Acne

Causes

• Excess Sebum Production: Overactive sebaceous glands produce too much oil, which can clog pores.
• Dead Skin Cell Accumulation: Skin cells shed too quickly and stick together, blocking hair follicles.
• Bacteria: Propionibacterium acnes (now Cutibacterium acnes), a common skin bacterium, can multiply rapidly in clogged follicles, leading to inflammation and pus.
• Inflammation: The body's immune response to the bacteria and clogged follicles causes redness and swelling.
• Hormonal Changes: Androgens (male hormones present in both sexes) increase during puberty, stimulating sebaceous glands. Hormonal fluctuations during menstruation, pregnancy, or due to conditions like PCOS can also trigger acne.
• Genetics: A family history of acne increases an individual's likelihood of developing it.
• Diet: While research is ongoing, some studies suggest a link between high-glycemic index foods (e.g., sugary drinks, white bread) and dairy products with acne severity in some individuals.
• Stress: Stress itself doesn't cause acne, but it can worsen existing acne by affecting hormones.
• Medications: Certain drugs, such as corticosteroids, testosterone, lithium, and some anti-tuberculosis drugs, can cause acne as a side effect.
• Friction or Pressure: Mechanical irritation from helmets, tight clothing, or prolonged pressure can trigger "acne mechanica."

Symptoms

• Comedones:
  • Whiteheads (closed comedones): Small, flesh-colored or whitish bumps that are closed at the surface.
  • Blackheads (open comedones): Small, dark or black spots that are open at the surface; the dark color is due to oxidation, not dirt.

• Inflammatory Lesions:
  • Papules: Small, red, tender bumps.
  • Pustules: Red, tender bumps with a white or yellowish center of pus.
  • Nodules: Large, solid, painful lumps beneath the surface of the skin.
  • Cysts: Large, painful, pus-filled lesions deep under the skin, which can cause scarring.

• Other symptoms:
  • Redness and inflammation around lesions.
  • Pain or tenderness in affected areas.
  • Post-inflammatory hyperpigmentation (dark spots after lesions heal).
  • Scarring (pitted or raised scars).

Diagnosis

• Medical history: The doctor will ask about your symptoms, their onset, family history of acne, and any potential triggers (e.g., diet, medications, stress).
• Physical examination: The doctor will examine the affected areas of your skin to identify the types of lesions present and assess their severity.
• Ruling out other conditions: In some cases, the doctor may ask questions or perform tests to rule out other skin conditions that might resemble acne, such as rosacea, folliculitis, or perioral dermatitis.

Treatment

• Topical Medications (applied to the skin):
  • Retinoids (e.g., tretinoin, adapalene, tazarotene): Unclog pores and prevent new breakouts.
  • Benzoyl peroxide: Kills bacteria and helps shed dead skin cells.
  • Antibiotics (e.g., clindamycin, erythromycin): Reduce bacteria and inflammation.
  • Salicylic acid: Helps exfoliate the skin and unclog pores.
  • Azelaic acid: Reduces inflammation and kills bacteria.

• Oral Medications (for moderate to severe acne):
  • Antibiotics (e.g., doxycycline, minocycline): Reduce bacteria and inflammation. Used for a limited time to avoid resistance.
  • Isotretinoin (Accutane): A powerful retinoid used for severe, nodular, or cystic acne that hasn't responded to other treatments. Requires strict monitoring due to potential side effects.
  • Hormonal therapies (for women, e.g., oral contraceptives, spironolactone): Help regulate hormones that contribute to acne.

• Procedures (performed by a dermatologist):
  • Chemical peels: Improve skin texture and reduce comedones.
  • Microdermabrasion: Exfoliates the skin.
  • Laser and light therapies: Reduce bacteria, inflammation, and improve scarring.
  • Corticosteroid injections: Directly into large cysts or nodules to reduce inflammation quickly.
  • Drainage and extraction: Manual removal of blackheads, whiteheads, or cysts.

• Lifestyle and Home Care:
  • Wash affected areas gently twice daily with a mild cleanser.
  • Avoid harsh scrubbing or picking at lesions.
  • Use non-comedogenic (non-pore-clogging) skin care products and makeup.
  • Shampoo hair regularly, especially if oily.
  • Avoid touching your face.
  • Manage stress.

Making Acne Treatment Work

Most acne treatment fails for reasons that have nothing to do with the drug: a retinoid abandoned during the rough first month, an antibiotic used alone for a year, or a regimen that never addressed the hormonal driver.

Retinoids: the first six weeks are the hard part

Tretinoin is applied at night as a pea-sized amount to the whole affected area on dry skin, not dabbed onto spots, and it commonly makes acne look worse for two to six weeks before it improves. Starting every other night, using a plain moisturizer, and judging results only at twelve weeks gets most people through. It makes skin burn easily, so in Florida a daily non-comedogenic sunscreen is part of the regimen rather than an option. Benzoyl peroxide in the morning kills the bacteria and prevents antibiotic resistance.

Antibiotics: always with benzoyl peroxide, never for long

Doxycycline is used for moderate inflammatory acne for about three to four months, alongside benzoyl peroxide and a retinoid, and then stopped while the topicals continue; extending it adds no benefit and breeds resistant bacteria. It causes marked sun sensitivity, which matters here. Topical clindamycin follows the same rule: combined with benzoyl peroxide, never alone.

Adult women: treat the hormones

Acne along the jawline and chin that flares before periods in adult women responds to spironolactone, which blocks the androgen effect on oil glands and takes about three months to work, or to a combined pill such as levonorgestrel-ethinyl estradiol. Acne with irregular periods or excess hair prompts a check for polycystic ovary syndrome.

Isotretinoin, and what is mistaken for acne

Isotretinoin is the one treatment that can end severe or scarring acne permanently, usually over four to six months, with monthly visits, lipid and liver tests, and strict pregnancy prevention through the federal iPLEDGE program. Red bumps across the cheeks with flushing and no blackheads are rosacea, which acne treatments aggravate. Uniform itchy bumps on the chest and back in humid weather are often a yeast folliculitis, one of the fungal skin infections common here, and it clears with an antifungal rather than acne treatment.

Sweat, sunscreen, and scars

Sweat and occlusion from helmets, hats, and tight athletic wear drive breakouts in a hot climate; showering promptly after exercise and choosing oil-free, non-comedogenic sunscreen matter more than any cleanser. Dark marks left after lesions heal fade over months with sunscreen and the retinoid; pitted scars do not fade, which is why nodular acne is referred early. Our dermatologic team manages treatment and refers when isotretinoin or procedures are needed; our Florida sun safety guide covers sunscreen choices. The NIAMS and MedlinePlus publish patient guidance on acne treatment.

If your acne has not improved after three months of treatment, or is leaving marks or scars, schedule a visit.