Acne

Acne is one of the most common skin conditions that affects millions of people worldwide, causing pimples, oily skin, and sometimes scarring that can impact both physical appearance and emotional well-being.

acne vulgaris

Table of contents

• What is acne?
• Who gets acne?
• Symptoms and types of acne spots
• Where does acne appear on the body?
• What causes acne?
• Emotional and mental health impact
• When to seek medical help
• Treatment options
• Self-care and prevention
• What to expect from treatment

What is acne?

Acne is a skin condition that occurs when your hair follicles become plugged with oil and dead skin cells^[1]. Your hair follicles are small tubes that hold a strand of your hair. There are several glands that empty into your hair follicles. When too much material is inside your hair follicle, a clog occurs^[2].

The condition creates various types of spots including whiteheads, blackheads, and pimples. Pimples are pus-filled, sometimes painful bumps on your skin^[2]. While acne is most commonly known for affecting teenagers during puberty, it can affect people of all ages. In fact, acne can start at any age^[4].

Who gets acne?

If you have acne, you are not alone. An estimated 80% of people ages 11 to 30 will have at least a mild form of acne^[2]. About 95% of people aged 11 to 30 are affected by acne to some extent^[4]. Acne is most common among teenagers and young adults undergoing hormonal changes, but it can also occur during adulthood. Adult acne is more common among women^[2].

Acne is most common in girls from the ages of 14 to 17, and in boys from the ages of 16 to 19. Most people have acne on and off for several years before their symptoms start to improve as they get older. Acne often disappears when a person is in their mid-20s. In some cases, acne can continue into adult life. About 3% of adults continue to experience acne^[4].

You may be more at risk of developing acne if you have a family history of acne. In fact, susceptibility to acne is primarily genetic in 80% of cases^[3]. Acne is known to run in families. If both your mother and father had acne, it’s likely that you’ll also have acne^[4].

Symptoms and types of acne spots

Acne causes spots, oily skin, and sometimes skin that’s hot or painful to touch^[4]. The resulting appearance can lead to lack of confidence, anxiety, reduced self-esteem, and, in extreme cases, depression or thoughts of suicide^[3].

There are 6 main types of spot caused by acne^[4]:

• Blackheads are small black or yellowish bumps that develop on the skin. They’re not filled with dirt, but are black because the inner lining of the hair follicle produces color^[4]. Blackheads are open plugged pores^[1].
• Whiteheads have a similar appearance to blackheads, but may be firmer and will not empty when squeezed^[4]. These are closed plugged pores^[1].
• Papules are small red bumps that may feel tender or sore^[4]. These are small, discolored bumps, often red to purple or darker than your natural skin tone^[2].
• Pustules are similar to papules, but have a white tip in the centre, caused by a build-up of pus^[4].
• Nodules are large hard lumps that build up beneath the surface of the skin and can be painful^[4].
• Cysts are the most severe type of spot caused by acne. They’re large pus-filled lumps that look similar to boils and carry the greatest risk of causing permanent scarring^[4].

Acne can be mild and cause a few occasional pimples, or it can be moderate and cause inflammatory papules. Severe acne causes nodules and cysts^[2]. All of these forms of acne can affect your self-esteem, and both cystic and nodular acne can lead to permanent skin damage in the form of scarring^[2].

• Face
• Forehead
• Chest
• Upper back
• Shoulders

Where does acne appear on the body?

Acne usually appears on the face, forehead, chest, upper back and shoulders^[1]. The most common places where you might have acne are on your face, forehead, chest, shoulders, and upper back^[2]. Oil glands exist all over your body. The common locations of acne are where oil glands exist the most^[2].

Acne most commonly develops on the face, which affects almost everyone with acne. The back is affected in more than half of people with acne, and the chest affects about 15% of people with acne^[4]. It primarily affects skin with a relatively high number of oil glands^[3].

What causes acne?

