Understanding Acne: A Guide

Acne is one of the most prevalent skin conditions worldwide, affecting an estimated 9.4% of the global population at any given time. While often associated with adolescence, acne impacts individuals of all ages, from teenagers to adults, with factors ranging from hormones to lifestyle choices playing significant roles. Despite being a condition that can significantly affect self-esteem and quality of life, few seek medical treatment. 

To bridge the gap between patient and medical access, this guide serves as a comprehensive overview of acne, exploring its causes, symptoms, treatment options, and preventive strategies, to help equip those affected with the knowledge to make informed decisions about fighting breakouts.

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What Is Acne?

Acne is a chronic inflammatory skin condition that occurs when hair follicles, or pores, become clogged with oil (sebum), dead skin cells, and bacteria. 

This blockage triggers inflammation within the pores, resulting in different lesion types, commonly called zits or pimples:

• Comedones: open (blackhead) or closed (whitehead) clogged skin pore
• Papules: small red bumps
• Pustules: pus-filled bumps
• Nodules: hard, painful lumps under the skin
• Cysts: painful fluid-filled lumps under the skin 

The Investigator Global Assessment (IGA) scale is one of the most widely used scales in clinical trials and medical practice to measure acne severity.

The Biology of Acne: What Causes It?

Acne starts with a tiny, invisible lesion called a microcomedo, which is the first step in the development of all acne types. This small clog forms deep in the hair follicle and comprises dead skin cells and oil. Over time, microcomedones can progress into comedones or more inflamed pimples like papules, pustules, and nodules. (39) 

Four main factors cause this progression:

1. Excessive sebum production
2. Hyperkeratinization of follicles, meaning that there is rapid multiplication and accumulation of skin cells within the hair follicles
3. Overgrowth of Cutibacterium acnes (formerly called Propionibacterium acnes) within clogged pores
4. Inflammatory immune responses triggered by C. acnes cause follicular damage and rupture, producing inflammatory lesions

Types of Acne and How to Identify Them

There are three main types of acne:

Non-Inflammatory Acne

Non-inflammatory, or comedonal, acne is characterized by clogged pores without signs of inflammation. This form of acne is milder compared to inflammatory acne and primarily involves the formation of comedones:

• Whiteheads (closed comedones) occur when a pore becomes clogged but remains closed at the surface. The trapped material creates a small flesh-colored or white bump at the skin's surface. 
• Blackheads (open comedones) remain open at the surface. When oil and dead skin cells inside the pore are exposed to air, they oxidize and turn dark, creating a small black dot. 

Inflammatory Acne

Inflammatory acne is associated with papules and pustules, which form deeper within the skin and contain pus. Inflammation within the lesion causes these pimples to be swollen, red, and painful. 

Nodulocystic Acne

Nodulocystic acne is the most severe form of inflammatory acne. People with nodulocystic acne develop solid nodules and pus-filled cysts that are red, inflamed, and painful under the skin. These lesions are at the highest risk of becoming infected and causing permanent scarring. 

Risk Factors and Common Triggers for Acne

Hormonal Triggers

Androgenic hormones, including DHEA, testosterone, and dihydrotestosterone, bind to receptors on skin cells and upregulate sebum production. Acne is prevalent during adolescence, affecting 85% of teens, because of the surge of androgens that occur during puberty. Acne is also a common symptom of medical conditions associated with elevated androgen levels, such as polycystic ovary syndrome (PCOS). 

For women, hormonal changes in estrogen and progesterone related to the menstrual cycle, pregnancy, and menopause can also trigger acne. 

Dietary Triggers

Some studies have suggested that eating certain foods can make acne worse: 

• Dairy products, especially skim milk
• High-glycemic foods
• Chocolate

Skincare and Cosmetics

Comedogenic products contain ingredients that can clog pores and worsen acne. Results from eleven studies evaluating the comedogenic potential of cosmetic ingredients identify many culprits, including lanolin, coconut oil, and D&C red dyes. By carefully reviewing skincare ingredient lists and choosing non-comedogenic, oil-free products, individuals can reduce the risk of acne breakouts.

Lifestyle Factors

Stress stimulates the hypothalamic-pituitary-adrenal axis and increases the production of hormones, including corticotropin-releasing hormone (CRH) and cortisol, that increase oil production. Additionally, stress can induce inflammation within the skin, further worsening acne. 

Research shows a strong correlation between poor sleep quality and acne. Sleep deprivation can contribute to hormonal imbalance, thereby influencing acne development. 

Diagnosing Acne: What to Expect in a Medical Evaluation

Acne is diagnosed clinically based on physical exam findings and a thorough medical history. Doctors will examine the skin, looking for the types and number of lesions present to determine the type and severity of the acne. They will also evaluate the skin for features of other skin conditions that can be easily confused with acne, including: 

• Folliculitis
• Hidradenitis suppurativa
• Perioral dermatitis
• Rosacea 
• Seborrheic dermatitis

Accurate diagnosis is important, as treating acne incorrectly could worsen symptoms. Dermatologists use their expertise to distinguish between these conditions, ensuring patients receive effective treatments that target the right cause.

