Medical Author : Gary W. Cole, MD, FAAD
Medical Editor : Melissa Conrad Stöppler, MD
What is acne?
Acne (acne vulgaris, common acne) is a disease of the hair follicles of the face, chest, and back that affects almost all teenagers during puberty -- the only exception being members of a few primitive Neolithic tribes living in isolation. It is not caused by bacteria, although bacteria play a role in its development. It is not unusual for some women to develop acne in their mid- to late-20s.
Acne appears on the skin as...
- occluded pores ("comedones"), also known as blackheads or whiteheads,
- tender red bumps also known as pimples or zits,
- pustules, and occasionally as
- cysts (deep pimples, boils).
You can do a lot to treat your acne using products available at a drugstore or cosmetic counter that do not require a prescription. However, for tougher cases of acne, you should consult a physician for treatment options.
What causes acne?
No one factor causes acne. Acne occurs when sebaceous (oil) glands attached to the hair follicles are stimulated at the time of puberty by circulating male hormones. Sebum (oil) is a natural substance that lubricates and protects the skin. Associated with increased oil production is a change in the manner in which the skin cells mature, predisposing them to plug the follicular pore. The plug can appear as a whitehead if it is covered by a thin layer of skin, or if exposed to the air, the darker exposed portion of the plug is called a "blackhead." The plugged hair follicle gradually enlarges, producing a bump. As the follicle enlarges, the wall may rupture, allowing irritating substances and normal skin bacteria access into the deeper layers of the skin, ultimately producing inflammation. Inflammation near the skin's surface produces a pustule; deeper inflammation results in a papule (pimple); if the inflammation is deeper still, it forms a cyst.
Here are some factors that don't usually play a role in acne:
- Food: Parents often tell teens to avoid pizza, greasy and fried foods, and junk food. While these foods may not be good for overall health, they don't cause acne or make it worse. Although some recent studies have implicated milk and pure chocolate in aggravating acne, these findings are very far from established.
- Dirt: Blackheads are oxidized oil, not dirt. Sweat does not cause acne and is produced by entirely separate glands in the skin. On the other hand, excessive washing can dry and irritate the skin.
- Stress: Some people get so upset by their pimples that they pick at them and make them last longer. Stress, however, does not play much of a direct role in causing acne.
In occasional patients, the following may be contributing factors:
- Heredity: If one of your parents had severe acne, it is likely that your acne will be more difficult to control.
- Pressure: In some patients, pressure from helmets, chin straps, collars, suspenders, and the like can aggravate acne.
- Drugs: Some medications may cause or worsen acne, such as those containing iodides, bromides, or oral or injected steroids (either the medically prescribed prednisone [Deltasone, Orasone, Prednicen-M, Liquid Pred] or the steroids that bodybuilders or athletes sometimes take). Other drugs that can cause or aggravate acne are anticonvulsant medications and lithium (Eskalith, Lithobid). Most cases of acne, however, are not drug related.
- Occupations: In some jobs, exposure to industrial products like cutting oils may produce acne.
- Cosmetics: Some cosmetics and skin-care products are pore clogging ("comedogenic"). Of the many available brands of skin-care products, it is important to read the list of ingredients and choose those which have water listed first or second if you are concerned about acne. These "water-based" products are usually best for those with acne.
What other skin conditions can mimic acne?
- Rosacea: This condition is characterized by pimples but not comedones and occurs in the middle third of the face, along with redness, flushing, and superficial blood vessels. It generally affects people in their 30s and 40s and older.
- Pseudofolliculitis: This is sometimes called "razor bumps" or "razor rash." When cut too close to the skin, growing hairs twist into the skin and produce tender bumps. This is a mechanical problem, and treatment involves shaving less (growing a beard, laser hair removal). Pseudofolliculitis can, of course, occur in patients who have acne, too.
