogena’s On-the-Spot Acne Treatment.
The painful inflammatory acne that we experience is caused by our body’s immune response to the bacteria in our pores. Merely cleansing our face does not deal with the bacteria, so we need to do something else to address this issue. A topical cream containing benzoyl peroxide is your best bet, since it does three important things to fight acne all at once.
First, it works as an exfoliant by helping dissolve those clogs of dead cells and oil after they form. Second, it has antibacterial properties that kill the bacteria that cause acne. If you remember, the acne bacteria Propionibacterium acnes is an anaerobic organism, meaning it can only survive in oxygen-deprived environments. Benzoyl peroxide injects oxygen into the skin and makes it uninhabitable for the bacteria, effectively killing them without the use antibiotics. And finally, the same oxygen rich environment that prevents acne from multiplying also helps in the healing of all types of acne. Apply a thin layer of the cream all over your face, and a second layer over the problem areas.
Finally, moisturize your skin with an oil-free moisturizer. I switch between Dermalogica Skin Smoothing Cream and DHC’s Salicylic Face Milk, depending on the condition of my skin that day.
The constant exfoliation and stripping of oils from our skin may excessively dry out our skin and therefore increase the chances of irritation. Properly reintroducing hydration into the skin not only eliminates flakiness which benzoyl peroxide can produce, it also helps prevent the skin from becoming red or irritated. But before putting anything on, make sure it is labeled “water-based,” “oil-free,” or “non-comodogenic”. Some moisturizers have ingredients in them that have been clinically shown to aggravate acne, so you want to make sure you stay away from those.
The table below from Acne.org lists ingredients which score a 3 or above on the 0-5 comedogenicity scale. If any of these are within the first seven ingredients on the ingredient list of a product you are choosing, you may want to reconsider.
Time to Call in The Specialist
If you don’t see a change in your acne condition or if it gets worse from using over the counter treatments, you should consult a dermatologist. Here are some treatments they may recommend:
Antibiotics – Oral antibiotics, such as tetracycline and doxycycline, are often prescribed for acne. If you eliminate the bacteria that cause inflammatory acne, then you get no acne. Taking antibiotics as directed will help your acne clear but the downside is that there may be a bacterial resistance with prolonged use.
Interlesional Corticosteroid Injection – When an acne cyst becomes severely inflamed, there is a good chance that it will rupture and scarring may result. To treat these severely inflamed cysts and prevent scarring, dermatologists may inject such cysts with a much-diluted corticosteroid. This lessens the inflammation and promotes healing.
Topical Retinoids – Retinoids are a derivative of vitamin A and considered a cornerstone in acne treatment. They work by regulating the cellular turnover in the skin cells to unclog pores and prevent whiteheads and blackheads from forming. Topical retinoids can irritate the skin and increase sun sensitivity so it is important to use sun protection and follow the dermatologist’s directions to maximize effectiveness. An added benefit in using topical retinoids is that they may help diminish the signs of aging, such as fine lines and wrinkles.
Oral Contraceptives – Oral contraceptives have been shown to effectively clear acne in women by reducing androgens (male sex hormones) in the body. Studies have shown a causal link between the dihydrotestosterone (DHT) and overactive sebaceous glands in women. The more DHT a woman has, the more likely she is to have acne. This makes sense, since puberty is when we first start experiencing acne breakouts, the same time our hormones kick into overdrive. By suppressing androgens in the body, you are also effectively suppressing the overactive sebaceous glands.
Lasers – Laser therapy works on the premise of exciting compounds called porphyrins (a type of pigment), which are inside acne bacteria. When the lasers excite the porphyrins, the porphyrins damage the bacteria wall, effectively killing the bacteria. However, consensus amongst researchers is that results are temporary since colonies of acne bacteria grow back quickly. Results are also incomplete, since lasers alone usually do not completely clear acne.
Accutane – It’s very simple: Accutane stops oil glands from making oil, and if oil glands don’t make oil, you can’t have acne. However, like any other potent drug, there are severe side effects that must also be taken into consideration. Probably the most widely known side effect of Accutane treatment is the effect it has on a developing fetus. Accutane must never be used while pregnant and even one dose of the drug while pregnant can cause severe birth defects. Women of childbearing potential must therefore submit to regular pregnancy tests are required to use two forms of birth control, both before, during, and for one month after treatment. The other most publicized side effect of the drug is depression and suicide. Even though medical studies concerning this issue were inconclusive, anybody that is a candidate for Accutane and has a history of depression or is taking medicine for depression should consult with the physician who is treating that depression.
How Long Does it Take Before I See Results?
How long does a new skincare regimen to work? The short answer is we are talking about weeks not days. This is a perfect example of when patience is a virtue; this is a process of evolution not revolution. If you are not realistic in your expectations you are just going to go from product to product. How many of us are guilty of tossing or returning a product after three days just because you did not see the results that you wanted?
When you are using a new regimen, it has to take at least a week to see any meaningful results, even with the best products. There are a lot of very good products out there, but there are no miracle products.
Most dermatologists recommend sticking to a regimen for 4 to 8 weeks before making changes to the treatment. It is very important to be aware of this time frame so that you do not become discouraged and discontinue the regimen. Conversely, if you see no change whatsoever after two months, you might want to check with your dermatologist regarding alternative therapies to treat acne.
“The role of follicular hyperkeratinization in acne” Journal of Dermatological Treatment. http://informahealthcare.com/doi/abs/10.1080/095466300750163645?journalCode=jdt
“The Response of Skin Disease to Stress” Journal of Dermatology. http://archderm.jamanetwork.com/article.aspx?articleid=479409
“How to wash acne-prone skin” Acne.org. http://www.skincarephysicians.com/acnenet/acne_prone_wash.html
“What is Acne?” American Academy of Dermatology. http://www.skincarephysicians.com/acnenet/acne.html
“Benzoyl peroxide: a review of its current use in the treatment of acne vulgaris” Expert Opinion on Pharmacotherapy. http://www.ncbi.nlm.nih.gov/pubmed/19761357
“Disorders of the sebaceous glands” Rook’s Textbook of Dermatology