Acne, types, causes, treatments and prevention

Key takeaways:

• Acne is a common skin condition in which the hair follicles under the skin become clogged, causing pimples and cysts to form. 
• Sebum or oil, dirt, occlusive skin care products, and dead skin cells can clog skin pores and cause acne. 
• Numerous factors, including age, hormones, genes, and bacterial infections, can contribute to acne. 
• To treat acne, consult a dermatologist to create a regimen that works for your skin type. Benzoyl peroxide, salicylic acid, retinoids, and topical antibiotics are among the substances to look out for in your skincare products.

Acne is a common skin condition in which the hair follicles beneath the skin become blocked, leading to the outbreak of lesions like whiteheads and blackheads, commonly called pimples. 

Contrary to the popular belief that acne affects only teenagers, 80% of people between the ages of 12 and 30 experience some form of acne, meaning adults, too, can be affected. 

Sebum (the oil that the skin produces to prevent drying out), dirt, occlusive skincare products, and dead skin cells are some of the things that can clog skin pores, leading to acne.

Acne treatment can be challenging sometimes, and for some people, attempts to treat it even appear to worsen it. This may be because they have not addressed the underlying cause, they are using the wrong skincare products, or they are using the right skincare products but in the wrong way.  

Causes of acne

There are several possible causes of acne, including: 

• Hormonal factors: Teenagers experiencing puberty, people who are seeing their periods, or pregnant individuals may get acne due to hormonal fluctuations. An increase in the production of androgen—male sex hormone—can also cause acne. This is why acne is a common symptom in people with hormone-related conditions like polycystic ovarian syndrome (PCOS).
• Genetic predisposition: Studies indicate that people without a family history of acne are less likely to develop the problem than people whose first-degree relatives have it. If you have a family history of acne, you should pay more attention to your skincare. 
• Excessive sebum production: People whose skin is always greasy and produces excessive sebum may be prone to acne. Hormonal medications like progesterone and testosterone and medical conditions affecting hormone-secreting organs like the ovaries, adrenal, and pituitary glands are possible causes of increased sebum production.
• Dead skin cells and clogged pores: The skin pores may become clogged with dirt and dead skin cells, making it hard for your skin to breathe. Some skincare products may be comedogenic, meaning they tend to clog skin pores, which causes acne. 
• Bacterial infection: Propionibacterium acnes, an acne-causing bacteria, can become embedded in the skin and cause comedones, which are little pimples on the chin and forehead.

Types of acne

Acne comes in different forms, and determining the type of acne you have will make the treatment process faster and easier. 

The types of acne include:

1. Acne vulgaris

This common inflammatory skin condition mainly affects the face but can also affect the upper arms, torso, and back. It manifests as papules (inflamed bumps without pus), pustules (contains pus), or nodules (hard, larger, inflamed, and painful bumps). It also causes whiteheads (tiny, raised, white, or skin-colored bumps) and blackheads (small black or dark-colored bumps).

Although acne vulgaris can affect people of all ages, teenagers are most likely to experience it. 

Some of the causes of acne vulgaris include:

1. Use of medications such as lithium, steroids, and anticonvulsants 
2. Exposure to excess sunlight
3. Use of occlusive wear like headbands
4. Oil-based cosmetics
5. Genetic factors

Treatments for acne vulgaris include salicylic acid, clindamycin, erythromycin, benzoyl peroxide, and topical retinoids. 

2. Acne rosacea

This type of acne is a chronic inflammatory skin disorder that typically affects the nose and cheeks. The exact cause of rosacea is unknown, but it is more frequent in women and middle-aged and older adults, though it can be rather severe in men, fair-skinned individuals, and those with a family history of rosacea. 

Some symptoms that distinguish acne rosacea from other skin conditions include:

1. Facial redness
2. Rashes
3. Visible blood vessels 
4. Skin thickening 
5. Eye irritation

3. Acne conglobata

Acne conglobata is a rare but severe form of nodulocystic acne, a type of acne with cysts and nodules. The acne appears as deep burrowing abscesses on the thighs, upper arm, back, shoulder, and chest, as well as double or triple-interconnecting comedones, cysts, and inflammatory nodules.