- Folliculitis: Pimples can occur on other parts of the body, such as the abdomen, buttocks, or legs. These represent not acne but inflamed follicles. If these don't go away on their own, doctors can prescribe oral or external antibiotics, generally not the same ones used for acne.
- Gram-negative folliculitis: Some patients who have been treated with oral antibiotics for long periods develop pustules filled with bacteria that are resistant to the antibiotics that were previously used. Bacterial culture tests can identify these germs, leading the doctor to prescribe different antibiotics or other forms of treatment.
When should you start acne treatment?
Since everyone gets acne at some time, the right time to treat it is when it bothers you or when the potential for scarring develops. This can be when severe acne flares suddenly, for mild acne that just won't go away, or even when a single pimple decides to show up the week before your prom or wedding. The decision is yours.
What can you do about acne on your own?
Moderation and regularity are good things, but not everyone can sleep eight hours, eat three good meals, and drink eight glasses of water a day. You can, however, still control your acne even if your routine is frantic and unpredictable. Probably the most useful lifestyle changes you can make are to never to pick or squeeze pimples. Playing with or popping pimples, no matter how careful and clean you are, nearly always makes bumps stay redder and bumpier longer. People often refer to redness as "scarring," but fortunately, it usually isn't in the permanent sense. It's just a mark that takes months to fade if left entirely alone.
Open the pores
Occasional visits to an esthetician who is an expert at removing blackheads can be beneficial.
Cleansing and skin care
Despite what you read in popular style and fashion magazines, there is no magic product or regimen that is right for every person and situation.
- Mild cleansers: Washing once or twice a day with a mild cleansing bar or liquid (for example, Dove, Neutrogena, Basis, Purpose, and Cetaphil are all inexpensive and popular) will keep the skin clean and minimize sensitivity and irritation.
- Exfoliating cleansers and masks: A variety of mild scrubs, exfoliants, and masks can be used. These products may contain salicylic acid in a concentration that makes it a very mild peeling agent. These products remove the outer layer of the skin and thus open pores. Products containing glycolic or alpha hydroxy acids are also gentle skin exfoliants.
- Retinol: Not to be confused with the prescription medication Retin-A, this derivative of vitamin A can help promote skin peeling.
- Antibacterial cleansers: The most popular ingredient in over-the-counter antibacterial cleansers is benzoyl peroxide.
- Topical (external) applications: These products come in the form of gels, creams, and lotions, which are applied to the affected area. The active ingredients that kill surface bacteria include benzoyl peroxide, sulfur, and resorcinol. Some brands promoted on the Internet and cable TV (such as ProActiv) are much more costly than identical and sometimes more potent products you can buy in the drugstore.
Benzoyl peroxide causes red and scaly skin irritation in a small number of people, which goes away as soon as you stop using the product. Keep in mind that benzoyl peroxide is a bleach, so do not let products containing benzoyl peroxide come into contact with fabrics, leaving unsightly white spots on colored clothes, shirts, towels, and carpets.
Reduce the oil
You cannot stop your oil glands from producing oil (unless you mess with your hormones or metabolism in ways you shouldn't). Even isotretinoin (Accutane, see below) only slows down oil glands for a while; they come back to life later. What you can do is to get rid of oil on the surface of the skin and reduce the embarrassing shine.
- Use a gentle astringent/toner to wipe away oil. (There are many brands available in pharmacies, as well as from manufacturers of cosmetic lines.)
- Products containing glycolic acid or one of the other alpha hydroxy acids are also mildly helpful in clearing the skin by causing the superficial layer of the skin to peel (exfoliate).
- Masks containing sulfur and other ingredients draw out facial oil.
- Antibacterial pads containing benzoyl peroxide have the additional benefit of helping you wipe away oil.
What are other things you can do for acne? Are there any home remedies for acne?
- Cosmetics: Don't be afraid to hide blemishes with flesh-tinted cover-ups or even foundation, as long as it is water-based (which makes it noncomedogenic). There are many quality products available.
