Acne is a very common disease. People who have it tend to have similar kinds of questions about it and its treatment. This section addresses some of the common questions asked by people with acne. Please remember that your dermatologist is always the best source of specific information about your individual health issues, including acne.
Questions and Answer do follow:
1. What causes acne?
The causes of acne are linked to the changes that take place as young people mature from childhood to adolescence (puberty). The hormones that cause physical maturation also cause the sebaceous (oil) glands of the skin to produce more sebum (oil). The hormones with the greatest effect on sebaceous glands are androgens (male hormones), which are present in females as well as males, but in higher amounts in males.
Sebaceous glands are found together with a hair shaft in a unit called a sebaceous follicle. During puberty, the cells of the skin that line the follicle begin to shed more rapidly. In people who develop acne, cells shed and stick together more so than in people who do not develop acne. When cells mix with the increased amount of sebum being produced, they can plug the opening of the follicle. Meanwhile, the sebaceous glands continue to produce sebum, and the follicle swells up with sebum.
In addition, a normal skin bacteria called P. acnes begins to multiply rapidly in the clogged hair follicle. In the process, these bacteria produce irritating substances that can cause inflammation. Sometimes, the wall of the follicle bursts, spreading inflammation to the surrounding skin. This is the process by which acne lesions, from blackheads to pimples to nodules, are formed.
2. I wash my face several times a day. Why do I still get acne?
Many people still believe that acne is caused by dirty skin. The truth is, washing alone will not clear up or prevent acne. Washing does, however, help remove excess surface oils and dead skin cells. Many people use all kinds of products, including alcohol-based cleansers, and scrub vigorously, only to irritate the skin further and worsen their acne. Washing the skin twice a day gently with water and a mild soap is usually all that is required. However, acne is actually caused by a variety of biologic factors that are beyond the control of washing. For that reason, you should use appropriate acne treatments for the acne.
3. Does stress cause acne?
Stress is commonly blamed for the development of acne. Stress can have many physiologic effects on the body, including changes in hormones that may theoretically lead to acne. In some cases, the stress may actually be caused by the acne lesions, not the other way around! If the acne is being treated effectively, stress is not likely to have much impact on the majority of people.
4. I never had acne as a teenager. Why am I now getting acne as an adult?
Usually, acne begins at puberty and is gone by the early 20s. In some cases, acne may persist into adulthood. Such types of acne include severe forms that affect the body as well as the face (which afflict males more than females) and acne associated with the menstrual cycle in women. In other cases, acne may not present itself until adulthood. Such acne is more likely to affect females than males.
There are several reasons for this. As females get older, the pattern of changes in hormones may itself change, disposing of sebaceous glands to develop acne. Ovarian cysts and pregnancy may also cause hormonal changes that lead to acne. Some women get acne when they discontinue birth control pills that have been keeping acne at bay. Sometimes young women may wear cosmetics that are comedogenic-that is, they can set up conditions that cause comedones to form.
5. What role does diet play in acne?
Acne is not caused by food. Following a strict diet will not clear your skin. While some people feel that their acne is aggravated by certain foods, particularly chocolate, colas, peanuts, shellfish and some fatty foods, there is no scientific evidence that suggests food causes or influences acne. Avoid any foods which seem to worsen your acne and, for your overall health, eat a balanced diet--but diet shouldn't really matter if the acne is being appropriately treated.
6. Does the sun help acne?
Many patients feel that sunlight improves their acne lesions and go to great lengths to find sources of ultraviolet light. There is no proven effect of sunlight on acne. In addition, ultraviolet light in sunlight increases the risk of skin cancer and early aging of the skin. It is, therefore, not a recommended technique of acne management, especially since there are many other proven forms of treatment for acne. Moreover, many acne treatments increase the skin's sensitivity to ultraviolet light, making the risk of ultraviolet light exposure all the worse.
7. What is the best way to treat acne?
Everyone's acne must be treated individually. If you have not gotten good results from the acne products you have tried, consider seeing a dermatologist. Your dermatologist will decide which treatments are best for you. For more information about the types of acne treatments that are available, and for basic acne treatment guidelines, please see Acne Treatments in the main part of AcneNet.
