The Call-On-Doc Guide to Acne

According to the guidelines set by the American Academy of Dermatology, there’s no universal grading system for acne, but each has similar symptoms and can be identified based on:

• The type and number of acne lesions
• The severity of acne
• location of acne
• Whether there is scarring

A key indicator of acne is acne lesions, also referred to as pimples. These are the primary indicators of acne, but inflammation and discoloration are other classic symptoms associated with acne. If picked at or popped, acne can worsen in appearance and become prone to infection. By appearance alone, the acne lesion you may get comes in several different forms and may look like: 

While known for acne lesions, the condition also comes in different forms that may have specific physical appearances when flaring up (2). These types of acne include: 

Cystic: Cystic acne is a severe form of acne characterized by deep, painful, and inflamed cysts that develop beneath the skin's surface (3). These cysts are typically larger and more noticeable than other types of acne lesions. Cystic acne results from an infection within the pores, causing the formation of tender, red nodules filled with pus. It can be filled with pus and often leads to scarring. 

Fungal: Fungal acne is recognized as pityrosporum folliculitis or malassezia folliculitis, developing into a type of acne-like skin condition caused by an overgrowth of yeast called Malassezia on the skin. While fungal acne is technically a skin condition, it has a similar appearance and associated symptoms (4). It is triggered when naturally occurring yeasts on the skin overgrow in a suitable environment (warm and humid), resulting in inflammation and small itchy bumps that resemble acne. The condition is most likely to appear in areas of the body with higher concentrations of oil glands, like the forehead, chest, and back. 

Hormonal: This type of acne is primarily driven by hormonal fluctuations in the body. It typically occurs during periods of hormonal imbalance, such as puberty, menstrual cycles, pregnancy, and menopause (5). Also referred to as adult acne, it is characterized by breakouts of whiteheads and blackheads that commonly appear on the lower face, jawline, and chin. These breakouts are often deep and tender, sometimes including cysts or nodules.

Nodular: A severe form of acne that presents as large, painful, and deep-seated nodules beneath the skin's surface. These nodules are characterized by their size, hardness, and inflammation (2). They often appear as firm, red or flesh-colored bumps that can be tender to the touch. Nodular acne tends to be resistant to typical over-the-counter treatments and may require medical intervention from a dermatologist. It can leave significant scarring if not properly managed. 

Acne itself is not typically considered a symptom of a specific disease. However, acne can be influenced by various factors, including hormonal imbalances, genetics, certain medications, and underlying health conditions. 

In some cases, certain medical conditions or hormonal disorders such as PCOS, Cushing's syndrome, and adrenal disorders can contribute to the development or exacerbation of acne. Additionally, certain medications like corticosteroids or certain anticonvulsants can cause acne as a side effect.

No, acne face mapping, a practice based on the concept that specific areas of the face correspond to specific internal organs or imbalances, is not considered accurate or supported by scientific evidence. While it may be intriguing to associate acne breakouts with certain regions of the face and link them to internal health issues, there is limited scientific basis for such claims.  

Treatment for acne should be based on individual factors and the specific type of acne being experienced, rather than relying on a one-size-fits-all approach based on face mapping. It is always best to consult with a dermatologist or healthcare professional for personalized advice on acne treatment.

Pores are small openings on the surface of the skin (except for the palms of your hands and soles of your feet) that house hair follicles and are connected to sebaceous glands. These glands produce sebum, an oily substance that helps lubricate and protect the skin. With around five million covering your body and 20,000 on your face, pores serve as channels for sebum and sweat to be released onto the skin's surface. While the sweat cools down your body, the sebum moisturizes your skin. 

Pores can become clogged when excess sebum (oil) production combines with dead skin cells and other debris on the skin's surface. This mixture can form a plug that obstructs the opening of the pore. Additionally, the use of certain skincare products, makeup, and environmental factors like dirt and pollution can contribute to pore clogging. This process then leads to the formation of acne. 

