Acne is a skin condition I’m all too familiar with. As a teenager, my skin was relatively clear, while many of my peers struggled with breakouts. But in my late twenties, my face seemed to explode. I developed several painful cysts, mostly on my jawline and chin. Occasionally one would pop up on my cheek or forehead. Every day a new one (or two) would appear. When I thought it couldn’t get worse, it always did.
I would often hide out and avoid meeting friends. I recall struggling, sometimes tearfully, to cover the multiple angry, red bumps that had taken over my face. No amount of makeup made them inconspicuous. There were mornings I considered calling into work, only to realize that things wouldn’t be much better the next day, or the day after that. It’s not like I could play hooky forever. Working in a salon meant I stood in front of a mirror all day too. I was embarrassed about my face and ashamed about just how much it bothered me on top of that. It really did a number on my mood and self-esteem. I spent a lot of time and money trying to rid myself of acne. I felt like my skin would never be clear.
I finally decided to visit a dermatologist–something I should’ve done much sooner in retrospect. With the help of some prescriptions and some patience, my skin began to settle down. I’m now 98% blemish-free (and have been for years) thanks to the medication and skincare advice from my dermatologist. I have a few scars that have luckily faded to almost nothing, and I still must be diligent with my skin care regimen, appointments, and prescriptions. Clearing and preventing acne requires consistency, dedication, and patience. A lot of people try something for a week or two and give up when they don’t see results (I was guilty of this), but it can take three to four months for acne treatments and prescriptions to take effect.
Acne affects 80% of adolescents and young adults in the United States. Around 40 to 50 million Americans suffer from it. It can have a devastating impact on self-esteem and even lead to depression. Long after acne has cleared, hyperpigmentation and scarring can serve as a painful reminder.
Though it’s more common in teenagers, acne can occur at any age. Newborn babies get acne, and many women will experience it in middle age. Acne doesn’t discriminate between men and women either.
There are several categories, causes, and treatments for acne. It’s enough information to fill a book, but I’m going to try and cover the basics in two posts. Today I’ll go over what causes acne and the different types. In my next post, I’ll discuss treatment. The kind of acne you have and/or the cause of it helps determine the best course of treatment.
The anatomy of a pimple
Acne begins when a pore gets clogged with dead skin cells. The skin typically sheds these cells without issue, but when the body makes a lot of sebum (the oil that keeps skin from getting too dry), it can cause the skin cells to stick together and get trapped in the pore(s). Gentle exfoliation can help prevent dead cells from clogging pores.
P. acnes is a bacterium that lives on our skin. Sometimes it can get inside the clogged-up pore. The bacteria multiply rapidly in this tiny, ready-made petri dish of sorts, causing inflammation. When the swelling goes very deep into the pore, it becomes a cyst or nodule. A blemish can range from a blackhead to a large, painful cyst depending on whether or not bacteria are present as well as the amount of inflammation
What sets this process in motion?
- Changes in hormone levels increase the production of sebum. More sebum means a greater chance that dead skin cells will become trapped. Puberty, menstruation, pregnancy, or conditions like Polycystic Ovary Syndrome (PCOS) cause fluctuating hormones that can lead to acne.
Certain cosmetics, skincare or hair products can clog pores. This handy chart from Acne.Org lists the most common pore-clogging ingredients. I cross check all of my skincare purchases against it (on my phone—right there in the store). You only have to check the first five to seven ingredients. Anything listed after that will be present in such a low concentration that it won’t cause a problem for most people. Remember, skincare ingredients are listed in order of predominance. You may see the words “non-comedogenic” on skincare or cosmetic products. Non-comedogenic means “not likely to clog pores.” This term is not regulated by the FDA, however; meaning manufacturers aren’t held accountable for making such a claim.
- Irritation can be responsible for breakouts. People with acne will sometimes wash or scrub their skin a lot. While it’s important to keep the skin clean, you can overdo it. Irritating the skin can cause or aggravate acne, so it’s important to treat your skin very gently. A washcloth or some other cleansing device can add to this irritation. The skin has a natural protective barrier that when compromised makes you more susceptible to new acne. Disrupting the skin’s barrier can also slow the healing time of blemishes that have already surfaced. Overaggressive washing isn’t the only type of irritation responsible for acne. Hats or backpack straps can lead to acne flare-ups as well.
- Irritating ingredients in skincare like denatured alcohol (SD, ethanol, denatured, isopropyl, methanol or ethyl alcohol), fragrance, or menthol can trigger breakouts. They cause imperceptible inflammation and compromise the skin barrier. Many acne products contain alcohol because of its ability to instantly degrease the complexion. But, stripping the skin of all oil only causes it to produce more later to compensate. Menthol makes inflamed skin feel cool and refreshed in the short term. But it irritates the skin, doing damage little by little with each use. Sometimes our well-meaning efforts to fight off acne can actually encourage it. Gentle products and gentle handling of the skin is critical to acne treatment and prevention.
