photo-80Medical science is still not close to deciphering what causes acne, but it’s not for lack of trying. Here I will summarize 9 recent studies that I have read which attempt to get to the bottom of it. Keep in mind that we have no definitive conclusions, just ongoing research. Warning: Big words!

Oxidative stress. Scientists published an article in the Journal of Drugs in Dermatology considering the role of oxidation as something that “may be an early event that helps to drive the acne process.” Could it be skin oil (sebum) oxidizing that causes acne? Could antioxidants help?

Growth hormone and IGF-1 (Insulin-like growth factor 1). A study in Iran attempted to evaluate the power of growth hormone and IGF-1 to affect male hormones and thus increase the severity of acne. “The mean serum levels of GH and IGF-1 of severe acne patients were significantly increased when compared with mild-, moderate acne patients, and healthy controls.” A second Turkish study further evaluated the link between IGF-1 and acne. Again a significant link was found between IGF-1 levels and acne severity.

Staphylococcus aureus (S. aureus). You may have heard of this in regards to “staph infections.” In the journal North American Journal of Medical Sciences, researchers looked at the Staphylococcus aureus levels in acne patients vs. healthy controls. Results were inconclusive. “S. aureus was detected in 21.7% of the subjects in acne, and in 26.6% of control groups.”

Altitude. An article in the European Journal of Pediatrics looked at 6,200 boys. Interestingly, they found that “the acne frequency decreased with the increasing of the altitude where the boys lived.” Why this might be the case we don’t know.

Inflammation. Three articles looked at inflammation more closely. The first in the Journal of Drugs in Dermatology further elucidates the particular sequence of inflammation that leads to acne lesion formation. “An important facet of the new paradigm is that a specific follicular pattern of innate inflammation occurs before and during follicular hyperkeratinization. Moreover, this inflammation persists during the resolution of the macular phase after inflammatory lesions flatten toward the end of their life cycle.” A second article in the Journal of Drugs in Dermatology further states this point, “Newer research has shown that inflammation may precede comedo formation. Gene array analysis of acne lesions has elucidated newer inflammatory mediators…” A third study, again published in the Journal of Drugs in Dermatology drives home the point, “Recent evidence suggests that subclinical inflammation is the primary event in lesion development and that inflammation persists throughout the lesion life-cycle. Therefore, all types of acne should be considered ‘inflammatory’ acne.”

Genetics and Lifestyle. An study performed in Italy and published in the Journal of the American Academy of Dermatology looked at family history, personal habits, diet, and menstrual history. Their conclusion: “Family history, body mass index, and diet may influence the risk of moderate to severe acne. The influence of environmental and dietetic factors in acne should be further explored.”

Thanks scientists for all your work! Hopefully we will keep getting closer to figuring out what causes acne so we can get to the root of it and wipe it out for good!


  • Bowe WP, Patel N, Logan AC. “Acne vulgaris: the role of oxidative stress and the potential therapeutic value of local and systemic antioxidants.” Journal of Drugs in Dermatology. 2012; 11(6): 742-6.
  • Saleh BO. “Role of growth hormone and insulin-like growth factor-1 in hyperandrogenism and the severity of acne vulgarism in young males.” Saudi Medical Journal. 2012; 33(11): 1196-200.
  • Tasli L, et al. “Insulin-like growth factor-1 gene polymorphism in acne vulgaris.” Journal of the European Academy of Dermatology and Venereology. 2013; 27(2): 254-7.
  • Khorvash F, et al. “Staphylococcus aureus in Acne Pathogenesis: A Case-Control Study.” North American Journal of Medical Science. 2012; 4(11): 573-6.
  • Robeva R, et al. “Acne vulgaris is associated with intensive pubertal development and altitude of residence–across-sectional population-based study on 6,200 boys.” European Journal of Pediatrics. 2013; 172(4): 465-71.
  • No authors listed. “Decoding Acne: Genetic Markers, Molecules, and Propionibacterium Acnes.” Journal of Drugs in Dermatology. 2013; 12(6): s61-2.
  • Weiss JS. “Messages from molecules: deciphering the code.” Journal of Drugs in Dermatology. 2013; 12(6): s70-2.
  • Stein Gold LF. “What’s New in Acne and Inflammation?” Journal of Drugs in Dermatology. 2013; 12(6); s67-9.
  • Di Landro A, et al. “Family history, body mass index, selected dietary factors, menstrual history, and risk of moderate to severe acne in adolescents and young adults.” Journal of the American Academy of Dermatology. 2012 67(6):1129-35.

