Acne is one of the most prevalent skin conditions globally, affecting millions of people at various stages of life. While it may often be considered an unwanted rite of passage for adolescents, acne can affect individuals well into adulthood, causing both physical and emotional distress.
While anyone can develop acne, certain factors, including age, gender, genetics, and lifestyle, make some people more prone to breakouts than others. Understanding these risk factors helps those affected better manage acne-prone skin and prevent future breakouts from occurring.
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Age and Acne: Why It's Not Just a Teenage Problem
The prevalence of acne peaks in adolescence and early adulthood, affecting 85% of people between the ages of 12 and 24. However, acne isn't just a problem teenagers face, with statistics revealing that 25% of women and 12% of men in their 40s still struggle with this skin condition. (2)
Adolescence: The Peak Acne Years
Puberty is the biological process during which a child's body undergoes physical and hormonal changes, transitioning into reproductive maturity. This period typically begins between ages 8 and 13 in girls and ages 9 and 14 in boys, though timing can vary (45).
Puberty is driven by a series of complex endocrinological changes orchestrated by the hypothalamic-pituitary-gonadal (HPG) axis. The process starts with the hypothalamus releasing gonadotropin-releasing hormone (GnRH), which stimulates the pituitary gland to secrete luteinizing hormone (LH) and follicle-stimulating hormone (FSH). In response, the gonads (ovaries in girls and testes in boys) increase the production of sex hormones: estrogen, progesterone, and testosterone. (49)
Androgenic hormones, including DHEA, testosterone, and dihydrotestosterone (DHT), are strongly implicated in hormonal acne because they bind receptors on skin cells and cause sebaceous glands to enlarge and produce more sebum, an oily substance that protects the skin. Excess sebum mixes with dead skin cells and clogs hair follicles, forming acne lesions called comedones (whiteheads and blackheads). When these clogged follicles become colonized by bacteria, primarily Cutibacterium acnes, inflamed acne lesions like papules, pustules, nodules, and cysts can occur.
As hormone levels rise during puberty, so does the risk of acne. Studies have reported prevalence rates of acne in teens ranging from 81-95% in males and 79-82% in females.
Adult Acne: Why It's Common Beyond the Teen Years
The prevalence of adult acne is increasing. According to a large survey that included over 1,000 men and women, the prevalence of acne in women by age group was:
- 20 to 29 years: 50.9%
- 30 to 39 years: 35.2%
- 40 to 49 years: 26.3%
- 50+ years: 15.3%
Adult acne is classified as either:
- Persistent: acne continues from adolescence into adulthood
- Late-Onset: occurs in individuals aged 25 years and older without a history of adolescent acne
Adult acne classically presents as long-lasting inflammatory lesions on the lower one-third of the face, neck, and jawline that possess a greater tendency to cause scarring. Acne also tends to have a stronger psychological impact on adults than teenagers, with up to 40% of affected adults experiencing psychiatric comorbidity, such as depression, anxiety, and emotional distress. (51)
Multiple factors can be responsible for adult acne, including:
- Hormonal imbalances
- Stress
- Genetics
- Use of comedogenic hair and skincare products
- Medications
- Medical conditions
- Diet
Gender Differences in Acne Risk
During adolescence, acne is more common and often more severe in males due to the higher levels of androgens that lead to more frequent and severe breakouts. In an epidemiologic study, the prevalence of teen acne was reported among 27.9% of boys and 20.8% of girls. (36)
However, adult acne (affecting individuals over age 25) is more prevalent in females, attributed mainly to hormonal factors related to the menstrual cycle and more frequent use of cosmetic products (36).
Genetics: The Inherited Risk for Acne
A study involving 400 twin pairs showed that 81% of acne was due to genetic factors. These factors increase risk by affecting the amount of sebum the skin produces, the skin microbiome, and the predisposition to inflammation. Individuals with first-degree family members who have acne are at an increased risk (up to three times higher) of getting acne themselves compared to individuals without a family history.
Certain individuals are genetically predisposed to having larger or more active sebaceous glands, which produce excess sebum, and follicular hyperkeratinization, a process in which skin cells within hair follicles shed abnormally and accumulate. Increased sebum production and hyperkeratinization are recognized as two of the key factors involved in acne pathogenesis.
An individual's genetic makeup also influences the composition and behavior of their skin microbiome, including the presence and activity of C. acnes. Different phylotypes (types with distinct genetic traits) of C. acnes have been linked to either healthy or acne-prone skin. Some people may inherit a skin microbiome that is more conducive to the growth of acne-causing bacteria, while others may have microbial communities that better support skin health.
Genetic factors also determine how the skin responds to inflammation. Certain genetic variants have been identified in predisposing an individual to favor stronger inflammatory immune reactions, which can lead to more severe and frequent acne breakouts.
Hormonal Factors: The Primary Driver of Acne
We have already discussed the central role androgens play in stimulating sebaceous glands to produce more sebum, leading to clogged pores and acne. This effect is pronounced in conditions characterized by androgen excess, such as polycystic ovary syndrome (PCOS), a prevalent hormonal disorder in women characterized by irregular menstrual cycles and ovarian cysts.
Elevations in insulin and insulin-like growth factor-1 (IGF-1) can further increase sebum production by promoting androgen synthesis.
Hormonal fluctuations related to the menstrual cycle, pregnancy, and menopause can also affect skin health. For instance, many women experience acne flare-ups in the week before their period or during menopause due to changes in estrogen and progesterone levels, which can influence sebaceous gland activity and skin inflammation.