While we cannot control some of the causes that worsen acne, it's important to be aware of of what does contribute to acne and things we can do to keep our skin healthy and as clear as possible.

Hormonal fluctuations: Hormonal fluctuations can play a significant role in the development of acne. Specifically, an increase in androgen hormones, such as testosterone, can stimulate the sebaceous glands to produce more sebum (oil). This excess sebum production can lead to the clogging of pores and create an environment conducive to the growth of acne-causing bacteria (Propionibacterium acnes). Additionally, hormonal changes can also affect the skin's cell turnover rate, leading to an accumulation of dead skin cells that can further contribute to pore blockages. Natural life events and conditions where hormone fluctuations play a bigger role in acne include:

• Puberty
• Menstrual cycles
• Pregnancy
• Menopause
• Occasions of higher stress
• Starting or stopping birth control
• Developing hormonal disorders

Excess sebum production: When the sebaceous glands produce an excessive amount of oil, it can contribute to clogged pores and the development of acne. The amount of sebum your body produces is caused by:

• Hormone treatments or medications
• Hormone imbalances
• Genetics
• Diet
• Stress
• Skin irritation
• Surrounding environment

Bacterial growth: Bacteria, specifically Propionibacterium acnes (P. acnes), contributes to the development of acne by playing a role in the formation of clogged pores, inflammation, and the progression of acne lesions. When excess sebum production combines with dead skin cells and other debris, it can clog the pores and create an environment where P. acnes bacteria thrive. As the bacteria multiply within the clogged pores, they produce substances that trigger an immune response and inflammation. This immune response leads to redness, swelling, and the formation of various acne lesions. Additionally, P. acnes bacteria break down the sebum, producing substances that further contribute to inflammation and tissue damage. 

Inflammation: Inflammation in the body can worsen acne by impeding the healing process as well as cause additional redness, swelling, and pain. Inflammation also contributes to acne by:

• Stimulating the production of sebum
• Promoting the accumulation of dead skin cells
• Trapping bacteria within pores
• Spreading acne across an area of the body

Medication: Certain types of prescriptions can cause and worsen acne. If you are struggling with acne and are taking any of the following, it might be contributing to your breakouts. Medications known to aid in acne include:

• Hormonal medications: Certain hormonal medications, such as some types of birth control pills or hormone replacement therapy, can impact hormone levels in the body. These hormonal fluctuations can sometimes lead to an increase in sebum production and pore blockage, making acne more likely to develop or worsen.
• Steroids: Oral or topical corticosteroids, commonly prescribed for conditions like asthma, allergies, or skin inflammations, can cause or worsen acne. Steroids can increase sebum production, disrupt the balance of hormones, and trigger inflammation, all of which contribute to acne formation.
• Lithium: Lithium is a medication used to treat bipolar disorder. However, it has been associated with the development or worsening of acne in some individuals. The exact mechanisms by which lithium affects acne are not fully understood, but it may influence hormone levels and sebum production.
• Antidepressants: Certain antidepressant medications, particularly those classified as tricyclic antidepressants or lithium-based mood stabilizers, have been linked to acne flare-ups in some individuals. Similar to lithium, the exact reasons behind this association are not fully clear.
• Anti-epileptic drugs: Some anti-epileptic medications, such as phenytoin or carbamazepine, have been reported to trigger or worsen acne in certain cases. The precise mechanisms involved are still under investigation.

