Understanding Acne: Causes, Types, and Effective Treatments Explained | Doctor Anne

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Almost everyone will experience pimples at one point in their life, and for many people, myself included, it isn’t just one or two. No, it is full blown acne. But don’t you worry, we have many efficient treatments available, and once you understand why you develop blackheads, papules and maybe even cysts, finding the right treatment is much easier.

 

A blonde woman holding a skin model
Understand your skin

 

Acne can affect everyone no matter their age and it almost always has a negative impact on self esteem and mental health. In order to treat it effectively, you need to understand what causes acne – so let’s talk basic skin function!

 

 

My acne experience

I was eleven when I had my first blackheads and twelve when I went to see a dermatologist because my whole face was covered in red and painful spots. Back then I thought acne was something you grow out of, but what can I say, after a short period of okay-ish skin age 15 to 25, my acne decided to return full force and believe it or not, it has stayed with me ever since.

Only that now I have it under control.

 

Blonde woman with acne
Me in 2008. If you look closely, you can see the acne despite the heavy layer of makeup

 

Where acne happens

Just to be clear, there is no difference between having spots and having acne. Acne is simply the medical term.

The skin structure in which acne manifests is called the „Pilosebaceous Unit„, a name coming from piles, the hair, and sebaceous gland or oil gland.

Each hair follicle, no matter if it produces strong pigmented hair like the one on your head or the baby hairs we often call peach fuzz, has the same structure: the hair follicle and the oil glands that secret their sebum into the channel here where it travels up to the skin surface and lubricates the skin.

That process usually works great until you reach adolescence and hormones start taking control of your life – both in the way you think and in the way your skin behaves. The ones to blame here are the androgens, commonly referred to as male hormones although everyone has them, just in varying concentrations. (More info: The best skincare routine for teenage skin)

These hormones affect the pilosebaceous unit in two different ways:

  1. They tell the oil glands to produce more oil
  2. They make your skin cells sticky so they clog up the opening of the pore

 

The different types of acne

Acne isn’t just a full face of cystic spots. There are different types that need different treatment, so let me break them down for you.

Acne starts with non-inflammatory lesions (non-inflammatory acne) on your face, referred to as blackheads and whiteheads. Both signal an accumulation of sebum and skin cells inside the pore, only that in whiteheads the content of the pore is underneath a layer of skin cells, so has no contact to air – the pore is blocked – and that in blackheads the sebum/ cell debris mixture is exposed to air, so it oxidizes and turns dark grey or black – the pore is open, just stuffed. (More info: The secret to smaller looking pores)

What might happen now is that the bacteria everyone has on their skin, especially one called Cutibacterium acne, goes into food frenzy – it feeds of sebum and suddenly there is a lot of that in one place, so it starts to replicate like crazy, causing bacterial overgrowth and an infection. That manifests on the skin as papule or pustule, depending on whether you see pus at the top of the lesion or just red and inflamed tissue. We crossed the line from non-inflammatory to inflammatory acne.

When the walls of the pilosebaceous unit rupture and the tissue around it gets inflamed too, you will develop nodules, red and painful spots or even cysts – cystic acne.

Another way to differentiate acne is into Light Acne, which is blackheads and whiteheads, either consistently or just occasionally, Medium Acne, which is blackheads, whiteheads and papules or pustules, and Severe Acne, which is everything plus cysts and a high potential for scarring.

 

What is hormonal acne?

You might have heard the term hormonal acne, referring to cystic acne along the jawline and most prevalent in adults, but that isn’t a correct classification. All acne is hormonal as in triggered by hormones, it is just that people develop different forms. And if the painful cysts developing around the jawline is actually more common in adult women is often reported, but more anecdotal evidence. Nobody really ran the numbers on that.

What we can say is that the majority of people develop acne in puberty, with people born male affected more often than people born female and that for some it goes away once they reach adulthood, for others it stays, often fluctuating in severity and for a third group, mostly women, appears for the first time in their mid-20s. While during puberty those born male are affected more often, in adulthood that changes and more people born female are.

Whenever you experience hormonal changes, puberty, pregnancy and perimenopause and menopause, chances are you will also experience acne.