Bodybuilders who use androgenic anabolic steroids—manufactured forms of testosterone usually abused by musclebuilders—are prone to developing acne conglobata. 

A steroid like prednisolone and retinoids like isotretinoin can be used to treat this form of acne.

4. Acne mechanica

Acne mechanical is a form of acne that forms as inflammatory papules and pustules. They are caused by friction from constant rubbing, stretching, and squeezing of the skin combined with heat, pressure, and occlusion. Athletes involved in sports that involve constantly rubbing or stretching body parts are at risk of getting acne mechanica.

Factors affecting acne

Some factors may influence the development of acne, including:

Menstrual cycle

According to studies, 63% of women see an increase in the frequency of inflammatory acne lesions in the last few days of their menstrual cycles. The underlying cause of acne in these women is tied to hormones.

Hormones

Androgen, the hormone responsible for growth and reproduction in both males and females, stimulates androgen receptors in the oil glands and root of the follicles that produce hair, causing sebum and a protein called keratin to accumulate in follicles, resulting in open and closed papules that serve as a growth medium for Propionibacterium acne.

Insulin is another hormone that can indirectly play a role in acne development because it stimulates the release of androgen from the ovary in females. People with health conditions like PCOS have high insulin in the blood, which triggers the release of excess testosterone, leading to symptoms like acne and excess hirsutism.

Age

Acne is common in teens because most of them are in the stage of puberty, which is characterized by increasing and fluctuating hormones. However, some people develop acne in their 30s, 40s, and even 50s. This is known as "adult-onset acne." Adult acne is more common in women than males because of hormonal fluctuations during menstruation, pregnancy, perimenopause, and menopause.

Some factors that may influence this include;

• hormones and the menstrual cycle
• Stress
• Hair products, skin care products, and makeup that can clog pores
• Diet
• Some medications like corticosteroids, anabolic steroids, and lithium

Hormonal changes during puberty

During puberty, the body produces testosterone, which in females maintains muscle and bone strength, and encourages the growth and development of the penis and testicles in males. An increase in testosterone levels can cause acne. 

Because the sebaceous glands are hormone-sensitive, they overproduce sebum in response to elevated testosterone levels.

Pregnancy

According to studies, over 40% of pregnant women in their late 20s and early 30s have acne. The root cause of pregnancy acne is unknown, and treatment options have limitations due to the need to keep the fetus safe in its mother's womb. However, pregnancy-related acne may be linked to an increase in reproductive hormones, particularly progesterone, which may increase the amount of sebum the skin produces.

Common acne treatments and their effectiveness

There are different treatment options for acne, including:

1. Topical acne treatments

Topical treatments can be beneficial in mild and moderate acne. They can be used alone or in combination. To choose the best topical treatment for your condition, seek the help of a licensed aesthetician or a dermatologist. First-line topical treatments for acne may include the following:

• Benzoyl peroxide: Benzoyl peroxide is anti-inflammatory and bactericidal, which means it eliminates acne-causing bacteria. It comes in different forms (washes, lotions, creams, and gels) and concentrations (2.5-10%). It is suitable for treating mild to moderate acne vulgaris. One disadvantage of benzoyl peroxide is that it causes dryness, irritation, and bleaching of clothing, hair, and bed linen, so it may be best not to apply it every day.
• Azelaic acid: Azelaic acid is a well-known topical acne treatment option with a typical strength of 20% for creams or 15% for gels. It is a recommended first-line treatment for both inflammatory and non-inflammatory acne. According to research, it has a triple action effect on acne—keratolytic effect, antimicrobial, and anti-inflammatory effect—and is a possible acne treatment option during pregnancy and lactation.
• Tea tree oil: Tea tree oil is an essential oil derived from the leaves and branches of the tree Melaleuca alternifolia (Maiden and Betch). It has antibacterial, anti-inflammatory, and antioxidant properties. Because of these qualities, tea tree oil is appropriate for acne therapy, particularly mild to moderate acne. Before using tea tree oil, carefully run a patch test and certify that it is safe for your skin. 
• Topical retinoids: Topical retinoids are one of the most essential and effective acne treatment options. They are excellent at treating comedones and small acne blemishes while providing direct anti-inflammatory benefits. Some retinoids to try include tretinoin, isotretinoin, adapalene, and tazarotene. But they have varying efficacy and tolerance. They can also cause side effects like erythema(skin redness), dryness, itching, and stinging sensations. 