Poor skincare habits: Poor skincare habits can contribute to the development or worsening of acne in several ways:

• Inadequate cleansing: Failing to cleanse the skin properly can lead to the accumulation of dirt, oil, dead skin cells, and other impurities on the surface of the skin. This buildup can clog pores and contribute to the development of acne.
• Using harsh or irritating products: Using skincare products that are too harsh or irritating for your skin type can disrupt the skin's natural balance and cause inflammation. This can trigger an overproduction of sebum and lead to clogged pores, increasing the likelihood of acne breakouts.
• Not removing makeup or cosmetics: Leaving makeup or cosmetics on the skin for extended periods can contribute to clogged pores and acne. These products can mix with sebum, dead skin cells, and environmental pollutants, creating a breeding ground for bacteria and increasing the risk of acne formation.
• Overwashing or excessive scrubbing: While it's important to keep the skin clean, overwashing or excessive scrubbing can strip the skin of its natural oils and disrupt its protective barrier. This can trigger an overproduction of sebum as the skin tries to compensate for the loss of moisture, leading to acne flare-ups.
• Not moisturizing properly: Failing to moisturize adequately can lead to dryness and dehydration, which can prompt the skin to produce more sebum in an attempt to compensate. This can result in clogged pores and acne breakouts.
• Touching or picking at the skin: Constantly touching or picking at the skin can transfer bacteria and other impurities from the hands to the face, increasing the risk of pore blockage and inflammation. It can also lead to the introduction of more bacteria into existing acne lesions, prolonging their healing time and potentially causing scarring.

Diet: Some dietary factors have been thought to contribute to and worsen acne. A few examples include:

• High glycemic index foods: Consuming foods with a high glycemic index, such as refined carbohydrates, sugary snacks, and processed foods, can cause a rapid spike in blood sugar levels. This can trigger a cascade of hormonal responses that may increase sebum production and promote inflammation, both of which can contribute to acne formation.
• Dairy products: Some studies suggest a possible link between the consumption of dairy products, particularly skim milk, and the development or worsening of acne. It is hypothesized that hormones and bioactive substances present in dairy products may influence the skin's oil production and promote inflammation.
• Foods high in saturated and trans fats: Diets rich in saturated and trans fats, commonly found in fried foods, fast food, and fatty meats, have been associated with increased acne risk. These fats may contribute to inflammation and influence sebum production, potentially worsening acne symptoms.
• Insufficient intake of fruits and vegetables: A diet lacking in fruits and vegetables means missing out on essential vitamins, minerals, and antioxidants that support overall skin health. Adequate intake of these nutrient-dense foods may help promote a healthy complexion and potentially reduce the risk of acne.
• Food sensitivities or allergies: Some individuals may have specific food sensitivities or allergies that can trigger inflammation and skin reactions, including acne breakouts. Identifying and eliminating trigger foods can be beneficial for managing acne in such cases.

Stress: Stress can trigger hormonal imbalances and exacerbate existing acne or contribute to new breakouts. When experiencing stress, the body releases hormones like cortisol, which can stimulate the sebaceous glands to produce more sebum. The excess sebum, along with dead skin cells and bacteria, can clog pores and lead to acne breakouts. Moreover, stress can promote inflammation, impair the skin's barrier function, increase skin sensitivity, and potentially lead to unhealthy skincare habits, all of which can worsen acne symptoms.

Acne is typically diagnosed based on a visual examination of the skin by a healthcare professional, usually a dermatologist (1). The diagnosis is made by assessing the presence of characteristic acne lesions such as comedones (blackheads or whiteheads), papules, pustules, nodules, or cysts. The healthcare professional will evaluate the location, distribution, and severity of the acne lesions to determine the appropriate diagnosis. In some cases, understanding the patient's medical history and lifestyle factors can help a medical provider better understand the underlying causes or contributing factors. If you feel as though you need to consult with a professional, you can start a visit online with a board-certified dermatologist right now.