 

How do you best treat acne?

Remember, there are four pillars in developing acne:

  1. Excess oil production due to overactive sebaceous glands
  2. Increased stickiness of the skin cells leading to clogged pores
  3. Bacterial overgrowth
  4. Inflammation.

All these steps can be targeted individually, and depending on the severity of your acne you will need to combine one or more different things.

 

Light acne with blackheads
Light acne with blackheads

 

Light acne or non-inflammatory acne

If you see clogged pores in the form of blackheads and whiteheads on your face chest or back, you have a light form of acne. The first and often only treatment step needed here is to address the pore clogging, ideally with something that gets into the pores and breaks up the sticky skin cells – Salicylic Acid (More info: The benefits of acids in your skincare explained). It is oil soluble, available as leave on or wash off, and easy to get at your local drugstore.

Another thing you can do is try to regulate your oil production. Now the size and the activity of your oil glands are mainly determined by your genetics and your hormones, and neither of that is in your control. But certain ingredients might help balance things out, think Niacinamide, Zinc, Centella Asiatica or Green Tea Extract, and using a clay mask regular can help absorb the oil quicker so it doesn’t stay on the skin too long. (More info: The benefits of Niacinamide in your skincare routine explained, The benefits of Centella Asiatica in your skincare routine explained  and The benefits of Green Tea Extract in your skincare routine explained)

 

Inflammatory acne
Inflammatory acne
Picture credit: DermNetNZ

 

Medium or inflammatory acne

Once you start developing pustules or papules, you have bacterial overgrowth. In addition to the things you did in step one for light acne, you might want to add Benzoyl Peroxide, preferably as a cleanser – beware of the fabric bleach, I still have ruined towels from that! Lower concentrations are available without prescription and help calm down inflammation and keep bacteria at bay.

You might also want to try adding a retinoid to help with cell turnover, but if they have an effect on acne depends on their formulation – the more effective ones are prescription in most countries, with Adapalene or Differin being the exception in the US.

Antibiotics might be considered here as well, but for those as well as for stronger retinoids you need to see a doctor.

 

Cystic Acne on the cheek
Cystic Acne
Picture credit: DermNetNZ

 

Severe or cystic acne

While Salicylic Acid, Benzoyl Peroxide and Retinoids are key factors in treating severe acne as well, I would urge you to go see a doctor if you suffer from it. The reason is the high risk for scarring that comes with the cysts, and once the scar has formed, it is really hard to treat.

Prevention is key, and the best prevention is by quickly controlling the underlying condition. That can be done with oral antibiotics, spironolactone, prescription retinoids or even oral retinoids, all under medical guidance.

 

New skincare from Stylevana, Geek and Gorgeous and Real Barrier standing in front of a dark background.
With so many options out there, it can be hard to pick the right products

 

Acne skincare

No matter where on the acne severity scale you are, the skincare you pick to go with your treatments of choice should be as gentle as possible. Both the over the counter as well as the prescription options can be irritating, and the last thing you want to do is anger an inflammatory skin condition further. No physical scrubs, no stripping alcohol laden toners – believe me, I learned that the hard way. When I was 13, acne was basically treated by burning your face off!

 

Snail mucin is refined before it is put into your skincare.
You do NOT need hormone testing when you suffer from acne!
Image by Michal Jarmoluk from Pixabay

 

Do I need to get my hormones tested if I have acne?

A very common question I get is if you should get your hormone levels checked as acne is, we mentioned that before, hormonal. The answer is no.

Despite being triggered by changes in hormones – and we all know that when the estrogen drops, so we have relatively more testosterone right before menstruation, our skin acts up – hormone levels don’t tend to come back altered. With the exception of an underlying condition like Polycystic Ovarian Syndrom of course.

Maybe it is better to say that the hormone concentration around the pilosebaceous unit is altered, or that in some people the pilosebaceous unit is more sensitive to hormonal changes. I certainly have no signs of an excess of male hormones – think deep voice, facial hair, builds muscle easily – but have suffered from acne for 32 years now.

 

The effect of diet on acne
A little chocolate never hurt anyone – or does it?