(Take note: Fatty alcohols, like cetyl, stearyl, and Cetearyl alcohol are common in skincare products and are beneficial for skin.)
- Diet has been said to influence acne, but there are a lot of myths out there. Greasy, fatty foods don’t cause acne (unless you’re wiping the grease on your face). There is mixed research on chocolate consumption as it relates to acne. Many studies point to sugar as a trigger because of its influence on certain hormones (perhaps explaining how chocolate got its reputation). Foods like dairy and soy can also influence hormones, activating breakouts. Eating a healthy, balanced diet is best for your overall skin health, and you may find that eliminating refined sugars and excess carbohydrates helps reduce breakouts.
- Some studies indicate that stress can trigger or worsen existing acne. Finding balance in life and making time for relaxation and fun is essential for health in general but can also help keep your complexion clear.
- Genetics are hugely responsible for acne. Breakout-prone skin runs in families. This could be why you likely know people with gorgeous skin who don’t give skin care much thought (let alone effort). They’re just not genetically predisposed to acne.
- Picking at skin or attempting to pop blemishes can make them worse. You can push the infection deeper–causing more inflammation. It’s also possible to damage a pore, making it prone to clogging. You might “expedite” the healing of a blemish, only to have a new one crop up in its place over and over. Picking your skin is a surefire way to end up with scarring too. I used to pick at my face like crazy, (and have the scars to prove it). There is something called Excoriation or Skin Picking Disorder (SPD), that’s pretty common. This is an excellent resource for anyone who feels like they can’t stop picking at their skin: https://www.skinpick.com/
How is acne categorized?
Acne is divided into two categories, inflammatory and non-inflammatory.
Non-inflammatory blemishes are considered the least severe type of acne and the easiest to treat. These blemishes aren’t usually swollen or painful. If you have this kind of acne, you can most likely get it under control on your own with over the counter skincare.
Whiteheads are also known as closed comedones. They’re small, white or flesh-colored bumps. They typically have a white center with a red or pink border.
Blackheads are also known as open comedones. They’re small, black or dark spots that are sometimes slightly raised.
Closed comedones that widen and open up become blackheads. The contents darken when exposed to air, giving them their black color. Some people think blackheads are “trapped dirt” because of their color, but it’s actually dead skin cells and sebum that has oxidized at the opening.
This category of acne is swollen, red, and warm to the touch. Inflammatory acne is more severe than non-inflammatory and can lead to atrophic or hypertrophic scarring. If this is the type of acne you’re experiencing, it’s best to see a dermatologist. There are two levels of inflammatory acne.
Small, pink, solid bumps under the surface of the skin are called papules. They’re usually tender, and you’ll see slightly red, swollen skin around the perimeter. Papules are similar to an inflamed whitehead without a visible center.
Pustules are larger than papules and have a defined center filled with white or yellow pus. They’re pinkish or red at their base. They’re like larger, inflamed whiteheads.
These types of blemishes can’t be treated successfully at home. (Although that doesn’t stop us from trying usually.) A doctor or dermatologist is required to eliminate and prevent cysts, nodules, and pseudocysts.
Untreated nodules and cysts can cause severe scarring.
Nodules are painful, hard, inflamed bumps that originate deep within the skin. They resemble a more substantial, deeper papule with no visible head or center. Nodules form when clogged pores cause damage beneath the surface of the skin.
Cysts are painful, inflamed, soft (compared to nodules), red or sometimes white lumps that are quite big. They’re the most severe type of blemish. Cysts develop even deeper under the skin than a nodule. It’s easy to confuse nodules and cysts because they can look similar on the surface. Something called a pseudocyst can resemble a cyst but is actually a nodule that has filled with pus.
Picking or attempting to pop nodulocystic acne will only worsen potential scarring. It can also make a cyst or nodule bigger, deeper and more inflamed. You’ll be much happier with the outcome when a dermatologist treats this type of blemish. Sit on your hands if you must. Avoid the mirror. Whatever it takes. Don’t pick, and see a physician as soon as possible.
In part II I’ll review treatments for the different categories of acne. If you have non-inflammatory or mild inflammatory acne, you should be able to get it under control/significantly improve it at home using over the counter treatments. Even if you require dermatologist intervention, you’ll still need a simple at-home skincare regimen. I’ll share some of my favorite products for clear skin and explain what to look for when you shop for skincare.