Fortunately, there are a number of treatments for acne that can effectively treat the condition and make it manageable in the long term. As it does come in multiple forms and levels of severity, there are similarly different solutions for acne based on medications that can be consumed, applied on the inflamed area, or operations that can be performed in more severe cases (6). The most common types of treatment for acne are topical or oral prescriptions: 

Topical: The intention behind topical acne medication is to treat and manage acne by targeting the condition on the surface. Applied directly to the skin’s surface, these medications typically come in the form of creams, gels, lotions, or other solutions with the purpose of:

• Balancing oil production: Topical acne medications manage oil production by targeting the sebaceous glands, which are responsible for producing sebum (skin oil). These medications contain active ingredients that help regulate sebum production, reducing excessive oiliness and preventing clogged pores. They can work by inhibiting sebaceous gland activity, reducing the amount of oil produced, or physically absorbing excess oil from the skin's surface. By managing oil production, topical acne medications help maintain a balanced sebum level, preventing the buildup of oil that can contribute to acne formation and promoting clearer, less oily skin. 
• Controlling bacteria growth: Topical acne medications play a crucial role in controlling facial bacteria growth, particularly the bacteria Propionibacterium acnes, which is associated with acne. These medications often contain antibacterial agents that directly target and inhibit the growth of these bacteria on the skin's surface. By reducing the population of acne-causing bacteria, topical medications help prevent the colonization of pores and hair follicles, which can lead to inflammation and acne lesions. Additionally, some topical medications have anti-inflammatory properties that help soothe existing acne and reduce the redness and swelling associated with bacterial infection. By controlling bacterial growth, topical acne medications contribute to a healthier skin environment, minimize the risk of infection, and promote clearer, blemish-free skin. 
• Reducing inflammation: These medications often contain anti-inflammatory ingredients such as corticosteroids, retinoids, or certain types of acids. When applied to the skin, they work by suppressing the inflammatory response, calming the redness, swelling, and discomfort commonly seen in acne lesions. They inhibit the production of inflammatory molecules, such as cytokines, and help normalize the skin's immune response. By reducing inflammation, topical acne medications promote the healing of existing acne lesions and prevent the formation of new ones.
• Regulating skin cell turnover: These medications often contain active ingredients such as retinoids, salicylic acid, or alpha hydroxy acids that help normalize the shedding of skin cells. They promote exfoliation and prevent the buildup of dead skin cells, which can clog pores and contribute to acne formation. By regulating skin cell turnover, topical acne medications encourage the renewal of the skin's surface, revealing fresher, healthier skin and reducing the occurrence of clogged pores and acne breakouts.
• Unclogging pores: These medications typically contain active ingredients such as salicylic acid, benzoyl peroxide, or retinoids that work in different ways to address clogged pores. Salicylic acid, for instance, is a keratolytic agent that helps exfoliate the skin and remove dead skin cells, allowing for the unclogging of pores. Benzoyl peroxide, on the other hand, has antibacterial properties that reduce the presence of acne-causing bacteria and help clear the debris within the pores. Retinoids promote cell turnover and prevent the accumulation of dead skin cells, reducing pore blockages. By targeting the factors that contribute to clogged pores, topical acne medications effectively unclog the pores, prevent the formation of new acne lesions, and promote clearer, healthier skin.

Oral: Medications taken orally for acne are typically prescribed when topical treatments are not enough to manage the condition, especially when it becomes moderate to severe. Targeting the body’s internal functions upon consumption, oral acne medications typically do the following:

• Combat bacteria: Oral acne medications combat bacteria by addressing the underlying bacterial overgrowth that contributes to acne development. One common type of oral medication prescribed for acne is antibiotics. Antibiotics work by inhibiting the growth and spread of bacteria, including the bacteria Propionibacterium acnes, which is commonly associated with acne. By targeting and reducing the population of acne-causing bacteria in the body, oral antibiotics help alleviate inflammation, prevent infection, and promote the healing of existing acne lesions. They can also help to prevent the formation of new breakouts. It's important to note that oral antibiotics are typically used for a limited duration and as part of a comprehensive treatment plan, as prolonged or indiscriminate use can contribute to antibiotic resistance. 
• Hormonal imbalances: Oral acne medications can block androgen hormones, which play a significant role in the development and exacerbation of acne. One commonly prescribed medication for this purpose is oral contraceptives, specifically those containing both estrogen and progestin hormones. These medications work by suppressing the production of androgens, such as testosterone, or by altering their effects on the body. By reducing the levels of androgens, oral contraceptives help regulate sebum (oil) production, decrease the likelihood of clogged pores, and prevent the formation of acne lesions. They can also help improve hormonal imbalances that contribute to acne in individuals with conditions like polycystic ovary syndrome (PCOS). It's important to note that oral contraceptives are typically prescribed for women and require careful consideration, as they may have potential side effects and contraindications.
• Isotretinoin: This oral medication, often referred to as Accutane or Roaccutane, is a potent treatment option for severe acne that has not responded to other treatments. Isotretinoin works by reducing sebum production, decreasing inflammation, and regulating the shedding of skin cells. It is highly effective but requires close monitoring due to potential side effects.
• Spironolactone: Part of a class of medications known as aldosterone antagonists or potassium-sparing diuretics. In relation to acne, spironolactone's anti-androgenic properties are believed to be responsible for its effectiveness. Acne in women is often associated with excessive production of androgens, such as testosterone. Spironolactone helps counteract this by blocking the effects of androgens on the oil glands in the skin, reducing sebum (oil) production. This can result in a decrease in the severity and frequency of acne breakouts.

Procedures: Patients with more severe cases of acne may not be able to manage their condition with topical solutions and oral medications alone. More severe cases will require more specialized and professional methods that require a person to be attended to by hands-on medical professionals. These can include:  

• Chemical peel: A type of cosmetic procedure used to improve the appearance and texture of the skin. Chemical peels involve the application of a chemical solution to the skin, which causes the outermost layer to exfoliate and eventually peel off. This process helps to unclog pores, remove dead skin cells, and reduce the buildup of oil and debris that can contribute to acne formation. By removing the outermost layer of the skin, chemical peels can also help improve the appearance of acne scars and tone. This can be done by a dermatologist or at a local spa and is open to anyone. It is important to limit this procedure to a maximum of once a month. For more recommendations on ways to improve and treat your skin, check out this blog with skincare tips from our dermatologist!
• Corticosteroid Injections: also known as intralesional corticosteroid injections, are a treatment option for certain types of acne lesions, particularly cystic and nodular acne. Corticosteroids are powerful anti-inflammatory medications that can be injected directly into the acne lesion to reduce inflammation, swelling, and promote healing.
• Incision and drainage: Also referred to as I&D, incision, and drainage is a procedure used to treat certain types of acne lesions, particularly large, deep, or persistent ones such as cysts or nodules. The medical professional, typically a dermatologist, first numbs the area with a local anesthetic to minimize discomfort. They then make a small incision into the acne lesion, allowing the trapped fluid, pus, or debris to be released. This helps to alleviate pain, reduce inflammation, and promote the healing process. After draining the acne lesion, the healthcare professional may gently apply pressure or use an instrument to remove any remaining debris. They may also apply an antiseptic or antibiotic ointment to prevent infection and aid in the healing process. Such a procedure can only be done by a trained healthcare professional. 
• Steroids: Corticosteroid injections are typically reserved for larger, more severe acne lesions, such as cysts or nodules. When injected directly into the acne lesion, corticosteroids help to rapidly decrease inflammation and swelling. This can lead to a significant reduction in the size and discomfort of the lesion.

As can be noticed, most treatments beyond topical are reserved for much more difficult-to-manage acne cases. Especially when it comes to getting procedures for the condition, it is best to exhaust other options and seek out professional help so that the best long-term solution can be developed for your case. 

For most cases of acne, topical treatments do the trick in toning down the severity of symptoms and provide a long-term solution. Popular products for topical acne treatment include adapalene, alpha hydroxy acids (AHAs), azelaic acid, and benzoyl peroxide (7). Commonly used topical treatments for acne, each has different mechanisms of action that contribute to improving acne symptoms. All are available over-the-counter or by prescription. Here's a breakdown of each treatment and their differences:

Adapalene:

• Adapalene is a retinoid that helps regulate skin cell turnover and prevents clogged pores.
• It reduces inflammation and improves the overall appearance of the skin.
• Adapalene is typically used in the evening and can be applied before or after moisturizer.