8. What kind of cosmetics and cleansers can an acne patient use?
Look for "noncomedogenic" cosmetics and toiletries. These products have been formulated so that they will not cause acne. Some acne medications cause irritation or pronounced dryness particularly during the early weeks of therapy, and some cosmetics and cleansers can actually worsen this effect. The choice of cosmetics and cleansers should be made with your dermatologist or pharmacist.
Heavy foundation makeup should be avoided. Most acne patients should select powder blushes and eye shadow over cream products because they are less irritating and noncomedogenic. Camouflaging techniques can be used effectively by applying a green undercover cosmetic over red acne lesions to promote color blending.
9. Is it harmful to squeeze my blemishes?
Yes. In general, acne lesions should not be picked or squeezed by the patient. In particular, inflammatory acne lesions should never be squeezed. Squeezing forces infected material deeper into the skin, causing additional inflammation and possible scarring.
10. Can anything be done about scarring caused by acne?
Scarring is best prevented by getting rid of the acne. Dermatologists can use various methods to improve the scarring caused by acne. The treatment must always be individualized for the specific patient. Chemical peels may be used in some patients, while dermabrasion or laser abrasion may benefit others. It is important that the acne be well controlled before any procedure is used to alleviate scarring.
11. How long before I see a visible result from using my acne medication?
The time for improvement depends upon the product being used, but in almost all cases it is more a matter of weeks or months instead of days. Most dermatologists would recommend the use of a medication or combination of medications daily for 4 to 8 weeks before they would change the treatment. It is very important for patients to be aware of this time frame so they do not become discouraged and discontinue their medications. Conversely, if you see no change whatsoever, you might want to check with your dermatologist regarding the need to change treatments.
12. Would using my medication more frequently than prescribed speed up the clearing of my acne?
No--always use your medication exactly as your dermatologist instructed. Using topical medications more often than prescribed may actually induce more irritation of the skin, redness and follicular plugging, which can delay clearing time. If oral medications are taken more frequently than prescribed, they won't work any better, but there is a greater chance of side effects.
13. My topical treatment seems to work on the spots I treat, but I keep getting new acne blemishes. What should I do?
Topical acne medications are made to be used in all acne-prone areas, not just individual lesions. Part of the goal is to treat the skin before lesions can form and to prevent the formation, not just to treat existing lesions. Patients are generally advised to treat all of the areas (forehead, cheeks, chin and nose) that tend to break out rather than just individual lesions.
14. My face is clear! Can I stop taking my medication now?
If your dermatologist says you can stop, then stop--but follow your dermatologist's instructions. Many times patients will stop their medication suddenly only to have their acne flare up several weeks later. If you are using multiple products, it may be advisable to discontinue one medication at a time and judge results before discontinuing them all at once. Ask your dermatologist before you stop using any of your medications.
15. Does it matter what time I use my medication?
Check with your dermatologist or pharmacist. If you were taking one dose a day of an antibiotic, you could probably take it in the morning, at midday or in the evening, although you should pick one time of day and stay with it throughout your treatment. With oral medications prescribed twice a day or three times a day, you should try your best to spread out the doses evenly. Some antibiotics should be taken on an empty or nearly empty stomach. For optimal results with topical treatments, you should strictly follow your dermatologist's recommendations. For example, if instructed to apply benzoyl peroxide in the morning and a topical retinoid at bedtime, it is important to follow these directions strictly. If the two were applied together at bedtime, for example, you could decrease the efficacy of the treatment because of chemical reactions that make them less effective.
16. I have trouble remembering to take my oral medication every day. What's a good way to remember? What should I do if I forget a dose?
This is a common problem. Many patients try to associate taking their medication with a routine daily event such as brushing teeth or applying makeup. It also helps to keep the medication close to the area where the reminder activity is carried out.
In most cases, if you miss a day of your oral treatment, do not double up the next day; rather, get back to your daily regimen as soon as possible--but there may be different instructions for different oral medications. Ask your dermatologist or pharmacist about what to do if you miss a dose of your particular medication.
17. I have been using topical benzoyl peroxide and an oral antibiotic for my acne and have noticed blue-black and brown marks developing on my face and some discoloration on my body. The marks are especially noticeable around acne scars and recently healed lesions. Is this a side effect of medication and is it permanent?
It is not possible to make general statements about side effects of medications that apply to individual cases. A dermatologist should be consulted. The facial marks and body discoloration described by the patient, in this case, do fall within the range of side effects of some antibiotics.