Clogged hair follicles or pores cause acne. When too much material is inside your hair follicle, a clog occurs. Your pores can clog with^[2]:

• Sebum: An oily substance that provides a protective barrier for your skin
• Bacteria: Small amounts of bacteria naturally live on your skin. If you have too much bacteria, it can clog your pores
• Dead skin cells: Your skin cells shed often to make room for more cells to grow. When your skin releases dead skin cells, they can get stuck in your hair follicles

When your pores clog, substances plug up your hair follicle, creating a pimple. This triggers inflammation, which is the body’s response to injury or infection. You feel inflammation as pain and swelling. You can also see inflammation through skin discoloration, like redness around a pimple^[2].

Another common factor is the excessive growth of the bacterium Cutibacterium acnes, which is present on the skin^[3]. Acne is most commonly linked to the changes in hormone levels during puberty, but can start at any age. Certain hormones cause the grease-producing glands next to hair follicles in the skin to produce larger amounts of oil. This abnormal sebum changes the activity of a usually harmless skin bacterium called P. acnes, which becomes more aggressive and causes inflammation and pus^[4].

In both sexes, hormones called androgens appear to be part of the underlying mechanism, by causing increased production of sebum^[3]. The hormones also thicken the inner lining of the hair follicle, causing blockage of the pores. Cleaning the skin does not help to remove this blockage^[4].

Hormonal changes, such as those that occur during the menstrual cycle or pregnancy, can also lead to episodes of acne in women. There’s no evidence that poor hygiene or sexual activity play a role in acne^[4]. The roles of diet and cigarette smoking in the condition are unclear, and neither cleanliness nor exposure to sunlight are associated with acne^[3].

Certain things in your environment contribute to acne, or they can make an acne breakout worse, including wearing tight-fitting clothing and headgear, like hats and sports helmets, as well as toxins in the air and certain weather conditions, especially high humidity^[2].

Emotional and mental health impact

Depending on its severity, acne can cause emotional distress and scar the skin^[1]. The resulting appearance can lead to lack of confidence, anxiety, reduced self-esteem, and, in extreme cases, depression or thoughts of suicide^[3]. While acne is not a serious health threat, it is significant in an emotional and social sense^[10].

If you have acne, often you have less self-confidence, and this can affect your social life or even your productivity at work^[10]. Acne can have a detrimental effect on self-esteem and daily living. When your acne is better, you are better^[11].

When to seek medical help

If you develop mild acne, it’s a good idea to speak to a pharmacist for advice. Several creams, lotions and gels for treating spots are available to buy from pharmacies. Products containing a low concentration of benzoyl peroxide may be recommended, but be careful as this can bleach clothing^[4].

If self-care remedies don’t clear your acne, see your primary care doctor. He or she can prescribe stronger medications. If acne persists or is severe, you may want to seek medical treatment from a doctor who specializes in the skin, called a dermatologist or pediatric dermatologist^[1].

You should see a doctor if you have moderate or severe acne or you develop nodules or cysts, as they need to be treated properly to avoid scarring. Try to resist the temptation to pick or squeeze the spots, as this can lead to permanent scarring^[4].

It’s best to seek help from a healthcare provider early so they can determine the best treatment option for you^[2]. The earlier you start treatment, the lower your risk of problems such as scarring^[1].

Treatment options

Although acne cannot be cured, it can be controlled with treatment^[4]. Effective acne treatments are available, but acne can be persistent. The pimples and bumps heal slowly, and when one begins to go away, others seem to crop up^[1]. Treatment is available to clear acne from your skin and prevent scarring^[2].

Treatment for acne depends on how severe it is. It can take several months of treatment before acne symptoms improve^[6]. With most prescription acne drugs, you may not see results for four to eight weeks. It can take many months or years for your acne to clear up completely^[5]. Treatments can take several months to work, so do not expect results overnight. Once they do start to work, the results are usually good^[4].