Alpha hydroxy acids:

• AHAs, such as glycolic acid and lactic acid, exfoliate the skin by removing dead skin cells.
• They help unclog pores and improve the skin's texture and tone.
• AHAs are usually used in the form of cleansers, toners, or serums and can be applied in the morning or evening.

Azelaic acid:

• Azelaic acid has anti-inflammatory and antimicrobial properties, making it effective against acne.
• It helps to reduce inflammation, control bacteria, and prevent clogged pores.
• Azelaic acid can be used in the morning or evening and is available in the form of creams, gels, or foams.

Benzoyl peroxide:

• Benzoyl peroxide has both antibacterial and anti-inflammatory effects, targeting acne-causing bacteria and reducing inflammation.
• It helps unclog pores, removes excess oil, and prevents new acne lesions.
• Benzoyl peroxide is typically applied once or twice daily, either as a spot treatment or all over the affected areas.

Managing acne involves adopting a consistent skincare routine and making lifestyle changes that promote healthy skin. Here are some tips to help manage acne:

• Cleanse gently: Use a gentle cleanser to wash your face twice a day, morning and evening. Avoid harsh scrubbing or overwashing, as it can irritate the skin and worsen acne.
• Avoid touching your face: Touching your face can transfer dirt, oil, and bacteria, which can clog pores and contribute to breakouts. Keep your hands away from your face as much as possible.
• Use non-comedogenic products: Choose skincare and makeup products labeled as non-comedogenic, which means they are less likely to clog pores and cause breakouts.
• Don't squeeze or pick at acne lesions: Squeezing or picking at pimples can lead to inflammation, scarring, and further spread of bacteria. Allow acne lesions to heal naturally or seek professional treatment.
• Manage stress: Stress can worsen acne, so practice stress management techniques like exercise, meditation, or deep breathing exercises to help reduce stress levels.
• Follow a healthy diet: While diet alone may not be the primary cause of acne, consuming a balanced diet rich in fruits, vegetables, whole grains, and lean proteins can support overall skin health.
• Keep hair and hair products away from the face: Hair products, such as oils or styling products, can clog pores when they come into contact with the skin. Keep hair off your face and avoid using heavy or greasy hair products.
• Protect your skin from the sun: Use a broad-spectrum sunscreen with SPF 30 or higher to protect your skin from harmful UV rays. Some acne treatments can increase sensitivity to the sun, so sun protection is essential.
• Avoid excessive exfoliation: While exfoliating can help remove dead skin cells, overdoing it can irritate the skin and trigger more acne. Limit exfoliation to 1-2 times a week with gentle exfoliants.

1. Wash your face: Start by washing your face with a gentle cleanser suitable for your skin type. Use lukewarm water and your fingertips to cleanse, avoiding harsh scrubbing.
2. Pat dry: Gently pat your face dry with a clean towel. Avoid rubbing, as it can irritate the skin.
3. Apply topical medication: Once your face is dry, apply the prescribed or recommended acne topical medication. This can include ingredients like adapalene, benzoyl peroxide, or azelaic acid. Follow the instructions provided by your healthcare professional or the product label for the correct amount and application method.
4. Allow absorption: Give the topical medication some time to absorb into the skin before applying any additional products. This usually takes a few minutes, but check the specific instructions for your medication.
5. Moisturize (if needed): If your healthcare professional or dermatologist recommends using a moisturizer, apply it after the topical medication has been absorbed. Opt for a non-comedogenic moisturizer suitable for your skin type.

Acne is a common condition that affects a wide variety of people. If you are struggling to manage your acne, consult with a dermatologist online today to get a custom treatment plan for short-term or long-term relief.