Cortisol, often called the body's "stress hormone," can also increase sebaceous gland activity. Cortisol production is governed by the hypothalamic-pituitary-adrenal (HPA) axis, in which a series of hormone signals ends in the adrenal glands' production of cortisol. The first of these hormones in this axis is called corticotropin-releasing hormone (CRH), which stimulates the production of oils and androgen hormones directly from the sebaceous glands. CRH can also induce inflammation within skin cells.
Lifestyle and Environmental Risk Factors
While internal factors play a significant role in acne development, our external environments and lifestyle choices are equally crucial in influencing the condition.
Diet and Nutrition
Research has linked high-glycemic foods, dairy, and processed foods to increased breakouts and acne severity. This relationship can be explained through a few mechanisms:
- These food groups are linked to higher insulin and IGF-1 levels (8, 63).
- Western diets, characterized by high intake of refined sugars, processed foods, and poor-quality fats, can shift the body's microbiome toward a dysbiotic state and fuel systemic inflammation.
Stress and Sleep Deprivation
Stress impacts the health of our skin in many ways, including the perpetuation of dysbiosis, inflammation, and hormonal imbalances. Stress activates the HPA axis, increasing the release of CRH and cortisol. (67)
Sleep deprivation also appears to be an aggravating factor for acne, given its propensity to overactive the HPA axis and increase levels of perceived stress, leading to elevations of stress-related hormones (12).
Skincare and Cosmetic Products
Comedogenic skincare and cosmetic products, meaning they clog pores, can lead to acne, especially in individuals who are already prone to breakouts. Ingredients like heavy oils can exacerbate the problem by trapping sebum and dead skin cells within hair follicles.
To reduce acne risk, it's important to use non-comedogenic products that do not clog pores and avoid overusing products that can irritate and dry out the skin (1).
A basic skincare routine for someone with acne-prone skin could include:
- Use a gentle cleanser twice daily to remove excess oil from the skin.
- Apply acne medication evenly over acne-prone skin to treat and prevent breakouts.
- Use a non-comedogenic moisturizer and sunscreen to prevent skin damage and irritation.
Environmental Factors
Environmental factors like pollution, humidity, and harsh climates can aggravate acne. Pollutants and particulate matter can irritate the skin and contribute to clogged pores. High humidity levels and temperatures cause the skin to produce more sweat and oil, which can mix with dead skin cells and bacteria to clog pores (69).
Acne mechanica is a type of acne triggered by physical factors that cause friction, pressure, or irritation on the skin. This form of acne is common in athletes or individuals who wear equipment that constantly rubs against the skin, such as tight clothing, helmets, sports equipment, or masks. The mechanical irritation can lead to the formation of comedones, papules, and pustules, as the skin's natural barrier is disrupted and sebaceous glands are stimulated.
Occupational and Behavioral Risk Factors
Acne venenata is a type of acne caused by exposure to certain chemical substances or irritants. This condition occurs when the skin comes into contact with substances that trigger acne-like eruptions, often in areas directly exposed to these chemicals. Common culprits include grease, oils, or industrial chemicals. Occupations with a higher risk for acne venenata involve frequent exposure to these chemicals and irritants. Examples may include kitchen workers, mechanics, and people working with heavy machinery.
Touching the face, picking at the skin, and popping pimples can worsen acne and increase the risk of painful acne, infection, and permanent scarring (42).
Medical Conditions and Medications Linked to Acne
Acne is a common symptom of endocrine disorders that result in the excess production of androgens, growth hormone, IGF-1, insulin, CRH, and cortisol. Examples include:
- Acromegaly
- Androgen-secreting tumors
- Congenital adrenal hyperplasia (CAH)
- Cushing syndrome
- Insulin resistance
- PCOS
Drug-induced acne can result from taking the following medications:
- Antiepileptics: phenobarbital and hydantoin derivatives
- Anti-tuberculosis drugs
- Halogen compounds: iodine, bromine, fluorine, chlorine
- Immunomodulators: interferon-beta
- Immunosuppressive drugs: corticosteroids and cyclosporine
- Lithium
- Testosterone replacement therapy (TRT)
- Thyroid hormones
- Vitamin B12
When to Seek Professional Help for Acne
If your acne persists despite over-the-counter treatments, becomes increasingly severe, or results in deep cysts and scarring, it may be time to consult a dermatologist. Persistent breakouts that do not improve with self-care methods can benefit from professional evaluation and treatment.
A dermatologist can provide personalized treatment plans and management strategies tailored to your specific needs and risk factors, including:
- Topical medications, including retinoids, antibiotics, and benzoyl peroxide
- Systemic drugs, such as oral antibiotics and isotretinoin
- Hormonal therapies, like oral contraceptive pills (OCPs) or anti-androgen medications to regulate hormones
- Advanced skincare procedures, such as chemical peels, laser therapy, and light-based treatments
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Key Takeaways
- A range of demographics and risk factors, including age, gender, genetics, hormonal changes, and lifestyle choices, influence acne development and severity.
- Understanding these risk factors helps us identify the individuals most likely to be affected by acne and mitigate acne more effectively by addressing personal triggers.
- Individuals struggling with acne are encouraged to speak with a healthcare provider to help them identify their unique acne triggers and develop a comprehensive and personalized treatment plan to achieve clearer skin.
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