 

Other contributing factors to acne

Genetics and hormones are surely the main drivers of acne, and frustratingly enough, they can’t be changed. My father had acne, I have acne, my kids will most likely get acne too – that is just how things go.

But are there other things that influence acne or acne severity? Of course there are. Stress is one, not cleansing the makeup off your face at night is another. Some studies report that for certain people food influences their skin, especially foods with a high glycemic index and dairy. But, and I can’t stress that enough, all those lifestyle factors play a much lesser role than genetics and hormones. If your parents both had acne, you can’t meditate your risk away. If your face is covered in cystic spots, cutting sugar and dairy won’t give you clear skin. (More info: Does your food influence your acne?)

Eat a balanced diet, try to reduce stress and get enough sleep, exercise and wash your makeup off at night – but for the love of whatever is holy to you: Treat your acne for what it is. A medical condition that needs medical treatment as it has the ability to leave you with permanent scars. Both on your body and your soul.

 

blisters of drugs
The pill is one of the options to improve acne – but not for everyone
Image by Leopictures from Pixabay

 

Is going on the pill good or bad for acne?

For people identifying as female going on the pill might help as well as it balances out the hormonal fluctuation. Acne while you are under gender affirming care is a whole different topic and should be discussed with an expert! I know there is a lot of bad mouthing the pill out there on the internet with praise of “natural hormone cycles” but as someone with acne and hormonally triggered migraines, let me tell you that being on the pill for the majority of my reproductive years has been a huge improvement in my quality of life and the main reason for my phase of okay-ish skin aged 15 to 25.

This effect differs from person to person though, so again: Discuss it with your treating doctor.

 

Sometimes only a visit to the doctor can help
Picture credit: Canva

 

When should I see a doctor?

There is no one right answer for that:

Whenever what you are doing doesn’t bring the improvement you hope for, when you start to scar or when it affects your mental health is the right time to see a doctor.

When that is differs for everyone, so only you can make that decision.

 

Woman with acne lesions on the side of her face
Acne is a chronic condition
Image by Alexander Grey from Pixabay

 

How long do I need to treat my acne?

How long you need to treat your acne depends.

For some it goes away once they are adults, but for many it is a chronic disease. The latest time for a first manifestation is for people entering menopause, so thinking of it as possibly a lifelong thing isn’t too far away from the truth.

I am 45 now and when I change my basic acne skincare regime, I develop first congestion and then cysts. I have given up the hope I might outgrow it. The good thing though is that once you figured out what works for you, it is easy to keep it under control – on my face, no one could tell that I still suffer from it.

And: An acne skincare regime shouldn’t be expensive. The actives are available in effective and affordable formulas, and quite a few of them will offer additional anti-aging benefits, meaning after the struggles you are rewarded with more graceful aging.

You will need to adapt your routine to your changing skin though, the oily teenage skin needs other products than the mature leaning dry acne sufferer, but at this day and age there is a right product for everyone out there.

 

TL;DR – Why you have pimples on your face

Almost everyone will face the wrath of pimples at some point, trust me, it’s not just you. Acne can hit hard and mess with your self-esteem, but understanding its causes makes treatment so much easier.

So, let’s get nerdy about skin. Acne pops up in something called the pilosebaceous unit, where your hair follicles and oil glands meet. Thanks to androgens (those pesky hormones that everyone has to some extent, not just those born male), your oil glands go into overdrive, and your skin cells turn into clingy little things that clog pores.

We’ve got:

  • Non-inflammatory acne: Think blackheads and whiteheads.
  • Inflammatory acne: Papules, pustules, nodules, and cysts.

Treatment depends on the severity: For light acne (blackheads/whiteheads), Salicylic Acid to fight congestion is a great start. For medium acne (papules/pustules), add Benzoyl Peroxide (but watch out for bleach stains!) and/ or retinoids. For severe acne (cysts), it’s time to see a doctor – treat it early to prevent scarring.

Remember, all acne is hormonal and often genetically determined. Stick to a gentle skincare routine and seek professional advice when things don’t improve, ideally before you develop scars and whenever your mental health gets affected.

Acne causes and treatment options explained
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