2. Oral acne treatments

Some oral treatment options for acne include antibiotics, isotretinoin, spironolactone, and hormonal contraceptives. 

In cases of moderate to severe acne, oral antibiotics can be used as the first line of treatment along with a topical agent such as benzoyl peroxide. 

Hormonal medications are an effective second-line treatment for acne in women, regardless of the underlying hormonal disorders. Some clinical research has found that estrogen-containing oral contraceptives can be beneficial, whereas those containing solely progesterone can aggravate acne.

When oral contraceptives are ineffective, spironolactone can come into play. According to a 2011 research, spironolactone can be used alone in a higher dose of 50-200 mg/d, as it has proven effective in improving acne. 

Menstrual abnormalities, feminization of a male fetus, and increased potassium levels are a few possible side effects of spironolactone.

• Oral antibiotics: Research has shown that antibiotics are generally safe and helpful in reducing the severity of acne. Doctors may prescribe antibiotics when topical treatments are not enough to treat acne skin. Antibiotics like tetracycline have anti-inflammatory properties and can be used to treat acne vulgaris. When tetracyclines are neither tolerated nor ineffective, macrolides, cephalosporins, penicillins, and trimethoprim-sulfamethoxazole can be effective.

• Oral Isotretinoin: Oral isotretinoin addresses the three primary causes of acne. It inhibits sebum production by 70%, prevents P. acnes from spreading, and reduces inflammation. Oral isotretinoin is effective in treating scarring and severe nodulocystic acne. However, it may cause adverse effects like inflammation of the pancreas, disease of the blood (blood dyscrasias), liver toxicity, and night blindness. This is why dermatologists must closely supervise its use.
• Oral contraceptives: Oral contraceptives (birth control pills) are the second-line treatment for acne in women. Deep-seated nodules on the lower face and neck may respond well to hormonal therapies like oral contraceptives. Some clinical research has shown that using estrogen-containing contraceptives may be beneficial since they lower the level of free testosterone. But keep in mind that certain oral contraceptives may worsen acne or cause other side effects. Still, seek a doctor's opinion before taking one for acne.

3. Light therapy for acne

Light and laser therapy are currently widely used in acne treatment since they appear safe and have few or no adverse effects. This acne treatment method uses LED light therapies such as red light, blue light, and infrared light. 

Red light penetrates deep into the skin, immediately affecting sebaceous glands and reducing inflammation. Blue lights also produce anti-inflammatory effects on acne. On the other hand, infrared lasers may lower the size of the sebaceous gland, resulting in less sebum production. 

According to a 2015 study, using just blue light (415nm) for 8-20 minutes twice weekly for four weeks reduced 60-70% of inflammatory acne lesions but had no impact on non-inflammatory acne lesions. In the same way, blue-red light therapy lessens inflammatory lesions while having a less noticeable effect on non-inflammatory acne lesions.

4. Laser treatment for acne

Laser treatment can be an efficient part of an acne treatment approach, even though the results may be unpredictable for everyone. Studies have shown that laser lessen the look of acne, but you may need to pair it with other acne treatments for the best results. Because laser treatments take time to produce visible results, you may require more than one session to achieve the desired outcomes. Tools and techniques for laser treatments include the following: 

• Blue, red, and blue+red light devices: Lights from these LED light therapy devices are also known as visible light because the colors are visible, and they are used to treat acne. This device does not treat blackheads, whiteheads, acne cysts, or nodules. 
• At-home devices: These are devices with visible light that you can use in the comfort of your own home. Compared to the dermatologist's tools, they are less potent. Moreover, they are limited to treating pimples, much as visible light devices. 
• Infrared light: Infrared light can only treat pimples and is ineffective in treating blackheads, whiteheads, cysts, or nodules. 
• Photodynamic therapy (PDT): PDT can be used to treat severe acne. Skincare therapists typically apply a solution to the face for 15 to 3 hours to increase its sensitivity to light after which they will treat the skin using a laser or other light-generating instrument. 
• Photopneumatic therapy: This procedure removes excess oil and dead skin cells from blocked pores. It is ineffective against acne nodules or cysts, although it can treat whiteheads, blackheads, and certain pimples.