Unique patterns of pigmentation are sometimes seen in acne patients treated with certain oral antibiotics—particularly minocycline. The pigmentation patterns that appear may include:
- Localized blue-black or brown marks in and around acne scars and in areas of previous acne inflammation
- A "muddy skin" appearance that may cover much of the body
- Diffuse brownish pigmentation of the feet and lower legs.
The pigmentation side effect gradually disappears after the therapy is discontinued. Any side effect of a medication should be noted by the patient and brought to the attention of the physician. While most side effects are temporary they should be discussed with the physician and monitored.
18. My doctor is prescribing a topical retinoid for my acne. He said a retinoid is a substance related to vitamin A. If the drug is related to vitamin A, shouldn’t vitamin A dietary supplements be helpful in getting rid of acne?
Dietary vitamin A is essential to good health, especially vision. It has healthful effects on the skin. Large doses of vitamin A for the treatment of acne is not recommended on grounds of safety. The retinoids and retinoid-like substances used as topical treatments for acne are prepared especially for their potent effect on the shedding of cell lining in the sebaceous follicle. Their use should be monitored by a dermatologist.
Dietary vitamin A has multiple health effects in the human body. Vitamin A is essential for good vision. Extreme vitamin A deficiency can result in blindness, usually accompanied by dry, scaly skin. Vitamin A overdose that far exceeds the Recommended Dietary Allowance (RDA) of 5,000 IU can have effects nearly as catastrophic. Extreme vitamin A overdose can cause the skin to blister and peel—an effect first seen in early North Pole explorers who nearly died after eating polar bear liver that has an extraordinarily high vitamin A content.
Topical retinoids are usually prescribed as a treatment for moderate to severe acne. Side effects are chiefly dermatologic, including redness, scaling and dryness of the skin, itching and burning. These side effects can usually be managed by adjustment of the amount and timing of retinoid applied to the skin. Dose adjustment must be discussed with the dermatologist who prescribed the treatment.
19. Are there any acne treatments specifically for people with dark skin? Are there any treatments specifically harmful to dark skin?
There are no acne treatments specifically for use on dark skin. Acne treatments are generally as safe and effective on dark skin as on the light skin. Some treatments for acne scars may cause temporary lightening of the dark skin.
Acne is a common skin disease that has the same causes and follows the same course in all colors of skin. Very dark or black skin may be less well-moisturized than lighter skin. Topical anti-acne agents such as benzoyl peroxide that have a drying effect on the skin should be used under the supervision of a dermatologist. Benzoyl peroxide also is a strong bleach and therefore must be applied carefully to avoid inadvertent decolorization of a patch of hair, towels or clothing.
Darker skin has a tendency to develop post-inflammatory hyperpigmentation (excessive skin darkening at places where the skin was inflamed). Severe inflammatory acne may result in dark spots. The spots resolve over time; a dermatologist may be able to recommend cosmetic measures to make the spots less apparent until they resolve. Some acne treatments, such as topical retinoids and azelaic acid, may also help fade the discoloration.
Removal of acne scars by dermabrasion or chemical peeling may cause temporary lightening or darkening of the dark skin in the areas of treatment. Scar treatment should be discussed with a dermatologist or dermatologic surgeon before it is undertaken. Alterations of melanin (dark pigments that give the skin its color) pigmentation such as vitiligo and melasma are not related to acne, but they may be present simultaneously with acne. The diagnosis and treatment of melanin pigmentation disorders such as vitiligo require a dermatologist with knowledge and experience in treating these conditions.
20. Is acne that appears for the first time in adulthood different from acne that appears in adolescence?
Acne has a specific definition as a disease of sebaceous follicles. This definition applies to acne that occurs at any age. However, it may be important to look for an underlying cause of acne that occurs for the first time in adulthood.
Current understanding of the causes of acne vulgaris is described in the Main Text section Why and how acne happens. In brief summary, acne vulgaris develops when excessive sebum production and abnormal growth and death of cells in the sebaceous follicle result in plugging of follicles with a mixture of sebum and cellular debris and formation of comedones (blackheads and whiteheads). Bacteria in the follicles—chiefly Propionibacterium acnes, the most common bacterial colonist of sebaceous follicles—may contribute to the inflammation of acne by the release of metabolic products that cause an inflammatory reaction. The pathogenic events, which cause disease, in the sebaceous follicle are believed to be due in large degree to changes in levels of androgenic (male) hormones in the body—a circumstance usually associated with growth and development between ages 12 and
21. Some acne investigators believe that although this understanding is generally correct, there is more yet to be learned about the causes of acne vulgaris.
