Breaking Out? Let's Break it Down.

You wake up in the morning hoping to have a great day, only to find a new pimple that has erupted seemingly out of nowhere. You spend the next hour wondering why on earth this has happened to you, and what you can do to treat it.


This is an experience that is shared by many of us. Luckily, there is a lot of research that has gone into figuring out what causes acne. Let’s break down why acne breakouts occur, and what we can do to treat and prevent them.



What is acne?


Acne vulgaris, more commonly known as “acne,” “zits,” or “pimples,” is an inflammatory skin condition that affects almost 80% of people between the ages of 11 and 30. Acne typically occurs in areas that have many sebaceous glands, such as the face, neck, back, buttocks, and chest, however, acne can present in any place aside from the palms of the hand and soles of the feet. Sebaceous glands produce an oily substance called sebum, which is involved in protecting the skin. Overproduction of sebum can lead to trapping of this substance in follicles, leading to the formation of a dense plug in our skin. This process is also known as “clogging the pores.” This plug attracts a type of bacteria that is normally found in our skin, known as Cutibacterium acnes, which grows inside the plug and leads to inflammation. This inflammation leads to the formation of pimples that we see on the surface of our skin.



What triggers acne production?


There are a few factors that can contribute to acne production:


Genetics

Although there is no “acne gene,” many studies have shown that genetics play a big role in acne development. Those who develop severe acne usually have a family history of acne.


Hormones

Androgens increase the size of sebaceous glands and therefore increase sebum production. Androgen production increases at the time of puberty, which is why acne typically begins at that time. Changes in hormones associated with the menstrual cycle in females can also cause acne flare-ups, particularly around the time of menses.


Sex

Although males and females are equally affected by acne, acne is usually more severe in males. However, acne usually develops earlier and persists for longer in females.


Skin Products

Greasy products, such as coal tar and oils, can form barriers on the skin and clog the pores. This leads to the formation of a dense plug in the follicles, leading to acne.


Products that Cause Friction on the Skin

Hats, helmets, headbands, masks, and many other products that form an occlusive barrier on the skin can lead to the formation of a dense plug in the follicles, leading to acne.


Environment

Heat, humidity, and sunlight can play a role in acne production and persistence. Heat induces sweating, and this sweat can clog pores and lead to acne. A humid environment causes this sweat to evaporate slower than usual, leaving the skin damp and sticky. As a result, a humid environment can clog the pores, ultimately leading to acne formation. Although the sun does not cause acne, unprotected exposure to sun rays can darken acne pimples and lead to scarring.


Emotions

The relationship between emotions and acne is still an area of study, but there are many studies that suggest that intense anger, stress, and anxiety may make acne worse and lead to breakouts.


Certain Drugs

Lithium, testosterone, progesterone, phenytoin, corticosteroids, anabolic steroids, phenobarbital, azathioprine, cyclosporine, isoniazid, disulfiram, and quinidine can all lead to drug-induced acne


Diet

The relationship between diet and acne is currently being studied. Some studies have linked dairy consumption with acne production, likely due to the hormone content in cow’s milk. Other studies have suggested that foods with a high glycemic index, such as white bread, cakes, cookies, potatoes, chips, dried fruits, and breakfast cereals, can increase acne production. The glycemic index measures foods based on how quickly they raise blood sugar; the higher the glycemic index, the faster the spike in blood sugar. In either case, studies have not yet determined a strong link between diet and acne.



When to See a Doctor


Although acne can usually be managed with over-the-counter products, it is time to see a doctor if:

  • Acne is due to a known or suspected hormonal condition, such as polycystic ovarian syndrome (PCOS) or hirsutism (excessive hair growth)

  • Acne is extremely distressing, and a psychological assessment is required

  • Acne is present along with bodily symptoms, such as a fever, fatigue, malaise, and general aches and pains

  • Children under the age of 11 are experiencing acne

  • Acne is severe and not responding to over-the-counter treatment

  • Severe scarring is present after inflammation has gone down



Tips and Tricks for Choosing an Acne Product


It is important to note that each person has unique skin. A product that works for one person may not work for another, and for this reason, it may take some time and experimentation to find an acne product that works well for you.