In addition to the physical exam, doctors will review the patient's medical history, paying close attention to signs of underlying hormonal issues, lifestyle factors, and skincare habits that could exacerbate the condition.

Diagnostic testing is not generally required for acne but can be utilized in atypical or severe presentations. When labs are ordered during an acne evaluation, they often include tests that screen for hormonal imbalances, insulin resistance, food sensitivities, and dysbiosis. 

Treatment Options for Acne

Acne treatment is determined based on lesion type, severity, and location on the skin. 

For non-inflammatory and mild inflammatory acne, first-line treatment consists of topical retinoids and benzoyl peroxide (34).  

• Topical retinoids, including dapalene (Differin), tazarotene (Tazorac), and tretinoin (Retin-A), are vitamin A derivatives that promote the turnover of skin cells and reduce inflammation. Common side effects include dryness, peeling, redness, and increased sensitivity to sunlight. (34) 
• Benzoyl peroxide is available over the counter and by prescription. It unclogs pores, reduces inflammation, and kills C. acnes bacteria, reducing lesion count within days of starting treatment. (34) 

Triple therapy with a topical retinoid, benzoyl peroxide, and antibiotic is recommended for treating moderate inflammatory acne. Topical antibiotics are generally recommended for treating papules and pustules, whereas oral antibiotics may be prescribed for treating nodular acne. (34) 

Isotretinoin (Accutane) is an oral vitamin A derivative that acts on all mechanisms of acne development to treat severe nodulocystic acne. While isotretinoin is highly effective in treating acne, it has a long list of potentially very serious side effects, including dry skin, inflammation of the lips, dry eyes, headache, elevated lipid levels, elevated liver enzymes, and birth defects if taken during pregnancy. (34) 

Oral medications may be recommended to manage hormonal acne, including:

• Combined oral contraceptive pills (OCPs) are FDA-approved for treating acne in females older than 15 because they prevent hormonal fluctuations during the menstrual cycle and reduce androgen levels. (34) 
• Spironolactone blocks androgen receptors to reduce sebum production. Side effects may include breast tenderness, menstrual irregularities, and elevated blood potassium levels. (34) 

Dermatologists can also perform the following medical procedures during an office visit:

• Corticosteroid injections into acne breakouts can reduce inflammatory symptoms and reduce the risk of scarring.
• Chemical peels use acids to exfoliate the skin and unclog pores to treat comedones and inflammatory lesions, improve skin texture, and reduce scarring. 
• Laser and light therapies target acne-causing bacteria and reduce inflammation. Blue light therapy, in particular, has been shown to reduce C. acnes bacteria.

Preventing Acne and Maintaining Clear Skin

Adopting an acne-friendly skincare routine can help prevent acne breakouts:

• Use a gentle, sulfate-free cleanser twice daily (morning and night) and after sweating to remove excess oil, dirt, and bacteria from the skin. Look for cleaners with acne-fighting ingredients like salicylic acid or benzoyl peroxide. 
• Hydrate the skin with a lightweight, non-comedogenic moisturizer. Look for oil-free or gel-based formulations to keep the skin balanced.
• Avoid touching your face with your hands.

Diet and nutrition can be a powerful tool in managing acne by reducing inflammation, balancing hormones, and promoting a healthy balance of bacteria living in the gut and on the skin. Research suggests that the following dietary habits can help manage acne:

• Eating a low-glycemic diet
• Avoiding dairy and whey protein
• Incorporating foods rich in omega-3 fatty acids and gamma-linolenic acid 
• Eating probiotic-rich foods

Implementing stress management techniques into your daily routine supports skin health by reducing perceived stress levels, improving sleep quality, promoting hormonal balance, and reducing systemic inflammation.

When to See a Dermatologist

If over-the-counter or prescription acne treatments aren't effectively managing your breakouts, or if your acne worsens, it's time to see your doctor or dermatologist. Signs that your acne may be becoming severe include increasing lesion count, the appearance of painful nodules or cysts, and facial scarring. 

When in doubt, don't hesitate to contact your doctor. Early intervention can prevent long-term skin damage, such as scarring and discoloration, which can be both physically and emotionally distressing.

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Key Takeaways

• Acne is a common skin condition that can significantly impact self-esteem and quality of life. 
• Acne requires a comprehensive approach to treatment that addresses the complex interactions of various factors contributing to its development.
• Consulting a healthcare provider will help you receive personalized care and develop an effective treatment plan that integrates lifestyle modifications and medical interventions. 
• Achieving clear, healthy skin may take time and effort, but with patience, consistency, and the support of a qualified professional, you can successfully manage your acne.