Tips for acne prevention and management

For many people, acne seems like a chronic skin condition that is difficult to manage or treat. But there are things one can do to effectively prevent acne, manage it, and even get rid of it.

Some helpful strategies for preventing and controlling acne breakouts include:

Having a proper skincare routine

With a proper skincare routine, you can prevent and manage the spread of acne. Utilizing products that contain benzoyl peroxide, salicylic acids, and retinoids may be a stepping stone for a good and stable routine. A proper skincare routine should include:

• A mild cleanser
• Face toner 
• A treatment agent (like retinoid and benzoyl peroxide)
• Moisturizer 
• Sunscreen(during the daytime)

Avoiding triggers and irritants

Another way to prevent acne is by avoiding anything that irritates your skin. Some products can trigger acne on the skin, especially for acne-prone skin.

Oily products, comedogenic products that clog pores, and excessive exfoliation can trigger acne on the skin. Therefore, be sure the word "non-comedogenic" is written on the product before applying any product to your skin. 

Adopting a healthy dietary and lifestyle habit

Diet can significantly affect acne. A high-glycemic diet like bread, white rice, cakes, and cookies can raise blood sugar, leading to inflammation and increased sebum production, which can worsen acne. So, it's important to avoid these foods and instead opt for healthy fats, proteins, and a moderate amount of low-glycemic carbs.

Acne complications and scarring

Aside from its impact on self-esteem, acne can cause complications like:

1. Post-inflammatory hyperpigmentation

Post-inflammatory hyperpigmentation is a skin disorder that occurs after skin injury or inflammation, making the skin produce extra melanin. It can be managed using photoprotection, and topical treatments, such as retinoids and azelaic acid.

2. Post-inflammatory erythema

Post-inflammatory erythema refers to skin redness at a particular location due to skin inflammation. Intense pulse light, pulse dye laser, and 5% topical tranexamic acid can all be beneficial in treating this.

3. Scarring

Scarring from acne occurs as a result of inflammation of acne blemishes. Acne scars are most common in more severe types of acne, particularly those resulting from cysts and nodules that rupture and cause harm to surrounding skin. To reduce the chances of having acne scars, avoid picking at your acne and get it treated right away. 

 Treatments for acne scarring include:

1. Laser treatment (ablative and non-ablative treatment) 
2. Punch techniques (using a medical tool that matches the size of an acne scar to remove the scar)
3. Subcision (inserting a small needle into the skin to separate the bands of scar tissue that is causing a scar to press deep down into the skin)

Antibiotic resistance

The use of antibiotics is essential in acne treatment, but one limitation of this treatment protocol is antibiotic resistance. 

Antibiotic resistance occurs when bacteria develop the ability to withstand medications intended to destroy them.

Recently, there have been some worries regarding antibiotic resistance. Due to this reason, several antibiotics, such as clindamycin and erythromycin, are no longer used to treat acne due to high resistance rates. According to a 2020 study, tetracyclines such as doxycycline, minocycline, and sarecycline are still the first-line therapy options for acne due to their proven safety and efficacy.

Shortening the course of treatment to as little as three to four months is crucial to prevent antibiotic resistance. Alternatively, consider other treatment options such as topical retinoids, benzoyl peroxide, topical salicylic acid, topical azelaic acid, or hormonal therapies.

When to speak to a dermatologist

If you have tried all available treatment protocols for acne and they have all proven abortive, then it is time to consult your dermatologist for professional care. Some skincare practices work better for specific skin types, and a dermatologist can help you figure out your skin type. Also, some treatment protocols require the advice and supervision of a licensed aesthetician or dermatologist to avoid worsening your condition.