There are thousands of products that sit on shelves and claim to treat acne. It can get very overwhelming to figure out which products are marketing schemes, and which ones are genuine. Thankfully, there are a few tricks that can be used to pick a product that will target acne without targeting your wallet at the same time:


  1. Don’t focus on the brand or claims written on the product. Rather, focus on the active ingredient. This is usually written on the front of the product and listed as the “medicinal ingredient” in the ingredients section. Choose an active ingredient that has strong evidence towards treating acne (discussed below).

  2. Pick products that are fragrance-free. Products with added fragrances, or parfums, can further irritate acne-prone skin.

  3. Don’t fall for marketing schemes - expensive items are not always better! Most acne products that are extremely expensive have the same active ingredients as the ones that are more affordable.

  4. Oil-free products are the way to go. Since acne is typically caused by over-production of the oily substance known as sebum, it is best not to introduce more oil onto acne-prone areas.

  5. Gels, creams, solutions, and lotions are usually more effective than washes and soaps. Since washes and soaps are only in contact with the skin for a short amount of time, it is hard to get the full benefit from these agents. Instead, using a gel, cream, solution, or lotion that remains in contact with the skin for a long period of time will ensure that the benefits of the product are maximized.



Over-the-Counter Acne Products


As mentioned before, there are thousands of products that are available for acne treatment. Focusing on the active ingredient will help make sure that you choose a product that is effective. There are five ingredients that are found over-the-counter and have strong evidence in treating and preventing acne:



Benzoyl Peroxide (2.5-5%)


Benzoyl peroxide is the standard treatment for mild to moderate acne. Benzoyl peroxide kills the C. acnes bacteria that causes inflammation. It also stops the formation of a dense plug in the skin due to sebum and may also reduce the amount of sebum produced.


Benzoyl peroxide is applied to the affected area, usually at nighttime after cleaning the skin. It is important to apply the product to the acne pimple itself, as well as the surrounding area. Start off by applying the product for about 15 minutes on the first night, and then wiping it off. Gradually increase the amount of time you keep the product on the skin, until you have it on for the entire night. This will help build up some tolerance to the product and reduce skin irritation.


Benzoyl peroxide may cause skin dryness, peeling, redness, and tingling. It may also bleach clothing and towels. These side effects are usually minimal, and can be managed by using moisturizing creams, applying at nighttime, dedicating a separate towel and shirt to be used when using the product, and by using the product every other day.


Benzoyl peroxide also increases photosensitivity of the skin – that is, it makes the skin more sensitive to the sun. This can increase the risk of rashes, sunburns, blistering, and bubbling in response to unprotected sun exposure. Avoiding direct sunlight, applying sunscreen with at least SPF 30 on the face and body, and wearing protective clothing, such as hats, long sleeve shirts, and long pants, will protect the skin from sun exposure.


Benzoyl peroxide is most commonly available in a strength of 2.5-5%. There are many products available, such as Benzagel, Neutrogena Rapid Clear, and PanOxyl. Any product with a concentration of benzoyl peroxide higher than 5% has no evidence of increased effectiveness but will have increased side effects.


Acne usually declines about 5 days after starting treatment, but it may take 8-12 weeks to achieve the full benefit of treatment.



Salicylic Acid (0.5-3.5%)


Salicylic acid is a peeling agent which removes excess skin cells from the surface of an acne pimple. It is also mildly anti-bacterial, anti-inflammatory, and may also stop the formation of a dense plug in the skin due to sebum production.


Salicylic acid is applied topically to the affected and surrounding area after cleansing the skin, similar to benzoyl peroxide. The side effects of salicylic acid are also similar to that of benzoyl peroxide; however, salicylic acid may also cause slight itchiness of the skin. At equal concentrations, salicylic acid is slightly milder and less effective than benzoyl peroxide, so it is a good option if your skin is not able to tolerate benzoyl peroxide.