magazineI’ve noticed over the years that anything I read about acne in magazines is usually replete with errors and terrible misinformation. I’m at my dad’s house for a few days right now and my step mother gets Fitness magazine. The cover claims “Clear Skin Breakthroughs That Really Work.” I had to crack it open and read it. Their advice boils down to using salicylic acid and perhaps staying away from milk. Wow. Such bad advice. First of all, anyone who researches acne to any degree knows that salicylic acid is very weak at controlling breakouts. The legal limit for salicylic acid products is 2% and at this concentration it does very little if anything to help clear the skin. And milk has been associated with breakouts in only very limited, confusing studies based on people recalling what they ate many years previously. This evidence is so flimsy that the authors in The Journal of Clinics in Dermatology concluded, “Our conclusion, on the basis of existing evidence, is that the association between dietary dairy intake and the development of acne is slim.”

unnamed-2I could go on and on here picking apart the deep horrendousness of this one supposed “Clear Skin Ahead” article as it is titled inside the magazine, but suffice it to say that this article will do nothing for anyone other than cause them frustration and confusion. This is true of upwards of 90% of other articles I have read in major magazines over the years. Can you tell I’m mad? Well, I am. Ok, I just have to quote one more thing from this article. Haha. Keep in mind that almost every journalist who has ever interviewed me has misquoted me, so I’m not dogging the doctor here. But they quote a doctor saying, “sweat and bacteria left on the skin after a workout can be a breeding ground for breakouts…” The reality is that bacteria on the surface of the skin has zero to do with acne. Zero. It is bacteria deep within the skin which causes acne. Far from clearing things up for the readers of Fitness magazine, this quote just reinforces yet another myth about acne.

Bottom line: Don’t believe pretty much anything you read in magazines about acne. And to extrapolate, don’t believe pretty much anything you read in magazines period.

summer humidityI live in San Francisco where the weather is almost always temperate–cool with low humidity. However, I am in Pennsylvania right now visiting family. I forget how unforgiving hot, sticky summer weather can be to acne-prone skin until I am enveloped in it. I’ve had to be super strict with The Regimen since I’ve been here to stay clear. This is par for the course in hot, humid weather, however. Researchers have found that people in hot and humid climates have more incidence of acne and more severe cases of acne than those in temperate climates. This is not to say that you can’t still stay clear during summer. It just takes stricter adherence to The Regimen.

Tips to stay clear in hot/humid climates:

1. If you end up sweating, try to be gentle when you dry off. Dab your skin gently with a towel or napkin and do not rub the sweat off. Constantly wiping off sweat can be irritating to the skin and cause a breakout. More tips on how to avoid irritation here.

2. Be super strict with The Regimen. Do it twice a day, every day, use plenty of benzoyl peroxide, and moisturize even if you don’t feel that you need to. In the summer it is even more important to follow The Regimen to a T.

3. Try adding 10% glycolic acid (AHA) to The Regimen to bump up the effectiveness even more. Just be sure to adequately protect your skin from the sun if you decide to add in glycolic acid.

4. Since body acne can be aggravated by irritation, and sweat + irritation can make this worse, you may need to treat your body in the summer as well.

Now go out and have some fun! :)

Screen Shot 2014-07-08 at 10.12.39 AMI’ve been working on the personalized advice page in order to make it more fun for people to fill out and easier for people to digest the information.

I have not launched this page yet. Instead, I’d like to get some people to test it and give me any feedback on issues they found. If you get a chance, please take the quiz and reply here with any issues you came across or comments you might have.

