…we still have no clue.

After scouring the research from the last several years regarding sebum (skin oil), acne bacteria, gene transcription, and a bunch of other super techie stuff, the answer to what causes acne is…um…we still have absolutely no idea. Most diseases are tricky things, and acne is no exception. Scientists are really only still scratching the surface when it comes to nailing down what actually happens that starts the acne ball rolling.

Let’s take acne bacteria for instance. Over the past few years, scientists have located more strains of P. Acnes, the bacteria present in human skin. We don’t know which strains might be harmful and which might actually be helpful. Furthermore, we don’t know which of the secretions of which of the bacteria strains cause problems and why. Additionally, we don’t know if it’s the secretions that cause a problem or if certain strains of bacteria interact with cells in some other way, such as interacting with cell RNA, toll-like receptors, or inflammation. And, um…if these bacteria do interact with skin cells in some way, we don’t know whether it’s dermal cells, oil cells, or immune/inflammatory cells.

The story is equally muddled when you look at the immune response of the skin, the inflammatory cascade, cell signaling, et cetera, et cetera.

Regardless, it’s not all bad news. Some directions of inquiry are starting to look more interesting than others. For instance, scientists are starting to frame acne as an inflammatory disease and are focusing in on how to mediate the body’s inflammatory response in the skin.

With time, we may be able to better specify what causes acne, which could theoretically lead to a cure. Rest assured that I’ll keep on top of the latest research. In the meantime, The Regimen should work well to keep acne under complete control, and in more severe cases, Accutane is an option as well.

The more I learn about antibiotic therapy for acne, the more wary and less enthused I become. Due to overuse and misuse over the past twenty years, antibiotic resistance has become widespread throughout the skin of the world population. This is evidenced by the increasing ineffectiveness of both oral and topical antibiotics in clinical studies. Antibiotics never worked very well for acne, and now they work even less well.

According to a “Global Alliance to Improve Outcomes in Acne” published in the Journal of the American Academy of Dermatology, antibiotics should be avoided as the sole treatment of acne. Researchers agree strongly that if antibiotic therapy is used, it should be combined with other therapies. When you look at the superior effectiveness of these other therapies the question arises as to why someone would want to include antibiotics at all. For example, when one takes into consideration the fact that benzoyl peroxide kills 99.9% of acne bacteria on its own and does not create resistant colonies of bacteria, one has to wonder why so many prescriptions for antibiotic acne therapy–over 11 million per year–are still written. According to an article published in the journal Expert Opinion on Pharmacotherapy, “…evidence demonstrates that [topical antibiotics] are no more effective against inflamed lesions than [benzoyl peroxide], and are less effective against non-inflamed lesions…To date, [benzoyl peroxide], as both mono- and combination therapy, is the most evidence-based approach.” Other acne treatments exist, and while they may not be as effective as benzoyl peroxide, they easily outpace antibiotics.

The misuse of antibiotics can also cause antibiotic resistance in other skin bacteria, especially the bacteria known to lead to impetigo and folliculitis. If all of this weren’t enough, when we look at how gene mutations work in bacteria, we see that genes which allow for resistance to antibiotics are easily transferred from acne bacteria to other bacteria in the skin, thus further promoting unwanted antibiotic resistance in other skin bacteria.

If your doctor has you on antibiotic therapy for acne and nothing else, it may be time to have a talk with her/him. The authors of the expert opinion review also note that topical antibiotics should be used for no longer than 3 months and oral antibiotics for no longer than 6 months. So, if you have been on antibiotic therapy for a long time, it may also be time for an appointment with your dermatologist. Since poor compliance with antibiotic regimens are one of the main causes of antibiotic resistance, just make sure you do not stop antibiotic therapy on your own without consulting with your physician first.