Salicylic acid is available in concentrations between 0.5-40%. There are many products available, such as Oxy Pads, The Ordinary, Neutrogena Rapid Clear, and Clearasil. Typically, 3.5% is the maximum concentration of salicylic acid that is used for the treatment of acne. Higher concentrations are reserved for treatments of other skin conditions, such as warts, calluses, and skin tags.


Acne usually declines about 8-12 weeks after starting treatment with salicylic acid.



Glycolic Acid (2-15%)


Glycolic acid causes desquamation of the skin – a process in which dead skin cells are sloughed away and replaced with new cells. This process helps prevent the formation of a dense plug in the skin, and therefore helps prevent the generation of acne.


Glycolic acid is applied to the entire affected area of the skin after cleansing. It may cause burning, stinging, tinging, dryness, and itchiness. These effects are usually mild and can be managed in similar ways as the side effects of benzoyl peroxide are managed. Glycolic acid also increases photosensitivity of the skin – make sure to take precautions to protect the skin from sun exposure.


Glycolic acid is available in concentrations of 2-15%. There are many products available, such as The Ordinary, Mario Badescu, and The Inkey List. Concentrations of 40% are used in professional clinics as chemical peels and are not available over-the-counter.

Acne usually declines in about 6-7 weeks after starting treatment with glycolic acid.



Zinc


Zinc acts by absorbing excess sebum to lower the chances of forming a dense plug in the skin. It also reduces shine and oiliness of the face, which may be a concern in those with acne-prone skin.


Zinc has typically been available as a cleanser; however, newer products, such as The Ordinary, are incorporating it into a serum that remains on the skin for a longer time.


Zinc products are typically well-tolerated, but they may cause some mild burning or stinging.

Noticeable differences in facial oiliness are usually evident 4-8 weeks after starting treatment with zinc.



Resorcinol


Resorcinol is mildly anti-bacterial, anti-fungal, and may also stop the formation of a dense plug in the skin due to sebum production.


Resorcinol is usually not available in single entity products; rather, it is available in products that also contain salicylic acid or sulfur. It is applied topically to the affected area. Take care not to apply it to a large area of the skin, as it may cause burning. Resorcinol may also cause hyperpigmentation in those with darker skin tones. It also requires protective packaging as it reacts to light and oxygen. Resorcinol also increases photosensitivity of the skin – make sure to take precautions to protect the skin from sun exposure.


Assessment of effectiveness is done after 4-8 weeks. If there is no noticeable difference in acne after 8 weeks, a different treatment option is preferrable.


Prescription Acne Products


For severe or persistent acne that does not respond to over-the-counter treatment, your doctor may recommend a stronger and more aggressive product to treat acne. These products require an evaluation by a physician and are only available with a prescription. They are not available for self-selection because they require supervision and follow-ups by your pharmacist and physician.



Retinoids


Retinoids are the main treatment used for severe and persistent acne. Retinoids can be applied on the skin (tretinoin, isotretinoin, adapalene), or can be taken by mouth (Accutane). Retinoids very effectively prevent the formation of dense plugs in the follicles of the skin. They also reduce the production of sebum. Retinoids that are applied on the skin can be used on a continuous basis, while oral retinoids are usually used daily for 1 month and can be extended based on an evaluation by your doctor.


Retinoids may cause skin dryness, eye dryness, and lip dryness. Your doctor may also recommend bloodwork to check liver and kidney function throughout treatment.

Retinoids also increase photosensitivity of the skin – make sure to take precautions to protect the skin from sun exposure.


Retinoids should not be used in pregnant women or women who are trying to get pregnant. There is strong evidence that retinoids can disrupt or halt the development of the fetus. Women who are using retinoids should take care not to become pregnant during treatment.