I coach people through The Regimen regularly. Something I’ve always noticed is that it’s much harder to get them cleared up when they are on alternative products. When I get them on products they clear up nicely. Sure, sometimes I need to get them to be more gentle, avoid getting sunburnt, etc. but oftentimes it’s as simple as just getting them off of other products and on to products.

Recently, I asked a bunch of people to look at The Regimen pages and tell me what products I thought they should use. Almost unanimously, they said the impression they got was that they could just as easily use alternative products on The Regimen and get clear. This is not the truth. What I’ve always tried to communicate is that you can theoretically use alternative products on The Regimen, but you need to choose them carefully and they may not work as quickly or as well.

Therefore, I have removed alternative products from The Regimen page. I feel it is a disservice to send people on a wild goose chase from the start. I’m getting way too many people telling me that they think The Regimen is not working when they are using alternative products and ultimately getting cleared up quickly when I get them switched over to products. If you are currently on The Regimen using alternative products and having problems, this may be the cause.

I still mention that you can use alternative products on the FAQ and of course people are welcome to discuss alternatives on the forums and around the Internet. I just wanted to keep you guys in the loop as always.

asiaPrevalence: Acne is prevalent in Asians. According to an article in Pediatric Dermatology, “Acne remains one of the most common dermatologic diagnoses in children of all races.” The authors of this article found that the most common reason that Caucasians visit the dermatologist is acne, while the most common reason that Asians visit the dermatologist is dermatitis (inflammation of the skin), with acne not far behind. Another study in the journal Acta Dermato-Venereologica looked at people of all ages in six cities around China and found not suprisingly that younger people experience more acne, and that males had more acne than females. However, they also found that prevalence of acne was lower in Asians than in Caucasians and far lower in Asian adults than Caucasian adults (1% vs. 13%).

Hyperpigmentation: The literature echoes what I have always said, which is that prevention is key when it comes to the dark/red spots that acne leaves behind. According to authors of an article in the Journal of the European Academy of Dermatology and Venereology, “The primary treatment of PIH (post-inflammatory hyperpigmentation) is prevention and treatment of the underlying inflammatory condition.” The Regimen is the best way to topically prevent acne and it works remarkably well in people of Asian heritage. The authors go on to note, “In addition to prevention, there are a variety of medication and procedures used to treat PIH. Although topical skin-depigmenting agents remain the treatment of choice for PIH, lasers and light sources may be an affective adjunctive therapy or alternative for treatment failures. When treating PIH, any treatment options selected should be optimized and utilized carefully because the treatments itself may worsen the PIH.”

Accutane: A 4-year retrospective study in The Journal of Dermatologic Treatment looked at how well Accutane (isotretinoin) worked for Asian skin. They concluded: “This study reaffirms the overall safety and efficacy of oral isotretinoin in Asian patients with acne vulgaris.” “Safety” is a relative term here since we know that Accutane can and will cause severe birth defects if taken when pregnant. If you are Asian and considering Accutane, do it only in close contact with a trusted physician.


  • Eimpunth S, Waniphadeedecha R and Manuskiatti W. “A focused review on acne-induced and aesthetic procedure-related post inflammatory hyperpigmentation in Asians.” Journal of the European Academy of Dermatology and Venereology. 2013; 27(1): 7-18.
  • Henderson MD, et al. “Skin-of-color epidemiology: a report of the most common skin conditions by race.” Pediatric Dermatology. 2012; 29(5): 584-9.
  • Gan EY, et al. “Isotretinoin is safe and efficacious in Asians with acne vulgaris.” Journal of Dermatologic Treatment. 2012; 24(5): 387-91.
  • Kundu RV and Patterson S. “Dermatologic conditions in skin of color: part 1. Special considerations for common skin disorders.” American Family Physician. 2013; 87(12): 850-6.
  • Shen Y, et al. “Prevalence of Acne Vulgaris in Chinese Adolescents and Adults: a Community-based Study of 17.345 Subjects in Six Cities.” Acta Dermato-Venereologica. 2011; 92(1): 40-4.