- Facials: While not absolutely essential, steaming and "deep-cleaning" pores is useful, both alone and in addition to medical treatment, especially for people with "whiteheads" or "blackheads." Having these pores unclogged by a professional also reduces the temptation to do it yourself.
- Pore strips: Pharmacies now carry, under a variety of brand names, strips which you put on your nose, forehead, chin, etc., to "pull out" oil from your pores. These are, in effect, a do-it-yourself facial. They are inexpensive, safe, and work reasonably well if used properly.
- Toothpaste: One popular home remedy is to put toothpaste on zits. There is no medical basis for this. Ditto for vinegar.
What is a good basic skin regimen?
These are all good basic skin regimens that may help with the acne battle:
- Cleanse twice daily with a 5% benzoyl peroxide wash. An alternative for those who are allergic to benzoyl peroxide is 2% salicylic acid.
- Apply a gel or cream containing 5% benzoyl peroxide; an alternative is sulfur or resorcinol.
- At night, apply a spot cream containing sulfur to the affected areas.
- Use a light skin moisturizer and water-based makeup.
How does a doctor treat acne?
If you haven't been able to control your acne adequately, you may want to consult a primary-care physician or dermatologist. The goal of treatment should be the prevention of scarring (not a flawless complexion) so that after the condition spontaneously resolves there is no lasting sign of the affliction. Here are some of the options available:
- Topical (externally applied) antibiotics and antibacterials: These include erythromycin (E-Mycin, Eryc, Ery-Tab, PCE, Pediazole, Ilosone), clindamycin (BenzaClin, Duac), sulfacetamide (Klaron), and azelaic acid (Azelex or Finacea).
- Retinoids: Retin-A (tretinoin) has been around for years, and preparations have become milder and gentler while still maintaining its effectiveness. Newer retinoids include adapalene (Differin) and tazarotene (Tazorac). These medications are especially helpful for unclogging pores. Side effects may include irritation and a mild increase in sensitivity to the sun. With proper sun protection, however, they can be used even during sunny periods. In December 2008, the U.S. FDA approved the combination medication known as Epiduo gel, which contains the retinoid adapalene along with the antibacterial cleanser benzoyl peroxide; it is applied once a day.
- Oral antibiotics: Doctors may start treatment with tetracycline (Sumycin) or one of the related "cyclines," such as doxycycline (Vibramycin, Oracea, Adoxa, Atridox, and others) and minocycline (Dynacin, Minocin). Other oral antibiotics that are useful for treating acne are cefadroxil (Duricef), amoxicillin (Amoxil, DisperMox, Trimox), and the sulfa drugs.
- Problems with these drugs can include allergic reactions (especially sulfa), gastrointestinal upset, and increased sun sensitivity. Doxycycline, in particular, is generally safe but can sometime cause esophagitis (irritation of the esophagus, producing discomfort when swallowing) and an increased tendency to sunburn.
- Despite the concern that the long-term use of tetracycline antibiotics for acne might "weaken the immune system" or induce bacterial resistance, these concerns seem to be unwarranted.
- Oral contraceptives: Oral contraceptives, which are low in estrogen to promote safety, have little effect on acne one way or the other. Some contraceptive pills have been shown to have modest effectiveness in treating acne. Those FDA approved for treating acne are Estrostep, Ortho Tri-Cyclen, and Yaz. Most dermatologists work together with primary physicians or gynecologists when recommending these medications.
- Spironolactone (Aldactone): This drug blocks androgen (hormone) receptors. It can cause breast tenderness, menstrual irregularities, and increased potassium levels in the bloodstream. It can help some women with resistant acne, however, and is generally well-tolerated in the young women who need it.
- Cortisone injections: To make large pimples and cysts flatten out fast, doctors inject them with a form of cortisone.