Benzoyl Peroxide with Clindamycin


As discussed earlier, benzoyl peroxide is the standard treatment for mild to moderate acne. For more severe and persistent acne, benzoyl peroxide can be combined with an antibiotic, such as clindamycin, into a gel or cream. Together, these agents target and eliminate the C. acnes bacteria, as well as reduce inflammation. Products with benzoyl peroxide and clindamycin can be used on a continuous basis.



Oral Antibiotics


Taking antibiotics by mouth can be considered if acne does not respond to products that are applied to the skin. Antibiotics such as tetracycline, doxycycline, and minocycline, are typically used as treatments for acne. These agents target the C. acnes bacteria and effectively reduce the inflammation associated with acne. These antibiotics can be taken for up to 3 months, but the duration can be decreased or increased based on evaluation by your doctor.

Oral antibiotics may cause stomach discomfort and diarrhea. Antibiotics may also increase photosensitivity of the skin – make sure to take precautions to protect the skin from sun exposure.



Hormonal Birth Control


Since acne can be associated with changes in the menstrual cycle, hormonal birth control is a useful option to control acne in females. Birth control reduces the androgens circulating in the blood stream, and therefore reduces sebum production.



How long will I need to use my acne treatment?


Acne is a condition that lasts for many years. Even when initial acne control is achieved by over-the-counter or prescription acne products, you will likely need continue using your acne product for many years. This ensures that the acne stays under control and does not flare up again.


The only exception to this is Accutane, which usually causes permanent reduction in acne.



What else can I do to help control acne?


There are some lifestyle modifications that can reduce the duration of acne, as well as prevent new acne pimples from appearing:

  1. Cleansing the face with a mild, unscented cleanser no more than 2 times a day can help remove dirt, oils, and other impurities from the face and prevent them from clogging pores and leading to the development of acne.

  2. Pillowcases and bedsheets pick up oils and dirt from the face and body. Washing them often can prevent these oils and dirt from clogging the pores.

  3. Do not pick and touch acne pimples. This can lead to bleeding and scarring.

  4. Wash your face and body after sweating – this prevents sweat from clogging the pores.

  5. Use a sunscreen on your face and body that will not clog your pores. These sunscreens are usually labelled as “acne friendly” or “non-comedogenic.” The sun can darken acne pimples and scars, so using a sunscreen will prevent this.

  6. Stress can make acne worse – finding ways to manage and cope with stressful situations can help prevent acne flare ups during stressful times.



Final Words


Although acne can be irritating to have, it is important to remember that it is a part of being human. Many people have had acne at some point in their lives, and it is not something to be ashamed of. It is a treatable and preventable skin condition, and it does not determine your self-worth or value.



 


References

  1. Dreno B, Pecastaings S, Corvec S, Veraldi S, Khammari A, Roques C. Cutibacterium acnes (Propionibacterium acnes) and acne vulgaris: a brief look at the latest updates. Journal of the European Academy of Dermatology and Venereology, 32(S2): 5-14. Published June 12, 2018. https://doi.org/10.1111/jdv.15043

  2. Elsevier Point of Care, 2021. Acne Vulgaris. Obtained from: https://www-clinicalkey-com.login.ezproxy.library.ualberta.ca/#!/content/clinical_overview/67-s2.0-e1e1fc86-07dc-41de-a32f-5e5d05192493#most-common-heading-22

  3. Lam C, Zaenglein AL. Contraceptive use in acne. Clinics in Dermatology 32(4): 502-515. Published July 11, 2014. https://doi.org/10.1016/j.clindermatol.2014.05.002

  4. Sihota, A. Acne. In: Compendium of Therapeutics for Minor Ailments. Canadian Pharmacists Association. Updated March 2, 2020. Accessed May 20, 2021. https://www-e-therapeutics-ca.login.ezproxy.library.ualberta.ca/search

  5. Thielitx A, Gollnick H. Topical Retinoids in Acne Vulgaris. American Journal of Clinical Dermatology, 9: 369-381. Published September 10, 2012. https://doi.org/10.2165/0128071-200809060-00003



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