Acne is one of the most common skin conditions. Although it is thought of as a bane of adolescence, adults commonly present with this frustrating condition to the dermatology office. Hormonal changes during adolescence that stimulate oil production tend to trigger acne in the teen years but some of these hormonal changes can linger past that time. This, coupled with a tendency for clogging of the pores and skin care practices, can make acne persist into the 20s, 30s, or even 40s.
Acne not only causes physical symptoms like pain, but it also has a tremendous impact on emotional health and self-image. Making the right diagnosis is important in order to choose the right treatment and prevent long-term complications like scarring. Acne can show up in a number of ways. Types of acne include comedonal acne consisting of blackheads and whiteheads, inflammatory acne consisting of red or pus-filled bumps, and nodular acne consisting of deep and painful acne knots.
Other conditions can mimic acne but are actually different and require a different treatment strategy. Rosacea shows up as redness, broken blood vessels, pimples, bumps, or a combination of these on the cheeks, nose, forehead, and chin. Unlike acne, rosacea is not caused by plugged pores, but rather by inflammation in the skin and increased sun sensitivity. Folliculitis, especially on the back, can look very similar to acne. Folliculitis is caused by infection of the hair follicles, usually by bacteria. Activities that promote sweating and friction, such as playing sports and wearing tight-fitting clothing can lead to folliculitis.
The link between diet and acne has been controversial. Some studies have shown that diets rich in high glycemic index foods that cause spikes in blood sugar, such as white bread, white rice, pastas, and refined sugars can increase the risk of acne. Milk consumption has also been associated with increased chance of acne. The effect appears to be minimal, however. Nonetheless, following a diet consisting of consumption of low glycemic index foods, such as whole grains, brown rice, fruits, and vegetables, is good for overall health.
Proper skin care for acne-prone skin begins with selection of the right types of skin care products that are applied directly to the skin. The use of gentle cleansers, moisturizers, sunscreens, and cosmetics that do not clog pores is essential. Terms that describe products that do not clog pores include: non-comedogenic, oil-free, and non-acnegenic. Washing the face in the morning and evening to remove dirt, oil, and cosmetics can help keep pores unplugged. Application of facial sunscreen in the morning can prevent darkening of acne blemishes. Medicated over-the-counter treatments can help remove dead skin cells from the surface of the skin that can plug pores, as in the case of the exfoliant salicylic acid. They can also kill the bacteria that promote acne, as in the case of benzoyl peroxide. Moisturizers can counteract the drying effects of cleansers and exfoliants by keeping the skin hydrated.
If changes in the skin care regimen fail to clear up the skin, it may be time to consult with a dermatologist. A number of treatments are available depending on the type of acne. Treatments have a variety of effects. They can prevent plugging of the pores, kill the bacteria that promote acne, block the effect of hormones on oil glands, reduce inflammation, or shrink oil glands.
Retinoids are a class of molecules derived from vitamin A that exists as both topical and oral forms. All retinoids help prevent plugging of the pores. Isotretinoin, commonly referred to as “Accutane,” is an oral retinoid use for severe acne or acne that does not respond to other treatments. The topical retinoids are particularly effective in treating comedonal acne. Oral antibiotics like doxycycline and minocycline kill Propionibacterium acnes, the bacteria that promote acne. They also have anti-inflammatory properties that help reduce redness and pain. Birth control pills and spironolactone help block the effect of hormones on oil glands. Anti-inflammatory steroids injected directly into the skin are a quick and effective way to deal with deep and painful acne bumps. Each treatment has a particular set of side effects.
It’s best to avoid “popping” pimples because, if not done properly, the pimple can actually pop inside the skin and cause more redness, pain, or even scarring. If scarring develops, there are a number of ways the surface and texture of the skin can be improved. Microneedling and fractionated lasers are techniques that create tiny injuries in the skin which, as they heal, result in stimulation of collagen production and resolution of scars. Microneedling employs microscopic needles whereas fractionated lasers use laser light to create the injuries.
Acne may be one of the most common skin conditions but there is no “one size fits all” approach to treating it. A dermatologist will choose the right treatment and skin care regimen for the right patient, taking into consideration the skin type, acne type, location, side effects of medications, other medical problems, allergies, interactions with other medications, and pregnancy status. With the wide variety of treatments currently available, nobody should suffer from the physical pain, emotional drain, and social stigma that acne can bring.
by Alexander Marzuka, MD