- Isotretinoin: Accutane was the original brand name; there are now several generic versions in common use, including Sotret, Claravis, and Amnesteem. Isotretinoin is an excellent treatment for severe, scarring persistent acne and has been used on millions of patients since it was introduced in Europe in 1971 and in the U.S. in 1982. It should be used for people with severe acne, chiefly of the cystic variety, which has been unresponsive to conventional therapies like those listed above. The drug has many potential serious side effects and requires a number of unique controls before it is prescribed. This means that isotretinoin is not a good choice for people whose acne is not that bad but who are frustrated and want "something that will knock acne out once and for all." In order to use the drug, the prescribing physician, the patient, and the supplying pharmacy must be enrolled in the online "iPLEDGE PROGRAM." Used properly, isotretinoin is safe and produces few side effects beyond dry lips and occasional muscle aches. This drug is prescribed for five to six months. Fasting blood tests are monitored monthly to check liver function and the level of triglycerides, substances related to cholesterol, which often rise a bit during treatment, but rarely to the point at which treatment has to be modified or stopped.
- Even though isotretinoin does not remain in the body after therapy is stopped, improvement is often long-lasting. It is safe to take two or three courses of the drug if unresponsive acne makes a comeback. It is, however, best to wait at least several months and to try other methods before using isotretinoin again.
- Isotretinoin has a high risk of inducing birth defects if taken by pregnant women. Women of childbearing age who take isotretinoin need two negative pregnancy tests (blood or urine) before starting the drug, monthly tests while they take it, and another after they are done. Those who are sexually active must use two forms of contraception, one of which is usually the oral contraceptive pill. Isotretinoin leaves the body completely when treatment is done; women must be sure to avoid pregnancy for one month after therapy is stopped. There is, however, no risk to childbearing after that time.
- Other concerns include inflammatory bowel disease and the risk of depression and suicide in patients taking isotretinoin. Recent evidence seems to indicate that these problems are exceedingly rare. Government oversight has resulted in a highly publicized and very burdensome national registration system for those taking the drug. This has reinforced concerns in many patients and their families have that isotretinoin is dangerous. In fact, large-scale studies so far have shown no convincing evidence of increased risk for those taking isotretinoin compared with the general population. It is important for those taking this drug to report changes in mood or bowel habits (or any other symptoms) to their doctors. Even patients who are being treated for depression are not barred from taking isotretinoin, whose striking success often improves the mood and outlook of patients with severe disease.
- Light treatments: Recent years have brought reports of success in treating acne using special lights and similar devices, alone or in conjunction with photosensitizing dyes. It appears that these treatments are safe and can be effective, but it is not clear that their success is lasting. At this point, laser treatment of acne is best thought of as an adjunct to conventional therapy, rather than as a substitute.
- Chemical peels: Whether the superficial peels (like glycolic acid) performed by estheticians or deeper ones performed in the doctor's office, chemical peels are of modest, supportive benefit only, and in general, they do not substitute for regular therapy.
- Treatment of acne scars: For those patients whose acne has gone away but left them with permanent scarring, several options are available. These include surgical procedures to elevate deep, depressed acne scars and laser resurfacing to smooth out shallow acne scars. Newer forms of laser resurfacing ("fractional resurfacing") are less invasive and heal faster than older methods, although results are less complete and the procedures may need to be repeated three or more times. These treatments can help, but they are never completely successful at eliminating acne scars.
How would you sum up current-day acne treatment?
Treating acne requires patience and perseverance. Any of the treatments listed above may take two or three months to start working (even isotretinoin). Unless there are side effects such as excessive dryness or allergy, it is important to give each regimen or drug enough time to work before giving up on it and moving on to other methods. Using modern methods, doctors can help clear up the skin of just about everyone.
Just hang in there. And don't pick. Please.
Kurokawa, Ichiro, et al. "New Developments in Our Understanding of Acne Pathogenesis and Treatment." Experimental Dermatology 18 (2009): 821-832.
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