Topical treatments

The most common topical prescription medications for acne include^[5]:

• Benzoyl peroxide works as an antiseptic to reduce the number of bacteria on the surface of the skin. It also helps to reduce the number of whiteheads and blackheads, and has an anti-inflammatory effect. It should be used sparingly, as too much can irritate your skin. It also makes your face more sensitive to sunlight. Benzoyl peroxide can have a bleaching effect, so avoid getting it on your hair or clothes^[6].
• Topical retinoids work by removing dead skin cells from the surface of the skin, which helps prevent them building up within hair follicles. Drugs that contain retinoic acids or tretinoin are often useful for moderate acne. Examples include tretinoin, adapalene and tazarotene^[5]. They’re usually applied once a day before you go to bed. It’s important to apply topical retinoids sparingly and avoid excessive exposure to sunlight. Topical retinoids are not suitable for use during pregnancy, as there’s a risk they might cause birth defects^[6].
• Topical antibiotics help kill the bacteria on the skin that can infect plugged hair follicles. They’re available as a lotion or gel that’s applied once or twice a day. A 6 to 8-week course is usually recommended^[6].
• Azelaic acid is often used as an alternative treatment for acne if the side effects of benzoyl peroxide or topical retinoids are particularly irritating or painful. Azelaic acid works by getting rid of dead skin and killing bacteria. It’s available as a cream or gel and is usually applied twice a day. The medicine does not make your skin sensitive to sunlight^[6].

Oral medications

If you have severe acne, or prescription medicines are not working, your doctor can refer you to an expert in treating skin conditions. For moderate or severe acne, you’ll usually be started on a combination of topical treatments, or antibiotic tablets combined with topical treatments^[6].

Hormonal therapies or the combined oral contraceptive pill can also be effective in women who have acne. In women, the combined contraceptive pill may be prescribed as treatment. But the progestogen-only pill or contraceptive implant can sometimes make acne worse^[6].

Self-care and prevention

Learning how to stop breakouts before they happen is the key to keeping acne under control^[10]. All treatment for acne is aimed at preventing inflammation and reducing breakouts before they happen^[10].

These self-help techniques may be useful^[4]:

• Do not wash affected areas of skin more than twice a day. Frequent washing can irritate the skin and make symptoms worse. Wash the affected area with a mild soap or cleanser and lukewarm water. Very hot or cold water can make acne worse.
• Do not try to “clean out” blackheads or squeeze spots. This can make them worse and cause permanent scarring.
• Avoid makeup, skincare and suncare products that are oil-based (sometimes labelled “comedogenic”). Use water-based non-comedogenic products, as they’re less likely to block the pores in your skin.
• Completely remove makeup before going to bed.
• If dry skin is a problem, use a fragrance-free water-based emollient.
• Regular exercise cannot improve your acne, but it can boost your mood and improve your self-esteem. Shower as soon as possible once you finish exercising as sweat can irritate your acne.
• Wash your hair regularly and try to avoid letting your hair fall across your face.

Make sunscreen a daily essential in your skincare routine. Opt for an oil-free sunscreen to prevent hyperpigmentation, which can cause lasting darkening of acne lesions for several months^[11]. When selecting makeup or facial moisturizers, opt for products labeled as non-comedogenic^[11].

Schedule a consultation with a skincare professional, preferably your dermatologist, to craft a tailored acne treatment plan. This not only helps in addressing existing acne issues but also allows for the identification of potential triggers^[11].

What to expect from treatment

If you’ve tried over-the-counter acne products for several weeks and they haven’t helped, a dermatologist can help you control your acne, avoid scarring or other damage to your skin, and make scars less noticeable^[5].

The treatment plan your doctor recommends depends on your age, the type and severity of your acne, and what you are willing to commit to. For example, you may need to wash and apply medications to the affected skin twice a day for several weeks^[5].

Treatment options for pregnant women are limited due to the risk of side effects. Talk with your doctor about the risks and benefits of medications and other treatments you are considering. And make follow-up appointments with your doctor every three to six months until your skin improves^[5].

For many women, acne can persist or may even start during adulthood. Most people have acne on and off for several years before their symptoms start to improve as they get older^[4].