Acne that appears after the age of 25-30 years is (1) a recurrence of acne that cleared up after adolescence, (2) a flare-up of acne after a period of relative quiet—for example, during pregnancy, or (3) acne that occurs for the first time in a person who had never previously had acne.
Acne that occurs in adulthood may be difficult to treat if there are multiple recurrences. Some patients with severe recurrent acne have undergone repeated courses of treatment with the potent systemic drug isotretinoin.
Acne flares in association with pregnancy or menstruation are due to changes in hormonal patterns.
Acne that appears for the first time in adulthood should be investigated for any underlying cause. Drugs that can induce acne include anabolic steroids (sometimes used illegally by athletes to “bulk up”), some anti-epileptic drugs, the anti-tuberculosis drugs isoniazid and rifampin, lithium, and iodine-containing drugs. Chlorinated industrial chemicals may induce the occupational skin disorder known as chloracne. Chronic physical pressure on the skin—for example, by a backpack and its straps, or a violin tucked against the angle of the jaw and chin—may induce so-called acne mechanica. Some metabolic conditions may cause changes in hormonal balance that can induce acne.
Some lesions that appear to be acne may be another skin disorder such as folliculitis—infection and inflammation of hair follicles—that require different treatment than acne. Acne that appears for the first time in adulthood should be examined and treated by a dermatologist.
22. My 15-year-old daughter has what I would describe as a very mild case of acne. She has made it much worse by constant picking and squeezing. She looks in the mirror for hours, looking for some blackhead or blemish she can pick or squeeze. Does she need psychological counseling?
Excessive picking and squeezing of otherwise mild acne is a condition called excoriated acne, seen most often in young women. A dermatologist may provide effective counseling.
The typical person with excoriated acne is a person—often a young women—who are so distressed with her appearance due to acne that she literally tries to "squeeze the acne out of existence." The acne is often very mild, but the person’s face may constantly be covered with red marks from squeezing, and open sores where lesions have been picked open.
The word excoriate means to scratch or abrade the skin. Excoriated acne is a medically recognized condition that should be discussed with a dermatologist. Occasionally giving in to a temptation to squeeze a blackhead is not defined as excoriated acne. Hours in front of a mirror, squeezing and picking every blemish is a definition of excoriated acne. A dermatologist may be able to counsel the patient regarding a course of treatment in which the patient can participate, but keep "hands off."
23. Can the rate of secretion or the composition of sebum be altered by diet? If it can, shouldn’t alteration of diet be considered a treatment for acne?
Diet has never been proven to have a role in the cause or treatment of acne. Dietary manipulation may have a role in the treatment of some scaling diseases of the skin, but not in the treatment of acne. The dietary cause is one of the most persistent myths about acne. Foods, such as chocolate or greasy foods, do not cause acne, but certain foods seem to make some people’s acne worse. The following can bring on or worsen it:
- Hereditary factors
- An increase in male hormones found in both males and females
- Emotional stress
- Oil and grease from cosmetics, work environment
No food has been shown to be effective in preventing or treating acne. A healthy diet is, of course, necessary for good general health.
24. Shouldn't I just try to eliminate sebum from my body?
No. When it isn't blocked in your pores, sebum helps keep your skin healthy.
25. Why does acne usually start at puberty?
No one knows for certain. What is known is that the sebaceous glands that produce sebum get much larger at puberty than they were before.
26. Why does the skin around a pimple turn red?
This redness is caused by the body's inflammatory response. Inflammation is a sign that your immune system is working to fight an infection. However, the inflammatory response doesn't always work perfectly, and can even be the cause of scarring.
27. If my skin turns red, does that mean that I'm going to have scars?
Usually, no. Even when there will be no permanent scar, the aftereffects of the inflammatory response can leave the skin red for months, sometimes for more than a year.
28. What are free radicals?
Free radicals are byproducts of oxidation in your body. We all need oxidation to occur as part of our life process, but there is concern that the buildup of unrecycled free radicals contributes to many conditions, including skin damage. Antioxidants, including several of the active ingredients in Acuzine, help prevent the buildup of free radicals.